Many of our audits find that clients are missing charges regarding single dose vial waste.  Drugs are packaged in vials classified as either single dose or multiple dose vials.  While the entire contents of single dose vials should be billed, waste for multiple dose vials should never be billed to the patients or to their insurance.  While this sounds relatively straightforward, there are a few nuances to these rules that should be considered.

Per CMS guidelines, if you are using a single dose vial for more than one patient, you should “schedule patients in such a way that they can use drugs and biologicals most efficiently in a clinically appropriate manner”.   In this case, the last person of the day to receive the drug is billed for the units of single dose vial drug wastage. 

CMS also does not cover drug waste when the waste is due to not having the appropriate vial size in stock.  For instance, the patient’s dose is 70mg of a drug that is only available in single dose vials of 100mg and 200mg.  If your practice only has the 200mg vial size in stock, only the 100mg size would be billable.  It is the responsibility of the physician to have the appropriate inventory available that will reduce the amount of drug wasted. 

The golden rule of coding is “if it’s not documented, it didn’t happen” – and this concept also applies to drug waste.  All clinics should have documentation of the amount of single dose vial drugs wasted and a waste log is highly recommended in addition to the computer generated reports from dispensing systems.

A recent lawsuit involving a major drug manufacturer also brought into the national spotlight the issues of billing for overfill.  Documentation will protect your practice and ensure that you are NOT billing for overfill and this is just another reason why your documentation is so important.  To state simply, you cannot bill for drugs that you did not pay for, including overfill. 

Your staff should be familiar with the drugs that your particular practice utilizes and how they are packaged.  Your clinical pharmacy should be able to provide your billing office with that information and it should be routinely updated.  Communication between the clinical and billing staff is essential to properly capture your treatment and waste charges.   

National Correct Coding Initiative (NCCI) edits were developed by CMS to encourage correct coding methodologies and to control improper coding leading to incorrect payment of claims.  NCCI edits assist CMS in avoiding improper payments when incorrect code combinations are reported. 

There are two sets of NCCI edits which are available on the CMS website:

(1)   NCCI Physician Edits- providers who bill Part B services

(2)   NCCI Hospital Outpatient PPS Edits- providers who bill Part B services to Part A

Within each set of NCCI edits, two types of coding situations are addressed (modifiers exist in each set to allow possible payment when billed with the secondary code):

(1)   Column 1/Column 2 Correct Coding Edits which apply to code combinations where one of the codes might be a component of a more comprehensive code.  The edit allows payment for the column 1 code only. 

(2)   Mutually exclusive code edits include those codes that cannot reasonably be completed in the same session. 

As of January 1, 2010, CMS modified the edits bundling CPT® codes 99201-99215 (New Patient Visits) and 99221-99223 (Inpatient Hospital Care) with radiation oncology procedures.  Now the evaluation and management codes are allowed with the use of NCCI-associated modifiers when billed on the same day as radiation oncology procedures.  These codes may be reported only once with an NCCI-associated modifier for the initial consultation with the patient.  The exception is that these evaluation and management codes should not be reported with an NCCI-associated modifier for other evaluation and management services during the course of radiation therapy and 90 days after the last treatment.