Health Information Management

Q/A: Correctly determining billing units for drugs

APCs Insider, September 14, 2012

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Q: We are having a heated discussion in our facility regarding reporting HCPCs codes for drugs. If the dosage of the drug doesn’t meet the HCPCS definition, we are reporting a charge for the drug but not the HCPCS code.

For example, HCPCS code J2405 is defined “per 1 mg,” but the dose that our physician ordered was 3.5mg. It was an unusual situation as he usually orders 4 mg and the math is easy. We don’t know what to do with the half milligram that was given since the HCPCs code is “per 1 mg.”
Our pharmacist wants us to report 3 units (3 mg) because we can support that amount. Our billing staff thinks the code can’t be reported at all and our chargemaster person wants only one line item with the HCPCS code to keep things simple. Can you help solve this conundrum?
A: CMS has instructed facilities to report units for drugs with HCPCS codes based on the description. The guidance is also documented in the CMS Claims Processing Manual (Pub. 100-04), chapter 17, section 10:
Drugs are billed in multiples of the dosage specified in the HCPCS code long descriptor. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit based on the HCPCS long descriptor for the code in order to report the dose provided.
For your specific example, HCPCs J2405 is defined as “Injection, ondansetron HCl, per 1mg.” This definition means that the units should be reported in 1mg increments. 
It is simple math when the dose ordered and administered is 4mg; the units reported are 4. However, when the dose of the drug is not equally divisible by the amount listed in the HCPCS code definition, you can still report the units.
Using the above guidance, the units would be 3.5 based on the dosage; the half mg (.5) is then rounded up to one mg and reported as an additional unit. So, an injection of Zofran 3.5 mg would be correctly reported as 4 units. 
Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.

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