Oncology & Hematology Coding Alert

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

If you’re hesitant about your drug coding savvy, you’re not alone. Bust these five myths that could land your RAC-targeted rituximab and bevacizumab claims in reimbursement limbo.

Myth #1: You Can Report J Code Units Based on Short Descriptor Alone

Reality: Not so fast. To accurately report any code, you need to refer to the full code descriptor as the short descriptor may not provide 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 1 unit equals 1 mg, then she risks reporting 100 times more rituximab than is appropriate.

Myth #2: You Don’t Need to Report Precise Units

Reality: You should always report the correct number of units. When reporting code J9310 (Injection, rituximab, 100 mg) for rituximab, coders often forget to convert milligrams to billing quantity units. The same is true when reporting bevacizumab with J9035 (Injection, bevacizumab, 10 mg). As a result, these coders’ practices could end up with significant overpayments that must be returned.

Tip: When billing Medicare for these drugs, you count one unit for every 100 mg of rituximab. Conversely, you’ll report only one unit for every 10 mg of bevacizumab. Always verify how many milligrams of rituximab or bevacizumab your oncologist administered. Then divide the dose given by the amount described as a single unit in the HCPCS code descriptor. The resulting number will be the quantity of the HCPCS code units you should report.

Example: You may read the nurse administered 200 mg of rituximab to a patient. Correct reporting of the amount is 2 units of 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 would be billing 200 units of rituximab. Since J9310 is defined as 1 unit being equal to 100 mg, 200 units would mean 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, when billing for rituximab, bevacizumab, or any other HCPCS medication, your reported units will each represent a specific number of milligrams. You must make a conversion from the administered amount to the unit equivalent before submitting the claim.

Myth #3: You Won’t Be Reimbursed for Wastage

Reality: Another concept that is crucial for clean rituximab and bevacizumab claims is that you may report to Medicare the amount administered, as well as the amount discarded since both drugs are only available as single-use vials. Medicare will reimburse for the full quantity of a 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, Associate Partner of Pinnacle Enterprise Risk Consulting Services, LLC.

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 accounting for wastage, you should be focused on the amount of rituximab or bevacizumab shown on the vial or package label. Recall Medicare’s language. 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, 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 can be reported. Auditors may look for this information to justify the units billed.

Myth #4: Modifier JW Rules are the Same for Every Payer

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

Example: When you read the patient received 810 mg from two vials of rituximab 500 mg, you will report 9 units (rounding up) 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 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 for bevacizumab is 10 mg of the drug in a single-use vial. The Medicare Learning Network (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 dose administered, and the amount discarded.

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

Myth #5: You Don’t Need to Worry About Medical Necessity Documentation

Reality: When billing for rituximab administration, make sure the physician documented a 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 which 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.