Medicare pays most Part B drugs at ASP+6%, which makes accurate dose, unit and wastage coding the difference of real money on every claim. The recurring audit findings are predictable: missing JW/JZ modifiers on discarded drug units, absent NDCs, and dose calculations that don't reconcile to the medication administration record.
Start with units. J-codes bill per dose (per milligram, per microgram, per unit as HCPCS defines each drug), and the billed units must reconcile exactly to the administration record — drug administered plus drug discarded from the vial. Since 2017, discarded amounts from single-dose containers are documented with modifier JW; more recently, JZ indicates no discarded amount from the single-use vial. Omitting either is a documented cause of Part B drug denials and recoupments.
Next, the NDC. CMS requires National Drug Code reporting on Part B drug claims, and mismatches between the NDC billed and the NDC administered surface in audits months later as overpayment findings. Our drug claim scrubbing reconciles NDC, dose, units and modifiers into one consistent story per claim — the same story the chart supports.
Third, authorization and regimen integrity. Oncology regimens change: dose reductions, holds, drug substitutions. Each change can invalidate a prior authorization or shift the payable J-code. We track regimen modifications against authorizations so a reduced dose bills the correct units and a substituted drug bills the correct code — without gaps that trigger medical-necessity denials on the highest-value claims a practice sends.
“Consumers rarely appeal denied claims (fewer than 1% of denied claims were appealed), and when they do, insurers usually uphold their original decision (66% of appeals were upheld).”