Postpayment Service-Specific Probe Results for Bevacizumab (Avastin) for April through June 2021

Postpayment Service-Specific Probe Results for Bevacizumab (Avastin®) in Alabama, Georgia and Tennessee for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code J9035-Bevacizumab (Avastin). This edit was set in Alabama, Georgia and Tennessee. The results for the first quarter postpayment review for claims processed April through June, 2021, are presented here.

Cumulative Results 
A total of 160 claims were reviewed, with fifteen of the claims completely or partially denied, resulting in an overall claim denial rate of 9.4 percent. The total dollars reviewed was $1,022,666.39, of which $36,550.86 was denied, resulting in a charge denial rate of 3.57 percent. Overall, there was a total of 43 auto-denied claims in the region.

Alabama Results
A total of 56 claims were reviewed, with three of the claims either completely or partially denied. This resulted in a claim denial rate of 5.36 percent. The total dollars reviewed was $333,046.48, of which $8,295.04 was denied, resulting in a charge denial rate of 2.49 percent. 

Georgia Results
A total of 98 claims were reviewed, with 12 of the claims either completely or partially denied. This resulted in a claim denial rate of 12.24 percent. The total dollars reviewed was $633,669.54, of which $28,255.82 was denied, resulting in a charge denial rate of 4.46 percent. 

Tennessee Results
A total of six claims were reviewed, with none of the claims denied. This resulted in a claim denial rate of 0.0 percent. The total dollars reviewed was $55,950.37 of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent. 

Denial Reasons and Prevention 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 for the timed services provided are documented clearly in the record

More Information

• 42 (CFR) Codes of Federal Regulations, Sections 410.27 and 424.5
• General Outpatient Billing: CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.4 (PDF, 1.27 MB)
• Drugs & Biologicals: CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Publication 100-04: Chapter 17, Sections 90.2. (PDF, 493.1 KB)
• Outpatient Rehabilitation: CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 5, Sections 20.2 (PDF, 693.68)

5D169/5H169 — Services Not Documented

Reason for Denial
This claim was partially or fully denied because the provider billed for services/items not documented in the medical record submitted.

How to Avoid This Denial

• Submit all documentation related to the services billed
• Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed
• Ensure that the documentation is complete with proper authentication and the signature is legible

More Information

• Code of Federal Regulations, 42 CFR — Sections 410.32 and 424.5
   

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
To avoid future denials for this reason:

• 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/diagnostic test was rendered, and the dates of service billed

More Information

• CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 (PDF, 652.5 KB)
• CMS Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual 
   

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 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 Additional Development Request (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 Additional Development Request (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 Additional Development Request (ADR).
• Gather all of the information needed for the claim and submit it all at one time
• Attach a copy of the Additional Development Request (ADR) request to each individual claim
• If responding to multiple Additional Development Requests (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

More Information

• CMS Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 34 (PDF, 109.36 KB)
• CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.2 (PDF, 652.5 KB)

The Next Steps
The service-specific postpayment medical review edits for HCPCS Code J9035 — Bevacizumab (Avastin) in Alabama, Georgia and Tennessee will be continued based on moderate charge denial rates and/or medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to the Appeals web page. Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.