• 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.
    • Review the CMS ASP Drug Pricing Files for Medicare reimbursement.

    Single-Use Vials

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

    • Avastin — 1 unit
    • EYLEA — 2 units
    • Lucentis — 3 or 5 units
    • Ozurdex — 7 units

    Read an article on coding for single-use vials.

    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. Read this article on getting reimbursements for multi-use 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

    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. 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 (J3300 Injection, triamcinolone acetonide, preservative free, 1 mg)
      >  J3300 4 units
      >  J3300 -JW 36 units

    • Example:
      > Visudyne 150 units (J3396 Injection, verteporfin, 0.1 mg)
      > J3396 63 units
      > J3396 -JW 87 units

    • Other drugs document “any residual medication discarded”

    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
      • 19 or EDI equivalent: Description of medication and dosage per insurance guidelines (e.g. Avastin)