Health Information Management

Q&A: Can we bill separate doses of a drug on the same day?

APCs Insider, November 8, 2013

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Q: On occasion, a patient undergoes a cardiac stress test with myocardial perfusion and a stress echo on the same day. While this doesn’t happen often, we are seeing an increase in the frequency. Both are done on the same day if the physician determines the patient’s clinical situation will allow it and the patient has to travel a long way to come back for the other test. The physician orders either adenosine or Persantine®, and usually the same drug for both tests. We administer two separate doses–one for the cardiac stress test and one for the stress echo. The pharmacy department reports the total number of units for the HCPCS code for the drug that was used. We have validated that our units are reported correctly based on the documentation, but we continue to have the line item for the drug denied.

A: The claim is hitting a medically unlikely edit (MUE) for the drug units. CMS established MUEs to prevent an inappropriate number of units from being reported on a given date of service. The unit of service established is based on the usual or ideal number of units that would be expected to be reported for the beneficiary on any given date of service.

However, CMS has also acknowledged that circumstances can occur when units greater than the MUE limit would be appropriate. According to the National Correct Coding Initiative (NCCI) manual, chapter 9, units for adenosine and Persantine (dipyridamole) may appropriately exceed the MUE in some cases: 

4. The MUE values for J0152 (injection, adenosine for diagnostic use, 30 mg) and J1245 (injection, dipyridamole, per 10 mg) were set for single pharmacologic stress tests. For the unusual patient who requires two different types of pharmacologic stress tests (e.g., myocardial perfusion and echocardiography) on the same date of service, the amount of drug utilized for each stress test should be reported on separate lines of a claim with modifier -59 appended to the code on one of the claim lines.

As long as the documentation supports the separate doses and the units reported, you should report the HCPCS code for the drug that was used on two line items, one line with modifier -59 to show that the patient received two separate doses for two separate tests.

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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