Corporate

February 1, 2016

Infliximab Injection (HCPCS Code J1745): Complex Medical Review –Kentucky and Ohio – Discontinue

The J15 Part A Medical Review department performed a service-specific complex review on outpatient services for HCPCS Code J1745, bill type 13X, related to Infliximab injection in Kentucky and Ohio. Based on the results summarized below, the complex review was discontinued.

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

  Charges Claims
Reviewed $23,564,332.53 1,263
Denied $3,762,603.89 224
Charge Denial Rate 16.0%  

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

  Charges Claims
Reviewed $45,828,930.83 2,969
Denied $9,758,708.40 581
Charge Denial Rate 21.3%  

The top denial reasons associated with this review are:

Denial Code 5D164/5H164 – No Documentation of Medical Necessity for Services

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 Avoid a Denial
    • 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 PDF and 424.5External PDF

Denial Code 5D161/5H161 – No Physician's Orders

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 Avoid a Denial
    • 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 your mail room staff to be aware of any mail you receive from CGS.
    • Be aware of the need to submit medical records within 45 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. Be sure to include the appropriate mail code.
    • You may also identify and respond to ADRs electronically via the myCGS web portal.

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

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


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