Pediatric Coding Alert

On Jan. 1, 2023, Medicare introduced modifier JZ (Zero drug amount discarded/not administered to any patient). The modifier has been in use for over a year now, but many coders are still questioning when and how to report JW (Drug amount discarded/not administered to any patient) versus JZ.

If you find yourself among these questioning coders, we’re here to clear up your confusion. We’ll start by reviewing what modifiers communicate to payers.

Understand the Basic Function of a Modifier

The right modifier will communicate additional information to improve accuracy or specificity in the claim.

More precisely, “modifiers are two-character codes reported with CPT^® and HCPCS Level II codes to modify or supplement the description of services rendered based on certain exceptions or circumstances. They do not change the code description, but they simply supplement the description of those codes,” according to Juan Lumpkin, provider relations senior analyst at CGS Administrators, LLC in Nashville, Tennessee.

Refresh Your Memory of Modifier JW

Modifier JW took effect January 1, 2017, and it tells the payer that the full content of a single-use drug or biological product was not administered to the patient, and the remainder was discarded. Specifically, the modifier gives the payer necessary information about the discarded amount.

This confusion with this modifier probably lies in the fact that vials 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 pediatrician 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 pediatrician must administer a dose to the patient that is smaller than the amount in a single-use vial, “per the Centers for Medicare & Medicaid Services [CMS], you’ll use modifier JW if the discarded amount is equal to or greater than 1 billing unit of the drug,” she continues.

Example: A pediatrician 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 in order 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 of the 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.

Review Correct Usage of Modifier JZ

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 instructed you to use the JZ modifier when the entire container is used as the dose administered and there is no discarded amount subject to modifier JW rules. You will use modifier JZ on the claim line with the administered amount.

Also: If the drug administered is less than one billing unit, report administering the full billing unit along with modifier JZ. This is because some payers don’t accept fractional billing units, so reporting JW would likely result in overpayment. Also, “your chart documentation should state, ‘any residual medication discarded,’” says Walaszek.

Note: Most private payers have adopted rules that mirror Medicare’s, but be sure to check specific payer policies.

Accurately Submit the Claim

While claim forms can differ from payer to payer, here is an example of what typical claim form would look like for instances calling for JW or JZ.

JW: Line #1:

• HCPCS Level II code for the medication given
• No modifier
• Number of units administered
• Calculated price for the administered amount

Line #2:

• HCPCS Level II code for the medication wasted
• JW modifier
• Number of units wasted
• Calculated price for the wasted amount

If there is no discarded waste from a patient’s drug administration, the coding should be entered on one line as follows:

JZ: Line #1:

• HCPCS Level II code for the medication given
• JZ modifier
• Number of units administered
• Calculated price for the administered amount.