Using incorrect billing units for drugs in payment claims to Medicare and Medicaid has escalated to the point that this is one of the key findings during examinations of our billing systems by recovery audit contractors (RACs). So here are a few tips to stay clear of trouble.
First, know that very expensive medications are a natural target for RAC audits. There have been so many issues with inappropriate and incorrect billing of rituximab and bevacizumab, for example, that in a recent publication of Medicare Learning Network’s MLN Matters (http://go.cms.gov/19oAlIR), these two drugs were used as examples of exactly how to use billing units correctly (Table). As the publication details, there are several key issues to keep in mind.
As a starting point, the article noted, be sure to focus on the overall goal—to convert the actual dose of a drug ordered for the patient into the number of billing units to be submitted for payment to Medicare or Medicaid. During that process, you’ll need to ensure that you’re using the assigned billing unit for the product. Sounds simple enough, right? After all, it’s just basic arithmetic! So how and where do things go awry? Here are a few potential source for miscalculations:
Your hospital’s billing department is doing the calculations manually, either because there is no computer system in the outpatient areas or, for whatever reason, the system can’t be programmed to do the calculations. Or the person(s) doing the calculations are not skilled in performing the conversions.
Rather than using automated “crosswalk” software to do these calculations before the information is sent to the billing system, order entry is being manipulated to accommodate billing units. These order-entry manipulations can lead to medication errors and other problems if the billing units rather than the dose appear on any clinical documents.
Multiple entries for the same product are being made in the charge description master and/or drug dictionary or pharmacy drug master, or there is a mismatch between the two, as well as inconsistencies in how billing units are assigned to each of these products.
There are multiple ways of acquiring the drug (automated cabinets, infusion center pharmacy, etc.), as well as different computer systems in outpatient clinics vs. the emergency room vs. pharmacy department, etc., resulting in a potential mismatch in the description of a product and its corresponding billing unit.
There’s no defined strategy for timely input of codes changes, billing unit changes or other updates.
e-Library a Crucial Tool
To avoid these types of problems, build an e-library for your pharmacy department that contains timely information on ever-changing reimbursement codes and policies. This will help you untangle the complex web of billing for medications. Here’s a list of tips and resources that you can use to build your e-library:
Someone on your staff may already be on the distribution list for these materials. But, who is that mystery person and does that information get to you in a timely fashion? Since it’s your pharmacy budget that’s taking the hit for mistakes that are made, be proactive, get on the distribution mailing lists and have information sent to you directly!