Coding for Injectable Drugs

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. Only bill for the amount given to each patient.
• When billing a compounded drug, use HCPCS code J3490 and list each drug and its dosage in the descriptor field. Reference: OIG report April 2014
• 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:
  > The number of injections
  > The injection sites
  > Units injected at each site
  > 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 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
  >  J3300 4 units
  >  J3300 -JW 36 units
• Other drugs document “any residual medication discarded”

Correct Coding for Commonly Injected Drugs

The Academy is currently updating the local coverage determination (LCD) policies for each Medicare Administrative Contractor (MAC). In the interim, please email coding@aao.org for questions regarding injection policies.

Table of Common Drugs

Use this table as a reference to help you learn more about the HCPCS office, HCPCS facility, description and units for commonly injectable drugs.

• Table of Common Drugs — Updated Nov. 2016 (pdf)

National Drug Code

The National Drug Code is a unique 10-digit, three-segment number. It is a universal product identifier for human drugs in the United States. The code is present on all nonprescription (over-the-counter) and prescription medication packages and inserts in the United States.

• Drug NDC Numbers

Listing Your National Drug Code (NDC) Number Correctly on Claims

Many NDC numbers listed on drug packaging are in 10 digit format. The NDC number is essential for proper claim processing when submitting claims for drugs used. However to be recognized by payers, it must be formatted into an 11 digit 5-4-2 sequence. This requires a zero to be placed in a specific position to meet the 5-4-2 format requirement. As not all NDC numbers are set up the same, the table below provides examples of appropriate position of the zero based on the three segment numbers listed on the packaging.

While many practice management systems automatically remove the hyphens, be sure they are excluded from submission on the claim.