MOS Newsline
- MOS NewsLine, Summer 2011
- MOS News Line, Spring 2010
- MOS News Line, Fall 2009
- MOS News Line, Spring 2009
- MOS News Bulletin, Spring 2008
WPS article on on reducing error rates for chemotherapy-related services
WPS Medicare has noted a recent increase in errors assessed for chemotherapy-related services. These services have the potential to have a large impact on Comprehensive Error Rate Testing (CERT) error rates for WPS Medicare and on a national level. To assist its providers and combat potential future errors, WPS has asked us to let our state society members know about an educational article written specifically for those who perform and bill chemotherapy-related services.
Update on Aloxi Denials
MO Healthnet Division has responded to the Missouri Oncology Society's letter of August 4, 2011, regarding Aloxi denials for chemotherapy patients in the Missouri HealthNet pharmacy program.
The response states that “Providers that received denied claims for the injectable antiemetics can re-submit their claims for payment, if they haven’t done so already.”
During the July implementation of the annual changes to the edit, explains MO Healthnet Division Director Ian McCaslin, MD, MPH, the injectable antiemetics were inadvertently included in the clinical edit criteria causing claims to deny for patients receiving these drugs for chemotherapy. The intention of this edit was to create a preferred drug list for the oral outpatient treatment of non-cancer related nausea and vomiting and not to restrict access to antiemetics used in currently accepted national guidelines for treatment for oncology patients.
The MO HealthNet Division (formerly Division of Medical Services) is one of six agencies reporting to the Department of Social Services (DSS). The MO HealthNet Division is responsible for the administration of services provided in accordance with Title XIX, Public Law 89-97, 1965 amendments to the federal Social Security Act, 42 U.S.C. Section 301. The purpose of the MO HealthNet Division is to purchase and monitor healthcare services for low income and vulnerable citizens of the State of Missouri.
WPS eNews
Wisconsin Physician Services (WPS) Medicare Jurisdictions 5 and 6 has issued a positive local coverage determination for CellSearch® Circulating Tumor Cell test. This policy will become effective 2/15/12. This coverage policy is for the CellSearch® (Veridex) Circulating Tumor Cell (CTC) assay utilizing CPT codes 0279T and 0280T. The policy clearly states that all other methods for circulating tumor cell detection, including PCR (RTPCR) assays, are non-covered as they are considered investigational.
Circulating tumor cells represent the point in the metastatic process of solid tumors when cells from a primary tumor invade, detach, disseminate, colonize and proliferate in a distant site. Detection of elevated CTCs during therapy is an accurate indication of subsequent rapid disease progression and mortality in breast, colorectal and prostate cancer. Therefore, CTC testing will be limited to metastatic breast, colorectal and prostate cancer. CTC testing for all other malignant diagnoses will be denied as not reasonable and necessary. The WPS policy can be found in its entirety at www.wpsmedicare.com, Circulating Tumor Cells Assays – L-32218.
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In Section V of its eNews for Monday, October 17, 2011, Wisconsin Physicians Services (WPS) provided instructions to providers on the documentation to be submitted to get high dollar drug claims paid in a timely fashion. The instructions read:
What documentation do I have to submit to get my high dollar drug claims paid timely?
To expedite your payment and to avoid CERT errors submit at least:
- The original medication order that is signed by the ordering physician. A complete order will include the drug name, the ordered dose, and the ordered frequency.
- The flow sheet, which includes the patient's name, dated the same as the date of service billed, shows the name of the medication given, the amount of the medication given, and any wasted amount of the medication.
The information also is available on the WPS website in the news scroll.
Please note that the "Medicare Tip of the Week," also contained in the October 17th issue, is a link to specific policy requirements for certain chemotherapy drugs and their adjuncts. To view this policy, go to: www.wpsmedicare.com/j5macpartb/policy/active/local/l28576_honc010.shtml.
Payment for Neulasta® (pegfilgrastim)
Following a letter from MOS President Joseph J. Muscato, MD, FACP, the Missouri Consolidated Health Care Plan has decided to reverse its decision requiring patients to now receive Neulasta® (pegfilgrastim) from a specialty pharmacy. Effective July 29, 2011, Neulasta® (pegfilgrastim) will be covered and processed as any other condition covered under MCHCP's medical plan, allowing prescribers to administer this medication at the physician's office. For more information, please read the two letters below.
Letter from President Muscato regarding MCHCP's policy
Response from Judith Muck, Interim Executive Director, MCHCP
Posted 8-8-2011
Filing Medicare High-Dollar Claims with WPS
A message from Joseph J. Muscato, MD, FACP, MOS President
I've heard from some of the MOS membership about your trials and tribulations with filing Medicare high-dollar claims with Wisconsin Physicians Service Insurance Corporation (WPS). As you know, the edits in the WPS system monitor claims that are approved for $5,000 or more, and WPS may review these high-dollar claims for any service. These reviews are expected to continue into the future. CMS will send a development letter; however as soon as a Medicare control number is assigned to the claim, you may send supporting information to WPS by fax at 608.223.7546.
CMS-approved Audit Issues
HealthDataInsights, Inc., the Medicare Recovery Audit Contractor (RAC) for Region D, identified on its website CMS-approved audit issues.
The following claims will be edited automatically and monies recouped in these areas if they were billed incorrectly:
- Pegfilgastim claims not billed with the 6 mg unit of service
- Newborn pediatric CPT codes billed for patients exceeding age limit
- Once in a lifetime procedures
- Excessive units—Untimed codes
- Excessive units—Blood transfusions
- Excessive units—Bronchoscopy
- Excessive units—IV hydration
Posted 9/17/09
Anthem BCBS Announces Policy Change: Pre-Certs for Chemotherapy Drugs
