Medication Coding

Margaret Chang, MD, MS

To ensure proper reimbursement of intravitreal pharmacologic medication, proper processes and careful documentation must be in place to prevent denials and audit failures.

First, the procedure note must document the indication for the intravitreal injection. This indication must be a covered diagnosis based on the published policy or FDA label. Ideally, the procedure notes should also document the medication dosage in both mg and ml, as well as the amounts of drug injected and wasted (e.g., “residual medication less than one unit was discarded”) as appropriate.

When coding for the medication, the proper Healthcare Common Procedure Coding System (HCPCS) code (i.e., either a J-code for most intravitreal agents or a Q-code for biosimilars) needs to be reported, along with the appropriate units administered. On a second line, the same HCPCS code must be listed with a -JW modifier and the remaining units discarded, if applicable. If no waste has occured, such as in cases where pre-filled syringes or single-dose vials were used, the second line must list the HCPCS code with a -JZ modifier.

Next, the CPT code 67028 must be linked to a covered ICD-10 diagnosis and reported with the correct anatomical modifier (i.e. -RT, -LT, or -50). This process will ensure that an intravitreal injection in a fellow eye performed within 28 days of an injection in the first eye will not be denied or flagged for review.

On the CMS-1500 claim form, item 19 should list the medication name and dosage in mg/ml, as well as the invoice amount. On item 24a or EDI loop 2410, the National Drug Code (NDC) must be submitted as an 11-digit code in 5-4-2 format, preceded by an “N4” qualifier. It should then be followed by the unit of measurement (UOM) (e.g., ml) and the appropriate amount (e.g., ML0.05). NDC numbers are listed on drug packaging in 10-digit formats and require an extra “0” to convert the sequence to the 5-4-2 format. Not all NDC numbers are set up the same way, but most practice management systems convert NDCs to ensure correct claim processing. For instance, aflibercept’s 10-digit NDC code is 61755-005-02. Because it is in 5-3-2 format, it would be submitted as N461755000502 ML0.05.

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