Description
Claims billed with excessive or insufficient units will be reviewed to determine the actual amount administered and the correct number of billable/payable units.
Affected Code(s)
C9132, J0178, J0180, J0202, J0221, J0256, J0475, J0485, J0490, J0583, J0585, J0588, J0775, J0881, J0894, J0897, J1300, J1439, J1459, J1557, J1561, J1566, J1568, J1569, J1572, J1602, J1745, J1786, J1930, J2182, J2323, J2326, J2350, J2353, J2357, J2505, J2507, J2562, J2778, J3101, J3262, J3357, J3380, J3385, J3489, J7312, J7325, J7326, J7327, J9022, J9023, J9033, J9035, J9041, J9042, J9043, J9047, J9055, J9145, J9173, J9176, J9179, J9205, J9228, J9263, J9264, J9271, J9280, J9285, J9299, J9301, J9303, J9305, J9306, J9307, J9308, J9310, J9311, J9312, J9315, J9354, J9395, Q2043, Q2050, J1750, Q0138, 20610, 20611, 67028, 96360, 96361, 96365, 96366, 96367, 96368, 96369, 96370, 96371, 96372, 96373, 96374, 96375, 96376, 96377, 96401, 96402, 96405, 96406, 96409, 96411, 96413, 96415, 96416, 96417, 96420, 96422, 96423, 96425, 96440, 96446, 96450, 96542, J0220, J0480, J0584, J0586, J0587, J0598, J1442, J1610, J1640, J2278, J3111, J3370, J7170, J7179, J7198, J7201, J7205, J7207, J9025, J9032, J9153, P9045, P9047, J1750, Q0138, J0179, J0207, J0222, J0223, J0257, J0291, J0401, J0517, J0565, J0596, J0597, J0598, J0638, J0791, J0795, J0840, J0841, J0850, J0875, J0896, J1162, J1190, J1290, J1303, J1322, J1458, J1571, J1575 J1743, J1746, J1931, J1943, J1944, J2350, J2407, J2425, J2426, J2724, J2783, J2786, J2794, J2860, J3032, J3060, J3095, J3241, J3245, J3304, J3358, J3396, J9039, J9044, J9050, J9119, J9120, J9144, J9155, J9203, J9204, J9207, J9210, J9227, J9229, J9309, J9317, J9325, J9330, J9352, J9357, J9358, J9400, C9074, J0224, J1305, J1823, J2506, J7168, J7311, J7313, J7314, J9047, J9061, J9177, J9223, J9247, J9261, J9266, J9272, J9281, J9308, J9316, J9318, J9319, J9353, Q5103, Q5104, Q5107, Q5108, Q5111, Q5115, Q5118, Q5119, Q5120, Q5121, Q5122, J0129, J0219, J0491, J0717, J0741, J1302, J1306, J1437, J1448, J1449, J1556, J1559, J1628, J1826, J1952, J2356, J2406, J2777, J3145, J3240, J3315, J7169, J7318, J7322, J7351, J7511, J9034, J9037, J9198, J9202, J9245, J9268, J9269, J9274, J9298, J9302, J9304, J9332, J9349, J9355, J9356, J9359, J9600, Q3027, Q5123, Q5124, Q5126, Q5128, Q5130
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. 42 CFR §414.904(a)(3)- Average sales price as the basis for payment; Method of payment
9. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals; §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements- General; §90.2- Drugs, Biologicals, and Radiopharmaceuticals; §100.2.9- Submission of Claims with the Modifier JW, “Drug Amount Discarded/Not Administered to Any Patient”
10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services; §50.3- Incident to Requirements; §60.1- Incident to Physician’s Professional Services
11. Medicare Alpha-Numeric HCPCS File- Alpha-Numeric HCPCS | CMS
12. AMA CPT Codebook
13. HCPCS Level II Codebook
14. Medicare Part B Drug Average Sales Price; ASP Pricing File- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice
15. U.S. National Library of Medicine DailyMed