Wiki Billing Wastage on Single-Use Vials when JW is not recognized

[jwest10782]

I work with several neuro practices and ran into a situation with a third party biller in Rhode Island billing for Botox. This particular payer does not recognize the JW modifier. The provider injected 155 units for chronic migraine and discarded 45 units. I advised the billing company that they should be billing one line with J0585 at 200 units because it is a single-use vial and the JW modifier is not recognized by this plan. They are refusing to do this and continue to bill J0585 at 155 units as well as a second line with J0585 and JW modifier with 45 units. The payer pays the line for 155 units, but not the line with JW at 45 units. The biller is insisting the provider needs to write off the 45 discarded units and that they cannot bill 200 units because the appropriate way to bill is using the JW modifier (even though this is a Medicare mandate and not all commercial plans recognize JW). Theywant me to provide something in writing that shows it is appropriate to bill for a whole a single-use vial when there is wastage for a company that doesn't recognize the JW modifier, but I am at a loss. I just want to make sure the provider is getting paid for the drug appropriately. Please help!!!!

 

[sarab86]

For the payer that is denying the JW modifier, is there a payment policy with the carrier that indicates how waste should be reported?

The whole point behind the JW modifier was to improve documentation. I would say it is definitely appropriate to bill the full 200 units as long as it is clearly documented what was done with the wasted units. The provider paid for the whole bottle, he should be able to bill for the whole bottle, whether that is on 1 line or 2 with JW. When this is on 2 lines you are still getting paid for the wasted units, it is just reported on the claim where those units went. If the carrier isn't tracking waste and hasn't made policy updates to match CMS, the provider shouldn't have to take a loss on that.

Hope that helps.

 

[thomas7331]

I agree, the payer policy would be your first source of truth and your best first step is to reach out to the payer for instructions. But in the absence of a payer policy that addresses this, and if the payer is not yet accepting the JW modifier, the default would be to report this per the guidelines that were in place prior to the implementation of the modifier. If you search the CMS notifications prior to when the JW became mandatory, during the period when the modifier was optional, you should find that the correct way to report this was to bill for the entire amount of the drug used, being the amount administered plus the amount wasted, the full 200 units in this case. So I would disagree with what the biller is telling you.

In your position, I would also point out that this is not the biller's place to 'insist' on this. The claims belong to your practice and are your practice's financial responsibility; their role should be to perform their services according to your instructions and they certainly cannot tell your provider what they have to write off. If they disagree, they should be the ones providing you with something in writing, not the other way around!