DUR: Appropriate Drug Billing Unit Standards for Medi-Cal
Each time a drug is billed to Medi-Cal, the claim must state how much of the drug was provided. Knowing which unit measurement to use allows for proper reimbursement and decreases the likelihood of the provider being under- or over-paid. This article summarizes the National Council on Prescription Drug Programs (NCPDP) Billing Unit Standards, provides examples of common billing unit errors, and briefly discusses how physicians and clinics bill for drugs.
I. Pharmacies
Pharmacy claims follow a standard set of rules established by NCPDP. These rules are summarized below.
Table 1: Adapted from NCPDP Billing Unit Standards Version 2.0
Dose Form |
Proper Unit of Measurement |
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Exceptions to NCPDP Billing Unit Standards
The following products are current exceptions to the general rules regarding billing unit standards. These products must be billed in units measured per each or eaches.
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1 each |
Inhalers: As stated in the rules, use the unit of measurement listed on the product. If both volume and weight are listed on the product, then use the first unit listed. For example, if the package states “14 gm (10 mL),” then 14 grams is used. If the product weight is listed in terms of mcg or mg, the billing unit is converted to gm. Please note that Pulmicort Turbuhaler is an exception to this rule and is billed as
"each.”
Rounding Off: Do not round off. If the quantity is not a whole number, then submit the quantity in the metric decimal form. For example, a 3.5 gm tube of ointment should be expressed as 3.500, rather than rounding to 4. Do not include measurement units such as gm or cc. For more information on rounding, see the Pharmacy Claim Form (30-1) Completion section in the provider manual.
Kits: A kit must be billed as each kit rather than as separate components or according to units of measurement. Kits have at least two different items in the same package, intended for dispensing as a unit, and the kit has a single NDC number. The two items may or may not be drugs. Below are three different types of kits:
- Two drug items that each have a different billing unit standard (example: tablet and liquid)
- One drug plus alcohol swab or cotton (example: Copaxone)
- Meter plus test strips
Proprietary Computer Systems: Some computer systems convert the units that an operator enters. For example, a “1” is entered for a four-ounce bottle of cough syrup and the computer system converts it to “120” because the bottle size is 120mL. Medi-Cal has identified claims submitted for 14,400 units (mL) because the quantity entered was “120” and the pharmacy’s computer multiplied that by 120 for a total of 14,400 mL.
Table 2: Examples of Erroneous Billing
| Quantity Dispensed | Exampls of Erroneous Billing |
Type of Error | Correct Billing Unit |
Duragesic 50 mcg/hr Patches |
“10” for 10 days supply | Over-billing | 5 patches |
| “1” for 1 box | Under-billing | 5 patches | |
| Augmentin 200mg/28.5 mg/5mL Suspension 1 bottle of 100 mL |
“200” for 200 mg | Over-billing | 100 mL |
| “1” for 1 bottle | Under-billing | 100 mL | |
| Lovenox 30mg/0.3mL Pre-Filled Syringes 12 syringes of 0.3 mL |
“12” for 12 pre-filled syringes | Over-billing | 3.6 mL |
| “4” for 3.6 mL rounded up to the nearest whole number | |||
| Humalog 100U/mL 1 vial of 10 mL |
“1” for 1 vial | Under-billing | 10 mL |
| “1000” for 1000 units | Over-billing | 10 mL | |
| Copaxone Pre-Filled Syringe Solution for Injection Kit 1 box (kit) of 30 pre-filled syringes |
“30” for 30 pre-filled syringes | Over-billing | 1 kit |
| “30” for 30 mL (1 mL per pre-filled syringe) |
Over-billing | 1 kit |
II. Physicians and Clinics
Injection Codes
There are codes for claims submitted by physicians and clinics for drugs administered to recipients. These codes do not necessarily follow NCPDP rules. Therefore, providers must look up the product in the list of codes for injections in the appropriate Part 2 provider manual. The injection codes are also listed in the following two ways:
- Injection codes are listed in the Injections: List of Codes section of the appropriate Part 2 provider manual.
- The Injections: List of Codes section may also be found on the Medi-Cal Web site.
Physician and Office-Administered Injection Pricing
Providers may look up current Medi-Cal maximum reimbursement rates on the Medi-Cal Rates page. On the “Medi-Cal Rates” page, either click “Download All Medi-Cal Rates” or “View Medi-Cal Rates by Procedure Code.” To search rates by procedure code, click the link displaying the code range with the code you are searching for.
The maximum amount payable for the first unit is the cost of the drug plus an administration fee. For quantities greater than one unit, the cost of the additional units is added to the amount payable for the first unit. The price per unit published by Medi-Cal is the price for the first unit (including the administration fee). Providers can downlaod all Medi-Cal maximum reimbursement rates or search by procedure code from the Web page.
Conclusion
Incorrect billing practices generate erroneous payments and skew utilization information, which may trigger an audit review of provider claims and/or an investigation into possible fraudulent activity. To avoid these outcomes and to increase the likelihood of correct claims processing and payment, providers should pay close attention to drug billing unit standards when they submit claims for reimbursement.
Note:
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