Pre-Payment Review Results for Avastin® (Bevacizumab) for October to December 2024

Published 02/13/2025

Pre-Payment Review Results for Avastin® (Bevacizumab) 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 J9035 for Avastin® (Bevacizumab). 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
39 1 3% $153,464.47 $290.35 0.2%

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. 0 0 0 0
S.C. 0 0 0 0
Va. 0 0 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. 0 0 0% $0 $0 0%
W. Va. 39 1 3% $153,464.47 $290.35 0.2%

Risk Category

The categories for HCPCS codes J9035 for Avastin® (Bevacizumab) for TPE are defined as:

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

Figure 1. Risk Category for Avastin.

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
100% 5D199, 5H199 Billing Error 1

Denial Reasons and Recommendations

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 ADR, corresponds with the date that the service was rendered, and the dates of service billed

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.


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