Postpayment Service-Specific Probe Results for Bevacizumab (Avastin) for January Through March 2021
Postpayment Service-Specific Probe Results for Bevacizumab (Avastin®) in North Carolina, South Carolina, Virginia, and West Virginia for January Through March 2021
Palmetto GBA performed service-specific post payment probe review on HCPCS Code J9035 – Bevacizumab. 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 64 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined. Two claims were either completely or partially denied, resulting in an overall claim denial rate of 3.13 percent. The total dollars reviewed was $266,660.84, of which $11,101.05 was denied, resulting in a charge denial rate of 4.16 percent. Overall, there was a total of 20 auto-denied claims in the region.
North Carolina Results
A total of 19 claims were reviewed, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 5.26 percent. The total dollars reviewed was $62,994.56, of which $2,329.58 was denied, resulting in a charge denial rate of 3.70 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% |
5D164/5H164 |
No Documentation of Medical Necessity |
1 |
South Carolina Results
No claims were reviewed in South Carolina.
Virginia Results
A total of 27 claims were reviewed, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 3.70 percent. The total dollars reviewed was $143,597.73, of which $8,771.47 was denied, resulting in a charge denial rate of 6.11 percent. The top denial reasons was identified, and the number of occurrences based on dollars denied are:
|
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
|
100% |
System Rejection |
System Rejection |
1 |
West Virginia Results
A total of 18 claims were reviewed, with 0 of the claims either completely or partially denied. This results in a claim denial rate of 0 percent. The total dollars reviewed was $60,068.55, of which $0 was denied, resulting in a charge denial rate of 0 percent.
Denial Reasons and Prevention Recommendations
5D164/5H164 — No Documentation of Medical Necessity
Reason for Denial
This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.
How to Avoid This Denial
- Submit all documentation related to the services billed which support the medical necessity of the services
- A legible signature is required on all documentation necessary to support orders and medical necessity
- Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis
More Information
- Code of Federal Regulations, 42 CFR — Section 411.15
- Social Security Act (SSA) — Section 1862(a)(1)(A)
- Palmetto GBA Local Coverage Determination (LCD) and National Coverage Determination (NCD) articles which are available on our website
- CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF, 652.5 KB)
- CMS Medicare Learning Network (MLN) Matters article MM6698 (PDF, 109 KB) — "Signature Guidelines for Medical Review Purposes"
- Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices
The Next Steps
The service-specific targeted medical review edits for HCPCS Code J9035 (Bevacizumab) 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 Leve Appeal form (PDF, 237 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.