Active Medical Review List
Published 04/17/2026
| LOB | Code Type | Specific Code | Edit Topic | Edit Description |
|---|---|---|---|---|
| Home Health | Bene Sharing | All | Home Health Services for Eligibility and Medical Necessity Bene Sharing | Review of Claims Submitted for Home Health Services for Eligibility and Medical Necessity Bene Sharing |
| Home Health | HIPPS | All | Home Health Services for Eligibility and Medical Necessity | Review of Claims Submitted for Home Health Services for Eligibility and Medical Necessity |
| Home Health | HIPPS | Low Biller Probe and Educate | Home Health Medical Necessity | Review of Home Health Medical Necessity |
| Hospice | Bene Sharing | All | Hospice Services Bene Sharing | Review of Claims Submitted for Hospice Services for Eligibility and Medical Necessity Bene Sharing |
| Hospice | Rev Code | General Inpatient Care (GIP) | GIP | Review of Inpatient Claims for Inpatient Hospice Care Greater Than or Equal to 7 Days for revenue Code 656 and Place of Service Codes Q5004–Q5009 |
| Hospice | Rev Code | New Hospice Providers | New Hospice Providers | Review of New Hospice provider Claims |
| Hospice | Rev Code | 0651, 0652, 0655, 0656 | Hospice Length of Stay (LOS) Greater than 365 Days | Review of Claims Submitted for Hospice LOS Greater than 365 days |
| Hospice | Rev Code | Routine Home Care (RHC) — Rev Code 651 | RHC — Rev Code 651 | Review of hospice RHC — Rev Code 651 |
| Hospice | Rev Code | 0652 | Hospice Services Continuous Home Care | Review of Claims Submitted for Hospice Services Continuous Home Care |
| Hospice | Diagnosis Codes | Non-Cancer Length of Stay (NCLOS) | NCLOS | Review of Hospice Claims for NCLOS |
| Hospice | High Risk Hospice | High Risk Hospices in Texas | Review of Claims for High-Risk Hospices in Texas | |
| Hospice | Provisional Period of Enhanced Oversight for New Hospice Providers for Texas | PPEO Hospices | Provisional Period of Enhanced Oversight for New Hospice Providers for Texas | |
| Hospice | Rev Code/Place of Service | 0656, 0651, 0655/Q5005 | Hospice Place of Service | Review of Claims Submitted for Hospice Place of Service, Revenue-Specific Audit |
| Hospice | Rev Code/Place of Service | 0655/Q5003–Q5004 | Hospice Respite | Review of Claims Submitted for Respite Care Based on Place of Service |
| Hospice | Rev Code | Low Biller Probe and Educate | GIP | GIP |
| Part A | Inpatient Short Stay | Inpatient Short Stay | Inpatient Short Stay Less than 2 Midnights | Inpatient Short Stay Less than 2 Midnights |
|
Part A |
HCPCS |
J2505, J2506 |
J2505 — Pegfilgrastim (Neulasta®), 6 mg |
Review of Outpatient Claims for J2505; this Code Was Retired as of Jan. 1, 2022 |
| Part A | HCPCS |
J9311, J9312 |
HCPCS J9311, J9312 — Rituximab (Rituxan®) 10 mg and Hyaluronidase/Rituximab, 10 mg |
Review of Outpatient Claims for Rituximab (Rituxan®) 10 mg and Hyaluronidase/Rituximab, 10 mg |
| Part A | HCPCS | J9144 | Low Biller Probe & Educate Darzalex® (Daratumumab) | Review of Outpatient Claims for Darzalex® (daratumumab) |
| Part A | HCPCS | J9299 | Low Biller Probe & Educate Opdivo® (Nivolumab) | Review of Outpatient Claims for Opdivo® (nivoloumab) |
| Part A | HCPCS |
J1745 |
Infliximab (Remicade®) | Review of Outpatient Claims for Infliximab (Remicade®) |
| Part A | HCPCS | J0897 | Denosumab (Prolia®) | Review of Outpatient Claims for HCPCS J0897 – Denosumab (Prolia®) |
| Part A | HIPPS | ID, IE, JD, KA, KD, KE | Skilled Nursing Facility (SNF) | Review of SNF Claims w/ an Emphasis on Codes in HIPPS Categories: ID, IE, JD, KA, KD, KE |
| Part A | HCPCS |
G0277 |
Hyperbaric Oxygen (HBO) Therapy |
Review of Inpatient Claims for HBO Therapy |
| Part A | DRG | 682, 683 | Renal Failure | Review of Claims for Renal Failure |
| Part A | CPT® | 23472 | Low Biller Probe & Educate Total Shoulder Arthroscopy (TSA) | Review of Outpatient Claims for TSA |
| Part A | CPT® | 27130, 27447 | Total Hip Arthroplasty/Total Knee Arthroplasty | Review of Claims for Total Hip Arthroplasty/Total Knee Arthroplasty |
| Part A | CPT® | 97110 | Low Biller Probe & Educate Therapeutic Exercise | Review of Claims for Therapeutic Exercise |
| Part A |
CPT® |
97112 |
Low Biller Probe & Educate Neuromuscular Re-education | Review of Claims for Neuromuscular Re-education |
|
Part A |
CPT® |
97140 |
Manual Therapy |
Review of Outpatient Claims for Manual Therapy |
| Part A | CPT® | 97110, 97112, 97140 | Therapy Cap Review w/ KX HCPCS Modifier | Review of Outpatient Claims for Therapy Services Billed w/ KX HCPCS Modifier |
| Part A | CPT® | 92507, 92526, 97129, 97130 | Speech-Language Pathology Therapy | Review of Outpatient Claims for Speech-Language Pathology Therapy |
| Part A | DRG | 177–179 | Low Biller Probe & Educate Respiratory Infections and Inflammations w/ MCC and w/o CC or MCC |
Review of Claims for Respiratory Infections and Inflammations w/ MCC and w/o CC or MCC |
| Part A | DRG | 291–293 | Heart Failure and Shock w/ or w/o CC/MCC | Review of Claims for Heart Failure and Shock w/ or w/o CC/MCC |
| Part A | DRG | 470 | Low Biller Probe and Educate Major Joint Replacement | Joint Replacement, Review of Claims Submitted for Major Joint Replacement |
| Part A | DRG | 870–872 | Septicemia or Severe Sepsis Greater than 96 Hours | Review of Claims for Septicemia or Severe Sepsis Greater than 96 Hours |
| Part A |
DRG |
885 |
Low Biller Probe & Educate Psychoses | Review of Inpatient Claims for DRG 885 Psychoses |
| Part A | DRG | 266–267 | TAVR | Review of Claims for DRG 266–267 TAVR |
| Part A | DRG | 226–227 | Defibrillator Implant w/o Cardiac Cath | Review of Claims for DRG 226–227 Cardiac Defibrillator Implant w/o Cardiac Cath |
| Part A | DRG | 219–221 | Cardiac Valve and Oth Maj Cardiothoracic Proc w/o Card Cath | Review of Claims for DRG 219–221 Cardiac Valve and Oth Maj Cardiothoracic Proc w/o Card Cath |
| Part A | DRG | 602–603 | Low Biller Probe & Educate DRG 602–603 Cellulitis | Review of Claims for DRG 602–603 Cellulitis |
| Part A | Combined Inpatient Rehabilitation Services (IRF): CMGs A0103 – D0103, A0104 –D0104, A0106 – D0106, A0302 – D0302, A0303 – D0303, A0304 – D0304, A0305 –D0305, A0601 –D0601, A0602 –D0602, A0603 – D0603, A0604 – D0604, A0703 – D0703, A0704 – D0704, A0902 – D0902, A0903 – D0903, A0904 – D0904, A1404 – D1404, A2002 – D2002, A2003 – D2003, A2004 – D2004, A2005 – D2005 | Combined IRF |
Review of IRF |
|
| Part A |
CPT® |
77301 |
Intensity Modulated Radiotherapy (IMRT) Planning |
Review of Outpatient Claims for Diagnostic Imaging: IMRT Planning |
| Part A | CPT® | 77338 | MLC Device(s) for IMRT | Review of Outpatient Claims for Diagnostic Imaging: MLC Device(s) for IMRT |
| Part A | CPT® | 97530 | Low Biller Probe & Educate Therapeutic Activities | Review of Outpatient Claims for Therapeutic Activities |
| Part A | HCPCS | J9144 | Darzalex® (Daratumumab) | Review of Outpatient Claims for Daratumumab |
| Part A | HCPCS | J9299 | Nivolumab | Review of Outpatient Claims for Nivolumab |
| Part A | HCPCS | J2350 | Ocrelizumab | Review of Outpatient Claims for Ocrelizumab |
| Part A | HCPCS | J1459 | HCPCS J1459 — Privigen | Review of Outpatient Claims for Privigen |
| Part A | HCPCS | J9041 | Bortezomib | Review of Outpatient Claims for Bortezomib |
| Part A | SNF Probe and Educate | SNF | SNF | SNF 5-Claim Probe and Educate Project |
| Part A | DRG | 177–179 | Low Biller Probe & Educate Respiratory Infections and Inflammations w/ MCC and w/o CC or MCC | Review of Claims for Respiratory Infections and Inflammations w/ MCC and w/o CC or MCC |
| Part A | DRG | 377–379 | Gastrointestinal Hemorrhage | Review of Claims for DRG 377–379 Gastrointestinal Hemorrhage |
| Part A | DRG | 273–274 | Percutaneous Intracardiac Procedures | Review of Claims for DRG 273–274 Percutaneous Intracardiac Procedures |
| Part A | DRG | 266–267 | TAVR | Review of Claims for DRG 266–267 TAVR |
| Part A | DRG | 226–227 | Cardiac Defibrillator Implant w/o Cardiac Cath | Review of Claims for DRG 226–227 Cardiac Defibrillator Implant w/o Cardiac Cath |
| Part A | DRG | 219–221 | Cardiac Valve and Oth Maj Cardiothoracic Proc w/o Card Cath | Review of Claims for DRG 219–221 Cardiac Valve and Oth Maj Cardiothoracic Proc w/o Card Cath |
| Part A | DRG | 377–379 | Low Biller Probe & Educate Gastrointestinal Hemorrhage | Review of Claims for DRG 377–379 Gastrointestinal Hemorrhage |
| Part A | DRG | 602–603 | Low Biller Probe & Educate DRG 602–603 Cellulitis | Review of Claims for DRG 602–603 Cellulitis |
| Part A | DRG | 640–641 | Misc Disorders of Nutrition | Review of Misc Disorders of Nutrition |
| Part A | HCPCS | J9271 | Low Biller Probe & Educate Pembrolizumab (Keytruda®) | Review of Outpatient Claims for Pembrolizumab (Keytruda®) |
| Part A | DRG | 189 | Pulmonary Edema and Respiratory Failure | Review of Inpatient claims for DRG 189, Pulmonary Edema and Respiratory Failure |
| Part A | DRG | 853–854 | Infectious and Parasitic Diseases w/ O.R. Procedures | Review of Inpatient Claims for DRG 853–854, Infectious Diseases w/ O.R. Procedures w/ MCC, Review of Inpatient Claims for DRG 853–854, Infectious Diseases w/ O.R. Procedures w/ CC |
| Part A | DRG | 689–690 | Kidney and Urinary Tract Infections | Review of Inpatient Claims for DRG 689–690, Kidney and Urinary Tract Infections w/ MCC, Review of Inpatient Claims for DRG 689–690, Kidney and Urinary Tract Infections w/o MCC |
| Part B | CPT® |
66984 |
Extracapsular Cataract Removal w/ Insertion |
Review of Outpatient Claims for Extracapsular Cataract Removal w/ Insertion |
| Part B | CPT® |
97110 |
Therapeutic Exercise |
Review of Outpatient Claims for Therapeutic Exercise |
| Part B | CPT® | 99213–99215 | Established Patient Office Visit | Review of Claims for Established Patient Office Visit |
| Part B | CPT® | 97110, 97112, 97140, 97530, 92526, 97129, 97130, 92507 | Therapy Cap Review w/ KX Modifier | Review of Outpatient Claims for Therapy Services billed w/ KX Modifier |
| Part B | CPT® | 99232–99233 | Hospital Subsequent Visit | Review of Claims for Hospital Subsequent Visit |
| Part B | CPT® | 99284, 99285 | Emergency Department Services | E/M: CPT® Codes 99284–99285 Emergency Department Services |
| Part B | CPT® | 99291, 99292 | Critical Care Services | E/M: CPT® Codes 99291–99292 Critical Care Services |
| Part B | CPT® | 80061 | Diagnostic Services: Laboratory Tests — Lipid Panel | Review of Laboratory Tests: CPT® 80061 Lipid Panel |
| Part B | CPT® | 80061, 83721 | Diagnostic Services: Laboratory Tests Lipid Panel and Assay of Blood Lipoprotein | Review of Laboratory Tests: CPT® 80061 (Lipid Panel), CPT® 83721 (Assay of Blood Lipoprotein) |
| Part B | HCPCS |
J2778 |
Ranibizumab (Lucentis®) |
Review of Outpatient Claims for Ranibizumab (Lucentis®) |
| Part B | HCPCS |
J1745 |
Infliximab (Remicade®) |
Review of Outpatient Claims for Infliximab (Remicade®) |
| Part B | HCPCS |
J0178 |
Aflibercept (Eylea®) |
Review of Outpatient Claims for Aflibercept (Eylea®) |
| Part B | HCPCS | J9311, J9312 | HCPCS J9311, J9312 — Rituximab (Rituxan®) | Review of Outpatient Claims for Rituximab (Rituxan®) |
| Part B | CPT® |
11042–11047 |
Surgical Debridement |
Review of Outpatient Claims for Surgical Services, Surgical Debridement |
| Part B | CPT® |
90960–90967 |
ESRD —Monthly Outpatient ESRD —Related Services |
Review of Outpatient ESRD Claims w/ CPT® 90960–90967 |
| Part B | HCPCS |
A0427, A0429, A0425 |
Ambulance Service, Advanced Life Support, Emergency Transport/Ambulance Service, Basic Life Support, Emergency Transport/Ground Mileage |
Review of Ambulance Claims for Ambulance Service, Advanced Life Support, Emergency Transport/Ambulance Service, Basic Life Support, Emergency Transport/Ground Mileage |
| Part B | HCPCS | 80305–80307, G0480–G0483 | HCPCS 80305–80307, G0480–G0483 — Diagnostic Services: Clinical Labs | Review of Outpatient Claims for Drugs of Abuse Laboratory Tests: HCPCS 80305–80307, G0480–G0483 |
| Part B | CPT® | 93306 | Echocardiography w/ Contrast | Review of Outpatient Claims for Echocardiography w/ Contrast |
| Part B | CPT® | 82542 | Column Chromatography/Mass Spectrometry | Review of outpatient claims for Drugs of Abuse Laboratory Tests: Column Chromatography/Mass Spectrometry |
| Part B | HCPCS | J0897 | Denosumab (Prolia®) | Review of Outpatient Claims for HCPCS J0897 — Denosumab (Prolia®) |
| Part B | HCPCS | J0717 | Certolizumab Pegol (Cimzia®) | Review of Outpatient Claims for HCPCS J0717 — Certolizumab Pegol (Cimzia®) |
| Part B | HCPCS | J0129 | Abatacept (Orencia®) | Review of Outpatient Claims for HCPCS J0129 – Abatacept (Orencia®) |