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

Published 05/03/2022

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Code Type

Specific Code

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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)

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

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

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 11042-11047 — 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 CPTs 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