Pre-Payment Review Results for Remicade® (Infliximab) for July to September 2024

Published 10/23/2024

Pre-Payment Review Results for Remicade® (Infliximab) for Targeted Probe and Educate (TPE) for July to September 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Healthcare Common Procedure Coding System (HCPCS) code J1745 for Remicade® (Infliximab). The reviews with edit effectiveness are presented here for Alabama, Georgia and Tennessee.

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
5 3 2 13
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
158 36 23% $254,721.65 $36,280.58 14%

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. 1 1 0 3
Ga. 1 1 0 6
Tenn. 3 1 2 4
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. 38 3 8% $76,618.46 $8,390.88 11%
Ga. 24 0 0% $48,704.40 $0.00 0%
Tenn. 96 33 34% $129,398.79 $27,889.70 22%

Risk Category
The risk categories for HCPCS code J1745 for Remicade® (Infliximab) are defined as:

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

Figure 1. Risk Category for Remicade.

The risk categories for HCPCS code J1745 for Remicade (Infliximab) are defined as: Minor 40% and Minor 60%

Top Denial Reasons

Table 6: Top Denial Reasons
Percent of Total Denials Denial Code Denial Description Number of Occurrences
40% NOTML Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed 4
30%

 

NODOC

 Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(a) (1) (A) of the ACT for the Service Billed, and this Service Has Been Denied 3
20% WRONG Documentation Received Contains an Incorrect, Incomplete or Illegible Patient Identification or Date of Service 2
10% BILER Claim Billed in Error per Provider 1

Denial Reasons and Recommendations

NOTML — Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

  • Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological or laboratory results.
  • Verify that documentation to support the level of service billed is included
     

NODOC — Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(a) (1) (A) of the ACT for the Service Billed, and this Service Has Been Denied

  • Submit all documentation related to the services billed within 45 days of the date on the ADR letter
  • Review documentation prior to submission to ensure that the documentation is complete and that all dates of service requested are included
  • Include any additional information pertinent to the date of service requested to support the services billed. For example, original chart notes, diagnostic, radiological or laboratory results.
  • For claims denied with a M127 or N29 code listed on the remittance advice, be sure to submit all documentation for all dates of service on that claim with a reopen/redetermination request form by fax to JM Part B (803) 699–2427, JJ Part B (803) 870–0139, or RRB Appeals (803) 462–2218
     

WRONG — Documentation Received Contains an Incorrect, Incomplete or Illegible Patient Identification or Date of Service

  • Review all documentation prior to submission to ensure that it is for the correct patient and date of service
  • Ensure that patient identifiers are legible and complete
  • Ensure that the complete date of service is clearly and legibly noted on all documentation
  • Prior to billing claims, review the information to determine that the correct patient identifier and the correct date of service are listed in the appropriate field
     

BILER — Claim Billed in Error per Provider

  • Prior to billing claims, review the information to determine that the correct information is listed in the appropriate fields
  • For all claims previously billed and denied by medical review, do not resubmit the claims. If you disagree with the decision from Medical Review, you must submit the appropriate documentation with a completed redetermination request form to the appeals department. This information can be sent by fax to JM Part B Appeals (803) 699–2427, JJ Part B Appeals (803) 870–0139, or RRB Appeals (803) 462–2218.
  • If documentation indicates that both an NPP and a physician performed the service, and the claim is billed under the physician’s NPI, the billing physician must sign the record. Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantive portion of the E/M visit. (A substantive portion of the E/M visit includes at least one of the three key components: history, exam, or medical decision-making.)
  • If documentation occurs in a teaching environment, review the documentation to ensure that the billing provider has provided a teaching attestation and a signature
     

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 (PDF). 

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. 


Was this article helpful?