Review Results for Service Specific Post-Payment Review of J0585 – Botulinum Injection, onabotulinumtoxinA

Background

In an effort to reduce the Part B CERT error rate, the MR Department conducted a service specific post payment review of HCPCS code J0585 (onabotulinumtoxinA). The primary focus of these audits was to determine whether the medical necessity of the services billed was at the correct code per Medicare guidelines.

National Government Services randomly selected 795 claims billed for HCPCS J0585 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• J0585– Botulinum Injection, onabotulinumtoxinA, 1 unit

Results

Decision	Number of Claims
Allow	289
Deny	406
Partial Denial	10
Non-Response Denial	88
Rescinded Review	2

 

• 422 claims from Illinois with 157 allowed and 265 denied for a claims error rate of 62.80%
• 203 claim from Minnesota with 65 allowed and 138 denied for a claims error rate of 67.98%
• 168 claims from Wisconsin with 67 allowed and 101 denied for a claims error rate of 60.12%

Key Reasons Services Were Denied

• Documentation did not support medically necessity due to one or more of the following: The submitted documentation is missing a covered indication; a statement indicating the condition was unresponsive to conventional treatment; dosage, site and frequency of injection; description of treatment effectiveness
• Documentation was insufficient or incomplete
• Failure to respond to the request for documentation

Recommendations

• Send the requested records within the requested time frame to avoid a denial for no documentation.
• Familiarize yourself with available Botulinum Injection, onabotulinumtoxinA guidelines and other CMS publications listed below.
• Share this information with your coding personnel to ensure they are properly billing before sending the claim to Medicare.
• If you feel your application of this code is correct, ensure your documentation supports your usage.

Related Content

• Local Coverage Determination: Botulinum Toxins LCD L33646
• Local Coverage Article: Billing and Coding: Botulinum Toxins LCA A52848
• Social Security Act (SSA ), Title XVIII
  • Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
  • Health Insurance for the Aged and Disabled, Section 1862(a)(10) excludes coverage for cosmetic surgery
  • Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
• 42 CFR Section 410.32, Diagnostic x-ray tests, diagnostic laboratory tests and other diagnostic tests: Conditions. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter)
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual
  • Chapter 8, Section 50.5 Drugs and Biologicals (Coverage of SNF services) and Section 70 Medical and Other Health Services Furnished to SNF Patients
  • Chapter 12, Section 40.9 Drugs and Biologicals (Comprehensive Outpatient Rehabilitation Facility [CORF] Coverage)
  • Chapter 15, Section 50.1–50.5 Drugs and Biologicals and Section 260 Ambulatory Surgical Center Services
  • Chapter 16, Section 120 Cosmetic Surgery
• CMS IOM Publication 100-04, Medicare Claims Processing Manual
  • Chapter 17, Section 40 Discarded Drugs and Biologicals
  • Chapter 30, Section 20.2.1 Categorical Denials

Posted 12/8/2021