Adding a Layer to the Onion - Route of Administration Modifiers

Billing modifiers are typically two characters composed of either letter or numbers, and a CMS Form-1450 or UB-04 can accommodate up to four modifiers on each CPT (Level I HCPCS) or Level II HCPCS. Modifiers are designed to provide the payer with more specificity about the service rendered, improve accuracy of coding, used to overcome edits (e.g. NCCI) or drive payment.

Route of administration modifiers are not new to billing and coding. While some MACs recognized the route of administration modifiers, reporting them on the claim was voluntary. However, we are seeing individual MACs now require the application of these modifiers to select drugs.

JA – intravenous

JB – subcutaneous

Instructions from the MACs may be found in CMS LCD or Articles that are specific to billing and coding complex drugs or in self-administered drug exclusion. This creates a level of complexity when applying these to select drugs.

Take for example, abatacept (Orencia) which is billed with HCPCS J0129. Orencia is formulated as a lyophilized powder for IV infusion and pre-filled syringes for subcutaneous administration. The IV formulation may be billed to Medicare Part B, but the subcutaneous formulation is considered a self-administered drug and not payable by Medicare Part B. Depending on your MAC’s individual instructions for self-administered drugs and the addition of the route of administration modifiers, the billed line items may look like this on the claim:

Failing to include these modifiers when required, may lead to charge lines rejecting in the billing software or incorrect payment.

Shout Outs! Revenue integrity teams evaluate your individual MAC requirements and determine if the JA and JB modifiers are required. Collaborate with your Pharmacy teams to help identify specific drugs where these should be applied.

Billing and/or coding teams develop a process to capture charges and apply the appropriate administration modifier to the HCPCS or consider building separate profiles based on the unique NDC that represents the formulation.