Noridian Jurisdiction A, DME MAC, Medical Review will be initiating a service specific prepayment targeted review of claims for each of the following HCPCS code(s):

• J7626: BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG
• J7677: REVEFENACIN INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, 1 MICROGRAM

Service specific targeted reviews are initiated to prevent improper payments for services identified by CERT or Recovery Auditors as problem areas, as well as, problem areas identified by data analysis. This review is being initiated based on a high Comprehensive Error Rate Testing (CERT) error rate.

In order to evaluate compliance with Medicare coverage and coding rules, all suppliers billing Jurisdiction A for HCPCS codes listed above are subject to this review. Suppliers of the selected claims will receive an Additional Documentation Request (ADR) letter asking for the following specific information to determine if the item billed complies with the existing reasonable and necessary criteria:

• Treating physician's dispensing and written order
• Beneficiary's medical records (which may include; practitioner medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary
• Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD), Policy Article, and/or Standard Documentation Requirement Article (A55426) requirements
• Any other supporting documentation

Failure to supply the above requested information within 45 days of the date of the letter will result in the claim being denied. The following methods may be used for submission of the documentation:

• Noridian Medicare Portal - https://www.noridianmedicareportal.com
• Electronic Submission of Medical Documentation (esMD); for more information about esMD, see www.cms.gov/esMD
• Fax
• Mail
• CD/DVD using the appropriate mailing address

The ADR letter provided will also provide instruction for submitting claims and should be sent in with the requested documentation. For additional information on responding to the ADR, refer to the Claim Review Preparation page on our website.

It is important for suppliers to be familiar with the documentation requirements and utilization parameters. The following references are used in the medical review of claims and can be accessed on the Noridian DME Consolidated Resource website.

• National Coverage Determination (NCD) 200.2
• Local Coverage Determination (LCD) L33370
• Policy Article A52466
• Standard Documentation Requirements Article A55426

Additional information, educational opportunities and training tools related to this product category are available in Education & Outreach.

Information about prepay reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3.