Pediatric Coding Alert

Question: One of our physicians treated a patient with a nebulizer, but the patient would not fully comply and refused to keep the mask on. Therefore, the patient only received one of the two units of liquid albuterol we placed in the machine. Do I bill that as one unit then append modifier JW to the other unit?

Oregon Subscriber

Answer: Modifier 52 (Reduced services) is likely the most appropriate modifier to report this scenario, but check the payer policy. When it comes to pairing modifiers with procedures, some payers define “procedure” narrowly to mean invasive therapies only. For example, modifier 53 (Discontinued procedure) specifies surgical and diagnostic procedures only and refers to determination based on patient safety.

As far as the liquid albuterol, the use of JW (Drug amount discarded/not administered to any patient) will also likely depend on the carrier’s policy. It’s possible that the unused portion the modifier descriptor refers to applies only to wastage billing for partial use of single-use vials. It might even be helpful to check to see how each of the top payers want you to report this kind of thing. It is possible some will say you can bill your patient for wholly unused portions. If that’s the case, get that policy in writing.

Note: When billing unused material, be sure to be very clear with the documentation to ensure the carrier doesn’t misunderstand and think you administered the whole product to the patient.