Pre-Payment Review Results for Remicade® (Infliximab) for October to December 2024

Published 02/13/2025

Pre-Payment Review Results for Remicade® (Infliximab) 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 Systems (HCPCS) code J1745 for Remicade® (Infliximab). 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
3 2 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
64 3 5% $119,581.31 $3,889.34 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
N.C. 1 1 0 0
S.C. 0 0 0 0
Va. 1 1 0 0
W. Va. 1 0 1 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. 36 0 0% $67,529.45 $0 0%
S.C. 0 0 0% $0 $0 0%
Va. 20 0 0% $40,183.71 $0 0%
W. Va. 8 3 38% $11,868.15 $3,889.34 33%

Risk Category

The 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.

Pie chart showing 33% major findings and 67% minor

Top Denial Reasons

Table 6. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
50% 5D151, 5H151 Units Billed More Than Ordered 1
50% 56900 Auto Deny — Requested Records Not Submitted Timely 1

Denial Reasons and Recommendations

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

56900 — Auto Deny — Requested Records Not Submitted Timely

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original ADR to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the ADR is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review department. Fax and electronic data submissions are also accepted as indicated on the ADR.
  • Gather all of the information needed for the claim and submit it all at one time
  • Attach a copy of the ADR request to each individual claim
  • If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips.
  • Do not mail packages C.O.D.; we cannot accept them

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 (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?