Even before this, however, the Centers for Medicare & Medicaid Services (CMS) regularly provided guidelines about the right way to bill units in its quarterly hospital outpatient prospective payment system (OPPS) updates. (See guidelines on the Correct Reporting of Units for Drugs in the latest OPPS update at https://www.cms.gov/MLNMattersArticles/downloads/MM7117.pdf.)
Now, in the first-ever Medicare Quarterly Provider Compliance Newsletter (issued just this month), CMS again addresses the topic in a section entitled Other Drug Codes-Incorrect Number of Units Billed. The agency states that during the demonstration project RACs “determined that excessive/multiple units comprised many of the billing errors made by outpatient hospitals, and those errors totaled more than $2 million dollars. In most cases denials occurred because documentation was not sufficient to support the units billed.”
CMS also provides guidance on how providers can avoid the above problem as well as recommendations for improvement. For example:
- Do not bill the units based on the way the drug is packaged, stored, or stocked.
- If the HCPCS descriptor for the drug code specifies 1 mg and a 10-mg vial of the drug was administered, bill 10 units.
- Review the complete long descriptors for the most complete information about the applicable HCPCS codes.
Examples of Drug Units
The following are among the issues listed under the “drugs vs. units” focus on the web site of Connolly Healthcare for region C (www.connollyhealthcare.com/RAC):
- Tenecteplase (J3100) represents 50 mg per unit and should be billed as one unit for every 50 mg per patient, per date of service.
- Adenosine represents 6 mg per unit and should be billed as one unit for every 6 mg per patient per date of service.
- Zoledronic acid, (Reclast) represents 1 mg per unit and should be billed as 1 unit for every 1 mg per patient.
- Zoledronic acid, (Zometa) represents 1 mg per unit and should be billed as one unit for every 1 mg per patient. Claims for J3487 should be submitted so that the billed units represent the administered units, not the total number of milligrams. Zometa is given as a single 4 mg injection and the number of units billed on a claim should be 4.
- Darbepoetin alfa (ESRD) (J0882) represents 1 microgram (mcg) per unit and should be billed as one unit for every 1 mcg per patient.
On its website (http://racb.cgi.com), CGI Federal, the region B RAC, lists the following as a complex review:
- Oxaliplatin represents 0.5 mg per unit and should be billed as one unit every 0.5 mg administered per patient per date of service.
HealthDataInsights http://racinfo.healthdatainsights.com, the region D RAC, lists the following drug issue:
- Neulasta (HCPCS code J2505): Claims submitted with the total number of milligrams instead of one unit per 6mg. Claims for J2505 should be submitted so that the units billed represent the number of multiples of 6 mg administered, not the total number of mgs.
Diversified Collection Services (www.dcsrac.com), the region A RAC, also lists the following as an issue of interest:
- Neulasta: A potential vulnerability may exist if the code J2505 is billed with more than one unit per patient per date of service. Therefore, an issue may exist when these codes are billed and are reimbursed under Medicare Part B inside of this time frame.
About the Author
Randy Wiitala, BS, MT (ASCP) is a senior healthcare consultant with Medical Learning, Inc. (MedLearn), St. Paul, MN. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that will equip healthcare organizations with their coding, chargemaster, reimbursement management and RAC solutions.
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