Corporate

January 5, 2015

Outpatient Services for Infliximab Injection (HCPCS Code J1745): Complex Review, Kentucky/Ohio - Continued

The J15 Part A Medical Review department performed service-specific complex reviews on outpatient services for HCPCS code J1745, type of bill (TOB) 13X, for Infliximab injections in Kentucky and Ohio.  Based on the results summarized below, the complex review was continued. 

Kentucky-Complex Edit Results:  Infliximab Injection (HCPCS Code J1745)

 

Charges

Claims

Reviewed

$6,837,198.96

384

Denied

$1,765,330.04

103

Charge Denial Rate

25.8%

 

Ohio-Complex Edit Results:  Infliximab Injection (HCPCS Code J1745)

 

Charges

Claims

Reviewed

$12,928,000.46

879

Denied

$3,239,594.60

211

Charge Denial Rate

25.1%

 

The top denial reasons associated with this review 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.
    • 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

  • 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:

 

Denial Code 56900 – Requested Records Not Submitted

  • Reason for denial:
    • The medical records were not received in response to an Additional Documentation Request (ADR) in the required timeframe; 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 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 CGS Part A Provider Contact Center at 866.590.6703.


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