Palmetto/J1MAC News

The following information has been received by ANCO.


****PALMETTO/J1MAC NEWS****
July 2009 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing
Files and Revisions to Prior Quarterly Pricing Files

This MLN article, Change Request (CR) 6471, instructs Medicare Contractors
to download and implement the July 2009 ASP drug pricing file to determine
the payment limit for claims for separately payable Medicare Part B drugs
processed or reprocessed on or after July 6, 2009 with dates of service
July 1, 2009, through September 30, 2009.
http://www.palmettogba.com/palmetto/Providers.nsf/vMasterDID/7S9LVX6631?opendocument


Erythropoietin Stimulating Agents (ESAs) for the Treatment of Anemia Unrelated to Dialysis Therapy  Rounding Error

States Applicable to Alert:
American Samoa, Guam, Hawaii, Nevada, Northern Mariana Islands, Northern
California and Southern California

Background Information:
From April 1, 2009 through May 9, 2009, there was an error in the EDI system, which may have caused claims submitted with a Hematocrit (HCT) and/or Hemoglobin (HGB) level, to process incorrectly. The system may have been erroneously rounding the levels to the nearest whole number. Claims with .4 or below were rounded down and claims with .5 or higher were rounded up. If the levels were rounded to high (i.e. if the HBG was rounded to 10.0 or the HCT was rounded to 30.0) then the service may have been denied in error.

Applies To Procedure Code(s):
J0881
J0885

Modifier(s):
EA

Remark /Reason Codes:
50 - These are non-covered services because this is not deemed a "medical necessity" by the payer.
N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.

MAC Action:
Services brought to our attention by affected providers will be adjusted.

Provider Action:
If you feel that you have claims that meet this criteria please contact the Telephone Reopening Line at 1-866-669-5543 to have your claims reopened. You may also request your Reopenings in writing.