Pre-Payment Review Results for Opdivo for January to March 2025

Published 04/14/2025

Pre-Payment Review Results for Opdivo for Targeted Probe and Educate (TPE) for January to March 2025

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Healthcare Common Procedure Coding System (HCPCS) code J9299 for Opdivo. The reviews with edit effectiveness are presented here for January to March 2025.

Cumulative Results

Table 1. Cumulative Results.
Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
6 5 1 0
Table 2. Cumulative Results.
Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
240 10 4% $3,249,096.94 $106,998.97 3%

Probe One Findings

Table 3. Probe One Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
Ala. 0 0 0 0
Ga. 2 1 1 0
Tenn. 4 4 0 0
Table 4. Probe One Findings.
State Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
Ala. 0 0 0% $0.00 $0.00 0%
Ga. 80 10 13% $1,206,921.11 $106,998.97 9%
Tenn. 160 0 0% $2,042,175.83 $0.00 0%

Risk Category

The categories for HCPCS code J9299 for Opdivo are defined as:

Table 5. Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Figure 1. Risk Category.

Pie chart showing 17% Major findings and 83% Minor findings

Top Denial Reasons

Table 6. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
20% 5DTDP, 5HTDP Dependent Services Denied (Qualifying Service Denied Technically) 1
20% 5D169, 5H169 Services Not Documented 1
20% 5D151, 5H151 Units Billed More Than Ordered 1
20% 5D164, 5H164 No Documentation of Medical Necessity 1
20% 5DMDP, 5HMDP Dependent Services Denied (Qualifying Service Denied Medically) 1

Denial Reasons and Recommendations

5DTDP/5HTDP — Dependent Services Denied (Qualifying Service Denied Technically)

Reason for Denial
The dependent services will not be covered if the qualifying service has been denied. For example, the service procedure was not documented, therefore all other charges cannot be allowed.

How to Avoid This Denial

  • Ensure all documentation is submitted to support service was rendered
  • Ensure documentation supports the claim as billed
  • Ensure all documentation is properly and legibly signed

Resources

5D169/5H169 — Services Not Documented

Reason for Denial
This claim was partially or fully denied because the documentation submitted is insufficient for the services billed.

How to Avoid This 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
  • Ensure that the documentation is complete with proper authentication and the signature is legible

Resources

5D151/5H151 — Units Billed More Than Ordered

Reason for Denial
The medical record provided for the outpatient service did not support the number of units billed on the claim. Per the documentation, more units were billed than provided.

How to Avoid This Denial
Under the Outpatient Prospective Payment System (OPPS), when HCPC code reporting is required the number of times the service or procedure was performed or the amount of the service used must also be accurately reported in the service units. 

  • For time based general outpatient services, make sure the start and end time, or total length of the service is documented clearly in the record
  • For other general outpatient services, make sure the amount of the service is documented clearly in the record
  • When reporting drugs or biologicals make sure the amount of the drug given is clearly documented and properly converted into units when submitted for payment
  • For outpatient therapy services, make sure the timed treatment minutes/unit(s) for the timed services provided are documented clearly in the record

Resources

5D164/5H164 — No Documentation of Medical Necessity

Reason for Denial
This claim was denied because the documentation submitted does not support the medical necessity of the service reviewed. The records did not contain any covered condition/indication, symptomology or diagnostic results that would support the service was reasonable and necessary for the treatment of the beneficiary.

How to Avoid This Denial

  • Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:
    • A covered indication or condition for the service billed
    • A physician/NPP is managing the care of the covered indication or condition billed is documented in the record
    • Any medical history that supports a need for the service
    • Any diagnostic results or symptomology that supports a need for the service
    • Legible documentation
  • Submit all documentation to support ongoing skills of a qualified therapist were required to complete the treatment and that the initiation of therapy treatment services were medically necessary
  • ABN is valid, complete, and submitted in the record if applicable
  • A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support medical necessity
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis
  • Submit treatment note documentation that contains date of treatment, description of modality/procedure to support accurate billing, total treatment minutes/ total timed code treatment minutes and signature of qualified professional
  • Documentation to include the therapy discharge note and summary
  • All documentation submitted is legible

Resources

5DMDP/5HMDP — Dependent Services Denied (Qualifying Service Denied Medically)

Reason for Denial
The dependent services will not be covered if the qualifying service has been denied. For example, the service was denied as documentation did not support medical necessity, therefore all other charges associated with the service under review cannot be allowed and will be denied as dependent to the medical denial of the qualifying service.

How to Avoid This Denial

  • Ensure the documentation provided supports the services were reasonable and medically necessary for the treatment of the beneficiary
  • Ensure all records are properly and legibly signed
  • Ensure documentation supports the service(s) was rendered

Resources

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form.

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.


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