Oncology & Hematology Coding Alert

Question: We've been getting denials for J9395 based on the number of units. Is there an MUE for this code?

Illinois Subscriber

Answer: HCPCS codes, like CPT codes, are subject to Medicare's Medically Unlikely Edits (MUEs), which are basically edits on the number of units you submit on a line.

The idea is that the MUE number is the maximum number of units expected for a given code in the vast majority of cases. Unfortunately, Medicare does not publish all of the MUEs. Currently, none of the J-code MUEs are published with the others at www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp.

Likely denial cause: Code J9395 (Injection, fulvestrant, 25 mg) has an MUE of 10, so CMS allows a maximum of 10 units. This number was chosen because the FDAapproved prescribing information at the time the edit was created was 250 mg. (The approved 250 mg divided by the descriptor's 25 mg results in 10 units.)

Problem: The FDA approved a 500 mg dose in the fall of 2010. Reporting that 500 mg dose requires 20 units, which is twice the MUE.

Solution: CMS has said it will change the MUE April 1 (retroactive to Jan. 1, 2011). In the meantime, CMS suggests two options. You can hold the 500 mg claims until April 1. Or, in this very special instance, you may submit claims for 20 units -- which reflects that 500 mg dose -- before April 1 by reporting J9395 on two lines with modifier 59 (Distinct procedural service) on one of the codes. By reporting 10 units per line you claim the 20 units without triggering the MUE denial.

Watch for: If your practice has been submitting more than 10 units for fulvestrant (Faslodex), warn your staff to look for MUE-related denials. If you had claims denied between Jan. 1 and April 1, you will be able to resubmit those claims or appeal them for payment.

Resource: You can read the notice from CMS here: www.wpsmedicare.com/part_b/departments/claims/mue-j9395.shtml.

Final note: Coders have been reporting similar issues with 5FU (J9190, Injection, fluorouracil, 500 mg) and epoetin alfa (J0885, Injection, epoetin alfa, [for non-ESRD use], 1000 units). Experts suggest alerting your carrier and oncology society to be sure the problem doesn't go unnoticed.