Tips for Getting Immunosuppressive Drug Claims Paid
A service-specific prepayment review of HCPCS Level II code J7507 Tacrolimus, immediate release, oral, 1 mg conducted by CGS, durable medical equipment Medicare administrative contractor (DME MAC) for jurisdiction C, shows a 44 percent error rate for fourth quarter 2013 claims and a 45 percent error rate for first quarter 2014 claims. The primary reason for denial (45 percent): Medical records were not provided upon request.
CGS conducted a widespread post payment probe review of HCPCS Level II code J7515 Cyclosporine, oral, 25 mg, as well. The combined calculated error rate of the two probe reviews was 87 percent.
Upon the DME MAC’s request, suppliers/providers must provide copies of the following documents:
- Proof of delivery;
- Detailed written order;
- Written documentation of a dispensing order;
- Proof of a refill request; and
- Medical records confirming the transplant, the date of the transplant, the facility where the transplant occurred, and that the beneficiary continues to use and have a medical need for the drug.
Proof of Delivery
In many cases, delivery documentation was provided, but inadmissible. Delivery documentation must:
- Include the name of the drug;
- Include a signature or tracking information to confirm delivery;
- Be legible; and
- Indicate the date of service billed matches the delivery/shipping date.
Detailed Written Order
A copy of the detailed written order must be provided upon request, and this order must be:
- Complete; and
- Signed by the ordering physician or non-physician practitioner.
Also upon request, make sure to provide the DME MAC with pertinent medical records, and that the medical records document that the drug was included in the physician’s plan of care for the patient; the name of the transplant center is indicated; the transplant is documented, and the records are signed. The Immunosuppressive Drug DIF is a retired Centers for Medicare & Medicaid Services form and no longer required or recognized as supporting documentation by MACs.
Failure to provide records to support that the coverage criteria listed in CGS’s Immunosuppressive Drugs local coverage determination (L11521) and policy article (A25526) were met will result in claim denial, CGS warns.
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