Widespread Targeted Review Results - FI - HCPCS J0885/Q0136       

Part A Medical Review has recently completed the 1st Quarter widespread targeted prepay review of outpatient hospital billing of Healthcare Common Procedure Coding System (HCPCS) J0885/Q0136 (EPO) processed January 1, 2008 through March 31, 2008.  Educational articles providing the results of previous reviews and guidelines for the appropriate utilization of Epoetin Alpha (EPO) were posted on “What’s New from Cahaba ” Web page on August 23, 2006, October 31, 2006, February 5, 2007, May 2, 2007, July 26, 2007, October 22, 2007, and February 28, 2008.  These articles may be found on the What’s New from Cahaba page. 

The review results are as follows:

The medical review decisions were based on local coverage determination (LCD) L20432, which outlines indications and coverage guidelines for Epoetin Alpha (EPO) use in non-end stage renal disease (ESRD) patients during this review timeframe.  All providers administering EPO injections are strongly encouraged to review LCD-L20432 for full details of documentation and coverage criteria.  The LCD may be found on the Active LCDs page.

The majority of denials were due to one of the following reasons:

86 claims lacked medical necessity to support EPO administration for non ESRD conditions (denial reason 54155):  This denial reason included the documentation of EPO administration without a covered diagnosis, and/or the documentation of EPO administration with normal hemoglobin/hematocrit levels without explanation of the necessity of EPO continuation.  For a complete listing of medical indications for the appropriate use of EPO in non-ESRD patients, please review LCD L20432.

52 claims lacked timely submission of documentation in response to an Additional Development Request (ADR) (denial reason 56900):  Claims were denied due to a lack of record submission in a timely manner.  According to The Medicare Program Integrity Manual, (CMS Pub. 100-08, Ch. 3, § 3.4.1.2, if a coverage or coding determination cannot be made based upon the information on the claim, the Fiscal Intermediary (FI) may solicit additional documentation from the provider by issuing an Additional Documentation Request (ADR) and must notify the provider of the 30 day time-period to respond.  If the ADR-requested information is not is received within 45 days after the date of the request, then the claim must be denied. 

To eliminate 56900 denials, please review the following elements to ensure appropriate and timely record processing:

• Effective January 1, 2007 Cahaba stopped sending letters informing providers of ADRs.  Instead, providers must access the Fiscal Intermediary Standard System (FISS) to identify claims selected for ADR.  Claims selected for ADR can be identified by accessing FISS Inquiry Option 12, and will appear in status location S B6001.  Pages 07 and 08 of the claim will contain the date your documentation is due and the elements of documentation requested.
• Print screen the ADR letter and attach the copy to the front of the requested medical documentation.
• Send requested information to the address on the ADR letter.
• Do NOT send certified mail or overnight mail.
• Include ALL requested documentation outlined in the ADR.
• Submit the above information via regular mail in a timeframe to ensure the FI receives the information by the 45th day after the date of the request.

Refer to the Inquiry Menu section of the Fiscal Intermediary Standard System (FISS) Reference Guide for detailed information on how to access ADRs.

66 claims did not contain documentation to support the HCPCS code billed (denial reason 53603):  This denial reason included claims submitted for HCPCS J0885 when the documentation indicated the patient was receiving dialysis.  Providers are reminded that J0885 is defined as EPO, per 1000 units for non-ESRD patients.  The appropriate HCPCS for ESRD patients on dialysis is J0886 (EPO, per 1000 units for ESRD on dialysis).

43 claims did not contain key elements of documentation required to determine the medical necessity of the services provided (denial reason 55520):  To enable a medical review and to ensure coverage for EPO, the documentation submitted, at a minimum must include:

• All labs pertinent to the indications for EPO administration
• Patient’s weight in kilograms
• Starting dose per kilograms
• Diagnosis
• Physician History and Physical
• Physician orders
• Medication administration documentation (e.g. treatment notes)
• Any additional documentation pertinent to EPO orders/treatment

As a result of this targeted review, Part A Medical Review will continue the targeted pre-pay review of all outpatient hospitals (bill type 13X) billing J0885 and/or Q0136, identified by edit reason code 5112K.  Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review.

Page last updated: May 21, 2008

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