Wiki Can you under bill units of drugs knowing Medicare will deny??

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mamaluvspurple

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I bill patient's chemo and Medicare will deny any claim that has more than 35 units which includes waste of J9041. I am being asked by my supervisor to bill for example, if the patient received 25 units and 20 units waste to omit the waste on the claim. Another example, if the patient received 40 units of this drug, I am being asked to only bill 35 units so it does not deny. Is this not fraudulent billing?? If so, I cannot find any reference to support it is. I can only find up charging info. Thanks for your help!
 
They are denying that amount of units because of the MUEs. The MUEs I am showing for this code J9041 is 35, so the max for a clean claim to be billed is 35 units. However, these are "medically UNLIKELY edits" which means that the excessive units COULD BE possible, but unlikely and proving medical necessity would need to be performed. So a redetermination with the documentation proving the reason for the extra units, and the payor will reprocess the claim.
The way medicare works is that it is all electronic, so their system will automatically deny a claim if the units exceed the amount the computer was set to approve. So in your case, yes they are denying, but billing less units just to pass the edit could be fraudulent. I would send an appeal with documentation showing the reason for excess units and see what they say. Its worth a shot.

Let me know if you have anymore questions, I would be happy to help.
 
haraml7 said:
They are denying that amount of units because of the MUEs. The MUEs I am showing for this code J9041 is 35, so the max for a clean claim to be billed is 35 units. However, these are "medically UNLIKELY edits" which means that the excessive units COULD BE possible, but unlikely and proving medical necessity would need to be performed. So a redetermination with the documentation proving the reason for the extra units, and the payor will reprocess the claim.
The way medicare works is that it is all electronic, so their system will automatically deny a claim if the units exceed the amount the computer was set to approve. So in your case, yes they are denying, but billing less units just to pass the edit could be fraudulent. I would send an appeal with documentation showing the reason for excess units and see what they say. Its worth a shot.

Let me know if you have anymore questions, I would be happy to help.
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thank you!!
 
We regularly give Velcade and have never had more than 35 billed units because of the single-dose vial. 20 mg of waste is not normal. Have you verified that the drug documentation is correct?
 
haraml7 said:
They are denying that amount of units because of the MUEs. The MUEs I am showing for this code J9041 is 35, so the max for a clean claim to be billed is 35 units. However, these are "medically UNLIKELY edits" which means that the excessive units COULD BE possible, but unlikely and proving medical necessity would need to be performed. So a redetermination with the documentation proving the reason for the extra units, and the payor will reprocess the claim.
The way medicare works is that it is all electronic, so their system will automatically deny a claim if the units exceed the amount the computer was set to approve. So in your case, yes they are denying, but billing less units just to pass the edit could be fraudulent. I would send an appeal with documentation showing the reason for excess units and see what they say. Its worth a shot.

Let me know if you have anymore questions, I would be happy to help.
Click to expand...
Hello! I happened across this thread, and I am curious as to where you obtained the information of MUE's? Is that available for anyone to access? I am having similar issues with Medicare denying for max units and would love to be able to reference the material to take a further look. Please note, I am dealing with Integ codes and not drug codes.
 
SamrPen said:
Hello! I happened across this thread, and I am curious as to where you obtained the information of MUE's? Is that available for anyone to access? I am having similar issues with Medicare denying for max units and would love to be able to reference the material to take a further look. Please note, I am dealing with Integ codes and not drug codes.
Click to expand...
yes, that can be found on medicarefsco.com under MUEs. You may have to do some reading but its in there. it public information. I see you are in ohio so your MAC carrier is CGS so you would look at cgsmedicare.com. search for MUEs. let me know if this helps.
 
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