Last Modified: 6/7/2024
Location: FL, PR, USVI
Business: Part B
When billing for drugs, please be sure that units administered are accurately reported in dosage/units specified in the HCPCS long code descriptor.
Before submitting the claim, review the long descriptors for the HCPCS code you are billing since the short descriptors don’t always capture the complete description of the drug.
When submitting a claim, report the units in multiples of the dosage included in the long HCPCS code descriptor. If the dosage given is not a multiple of the number in the HCPCS code description, round up to the nearest whole number. Don’t bill units based on the way the drug is packaged, stored, or stocked.
It is not appropriate to bill for the full amount of a drug when it has been split between two or more patients. Bill only for the amount administered to each patient.
Examples of how to report single and multiple units on a claim.
• If the description for the drug code is 6 milligram (mg), and 6 mg of the drug was administered to the patient, the units billed should be 1.
• To calculate this, it is 6 mg (administered)/6 mg (HCPCS code description) = 1 unit
• If the description for the drug code is 50 mg, and 200 mg of the drug was administered to the patient, the units billed should be a total of 4.
• To calculate this, it is 200 mg (administered)/50 mg (HCPCS code description) = 4 units
• If the HCPCS code descriptor for the drug code specifies 1 mg and a 10 mg package of the drug was administered to the patient, the units billed should be 10 even though only 1 mg was administered.
• To calculate this, it is 10 mg (administered)/1 mg (HCPCS code description) = 10 units
Example of coding based on the dosage descriptor when the dosage is not a multiple of the code descriptor. Remember to round to the next highest unit for the code.
• Description of drug is 6 mg
• 10 mg administered
• 10 mg (administered)/6 mg (HCPCS code description) = 1.67 units
• 2 units are billed due to rounding to the next highest unit
Example of full dosage provided is less than the dosage for the code descriptor specifying the minimum dosage for the drug. In this situation, report the code for the minimum dosage amount.
• Description of drug is 50 mg
• 48 mg administered
• 48 mg (administered)/50 mg (HCPCS code description) = 0.96 units
• 1 unit is billed due to reporting the code for the minimum dosage amount
CMS encourages physicians, hospitals and other providers and suppliers to care for and administer drugs and biologicals to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.
When billing for a drug from a single-dose container or single-use package and part of the drug is being discarded, bill the discarded amount with the JW modifier on a separate line.
Example:
• The patient received 150 mg of JXXXX from a 200 mg single-use package. Due to the packaging of the drug, 50 mg weren’t used and were discarded. 1 mg = 1 unit
• On line 1, report JXXXX with 150 units
• On line 2, report JXXXX with modifier JW and 50 units
If you didn’t discard any of the drug from a single-dose container or single-use package, report the JZ modifier on the claim starting on July 1, 2023.
Example:
• The patient received 200 mg of JXXXX. This single-use package contained 200 mg and none of the drug was discarded.
• Report JXXXX with modifier JZ and 200 units.
Multi-use containers or packages are not subject to payment for discarded amounts of the drug. Only report the amount administered.
Example:
• The patient received 160 mg of JXXXX. This multi-use package contains 400 mg. 10 mg = 1 unit
• Report one line of JXXXX with 16 units
Incorrect billing may result in the denial of the claim.
When providing a drug and the total billed amount exceeds $99,999.99, two claims should be submitted.
When billing two claims ensure that your total dollar amounts are different on each claim, use modifier 76 to indicate repeat service on the subsequent claim(s) and notate in the narrative why the claim is split this way. This will prevent the system from assuming the claims are an exact duplicate.
Example: The patient received 25 mgs of JXXXX for a total billed amount of $125,000.00. The unit of service is based on 1 mg. Based on the dollar amount two separate claims need to be submitted.
To distinguish between the initial dose of a drug and subsequent doses of that same drug used in a sequential series in the treatment of a condition where drugs are administered in a series throughout a course of therapy, report modifier EJ to identify the subsequent doses.
• Do not report an initial dose of a drug with the EJ modifier.
• The EJ modifier is informational only.
References:
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