Updated on: January 30, 2013

Focus of Current RAC Issues: Billed Units Must Equal Administered Units

By
Original story posted on: February 2, 2011

wiitalaRFor some time now, hospital outpatient providers have had a real problem billing the right number of units for the dose given, and this fact has come under the microscope of all four of the Recovery Audit Contractors (RACs).

Connolly Healthcare, the RAC for Region C, lists several drugs it is investigating.

Over the last year or two, the Centers for Medicare & Medicaid Services (CMS) have provided guidelines in its quarterly hospital outpatient prospective payment system (OPPS) updates about the right way to bill units. In the first Medicare Quarterly Provider Compliance Newsletter (issued in early October, 2010), 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."

In that document, 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 HCPCS level II longdescriptors for the most complete information about the drug.

What the RACs Say

RACs are finding that many hospital outpatient providers are submitting claims for the total number of milligrams instead of just one unit per the dosage of mg given. The lesson is clear: The billed units represent the administered units, not the mg or mcg listed below in the second column.

All but two of the drugs listed below have been posted by Connolly Healthcare.  Unless noted otherwise, hospital outpatient providers should bill only one unit for the mg or mcg (per patient, per date of service) listed in the second column below.

For example, a 50 mg dosage of Tenecteplase (J3100) would NOT be billed as 50 units. It would, instead, be billed as one unit. If two 50 mg dosages of Tenecteplase (J3100) were given, the number of units would be two.

The table below lists the drugs and units that are included as issues on RAC web sites.  Always note the dates of service (DOS) that will be reviewed by the RACs because they generally do not always relate to the current codes and descriptors.

Drugs Now Under RAC Review

Number of mg Per Unit

Tenecteplase (J3100)

50 mg

Zoledronic acid (Reclast)

1 mg

Zoledronic acid (Zometa)1

1 mg

Darbepoetin alfa (ESRD) (J0881)

1 microgram (mcg)

Darbepoetin alfa (ESRD) (J0882)

1 mcg

Pamidronate disodium (J2430)

30 mg

Adenosine

6 mg

Adenosine

30 mg

Docetaxel (J9170)

20 mg

Injection, pegfilgrastim (J2505)

6 mg

Carboplatin (J9045)

50 mg

Bevacizumab (J9035)

10 mg

Irinotecan (J9206)

20 mg

Docetaxel (J9170)

20 mg

Carboplatin (J9045)

50 mg

Bevacizumab (J9035)

10 mg per unit

Neulaste2 (J2505)

6 mg

Oxaliplatin3

0.5 mg

 


1Zometa (J3487) is given as a single 4 mg injection and the number of units billed on a claim should be 4.

2This issue is not listed by Connolly Healthcare (www.connollyhealthcare.com/RAC) but is listed by the Region D RAC, HealthDataInsights (http://racinfo.healthdatainsights.com) and by the Region A RAC, Diversified Collection Services (www.dcsrac.com),

3This issue is listed only by the CGI Federal, the Region B RAC, at http://racb.cgi.com/Issues.aspx.


Then and Now

As stated above, when checking your RAC listings for issues to be reviewed, be very aware of the dates of claims being reviewed. Two good examples are found in the list above.

Specifically, the issues list posted by the Connolly Healthcare RAC states that tenecteplase (J3100) would need to be billed as 1 unit/50 mg. For current claims, this is not correct because J3100 does not even exist anymore. It has been replaced by J3101, which needs to be billed as 50 units/50 mg.

Docetaxel is also incorrect since J9171, which needs to be billed as 1 unit/1 mg, has now replaced J9170.

Drugs under RAC Review

DOS Being Reviewed

Our Clarifications

Tenecteplase, 50 mg (J3100)

10/01/2007-open

CMS deleted code J3100 effective January 1, 2009-the date that code J3101 took effect. According to the CMS HCPCS Level II file, the dosage for J3101 is 1 mg; therefore, 1 unit would be billed per 1 mg injection. Even though it is no longer an active code, the 2011 HCPCS Level II file also includes J3100, which has a dosage of 50 mg.

Docetaxel, 20 mg (J9170)

10/01/2007-12/31/2009

CMS deleted code J9170 effective January 1, 2010-the date that J9171 (1 mg) took effect. One  unit should be billed for 1 mg given.

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.

Contact the Author

rwiitala@medlearn.com

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

To read article entitled, "Keep  Patients Hospitalized Longer, Shorter? DRGs: Then and Now," please click here

See guidelines on the Correct Reporting of Units for Drugs at https://www.cms.gov/MLNMattersArticles/downloads/MM7117.pdf

Randy Wiitala, BS, MT (ASCP)

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