Physician-administered drugs — dose, units and wastage

How units billed for an infused or injected drug are reconciled against the dose the record says was given, and when discarded drug is payable.

All policies

Current version

v2.0

in force since 2026-03-01 · as at 2026-04-02

Versions on file

back to 2024-07-01

Applies to

Medicare Advantage · Medicaid · Marketplace

All states

Cited in this batch

claims tested against it

Where this sits

OwnerPharmacy Payment Integrity

Lines of businessMedicare Advantage · Medicaid · Marketplace

StatesAll states

External basisCMS Part B ASP pricing file · Medically Unlikely Edits · JW / JZ modifier guidance

Version history

Newest first

A claim is tested against the version that was in force on its date of service. For a service last autumn, that is not the version at the top of this list.

v2.0 2026-03-01 → current In force now

Billed units must now reconcile to the administered dose recorded in the infusion record. Passing the MUE ceiling is no longer sufficient on its own. Discarded single-dose-vial drug is payable only on a separate line carrying modifier JW; a line with no wastage requires JZ.

Extracted from CPP-061_physician-administered-drugs_v2.0.md — 3 pages, indexed under __live__, so a finding on this version can quote it.

Billed units = administered dose ÷ the HCPCS billing unit, rounded to whole units.
The administered dose must appear in the medication administration record for the date of service.
Units within the MUE ceiling are not thereby validated — the MUE is a maximum, not an allowance.
Discarded drug from a single-dose vial is payable only on a separate JW line.

v1.4 2024-07-01 → 2026-02-28 Superseded

Baseline drug-unit policy. Units at or below the MUE ceiling were accepted without reconciliation to the administered dose.

Extracted from CPP-061_physician-administered-drugs_v1.4.md — 2 pages, indexed under v1.4, so a finding on this version can quote it.

Billed units at or below the published MUE ceiling for the code are payable as submitted.
Units above the MUE ceiling are reviewed against the record.

Claims in this batch tested against this policy

2 of 25

Claim	Date of service	Version applied	Role	Paid	At risk
CLM-0000021	19 Mar 2026	v2.0	Decisive	$8,069.76	$1,344.96
CLM-0000024	24 Feb 2026	v1.4 not the current version	Decisive	$3,083.85	—

This policy is synthetic — an internal document written for this demo. The external basis it cites is real.