Billing and Coding: Drugs and Biologicals

Coverage and billing for drugs and biologicals require that services within the LCD be medically necessary and fully documented (history, exam, diagnostic tests). Claims must include valid ICD-10-CM codes; IV use of drugs with available oral forms requires an additional ICD-10 code documenting oral route inappropriateness. Modifier JW must be used when drug waste is discarded (with amounts documented) and modifier JZ is required effective 7/1/2023 when no waste is present; drugs obtained at no cost should be billed per specified rules ($0.01 on/after 5/7/2018, previously $0.00 with narrative).

"Services (drugs and biologicals) included within the referenced LCD are covered when the medical record fully documents medical necessity, including relevant history, physical exam, and pertinent d..."

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