Rituximab - JF - Healthcare Common Procedure Coding System (HCPCS) J9312 - Service Specific Targeted Review Final Findings

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs post-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 and closure of the case for HCPCS J9312. 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.

Summary of Findings

Since the initiation of the review, 499 claims were reviewed from April 16, 2021 through October 8, 2021. The breakdown of those findings are as follows:

  • 213 claims were allowed.
  • 286 claims were denied in full for the following reasons:
    • The requested records were not received.
    • The documentation did not support medical necessity

The overall error rate since the initiation of this service specific targeted review is 65.18%. The error rate is calculated by dividing the dollar amount of charges billed in error (minus any confirmed under-billed charges) by the total amount of charges for services medically reviewed. If you 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, although this will not affect the error rate of the post-payment review.

Education

Failure to Return Records

When the MAC requests documentation for review, it is the provider’s responsibility for the requested documentation to be received within 45 calendar days from the request. The MAC will not grant extensions to providers who need more time to comply with the request. Payment will not be made to any provider unless they have furnished the information as requested in order to determine the amounts due to the provider. Medicare will not pay for services unless they are deemed necessary and sufficient information is submitted that shows that services were provided. For payment, the services must be determined to be reasonable and necessary for the prevention or treatment of illness. Refer to Social Security Act 1815(a), 1833(e), 1862(a)(1)(A).

Medical Necessity

As laid out in section 1862(a)(1)(A) of Title XVIII of the Social Security Act, no Medicare payment may be made for items or services that are not reasonable and necessary for diagnosis or treatment of illness/injury or to improve the function of a malformed body part.

Medical necessity is a term used when determining whether a diagnosis or treatment by a physician is considered appropriate or inappropriate, based on medical standards of care. Medicare can only allow services that meet this standard. In order to be considered medically necessary, items and services must be proven as safe and effective.

Medicare is aware that some patients do and will require professional services at a greater frequency and duration than others, including more extensive diagnostic procedures. Documentation verifying medical necessity for such treatment must be recorded in the medical records. Documentation that the services were rendered is necessary in order for a claim to be properly evaluated. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2.

Rituxan

For the administration of rituximab (Rituxan), the Food and Drug Administration (FDA) outlines rheumatoid arthritis (RA) in combination with Methotrexate or a similar medication such as Azulfidine in adult patients with moderately-to severely active RA with an inadequate response to one or more tumor necrosis factor (TNF) antagonist therapies as an indication for rituximab (Rituxan). The medical records should support:

  • Severity of RA
  • History of TNF antagonist therapies tried prior to initiating rituximab
  • Use of Methotrexate or a similar medication such as Azulfidine in combination with rituximab

Rituxan is also utilized in the treatment of chronic lymphocytic leukemia (CLL), microscopic polyangiitis, non-Hodgkin’s lymphoma (NHL), pemphigus and Wegener’s granulomatosis. The medical records should support an approved indication per the FDA label.

Resources

For additional educational resources, please visit our Education and Outreach department.

Provider Action Required

Providers should review individual claim determinations.

To review individual claim comments via the Noridian Medicare Portal, complete the following steps:

  1. Log into Noridian Medicare Portal at https://www.noridianmedicareportal.com/
  2. Choose Claim Status from the menu bar.
  3. On the Claim Status Inquiry page:
    1. Fill in all Provider/Supplier Details.
    2. Select MEDB under Program drop down box
    3. Fill in all Beneficiary Details
    4. Fill in Claim Details.
  4. Click the Submit Inquiry button at the bottom of the form.
  5. On the Claim Status Results page
    1. Choose View Claim.
    2. On the right side of the page will the heading: Related Inquiries
    3. Choose Noridian Comments.
  6. Scroll down the page and under the Claim Status Line Details the comment will display.

Note: If documentation was sent late (>45 days from the date of the ADR), the claim may have been reopened by the examiner. These reviews are not currently available on the portal.

Initial documentation must be sent by fax, mail or esMD. Additional documentation requested can be submitted fax, mail or Noridian Medicare Portal.

Further provider action recommended includes:

  • Provide education regarding errors noted to applicable staff members.
  • Verify documentation supports medical necessity of HPCPCS J9312
  • Ensure ADR submissions are timely, complete, and include all documentation to support medical necessity and a valid physician order.
  • If records supporting the services on the claim are located at another facility, as the billing provider, your facility is responsible for obtaining those records for review.

Summary

Based on the error rate for this service specific probe this case is now closed 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 in the future, data indicates variances or high utilization, providers may be subject to a pre-payment or post-payment review.

If you would like to receive information regarding findings specific to your facility prior to the completion of the review, send an email to medicalreviewb@noridian.com. In order to facilitate the response, follow these instructions:

  • Complete the Subject line with the following information: Results request for HCPCS J9312 targeted review
  • In the body of the email, include the following elements:
    • Your name, title, and telephone number
    • The facility name
    • NPI Number
    • Short description of information you would like to receive
  • Indicate if you would like to receive results via phone call, fax or US Mail and include a fax number or mailing address as applicable.

Upon request receipt, Noridian Medical Review will respond as timely as possible.. Requests may take up to two weeks to be completed.

If you have any questions, contact the Provider Contact Center.

 

Last Updated Mon, 25 Oct 2021 15:28:15 +0000