Otolaryngology Coding Alert

Question: A patient with spasmodic dysphonia presents for percutaneous botox injections into the neck muscles. The otolaryngologist injects 36 units from a 100- cc single-dose vial. Because our office could not schedule for botox treatments that day, we have to discard 64 units. What modifier should I use to communicate the wasted units to the Medicare carrier?

New Jersey Subscriber

Answer: If a carrier wants you to itemize the waste, use Medicare modifier JW (Drug amount discarded/not administered to any patient). Medicare will reimburse for Botox-A wastage. Append modifier JW to J0585 (Botulinum toxin type a, per unit).

Report the wastage amount in the units field, such as J0585-JW x 64 for the example you describe. On the CMS-1500 claim form, also enter:

- 64613 (Chemodenervation of muscle[s]; neck muscle[s] [e.g., for spasmodic torticollis, spasmodic dysphonia]) for the percutaneous injections

- J0585 x 36 for the botox units used.

Watch out: Not all carriers require modifier JW. Some Medicare carriers may alternatively require you to indicate the unused portion on line 19. You would code the entire vial with the drug code, such as J0585 x 100, and enter the unused amount, for example, "64," in the narrative field.

The competitive acquisition program (CAP), a voluntary Part B drug purchasing program, requires line itemization with modifier JW. If you participate in CAP, you must also use a second modifier to indicate whether the item should be "no-pay" (J1) or "furnish as written" (J3). In transmittal 1248, which added this requirement, Medicare also grandfathered in any policies that required using modifier JW and allowed them to continue.

Important: Modifier JW is a Medicare-specific modifier, so ask private payers if they accept it.