• General Guidelines

    • Use the appropriate Healthcare Common Procedure Coding System (HCPCS) based on code descriptor.
    • Not Otherwise Classified (NOC) codes (eg J3490, J3590, J7999) should only be reported for those drugs that do not have a valid HCPCS code which describes the drug being administered or per payer policy.
    • IReport name of drug, dosage and route of administration in item 19 of the CMS-1500 or EDI equivalent.
    • 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 submit for payment. (eg sample drug or specialty pharmacy)
    • 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. Only bill for the amount given to each patient. This is only permitted for Botox injections and a published payer policy allowing. 
    • When billing a compounded drug, use HCPCS code J3490 or J7999 and list each drug and its dosage in the descriptor field. List all NDCs for each drug administered in item 24 of the CMS-1500. Reference: OIG report April 2014.
    • To order a HCPCS book visit the Academy Store.
    • Review the CMS ASP Drug Pricing Files for Medicare reimbursement.
    • When billing injections, always include the HCPCS drug code, even when no payment from the payer is required. For sample drugs, report the appropriate HCPCS code and $0.0 or $0.1 charge.

    Single-Use Vials or Pre-Filled Syringes

    When there is no measurable wastage (1 unit or less) report the units injected.  For example: 

    • EYLEA — 2 units
    • Lucentis — 3 or 5 units
    • Ozurdex — 7 units
    • Vabysmo – 60 units
    Document in the procedure note: residual medication less than 1 unit was discarded

    For more information, review the EyeNet article: Correct coding for single-use vials.

    Multidose Vials

    Insurance companies will only pay for the amount administered to the patient and will not pay for any discarded amounts of the drug when designated as a “multidose” vial. See "Reporting Units of Drugs – Examples" section below. Read this EyeNet article How to get reimbursed for multidose  vials.

     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:
    >The number of injections
    >The injection sites
    >Units injected at each site
    >Amount of medication wasted

    Calculating Units of Drugs – Examples

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

    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, and is 1 unit or greater, insurance will cover the amount discarded as well as the amount administered.
    • The amount ordered, administered, and the discarded must be documented in the medical record. The date and time of administration should also be included.
    • The amount documented as wastage shall not be used on another patient, nor billed again to Medicare or other payer.
    • Reminder: payment for discarded drugs only applies to single use vials.
    • Modifier –JW identifies unused/wasted drug for single dose vials.
    • Effective Jan. 1, 2017 mandatory use of modifier -JW for Medicare Part B claims demonstrating units wasted:
      • Example:
        • >Triesence 40 units, 40 mg single-use vial
          • J3300 Injection, triamcinolone acetonide, preservative free, 1 mg
        • >J3300 4 units
        • >J3300 -JW 36 units
      • Example:
        • >Visudyne 150 units, 15 mg single-use vial
          • J3396 Injection, verteporfin, 0.1 mg
        • >J3396 63 units
        • >J3396 -JW 87 units

    Checklist/Guide for Coding Injections

    • CPT 67028, eye modifier appended (-RT or-LT)
      • Bilateral injections billed with a -50 modifier per payer guidelines. (Medicare Part B claims billed with 67028-50 on one line, fees doubled and 1 unit.)
    • HCPCS J-code for medication
    • Appropriate units administered (i.e., EYLEA 2 units)
    • HCPCS J-code on a second line for wasted medication, if appropriate
      • -JW modifier appended
    • Medically necessary ICD-10 code appropriately linked to 67028 and J-Code (s)
    • On the CMS-1500 claim form in item
      • 24a or EDI loop 2410: 11-digit NDC code in 5-4-2 format, proceeded by “N4” qualifier followed by unit of measurement (UOM), ML and appropriate amount (eg ML0.05)
        • Example Avastin: N450242006001 ML0.05
      • 19 or EDI equivalent: Description of medication and dosage per insurance guidelines (e.g. Avastin and NOC codes)