Postpayment Service-Specific Probe Results for Prolia (Denosumab) for April through June 2021

Published 07/27/2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code J0897 — Prolia® (Denosumab). This edit was set in Alabama, Georgia and Tennessee. The results for the first quarter postpayment review, for claims processed April through June, 2021, are presented here.

Cumulative Results 
A total of 286 claims were reviewed, with 127 of the claims completely or partially denied, resulting in an overall claim denial rate of 44.41 percent. The total dollars reviewed was $216,058.10, of which $58,333.42 was denied, resulting in a charge denial rate of 27.00 percent. Overall, there were 108 auto-denied claims in the region. 

Alabama Results
A total of 37 claims were reviewed, with 16 of the claims either completely or partially denied. This resulted in a claim denial rate of 43.24 percent. The total dollars reviewed was $28,878.31, of which $10,507.06 was denied, resulting in a charge denial rate of 36.38 percent. The top denial reasons identified, and number of occurrences based on dollars denied were: 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

56.25%

5D164/5H164

No Documentation of Medical Necessity

9

31.25%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

5

12.50%

5DTDP/5HTDP

Dependent Services Denied (Qualified Service Denied Technically)

2

Georgia Results
A total of 208 claims were reviewed, with 96 of the claims either completely or partially denied. This resulted in a claim denial rate of 46.15 percent. The total dollars reviewed was $153,796.13, of which $34,084.63 was denied, resulting in a charge denial rate of 22.61 percent. The top denial reasons identified, and number of occurrences based on dollars denied were: 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

51.04%

5D199/5H199

Billing Error

49

25.00%

5D164/5H164

No Documentation of Medical Necessity

24

18.75%

5DMDP/5HMDP

Dependent Services Denied (Qualifying Services Denied Medically)

18

3.13%

5D169/5H169

Services Not Documented

3

1.04%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

1

1.04%

5DTDP/5HTDP

Dependent Services Denied (Qualifying Service Denied Technically)

1

Tennessee Results
A total of 41 claims were reviewed, with 15 of the claims either completely or partially denied. This resulted in a claim denial rate of 36.59 percent. The total dollars reviewed was $33,383.66, of which $13,741.73 was denied, resulting in a charge denial rate of 41.16 percent. The top denial reasons identified, and number of occurrences based on dollars denied were:

Percent of Total Denials Denial Code Denial Description Number of Occurrences

100.00%

5D164/5H164

No Documentation of Medical Necessity

15

Denial Reasons and Prevention Recommendations

5DMDP/5HMDP — Dependent Services Denied (Qualifying Service Denied Medically)

Reason for Denial
The dependent services will not be covered if the qualifying service has been denied. For example, the service was denied as documentation did not support medical necessity, therefore all other charges associated with the service under review cannot be allowed and will be denied as dependent to the medical denial of the qualifying service.

How to Avoid This Denial

  • Ensure the documentation provided supports the services were reasonable and medically necessary for the treatment of the beneficiary
  • Ensure all records are properly and legibly signed
  • Ensure documentation supports the service(s) was rendered

More Information

5D199/5H199 — Billing Error

Reason for Denial
The services billed were not covered because the documentation provided did not support the claim as billed by the provider.

How to Avoid This Denial
To avoid future denials for this reason:

  • Check all bills for accuracy prior to submitting to Medicare
  • Ensure that the documentation submitted, in response to the ADR, corresponds with the date that the service was rendered, and the dates of service billed

More Information

5D164/5H164 — No Documentation of Medical Necessity

Reason for Denial
This claim was denied because the documentation submitted does not support the medical necessity of the service reviewed. The records did not contain any covered condition/indication, symptomology or diagnostic results that would support the service was reasonable and necessary for the treatment of the beneficiary.

How to Avoid This Denial

  • Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:
    • A covered indication or condition for the service billed. 
    • A physician/NPP is managing the care of the covered indication or condition
    • Any medical history that supports a need for the service
    • Any diagnostic results or symptomology that supports a need for the service
  • A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support medical necessity
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

More Information

5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed

Reason for Denial
Medicare cannot pay for this service because one or more requirements for coverage were not met.

How to Avoid a Denial
Documentation that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • Clear physician’s order with indication of need, dose, frequency and route 
  • Date and time of associated chemotherapy, as applicable
  • Relevant medical history documented prior to the DOS and signed by the physician or appropriate nonphysician provider to include:
    • Clear indication of the diagnosis
    • Clinical signs and symptoms
    • Prior treatment and response as applicable
    • Stage of treatment as applicable 
    • Clear and complete documentation of administration signed by the person providing the service
  • Ensure the service was provided per the coverage guidelines for the service.
  • Documentation of administration 

More Information

5DTDP/5HTDP — Dependent Services Denied (Qualifying Service Denied Technically)

Reason for Denial
The dependent services will not be covered if the qualifying service has been denied. For example, the service procedure was not documented, therefore all other charges cannot be allowed.

How to Avoid This Denial

  • Ensure all documentation is submitted to support service was rendered
  • Ensure documentation supports the claim as billed
  • Ensure all documentation is properly and legibly signed

More Information

5D169/5H169 — Services Not Documented

Reason for Denial
This claim was partially or fully denied because the provider billed for services/items not documented in the medical record submitted.

How to Avoid This Denial

  • Submit all documentation related to the services billed.
  • Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed.
  • Ensure that the documentation is complete with proper authentication and the signature is legible
     

56900 — Auto Deny — Requested Records Not Submitted Timely 

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original Additional Development Request (ADR) to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the Additional Development Request (ADR) date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the Additional Development Request (ADR) is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the Additional Development Request (ADR). Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review Department. Fax and electronic data submissions are also accepted as indicated on the Additional Development Request (ADR).
  • Gather all of the information needed for the claim and submit it all at one time
  • Attach a copy of the Additional Development Request (ADR) request to each individual claim
  • If responding to multiple Additional Development Requests (ADRs), separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips. 
  • Do not mail packages C.O.D.; we cannot accept them

More Information

The Next Steps
The service-specific postpayment medical review edits for HCPCS Code J0897 — Prolia® (Denosumab) in Alabama, Georgia and Tennessee will be continued based on moderate charge denial rates and/or medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to JJ Redetermination: 1st Level Appeal form. Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.