JM Parts A, B and Home Health and Hospice Targeted Probe and Educate Active Medical Review List

Published 09/19/2024

LOB Code Type Specific Code Edit Topic Edit Description
Home Health Bene Sharing All Home Health Services for Eligibility and Medical Necessity Bene Sharing Review of claims submitted for home health services for eligibility and medical necessity bene sharing

Home Health

HIPPS

 All

Home Health Services for Eligibility and Medical Necessity

Review of claims submitted for home health services for eligibility and medical necessity
Hospice Bene Sharing All Hospice Services Bene Sharing Review of claims submitted for hospice services for eligibility and medical necessity bene sharing
Hospice Rev Code

General Inpatient Care (GIP)

GIP

Review of inpatient claims for inpatient hospice care greater than or equal to 7 days for revenue code 656 and place of service codes Q5004–Q5009
Hospice Rev Code New Hospice Providers New Hospice Providers Review of new hospice provider claims
Hospice Rev Code 0651, 0652, 0655, 0656 Hospice Length of Stay (LOS) Greater than 365 Days  Review of claims submitted for hospice LOS greater than 365 days
Hospice Rev Code Routine Home Care (RHC) — Rev Code 651 RHC — Rev Code 651 Review of hospice RHC — Rev Code 651
Hospice Rev Code 0652 Hospice Services Continuous Home Care Review of claims submitted for hospice services continuous home care
Hospice  Diagnosis Codes Non-Cancer Length of Stay (NCLOS) NCLOS Review of hospice claims for NCLOS
Hospice High Risk Hospice   High Risk Hospices in Texas Review of claims for high risk hospcies in Texas
Hospice  Provisional Period of Enhanced Oversight for New Hospice Providers for Texas   PPEO Hospices Provisional period of enhanced oversight for new hospice providers for Texas

Part A

HCPCS

J9271

Pembrolizumab (Keytruda®)

Review of outpatient claims for Pembrolizumab (Keytruda®)

Part A 

HCPCS

J2505, J2506

J2505 — Pegfilgrastim (Neulasta®), 6mg

J2506 — Pegfilgrastim (Neulasta®), excludes biosimilar, 0.5mg

Review of outpatient claims for J2505; this code was retired as of Jan. 1, 2022.

J2506 is effective Jan. 1, 2022 for providers to bill.

Part A 

HCPCS

J9311, J9312

HCPCS J9311, J9312 — Rituximab (Rituxan®) 10 mg and Hyaluronidase/Rituximab, 10 mg

Review of outpatient claims for Rituximab (Rituxan®) 10 mg and Hyaluronidase/Rituximab, 10 mg

Part A 

HCPCS

J9035

Bevacizumab (Avastin®) 10mg

Review of outpatient claims for Bevacizumab (Avastin®) 10mg

Part A 

HCPCS

J1745

Infliximab (Remicade®)

Review of outpatient claims for Infliximab (Remicade®)
Part A HIPPS ID, IE, JD, KA, KD, KE Skilled Nursing Facility (SNF) Review of SNF claims with an emphasis on codes in the following HIPPS categories: ID, IE, JD, KA, KD, KE

Part A

HCPCS

G0277

Hyperbaric Oxygen (HBO) Therapy

Review of inpatient claims for HBO Therapy
Part A DRG 682, 683 Renal Failure Review of claims for renal failure
Part A CPT®  23472 Total Shoulder Arthroscopy (TSA) Review of outpatient claims for TSA
Part A CPT® 27130, 27447 Total Hip Arthroplasty/Total Knee Arthroplasty Review of claims for total hip arthroplasty/total knee arthroplasty
Part A CPT® 97110 Therapeutic Exercise Review of outpatient claims for Therapeutic Exercise

Part A 

CPT®

97112

Neuromuscular Reeducation

Review of outpatient claims for rehabilitation services: Neuromuscular Reeducation

Part A 

CPT®

97140

Manual Therapy

Review of outpatient claims for Manual Therapy
Part A CPT® 97110, 97112, 97140 Therapy Cap Review with KX HCPCS Modifier Review of outpatient claims for Therapy Services billed with a KX HCPCS modifier
Part A DRG 177–179 Respiratory Infections and Inflammations with MCC and Without CC or MCC Review of claims for respiratory infections and inflammations with MCC and without CC or MCC
Part A DRG 291–293 Heart Failure and shock with or without CC/MCC Review of claims for heart failure and shock with or without CC/MCC
Part A DRG 470 Major Joint Replacement Joint replacement, review of claims submitted for Major Joint Replacement
Part A DRG 870–872 Septicemia or Severe Sepsis Greater than 96 Hours Review of claims for septicemia or severe sepsis greater than 96 hours

Part A 

DRG

885

Psychoses

Review of inpatient claims for Psychoses
Part A IRF Combined Inpatient Rehabilitation Services (IRF): CMGs
A0103 – D0103, A0104 –D0104, A0106 – D0106, A0302 – D0302, A0303 – D0303, A0304 – D0304, A0305 –D0305, A0601 –D0601, A0602 –D0602, A0603 – D0603, A0604 – D0604, A0703 – D0703, A0704 – D0704, A0902 – D0902, A0903 – D0903, A0904 – D0904, A1404 – D1404, A2002 – D2002, A2003 – D2003, A2004 – D2004, A2005 – D2005		 Combined Inpatient Rehabilitation Services (IRF)

Review of IRF

Part A 

CPT®

77301

Intensity Modulated Radiotherapy (IMRT) Planning

Review of outpatient claims for diagnostic imaging: IMRT Planning

Part A  

CPT®

77338

MLC Device(s) for IMRT

Review of outpatient claims for diagnostic imaging: MLC Device(s) for IMRT
Part A CPT® 97530 Therapeutic Activities Review of outpatient claims for Therapeutic Activities
Part A HCPCS J9144 Darzalex® (Daratumumab) Review of outpatient claims for Daratumumab
Part A HCPCS J9299 Nivolumab Review of outpatient claims for Nivolumab
Part A HCPCS J2350 Ocrelizumab Review of outpatient claims for Ocrelizumab
Part A HCPCS J1459 HCPCS J1459 — Privigen Review of outpatient claims for Privigen
Part A HCPCS J9041 Bortezomib Review of outpatient claims for Bortezomib
Part A SNF Probe and Educate SNF SNF SNF 5-Claim Probe and Educate Project

Part B

CPT®

66984

Extracapsular Cataract Removal with Insertion

Review of outpatient claims for Extracapsular Cataract Removal with Insertion

Part B

CPT®

97110

Therapeutic Exercise

Review of outpatient claims for Therapeutic Exercise
Part B CPT® 99213–99215 Established Patient Office Visit Review of claims for established patient office visit
Part B CPT® 97110, 97112, 97140, 97530, 92526, 97129, 97130, 92507 Therapy Cap Review with KX Modifier Review of outpatient claims for Therapy Services billed with a KX Modifier
Part B CPT® 99232–99233 Hospital Subsequent Visit Review of claims for hospital subsequent visit

Part B

HCPCS

J2778

Ranibizumab (Lucentis®)

Review of outpatient claims for Ranibizumab (Lucentis®)

Part B

HCPCS

J1745

Infliximab (Remicade®)

Review of outpatient claims for Infliximab (Remicade®)

Part B 

HCPCS

J0178

Aflibercept (Eylea®) 

Review of outpatient claims for Aflibercept (Eylea®) 

Part B 

HCPCS

J9311, J9312

HCPCS J9311, J9312 — Rituximab (Rituxan®)

Review of outpatient claims for Rituximab (Rituxan®)

Part B 

CPT®

11042–11047

Surgical Debridement 

Review of outpatient claims for surgical services, surgical debridement 

Part B

CPT®

90960–90967

ESRD —Monthly Outpatient ESRD —Related Services

Review of outpatient ESRD claims with CPT® 90960–90967

Part B 

HCPCS

A0427, A0429, A0425

Ambulance Service, Advanced Life Support, Emergency Transport/Ambulance Service, Basic Life Support, Emergency Transport/Ground Mileage

Review of Ambulance claims for Ambulance Service, Advanced Life Support, Emergency Transport/Ambulance Service, Basic Life Support, Emergency Transport/Ground Mileage

Part B 

CPT®

93306

Echocardiography with Contrast

Review of outpatient claims for  Echocardiography with Contrast

Part B

HCPCS

80305 – 80307, G0480 – G0483

HCPCS 80305–80307, G0480–G0483 — Diagnostic Services: Clinical Labs

Review of outpatient claims for Drugs of Abuse Laboratory Tests: HCPCS 80305–80307, G0480–G0483
Part B CPT® 82542 Column Chromatography/Mass Spectrometry Review of outpatient claims for Drugs of Abuse Laboratory Tests: Column Chromatography/Mass Spectrometry

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