Wiki Billing Units for Gammagard J1569

[tjones05]

Looking for help. My clinic started billing for this and I am trying to find how the units are billed because when Medicare paid it was severely under paid. I have found 1 article that states One (1) unit of service (UOS) is 500mg.

This patient used 72 grams so based on the 1 UOS we billed 144units.

Does anyone know if this correct?

Thanks

 

[thomas7331]

Yes, the HCPCS description is 500mg, so 144 units would be correct for 72 grams.

The current Medicare drug pricing file shows $46.50 per unit for this code, so you should have been paid around $6,700 for this - is that what you're getting? I'd caution that since Medicare bases its payment on the average price of the drug paid across the country, the reimbursement can often be less that what an individual provider pays for a drug. Large provider organizations are able to negotiate lower prices for drugs because they can afford to purchase larger volumes, and this puts smaller provider offices at a big disadvantage. If you're not able to recover your costs for something like this, it's probably better to refer the patient out to a larger facility to get this service.

You can find Medicare's payment rates, updated quarterly, at this web page: https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/2023-asp-drug-pricing-files