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Issue Number - Name
0074 - Excessive or Insufficient Drugs and Biologicals Units Billed
Review Type
Complex
Claim Type
Outpatient Hospital Claims & Physician Claims
Region and State
RAC 1-4
All States
Date Approved
2017-12-21

Description

Units Billed Drugs and Biologicals should be billed in multiples of the dosage specified in the HCPCS code long descriptor. The number of units billed should be assigned based on the dosage increment specified in that HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriate, discarded drug waste. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Claims billed with excessive or insufficient units will be reviewed by a nurse, registered pharmacist, certified pharmacy technician, or certified coder to determine the actual amount administered and the correct number of billable/payable units.

Affected Code(s)

  • C9025, C9295, J0129, J0178, J0256, J0583, J0585, J0894, J0897, J1300, J1459, J1561, J1566, J1569
  • J1572, J1745, J2323, J2353, J2357, J2505, J2778, J2796, J2997, J3101, J3262, J3487, J7325, J9033, J9035
  • J9041, J9043, J9055, J9171, J9228, J9263, J9264, J9299, J9303, J9305, J9306, J9310, J9351, J9355, Q2050, J9034

Applicable Policy References

  • 42 Code of Federal Regulations, Section 405.980 (b) and (c)
  • 42 Code of Federal Regulations, Section 405.986
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, Sections 10, 40, 70 and 90.2
  • Medicare Alpha-Numeric HCPCS File 
  • Annual American Medical Association, CPT Manual
  • Annual HCPCS Level II Manual
  • Medicare Part B Drug Average Sales Price, ASP Pricing File 
  • U.S. National Library of Medicine DailyMed