November 2, 2015
Outpatient Services for Rituximab Injection - (HCPCS Code J9310) – Ohio - 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 Ohio. Based on the results summarized below, the complex review was discontinued.
Ohio - Complex Edit Results: Rituximab Injection (HCPCS Code J9310)
Charges | Claims | |
---|---|---|
Reviewed | $1,861,067.06 | 54 |
Denied | $21,432.00 | 1 |
Charge Denial Rate | 1.2% |
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, handwritten signature is required on all documentation necessary to support orders and medical necessity.
- Use the most appropriate ICD - 9 - CM/ICD - 10 - CM codes to identify the beneficiary's medical diagnosis.
- For more information, refer to:
- CMS Medicare Program Integrity Manual (Pub. 100 - 08), chapter 3, section 3.3.2.4
- CMS MLN Matters article MM6698, "Signature Guidelines for Medical Review Purposes"
- Definition of "medically necessary": Social Security Act (SSA), Section 1862 (a)(1)(A)
- Code of Federal Regulations: 42 CFR 410.32
Individual providers with significant denials will be contacted for one - on - one education.
If you have questions regarding this review, please contact the Part A Provider Contact Center at 866.590.6703.