CPP-061_physician-administered-drugs_v1.4.md

# CPP-061 — Physician-administered drugs: dose, units and wastage **Version 1.4 · Effective 1 July 2024 · Superseded 28 February 2026 by v2.0** Owner: Pharmacy Payment Integrity Applies to: Medicare Advantage · Medicaid · Marketplace — all states External basis: CMS Part B ASP pricing file · Medically Unlikely Edits > **This version is superseded.** It is retained because a claim is adjudicated > against the policy in force on its date of service. For a service before > 1 March 2026, this is the governing text. ## 1. Purpose This policy governs the number of units payable for an infused or injected drug billed under a HCPCS Level II J-code on the medical benefit. ## 2. Criteria ### 2.1 Unit ceilings Billed units at or below the published Medically Unlikely Edit ceiling for the code and setting are payable as submitted. No further reconciliation against the clinical record is required for a claim within the ceiling. ### 2.2 Units above the ceiling Units above the Medically

code and setting are payable as submitted. No further reconciliation against the clinical record is required for a claim within the ceiling. ### 2.2 Units above the ceiling Units above the Medically Unlikely Edit ceiling are reviewed against the clinical record. The reviewer requests the medication administration record for the date of service and compares the administered dose to the billed units.

### 2.3 Unit calculation Where reconciliation is required, billed units equal the administered dose divided by the billing unit published in the HCPCS long descriptor, rounded to whole units. ### 2.4 Wastage Drug discarded from a single-dose vial is payable where the discarded amount is recorded in the clinical record. Modifier JW is preferred but not required for payment. There is no attestation requirement for a line with no wastage. ## 3. Recovery The recoverable amount is the excess units multiplied by the per-unit payment limit published in the CMS Part B ASP pricing file for the quarter containing the date of service. ## 4. Note on the successor version Version 2.0, effective 1 March 2026, removes the safe harbour in section 2.1. A claim inside the MUE ceiling is no longer accepted without reconciliation to the administered dose, and modifier JZ becomes mandatory on a line with no wastage. A claim with a date of service before 1 March 2026 is not affected.