CMS clarifies Modifier JW use with drugs

Date: September 7, 2016

As we previously noted in a prior WebNews on June 14, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Transmittal that required mandatory use of modifier JW on claims for “discarded drug or biological amount not administered to any patient”.  This Transmittal (3530) was replaced by Transmittal 3538 released on June 9, 2016 with an implementation date of January 1, 2017.  That date remains as the effective date for JW use.  You can link to Transmittal 3538 here.

What was not clear is whether an unused drug or biological should appear on claims in all situations with modifier JW – even if there is no reimbursement expected.  On August 26, 2016, CMS released a short 5-page FAQ which helps some.  This FAQ notes:

  • Prior policy allowed the MACs to choose whether to require the JW modifier. MACs were also able to issue jurisdiction-specific instructions for the use of the modifier.  That is no longer the case.
  • The modifier is not required:
    • If no discarded drug is being billed to any payer.
    • When drugs are not separately payable, such as packaged drugs and those administered in a Rural Health Clinic (RHC) or a Federally Qualified Health Center (FQHC).
    • Drugs paid under the Part B drug Competitive Acquisition Program (CAP).  Note that CAP remains on hold and there is no current list of CAP medications.
    • Perhaps most importantly, the question of “overfill” is addressed.  Remember that many of our intravitreal drugs contain overfill to ensure that an adequate amount of drug is placed into the syringe for use even though, as a single-dose vial, the overfill is not billable nor can it be used for other beneficiaries by “splitting” the vials.  CMS notes this:
      • The JW modifier must not be used to report overfill wastage.
      • Beginning January 1, 2011, Medicare issued regulations expressly prohibiting billing for overfill, which is any amount of drug greater than the amount identified on the package or label.
      • CMS also re-addressed (without change) the important issue of documenting unused drug.  CMs noted “CMS expects that providers and suppliers will maintain accurate (medical and/or dispensing) records for all beneficiaries as well as accurate purchasing and inventory records for all drugs that were purchased and billed to MedicareProviders and suppliers should also check with the MAC that processes their Part B drug claims in case additional information on billing and documentation is available at the local level.”  We strongly agree that this provides the most compliance and also suggest that your operative notes document that all unused drug (including overfill) is discarded via the appropriate method.

Recent News

CMS Extends Deadline for MIPS 2023 Data Submission

CMS has extended the data submission period for the Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in the 2023 performance year of the ...

Congress Passed bill for MPFS

The recent passing of a partial government funding bill by Congress on March 8 is important to Medicare beneficiaries. This bill includes policies aimed at addressing ...

Change to Processing for Telehealth Services Billed with POS 10

In calendar year (CY) 2024, the Centers for Medicare & Medicaid Services (CMS) issued a change to processing for telehealth services billed with POS 10. ...

Diabetes Cost Measure Misattributed to Ophthalmologists

The American Society of Cataract and Refractive Surgery (ASCRS), the American Society of Retina Specialists (ASRS) and the American Academy of Ophthalmology (AAO), met recently ...

Review Your 2022 MIPS Performance Feedback and Final Scores

The Centers for Medicare & Medicaid Services (CMS) has released the Merit-Based Incentive Payment System (MIPS) performance feedback and final scores for the 2022 performance ...

JZ Modifier Required July 1, 2023

The much-anticipated mandatory reporting of the JZ modifier for Part B Medicare begins July 1, 2023.  The new Medicare policy can be found here.  The ...

Cigna Hits the Brakes on Their New Modifier 25 Policy

Following fierce opposition from the physician community, the insurer Cigna announced today a delay in implementing a policy (PDF) that would have required submitting medical ...

Medical Consulting Group and Corcoran Consulting Group Announce Merger

Springfield, MO, April 27th, 2023. Medical Consulting Group (MCG), a provider of consulting services to ophthalmic practices and companies, and Corcoran Consulting Group (CCG), a ...

IHEEZO Gel gains Medicare Pass-Through

On March 13, 2023, Harrow® announced that the Centers for Medicare & Medicaid Services (CMS) has approved transitional pass-through reimbursement status for chloroprocaine hydrochloride ophthalmic ...

Cigna Change Modifier 25 Policy

As a result of a recent review, Cigna has announced it will require the submission of office notes with claims submitted for evaluation and management ...

Congress makes positive adjustments that affect ophthalmologists

In this Healio Video Perspective from Hawaiian Eye 2023, Kevin J. Corcoran, COE, CPC, CPMA, FNAO, discusses ophthalmic economic and regulatory updates for the year. ...

HHS Extends Covid-19 PHE

On Thursday, October 13, the U.S. Department of Health & Human Services (HHS) Secretary Xavier Becerra extended the nation's COVID-19 PHE for an additional 90 ...

Noridian Changes to Goniotomy LCD

Noridian has made changes to their Goniotomy coverage policy effective October 1st, 2022. It states: “Since there is no specific CPT® code for goniopuncture or ...

2021 MIPS Performance Feedback, 2021 MIPS Final Score, and 2023 MIPS Payment Adjustment Information

The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) performance feedback and final scores for the 2021 performance year, ...

Telehealth Place of Service Update

With a recent change to telehealth billing, billers need to be aware of an additional Place of Service code. What changed? Effective January 1, 2022, ...

Extension of Telehealth Flexibility

Last week, the U.S. House of Representatives approved legislation to further extend the Medicare telehealth flexibilities first instituted in response to the COVID-19 pandemic. If ...

AETNA No Longer Requiring Prior Authorization for Cataract Surgery

The American Society of Cataract and Refractive Surgery (ASCRS) and American Academy of Ophthalmology (AAO) have spearheaded a year-long effort to remove the policy that ...

2021 MIPS Final Score Preview Now Available

The Centers for Medicare & Medicaid Services (CMS) has opened the Final Score Preview period for the Merit-based Incentive Payment System (MIPS).  You can now ...

Guidance for Coding Goniotomy

Summary:   Two new ophthalmic surgical products have attracted interest from surgeons:  Streamline Viscoelastic Injector® (New World Medical) and IACCESS™ trabecular trephine (Glaukos).  In both cases, ...

CIGNA Changes Their Modifier 25 Policy

As a result of a recent review, CIGNA will require the submission of office notes with all claims submitted with evaluation and management (E/M) CPT ...

CMS Reweights Scoring for Cost Category for Groups in 2021 Quality Payment Program

The Centers for Medicare & Medicaid Services (CMS) announced on Monday, April 25th, that ALL eligible MIPS providers will automatically receive re-weighting of the Cost ...

IACCESS™ Trabecular Trephine – How to Code?

Summary:   Glaukos’ new product, the IACCESS™ trabecular trephine, raises interesting coding questions.  Standalone procedures should be reported on a claim for reimbursement as unlisted procedure, ...

Streamline® Viscoelastic Injector – How to Code?

Summary:   New World Medical’s new product, the Streamline® Viscoelastic Injector, raises interesting coding questions.  Standalone procedures with it should be reported on a claim for ...

HHS Extends the Public Health Emergency Waivers

On April 12, 2022, Secretary of Health and Human Services Xavier Becerra again renewed the public health emergency declaration that was initiated at the end ...