Oncology & Hematology Coding Alert

Caution: JW modifier is only for single-use vial or package drugs and biologicals.

Modifier JW is has been around for quite some time. When a single dose vial is used, the provider reports the amount of drug administered to the patient.  On a second line, the portion of the single dose vial that was wasted is reported with modifier JW.  “This is the appropriate use of the modifier, however not all MACs have consistently required its use for the wasted portion of single dose vials for all providers,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Managing Director of Pinnacle Enterprise Risk Consulting Services (“PERCS”), a division of Pinnacle Healthcare Consulting. “As a result of this Change Request (updated on May 24, 2016) and going into effect on July 1, 2016 will require all providers to use of modifier JW to indicate the unused portion of the single dose vial on a separate line on the claim.”

“Secondly, documentation of the wastage amount was required, but the location of the documentation was not specific,” Loya says.  Under this change, “Providers must record the discarded amounts of drugs and biologicals in the patient’s medical record.”

Benefit: Reporting modifier JW will allow payment for the amount of discarded drug or biological, in certain situations, CMS reports.

For instance, let’s say your provider treats a patient with 95 units of a single-use 100-unit vial of a drug and discards the remaining 5 units. According to section 40 of chapter 17 of the Medicare Claims Processing Manual, which provides policy detailing the use of the modifier JW, you would code for the 95 units of the drug on one line, and the 5 remaining units on another line with modifier JW appended.

Remember, JW is Not for All Unused Drugs

The CR does not open the door to using modifier JW in all discarded drug/biological situations. CMS does prohibit coding for the discarded drug with JW when “the actual dose of the drug or biological administered is less than the billing unit,” CMS reports.

Here is an example. “One billing unit for a drug is equal to 10 mg of the drug in a single-use vial. A 7mg dose is administered to a patient, while 3mg of the remaining drug is discarded. The 7mg dose is billed using one billing unit that represents 10mg on a single line item,” CMS reports.

Explanation: “The single line item of 1 unit would be processed for payment of the total 10mg of drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of drug is not permitted because it would result in overpayment. Therefore, when the billing unit is equal to or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted,” CMS continues.

Medicare also makes clear that the JW modifier is only for single-use vial or package drugs and biologicals, Hammer explains.

According to section 40 of Chapter 17 of the Medicare Claims Processing Manual, “Multi-use vials are not subject to payment for discarded amounts of drug or biologicals.”

“As noted in MM9603, the JW modifier is also not used on claims for Competitive Acquisition Program (CAP) drugs,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “For CAP drugs, see subsection 100.2.9 of Chapter 17 of the Medicare Claims Processing Manual for additional discussion of the discarded remainder of a vial or other packaged drug or biologicals in the CAP,” says Moore.

Resource: To read the transmittal for yourself, go to: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3530CP.pdf. Then, type in “R3508CP” in the search box in the right corner of the page. On the results page, click on the “R3508CP — Centers for Medicare & Medicaid Services” link. You can also read the MLM article at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9603.pdf.