Postpayment Service-Specific Probe Results: Pegfilgrastim (Neulasta) for January Through March 2021
Palmetto GBA performed service-specific post payment probe review on HCPCS Code J2505 – Pegfilgrastim (Neulasta®). This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed January through March 2021, are presented here.
Cumulative Results
A total of 62 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined, with one of the claims either completely or partially denied, resulting in an overall claim denial rate of 1.61 percent. The total dollars reviewed was $359,862.69, of which $16.53 was denied, resulting in a charge denial rate of 0.01 percent. Overall, there were no auto-denied claims in the region.
North Carolina Results
A total of 33 claims were reviewed, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 3.03 percent. The total dollars reviewed was $208,968.21, of which $16.53 was denied, resulting in a charge denial rate of 0.01 percent. The top denial reason was identified, and the number of occurrences based on dollars denied are:
|
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
|---|---|---|---|
|
100% |
5D199/5H199 |
Billing Error |
1 |
South Carolina Results
A total of 25 claims were reviewed, with none of the claims completely or partially denied. This resulted in a claim denial rate of 0.0 percent. The total dollars reviewed was $111,991.48, of which $0 was denied, resulting in a charge denial rate of 0.0 percent.
Virginia Results
A total of four claims were reviewed, with none of the claims either completely or partially denied. This resulted in a claim denial rate of 0 percent. The total dollars reviewed was $38,903.00, of which $0 was denied, resulting in a charge denial rate of 0.0 percent.
West Virginia Results
No claims were reviewed this period.
Denial Reasons and Prevention Recommendations
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
- 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), 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF)
- CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual
The Next Steps
The service-specific post payment medical review edits for HCPCS Code J2505 Pegfilgrastim (Neulasta) in North Carolina, South Carolina, Virginia and West Virginia will be continued based on moderate charge denial rates and 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 Redetermination 1st Level Appeal form (PDF, 237 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.