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Coding Guidelines for Injections

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General Guidelines

  • Use the appropriate Healthcare Common Procedure Coding System (HCPCS) based on code descriptor.
  • Not Otherwise Classified (NOC) codes should only be reported for those drugs that do not have a valid HCPCS code which describes the drug being administered.
  • Remarks are required to include dosage, name of drug, and route of administration.
  • You cannot bill for drugs that can be self-administered. The injection must be administered by physician.
  • If there is no expense to the physician for the drug, don’t bill for it.
  • Units of drugs must be accurately reported in terms of dosage specified in Health Care Procedure Code System (HCPCS) descriptor.
  • Do not bill units based on the way the drug is packaged, stored, or stocked.
  • Do not bill for the full amount of a drug when it has been split between two or more patients. Bill only for the amount given to each patient.
  • When combining drugs for a single injection, practices must bill each drug individually on separate claim lines.
  • To order a HCPCS book visit the Academy Store.

Single Use Vials

Whether there is wastage or not, submit the number of units assigned to the drug. For example:

  • Avastin — 1 unit
  • EYLEA — 2 units
  • Lucentis — 5 units
  • Ozurdex — 7 units
  • Triesence — 40 units

Multiple Use Vials

Insurance companies will only pay for the amount administered to the patient and will not pay for any discarded amounts of the drug. See "Reporting Units of Drugs – Examples" section below.

Botulinum Toxins

  • For Medicare Part B patients, payment policy allows for only one injection code per side of the body regardless of the number of needle passes made into the site.
  • Proper documentation of complex or multiple injection sites can support and warrant additional reimbursement with some commercial payers while others pay one amount regardless of the number of injections.
  • Chart documentation should include:
      o The number of injections
      o The injection sites
      o Units injected at each site
      o Amount of medication wasted

Reporting Units of Drugs – Examples

Reminder: Documentation in the patient’s medical record must reflect the drug and dosage.

Example 1: HCPCS description of drug is 6 mg 
  6 mg are administered = 1 unit is billed

Example 2: HCPCS description of drug is 50 mg 
  200 mg are administered = 4 units are billed

Example 3: HCPCS description of drug is 1 mg 
  10 mg vial of drug is administered = 10 units are billed

Example 4: When billing a NOC drug 
  Submit 1 for the units. In Box 19 of the CMS 1500 form or electronic equivalent indicate the exact name of the drug and the dosage.

Drug Wastage

  • If the remainder of a vial must be discarded after being administered, insurance will cover the amount discarded as well as the amount administered.
  • The amount ordered, administered, and the amount discarded must be documented in the medical record.
  • Reminder: payment for discarded drugs only applies to single use vials.
  • Modifier –JW identifies unused/wasted drug.
  • Many Medicare Part B as well as commercial insurance plans no longer require physicians to report wastage with modifier –JW. The medical record must document the amount administered and the amount wasted however.