Elizabeth Lamkin, CEO of Pace Healthcare Consulting in Hilton Head, S.C., answers a reader's question about recovery audit contractors' denials of claims that mistakenly identify drug dosages by milligrams instead of by six-milligram units. Ms. Lamkin mentioned this problem in "3 Coding Problems RACs Often Identify."
Reader's question: In regards to billing for each milligram instead of for six-milligram units, which drug is Ms. Lamkin referring to? Different drugs have different numbers of billing units.
Elizabeth Lamkin: The approved lists for all four RACs have identified many drugs for review of unit versus dose. One example is Adenosine, where RACs have two approved issues for separate dosages of 6 mg. and 30 mg. units. RACs also have identified incorrect units for dosages of the drugs Bevacizumab and Neulasta.
Most of these RAC audits are automated reviews and do not include medical necessity. However, automated reviews can scan many claims quickly and until you receive a demand letter, you do not know which claims are being reviewed.
The reason unit versus dose billing is vulnerable is the complexity of bringing together the chargemaster, clinical documentation and correct coding. Here are three examples of vulnerabilities.
1. If the hospital's chargemaster is not up-to-date, it will develop a pattern of disregard. Finance and the clinical department directors should review the chargemaster annually to ensure accuracy and compliance with any changes in coding.
2. Both hospital and physician documentation must support the claim with correct date of service, place of service and units of service. Lack of good clinical documentation may result in under-coding or over-coding. For instance, most claims involving unit versus dose should only occur once per date per patient. Incorrect documentation of the date or the units will create a medically unlikely unit (MEU) that will be caught in the RAC's automated review. Even though this is usually a simple clerical error, the claim will still be considered an overpayment and the payment will be recouped.
3. The coding must be correct with the appropriate use of CPT, HCPCS and J codes. Coders should be up-to-date on modifiers and trained on Correct Coding Initiative and Outpatient Code Editor edits.
We suggest a proactive approach to deal with these vulnerabilities. The facility should have a mechanism to review the approved issues for its RAC region and determine how many identified issue claims were submitted by the facility since Oct. 2007, the current beginning of the RAC look-back period. While one cannot correct past errors, future billing should be compliant with CMS rules.
Some RACs provide links for hospitals to review advice posted by CMS. But unfortunately RAC websites are difficult to search and issues are added regularly. For our clients, we have created an issues database that is searchable for hospitals looking for risk areas. A facility can create it’s own database or subscribe to a service.
Learn more about Pace Healthcare Consulting.
Reader's question: In regards to billing for each milligram instead of for six-milligram units, which drug is Ms. Lamkin referring to? Different drugs have different numbers of billing units.
Elizabeth Lamkin: The approved lists for all four RACs have identified many drugs for review of unit versus dose. One example is Adenosine, where RACs have two approved issues for separate dosages of 6 mg. and 30 mg. units. RACs also have identified incorrect units for dosages of the drugs Bevacizumab and Neulasta.
Most of these RAC audits are automated reviews and do not include medical necessity. However, automated reviews can scan many claims quickly and until you receive a demand letter, you do not know which claims are being reviewed.
The reason unit versus dose billing is vulnerable is the complexity of bringing together the chargemaster, clinical documentation and correct coding. Here are three examples of vulnerabilities.
1. If the hospital's chargemaster is not up-to-date, it will develop a pattern of disregard. Finance and the clinical department directors should review the chargemaster annually to ensure accuracy and compliance with any changes in coding.
2. Both hospital and physician documentation must support the claim with correct date of service, place of service and units of service. Lack of good clinical documentation may result in under-coding or over-coding. For instance, most claims involving unit versus dose should only occur once per date per patient. Incorrect documentation of the date or the units will create a medically unlikely unit (MEU) that will be caught in the RAC's automated review. Even though this is usually a simple clerical error, the claim will still be considered an overpayment and the payment will be recouped.
3. The coding must be correct with the appropriate use of CPT, HCPCS and J codes. Coders should be up-to-date on modifiers and trained on Correct Coding Initiative and Outpatient Code Editor edits.
We suggest a proactive approach to deal with these vulnerabilities. The facility should have a mechanism to review the approved issues for its RAC region and determine how many identified issue claims were submitted by the facility since Oct. 2007, the current beginning of the RAC look-back period. While one cannot correct past errors, future billing should be compliant with CMS rules.
Some RACs provide links for hospitals to review advice posted by CMS. But unfortunately RAC websites are difficult to search and issues are added regularly. For our clients, we have created an issues database that is searchable for hospitals looking for risk areas. A facility can create it’s own database or subscribe to a service.
Learn more about Pace Healthcare Consulting.