- Change to Roster Claims Information Entry in the Fiscal Intermediary Standard System Direct Data Entry
- Drugs and Biologicals - Coverage and Billing
- Medicare Part B Drug Coverage
- Covered Medicare Part B Drugs/Biologicals
- Self-Administered Drug Exclusion
- Medicare Part B General Billing
- Discarded Drugs/Wastage and JW, JZ Modifier
- Chemotherapy General Infusion Information
- Unlisted Codes for Drugs and Biologicals (J3490, J3590 and J9999)
- Compound Drugs
- Patient-Supplied or Free-of-Charge Drugs
- Prolonged Drug and Biological Infusions Using an External Pump
- Coding for Sinuva™ Claims
- Radiopharmaceutical Reimbursement
- Dermal Injections for Treatment of Facial Lipodystrophy Syndrome
- Factor VIII Billing
- Intravitreal Beovu (Brolucizumab-dbl) Billing
- Proper Billing for LEQVIO® HCPCS Code J1306
- Erythropoiesis Stimulating Agents: Clinical Indications and Coverage Criteria Overview
- Proper Billing for TEZSPIRE™ HCPCS Code J2356
- Proper Billing Units for HCPCS Code J7320
- Providers Performing Facet Joint Injections (CPT Code 64476)
- Skin Substitutes
- Vaccines
- Related Content
Dermal Injections for Treatment of Facial Lipodystrophy Syndrome
Table of Contents
- Dermal Injections for Treatment of Facial Lipodystrophy Syndrome
- Billing Guidelines
- Claim Completion Instructions
- Wastage
- Claim Completion Instructions for Waste
- Related Content
Dermal Injections for Treatment of Facial Lipodystrophy Syndrome
Dermal injections, such as Sculptra, are covered by Medicare when used in the treatment for LDS for patients with HIV. LDS is often characterized by a loss of fat that results in a facial abnormality such as severely sunken cheeks. This fat loss can arise as a complication of HIV and/or HAART. Due to their appearance, patients with LDS may become depressed, socially isolated, and in some cases may stop their HIV treatments in an attempt to halt or reverse this complication.
Billing Guidelines
Sculptra (CPT/HCPCS Q2028) is calculated as 0.5mg and is packaged as a SDV containing 367.5mg per vial; and cannot be split up for payment.
- Each billing unit = 0.5mg
- One vial is 367.5 mg = 735 units
- Two vials are 735 mg = 1470 units
Therefore, depending on how many vials were administered, total quantity/units billed would be noted as the following in item 24G or the electronic equivalent: 735 or 1470.
Claim Completion Instructions
Enter the name of the drug, NDC number, dosage administered and invoice cost as “total cost $xxx.xx” or “price per vial $xxx.xx” in the claim narrative. (Item 19 or Loop 2300, Field NTE02)
Wastage
Effective 1/1/2017, providers and suppliers are required to report the JW modifier as a way to identify, and be paid for, unused drugs and biologicals.
- The JW modifier is applied to the amount of drug or biological that is discarded, and it is billed on a separate line item; and
- The discarded drug/biological must be documented in the patient’s medical record.
When billing for waste, ensure the following is present on the claim:
- A line with the amount administered of the HCPCS code.
- A separate line for the wasted amount of the HCPCS code with the JW modifier behind it.
Claim Completion Instructions for Waste
Enter the name of the drug, NDC number, amount wasted and invoice cost as “total cost $xxx.xx” or “price per vial $xxx.xx” in the claim narrative. (Item 19 or Loop 2300, Field NTE02)
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 40 - Discarded Drugs and Biologicals
- Medicare Program: JW Modifier: Drug/Biological Amount Discarded/Not Administered To Any Patient Frequently Asked Questions
- National Coverage Determination (NCD) for Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS) (250.5)
Reviewed 3/26/2024