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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:

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 call the CGS Part A Provider Contact Center at 866.590.6703.


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