Inappropriate Use of Units Costs Practice Over $800,000

June 11th, 2018 - Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
Categories:   Office of Inspector General (OIG)   Laboratory|Pathology   Drugs|Pharmaceuticals|FDA   Billing   HCPCS Coding  
0 Votes - Sign in to vote or comment.

A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut submitted multiple units for urine drug screening tests. The press release stated that "Urine drug screening tests use a single sample of a patient’s urine to test for multiple classes of drugs. Although the test screens a patient’s urine for multiple classes of drugs, Medicare considers it a single test that should be billed only once per patient encounter."

The proper billing of units has proven to be problematic for more than just lab tests. Problems are also commonly reported with the billing of drugs and biologicals, timed codes, and multiple injections.

Drugs and Biologicals

One OIG review of a single MAC found a 57% error rate in the billing of drugs and biologicals. There are several reasons why there could be billing problems. Providers need to understand all the rules to ensure that they are billing properly. These problems commonly arise because packaging dosages typically don't match up with HCPCS descriptions. Claims MUST match up. For example, if the description for the HCPCS code specifies 25 milligrams and 100 milligrams are administered, 4 units should be billed.

So what do you do when they don't match up? Follow payer guidelines. According to Medicare, Do "not bill the units based on the way the drug is packaged, stored, or stocked. That is, if the HCPCS code descriptor for the drug code specifies 1 mg and a 10 mg vial of the drug was administered to the patient, bill 10 units, even though only 1 vial was administered." In this Medicare example, the drug would have been under-billed. However, more commonly, the drug is over-billed with too many units.

Another problematic area is rounding. What if the dosage doesn't match up to the packaging? According to Medicare, always round up. They state, "If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit." CMS has emphasized that units billed should be based on the dosage in the code description. There are two common problems that arise in this situation

  1. What if you only administer 10 mg and the code description states 25 mg? You round up and bill for one unit.
  2. What if there are multiple codes with varying dosages? Bill the code with the next unit. For example, what should you bill if you administer 50 mg of methylprednisolone acetate?There are 3 HCPCS codes:

Report the drugs as close to the way in which the provider administered them. Since Depo Medrol (methyprednisolone acetate) does not come in vials of 60 mg/cc, just bill what the provider used, which would likely be 3 cc from the 20 mg vial. Therefore, bill:

J1020 with 3 units (20 mg X 3 units = 60 mg)

Notes:

  • When selecting the HCPCS code, be sure to select the one with the proper administration method (e.g., intravenous, subcutaneous, intravenous push).
  • Don't forget to include the NDC, description and unit in the red shaded portion of Item Number 24 of the 1500 Claim Form (e.g., N400026065871 Immune Globulin Intravenous    UN2). 
  • CLICK HERE to review the Medicare Claims Processing Manual, Chapter 17 - Drugs and Biologicals.

Injections

Injections are also a complex problem which is not fully addressed in this article. A few examples include:

1. Injection of lidocaine mixed with Depo Medrol 40 mg was injected into the right knee joint space.

  • Report 20610 (1 unit) for the joint injection
  • Report J1030 (1 unit) for the Depo Medrol. The lidocaine is considered bundled and would not be billed separately.
  • However, if both knees were injected, then bill 20610 with 2 units (one per knee).

2. After alcohol prep, a 24-guage 3.5-inch needle filled with a total of 10 ml (5 ml per side) of 0.25% Marcaine and 40 mg of Kenalog was used to inject four trigger points in the right gluteus medius and two into the left gluteus medius muscles (a total of two muscle groups). 

  • Report 20552 (1 unit). Even if you inject a patient's trigger points 10 times in the same muscle group, you may only bill a single unit of 20552 because the code description is based on the number of muscle groups injected and not how many injections were administered.
  • Report J3301 (4 units). The description for J3301 is for 10 mg, so 4 units = 40 mg.
  • Do not report the Marcaine, as it is considered bundled as the local anesthetic.

3. A total of 15 mL of 0.25% Marcaine, with 60 mg of Kenalog was used to inject multiple trigger points in the bilateral supraspinatus muscles and the right deltoid muscle. 

  • Report 20553 (1 unit) for 3 or more muscle(s)
  • Report J3301 (6 units) The description for J3301 is for 10 mg, so 6 units = 60 mg.
  • Do not report the Marcaine, as it is considered bundled as the local anesthetic.

CLICK HERE for a helpful webinar with more comprehensive information.

Timed Codes

Timed codes have rounding rules which can vary by payer. In fact, there are slight differences between Medicare and the AMA regarding the 8-minute rounding rule (CLICK HERE). Providers need to be aware of these differences and document and bill the encounter properly in accordance with payer rules.

Find-A-Code Help

Find-A-Code offers some help at the code level. Keep in mind, that there is no substitute for reading the rules and carefully reviewing packaging.

  • Medically Unlikely Edits (MUEs): Click on the [Additional Code Information (Global Days, MUEs, etc.)] bar beneath the code and look for the "Medically Unlikely Edits (MUEs)." Not all codes have MUEs, but be sure to check if they are available. Medicare sets these limits, so when a claim is submitted which exceeds the MUEs, it is likely to trigger an audit.
  • Commercial Payer Policies: Click on the [Commercial Payer Policies] bar to review payers with policies regarding that service. Some include detailed information about units so it's valuable to check for applicable policies.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Medicare Updates -- SNF, Neurostimulators, Ambulance Fee Schedule and more (2022-10-20)
October 27th, 2022 - CMS - MLNConnects
Skilled Nursing Facility Provider Preview Reports: Review by November 14 - Help Your Patients Make Informed Health Care Decisions - Ambulance Fee Schedule: CY 2023 Ambulance Inflation Factor & Productivity Adjustment - Compliance - Implanted Spinal Neurostimulators: Document Medical Records - Claims, Pricers, & Codes...
2023 Evaluation & Management Updates Free Webinar
October 24th, 2022 - Aimee Wilcox
Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.
Are Leading Queries Prohibited by Law or Lore?
October 13th, 2022 - Erica E. Remer
AHIMA released its CDI Practice Brief Monday. At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the day before. My rabbi was talking in her sermon about the difference between halacha and minhag. Halacha is law; it is the prescriptions...
2023 ICD-10-CM Guideline Changes
October 13th, 2022 - Chris Woolstenhulme
View the ICD-10-CM Guideline Changes for 2023 Chapter 19 (Injury, poisoning, and certain other consequences of external causes [S00-T88])The guidelines clarify that coders do not need to see a change in the patient’s condition to assign an underdosing code. According to the updated guidelines, “Documentation that the patient is taking less ...
Z Codes: Understanding Palliative Care and Related Z Codes
October 11th, 2022 - Gloryanne Bryant
Palliative care is often considered to be hospice and comfort care. Palliative care is sometimes used interchangeably with “comfort care” and then again sometimes with “hospice care.”  But these terms do have slightly different meanings and sometimes the meaning varies depending on who is stating it. The National...
2023 ICD-10-CM Code Changes
October 6th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
Yes, You Have What It Takes To Lead Your Practice And Your Profession
September 20th, 2022 - Kem Tolliver
If you’ve been in any healthcare role for more than two years, you’ve seen quite a bit of change. And guess what, it’s not over. We are living and working in uncertain times. This climate requires each of us to step outside of our comfort zones to lead exactly where we stand. It’s not required of one to have a “title” to lead. What is required, however, is a willingness to trust your instincts, look for answers and rely on your team.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association