Healthcare Fraud Shield’s Latest Article: Let’s Talk About Modifier JW!

26 Jun

Let’s refresh our memories on what modifiers are and what they do.  Modifiers are extra characters that may be letters, numbers or both that are appended to either a CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) Code.  Modifiers provide additional information about equipment, service, procedure, and/or condition of a patient.  Some modifiers may also have an impact on reimbursement. 

What is Modifier JW?
Modifier JW is defined as Drug amount discarded/not administered to any patient. Effective January 1, 2017, CMS required providers to submit Modifier JW on Part B claims for the discarded material for drugs and biologicals.[1]
How is it billed?

According to CMS, This modifier should not be used for[2]:

  • drugs or biologicals administered in a Rural Health Clinic (RHC) or a Federally Qualified Health Center (FQHC).
  • claims for hospital inpatient admissions that are billed under the Inpatient Prospective Payment System
  • drugs or biologicals from multi-dose or multi-use packages
Modifier JW should only be used for drugs in single dose or single use packaging.[2] If a provider administers 30 units of a 50 unit single use file and discards the 20, then the provider should bill the appropriate code with 30 units on one line with no modifier and the same code on a separate claim line with 20 units and modifier JW.   
Modifier JW should not be used when the dosage administered plus the discarded amount would be less than or equal to the billing unit.  For example, if 1 unit equals 10 mg and the provider only administers 5 mg and discards 5 mg, then the provider would submit the appropriate code with 1 unit and no modifier.
Another example provided by UnitedHealthcare in their policy is as follows:
“Example of vial size selection, the CPT/HCPCS code for Drug A indicates 1 unit = 30 mg. Drug A is available from the manufacturer in 60mg and 90mg vials. The amount prescribed for the patient is 48 mg. If the provider uses a 90 mg vial to administer the dose, the provider may only submit 2 units (rather than 3 units) as the doses available from the manufacturer allow the prescribed amount to be administered with a 60 mg vial”.[3]
What to look for?

It is important to check your respective plan policies and guidelines.  However, it is recommended to look for providers billing for this modifier excessively and for the average number of units higher per patient than other providers.  Keep in mind, many dosage amounts for drugs or biologicals are based on various guidelines including the patient’s weight and diagnosis.    The dosage amount used and the amount discard should be documented in the medical record (compounding record).  Therefore, if the dosage amount is based on a patient’s weight one could calculate the appropriate drug amount based on the information in the medical records. This information would include the physician’s order, patient’s weight and medically necessity of the treatment.

Another area of review would be to look for providers appending a modifier JW for drugs or biologicals that come in a multi-use dose or package. Crosswalk the J code to the drug’s NDC number which would provide the specific package size.
When requesting records, make sure this request includes the following components of the records:  compounding records, nurse’s infusion records, physician’s orders, progress notes and drug invoices.
If you have any questions or comments, please contact SIU@hcfraudshield.com.
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