# Epifix and JW modifier



## rai2004575 (Apr 14, 2017)

Hi all,

Having some trouble with payments for billing of Epifix and the JW modifier with CMS.

Per CMS, wastage is allowable to be billed for unused drugs/biologicals from single use vials/packaging that are appropriately discarded. Epifix is a biological. Per CMS - "In general, the modifier policy applies to all separately payable Part B drugs that are designated as single-use or single dose on the FDA-approved label or package insert. Accordingly, use of the modifier is not appropriate for drugs that are from multiple dose vials or packages. Package inserts are available on the FDA website at http://www.accessdata.fda.gov/scripts/cder/drugsatfda/."

We use single package sizes of 39cm^2 and 116cm^2. Since the code billed is "Q4131- Epifix, per square cm", we are treating one billing unit as 1cm^2. So if we use one whole 39cm^2 package, it is billed on one line with 39 units. Since there was no waste, a second line with JW is not billed.

If we were to use 30cm^2 of a 39cm^2 piece, it gets billed one line with 30 units, and a second line with 9 units and a JW.

As far as I can tell, that is the correct way to bill this.  Is there something I'm missing? Should patient's be scheduled in such a way to avoid wastage, such as scheduling them consecutively and using any unused biological from the first patient, on the next patient? Or can it be as simple as the fact that I checked the FDA-approved label/package insert list, and Epifix isn't yet listed there?

I was also thinking providers should explicitly state they are using a single package 39cm^2 graft, so that documentation supports their use of a single package product.

Anyone with more experience billing these codes/modifiers, your insight is greatly appreciated!


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## thomas7331 (Apr 17, 2017)

It sounds like you are using the modifier appropriately, but since this a new reporting requirement, I'd expect that some payers may not necessarily have this correctly set up in their systems.  What kind of 'trouble' exactly are you having with the payments?  Are you billing this for a facility or physician office?  For a facility claim, you wouldn't see separate line item payment for this code - the reimbursement for the product would be rolled up into the facility case rate.  (Also, Epifix is Q4131, not Q4121?)


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