Pre-Payment Review Results for Daratumumab (Darzalex FasproŽ) for October to December 2024

Published 02/13/2025

Pre-Payment Review Results for Daratumumab (Darzalex Faspro®) HCPCS J9144 through J9145 for Targeted Probe and Educate (TPE) for October to December 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Healthcare Common Procedure Coding System (HCPCS) codes J9144 through J9145 for Daratumumab (Darzalex Faspro®). 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
2 2 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
40 0 0% $470,906.19 $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. 1 1 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% $316,751.02 $0 0%
W. Va. 20 0 0% $154,155.17 $0 0%

Risk Category

The categories for HCPCS codes J9144 – J9145 for Daratumumab (Darzalex Faspro®) for TPE are defined as:

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

Figure 1. Risk Category for Daratumumab.

Pie chart showing 100% minor findings

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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