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Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs

Medical Review - Active Edits and Probes

Medical Review Part A has the following service specific Probe/ Edits in effect for Jurisdiction H.

Probe/Edit

Procedure

Description

Documentation Required for Successful Review

(It is required that all documentation submitted must be legible with correct billed date of service and must be clearly signed by the billing/rendering provider)

5H162

Implemented:
3/2/2016

J1786

Imiglucerace- 10 units

Physician’s orders.
Documentation must contain pertinent history and progress notes to validate the diagnosis submitted on the claim.
Documentation to support the medical necessity for the administration of imiglucerase. A recent weight must be documented since this is a weight based infusion.
Recent laboratory studies to include cbc/diff.
Beneficiaries who were or are participating in a clinical trial must include the clinical trial name, sponsor of the clinical trial, and the sponsor-assigned protocol number. 
Treatment/medication record must include the patient’s name, date, dosage, time, and route of imiglucerase, and signature of individual who administered the drug.
Documentation of wastage, if applicable. Reason for the waste and how the vial was reconstituted should also be included.

5H163

Implemented:
3/2/2016

J9228

Ipiliumumab- 1 mg

Physician’s orders.
Documentation must contain pertinent history and progress notes to validate the diagnosis submitted on the claim.
Documentation to support the medical necessity for the administration of ipilimumab, (i.e. Melanoma). A recent weight must be documented since this is a weight based infusion.
Beneficiaries who were or are participating in a clinical trial must include the clinical trial name, sponsor of the clinical trial, and the sponsor-assigned protocol number. 
Treatment/medication record must include the patient’s name, date, dosage, time, and route of ipilimumab, and signature of individual who administered the drug.
Documentation of wastage, if applicable. Reason for the waste and how the vial was reconstituted should also be included.

5H165

Implemented:
3/2/2016

Q2043

Sipuleucel T- per infusion

Physician’s orders.
Documentation must contain pertinent history and progress notes to validate the diagnosis submitted on the claim.
Documentation to support the medical necessity for the administration of sipuleucel-t, (i.e. Advanced asymptomatic prostate cancer).
Beneficiaries who were or are participating in a clinical trial must include the clinical trial name, sponsor of the clinical trial, and the sponsor-assigned protocol number. 
Treatment/medication record must include verification of the patient with the product, since it is an autologous cellular immunotherapy. The patient’s name, date, dosage, time, and route of sipuleucel-t, and signature of individual who administered the transfusion must be documented.
Documentation of premedication given at least 30 minutes prior to transfusion.
Itemized bill.

5H078

Implemented:
8/25/2015

ICD-9: 260

ICD-10: E40, E42

Kwashiorkor / Marasmic Kwashiorkor

>4 day length of stay

Admission and discharge summary to support the diagnosis of this rare form of malnutrition
All signed/authenticated physician orders pertaining to the DOS billed
Comprehensive history and physical including documentation to support this diagnosis
All progress notes to include consults with nutritional support and other disciplines
All lab studies to include protein and albumin levels, patient weight and BMI
Treatment logs and notes related to the care of the patient with this diagnosis
Any medication records, nutritional records and infusion records
Summary discharge note and follow up treatment plan

56770

Implemented:
1/1/1996

XXXX

Demand Bill (SNF)

Handled individually with the SNF provider on a case by case basis

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Last modified:  10/02/2017