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October 25, 2016

Results of Widespread Prepayment Probe Conducted for OH and KY: Drugs Administered for Macular Degeneration

In July 2016, CGS initiated a widespread service-specific prepayment probe to address potential insufficient documentation issues with the administration of drugs for macular degeneration. The results of the probe are provided below.

Documentation was reviewed for compliance with Medicare rules and regulations such as: medical necessity; appropriate orders and signatures; administration/deliverance of the service; as well as correct coding and billing of the drug as administered, per medical necessity.

Codes reviewed included HCPCS code J0178 (Aflibercet (Eylea) 2 mg) and HCPCS code J2778 (Ranibizumab (Lucentis) 0.5 mg) given directly in the eye every 28-31 days. The injection may be given bilaterally on the same day in the physician's office, hospital or clinic.

Initially, the only diagnosis that was paid was Wet AMD (ICD-10 code 35.32). However, after commencing with the review, the following diagnoses were added:

ICD-10 codes:

E10.321 (mild nonproliferative DR with ME)
E10.331 (moderate nonproliferative DR with ME)
E10.341 (severe nonproliferative DR with ME)
E10.351 (proliferative DR with ME) Type 2 diabetes with…
E11.321 (mild nonproliferative DR with ME)
E11.331 (moderate nonproliferative DR with ME)
E11.341 (severe nonproliferative DR with ME)
E11.351 (proliferative DR with ME)
E08.321 (mild nonproliferative DR with ME)
E08.331 (moderate nonproliferative DR with ME)
E08.341 (severe nonproliferative DR with ME)
E08.351 (proliferative DR with ME) Drug- or chemical-induced diabetes with…
E09.321 (mild nonproliferative DR with ME)
E09.331 (moderate nonproliferative DR with ME)
E09.341 (severe nonproliferative DR with ME)
E09.351 (proliferative DR with ME) Other specified diabetes with…
E13.321 (mild nonproliferative DR with ME)
E13.331 (moderate nonproliferative DR with ME)
E13.341 (severe nonproliferative DR
H35.81 Retinal edema Central retinal vein occlusion
H34.811 (Right Eye)
H34.812 (Left Eye)
H34.813 (Bilateral)
H34.831 (Right Eye)
H34.832 (Left Eye)
H34.833 (Bilateral)

NOTE: Providers should request Reopenings on claims that were denied inappropriately if submitted with one of the ICD-10 codes listed above. If you submitted claims with an ICD-10 code other than those listed above and disagree with the medical necessity denial, please request a Redetermination and include documentation to support medical necessity.

A total of 157 records were reviewed by our clinicians (36 claims were denied due to non-response) which resulted in an error rate of 45.94%.

Findings resulting in denial of the service billed included:

  1. No records recieived: 36 claims
  2. No diagnosis of Wet AMD (ICD-10 code 35.32): 22 claims
  3. No documentation of wastage: 9 claims
  4. No signature: 4 claims
  5. Wrong date of service submitted: 1 claim
  6. Untimely signature: 2 claims
  7. Eylea given in less than 28 days: 1 claim
  8. Wrong code billed- billed for Eylea when Evastin is documented as given: 1 claim
  9. Documentation did not support both eyes injected when billed bilaterally: 1 claim
  10. Duplicate claims: 2 claims
  11. No updated exam: 1 claim

Through our review, we have identified the need for ongoing education. Please refer to the resources below for additional information. You may also contact our Provider Outreach and Education (POE) staff for additional education at J15_PartB_Education@cgsadmin.com.

Resources:

Wastage/Discard Drugs:

Signatures:

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