Postpayment Service-Specific Probe Results for Keytruda (Pembrolizumab) for April through June 2021
Postpayment Service-Specific Probe Results for Keytruda (Pembrolizumab) 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 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 April through June, 2021, are presented here.
Cumulative Results
A total of 91 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined, with 16 of the claims either completely or partially denied, resulting in an overall claim denial rate of 17.58 percent. The total dollars reviewed were $798,202.48, of which $100,550.01 were denied, resulting in a charge denial rate of 12.6 percent. Overall, there were a total of 23 auto-denied claims in the region.
North Carolina Results
A total of 71 claims were reviewed, with 13 of the claims either completely or partially denied. This resulted in a claim denial rate of 18.31 percent. The total dollars reviewed were $670,266.38, of which $88,339.55 were denied, resulting in a charge denial rate of 13.18 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 |
38.46% |
5DMDP/5HMDP |
Dependent Services/Items Denied Because Qualifying Services Denied Medically |
5 |
38.46% |
5DTDP/5HTDP |
Services Technically Denied |
5 |
23.08% |
5D199/5H199 |
Billing Error |
3 |
South Carolina Results
A total of 20 claims were reviewed, with three of the claims either completely or partially denied. This resulted in a claim denial rate of 15.0 percent. The total dollars reviewed were $127,936.10, of which $12,210.46 were denied, resulting in a charge denial rate of 9.54 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 |
2 |
33.33% |
5D199/5H199 |
Billing Error |
1 |
Virginia Results
No claims were reviewed in Virginia.
West Virginia Results
No claims were reviewed in West Virginia
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) rendered
More Information
- 42 (CFR) Code of Federal Regulations, Section 410.32
- CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 6 (PDF, 215.49 KB)
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 the service (s) rendered
- Ensure documentation supports the claim as billed
- Ensure all documentation is properly and legibly signed
More Information
- 42 (CFR) Code of Federal Regulations, Section 410.32
- CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 6 (PDF, 215.49 KB)
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/diagnostic test was rendered, and the dates of service billed
More Information
- CMS Internet-Only Manual (IOM), Pub100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 (PDF, 652.5 KB)
- CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual
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); 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
- CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 34 (PDF, 109.36 KB)
- CMS Internet-Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.3.2 (PDF, 652.5 KB)
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 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.