Oncology & Hematology Coding Alert

Question: Palmetto is doing a review of J9355 claims because people are reporting units incorrectly. What is the appropriate way to report units for multi-use vials?

South Carolina Subscriber

Answer: For multi-use vials, you should report units based on the amount of drug administered to the patient. So if the patient receives 188 mg of Herceptin, you should report 19 units of J9355 (Injection, trastuzumab, 10 mg). Divide 188 mg by the 10 mg in the code definition to get 18.8. Then round up to get 19 units. (See Medicare Claims Processing Manual [MCPM], Chapter 17, Section 10, for more information: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf).

Key point: You should report only the amount actually administered. Multi-use vials are not subject to payment for discarded amounts of drug or biological, according to MCPM, Chapter 17, Section 40. You should bill wastage only for amounts not used from single-dose vials (SDV) or packages.

More details: Palmetto announced a service-specific prepay complex review of J9355 claims for the payer's providers in North Carolina, South Carolina, Virginia, and West Virginia. Palmetto's data analysis showed providers are billing for the multi-dose vial instead of reporting the amount administered. Experts report that the OIG is reviewing Herceptin reporting, as well.