Medicare adjusts Faslodex claims edit
Put words in our mouth
On Jan. 1, CMS implemented a Medically Unlikely Edit (MUE) for injectable drug Faslodex (fulvestrant, 25 mg), HCPCS code J9395.
The edit was set at 10 units of service, meaning that a physician could bill a maximum of 250 mg per day (the then-current FDA approved dosage), per patient. Shortly before the implementation date, the FDA increased the approved dosage to 500 mg. CMS was not able to update the amount of its edit to reflect the new FDA dosage in time for the January implementation. However, after the initial implementation, CMS went back and subsequently increased the edit to 20 units of service to allow a maximum of 500 mg to be billed per patient per day. The new edit is retroactive to Jan. 1.
Because of the lag time between the FDA increase and the edit adjustment, physicians may delay submission of their Faslodex claims until April 1. Alternatively, in this instance only, physicians may submit their claims prior to April 1 by reporting J9395 on two lines of a claim, utilizing modifier -59 with the modifier on only one claim line. The physician may report 10 units of service on each claim line.
If physicians have had their claims denied due to this MUE value, they may resubmit their claims or they may appeal them to their local claims processing contractor after April 1.