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Oncology & Hematology Coding Alert

Reader Questions:

J9395 MUE Update Slated for April

Published on Wed Mar 09, 2011

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