Part B service-specific review – drugs and biologicals (J0178 Eylea, J0897 Prolia, J2778 Lucentis, J9217 Lupron (Leuprolide))
On August 17, 2020, medical review activity resumed, as directed by CMS, with implementation of post-payment service-specific medical record review.
First Coast is tasked with preventing inappropriate Medicare payments. One of the ways this is conducted is through medical review of claims. This helps to ensure that Medicare pays for services that are covered, coded correctly, and medically reasonable and necessary.
High level results and top denial / partial denial reasons are listed below for the post-payment service specific reviews for drugs and biologicals (J0178 Eylea, J0897 Prolia, J2778 Lucentis, J9217 Lupron (Leuprolide)) that have been conducted by First Coast. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information.
Drugs and biologicals (J0178 Eylea, J0897 Prolia, J2778 Lucentis, J9217 Lupron (Leuprolide)) (April-May 2021)
Top full / partial denial reasons:
The most common reasons for denial or partial denials are the following:
- Level of care / incorrect coding – Documentation submitted for review did not support the number of administered units, therefore the claim was changed to reflect the appropriate units administered supported by the documentation.
- Medical necessity – The documentation lacked evidence to support the service as medical necessary and reasonable. The documentation lacked evidence to support the requirements of the First Coast Local Coverage Determination (LCD).
- Insufficient documentation – The documentation provided was insufficient to support the services as billed to Medicare. First Coast medical review makes multiple attempts to correct these error types before completion of the review.
- Billing errors – The documentation submitted was for the incorrect date of service.