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Stacy Posted Mon 15th of August, 2016 16:17:34 PM
When we administered 438 mg of Herceptin (438 divided by 10 = 43.8) we rounded the units and billed 44 units. There are two examples in Oncology and Hematology Coding Alert (Mar 14, 2013 and Sep 13 2012) that explain that we should round up on the units. Also, the Sep 13, 2012 article refers to IOM Manual 104c17.pdf. The IOM manual seems to indicate under example 2 for HCPCS code J9355 to round up if the dosage is greater or lesser than the code indicates. However, Novitas changed the units from 44 to 43.8 and calculated the payment using 43.8. When we appealed the payment, Novitas sent a Medicare Appeal Decision letter to us saying that 43.8 is covered but Novitas determined that 0.2 mg is not covered by Medicare. Should we bill for units using decimalssuch as 43.8 or 23.2. The dosage is based on the patient's weight. Should we ask the physician to order Herceptin using mgs that are a multiple of "10" so the units will always = a round number.
SuperCoder Answered Tue 16th of August, 2016 05:00:49 AM

Hi,

The section 40 of the following link will guide you to apppend modifier JW and bill the wasted units seprately so that they can be reimbursed.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf

Stacy Posted Tue 16th of August, 2016 13:34:19 PM
Thanks for your reply, However, Herceptin is supplied in a multi-dose vial. There is no waste. Is it correct to round 43.8 to 44 units when billing for 438 mg of Herceptin from a multi dose vial or should we bill 43.8. When I figure the payment amounts, it seems there is an overpayment when I "do the math" for 44 units vs. 43.8.
SuperCoder Answered Wed 17th of August, 2016 02:28:54 AM

Hi,

Accoring to CMS link stated above , 43.8 units should be billed and not 44.

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