JM Parts A, B and Home Health and Hospice Targeted Probe and Educate Active Medical Review List
LOB |
Code Type |
Specific Code |
Edit Topic |
Edit Description |
---|---|---|---|---|
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 |
Rev Code |
General Inpatient Care (GIP) |
General Inpatient Care (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 | Diagnosis Codes | Non-Cancer Length of Stay (NCLOS) | Non-Cancer Length of Stay (NCLOS) | Review of hospice claims for Non-Cancer Length of Stay (NCLOS) |
Hospice | Revenue Code | Routine Home Care (RHC-Rev Code 651) | Routine Home Care (RHC-Rev Code 651) | Review of Hospice Routine Home Care (RHC-Rev Code 651) |
Part A |
HCPCS |
J9271 |
HCPCS J9271 — Pembrolizumab (Keytruda®) |
Review of outpatient claims for HCPCS J9271 — Pembrolizumab (Keytruda®) |
Part A |
HCPCS |
J2505/J2506 |
HCPCS J2505 — Pegfilgrastim (Neulasta®), 6mg/ HCPCS J2506 — Pegfilgrastim (Neulasta®), excludes biosimilar, 0.5mg |
Review of outpatient claims for HCPCS J2505; this code was retired as of 1/1/22. HCPCS J2506 is effective 1/1/22 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 HCPCS J9311 & J9312 — Rituximab (Rituxan®) 10 mg and Hyaluronidase/Rituximab, 10 mg |
Part A |
HCPCS |
J9035 |
HCPCS J9035 — Bevacizumab (Avastin®), 10mg |
Review of outpatient claims for HCPCS J9035 — Bevacizumab (Avastin®), 10mg |
Part A |
HCPCS |
J0897 |
HCPCS J0897 — Denosumab (Prolia®) |
Review of outpatient claims for HCPCS J0897 — Denosumab (Prolia®) |
Part A |
HCPCS |
J1745 |
HCPCS J1745 — Infliximab (Remicade®) |
Review of outpatient claims for HCPCS J1745 — Infliximab (Remicade®) |
Part A | HIPPS | ID, IE, JD, KA, KD, KE | Skilled Nursing Facility (SNF) | Review of Skilled Nursing Facility (SNF) Claims with an emphasis on codes in the following HIPPS categories: ID, IE, JD, KA, KD, KE |
Part A | IRF | A0106 – D0106 | Inpatient Rehabilitation Services (IRF): Stroke M<41.50 & A<84.50 | Review of Inpatient Rehabilitation Services (IRF): Stroke M<41.50 & A<84.50 |
Part A |
HCPCS |
G0277 |
HCPCS G0277 — Hyperbaric Oxygen Therapy (HBO) |
Review of inpatient claims for HCPCS G0277 — Hyperbaric Oxygen Therapy (HBO) |
Part A |
CPT® |
97110 |
CPT® 97110 — Therapeutic Exercise |
Review of outpatient claims for CPT® 97110 — Therapeutic Exercise |
Part A |
CPT® |
97112 |
CPT® 97112 — Neuromuscular Reeducation |
Review of outpatient claims for Rehabilitation Services: CPT® 97112 — Neuromuscular Reeducation |
Part A |
CPT® |
97140 |
CPT® 97140 — Manual Therapy |
Review of outpatient claims for CPT® 97140 — Manual Therapy |
Part A | DRG | 470 | DRG 470 — Major Joint Replacement | Joint Replacement, Review of claims submitted for DRG 470 — Major Joint Replacement |
Part A |
DRG |
885 |
DRG 885 — Psychoses |
Review of inpatient claims for DRG 885 — Psychoses |
Part A |
IRF |
A0604–D0604 |
Inpatient Rehabilitation Services (IRF): 0604 — Neurological M<25.85 |
Review of Inpatient Rehabilitation Services (IRF): 0604 — Neurological M<25.85 |
Part A |
IRF |
A2004–D2004 |
Inpatient Rehabilitation Services (IRF): Misc |
Review of Inpatient Rehabilitation Services (IRF): misc. codes |
Part A |
CPT® |
77301 |
CPT® 77301 — Intensity Modulated Radiotherapy (IMRT) Planning |
Review of outpatient claims for diagnostic imaging: CPT® Codes 77301 — Intensity Modulated Radiotherapy (IMRT) Planning |
Part A |
CPT® |
77338 |
CPT® 77338 — MLC Device(s) for IMRT |
Review of outpatient claims for diagnostic imaging: CPT® Code 77338 — MLC Device(s) for IMRT |
Part B |
CPT® |
66984 |
CPT® 66984 — Extracapsular Cataract Removal with Insertion |
Review of outpatient claims for CPT® 66984 — Extracapsular Cataract Removal with Insertion |
Part B |
CPT® |
97110 |
CPT® 97110 — Therapeutic Exercise |
Review of outpatient claims for CPT® 97110 — Therapeutic Exercise |
Part B |
HCPCS |
J0897 |
HCPCS J0897 — Denosumab (Prolia®) |
Review of outpatient claims for HCPCS J0897 — Denosumab (Prolia®) |
Part B |
HCPCS |
J2778 |
HCPCS J2778 — Ranibizumab (Lucentis®) |
Review of outpatient claims for HCPCS J2778 — Ranibizumab (Lucentis®) |
Part B |
HCPCS |
J1745 |
HCPCS J1745 — Infliximab (Remicade®) |
Review of outpatient claims for HCPCS J1745 — Infliximab (Remicade®) |
Part B |
HCPCS |
J0178 |
HCPCS J0178 — Aflibercept (Eylea®) |
Review of outpatient claims for HCPCS J0178 — Aflibercept (Eylea®) |
Part B |
HCPCS |
J9311/J9312 |
HCPCS J9311 & J9312 — Rituximab (Rituxan®) |
Review of outpatient claims for HCPCS J9311 and J9312 — Rituximab (Rituxan®) |
Part B |
HCPCS |
J0717 |
HCPCS J0717 — Certolizumab (Cimzia®) |
Review of outpatient claims for HCPCS J0717 — Certolizumab (Cimzia®) |
Part B |
HCPCS |
J0129 |
HCPCS J0129 — Abatacept (Orencia®) |
Review of outpatient claims for HCPCS J0129 — Abatacept (Orencia®) |
Part B |
CPT® |
11042–11047 |
CPT® 1104–11047 — Surgical Debridement |
Review of outpatient claims for surgical services: CPT® 11042–11047 — Surgical Debridement |
Part B |
CPT® |
90960–90967 |
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 |
CPT®93306 — Echocardiography with Contrast |
Review of outpatient claims for CPT® 93306 — 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 | CPT® 82542 — Column Chromatography/Mass Spectrometry | Review of Outpatient claims for Drugs of Abuse Laboratory Tests: CPT® 82542 — Column Chromatography/Mass Spectrometry |
Part B | HCPCS | Q4174 | Q4174 — Palingen | Review of Q4174 — Palingen |
Part B | HCPCS | Q4177 | Q4177 — Floweramnioflo | Review of Q4177 — Floweramnioflo |