Corporate

July 7, 2014

Outpatient Services for Rituximab Injection-(HCPCS Code) J9310 – Kentucky - Discontinued

The J15 Part A Medical Review department performed a service-specific complex review on outpatient services for HCPCS Code J9310, type of bill (TOB) 13X, for Rituximab injections in Kentucky.  Based on the results summarized below, the complex review was discontinued. 

Kentucky-Complex Edit Results:  Rituximab Injection (HCPCS Code J9310)

 

Charges

Claims

Reviewed

$3,100,133.91

102

Denied

$423,635.26

16

Charge Denial Rate

13.7%

 

The top denial reasons associated with this review are:

Denial Code 5D164/5H164 – No Documentation of Medical Necessity for Services

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:
    • Code of Federal Regulations, 42 CFR – Sections 410.32External Website and 424.5External Website

Denial Code 5D161/5H161 – No Physician’s Orders

Individual providers with significant denials will be contacted for one-on-one education. 

If you have questions regarding this review, please contact the Medical Review department at 803.763.4999.


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