Oncology & Hematology Coding Alert

Don’t forget to convert milligrams to units to capture every dollar you deserve.

CMS recently updated the Medicare Learning Network (MLN) Matters SE1316 with additional tips to help oncology coders keep their RAC-targeted rituximab and bevacizumab claims in the clear, with the added bonus that the tips will boost their drug coding savvy in general.

Heed the following advice on accurately billing units for rituximab or bevacizumab so you’re earning all your deserved pay.

Check the Descriptors

The first piece of advice the MLN Matters adds is that you need to be sure to report units based on the code’s long descriptor. The code’s short descriptor may not provide you with enough information.

For example: The short descriptor for J9310 states only “Rituximab injection.” The long descriptor, in contrast, provides you with the numbers you need to properly calculate units: Injection, rituximab, 100 mg.

The long descriptor clarifies that 1 unit equals 100 mg. If a coder using only the short descriptor assumes that 1 unit equals 1 mg, then she risks reporting 100 times more rituximab than is appropriate.

Tip: Both short and long descriptors are available online at www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html. Click the year for the Alpha-Numeric HCPCS file you want to view. You can then download and open a ZIP file that contains HCPCS code data.

Calculate Units with Precision

The next piece of added guidance is that coders should always report the correct number of units. When reporting code J9310 (Injection, rituximab, 100 mg) for rituximab, one common error coders may make is to not convert milligrams to units; the same is true when reporting bevacizumab with J9035 (Injection, bevacizumab, 10 mg). As a result, the practice may end up with a significant overpayment that has to be returned.

Tip: When billing Medicare for rituximab, you count one unit for every 100 mg of rituximab and 10 mg of bevacizumab. Always verify how many milligrams of rituximab or bevacizumab were used and convert that amount into units. Make sure the quantity documented is consistent with the units you are billing.

Example: You may read that the nurse administered 200 mg of rituximab to a patient. Correct reporting of the amount is 2 units of rituximab HCPCS Code J9310 (200 mg administered divided by 100 mg per unit equals 2 units). Similarly, if the nurse administered 400 mg of bevacizumab, the correct reporting amount is 40 units.

Beware: A potential error can be billing 200 units of rituximab. Since J9310 is defined as 1 unit being equal to 100 mg, 200 units would mean that your physician administered an unlikely high dosage of 20,000 mg of rituximab for that date of service (200 x 100 = 20,000). Watch out for this error every time you bill for rituximab.

Remember billing for rituximab, bevacizumab, or any other HCPCS medication is reported in units not in milligrams and a conversion from the administered amount to the unit equivalent must be made before submitting the claim.

Account for Wastage for Full Reimbursement

Another concept that is crucial for clean rituximab or bevacizumab claims is that you may report to Medicare the amount administered, as well as the amount that is discarded because rituximab and bevacizumab are available only as single-use vials. Medicare will reimburse for the full quantity of single-use vial for any amount that is wasted when it cannot be used on another patient. “This concept does not apply to multi-use vials,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc.

Medicare’s exact language: “When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label” Medicare Claims Processing Manual, Chapter 17, Section 40, at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c17.pdf.

Don’t miss: When you account for wastage, you should be clearly focused on the amount of rituximab or bevacizumab shown on the vial or package label. Recall Medicare’s language that it pays for the drug “up to the amount” on the label. Rituximab is available as 100 mg/10 mL and 500 mg/50 mL solution and bevacizumab as 100 mg/4 mL and 400 mg/16 mL solution in single-use vials. “As with any other supply or service, Medicare and most other third party payers, require supporting documentation to validate the entire amount billed in order to be reimbursed,” says Loya.

Fortunately, you need not focus on how the wastage occurred. Just be sure the clinical staff has documented the amount administered and the amount wasted so both amounts can be reported. Auditors may look for this information to justify the units reported.

Check for Payer-Specific JW Modifier Rules

Each individual payer may have its own preference for reporting drug wastage. Even each individual Medicare carrier can to apply its own policy. To be sure you are following your payer’s rules for reporting drug wastage, look to the instruction from the payer regarding modifier JW (Drug amount discarded/not administered to any patient). In general terms, you apply the JW modifier to only the amount of rituximab or bevacizumab discarded and documented.

Example: When you read that the patient received 810 mg from two vials of rituximab 500 mg, you will report 9 units on one line item as the amount administered. For the drug discarded, report 1 unit with the JW modifier on a second line item. “Some carriers may allow the entire amount to be billed without a modifier JW, but the entire amount in question (administered and wasted) must be supported,” says Loya.

When to avoid JW modifier? One exception to the general rule is that you should not apply the JW modifier when the actual dose of rituximab administered is less than one billing unit.

One billing unit for rituximab is equal to 100 mg of the drug and that for bevacizumab is 10 mg of the drug in a single-use vial. MLN uses a hypothetical example where the oncologist administered 80 mg rituximab to a patient while 20 mg of the remaining drug was discarded. In this case, you bill the 80 mg dose using one billing unit that represents 100 mg on a single line item. This single line item of 1 unit would be processed for payment of the total 100 mg of drug administered and discarded.

You should not bill another unit on a separate line item with the JW modifier for the discarded 20 mg of drug. This would result in overpayment. Hence, you do not apply the JW modifier when one billing unit is equal to or greater than the total actual dose and the amount discarded.

Remember: For more information on reimbursement and calculation for discarded drugs, review Medicare Claims Processing Manual, Chapter 17, Section 40.

Check for Documentation of Medical Necessity

When billing for rituximab administration, make sure the physician documented diagnosis or condition supporting the medical necessity of the medication ordered and administered. This may include the physician’s order for the medication therapy and services billed. Because billing for any service must be at the direction of the treating physician, confirm the order(s) are dated prior to or on the date(s) of service.

If not adequately noted on the order, you may need to review and consider the physician’s progress note indicating the purpose of the order and may be stated in the history, physical examination, impression and care plan detail. Check documentation to confirm there is supporting evidence for diagnosis of the underlying condition which necessitates the administration of rituximab or bevacizumab.