Drug HCPCS and Units
and Multipliers, Oh My!
August 13, 2014
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We work to ensure America’s healthcare
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improving community health.
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Jennifer Kennebeck, MBA, RHIA, CCS
Jenny is Senior Client Partner, Operations for G2N,
Inc. G2N provides coding, chargemaster and other
revenue cycle consulting services.
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Jennifer Kennebeck, MBA, RHIA, CCS
• Jenny has been a coder for over 20 years, working through all
types of coding and coding management ultimately ending up in
the revenue cycle and on chargemaster teams
• B.S. in HIM from SLU; MBA from Fontbonne; Credentialed as an
RHIA, CCS and CCS-P
• Background in large system hospitals, with experience in all facets
of the revenue cycle
• Joined G2N in 2002
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Agenda
By the end of the hour, you’ll know:
The Medicare rules on billing for drugs
The importance of matching HCPCS units to
drug used
How multipliers make it all work
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Regulations and Guidelines
• Rules can be found here:
Medicare Claims Processing Manual
Chapter 17 – Drugs & Biologicals
Section 90.2 – Drugs, Biologicals &
Radiopharmaceuticals
https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c17.
pdf
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Regulations and Guidelines
• The Basics:
– All drugs should be reported with a HCPCS (if
there is one) regardless of payment
– Units on the claim must be consistent with the
number of units administered to the patient
– Payment includes:
• Acquisition
• Overhead
• Special handling (chemo, radiopharmaceuticals)
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Regulations and Guidelines
• Revenue Codes:
– If a HCPCS is used AND separate payment is
attached to the code, must use 636
– If a HCPCS is used, but payment is packaged,
use 250 or 636
– If no HCPCS for the drug, use 250
– If drug is self-administered, use 637 (or whatever
works in your system to force the line to noncovered)
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How Does it Work in Your System?
• Multipliers
– May be in CDM or in Pharmacy system
– If using, know what effect they will have on units
and price
– Some systems only apply the multiplier to the
units, others to units and price, so adjust
accordingly.
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Key Terms
• Dosage
– Amount of drug prescribed to patient
• Concentration
– Amount of drug per volume unit (cc, ml, iu)
• Volume
– Amount of liquid per vial
• Waste / Wastage
– Amount of drug not given to a patient, but cannot be
used on another
• The Metric System
– An mL and a cc are the same unit of measure
– You will need to convert micrograms to milligrams and
milli-equivalents (mEqs) to mg (and other conversions)
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Polling Question #1
Who is responsible for the assignment of HCPCS
codes for drugs in your facility?
A. CDM Manager / Coordinator
B. Pharmacist / Pharmacy staff
C. Coding
D. Whoever happens to get the request
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Interpreting the Code
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Orencia as an Example
• J0129 – Injection, abatacept, 10 mg
– Bill 1 unit for each 10mg used
– Status Indicator – K – Nonpass-Through
Drugs and Nonimplantable Biologicals,
including Therapeutic
Radiopharmaceuticals
– Paid under OPPS; separate APC payment
– $32.21 for each 10mg used
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Orencia as an Example
• CDM Request:
– Orencia Injection 15ml
– J0129 – Injection, abatacept, 10 mg
• Questions:
– What is the concentration?
– Is this a single dose vial (SDV)?
– Is this a multi dose vial (MDV)?
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Orencia as an Example
• Who can answer my questions?
– Pharmacy staff
– Drug website
– Medical record
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Orencia as an Example
• My preference?
– Google the drug name
– Look for the manufacturer website
– Are you a healthcare professional? YES!
– Get the prescribing information / package insert
– Look for “How Supplied”
– If you can’t get it here…talk to pharmacy
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Orencia as an Example
• What does this tell us?
• Concentration = 250mg per 15mL
• This is a single use vial
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CDM Impact
• How are your charges requested and loaded?
–Request: Furosemide 10mg/cc
–Questions
»How big is the vial  10cc = 100mg vial
»Is it a SDV or not?  yes, bill whole vial
–J1940= Furosemide up to 20mg
»Bill anything less than 21mg as 1 unit
»Bill 10 units for 100mg
–Description recommendation
»Furosemide 10mg/cc 10ml
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CDM Impact
• Charge for 10cc vial is $100
• CDM houses multiplier and effects price and
units
• Load as:
– Furosemide 10mg/cc 10ml
– Multiplier 10
– Charge $10
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Conversions
• Drug ordered and administered as 10mg
• Drug J code is per mcg (microgram)
• How many units are billed for a 10mg
administration?
• Google: “convert 10mg to mcg”
• 10,000
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Let’s Talk About Waste
Still using the Orencia example:
• Only 200mg is administered to the patient
• 50mg is wasted
• From the prescribing information, we know this is a
single dose vial, so it can’t be used on anyone else
• Bill J0129 x 25, 250mg in the vial
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JW Modifier
• Modifier JW – Drug amount discarded / not
administered to any patient
• CMS states to bill wasted drug on separate
line with JW modifier
• BUT…
– The MACs are choosing to accept or not
• WPS does not require
• Noridian does not require
• Check with yours
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OIG Targets
• Billing of waste with a Multi-Dose Vial
– Herceptin
– Many hospitals were billing for full vials when the
full amount was not used on a single patient
• Could have been wasted
• Could have been used on another patient
– Contractors overpaid millions to hospitals
– https://oig.hhs.gov/oas/reports/region5/51300024.asp
We’ll discuss this issue more later…
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Polling Question #2
Do you know if drug waste is being documented
in the medical record?
A.
B.
C.
D.
Yes, in the MAR
Yes, in the pharmacy system
Only with anesthesia
No
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Payment
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Payment
• Status indicator N – packaged, no separate payment
• Status indicator K – Nonpass-Through Drugs and
Nonimplantable Biologicals, including Therapeutic
Radiopharmaceuticals. Paid under OPPS; separate
APC payment.
• Status indicator G – Additional payment for
drug/biological pass through
• Status indicator H – Additional payment for Passthough…and radiopharmaceutical agents
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Payment
• So…again going back to our Orencia example
• SI K – these have an APC assigned to them that
pays according to the units on the HCPCS code.
• J0129 = $32.21 per 10mg
• J0129 @25 units = $805.25
J0129 billed with only 1 unit (because one vial was
dispensed) results in under payment of $773
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Other Considerations
• Erythrocyte Stimulating Agents (ESAs)
– Diagnosis (ESRD or non ESRD)
– Anemia diagnosis etiology
– Most recent Hgb or Hct reading (reported
using value codes)
– High incidence of denial because of
incorrect code use
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Other Considerations
• Aranesp:
– J0881 = Injection, darbepoetin alfa, 1 microgram (nonESRD use)
– J0882 = Injection, darbepoetin alfa, 1 microgram (for
ESRD on dialysis)
• Epogen/Procrit:
– J0885 = Injection, epoetin alfa, (for non-ESRD use), 1000
units (Epogen / Procrit)
– J0886 = Injection, epoetin alfa, 1000 units (for ESRD on
dialysis) (Epogen / Procrit)
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Other Considerations
Modifiers:
EA = ESA, chemo induced anemia
EB = ESA, radiation induced anemia
EC = ESA, non-radiation, non-chemo induced
anemia
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Examples
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Example 1:
• CDM Request:
Herceptin 440mg INJ / J9355 / 636
• Is this is SDV or MDV?
• What is the payment unit?
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Example 1:
•
•
•
•
•
J9355 = Injection, trastuzumab, 10 mg
SI = K, $82.37 per 10mg
Full vial of Herceptin = 440mg
Units on claim for full vial = 44
Payment = $3624
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Example 1:
• Herceptin prescribing info:
• “Extra” or “waste” could be used on another
patient
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Example 1:
• At time of charging, units administered to the
patient must be entered.
• Administered 600 mg:
– 2 vials need to be reconstituted to dose this
patient (880mg)
– Charge should be entered as 60 units
• Not 2
• Not 88
• Not 44
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Example 1:
• What if no other patient is scheduled within
28 days?
– Hospital takes the loss of the 28 units
• Is there any way to avoid a loss?
– Tight scheduling of these patients will minimize
the loss
– Dosage by weight, so dose for every patient
could be different every visit
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Example 2
• Patient receives the following (by injection)
• Rituxan 1000mg
• Methylprednisolone 100mg
• Charges are:
• J9310 X10
• J1020 X100
J9310 – rituximab $707.47 per 100mg
J1020 – methylprednisolone $0 per 20mg
are these charges correct?
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Example 2
• No, they are not.
• Rituxan is OK
• J9310 X10 = 1000mg
• It is a single use vial.
• Packaged in 100mg and 500mg vials
• Units to be billed are same whether 10-100mg vials
are used or 2-500mg vials are used
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Example 2
• No, they are not.
• Methylprednisolone is incorrect
• J1020 per 20mg, 100mg given= 5 units, not 100
• J1020 has status indicator of N – no additional
payment, packaged
• Does it matter that the units are wrong when
there is no payment? YES!
• Reporting 100 units of J1020 indicates patient
received 2,000mg of a steroid
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Example 3:
• Patient receives:
– Aloxi 0.25mg
– Avastin 50mg
– Alimta 740mg
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Example 3:
• Charges come across:
– J2469 X1 (Aloxi 0.25mg)
– J9035 X 1 (Avastin 50mg)
– J9305 X 10 Alimta 740mg
J2469 - $19.26 per 25mcg
J9035 - $66.55 per 10mg
J9305 - $60.33 per 10mg
Are the charges correct?
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Example 3:
• Charges are not correct:
– Aloxi is OK (25mcg = 0.25mg)
– Avastin should be billed in 10mg units
• 50mg = 5 units; smallest vial is 10 units
• Prescribing information shows SDV, so full vial can be
billed (10 units)
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Example 3:
• Alimta is billed in 10mg units
– 740mg = 74 units; drug supplied in 100mg and
500mg vials; pharmacy stocks both
– Prescribing info shows SDV, least waste will be from
1-500mg vial and 3-100mg vials (800mg=80units
including 6 units of waste)
– Billing 2-500mg vials would result in 26 units of waste
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Example 3:
• Payment for charges as billed:
–
–
–
–
Aloxi Avastin Alimta Total:
$16.26
$60.55
$603.30
$680.11
• Payment for corrected charges:
–
–
–
–
Aloxi $16.26
Avastin - $332.75
Alimta - $4,826.40
Total:
$5,185.41
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Example 3:
• Medicare expects to be billed for the smallest
vial size available
• Least amount of waste is paid
• Different vial sizes may need to be used to
achieve the least amount of waste
• Not pleasant for pharmacy stocking
• Better than repayments
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Polling Question #3
How accurate do you think your drug billing is?
A.
B.
C.
D.
Not at all
If no multiplier is involved, the line is right
Some of if is right, but we have work to do
This webinar is validating we know what we’re
doing!
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Review
• Apply HCPCS codes whenever there is one for
the drug regardless of payment.
• Use correct revenue code for charge (250, 636,
637)
• Units must match units on the code
• Units matter even if there is no payment
• Multipliers can reside in chargemaster or in
pharmacy system
• Use internet resources as necessary (Google)
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Questions?
Jennifer Kennebeck, MBA, RHIA, CCS, CCS-P
Senior Client Partner, Operations
[email protected]
Office: 314.835.9311
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