JM Parts A, B, Home Health and Hospice Active Medical Review List
| 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 hospices 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®) |
| Hospice | Rev Code/Place of Service | 0656, 0651, 0655/Q5005 | Hospice Place of Service | Review of claims submitted for hospice place of service, Revenue-Specific Audit |
| Hospice | Rev Code/Place of Service | 0655/Q5003–Q5004 | Hospice Respite | Review of claims submitted for Respite care based on Place of Service |
|
Part A |
HCPCS |
J2505, J2506 |
J2505 — Pegfilgrastim (Neulasta®), 6 mg |
Review of outpatient claims for J2505; this code was retired as of Jan. 1, 2022. |
| 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 |
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 A | DRG | 377–379 | Gastrointestinal Hemorrhage | Review of claims for DRG 377–379 Gastrointestinal Hemorrhage |
| Part A | DRG | 273–274 | Percutaneous Intracardiac Procedures | Review of claims for DRG 273–274 Percutaneous Intracardiac Procedures |
| 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 |