Reviews by Demonstration RACs indicated that claims were paid for pharmaceutical injectables with an incorrectly billed number of units; claims paid incorrectly by fee schedule and drugs billed under incorrect HCPCS codes totaled more than $5 million dollars.
Guidance on How Providers Can Avoid These Problems
– CMS published MLN Matters® article 6950, which describes injectable drugs, including intravenously administered drugs typically eligible for inclusion under the “incident to” benefit. MM6950 can be reviewed at http://www.cms.gov/MLNMattersArticles/downloads/MM6950.pdf (pdf) on the CMS website.
– Drug coverage is discussed in Chapter 17 of the Medicare Claims Processing Manual (http://www.cms.gov/manuals/downloads/clm104c17.pdf (pdf)), especially Section 40 (Discarded Drugs and Biologicals), Section 70 (Claims Processing Requirements – General), and Section 80 (Claims Processing for Special Drug Categories).
Recommendations
– Be sure staff is aware of the manual chapter and article cited previously regarding Medicare policy on billing for drugs.
– Ensure you adequately document a physician’s drug orders, dosage administered, and when required by CMS policy, the drug dosage wasted amount.
Source: CMS.
