HCPCS J0897: Injection, Denosumab, 1mg - JE Part B
HCPCS J0897: Injection, Denosumab, 1mg
In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.
This is to update providers of the claim review findings for HCPCS J0897, Injection, Denosumab, 1mg. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.
The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS J0897, Injection, Denosumab, 1mg. The quarterly edit effectiveness results from April 1, 2024, to June 30, 2024, are as follows:
Top Denial Reasons
- Failure to Return Records
- Documentation submitted does not support medical necessity
- The appropriate primary code has not been billed or paid
Educational Resources
Education
Denosumab is a monoclonal antibody used for the treatment of osteoporosis in postmenopausal women with a high risk of bone fractures that were not successful with other osteoporosis therapies. Denosumab reduces the possibility of fractures of the hip and vertebral and non-vertebral fractures because it is a RANK Ligand inhibitor. It works by binding to the Rank Ligand inhibiting osteoclast formation, function, and survival, therefore preventing the osteoclasts from resorbing bone. The recommended dose is 60 mg every six months. Denosumab is administered by subcutaneous injection.
Failure to Return Records
The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.
"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."
Incomplete And/or Insufficient Documentation
When additional documentation has been requested to verify compliance with the CPT® code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C)
For additional educational resources, please visit our Education and Outreach department.
