Original story posted on: August 2, 2013

Drill Down: Maximum Allowable Units

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RAC Region B contractor CGI posted a semi-automated issue that targets professional drug claims which have quantities beyond the maximum allowable units based on the Palmetto GBA Drugs & Biologicals: Maximum Allowed Units (MAU) list. Palmetto GBA developed maximum allowed units (MAU) modeled from the medically unbelievable edits (MUE) implemented by Centers for Medicare & Medicaid Services (CMS).

Why did Medicare Administrative Contractors Palmetto GBA make its own MAU? Since drug calculations require accurate conversion of drug units supplied, the total amount given to a patient, and the units billed, these multiple mathematical conversions by the billing staff caused errors on claims submitted. Palmetto GBA therefore decided to create a maximum allowed units table modeled from the CMS MUE table.

Palmetto used specific guidelines to create the table, such as:

  • Lethal dose per package insert
  • For multiple-dose drugs, MAU allows expected dose for 12-hour period and appropriate for clinic/office environment
  • For weight-based calculations, MAU allows the following:
    • 2.4 m2 BSA maximum
    • 110 kg lean body weight maximum
  • For emergency injectables, MAU allows one dose, plus one repeat dose to cover patient move from the clinic/OP setting to ER and IH
  • For multiple-use drugs, MAU reflects maximum for all uses. Note that based on the varied parameters, Palmetto GBA expects the average patient may receive dosage below the MAU and will continue to monitor utilization outliers for further action.

A complete list and billing instructions being referenced by this RAC issue on Palmetto GBA’s website can be found here: http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/7REJY56858

To read the multiple tables contained on the website, I will provide an example. On the web page, you will see the table titled MAU Legend with numbers in the first column that describe how the code is handled. For example, #5 means Special Instructions (select HCPCS code to view instructions) and in this case I will use HCPCS code J1170. In the table titled Maximum Allowed Units List the second column is the HCPCS code, followed by the code description, and then the MUA in the fourth column, which in this case it is 300 MAU. The fifth column is the release date of the code and the sixth column is the reassessment date.

MAU Legend:

#

Description

1

Deleted code for dates of service on or after 01/01/2009

2

Non-covered Part B services

3

Self-administered drug

4

Drug removed from U.S. market

5

Special Instructions (select HCPCS code to view instructions)

6

Deleted code for dates of service on or after 01/01/2008

7

Deleted code for dates of service on or after 04/01/2008

8

New codes for dates of service on or after 01/01/2009

9

Deleted code for dates of service on or after 01/01/2010

10

Deleted code for dates of service on or after 01/01/2011

 

Maximum Allowed Units List

KEY

HCPCS Code

Code Description

MAU

Release Date

Reassessment
Date

5

J1170

Injection, hydromorphone, up to 4 mg

300

11/7/2008

 

 

Special Instructions, as mentioned above for HCPCS code J1170, are as follows for submitting paper or electronic claims.

HCPCS Code J1170 - Hydromorphone
For Hydromorphone implantable pump use, providers must submit the invoice with the total units that are used to fill the pump.

  • For paper claim submissions, enter “compound prescription, invoice attached” in Item 19 and include a copy of the pharmacy invoice
  • For electronic claim submission, enter “fax” in the narrative field and include a copy of the pharmacy invoice with the appropriate cover sheet

This is a semi-automated review edit to identify professional drug claims which were submitted with quantities beyond the maximum allowable amount first, and then request any supporting documentation required per special Instructions or for individual consideration.

RAC issues for the week of August 5–August 9, 2013:

RAC Region B CGI

DME Claim Types

  • DME Home Health Consolidated Billing - NGS - Under the Prospective Payment System (PPS) a Home Health agency must bill for all Home Health services, which include nursing, therapy, home health aide, medical social services, routine and non-routine supplies, except DME. DME was excluded from the Balanced Budget Act (BBA) as an established consolidated billing requirement by the Balanced Budget Refinement Act (BBRA.) The law requires that all Home Health services paid on a cost basis be included in the PPS rate; therefore, the PPS rate will include all nursing, therapy, aide, medical social services, routine and non-routine medical supplies. Both routine and non-routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care. The CMS publishes a list of these medical supplies annually, identified by HCPCS code. If no home health plan of care is in place, non-routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.

Outpatient Hospital Claim Types

  • Outpatient Home Health Consolidated Billing - CGS - Under the Prospective Payment System (PPS) a Home Health agency must bill for all Home Health services, which include nursing, therapy, home health aide, medical social services, routine and non-routine supplies, except DME. DME was excluded from the Balanced Budget Act (BBA) as an established consolidated billing requirement by the Balanced Budget Refinement Act (BBRA.) The law requires that all Home Health services paid on a cost basis be included in the PPS rate; therefore, the PPS rate will include all nursing, therapy, aide, medical social services, routine and non-routine medical supplies. Both routine and non-routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care. The CMS publishes a list of these medical supplies annually, identified by HCPCS code. If no home health plan of care is in place, non-routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.
  • Outpatient Home Health Consolidated Billing - WPS - Under the Prospective Payment System (PPS) a Home Health agency must bill for all Home Health services, which include nursing, therapy, home health aide, medical social services, routine and non-routine supplies, except DME. DME was excluded from the Balanced Budget Act (BBA) as an established consolidated billing requirement by the Balanced Budget Refinement Act (BBRA.) The law requires that all Home Health services paid on a cost basis be included in the PPS rate; therefore, the PPS rate will include all nursing, therapy, aide, medical social services, routine and non-routine medical supplies. Both routine and non-routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care. The CMS publishes a list of these medical supplies annually, identified by HCPCS code. If no home health plan of care is in place, non-routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.

Professional Claim Types

  • Drug - Maximum Allowable Units - This semi-automated edit is to identify professional drug claims which were submitted with quantities beyond the maximum allowable amount based on the Palmetto Drug & Biologicals: Maximum Allowed Units (MAU) list.
  • Professional Home Health Consolidated Billing - CGS - Under the Prospective Payment System (PPS) a Home Health agency must bill for all Home Health services, which include nursing, therapy, home health aide, medical social services, routine and non-routine supplies, except DME. DME was excluded from the Balanced Budget Act (BBA) as an established consolidated billing requirement by the Balanced Budget Refinement Act (BBRA.) The law requires that all Home Health services paid on a cost basis be included in the PPS rate; therefore, the PPS rate will include all nursing, therapy, aide, medical social services, routine and non-routine medical supplies. Both routine and non-routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care. The CMS publishes a list of these medical supplies annually, identified by HCPCS code. If no home health plan of care is in place, non-routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.
  • Professional Home Health Consolidated Billing - WPS - Under the Prospective Payment System (PPS) a Home Health agency must bill for all Home Health services, which include nursing, therapy, home health aide, medical social services, routine and non-routine supplies, except DME. DME was excluded from the Balanced Budget Act (BBA) as an established consolidated billing requirement by the Balanced Budget Refinement Act (BBRA.) The law requires that all Home Health services paid on a cost basis be included in the PPS rate; therefore, the PPS rate will include all nursing, therapy, aide, medical social services, routine and non-routine medical supplies. Both routine and non-routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care. The CMS publishes a list of these medical supplies annually, identified by HCPCS code. If no home health plan of care is in place, non-routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.

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

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Margaret Klasa, DC, APN, Bc

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