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Resource Medications/Drug Coding

  • Drug HCPCS codes must be billed based on the amount, such as milligrams (mgs) in the HCPCS code description, not on standard usage or packaging amounts.
  • Most hospitals accomplish this by using a “multiplier” in their charge description master (CDM), which presents the challenges of making sure all drugs that need a multiplier have one, there are no errors or typos in the multiplier amounts, and the multipliers are kept updated with code description changes.
  • CMS often changes drug HCPCS codes and/or the HCPCS description. This is especiallychallenging when the amount in the description changes.
  • Medical record documentation should include the dosage amount in the physician’s order and in the administration record.
  • If the dose administered does not match the dosage amount the physician ordered, a corrected order should be obtained from the ordering physician.
  • If the drug dose is based on the patient’s weight, there should be documentation in the medical record of the patient’s weight.
  • Medicare does not allow providers to bill for wastage of multi-dose vials.
  • When billing for wastage associated with single-dose vials, there should be documentation in the medical record of the dose given and the amount wasted.
  • Medicare is applying Medically Unlikely Edits (MUEs) to a number of drug quantities. Although there are no published MUEs for drugs (HCPCS “J” codes), it is the understanding of MMP, Inc. that the quantity limitations are based on manufacturer package inserts. Providers should carefully review Medicare remittances to determine which drugs are being denied for MUEs and the likely MUE quantity.









 
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