Incorrect Units Reporting Adds Up to Costly Mistake

A North Carolina fiscal intermediary incorrectly paid 89 of 91 Medicare claims for oxaliplatin services reviewed in an Office of Inspector General (OIG) audit. Prior to the April 23 report, implicated hospitals had already identified and refunded $1,762,070 in overpayments to Palmetto GBA. The OIG has requested Palmetto GBA recapture the remaining overpayments totaling $160,096.

Oxaliplatin (trade name Eloxatin™) is a chemotherapy drug used to treat colon or rectal cancer. The Centers for Medicare & Medicaid Services (CMS) Transmittal A-03-051, Change Request 2771, dated June 13, 2003, instructs outpatient hospitals to bill for oxaliplatin using HCPCS Level II code C9205 Injection, oxaliplatin, per 5 milligrams to allow pass-through payment under the Outpatient Prospective Payment System (OPPS).

Watch your units! The OIG audit found, on 89 claims processed between 2004-2005, Palmetto GBA paid five hospitals 10 times the correct number of service units for oxaliplatin furnished to Medicare patients by paying one service unit per 0.5 mg of oxaliplatin administered instead of one service unit for each 5 mg.

Remember: The Medicare Claims Processing Manual, Pub. 100-04, chapter 4, sec. 20.4, states, “The definition of service units … is the number of times the service or procedure being reported was performed.”

In addition to recovering the remaining overpayments, the OIG recommended in the report for Palmetto GBA to establish procedures to ensure that units billed for pass-through drugs under the OPPS correspond to the units of drug administered.

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2 Responses to “Incorrect Units Reporting Adds Up to Costly Mistake”

  1. Gwen Davis CPC says:

    The EdgeBlast Quiz implies you should use C9205 currently in 2009 for billing Oxaliplatin under OPPS pass through. This is incorrect- This code was deleted as of 1-1-2006. There was both a Jcode and a Ccode in 2004/2005 that reflected two different billing amounts. One was 0.5mg and one was 5mgs, It is important to remember to aways review the HCPCS units, per HCPCS to make sure that code quantity accurately reflects your Drug Dose. You will want to retrospectively audit your records for the years 2004/2005 as the OIG IS going back and correcting their records and it would be better if you paid them before they asked your for their money back.

    OIG Review of Hospital Oxaliplatin Billing
    The Office of Inspector General (OIG) is currently auditing claims billed by hospitals for oxaliplatin during Calendar Years 2004 and 2005. Under the Medicare hospital outpatient prospective payment system, as a new drug oxaliplatin was eligible for a higher transitional pass-through payment amount from July 1, 2003, to December 31, 2005. Hospitals were to bill using the code C9205 (Injection oxaliplatin, 5 mg) to obtain the pass-through payment. Some hospitals submitting claims under C9205, however, incorrectly used the unit for the practitioner’s code (J9263, Injection oxaliplatin, 0.5 mg). Consequently, the hospitals submitted claims for ten times the amount of oxaliplatin actually administered.

    More information regarding the oxaliplatin audits can be found on the OIG website.

  2. robin fernandez says:

    can someone tell me if the definition of service units is the same for physician office? this is from the part b hospital section of the claims proc manuel. i need to know what the policy is for phy office i have looked and cannot find in mcr claims proc manuel.
    thanks,

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