Pre-Payment Review Results for Eyleaź (Aflibercept) for July to September 2024

Published 10/25/2024

Pre-Payment Review Results for Eylea® (Aflibercept) 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) code J0178 for Eylea® (Aflibercept). 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 1
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
23 4 17% $20,317.82 $3,574.20 18%

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 1
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%

$0.00

$0.00

 0%
S.C. 0 0 0% $0.00 $0.00 0%
Va. 23 4 17% $20,317.82 $3,574.20 18%
W.Va. 0 0 0% $0.00 $0.00 0%

Risk Category
The categories for HCPCS code J0178 for Eylea® (Aflibercept) are defined as:

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

Figure 1. Risk Category for Eylea.

The categories for HCPCS code J0178 for Eylea (Aflibercept) are defined as: Minor 100%
 

Top Denial Reasons

Table 6: Top Denial Reasons
Percent of Total Denials Denial Code Denial Description Number of Occurrences
50% NOTML Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed 1
50% BILER Claim Billed in Error per Provider 1

Denial Reasons and Recommendations

NOTML — Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

  • Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological or laboratory results.
  • Verify that documentation to support the level of service billed is included
     

BILER — Claim Billed in Error per Provider

  • Prior to billing claims, review the information to determine that the correct information is listed in the appropriate fields
  • For all claims previously billed and denied by medical review, do not resubmit the claims. If you disagree with the decision from medical review, you must submit the appropriate documentation with a completed redetermination request form to the appeals department. This information can be sent by fax to JM Part B Appeals (803) 699–2427, JJ Part B Appeals (803) 870–0139, or RRB Appeals (803) 462–2218.
  • If documentation indicates that both an NPP and a physician performed the service, and the claim is billed under the physician’s NPI, the billing physician must sign the record. Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantive portion of the E/M visit. (A substantive portion of the E/M visit includes at least one of the three key components: history, exam, or medical decision*making.)
  • If documentation occurs in a teaching environment, review the documentation to ensure that the billing provider has provided a teaching attestation and a signature
     

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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