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

Published 04/03/2024

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Code Type

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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 bene sharing

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 Rev Code 0651, 0652, 0655, 0656 Hospice-Length of Stay (LOS) Greater than 365 Days  Review of claims submitted for Hospice-Length of Stay (LOS) Greater than 365 Days
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)
Hospice Revenue 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) 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 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

HCPCS

G0277

HCPCS G0277 — Hyperbaric Oxygen Therapy (HBO) 

Review of inpatient claims for HCPCS G0277 — Hyperbaric Oxygen Therapy (HBO) 
Part A DRG 682/683 Renal Failure Review of claims for renal failure
Part A CPT®  23472 CPT® 23472 – Total Shoulder Arthroscopy (TSA) Review of outpatient claims for CPT® 23472 – Total Shoulder Arthroscopy (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

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 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 DRG 470 — Major Joint Replacement Joint Replacement, Review of claims submitted for DRG 470 — 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

DRG 885 — Psychoses

Review of inpatient claims for DRG 885 — 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 and A2005 -D2005 Combined Inpatient Rehabilitation Services (IRF) Review of Inpatient Rehabilitation Services (IRF) Review of Inpatient Rehabilitation Services (IRF)

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 A CPT® 97530 CPT® 97530 — Therapeutic Activities Review of outpatient claims for CPT® 97530 — Therapeutic Activities
Part A HCPCS J9144 Darzalex® (Daratumumab) Review of outpatient claims for HCPCS J9144 - Daratumumab
Part A HCPCS J9299 HCPCS J9299 — Nivolumab Review of outpatient claims for HCPCS J9299 — Nivolumab
Part A HCPCS J2350 HCPCS J2350 — Ocrelizumab Review of outpatient claims for HCPCS J2350 — Ocrelizumab
Part A HCPCS J1459 HCPCS J1459 — Privigen Review of outpatient claims for HCPCS J1459 — Privigen
Part A HCPCS J9041 HCPCS J9041 — Bortezomib Review of outpatient claims for HCPCS J9041 — Bortezomib

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 CPT® 99213-99215 Established Patient Office Visit Review of claims for established patient office visit

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

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