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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:

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.

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