Q&A: Proper representation of drug units in the CDM

Q. How can revenue integrity professionals ensure drug units are properly represented in the charge description master (CDM)?

A. Pharmacy drug units can be a challenge to properly incorporate in the CDM and may require the involvement of your pharmacy. The following example offers some insight into the detail required.

Example: A physician orders 2 mg of a drug that is defined by a HCPCS code (J Code) as 5 mg. The vial size is 5 mg. What do we bill?

In this case, we should bill one unit with no wastage because the lowest unit is 5 mg. If there was a smaller vial size (i.e., a 2 mg vial), we would continue to bill one unit. But if the vial size provided to the patient is the 5 mg vial and we bill for one unit, our investigation may raise the question as to why the pharmacy issued or the nurse dispensed a larger vial than what was needed. Because there was a smaller vial size available that would fulfill the full unit of drug necessary, we would capture the unreimbursed waste here for administrative reporting purposes.

If a physician orders 2 mg of a drug that is defined by a HCPCS code (J Code) as 1 mg and the vial size is 5mg, we should bill two units and then report wastage of three units with modifier -JW.

Unused portions of a single-use vial or other single-use packages are billable to Medicare if a portion of the drug is administered to the patient and the remainder is discarded. In the scenario where the drug is defined by a HCPCS code as 1 mg, however, we would have to report waste because the vial size used (5 mg) was larger than what the HCPCS code represents (1 mg).

For more information, see The Revenue Integrity Manager's Guidebook.

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