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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : Multi-Dose Vials Calculation Examples
Below is an example of calculating the correct billing units for a drug administered from a multi-dose vial. Calculations for multi-dose vials differ from those for single-dose vials.
A patient receives 220 mg Herceptin IV in the physician’s office. A 440 mg multi-dose vial is used. The NDC of the product used is 50242-134-68 (Herceptin 440 mg/20ml in solution form). The provider should bill J9355 for trastuzumab with 22 HCPCS units and the NDC units submitted should be 10 ML. Another dose of 220 mg (or 10 ml) of Herceptin remains in the vial.
HCPCS CODE BILLING UNIT(s) = Dose divided by units found in HCPCS code

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