Part B Insider (Multispecialty) Coding Alert

Published on Fri Jan 01, 2010 PDF

Check out these errors -- and how to steer clear of them.

When you think of MACs auditing "high-dollar payments," you're probably envisioning reviews of surgical claims or lengthy hospital visits. But a recent OIG audit revealed something different altogether -- a smattering of claims for injectibles billed improperly.

Follow a few hard and fast rules, and you can ensure that your injectible coding stays on the straight and narrow.

The facts: The OIG sought to determine whether one MAC's highdollar payments (payments over $10,000) to Arkansas Part B providers in 2005 were appropriate, according to the report, which the OIG published on Jan. 14.

The findings: One hundred percent of the 11 high-dollar payments that the payer issued were related to J codes, which represent injectible drugs. The OIG discovered the following errors:

• In six claims, the provider used the invoice price to bill HCPCS code J3490 (Unclassified drugs), and the payer reimbursed the invoice amount rather than the "Red Book" amount, which is what is required. This resulted in overpayments of $5,938.

Solution: Many physicians' offices do not keep a Red Book on hand, says Barbara J. Cobuzzi,  MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions. In most cases, the MAC should pay you based on the Red Book amount, and not on your invoice amount. However, if your MAC expects you to report certain amounts when billing unclassifiable drug code J3490, get the information in writing and ask them for a copy of the fees for these medications.

Keep in mind: Don't let this audit sway you from reporting J3490 when it's the appropriate code. If the drug that your physician injected is not listed in HCPCS, J3490 is usually the right code.

For example: Physicians often inject marcaine as an anesthetic along with joint injection medication. "Marcaine or Sensorcaine is billable with J3490 to Medicare," says Christie Thomas, CPC, PCS with Mercy Physicians Group in Fort Scott, Kan. Medicare payers will not reimburse you for the marcaine, so you should bill it with a 0.00 charge, but J3490 best describes the substance injected. In addition, you should report all other drugs that the physician injected into the patient's joint.

• In two claims, the provider billed J9010 (Injection, alemtuzumab, 10 mg) for 30 units rather than 3 units, which was attributed to being a "keying mistake," resulting in overpayments of $22,101.

Solution: Many software systems allow you to set up limits for each code. For instance, you could tell your system to alert you if you enter any number of units over 10 for an alemtuzumab injection. Then if the system alerts you, you could manually review these claims before you submit them to ensure that you entered the units properly. In addition, CMS now has its medically unnecessary edits (MUEs) in place to catch these types of errors before overpayments are made.

• For one claim, the payer incorrectly processed the number of units of J9035 (Injection, bevacizumab, 10 mg). Even though the provider submitted a claim for 90 units of the code, the MAC paid for 901 units, resulting in overpayments of $6,536.

Solution: If you receive payment that is astronomically higher than the amount you billed, that's a red flag. Check the payment amount against your claim and refund the overpayment to Medicare before the OIG steps in and requires you to do so.

• In the remaining two cases, the providers billed the incorrect number of units of drugs, resulting in overpayments of $16,463.

In one case, "the provider mistakenly billed HCPCS code J2505 for six units rather than one unit because the dosage strength for one unit of code J2505 (Injection, pegfilgrastim, 6 mg) was 6 milligrams," the OIG noted.

Solution: Always check the number of drug units that the code descriptor indicates before you select how many units you should bill. To read the entire OIG report,