Coding Guidelines for Injectable Drugs (HCPCS codes)

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.

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

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.

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 wastedExample:>  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)

Reference:

https://www.aao.org/practice-management/coding/injectable-drugs

3 thoughts on “Coding Guidelines for Injectable Drugs (HCPCS codes)”

  1. Pingback: Coding Guidelines for Injectable Drugs (HCPCS codes) – medicalbilling

Leave a Reply

error: Content is protected !!
Meloxicam: Soothing Pain, Empowering Mobility Lupus Unmasked: Unraveling the Mystery of Its Symptoms “Defeating Lymphoma: Empowering the Immune Battleground”