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May 8, 2013

Documentation Reminders: Immunosuppressive Drugs

Claim reviews by both CGS and the Comprehensive Error Rate Testing (CERT) Review Contractor show a high percentage of documentation errors involving claims for immunosuppressive drugs. Suppliers are reminded that, upon the request of a Medicare contractor, they must provide copies of the following documents:

  1. Proof of delivery;
  2. Detailed written order;
  3. Written documentation of a dispensing order (if delivery occurred prior to the supplier obtaining a detailed written order);
  4. Proof of a refill request; and
  5. Medical records confirming the transplant, the date of the transplant, the facility where the transplant occurred, and that the beneficiary continues to use the drug.

Failure to provide these records, or for the records to support that the coverage criteria listed in the Immunosuppressive Drugs Local Coverage Determination (LCD) and Policy Article (PA) were met, will result in claim denial.

A summary of common errors identified by CGS and CERT reviewers follows.

Delivery Documentation:

Physician Order:

Medical Records:

For questions regarding documentation requirements for Immunosuppressive Drug claims, suppliers should refer to the Immunosuppressive Drugs LCD and PA, Chapter Three of the Jurisdiction C Supplier Manual and the online article, "Lessons Learned: Widespread Probe Reviews of J7507 and J7517".

Additionally, the CGS Provider Outreach and Education (POE) staff offers an extensive range of both general and policy-based webinars. A new webinar schedule is posted monthly. For information on the current webinar schedule and to register for a webinar, suppliers should click on "Webinars" under the CGS DME MAC Jurisdiction C Education tab.

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