As of April 2021, Medicare requires the use of the JA or JB modifier when billing for drugs that have one Healthcare Common Procedure Coding System (HCPCS) Level II (J or Q) code but multiple routes of administration. In response to numerous inquiries from ACR members, the Medicare Administrative Contractors (MACs) have provided the following guidance on billing with the JA and JB modifiers.
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Drugs that require a JA or JB modifier will be marked with an asterisk (*) on the Usually Self-Administered Drug (USAD) List. Intravenous infusion of the drug must be billed with the JA modifier and subcutaneous injection of the drug with the JB modifier. Claims billed with the JA modifier are not part of the SAD exclusion. The MAC will process claims with the JA modifier applying the policy that, not only is the drug medically reasonable and necessary, but also that the route of administration is medically reasonable and necessary.
Claims for drugs marked with an asterisk (*) billed without a JA or JB modifier will be denied. One of the following denial messages will be received for Part B:
- CARC 16 – Claim/service lacks information or has submission/billing error(s); OR
- RARC N823 and N822 – Missing procedure modifier(s).
If a claim is denied, for Part A, providers can create an adjustment and resubmit their claim. For Part B, providers can resubmit their claim or request a re-opening.
For specific questions regarding billing or denials, reach out to your MAC using the following contact numbers:
- CGS customer service: 866-276-9558
- NGS provider contact center
- In Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island or Vermont: 866-837-0241
- In Illinois, Minnesota or Wisconsin: 866-234-7340
- Noridian Healthcare Solutions provider contact center
- Region JE: 855-609-9960
- Region JF: 877-908-8431
- Palmetto customer service
- Region JJ: 877-567-7271
- Region JB: 855-696-0705
- WPS customer service: 866-518-3285
For assistance working with the Medicare contractor for your region, or for help with any other insurance issues, contact ACR practice advocacy staff at email@example.com.