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November 21, 2014

Outpatient Services for Immune Globulin Injection (HCPCS Code J1569): Probe Medical Review, Kentucky – Advanced to Targeted Review

The J15 Part A Medical Review department has performed a service-specific probe review on outpatient services for Immune Globulin Injection (HCPCS Code J1569), type of bill 13X in Kentucky.  Based on the results summarized below the review was advanced to targeted medical review.  

Kentucky-Probe Edit Results:  Immune Globulin Injection (HCPCS Code J1569)

 

Charges

Claims

Reviewed

$2,979,097.85

140

Denied

$1,198,135.11

55

Charge Denial Rate

40.2%

 

The top denial reasons associated with this review are:

5D161/5H161 – No physician’s orders

Reason for denial:

  • The claim was 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 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:

5D164/5H164 –No documentation of medical necessity

Reason for denial:

  • This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.

How to prevent denials:

  • Submit documentation to support all required components of the service when responding to the ADR.
  • 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:

Denial Code 56900 – Requested records not submitted

  • Reason for denial:
    • The medical records were not received in response to an ADR in the required time frame; therefore, we were unable to determine medical necessity.
  • How to prevent denials:
    • Monitor your claim status on Direct Data Entry (DDE).  If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted.  Please note: CGS may request records through our Medical Review or Claims departments, and other contractors such as the Zone Program Integrity Contractor (ZPIC) may also request records.  Ensure the records are submitted to the appropriate entity.
    • Alert you mail room staff to be aware of any mail you receive from CGS.
    • Be aware of the need to submit medical records within 30 days of the date on the Additional Documentation Request (ADR) in the upper left corner.
    • Gather all information and submit at one time.
    • Submit medical records as soon as the ADR is received.
    • Attach a copy of the ADR to each individual claim.
    • If you are responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records.  Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost.
    • Do not mail packages COD; we cannot accept them.
    • Return the medical records to the address indicated in the ADR.

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

If you have questions regarding this review, please call the Part A Provider Contact Center at 866.590.6703.


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