Billing Calculator for Medicare Part B Drugs

It turns a drug code into the numbers a claim needs. Pick a HCPCS drug code, enter the billing units administered and the markup your charge master applies, and the calculator returns the Medicare allowed amount for those units, the 80 percent Medicare pays, the 20 percent patient coinsurance, the charge you should submit, and the hospital outpatient (APC) allowed amount for the same code. No account is needed, and you can price five drugs a day free.

The free calculator runs on the Medicare Payment Limit, which is the amount Medicare Part B allows per billing unit, generally ASP plus 6 percent. It also returns the hospital outpatient (APC) limit. ASP, WAC, and AWP are manufacturer-sourced benchmarks that sit behind a subscription, so they appear on the result as a locked row rather than in the free math. With a subscription you can compare the same claim against ASP, WAC, and AWP as well as the allowed amount. See the drug price lookup for how the four benchmarks differ.

Yes. Units and markup are both free inputs, and the result recalculates as you change either one. If you have the dose rather than the unit count, switch the amount field from Units to Dose and the calculator converts it for you against the code's unit definition. J9035 is "Injection, bevacizumab, 10 mg", so a 400 mg dose is 40 units. Part units always round up to the next whole unit, and the leftover is discarded drug you report with the JW or JZ modifier.

Anyone who touches a buy-and-bill claim. Billing and revenue cycle teams use it to check a charge before submission, oncology and specialty practices to model the cost of an infusion or injection, practice administrators and finance teams to run budgeting and forecasting scenarios, and payers and consultants to validate charges against the published payment limit during reviews and audits.

Two of the most common reasons a drug claim pays less than expected are a wrong unit count and a charge submitted below the allowed amount. Payers pay the lesser of the two, so an under-priced charge simply pays at the charge. Seeing the units, the allowed amount, and your charge side by side catches both before the claim leaves. The 80/20 split also tells the front desk what to expect from the patient or a secondary payer. Where a fractional dose leaves discarded drug, bill the remainder with the JW and JZ modifiers. A third reason is a drug that was never payable under the benefit at all, which the Part B coverage check will tell you before you bill it.

You can price five different drugs each day, free. Changing the units, dose, markup, or place of service on a drug you have already loaded never counts as another use, and the count resets every day. A subscription removes the daily limit and adds ASP, WAC, and AWP beside the payment limit on every calculation.