Wiki Please help with proper injectable drug guidelines.

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Brandy0618

Brandy0618

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We received a letter from a carrier reporting that claims are required to be submitted based on (HCPCS) units, not the dosage administered. As I research this I am more confused that when I started. The example in the front of HCPCS explaining that if one ostomy pouch is used it should be reported as a quantity of 10 since the pouch comes in a quantity of 10. This really sounds like fraud to me. The injectable most used in our office is J0561, and J0696. We order these in boxes of 10, however it simply sounds like fraud to report 10 on the quantity box when we only used one vial out of the box, whether it was 1.2 million or 600,000.00. Could anyone help shed some light on this for me? Thank you so much, Brandy Blue-Smith CPC
 
I've never billed an ostomy pouch in an office setting, because we are not a DME supplier, but I can comment on the J codes. There's a difference between billable units (what your insurance company is asking for) and administered units.

You must report the billable units based on the dosage given as outlined in HCPCS. If you don't have a current HCPCS book, you'll need to get one. So with J0561, a single billable unit is equivalent to 100,000 adminstered units. You have to identify (by documentation) how much Penicillin G was given, and if they're reporting 'one vial", this is a really bad documentation practice. They must report the dosage based on the billable units, whether it's units, milligrams, millileters, whatever. So if they've adminstered 200,000 units, you'd bill 2 units on the HCFA form.

J0696 is billed by milligrams. Each billable unit is 250 milligrams. So if a gram of Rocephin is administered, you'd bill 4 units. Sometimes you have to check the box to see the weight or volume of the medication per each vial, but the provider should absolutely document in terms of the billable unit....otherwise there can be confusion.

Hope this helps.
 
Since I can't review the EOB or whatever it is that you are reading, from this view it appears like you may/might/possibly be mixing up the package with the HCPCS description.

For example:
A5053 Ostomy pouch, closed; for use on faceplate, each
~This is billed as a unit, meaning when a single pouch is sold to the patient or used on the patient you bill a single (1) unit.
If they come in a package of 10, unless you are giving the entire box to the patient you would not bill for 10 units.

I won't repeat what Pam Brooks wrote, I concur with her description on the drugs.
 
This is an actual letter from Cigna. We as an office are not billing an ostomy pouch. If you will turn to the Introduction-i in the HCPCS book at the bottom of the page read the example of Quantity alert....this is what I am referring to when I say "10 must be indicated in the quantity box on the CMS claim form to ensure proper reimbursement". We are not billing this. This letter acutally says "Cigna is aligning with the (CMS) guidelines. CMS guidelines require claims to be submitted based on (HCPCS) units, not the dosage". It goes on to say......"Beginning June 1 2014, Cigna may request additional documentation if a claim for an injectable drug is submitted inappropriately using dosage units instead of HCPCS units.
 
Unfortunately, we all have different books and I don't have that verbiage in mine to review and help determine what needs to be done. You might send me a private email and I am open to scanning in our book pages and helping you through finding the guidelines that can get you what you need to figure out how to bill.

Somewhere there is confusion, but I can't help on this forum well enough with this complex problem.
 
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