By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"
Patient Advocate, Certified Mediator
AdvimedPro
April 10, 2024
Units are often used in Billing, so that insurance companies understand better what specific medical service was rendered to a patient and how long it took, or how much medication was prescribed.
Units are descriptive codes which can get a claim denied, so let’s explore their small but mighty influence.
A. Two kinds of Units : Time and Dose
1. Many procedure codes used to bill an insurance already include units of time or dosage, however not all do.
· Example: 99214: Established patient office or other outpatient visit, 30-39 min
· 96360: IV hydration, initial 31-90 min
2. Time Units are calculated in 15 min increments
· 1 unit = 15 min
· BUT must be at least 8 min
· Any time increment of less than 8 min cannot be billed as a full unit, and is a loss to the medical provider
· So technically 1 unit = 8-22 min
3. Some codes requiring time units are for therapy
· ABA Therapy for Autism: 97154: Adaptive behavior treatment, each 15 minutes
· Occupational/Physical Therapy: 97530: Therapeutic Activity, each 15 minutes - 97110 Therapeutic Exercise, each 15 minutes
4. Drug Units
· Each code includes a specific amount of mgs or other criteria
· A treatment plan or prescription needs to include the quantity of that drug/prescription
· The number of units used to bill insurances is calculated by the ratio of prescribed dosage divided by what 1 unit is per the drug label.
· Ex: I unit of a drug is 200mg per the label. The treatment calls for 1,200 mg. The billing units will be 6. (1,200 : 200)
B. Why it matters
1. Policy Limits
· Many policies limit units, especially for therapy, to a certain number per day, or per year. Once met, the insurance will deny any additional service billed with more units than allowed
2. Therapy sessions may be longer for the sake of Billing. Occupational therapists are allowed to add all the time units of all the services they render a day. But remember, 8 min or less are not payable. So you may have to extend a session by 8 min in order for the provider NOT to lose payment
3. “Off Label”: this is the most troublesome, and costly! If you are more generously sized or have a proven resistance to a drug, your Dr may need to prescribe a higher dose than the one approved by the FDA or indicated on the drug label. Insurance companies routinely deny payment for “off-label” use, saddling with the full cost.
C. What can you do?
1. File an appeal to fight any denial based on Units:
2. Use arguments such as:
· Medical necessity: your autistic child was prescribed and needs more than the 24 yearly sessions allowed by the plan
· Clinical circumstances: Because of your weight, a higher dose of a chemo drug must be administered, even if over the limit set by the FDA, or you have become resistant to the drug you require, and a higher dosage has become essential for maintenance or improvement of your condition
· Coverage is unfair or too limited: 10 physical therapy sessions after you broke your leg or had a stroke are not enough for you to regain full control and use of your body
· Medical policy out of date: standards of care (the usual way this is handled by the majority of US doctors) is to have at least 1 ABA session per week for an autistic child, but the policy only allows 2 sessions per month
3. Your Doctor should file the appeal or provide you with the appropriate and supportive documentation. Filing an appeal without proving your arguments is not a winning strategy. Google can help you find other insurance companies’ medical policies (if more generous), or help prove the plan is not meeting current US standards of care.
Units are often dismissed as minor additions to a claim, but they hold more power than you may think. While you will not notice them on paid claims, they certainly have enough might to stop a cancer treatment or prescribed therapy.
Fortunately, appeals are often successful, as long as justification and medical records are included.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
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@martine brousse 2024 @ the medical bill whisperer 2024