Postpayment Service-Specific Probe Results for Drugs and Biological Services: Ranibizumab (Lucentis) for January through March 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code J2778 — Ranibizumab (Lucentis). 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 430 claims were reviewed, with 30 of the claims either completely or partially denied, resulting in an overall claim denial rate of 6.98 percent. The total dollars reviewed was $764,772.12 of which $55,618.70 was denied, resulting in a charge denial rate of 7.27 percent. Overall, there were a total of 65 auto denied claims in the region. 

North Carolina Results
A total of 285 claims were reviewed, with 14 of the claims either completely or partially denied. This resulted in a claim denial rate of 4.91 percent. The total dollars reviewed was $491,529.82, of which $21,035.60 was denied, resulting in a charge denial rate of 4.28 percent. The top denial reason identified, and number of occurrences based on dollars denied are:  

South Carolina Results
A total of 34 claims were reviewed, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 2.94 percent. The total dollars reviewed was $62,317.45 of which $1,819.89 was denied, resulting in a charge denial rate of 2.92 percent. The top denial reason identified and number of occurrences based on dollars denied are:

Virginia Results
A total of 71 claims were reviewed, with 15 of the claims either completely or partially denied. This resulted in a claim denial rate of 21.13 percent. The total dollars reviewed was $141,233.07, of which $32,763.21 was denied, resulting in a charge denial rate of 23.20 percent. The top denial reason identified and number of occurrences based on dollars denied are:  

West Virginia Results
A total of 40 claims were reviewed, with none (0) of the claims either completely or partially denied. This resulted in a claim denial rate of 0.0 percent. The total dollars reviewed was $69,691.78 of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent. There were no denial reasons identified.  

Denial Reasons and Prevention Recommendations

BILER — Claim Billed in Error per Provider

• Prior to billing claims, review the information to determine that the correct information is listed in the appropriate fields
• For all claims previously billed and denied by medical review, do not re-submit the claims. If you disagree with the decision from medical review, you must submit the appropriate documentation with a completed redetermination request form to the appeals department. This information can be sent by fax to JM Part B Appeals (803) 699–2427, JJ Part B Appeals (803) 870–0139, or RRB Appeals (803) 462–2218.
• If documentation indicates that both an NPP and a physician performed the service, and the claim is billed under the physician’s NPI, the billing physician must sign the record. Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantive portion of the E/M visit. (A substantive portion of the E/M visit includes at least one of the three key components: history, exam, or medical decision-making.)
• If documentation occurs in a teaching environment, review the documentation to ensure that the billing provider has provided a teaching attestation and a signature

NOTMN — Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

• Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological, or laboratory results.
• Verify that documentation to support the level of service billed is included. Please refer to the Medical Policies section of the Palmetto GBA website.

The Next Steps
The service-specific targeted medical review edits for Drugs and Biological Services: HCPCS Code J2778 — Ranibizumab (Lucentis) — 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 Redeterminaton: 1st Level Appeal Form (PDF, 386 KB).  

Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.