Wiki J9190/5-fu

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NESmith

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Zephyrhills, FL
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Good Morning We have been getting denials from Medicare when billing J9190 for CO-50 (Not Medically Necessary). Upon calling Medicare we were told that there is now an internal MUE but they can not tell us what it is. They states this told place starting Jan.1 2011, but we just starting getting denials. Does anyone know what the new MUE is for J9190? Thanks as always for your help.
 
The CMS MUEs for Faslodex and 5 FU have been contested. The values for these drugs are scheduled to be adjusted on 4/1/2011. Until then providers may choose to hold claims or submit claims prior to this day reporting J9395 on two lines of the claim (10 units on each line) with the 59 modifier on one line. To my knowledge, there is no published instructions on billing 5FU with the 59modier. However, considering the fact that claims with more than 2 units of 5FU per line hitting the MUE, we have been reporting 5FU on several lines with 2 units per line and the 59 modifier on all but the first line. This is how we would report 5FU in FOLFOX regimen (725mg as IV push in the office and 4,525mg in pump over 36hrs):

96411
J9190 x2units (pos 11)

96416 -59
J9190 x2units (pos 12)
J9190 x2units (pos 12) / 59 mod
J9190 x2units (pos 12) / 59 mod
J9190 x2units (pos 12) / 59 mod
J9190 x2units (pos 12) / 59 mod

Best regards -
 
Fabulous plan LPetrova! It's always something with Medicare and I'm starting to think they are pulling these MUEs out to keep us all on our toes. Unfortunately, creativity is becoming the name of the game. Good luck NESmith!
 
i have another question on 5fu placed in pump

Can you bill for the drug that is placed in the pump, when the pump itself is supplied and billed by a separate company not the physician's office? The physician office supplies the 5FU and all other aspects of the chemotherapy regimen. This has been a question for years that comes up now and then with every new nurse[CMS addressed this several years back, yet I can't find the article on the CMS website]. Looking forward to your comments.
 
We use and outside company for our pumps, but bill for the drug we load into the pump. We do the connect and disconnect of the pump as well and bill for those. We've not had any issues with doing this throughout our internal and external chemo audits. Hope this information proves helpful. Good luck!
 
Hello all! I see that this thread is from 2011! I am currently receiving UHC Community Plan denials for exceeds number/frequency of units. Is anybody else having this issue currently?
 
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