JJ Part A and Part B Targeted Probe and Educate Active Medical Review List
LOB |
Code Type |
Specific Code |
Edit Topic |
Edit Description |
---|---|---|---|---|
Part A |
HCPCS |
J9271 |
HCPCS J9271 — Pembrolizumab (Keytruda®) |
Review of outpatient claims for HCPCS J9271 — 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 1/1/22. HCPCS J2506 is effective 1/1/22 for providers to bill |
Part A |
HCPCS |
J9311, J9312 |
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 |
HCPCS J9035 — Bevacizumab (Avastin®), 10mg |
Review of outpatient claims for HCPCS J9035 — Bevacizumab (Avastin®), 10mg |
Part A |
HCPCS |
J0897 |
HCPCS J0897 — Denosumab (Prolia®) |
Review of outpatient Claims for HCPCS J0897 — Denosumab (Prolia®) |
Part A |
HCPCS |
J1745 |
HCPCS J1745 — Infliximab (Remicade®) |
Review of outpatient claims for HCPCS J1745 — Infliximab (Remicade®) |
Part A |
HCPCS |
G0277 |
HCPCS G0277 — Hyperbaric Oxygen Therapy (HBO) |
Review of inpatient claims for HCPCS G0277 — Hyperbaric Oxygen Therapy (HBO) |
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 |
CPT 97110 — Therapeutic Exercise |
Review of outpatient claims for CPT 97110 — Therapeutic Exercise |
Part A |
CPT® |
97112 |
CPT 97112 — Neuromuscular Reeducation |
Review of Outpatient claims for Rehabilitation Services: CPT 97112 — Neuromuscular Reeducation |
Part A |
CPT® |
97140 |
CPT 97140 — Manual Therapy |
Review of outpatient claims for CPT 97140 — Manual Therapy |
Part A | DRG | 470 | DRG 470 — Major Joint Replacement | Review of claims submitted for DRG 470 — 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 |
DRG 885 — Psychoses |
Review of inpatient claims for DRG 885 — Psychoses |
Part A |
IRF |
A0604 – D0604 |
Inpatient Rehabilitation Services (IRF): 0604 — Neurological M<25.85 |
Review of Inpatient Rehabilitation Services (IRF): 0604 — Neurological M<25.85 |
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 |
IRF |
A0106 – D0106 |
Inpatient Rehabilitation Services (IRF): Stroke M<41.50 & A<84.50 |
Review of Inpatient Rehabilitation Services (IRF): Stroke M<41.50 & A<84.50 |
Part A |
HIPPS |
ID, IE, JD, KA, KD, KE |
Skilled Nursing Facility (SNF) |
Review of Skilled Nursing Facility (SNF) Claims with an emphasis on codes in the following HIPPS categories: ID, IE, JD, KA, KD, KE |
Part A |
CPT® |
90999 |
CPT 90999 — End Stage Renal Disease (ESRD) — Renal Dialysis |
Review of claims submitted for outpatient CPT — 90999 — End Stage Renal Disease (ESRD) |
Part A |
HCPCS |
G0491 |
HCPCS G0491 — End Stage Renal Disease (ESRD) — Renal Dialysis (Acute Kidney Injury) |
Review of Claims submitted for Acute Kidney Injury without End Stage Renal Disease (ESRD) — Renal Dialysis |
Part B |
CPT® |
66984 |
CPT 66984 — Extracapsular Cataract Removal with Insertion |
Review of outpatient claims for CPT 66984 — Extracapsular Cataract Removal with Insertion |
Part B |
CPT® |
97110 |
CPT 97110 — Therapeutic Exercise |
Review of outpatient claims for CPT 97110 — Therapeutic Exercise |
Part B | CPT® | 99211-99215 | Established Patient Office Visit | Review of claims for established patient office visit |
Part B |
HCPCS |
J0897 |
HCPCS J0897 — Denosumab (Prolia®) |
Review of outpatient claims for HCPCS J0897 — Denosumab (Prolia®) |
Part B |
HCPCS |
J2778 |
HCPCS J2778 — Ranibizumab (Lucentis®) |
Review of outpatient claims for HCPCS J2778 — Ranibizumab (Lucentis®) |
Part B |
HCPCS |
J1745 |
Infliximab (Remicade®) |
Review of outpatient claims for Infliximab (Remicade®) |
Part B |
HCPCS |
J0178 |
HCPCS J0178 — Aflibercept (Eylea®) |
Review of outpatient claims for HCPCS J0178 — Aflibercept (Eylea®) |
Part B |
HCPCS |
J9311, J9312 |
HCPCS J9311 & J9312 — Rituximab (Rituxan®) |
Review of outpatient claims for HCPCS J9311 and J9312 — Rituximab (Rituxan®) |
Part B |
HCPCS |
J0717 |
HCPCS J0717 — Certolizumab (Cimzia®) |
Review of outpatient claims for HCPCS J0717 — Certolizumab (Cimzia®) |
Part B |
HCPCS |
J0129 |
HCPCS J0129 — Abatacept (Orencia®) |
Review of outpatient claims for HCPCS J0129 — Abatacept (Orencia®) |
Part B |
CPT® |
11042–11047 |
CPT 11042–11047 — Surgical Debridement |
Review of outpatient claims for Surgical Services: CPT 11042–11047 — Surgical Debridement |
Part B |
CPT® |
90960–90967 |
CPT 90960–90967 — ESRD — Monthly Outpatient ESRD-Related Services |
Review of outpatient ESRD claims with CPTs — 90960–90967 |
Part B |
HCPCS |
A0427, A0429, A0425 |
Ambulance Services (Emergent): HCPCS Codes 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 | HCPCS | Q4174 | Q4174 — Palingen | Review of Q4174 — Palingen |
Part B | HCPCS | Q4177 | Q4177 — Floweramnioflo | Review of Q4177 — Floweramnioflo |
Part B |
CPT® |
93306 |
CPT 93306 — Echocardiography with Contrast |
Review of outpatient claims for CPT 93306 — 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 |
CPT 82542 — Column Chromatography/Mass Spectrometry |
Review of Outpatient claims for Drugs of Abuse Laboratory Tests: CPT 82542 — Column Chromatography/Mass Spectrometry |
Part B |
CPT® |
80061 |
Diagnostic Services: Laboratory Tests CPT 80061 — (Lipid Panel) |
Review of Outpatient claims for Drugs of Abuse Laboratory Tests: CPT 80061 (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 | CPT 97112 — Neuromuscular Reeducation | Review of Outpatient claims for Rehabilitation Services: CPT 97112 — Neuromuscular Reeducation |
Part B | CPT® | 97530 | CPT 97530 — Therapeutic Activities | Review of outpatient claims for CPT 97530 — Therapeutic Activities |
Part B | CPT® | 97140 | CPT 97140 — Manual Therapy | Review of Outpatient claims for Rehabilitation Services: CPT 97140 — Manual Therapy |