Immunosuppressive Drugs Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for immunosuppressive drugs HCPCS codes J7503, J7507, J7518, J7520, and J7527 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 8.57%. The top 5 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). | 27.27% |
2. | The quantity of drugs dispensed is limited to a one month supply. Quantities of drugs dispensed in excess of a one month supply will be denied as not medically necessary. | 27.27% |
3. | The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212 | 18.18% |
4. | Documentation does not include information that supports that the beneficiary had a Medicare approved transplant per LCD/Policy Article requirements. | 18.18% |
5. | The supplier indicates the item(s) were billed in error. | 9.09% |
*The total percentage will be greater than 100% because some claims were denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to represent an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Immunosuppressive Drugs Documentation Checklist
- Immunosuppressive Drugs – LCD (L33824)
- Immunosuppressive Drugs – Policy Article (A52474)
- Immunosuppressive Drug Medical Review Resources
Updated: February 2, 2024