The Pharmacy portion of the facility chargemaster contains many intricate details required for proper insurance reimbursement of UB04 claims billing that is often housed in the Pharmacy module rather than the chargemaster or billing module. Due to systems limitations and a lack of cohesive understanding in departmental duties for NDC and dosage unit maintenance; claims are often missing critical data that will result in denials, under or over-coding of dosage units, and possible revenue and compliance issues. 

According the 2015 OIG (Office of Inspector General) Policy Statement, hospitals who have elected to bill any of their Outpatient drugs (not integral to a procedure) as Self-Administered must bill all in the same manner and may not bill a select few.  This has become an “all or nothing” requirement. “Hospitals must uniformly apply their policies regarding discounts or waivers on Noncovered SADs (e.g., without regard to a beneficiary’s diagnosis or type of treatment)”.

The newest issues facing Hospital Pharmacy and Billing departments is the January 1st, 2017 Medicare required application of JW Modifier assignment for the billing of Outpatient, discarded Single Dose Vial Waste. Identifying the applicable drugs as well as those drugs considered Self-Administered by Medicare can also cause audits, overpayments, and inconsistent billing. 

RIMR offers clients a solution to assist with HCPCS code assignment, dosage unit review, and identifying those drugs eligible for the JW modifier assignment of single-dose vial drugs. Revenue Code assignment, missing HCPCS, and description validation are expertly reviewed for accuracy and compliance which often leads to added Revenue.