What the amounts mean
- Payment limit is what Medicare allows per billing unit of the code: for most drugs, 106% of the manufacturer's average sales price (ASP). It already includes the 6% add-on.
- Billing units are the dose divided by the code's unit (for J1100, 1 mg). Medicare expects partial units rounded up.
- Coinsurance is usually 20%. Some drugs have a lower, inflation-adjusted coinsurance; the tool uses the rate in the CMS file.
- Amounts are before the Part B deductible and the 2% sequestration reduction.
- For drugs from single-dose containers, report any discarded amount on a separate line with modifier JW, or add JZ when nothing was discarded.
Payment limits are from the CMS Medicare Part B drug payment limit file, updated every quarter. A code being listed doesn't mean Medicare covers the drug for your patient: coverage is decided by the Medicare contractor (check the coverage checker). Medicare Advantage, Medicaid and commercial plans may pay differently. CPT is a registered trademark of the American Medical Association; CPT code descriptions aren't shown.