04/17/2018

Important Oncology Related News

WPS GHA is Increasing the High Dollar Review Threshold Amount from $7,500 to $10,000!

Based on the results of the audit of our Medicare Contractor, Wisconsin Physician Services (WPS) by the Office of Inspector General audit in 2009, WPS GHA implemented Multi Carrier System (MCS) edits to monitor high dollar claims. Initially the threshold was set at $5,000.00 or more and increased to $7,500.00 or more early in 2012, by request of MSHO.  These claims require a PRE-PAYMENT documentation review.

In March, by request of a member office, MSHO requested the threshold be raised due to, “undue burden and payment delays.”  On April 4, 2018, MSHO received an email from WPS that they have raised the threshold to $10,000 effective April 2, 2018.

While all High Dollar Pre-Payment reviews did not cease, it is good news for our members as  fewer of their claims will be impacted and more claims will be processed without requiring documentation review. 

If you have any questions about this alert, please contact Michelle Weiss at billing@msho.org. 

April 18, 2018 - MSHO and ASCO REVIEW PUMP POLICY CHANGE AND REIMBURSEMENT 

MSHO and ASCO have teamed up to address the significant negative financial impact of the change in billing for portable pumps.  This summary included not only the low reimbursement rate for the HCPCS Code G0498, but also the direct cost to providers from the supplier of $75.00 for use of the pump, as well as the problems with secondary insurance reimbursement.  We will soon be taking this issue directly to CMS to request a higher fee schedule and/or change in policy.  Keep an eye on this bulletin for further updates.

NEW - RITUXAN HYCELA C-CODE FOR HOSPITAL OUTPATIENT SETTING

The following is important information regarding a unique C-code that was recently assigned to RITUXAN HYCELA™ (rituximab/hyaluronidase human) by the Centers for Medicare & Medicaid Services (CMS). The C-code for RITUXAN HYCELA is C9467 (Injection, rituximab and hyaluronidase, 10 mg).

The unique C-code went into effect on April 1, 2018. Payers may require its use until a permanent J-code is assigned. The permanent J-code is expected to be available for use starting on January 1, 2019.

The C-code is used primarily in the Medicare hospital outpatient setting. Please check with your MAC to verify codes and any special billing requirements.

For more information about Genentech BioOncology Access Solutions call (888) 249‐4918 or visit Genentech-Access.com/ RITUXANHYCELA.