A specific example was a recent J-3490 claim for drugs used to treat a patient suffering from Osteomyelitis, a bone infection.
The drug’s NDC, 00409-4055-03 was mentioned on the HCFA 1500 which turned out to be Clymdamycin, a relatively low cost antibiotic. The provider charged total of 66 units of Clymdamycin for treatment over a 7 day hospital stay. The injectable was charged at a cost of $140.70 a unit, or a total
billed amount of $9,240.
The administrator, not knowing that it was really paying for Clymdamycin, only adjusted the billed amount by the network agreed-upon discount of 50% for J-3490 codes, thus reducing the billed amount from $9,240 to a paid amount of $4,620.
Had the claim be filed correctly for 66 900mg/6ml vials of Clymdamycin, it would have been determined that:
- The standard unit dose is 150 mg costing $0.938, hence the AWP Redbook cost would be $5.63 per 900 mg vial, not the $140.70 charged which also happens to be the cost of a box of 25 vials.
- The payments at AWP thus should be $371.58 (66 vials times $5.63) and not the $9,240 billed or $4,620 paid.
- As a result, the claim was overpaid by $4,248.42
- Additionally, a medical review should have brought out that the recommended dosage for 7 days would have been in the 14 vial range with a maximum recommended dosage around 35 vials, both below the 66 vials billed or far below the 1650 vials in 66-25 vial cases.