Ferric Carboxymaltose - JE Service Specific Post-Payment Final Findings - JE Part A
Ferric Carboxymaltose - JE Service Specific Post-Payment Final Findings
CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Noridian's priority is to minimize potential future losses to the Medicare Trust Fund by preventing inappropriate Medicare payments. This is accomplished through provider education, training, and the medical review of claims. A post-payment review has been initiated based on data analysis.
This is to update providers of the claim review findings and closure of the file of Healthcare Common Procedure Coding System (HCPCS) code J1439 for JE.
Summary of Findings
Since the initiation of the review, 150 claims were reviewed from May 3, 2021 through December 28, 2021 with an overall claim error rate of 40.7% and payment error rate of 38.6%. The breakdown of those findings are as follows:
- 89 claims were accepted
- 3 claims received correction for the following reason:
- Documentation did not support the number of units billed.
- 1 claim was partially denied for the following reason:
- Documentation did not support discarded amount of the medication to support units billed with the modifier JW.
- 57 claims were denied in full for the following reason:
- Documentation did not support medical necessity per FDA guidelines.
If you are a provider that had claims involved in the review sample and disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice.
|Paragraph Name||Paragraph Details|
|Injectafer® (Ferric Carboxymaltose)||Per the Food and Drug Administration (FDA) label, Injectafer® is an iron replacement therapy that is used for iron deficiency anemia in adults. There are two types of patients with iron deficiency anemia that can utilize Injectafer®. These include:
For additional information, reference the FDA label for Injectafer® and refer to the local coverage article, "Parenteral Iron Administration Coverage in Non-Dialysis Usage" A55653. for additional information on parenteral iron coverage.
|Correct Coding of Units||Per Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 17, Section 70, drugs are billed in multiples of the units specified in the narrative of the Healthcare Common Procedural Coding System (HCPCS) manual. If the dosage given is not a multiple of the HCPCS code, the provider rounds to the next highest unit in the HCPCS description for that code.
For example, if 2.5 milligrams of Zometa is administered, it is appropriate to bill for 3 units, as the HCPCS descriptor for Zometa is per 1 milligram. A second example of billing proper units per drug description is if 300 milligrams of Herceptin is administered, it is appropriate to bill for 30 units, as the HCPCS descriptor for Herceptin is per 10 milligrams.
|Discarded Drugs and Biologicals||Per Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 17, Section 40, providers seeking reimbursement for unused drugs or biologicals from single use vials or single use packages must apply the JW modifier to represent units discarded. A physician, hospital, or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient. Medicare provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label.
The JW modifier should be billed on a separate line to receive payment for the amount of the discarded drug or biological. Discarded amounts must be documented in the patient's medical record to support the units billed with the JW modifier. For example:
If one billing unit is equal to 10 milligrams (mg) of the drug in a single use vial and 7 mg is administered, the 7 mg is billed using one billing unit. Billing another unit on a separate line with the JW modifier for the discarded 3 mg is not permitted because it would result in overpayment.
View references used in review. Further educational opportunities may be found under Education and Outreach. If you are in need of an individualized education training event, contact the POE Department at firstname.lastname@example.org. If you need coding assistance, please check your CPT®, HCPCS, ICD-10 books and your specific association.
Provider Action Required
File results and trending errors are being shared with all providers to assess compliance and billing practices if the service is provided within your facility. If your facility had claim documentation requested for this review, please refer to the individual result letter you received. You can also access individual determinations for claims that were requested from your facility by reviewing comments in either DDE or on the Noridian Medicare Portal (NMP).
Further provider action recommended includes:
- Provide education regarding errors noted to applicable staff members.
- Verify documentation supports medical necessity of Healthcare Common Procedure Coding System (HCPCS) code J1439.
This service specific post-payment file is now closed for JE and Noridian will no longer request documentation for this review. Noridian will continue to monitor data analysis and perform medical review for medical necessity and appropriate coding practices.
If you have any other questions, contact the JE Provider Contact Center at 1-855-609-9960.
Last Updated Tue, 11 Jan 2022 18:11:42 +0000