Search Result - JF Part B
Outpatient Drugs and Biologicals
Hospitals and providers are reminded to ensure that units of drugs or biologicals administered to patients are accurately reported in terms of the dosage/units specified in the complete HCPCS code descriptor. Prior to submitting Medicare claims for drugs or biologicals, it is extremely important to review the complete long descriptors for the applicable HCPCS codes. Providers and hospitals should not bill the units based on the way the drug is packaged, stored or stocked.
Recent OIG audit findings indicate a problem with providers correctly coding the number of units billed with drug and biological charges. Below are examples of drugs and biologicals HCPCS codes, code descriptions and information on units to illustrate and assist in proper billing.
| HCPCS Level II Code | Code Description | Units |
|---|---|---|
| J0885 | Injection, epoetin alfa (for non-ESRD use), 1000 units | 1 unit per 1000 units |
| J1745 | Injection, infliximab, 10 mg | 1 unit per 10 mgs |
| J2805 | Injection, sincalide, 5 mcg | 1 unit per 5 mcgs |
| J9395 | Injection, fulvestrant, 25 mg | 1 unit per 25 mgs |
Example 1 - The HCPCS descriptor for the drug code is 10 mg and 700 mgs of the drug was administered to the patient; the units billed should be 70.
Example 2 - The HCPCS descriptor for the drug code is 5 mcg and 5 mcgs of the drug was administered to the patient; the units billed should be 1.
Example 3 - The HCPCs descriptor for the drug code is 25 mg and 250 mgs of the drug was administered to the patient; the units billed should be 10.
Additional findings included the following:
Providers are reporting a combination of incorrect units of service and incorrect HCPCS codes. For example, provider treating prostate cancer billed 12 units of service for leuprolide acetate injection (HCPCS code J1950, 3.75 milligrams per unit---total 45 mg), which is indicated for the treatment of endometriosis, uterine leiomyoma, and malignant neoplasm's of the breast. However, the provider should have billed 6 units of service for leuprolide acetate injections (HCPCS code J9217, 7.5 milligrams per unit---total 45 mg), which is indicated for the treatment of prostate cancer and was the dose actually administered.
Lack of Supporting Documentation
No documentation provided to support that a patient had received the drug service billed.
Incorrect HCPCS Codes
Providers are using incorrect HCPCS codes. For example, provider billed Medicare for 200 units of bevacizumab (HCPCS code J9035). However, the provider should have billed for 200 units of azacitidine (HCPCS code J9025), the drug actually administered.
Non-covered Use of a Drug
Providers are billing Medicare for the non-covered use of an outpatient drug. For example, provider billed for a drug (plerixafor) administered during a tandem bone-marrow transplant to a beneficiary with multiple myeloma, a service (tandem bone marrow transplant) that Medicare does not consider reasonable and necessary. Medicare does not pay for drugs administered for services not considered reasonable and necessary
Proper coding and billing of claims are necessary for accurate claim processing. Incorrect billing and documentation may result in underpayments or overpayments with subsequent recoupment and/or investigation.
Resources
- Healthcare Common Procedural Coding System (HCPCS) Manual
- CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 70
