JJ Parts A and B Active Medical Review List
Published 03/10/2026
| LOB | Code Type | Specific Code | Edit Topic | Edit Description |
|---|---|---|---|---|
| Part A | HCPCS | J9271 | Pembrolizumab (Keytruda®) | Review of outpatient claims for Pembrolizumab (Keytruda®) |
| Part A | HCPCS | J2505, J2506 | HCPCS J2505 — Pegfilgrastim (Neulasta®) 6mg HCPCS J2506 — Pegfilgrastim (Neulasta®), excludes biosimilar, 0.5mg |
Review of outpatient claims for HCPCS J2505; this code was retired as of Jan. 1, 2022 HCPCS J2506 is effective Jan. 1, 2022 for providers to bill |
| Part A | HCPCS | J9311, J9312 | Rituximab (Rituxan®) 10 mg and Hyaluronidase/ Rituximab, 10 mg | Review of outpatient claims for HCPCS J9311, J9312 — Rituximab (Rituxan®) 10 mg and Hyaluronidase/ Rituximab, 10 mg |
| Part A | HCPCS |
J9035 |
Bevacizumab (Avastin®), 10 mg | Review of outpatient claims for Bevacizumab (Avastin®), 10 mg |
| Part A | HCPCS |
J1745 |
Infliximab (Remicade®) | Review of outpatient claims for Infliximab (Remicade®) |
| Part A | HCPCS |
G0277 |
Hyperbaric Oxygen (HBO) Therapy | Review of outpatient claims for HBO Therapy |
| Part A | HCPCS | J0897 | HCPCS J0897 — Denosumab (Prolia®) | Review of outpatient Claims for HCPCS J0897 — Denosumab (Prolia®) |
| 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 |
Therapeutic Exercise | Review of outpatient claims for Therapeutic Exercise |
| Part A | CPT® |
97112 |
Neuromuscular Reeducation | Review of outpatient claims for rehabilitation Services — Neuromuscular Reeducation |
| Part A | CPT® |
97140 |
Manual Therapy | Review of outpatient claims for Manual Therapy |
| Part A | DRG | 266–267 | Cardiac Valve Replacement | Review of claims for DRG 266–267 Cardiac Valve Replacement |
| Part A | DRG | 470 | Major Joint Replacement | Review of claims submitted for Major Joint Replacement |
| Part A | DRG | 291–293 | Heart Failure and Shock with or without CC/MCC | Review of claims for heart failure and shock with or without CC/MCC |
| Part A | DRG | 682–683 | Renal Failure | Review of claims for renal failure |
| 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 |
Psychoses |
Review of inpatient claims for Psychoses |
| Part A | DRG | 177–179 | Respiratory Infections | Review of claims submitted for DRG 177–179 Respiratory Infections |
| 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 | 602–603 | Cellulitis | DRG 602–603 Cellulitis |
| Part A | DRG | 219–221 | Cardiac Valve & Other Major Cardiac Procedures without Cath | DRG 219 to 221 Cardiac Valve & Other Major Cardiac Procedures without Cath |
| Part A | DRG | 640–641 | Misc Disorders of Nutrition | DRG 640–641 Misc. Disorders of Nutrition |
| 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 with O.R. Procedures | Review of Inpatient claims for DRG 853–854, Infectious Diseases with O.R. Procedures with MCC, Review of Inpatient claims for DRG 853–854, Infectious Diseases with O.R. Procedures with CC |
| Part A | DRG | 689–690 | Kidney and Urinary Tract Infections | Review of Inpatient claims for DRG 689–690, Kidney and Urinary Tract Infections with MCC, Review of Inpatient claims for DRG 689–690, Kidney and Urinary Tract Infections without MCC |
| Part A | CPT® | 23472 | Total Shoulder Arthroplasty | Review of claims for Total Shoulder Arthroplasty |
| Part A | CPT® | 92507, 92526, 97129, 97130 | Speech Language Pathology Therapy | Review of outpatient claims for speech language pathology therapy |
| Part A | CPT® | 92507, 92526, 97129, 97130 | Speech Language Pathology Therapy Cap Review with KX Modifier | Review of outpatient claims for speech language pathology therapy services billed with a KX Modifier |
| Part A | CPT® | 97110, 97112, 97140 | Therapy Cap Review with KX HCPCS Modifier | Review of outpatient claims for therapy services billed with a KX HCPCS Modifier |
| Part A | CPT® | 97530 | Therapeutic Activities | Review of outpatient claims for Therapeutic Activities |
| Part A | IRF | 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 and A2005 – D2005 | Combined Inpatient Rehabilitation Services (IRF) | Review of IRF |
| Part A |
HIPPS |
ID, IE, JD, KA, KD, KE |
Skilled Nursing Facility (SNF) |
Review of SNF claims with an emphasis on codes in the following HIPPS categories: ID, IE, JD, KA, KD, KE |
| Part A | CPT® |
90999 |
End Stage Renal Disease (ESRD) — Renal Dialysis |
Review of claims submitted for outpatient CPT® 90999 — ESRD |
| Part A | HCPCS |
G0491 |
ESRD — Renal Dialysis (Acute Kidney Injury) |
Review of claims submitted for acute kidney injury without ESRD — Renal Dialysis |
| Part A | HCPCS | J9299 | Opdivo | Review of outpatient claims for Opdivo |
| Part A | HCPCS | J1459 | Privigen | Review of outpatient Claims for Privige |
| Part A | HCPCS | J9041 | Bortezomib | Review of outpatient Claims for Bortezomib (Velcade) |
| Part A | HCPCS | J2350 | Ocrelizumab | Review of outpatient Claims for Ocrelizumab (Ocrevus) |
| Part A | HCPCS | J9144, J9145 | Daratumumab | Review of outpatient Claims for HCPCS J9144/J9145 Daratumumab (Darzalex Faspro) |
| Part A | SNF Probe and Educate | SNF | SNF | SNF 5-Claim Probe and Educate Project |
| Part A | Inpatient Short Stay | Inpatient Short Stay | Inpatient Short Stay Less than 2 midnights | Inpatient Short Stay Less than 2 midnights |
| Part B | CPT® |
66984 |
Extracapsular Cataract Removal with Insertion |
Review of outpatient claims for Extracapsular Cataract Removal with 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 | 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 | CPT® |
11042–11047 |
Surgical Debridement |
Review of outpatient claims for Surgical Services: CPT® 11042–11047 — Surgical Debridement |
| Part B | CPT® |
90960–90967 |
ESRD — Monthly Outpatient ESRD-Related Services |
Review of outpatient ESRD claims with CPT® 90960–90967 |
| Part B | HCPCS |
A0427, A0429, A0425 |
Ambulance Services (Emergent): |
Review of Ambulance claims for Ambulance Services (Emergent): HCPCS Codes A0429 — Basic Life Support, Emergency, A0427 — Advanced Life Support, Emergency, A0425 — Ground Mileage |
| Part B | HCPCS | Q4100–Q4382 | Skin Substitutes with GW modifier appended to the claim | Review of Skin Substitute Claims Where the GW Modifier has been Appended to the Claim |
| Part B | CPT® | 93306 | Echocardiography with Contrast | Review of outpatient claims for Echocardiography with Contrast |
| Part B | CPT® / HCPCS | 80305–80307, G0480–G0483 | CPT® 80305–80307/HCPCS G0480–G0483 — Diagnostic Services: Clinical Labs | Review of outpatient claims for Drugs of Abuse Laboratory Tests: CPT® 80305–80307/HCPCS G0480–G0483 |
| Part B | CPT® | 82542 | Column Chromatography, Mass Spectrometry | Review of outpatient claims for Drugs of Abuse Laboratory Tests: Column Chromatography, Mass Spectrometry |
| Part B | CPT® | 80061 | Diagnostic Services: Laboratory Tests — Lipid Panel | Review of outpatient claims for Drugs of Abuse Laboratory Tests: Lipid Panel |
| Part B | CPT® | 80061, 83721 | Diagnostic Services: Laboratory Tests CPT® 80061 — Lipid Panel CPT® 83721 — Assay of Blood Lipoprotein) |
Review of outpatient claims for Drugs of Abuse Laboratory Tests: CPT® 80061 (Lipid Panel), CPT® 83721 (Assay of Blood Lipoprotein) |
| Part B | CPT® | 97112 | Neuromuscular Reeducation | Review of outpatient claims for rehabilitation Services — Neuromuscular Reeducation |
| Part B | CPT® | 97530 | Therapeutic Activities | Review of outpatient claims for Therapeutic Activities |
| Part B | CPT® | 97140 | Manual Therapy | Review of outpatient claims for rehabilitation services — Manual Therapy |
| Part B | CPT® | 99232–99233 | Hospital Subsequent Visit | Review of claims for hospital subsequent visit |
| Part B | CPT® | 97110, 97112, 97140, 97530, 92526, 97129, 97130, 92507 | Therapy Cap Review with KX Modifier | Review of outpatient claims for therapy services billed with a KX Modifier |
| 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 | 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®) |