November 21, 2014
Outpatient Services for Rituximab Injection (HCPCS code J9310): Ohio – Advance to Targeted Medical Review
The J15 Part A Medical Review department performed a service-specific prepay probe review on claims billed for the drug Rituximab (HCPCS code J9310) in Ohio. Based on the results summarized below, this service-specific prepay probe edit was advanced to targeted medical review in Ohio.
Ohio Service-Specific Probe Edit Results: Rituximab (HCPCS code J9310)
|
Charges |
Claims |
|---|---|---|
Reviewed |
$13,965,021.36 |
542 |
Denied |
$3,740,175.39 |
148 |
Charge Denial Rate |
26.8% |
|
The top denial reasons associated with this edit are:
Denial Code 5D164/5H164 – No Documentation of Medical Necessity for Services
- Reason for denial:
- The claims were fully or partially denied because the documentation submitted for review did not support the medical necessity of the services provided.
- How to prevent denials:
- Submit documentation to support that all services were medically necessary. Rituximab is addressed in CGS’s Local Coverage Determination (LCD) Chemotherapy and Biologicals (refer to the attachment to the LCD, “Chemotherapy and Biological Chart” for a list of ICD-9 codes for which CGS considers Rituximab to be medically necessary).
- A legible signature is required on all documentation necessary to support orders and medical necessity.
- Use the most appropriate ICD-9-CM codes to identify the beneficiary’s medical diagnosis.
- For more information, refer to:
- CGS LCD, Chemotherapy and Biologicals
(refer to the attachment “Chemotherapy and Biological Chart”, located under Associated Documents in the LCD) - CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, section 3.3.2.4
- CMS MLN Matters article MM6698, “Signature Guidelines for Medical Review Purposes”
- Definition of “medically necessary”: Social Security Act (SSA), Section 1862 (a)(1)(A)
- Code of Federal Regulations: 42 CFR 410.32
- CGS LCD, Chemotherapy and Biologicals
5D169/5H169 – Services Not Documented
- Reason for denial:
- The claims were partially or fully denied because the provider billed for services/items not documented in the medical record submitted.
- How to prevent denials:
- Submit all documentation related to the services billed.
- Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed.
- For more information, refer to:
Denial Code 5D161/5H161 – No Physician’s Orders
- Reason for denial:
- The claims were fully or partially denied because there were no physician’s orders submitted for review for all or some of the services billed.
- How to prevent denials:
- Upon request from CGS, submit a physician’s order along with your other supporting documentation.
- A legible signature is required on all documentation necessary to support orders and medical necessity.
- The copy of the order should be legible and dated.
- Make sure any orders submitted for review are for the dates of service billed.
- For more information, refer to:
- CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, Section 3.3.2.4
- CMS MLN Matters article MM6698, “Signature Guidelines for Medical Review Purposes”
- Definition of an “order”, for Medicare purposes: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 23, section 10.1.2
- Code of Federal Regulations: 42 CFR 410.32
- CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, Section 3.3.2.4
Individual providers with significant denials will be contacted for one-on-one education.
If you have questions regarding this review, please call the CGS Part A Provider Contact Center at 866.590.6703.
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