High-Cost Drug Charges are Questioned – Physician Reply is Surprising


ClaimDOC’s comprehensive line-by-line review of claims uncovers errors that basic claim repricing and auto-adjudication does not catch, leading to greater savings for health plans and their plan members. Our audit team analyzes all types of healthcare claims for a variety of potential concerns, including excessive usual and customary charges, duplication of claims, incorrect coding, unbundling of services, and many others. Our claims review is not intended to impact care decisions or medical practice.

In this Audit Spotlight, we focus on the review of two (2) physician claims reported/billed for high-dollar drug infusion services performed in an office/clinic setting to a member with the diagnosis of malignant melanoma.

Coding/Billing for Physician Services

CMS-1500 claims/electronic equivalent (837P) were submitted by different physicians in the same group practice for providing care/treatment in their Missouri clinic location (services reported with place of service (POS) code 11, defined as Office).

The following services were reported/billed on each of the two claims with different dates of service, a month apart.

CPT Code 96413 – defined as, Chemotherapy administration, intravenous infusion technique, up to 1 hour, single or initial substance drug, quantity unit of 1, charge of $566.

HCPCS code J9999 – defined as, Not otherwise classified, antineoplastic drugs, quantity unit of 2, charge of $82,166.

Total charges on each claim: $82,732

Use of Unlisted or Not Otherwise Classified CPT Codes or HCPCS Codes

The American Medical Association (AMA) Instructions for Use of the CPT® Codebook indicates, “Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.” The Instructions further notes, “When an unlisted procedure number is used, the service or procedure should be described.”

The majority of unlisted or not otherwise classified codes end with the final two digits of “99,”

When considering using an unlisted or not otherwise classified procedure or service code, coders/billers need to determine if the claim could be better represented using a specific procedure or service code with a modifier appended; or by reporting a CPT® Category III code; or by using an HCPCS code.

Supporting Documentation Requirements

Because unlisted, unspecified, or not otherwise classified procedure codes do not describe/designate a specific procedure or service, it is necessary for providers/suppliers to furnish supporting documentation to determine what specific services were furnished to the member.

Pertinent information should include:

  • A clear description of the nature, extent, and need for the procedure/service.
  • Comparable CPT/HCPCS procedure code, when possible.
  • Whether the procedure/service was performed independent from other services provided, or if it was performed at the same session.
  • Any extenuating circumstances which may have complicated the service/procedure.
  • Time, effort, and equipment necessary to provide the service.
  • The number of times the services was provided.

ClaimDOC auditors requested medical records for the two (2) physician claims submitted to determine what medication was given to the member to determine pricing for the “not otherwise classified” – HCPCS code J9999 reported and billed.

The information received from the physician’s office supported they had secured the drug free from the manufacturer for the member specific to the drug, Opdualag, reported/billed with HCPCS code J9999. The physician requested pricing/payment for only the CPT code 96413 to administer/infuse the drug for both of the two (2) submitted claims.

Billing and Coding: Patients Supplied Donated or Free-of-Charge Drug

According to the Centers for Medicare and Medicaid Services (CMS) National Coverage Policy regarding the billing and coding for donated or free-of-charge drug(s), among other guidelines, “Providers can only bill when such drugs are purchased by the physician, from the pharmacy, and are administered in the physician’s office.”

To alleviate chemotherapy of other drug administration code denial, a drug code must be present on the same or prior physician claim.

Information on the claim should include the following:

  • “Drug donated or free-of-charge drug”
  • Code description, strength, and dosage
  • Drug name
  • A charge of $0.01 should be reported/billed

The Takeaway

It is not clear why the physician reported/billed the drug charge of $82,166.00 on each of the two (2) claims, rather than reporting the drug with a charge of $0.01. Only after it was questioned as to what “unlisted” drug was given to the member was it revealed – the drug was provided free of charge to the patient.

As a result of the information received from the physician practice, ClaimDOC priced the administration/infusion code 96413, allowing $170.94 of the $566 charge on each of the two (2) claims for the administration/infusion of Opdualag. The drug was priced at zero on both claims – a total drug overcharge of $164,332 reported/billed on the combined two (2) physician claims.

ClaimDOC’s Comprehensive Claims Review and Goals

The value of ClaimDOC’s comprehensive line-by-line methodical “eyes on” exam and review of claims by healthcare professionals uncovers medical coding/billing errors typically not caught.

Coding and billing of healthcare services is complicated, resulting in mistakes and overcharges – seldom is underbilling identified. It is our passion to price claims appropriately and fairly for healthcare services provided to plan members, as well as help reduce associated healthcare costs/spend.

The improper reporting of services, coding/billing errors, and egregious charges can complicate matters for members to understand their healthcare bills and payments, impact the collection of patient balances, build a reputation of providers charging high fees, create burdens for patients having no insurance, and a host of others.

When an individual receives a bill for healthcare services appearing questionable/inappropriate, an inquiry to the provider and/or health plan should be made to obtain an explanation of the service(s), corresponding charges, and reimbursement.

ClaimDOC uses benchmark data of charges and costs nationally to negotiate fair and ethical payments. Our high-quality and expert review of claims identifies and prevents improper medical claim payments and maximizes long-term cost savings opportunities.  Employers turn to us to establish fair reimbursement rates for their plans allowing them to save money and provide richer benefits to their employees. A win-win for everyone.