Pre-Payment Review Results for Rituxan® (Rituximab) for July to September 2024

Published 11/11/2024

Pre-Payment Review Results for Rituxan® (Rituximab) 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) codes J9311–J9312 for Rituxan® (Rituximab). 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
7 7 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
194 5 3% $1,394,317.42 $21,130.44 2%

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. 3 3 0 0
S.C. 2 2 0 0
Va. 0 0 0 0
W.Va. 2 2 0 0
Table 3. 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. 77 3 4% $576,692.39 $11,215.78 2%
S.C. 65 2 3% $426,594.93 $9,914.66 2%
Va. 0 0 0% $0 $0 0%
W.Va. 52 0 0% $391,030.10 $0 0%

Risk Category

The categories for HCPCS codes J9311–J9312 for Rituxan® (Rituximab) for TPE are defined as:

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

Figure 1. Risk Category for Rituxan.

Pie chart showing 100% minor findings

Top Denial Reasons

Table 6. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
33% 5D164/5H164 No Documentation of Medical Necessity 2
33% 5DMDP/5HMDP Dependent Services Denied (Qualifying Service Denied Medically) 2
17% 5D199/5H199 Billing Error 1
17% 56900 Auto Deny — Requested Records Not Submitted Timely 1

Denial Reasons and Recommendations

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
  • Any medical history that supports a need for the service'
  • Any diagnostic results or symptomology that supports a need for the service
  • 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

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

5D199/5H199 — Billing Error

Reason for Denial
The services billed were not covered because the documentation provided did not support the claim as billed by the provider.

How to Avoid This Denial

  • Check all bills for accuracy prior to submitting to Medicare
  • Ensure that the documentation submitted, in response to the Additional Documentation Request (ADR), corresponds with the date that the service was rendered, and the dates of service billed

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 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 Additional Development Request (ADR) to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the Additional Development Request (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.

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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