Oncology & Hematology Coding Alert

Question: Medicare is giving me a medically unlikely edit (MUE) on J9045, saying the total units exceeded the units allowed (22) on the date of service (DOS) based on clinical benchmarks. I have verified the provider’s orders with pharmacy’s dosing and everything is correct. Is there a modifier I need to use to override the edit?>

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Answer: As one unit of J9045 (Injection, carboplatin, 50 mg) represents 50 mg, and Medicare allows 22 units of service (UOS) per DOS, then the maximum allowable dosage per date of service for a Medicare patient is 1,100 mg. This limit appears to be higher than several sources recommend.

If you have verified that the dose you are reporting is, indeed, accurate and is greater than the UOS allowed, you will not be able to use a modifier to override the Medicare MUE. However, you can appeal the edit per the National Correct Coding Initiative (NCCI) Policy Manual (www.cms.gov/files/document/ chapter1generalcorrectcodingpoliciesfinal11.pdf).

Remember: If Medicare denies the appeal, you cannot shift payment liability to the patient using an advanced beneficiary notice (ABN) “for UOS denied based on an MUE,” according to the manual.