07/24/2018

MSHO Reimbursement Alert

Outpatient Hospital Denials for ESAs

July 19, 2018

For the last few weeks, MSHO has been working with WPS Medicare to determine the reasoning for a multitude of denials for ESAs (J0881 & J0885) on outpatient hospital claims for diagnosis  codes which include Chemotherapy Induced Anemia, MDS and Chronic Kidney Disease.  The claims had the proper diagnosis codes, modifiers, HGB/HCT levels, etc., but were still denied.

MSHO was alerted today that WPS has identified the system problem and, as of yesterday (Wednesday, July 18th), it has been corrected.  Claims going forward should be paid correctly.  

WPS identified wrongfully denied claims as far back as October of 2017, and are in the process of doing a mass adjustment.  We have been instructed by WPS to tell our membership "Please don't rebill or appeal anything in the meantime."  They estimate the mass adjustment should take 2 - 3 weeks before outpatient hospital providers will begin to see the corrected payments.

If you have any questions about this alert, please contact Michelle Weiss, Senior Reimbursement Consultant to MSHO via email at billing@msho.org.