Postpayment Service-Specific Probe Results for Prolia (Denosumab) for April through June 2021

Published 08/24/2021

Postpayment Service-Specific Probe Results for Prolia (Denosumab) in North Carolina, South Carolina, Virginia and West Virginia for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code J0897 — Prolia (Denosumab). This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed April through June, 2021, are presented here.

Cumulative Results
A total of 770 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined, with 177 of the claims either completely or partially denied, resulting in an overall claim denial rate of 22.99 percent. The total dollars reviewed were $665,832.56, of which $96,652.82 were denied, resulting in a charge denial rate of 14.52 percent. Overall, there were a total of 183 auto-denied claims in the region.

North Carolina Results
A total of 383 claims were reviewed, with 129 of the claims either completely or partially denied. This resulted in a claim denial rate of 33.68 percent. The total dollars reviewed were $328,333.12, of which $59,844.89 were denied, resulting in a charge denial rate of 18.23 percent. The top denial reasons were identified and the number of occurrences based on dollars denied were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

48.06%

5D199/5H199

Billing Error

62

43.41%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

56

3.10%

5D164/5H164

No Documentation of Medical Necessity

4

3.10%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

4

2.33%

5DTDP/5HTDP

Services Technically Denied

3

South Carolina Results
A total of 121 claims were reviewed, with 20 of the claims either completely or partially denied. This resulted in a claim denial rate of 16.53 percent. The total dollars reviewed were $102,812.99, of which $16,652.95 were denied, resulting in a charge denial rate of 16.20 percent. The top denial reasons were identified and the number of occurrences based on dollars denied were: 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

85.00%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

17

10.00%

5DTDP/5HTDP

Services Technically Denied

2

5.00%

5D199/5H199

Billing Error

1

Virginia Results
A total of 189 claims were reviewed, with 11 of the claims either completely or partially denied. This resulted in a claim denial rate of 5.82 percent. The total dollars reviewed were $172,141.47, of which $9,421.44 were denied, resulting in a charge denial rate of 5.47 percent. The top denial reasons were identified and the number of occurrences based on dollars denied were: 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

63.64%

5D164/5H164

No Documentation of Medical Necessity

7

27.27%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

3

9.09%

5D199/5H199

Billing Error

1

West Virginia Results
A total of 77 claims were reviewed, with 17 of the claims either completely or partially denied. This resulted in a claim denial rate of 22.08 percent. The total dollars reviewed were $62,544.98, of which $10,733.54 were denied, resulting in a charge denial rate of 17.16 percent. The top denial reasons were identified and the number of occurrences based on dollars denied were: 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

35.29%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

6

35.29%

5D164/5H164

No Documentation of Medical Necessity

6

23.53%

5D199/5H199

Billing Error

4

5.88%

5D920/5H920

The Recommended Protocol was not Ordered and/or Followed

1

Denial Reasons and Prevention Recommendations

5DMDP/5HMDP — Dependent Services Denied (Qualifying Service Denied Medically)

Reason for Denial
The dependent services will not be covered if the qualifying service has been denied. For example, the service was denied as documentation did not support medical necessity, therefore all other charges associated with the service under review cannot be allowed and will be denied as dependent to the medical denial of the qualifying service.

How to Avoid This Denial

  • Ensure the documentation provided supports the services were reasonable and medically necessary for the treatment of the beneficiary
  • Ensure all records are properly and legibly signed
  • Ensure documentation supports the service(s) was rendered

More Information

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 was rendered, and the dates of service billed

More Information

 

5D164/5H164 — No Documentation of Medical Necessity

Reason for Denial

This claim was denied because the documentation submitted does not support the medical necessity of the service reviewed. The records did not contain any covered condition/indication, symptomology or diagnostic results that would support the service was reasonable and necessary for the treatment of the beneficiary.

How to Avoid This Denial

  • Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:
    • A covered indication or condition for the service billed
    • A physician/NPP is managing the care of the covered indication or condition
    • Any medical history that supports a need for the service
    • Any diagnostic results or symptomology that supports a need for the services
  • A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support medical necessity
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

More Information

5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed

Reason for Denial
Medicare cannot pay for this service because one or more requirements for coverage were not met.

How to Avoid This Denial
Documentation that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • Clear physician’s order with indication of need, dose, frequency and route
  • Date and time of associated chemotherapy, as applicable
  • Relevant medical history documented prior to the DOS and signed by the physician or appropriate nonphysician provider to include:
    • Clear indication of the diagnosis
    • Clinical signs and symptoms
    • Prior treatment and response as applicable
    • Stage of treatment as applicable
  • Clear and complete documentation of administration signed by the person providing the service
  • Ensure the service was provided per the coverage guidelines for the service
  • Documentation of administration

More Information

5DTDP/5HTDP — Dependent Services Denied (Qualifying Service Denied Technically)

Reason for Denial
The dependent services will not be covered if the qualifying service has been denied. For example, the service procedure was not documented, therefore all other charges cannot be allowed.

How to Avoid This Denial

  • Ensure all documentation is submitted to support service was rendered
  • Ensure documentation supports the claim as billed
  • Ensure all documentation is properly and legibly signed

More Information

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 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

The Next Steps
The service-specific postpayment medical review edits for HCPCS Code J0897— Prolia (Denosumab) — 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.