Postpayment Service-Specific Probe Results for Keytruda (Pembrolizumab) for July through September 2021


Postpayment Service-Specific Probe Results for HCPCS Code J9271— Keytruda® (Pembrolizumab) — in North Carolina, South Carolina, Virginia and West Virginia for July through September 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code J9271 — Keytruda® (Pembrolizumab). This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed July through September, 2021, are presented here.

Cumulative Results 
A total of 288 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined, with 25 of the claims either completely or partially denied, resulting in an overall claim denial rate of 8.68 percent. The total dollars reviewed were $2,601,140.28, of which $188,844.69 were denied, resulting in a charge denial rate of 7.26 percent. Overall, there were a total of 16 auto-denied claims in the region. 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

72.0%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

18

20.0%

5DTDP/5HTDP

Services Technically Denied

5

8.0%

5D164/5H164

No Documentation of Medical Necessity

2

North Carolina Results
A total of 175 claims were reviewed, with 18 of the claims either completely or partially denied. This resulted in a claim denial rate of 10.29 percent. The total dollars reviewed were $1,534,183.74, of which $135,663.80 were denied, resulting in a charge denial rate of 8.84 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

66.67%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

12

22.22%

5DTDP/5HTDP

Services Technically Denied

4

11.11%

5D164/5H164

No Documentation of Medical Necessity

2

South Carolina Results
A total of 39 claims were reviewed, with four of the claims either completely or partially denied. This resulted in a claim denial rate of 10.26 percent. The total dollars reviewed were $423,544.96, of which $27,438.07 were denied, resulting in a charge denial rate of 6.48 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

75.0%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

3

25.0%

5DTDP/5HTDP

Services Technically Denied

1

Virginia Results
No claims were reviewed in Virginia.

West Virginia Results
A total of 74 claims were reviewed, with three of the claims either completely or partially denied. This resulted in a claim denial rate of 4.05 percent. The total dollars reviewed were $643,411.58, of which $25,742.82 were denied, resulting in a charge denial rate of 4.00 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

100%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

3

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

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

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. 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 service
  •  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

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 J9271 — Keytruda® (Pembrolizumab) — in North Carolina, South Carolina, Virginia and West Virginia has been discontinued based on the resumption of Targeted Probe and Educate (TPE).

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 JM Redetermination: 1st Level Appeal form (PDF, 318 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.





Last Updated: 10/26/2021