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