0074 - Drugs and Biologicals: Incorrect Units Billed

Issue Name
0074 - Drugs and Biologicals: Incorrect Units Billed
Date
Review Type
Complex
Provider Type
Outpatient Hospital; Professional Services
MAC Jurisdiction
All A/B MACs

Description

Drugs and Biologicals are billed in multiples of the dosage specified in the HCPCS code long descriptor. The number of units billed should be assigned based on the dosage increment specified in that CPT/HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriate discarded drug waste.  When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label. Effective January 1, 2017, when processing claims for drugs and biologicals (except those provided under the Competitive Acquisition Program for Part B drugs and biologicals (CAP)), local contractors shall require the use of the modifier JW to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded. This modifier, billed on a separate line, will provide payment for the amount of discarded drug or biological. The JW modifier is only applied to the amount of drug or biological that is discarded. A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit. Claims billed with excessive or insufficient units will be reviewed to determine the actual amount administered and the correct number of billable/payable units. 

Affected Code(s)

C9132, J0178, J0180, J0202, J0221, J0256, J0475, J0485, J0490, J0583, J0585, J0588, J0775, J0881, J0894, J0897, J1300, J1439, J1459, J1557, J1561, J1566, J1568, J1569, J1572, J1602, J1745, J1786, J1930, J2182, J2323, J2326, J2350, J2353, J2357, J2505, J2507, J2562, J2778, J2796, J2997, J3101, J3262, J3357, J3380, J3385, J3489, J7312, J7325, J7326, J7327, J9022, J9023, J9033, J9035, J9041, J9042, J9043, J9047, J9055, J9145, J9171, J9173, J9176, J9179, J9205, J9217, J9228, J9263, J9264, J9271, J9280, J9285, J9299, J9301, J9303, J9305, J9306, J9307, J9308, J9310, J9311, J9312, J9315, J9351, J9354, J9395, Q2043, Q2050, J1750, Q0138, 20610, 20611, 67028, 96360, 96361, 96365, 96366, 96367, 96368, 96369, 96370, 96371, 96372, 96373, 96374, 96375, 96376, 96377, 96401, 96402, 96405, 96406, 96409, 96411, 96413, 96415, 96416, 96417, 96420, 96422, 96423, 96425, 96440, 96446, 96450, 96542, J0220, J0480, J0584, J0586, J0587, J0598, J1301, J1442, J1610, J1640, J2278, J3111, J3370, J7170, J7179, J7198, J7201, J7205, J7207, J9025, J9032, J9153, P9045, P9047, J0179, J0207, J0222, J0223, J0257, J0291, J0401, J0517, J0565, J0596, J0597, J0598, J0638, J0791, J0795, J0840, J0841, J0850, J0875, J0896, J1162, J1190, J1290, J1303, J1322, J1458, J1571, J1575, J1627, J1743, J1746, J1931, J1943, J1944, J1950, J2350, J2407, J2425, J2426, J2724, J2783, J2786, J2794, J2860, J3032, J3060, J3095, J3241, J3245, J3304, J3358, J3396, J9039, J9044, J9050, J9119, J9120, J9144, J9155, J9203, J9204, J9207, J9210, J9227, J9229, J9309, J9317, J9325, J9330, J9352, J9357, J9358, J9400, C9074, J0224, J1305, J1823, J2506, J7168, J7311, J7313, J7314, J9036, J9047, J9061, J9177, J9223, J9247, J9261, J9266, J9272, J9281, J9308, J9316, J9318, J9319, J9353, Q5103, Q5104, Q5107, Q5108, Q5111, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5120, Q5121, Q5122

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3.    42 CFR §405.929- Post-Payment Review
4.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
5.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6.    42 CFR §405.986- Good Cause for Reopening  
7.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8.    Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, 10- Payment Rules for Drugs and Biologicals; §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements- General; §90.2- Drugs, Biologicals, and Radiopharmaceuticals; §100.2.9- Submission of Claims with the Modifier JW, “Drug Amount Discarded/Not Administered to Any Patient”
9.    Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services; §50.3- Incident to Requirements; §60.1.A- Commonly Furnished in Physicians’ Offices
10.    Medicare Alpha-Numeric HCPCS File
11.    Annual American Medical Association: CPT Manual
12.    Annual HCPCS Level II Manual
13.    Medicare Part B Drug Average Sales Price; ASP Pricing File https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice
14.    U.S. National Library of Medicine DailyMed