04/02/2019

Payer Issue Tracking Page

Last Updated 4/2/19

WPS MEDICARE

Problem: MSHO has received recent reports of denials for ESAs (J0881 and J0885) for MDS. It appears that the update by WPS changed the diagnosis reporting from needing 2 diagnosis to needing just one primary diagnosis.. MSHO members reported that when they bill their claim with just one of the diagnosis listed on the LCD, they are reimbursed.  MSHO is still investigating.

Below is a list of the acceptable ICD-10 codes from the WPS LCD - REPORT ONLY ONE DIAGNOSIS

Reported 2/4/19 (Thank you Lynne Wilcox for bringing this issue to our attention!)

Update 2/19/19 - MSHO has received reports of additional issues related to wrongful denials of ESAs for Chemo Induced Anemia, MDS and Chronic Kidney Disease.  Examples have been sent to WPS for review and request for system correction.

Update/Resolution 3/19/19 - WPS indicated they will DENY any claims that include D64.9.  They stated this is not a payable code and even if you have the correct diagnosis code (above) along with the D64.9, they will deny the claim!

Additional Update/Resolution 3/22/19:  WPS shared with MSHO the following list of diagnosis codes that will cause your CLAIM to deny when billing an ESA for Chemotherapy Induced Anemia (which falls under the National Coverage Determination).  If any of the diagnosis codes from this list are anywhere on your claim, your claim will deny.  This list was published by CMS quite some time ago but it appears that WPS Medicare recently added these edits and now are enforcing this CMS policy.   To view this list refer to the R2202OTN International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs): CLICK HERE - be sure to scroll to the bottom of the article and look for the section on the spreadsheet that states:  Standard systems maintainers (SSMs) shall DENY non-ESRD ESA services for HCPCS J0881 or J0885 billed with modifier -EC (ESA, anemia, non-chemo/radio) when any one of the following diagnosis codes is present on the claim"

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No additional WPS system problems reported at this time, if you are experiencing any WPS related claim delays or wrongful denials, be sure to alert MSHO via email at billing@msho.org

BCBSM

Problem:  BCBSM is reimbursing VERY low on the new Imfinzi, J9173.

Reported 3/19/19

Problem: BCBSM has the maximum units for the Rituxan now J-code, J9312, 10 mg, loaded incorrectly in their system.  The Max unit used to be 1,200 mg... and BCBSM has a limit of 20 for the new code (200mg).  This has been reported and BCBSM is looking into it!

Reported: 2/31/19 - (Thank you Lori Peddicord & Sara Gouins for brining this issue to our attention!)

Update 2/19/19- (From BCBSM)  There is currently an update in process.  The HCPCS billable changed with the new code that was released in January 2019, and the quantity limit is being adjusted to meet most members dose needs. The max will be the qty of 200.  I was advised that this change will be retroactive to January 1, 2019.  I do not have any information on an implementation completion date at this time.

Update 3/4/19 - (From BCBSM)  We have been informed that the system has been updated with the correct MUE, however we do not have any confirmed payments.  MSHO is awaiting member offices' confirmation of the fix.

Resolution 3/20/19 - J9312 has been updated in the BCBSM system. Claims should process correctly going forward.  You should be able to call to get your claims reprocessed   (thanks to Lori Peddicord, CHONC for this update!!)

BCN

No BCN system problems reported at this time.

MEDICAID

Please see the Medicaid section of this newsletter for updates.

NOTE: If you have a payer issue that you believe is a system problem and you do not see it listed above, PLEASE report it to MSHO! 

To report, email the description of your issue, including the ICN Number, date of service, provider number and patient contract number to billing@msho.org.  Do not include the patient’s name.

REMINDER – MSHO’s role is to resolve payer issues that will/can impact all members; we do not address individual claim issues. Unique, patient specific issues should not be reported.