July 23, 2013

Drill Down: Excessive Units Billed for Zoledronic Acid

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It has been a quiet week for the RAC contractors as far as posting approved issues is concerned.  Only RAC Region A Performant posted an automated audit issue, for outpatient hospital providers for Zoledronic Acid, Zometa®, HCPCS code J3487, billed in excess of the standard intravenous infusion dosage of 4 mg per day, per patient.

Per the Novartis Pharmaceuticals literature referenced by the RAC contractor for this issue, Zoledronic Acid is in a group of medicines called bisphosphonates and it works to inhibit the release of calcium in the bones. It is used to treat high blood levels of calcium caused by cancer. Zoledronic Acid also treats multiple myeloma (a type of bone marrow cancer) or bone cancer that has spread from elsewhere in the body.

Zometa is injected into a vein through an IV. This injection is performed in a clinic or hospital setting since it must be administered slowly and can take at least 15 minutes to complete.

Due to the risk of clinically significant deterioration in renal function, which may progress to renal failure, single doses of Zometa should not exceed 4 mg and the duration of infusion should be no less than 15 minutes. In the trials and in post-marketing experience, renal deterioration, progression to renal failure, and dialysis have occurred in patients, including those treated with the approved dose of 4 mg infused over 15 minutes. There have been instances of this occurring after the initial Zometa dose.

3 DOSAGE FORMS AND STRENGTHS

  • 4 mg/100 mL single-use ready-to-use bottle
  • 4 mg/5 mL single-use vial of concentrate

This automated review will be targeting HCPCS code J3487 on claims for units greater than 4 mg, per day, per patient. For this issue, Performant references such resources as the Centers for Medicare & Medicaid Services (CMS) publications: Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.6 along with the Local Coverage Determination (LCD) Article “Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents.”  

RAC issues for the week of July 22–July 26, 2013:

RAC Region A Performant

Outpatient Hospital Claim Types

  • Zoledronic Acid (Zometa®) Excessive Daily Units - J12 - Zoledronic Acid (Zometa®) (HCPCS code J3487) billed in excess of the standard intravenous infusion dosage of four units (4 mg), per day, per patient.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payors.

Contact the Author

Margaret.Klasa@context4.com

To comment on this article please go to editor@racmonitor.com

Margaret Klasa, DC, APN, Bc

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