Immunosuppressive Drugs (HCPCS J7507, J7517, J7518 and J7520) Notification of Documentation Compliance Review

Noridian Jurisdiction D, DME MAC, Medical Review will be initiating a documentation compliance review of the following HCPCS code(s):

J7507: Tacrolimus, immediate release, oral, 1 mg

J7517: Mycophenolate mofetil, oral, 250 mg

J7518: Mycophenolic acid, oral, 180 mg

J7520: Sirolimus, oral, 1 mg

A documentation compliance review is a nonclinical, technical review verifying that submitted documentation meets payment requirements according to Local Coverage Determinations (LCD) for that DMEPOS item. 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 D 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
  • Medical records indicating:
    • The transplant date; and
    • The facility where the transplant was performed; and
    • The corresponding diagnosis code; and
    • Justification the item continues to be used by the beneficiary and remains reasonable and necessary.
  • Proof of delivery
  • Request for refill (if applicable)
  • The Advanced Beneficiary Notice (if applicable)
  • Any other supporting documentation

Failure to supply the above requested information within 45 days of the date on the letter will result in the claim being denied. Please fax or mail the requested documentation and a copy of the ADR letter. The ADR letter provided will also provide instruction for submitting documentation.

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Immunosuppressive Drugs Local Coverage Determination (LCD) L68 and Policy Article A25366.

Additional information, educational opportunities and training tools related to this product category are available on our Education and Outreach page.

Information about prepay reviews may be found in CMS Internet Only Manual (IOM), Medicare Program Integrity Manual, Publication 100-8, Chapter 3.

Last Updated Fri, 17 Apr 2015 03:22:52 +0000