JJ Part A and Part B Targeted Probe and Educate Active Medical Review List

Published 09/19/2024

LOB Code Type Specific Code Edit Topic Edit Description

Part A

HCPCS

J9271

Pembrolizumab (Keytruda®)

Review of outpatient claims for Pembrolizumab (Keytruda®)

Part A 

HCPCS

J2505, J2506

HCPCS J2505 — Pegfilgrastim (Neulasta®) 6mg

HCPCS J2506 — Pegfilgrastim (Neulasta®), excludes biosimilar, 0.5mg

Review of outpatient claims for HCPCS J2505; this code was retired as of Jan. 1, 2022

HCPCS J2506 is effective Jan. 1, 2022 for providers to bill

Part A 

HCPCS

J9311, J9312

Rituximab (Rituxan®) 10 mg and Hyaluronidase/ Rituximab, 10 mg

Review of outpatient claims for HCPCS J9311, J9312 — Rituximab (Rituxan®) 10 mg and  Hyaluronidase/ Rituximab, 10 mg

Part A 

HCPCS

J9035

Bevacizumab (Avastin®), 10mg

Review of outpatient claims for Bevacizumab (Avastin®), 10mg

Part A 

HCPCS

J1745

Infliximab (Remicade®)

Review of outpatient claims for Infliximab (Remicade®)

Part A

HCPCS

G0277

Hyperbaric Oxygen (HBO) Therapy

Review of outpatient claims for HBO Therapy
Part A CPT® 27130, 27447 Total Hip Arthroplasty/Total Knee Arthroplasty Review of claims for total hip arthroplasty/total knee arthroplasty

Part A

CPT®

97110

Therapeutic Exercise

Review of outpatient claims for Therapeutic Exercise

Part A 

CPT®

97112

Neuromuscular Reeducation

Review of outpatient claims for rehabilitation Services — Neuromuscular Reeducation

Part A 

CPT®

97140

Manual Therapy

Review of outpatient claims for Manual Therapy
Part A DRG 470 Major Joint Replacement Review of claims submitted for Major Joint Replacement
Part A DRG 291–293 Heart Failure and Shock with or without CC/MCC Review of claims for heart failure and shock with or without CC/MCC
Part A DRG 682–683 Renal Failure Review of claims for renal failure
Part A DRG 870–872 Septicemia or Severe Sepsis Greater than 96 Hours Review of claims for septicemia or severe sepsis greater than 96 hours

Part A 

DRG

885

Psychoses

Review of inpatient claims for Psychoses
Part A DRG 177–179 Respiratory Infections Review of claims submitted for DRG 177–179 Respiratory Infections
Part A CPT® 97110, 97112, 97140 Therapy Cap Review with KX HCPCS Modifier Review of outpatient claims for therapy services billed with a KX HCPCS Modifier
Part A CPT® 97530 Therapeutic Activities Review of outpatient claims for Therapeutic Activities
Part A IRF Combined Inpatient Rehabilitation Services (IRF): CMGs, A0103 – D0103, A0104 – D0104, A0106 – D0106, A0302 – D0302, A0303 – D0303, A0304 – D0304, A0305 – D0305, A0601 – D0601, A0602 – D0602, A0603 – D0603, A0604 – D0604, A0703 – D0703, A0704 – D0704, A0902 – D0902, A0903 – D0903, A0904 – D0904, A1404 – D1404, A2002 – D2002, A2003 – D2003, A2004 – D2004 and A2005 – D2005 Combined Inpatient Rehabilitation Services (IRF) Review of IRF

Part A

HIPPS

ID, IE, JD, KA, KD, KE

Skilled Nursing Facility (SNF)

Review of SNF claims with an emphasis on codes in the following HIPPS categories: ID, IE, JD, KA, KD, KE

Part A

CPT®

90999

End Stage Renal Disease (ESRD) — Renal Dialysis

Review of claims submitted for outpatient CPT® 90999 — ESRD

Part A

HCPCS

G0491

ESRD — Renal Dialysis (Acute Kidney Injury)

Review of claims submitted for acute kidney injury without ESRD — Renal Dialysis
Part A HCPCS J9299 Opdivo Review of outpatient claims for Opdivo
Part A HCPCS J1459 Privigen Review of outpatient Claims for Privige
Part A HCPCS J9041 Bortezomib Review of outpatient Claims for Bortezomib (Velcade)
Part A HCPCS J2350 Ocrelizumab Review of outpatient Claims for Ocrelizumab (Ocrevus)
Part A  HCPCS J9144, J9145 Daratumumab Review of outpatient Claims for HCPCS J9144/J9145 Daratumumab (Darzalex Faspro)
Part A SNF Probe and Educate SNF SNF SNF 5-Claim Probe and Educate Project

Part B

CPT®

66984

Extracapsular Cataract Removal with Insertion

Review of outpatient claims for Extracapsular Cataract Removal with Insertion

Part B

CPT®

97110

Therapeutic Exercise

Review of outpatient claims for Therapeutic Exercise
Part B CPT® 99213–99215 Established Patient Office Visit Review of claims for established patient office visit

Part B

HCPCS

J2778

Ranibizumab (Lucentis®)

Review of outpatient claims for Ranibizumab (Lucentis®)

Part B

HCPCS

J1745

Infliximab (Remicade®)

Review of outpatient claims for Infliximab (Remicade®)

Part B 

HCPCS

J0178

Aflibercept (Eylea®) 

Review of outpatient claims for Aflibercept (Eylea®) 

Part B 

HCPCS

J9311, J9312

Rituximab (Rituxan®)

Review of outpatient claims for HCPCS J9311 and J9312 — Rituximab (Rituxan®)

Part B 

CPT®

11042–11047

Surgical Debridement 

Review of outpatient claims for Surgical Services: CPT® 11042–11047 — Surgical Debridement 

Part B

CPT®

90960–90967

ESRD — Monthly Outpatient ESRD-Related Services

Review of outpatient ESRD claims with CPT® 90960–90967

Part B 

HCPCS

A0427, A0429, A0425

Ambulance Services (Emergent):

 A0429 — Basic Life Support, Emergency

A0427 — Advanced Life Support, Emergency

A0425 — Ground Mileage

Review of Ambulance claims for Ambulance Services (Emergent): HCPCS Codes A0429 — Basic Life Support, Emergency, A0427 — Advanced Life Support, Emergency, A0425 — Ground Mileage

Part B 

CPT®

93306

Echocardiography with Contrast

Review of outpatient claims for Echocardiography with Contrast

Part B

CPT® / HCPCS 

80305–80307, G0480–G0483

CPT® 80305–80307/HCPCS G0480–G0483 — Diagnostic Services: Clinical Labs

Review of outpatient claims for Drugs of Abuse Laboratory Tests: CPT® 80305–80307/HCPCS G0480–G0483

Part B

CPT®

82542

Column Chromatography, Mass Spectrometry

Review of outpatient claims for Drugs of Abuse Laboratory Tests: Column Chromatography, Mass Spectrometry

Part B

CPT®

80061

Diagnostic Services: Laboratory Tests — Lipid Panel

Review of outpatient claims for Drugs of Abuse Laboratory Tests: Lipid Panel

Part B

CPT®

80061, 83721

Diagnostic Services: Laboratory Tests

CPT® 80061 — Lipid Panel
CPT® 83721 — Assay of Blood Lipoprotein)

Review of outpatient claims for Drugs of Abuse Laboratory Tests: CPT® 80061 (Lipid Panel), CPT® 83721 (Assay of Blood Lipoprotein)
Part B CPT® 97112 Neuromuscular Reeducation Review of outpatient claims for rehabilitation Services — Neuromuscular Reeducation
Part B CPT® 97530 Therapeutic Activities Review of outpatient claims for Therapeutic Activities
Part B CPT® 97140 Manual Therapy Review of outpatient claims for rehabilitation services — Manual Therapy
Part B CPT® 99232–99233 Hospital Subsequent Visit Review of claims for hospital subsequent visit
Part B CPT® 97110, 97112, 97140, 97530, 92526, 97129, 97130, 92507 Therapy Cap Review with KX Modifier Review of outpatient claims for therapy services billed with a KX Modifier

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