Health Information Management

Q/A: Reporting limits for doses of Provenge

APCs Insider, August 17, 2012

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Q: We received a denial on a claim for Provenge® administration saying that the frequency had been exceeded. Is this some type of medically unlikely edit? We had the appropriate diagnosis and administration codes on the claim.

A: The edit that stopped payment for the claim is a frequency edit, which means that the service has met the number of times that it can be provided for a Medicare beneficiary.
 
Effective July 1, CMS has instituted a new edit for Provenge that limits the number of occurrences to three. Based on the manufacturer information, three doses of Provenge are all that are required for treatment. Based on this, CMS instituted an edit which prevents more than three claims (which equates to three doses) for Provenge from being reimbursed. Learn more about the edit in Transmittal 2394.
 
Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



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