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Note from Hugh

Medicare Weekly Update, September 11, 2007

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The OIG audit discussed below highlights what I believe (and I suspect CMS and the OIG believe) is an issue that continues to present significant compliance challenges for hospitals. The issue is incorrect reporting of units of service for drugs.

The OIG audit related to a single claims processed by Chisholm Administrative Services, the Oklahoma Medicare intermediary. The OIG discovered that a hospital had incorrectly reported the units of service for HCPCS code C9205 (Injection, Oxaliplatin, per 5 mg). The hospital had calculated units of service based on the mistaken belief that one unit of C9205 should be reported for each 0.5 mg of drug administered. Apparently, the hospital was confusing HCPCS code C9205 (Injection, Oxaliplatin, per 5 mg) with HCPCS code J9263 (Injection, Oxaliplatin, per 0.5 mg). The error resulted in an overpayment of $57,700 for the claim in question.

After 2005, hospitals should not continue to have problems with the units of service for this particular drug because HCPCS code C9205 was deleted effective January 1, 2006. However, hospitals should continue to pay carefully attention to the internal processes used to determine units of service for other drug codes. At a minimum, hospitals should consider implementing an internal edit to flag for manual review all outpatient claims over a certain dollar threshold. Finally, keep in mind that CMS has now implemented the medically unlikely edits, or MUEs, which are designed to (among other things) identify these types of errors.

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