Processing Error Results in Underpaid Faslodex Claims

A claims processing issue has resulted in claims for HCPCS Level II code J9395 Fulvestrant, 25 mg with dates of service on or after Jan. 1 to be improperly paid by at least one Medicare administrative contractor (MAC). The Centers for Medicare & Medicaid Services (CMS) recently discovered that providers were being underpaid for these claims because the payment limit for the breast cancer treatment drug was incorrectly set, according to Part B MAC Palmetto GBA.

Effective Jan. 1, 2011, the payment limit for J9395 is 500 mg, but Palmetto says it has been processing claims based on a payment limit of 250 mg. Consequently, Fulvestrant claims of more than 250 mg have been incorrectly denied by this contractor.

Palmetto says the error will be corrected by April 1. Until then, providers will need to be proactive to receive proper payment for J9395 claims.

Providers submitting claims for J9395 have two choices:

  1. Delay submission of Faslodex claims with a dosage greater than 250 mg until April 1; or
  2. Submit Faslodex claims with a dosage greater than 250 mg prior to April 1 and get paid up to the 500 mg limit by reporting J9395 on two lines of the claim using CPT® modifier 59 Distinct procedural service with the code on one claim line, reporting 10 units of service on each line.

Providers who have had claims for Faslodex denied on or after Jan. 1 due to this error should resubmit their claims using the second option or request a reopening after April 1.

Source: Palmetto GBA

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