Ambulatory Coding & Payment Report
Reader Question: Billing the Dosage
Question: How should our facility bill pharmaceutical J codes that are approved for APC payment, but the long descriptor either does not include a dosage or does not match the dosage administered?
Illinois Subscriber
Illinois Subscriber
Answer: Although J codes describe common dosages of medications, they often do not list the exact dose used. This is a carrier-specific billing policy that should be individually verified with the carriers you bill most frequently. Some payers will allow you to bill the dosage described by the J code even if it overstates what is used, while others request that in addition to billing the J code you also communicate the exact amount of the dose administered.
When dosages do not match how the drug is administered, you should use the unit field to report multiples of the dosage identified in the code descriptor. When no other J code more closely describes the amount of drug given, a multiplier should be used. For instance, if one gram of immune globulin (J1561) is administered from two 500-mg vials, the report should indicate HCPCS code J1561 with two units notated. If the amount of the drug administered to a patient is less than the amount described by the HCPCS code, a hospital may bill for one unit.
Medicare may reimburse for a drug in units that clinically do not represent what is considered a standard dosage, however. For example, if a drug is eligible for reimbursement in units of 10 mg and your facility uses 100 mg of the drug, to be properly reimbursed the claim should reflect 10 units of a 10 mg dose. Failing to do so could mean that your facility is losing reimbursement.
As the quantity billed should generally reflect the specific dosage administered, your particular pharmacy should evaluate how pharmaceuticals are ordered and revise the facilitys chargemaster descriptions to accommodate the specific unit doses indicated as payable under APCs.
- Published on 2001-09-01
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