Documenting “Units” on claims for services is a requirement for processing claims correctly. Identifying Units on a claim might be a difficult task sometimes. Documenting more units for a service than the documented amount or number can cause claim denial, overpayment, recoupment, or audits. On the other hand, documenting less units can also cause denials, underpayment, recoupment, or audits. Medical billing regulation requires reporting correct units for all services.
Units on the claim represent how many times a service has been provided to a patient on one day. Units on a claim can also represent time or amount. By documenting the correct unit, the biller lets insurance know how to price the service. Insurances have specific guidelines on how many billing units can be billed for any service on the same day. Using incorrect billing units will cause claim denial, underpayment, or overpayment.
Underbilling a claim by documenting fewer units can result in a loss of revenue. If you underbill high-cost services such as injectable medication, it will greatly affect the revenue. There are medical practices which had to close their offices for unsustainable losses.
Units in Medical Billing
Billing units are a way to measure time and frequency of services. Units are used to indicate the cost of a medical service as well.
For example, a therapist’s time with a patient is represented on the claim with one more unit depending on the block of time that insurances allocate per unit. An office visit to a Primary Care doctor is represented with one unit. Units for an injectable drug will depend on how many milligrams are used.
CPT codes indicate which services were done and units indicate how many of those services were done in a day. Diagnosis codes indicate why each of the services needed to be done. These codes and units are standardized to maintain uniformity in patients health records.
Types of Billing Units in Medical Coding
It is important to understand the different types of billing units in medical coding. These units are used to measure the quantity of a particular service provided to a patient.
Here are the two main types of billing units used in medical coding:
1. Timed vs Untimed Codes
Timed codes are used when the service provided is time-based, such as manual therapy, gait training, neuromuscular re-education, and therapeutic exercise. The time-based CPT codes are used to report the total time spent providing the service.
Untimed codes, on the other hand, are used for services that are not time-based, such as exams, testing, and procedures. These codes are typically reported as a single unit
2. Service-Based and Quantity-Based Units
Service-based codes are used to report a single unit of service provided to a patient. These codes are typically used for procedures that are performed once, such as a surgical procedure or an injection. The quantity of the service provided is reported as one unit.
Quantity-based units are used to report multiple units of service provided to a patient. These codes are typically used for services that are provided multiple times, such as physical therapy sessions or mental health counseling. The quantity of the service provided is reported as the number of units provided.
In addition to CPT codes, there are also HCPCS codes that are used to report services provided to patients. These codes are typically used for services that are not covered by CPT codes, such as durable medical equipment and supplies.
Applying Units in Different Healthcare Settings
In medical billing, the application of units can vary depending on the healthcare setting. In this section, I will discuss how units are applied for outpatient and inpatient billing, as well as special considerations for rehabilitation and therapy.
Outpatient vs Inpatient Billing
In outpatient billing, units are typically based on the number of times a procedure or service is performed. For example, if a patient receives physical therapy for 30 minutes, the session would be billed with one unit. However, if the patient received 60 minutes of physical therapy, two units would be billed.
In contrast, inpatient billing is based on the resources used during a patient’s stay. This includes the room, nursing staff, supplies, medications, and other items.
The Center for Medicare and Medicaid (CMS) has established medically unlikely edits (MUEs) that limit the number of units that can be billed for certain procedures. Doctors must keep in mind MUEs for services for documentation and billing purposes.
Billing more than allowed units will cause claim rejection and may also trigger audits. Practices should make a list of common procedures, services, and supplies and document allowed medical units for each.
Regulatory Compliance and Ethical Billing Practices
For a medical biller, regulatory compliance and ethical billing practices are of utmost importance. Failure to comply with regulations and government and insurance standards can lead to severe consequences, including fines, loss of license, and even criminal charges. In this section, I will discuss two critical aspects of regulatory compliance and ethical billing practices: Medically Unlikely Edits (MUEs) and Compliance, and Security and Privacy in Billing.
1. Medically Unlikely Edits (MUEs) and Compliance
Medically Unlikely Edits (MUEs) are a set of edits developed by the Centers for Medicare and Medicaid Services (CMS) to reduce the incidence of improper payments. MUEs are designed to identify services that are unlikely to be performed more than once on the same patient, on the same day, and by the same provider.
For a medical biller, it is essential to understand MUEs and ensure compliance with set standards. Failure to comply with MUEs can result in denied claims, audits, and even legal action. To ensure compliance with MUEs, it is essential to review the CMS website regularly and stay up to date with any changes in MUEs.
2. Security and Privacy in Billing
Security and patients’ privacy are integral parts of billing. Medical practices are expected to protect patient data and ensure compliance with regulations. Medical billers must ensure all patient data is kept secure and confidential. This includes taking steps to prevent unauthorized access to patient data, such as using secure passwords and limiting access to patient data to authorized personnel only.
Medical practices must also ensure compliance with regulations such as HIPAA, which sets standards for the privacy and security of patient data. Failure to comply with HIPAA can result in severe consequences, including fines and loss of license.
In addition to HIPAA, medical billers must also be aware of other government and insurance requirements which impact billing and patient processing. It is essential to stay updated with any changes in regulations and ensure compliance to avoid penalties.
