Pre-Payment Review Results for Privigen® for January to March 2025

Published 04/15/2025

Pre-Payment Review Results for Privigen® (Immune Globulin) 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 J1459 for Privigen®. The reviews with edit effectiveness are presented here for North Carolina, South Carolina, Virginia and West Virginia.

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
1 1 0 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
20 0 0% $153,330.34 $0 0%

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
N.C. 0 0 0 0
S.C. 0 0 0 0
Va. 1 1 0 0
W.Va. 0 0 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
N.C. 0 0 0% $0 $0 0%
S.C. 0 0 0% $0 $0 0%
Va. 20 0 0% $153,330.34 $0 0%
W.Va. 0 0 0% $0 $0 0%

Risk Category

The categories for HCPCS code J1459 for Privigen® (Immune Globulin) are defined as:

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

Figure 1. Risk Category for Privigen (Immune Globulin) HCPCS Code J1459.

Pie chart showing 100% Minor and 0% Major.

Top Denial Reasons

There are no denial reasons at this time.

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.


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