Ophthalmology and Optometry Coding Alert

Also: Use this clinical example to help you calculate drug waste.

If you find yourself still questioning when and how to report -JW (Drug amount discarded/not administered to any patient) versus -JZ, we’re here to clear up your confusion. Have a look at this handy primer on exactly how to utilize these lesser-known modifiers to refine your discarded drug billing practices.

Focus on the Big Picture First

There are several factors you must take into consideration when reporting the use of drugs and biologicals in your eye care practice. After pinpointing the respective procedure code, your next step in the process is to appropriately bill out for the type and amount of drug the physician administers. While that can be difficult in its own right, it gets even more complicated when you’ve got to account for the amount of drug or biological discarded.

Refresh Your Memory of Modifier JW

Since 2017, to obtain full reimbursement for single-dose containers or vials when at least one full unit is discarded, physicians must report the JW modifier. This tells the payer that the provider did not administer the full content to the patient; they discarded a portion.

The Centers for Medicare and Medicaid Services (CMS) outlines modifier JW as a HCPCS Level II modifier “used on a Medicare Part B drug claim to report the amount of drug or biological (hereafter referred to as drug) [from a single-use vial] that is discarded and eligible for payment under the discarded drug policy.”

“The confusion with this modifier probably lies in the fact that vial sizes differ. Multiuse vials contain several doses of the medication for multiple administrations, so you will only bill for the portion of the vial that your provider used, while single-use vials contain just one dose, so you will bill the entire vial,” says Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics LLP in Northampton, Massachusetts. In the event the physician must administer a dose to the patient that is smaller than the amount in a single-use vial, “per CMS, you’ll use modifier JW if the discarded amount is equal to or greater than one billing unit of the drug,” she continues.

Example: A physician administers 10 mg of dexamethasone sodium phosphate to a patient. The medication comes in a concentration of 4mg/mL per vial, which means the provider will have to inject 2.5 mL of the solution for the patient to receive 10 mg of the drug. The medication comes in 1 mL single-use vials, so the provider uses 2.5 mL from three single-use vials and discards 0.5 mL, or half the third single-use vial.

The HCPCS Level II Appendix 1 – Table of Drugs directs you to J1100 (Injection, dexamethasone sodium phosphate, 1 mg) for the injection. As the descriptor for J1100 tells you the billing unit for dexamethasone sodium phosphate is 1 mg, and the wastage in this example is 2 mg — an amount greater than the billing unit — you should go ahead and bill the amount of the medication used (2.5 mL) on one line of the claim, and the discarded amount (0.5 mL) on another line of the claim along with the JW modifier to indicate that your practice has discarded the given amount of the drug.

Use Modifier JZ When There’s Zero Waste

On Jan. 1, 2023, Medicare introduced modifier JZ. Unlike modifier JW, which you use when your provider administers part of a single-dose container and discards the rest, Medicare instructs you to use the JZ modifier when the entire single-use container is used as the dose administered and there is no discarded amount. You will use -JZ on the claim line with the administered amount.