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December 2018
Here are guidelines for billing medical drugs correctly
About National Drug Code quantities and conversions
See the June 2016 Record for information on calculating and billing National Drug Code quantities and tips on billing electronically. For information on a tool you can use to quickly and easily convert HCPCS or CPT units to NDC units, see the September 2017 Record.
Here are some general guidelines for billing injectable drugs:
- Use the appropriate HCPCS code based on code descriptor.
- Not-otherwise-classified codes should only be reported for drugs that don’t have a valid HCPCS code, which describes the drug being administered.
- Units of drugs must be accurately reported in terms of dosage specified in the HCPCS descriptor and the NDC descriptor.
- Hemophilia factor is an exception; follow current guidelines.
- If there’s no expense to the physician for the drug, don’t bill for it.
- Don’t bill units based on the way the drug is packaged, stored or stocked.
- Don’t bill for the full amount of a drug when it’s been split between two or more patients. Only bill for the amount given to each patient.
- Documentation in the patient’s medical record must indicate the drug and dosage.
Before you fill out the claim form to bill for a medical drug, you need the following:
- Amount of drug administered
- Procedure code
- Number of CPT or HCPCS units
- NDC number
- Number of NDC units
- NDC unit of measure
Here are some reporting examples:
Example 1: HCPCS description or billable units of drug is 6 mg.
6 mg. are administered = 1 unit is billed
Example 2: HCPCS description or billable units of drug is 50 mg.
200 mg. are administered = 4 units are billed
Example 3: HCPCS description or billable units of drug is 1 mg.
10 mg. vial of drug is administered = 10 units are billed
Procedure |
Procedure code billable units** |
Dose example |
HCPCS quantity (for dose example |
NDC code |
NDC billable units** |
NDC quantity (for dose example) |
90670 |
0.5 ML |
0.5 ML |
1 |
00005197101 |
ML |
ML0.5 |
90715 |
0.5 ML |
0.5 ML |
1 |
49281040010 |
ML |
ML0.5 |
J0129 |
10 mg |
250 mg |
25 |
00003218710 |
UN |
UN1 |
J0585 |
1 UN |
200 |
200 |
00023114501 |
UN |
UN2 |
J0696 |
250 mg |
250 mg |
1 |
00143985701 |
Determine by product used: If a powder needs to be reconstituted, then use UN; if an oral tablet, then use UN; if liquid in vial, then use ML. |
UN0.25 |
J0897 |
1 mg |
120 mg |
120 |
55513073001 |
ML |
ML1.7 |
J1569 |
500mg |
10,000 mg |
20 |
00944270002 |
Determine by product used: If a powder that needs to be reconstituted, then use UN; if an oral tablet, then use UN: if liquid in vial, then use ML. |
ML100 |
J1572 |
500 mg |
10,000 mg |
20 |
61953000400 |
ML |
ML200 |
J1745 |
10 mg |
1,100 mg |
110 |
57894003001 |
UN |
UN11 |
J1885 |
15 mg |
30 mg |
2 |
00409379301 |
ML |
ML2 |
J2357 |
5 mg |
150 mg |
30 |
50242004062 |
UN |
UN1 |
J3262 |
1 mg |
200 mg |
200 |
50242013501 |
ML |
ML10 |
J3301 |
10 mg |
20 mg |
2 |
00003029320 |
ML |
ML0.5 |
J3380 |
1 mg |
300 mg |
300 |
64764030020 |
UN |
UN1 |
J3420 |
1000 mcg |
2000 mcg |
2 |
00143961901 |
ML |
ML2 |
**Billable units can be found on the Injections Minimum Fee Schedule on web-DENIS.
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