When billing a bilateral injection and HCPCS J1040 with two units be sure to append the correct modifier or the total units billed on a single line of the claim, not to exceed the line MUE; to avoid a duplicate denial.
For example, HCPCS J1040 would require a modifier to be appended indicating it is a distinct/separate service (i.e., modifier 59/76/XS) if billed on two claim lines.
Note, this method can be used on other injectable drugs as well such as other steroids and hyaluronate medications.
The shingles vaccine is not covered by Medicare Part A or part B. It may be something covered under a Medicare Part D prescription drug plan. You will need to work with individual insurers to determine if they cover the vaccine.
Yes, append the GY modifier on both codes; when applicable.
Yes, if the dose is split and given on different service dates, bill each dose with the service date it was administered along with the waste. To avoid a denial, the separate dates should be billed together along with a comment on the claim explaining the reason for the split.
Yes, the waste with the JW modifier always goes on the second line regardless of the billed amount.
Yes, CMS prices unclassified drugs based on ASP. ASP files are updated by CMS quarterly. Visit Medicare Part B Drug Average Sales Price for this information.
Note: NOC and compound drugs not listed on the ASP files are priced by the MAC.
No, unclassified drug code C9399 is used in outpatient settings when billing Medicare for approved drugs that have not yet been assigned billing codes and have not been determined to be eligible for special OPPS pass-through payments. View Medicare to Pay for Unclassified, FDA-Approved Drugs Administered in Outpatient Departments for additional information.
You would round up for the dose given and down for the waste; so it does not exceed the total use given/wasted on the drug code.
No, payment for waste from a multi-dose vial is not payable under Medicare. Providers/suppliers are expected to have the most appropriate sized vial on hand to minimize the amount of discarded drugs.
Although, discarded drugs or wastage may be payable by Medicare when:
- A provider or supplier must discard the remainder of a single use vial/package after administering a dose or quantity to a Medicare patient.
- The amount of discard/waste is documented in the medical record.
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. Visit Drugs and Biologicals – Coverage and Billing>Discarded Drugs/Wastage and JW, JZ Modifier for additional details.
Yes, unlisted codes J3490, J3590 and J9999 billed to the Part B MAC are priced manually. When billing unlisted codes, the unit of service equals one and the following details must be entered into in Item 19 of the CMS-1500 or electronic claim equivalent:
- Name of the drug
- Dose administered (mg, cc, etc.)
- Route of administration (IV, IM, SC, PO, etc.)
- The invoice price (for new drugs if the WAC is unavailable, or for compounded drugs)
View Billing and Coding: Drugs and Biologicals A52855 for additional details.
Yes, established drug HCPCS codes require the exact name of the drug and the dosage documented on line Item 19 or the electronic equivalent. View CMS-1500 Claim Form Completion Instructions for additional details.
When submitting the same drug code with different NDC numbers, append modifier 76 to indicate a different drug or vial size was used and bill each NDC on separate lines.
It means that it is excluded. The table referenced in Self-Administered Drug Exclusion List: Medical Policy Article A53021 lists drugs that are not covered by Medicare..
Acceptable evidentiary criteria indicates:
- A/B MACs (A), (B), and (HH+H), and DME MACs are only required to consider the following types of evidence: peer reviewed medical literature, standards of medical practice, evidence-based practice guidelines, FDA approved label, and package inserts. A/B MACs (A), (B), and (HHH), and DME MACs may also consider other evidence submitted by interested individuals or groups subject to their judgment.
No, we’ve moved coverage for those drugs from articles to new LCDs, which only include off-label indications and diagnoses. These are the coding articles attached to the new LCDs: Billing and Coding: Off-Label Use of Intravenous Immune Globulin (IVIG); Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars.
Please note, our edits still allow FDA labeled and Compendia covered diagnoses, as listed in the previous articles. For complete up to date coverage refer to the LCD for Drugs and Biologicals, Coverage of, for Label and Off-Label Uses, which includes the description of how coverage is determined for these drugs.
Note: Coverage for additional drug codes will be moved from articles to new LCD’s in the future.