Does your practice submit claims to Medicare Part B for injectable drugs like Avastin, Lucentis, or Botox? If so, be sure you’re correctly reporting drug wastage with the JW modifier.
Drug companies label many Part B injectable and infusion drugs as “single-dose” or “single-use vial.” They are intended for a single patient or a single procedure. That’s usually because they lack preservatives that would keep them effective once a provider opens them. What doesn’t get used is “wastage” that’s discarded, instructor Elizabeth Cottle, CPC, OCS explained to a class of retina coders at the 2017 AAOE meeting in Chicago.
Here’s an example from the Medicare Learning Network:
Suppose the ophthalmologist treats an eye inflammation by injecting 4 units of Triesence (J3300), which typically comes in 40-unit single use vials, Cottle says. If the clinician has correctly documented the information in the note, you’d report:
- J3300 4 units
- J3300-JW 36 units
JW: When to Use It
You should have started appending the JW modifier to claims with unused drugs or biologicals—and documenting the discarded drug in the patient’s medical record—as of January 1, 2017. But failing to correctly report drug wastage is still an issue among many practices, and it’s one that auditors are keen to catch.
Many MACs began educating their providers on the rule last summer, observes Rhonda Buckholtz, CPC, CPMA, CRC, CDEO CPC-I, CHPSE, VP of strategic development at Eye Care Leaders. Take this example from WPS GHA:
“A single use vial that is labeled to contain 100 units of a drug has 95 units administered to the patient and 5 units discarded. The 95-unit dose is billed on one line. The discarded 5 units may be billed on another line with the JW modifier. Both line items would be processed for payment.”
You’ll still be paid for the discarded amount, up to the amount listed on the label of the single-use vial or package. “The key is to document the waste in the patient record,” Buckholtz told Ophthalmology Coding Alert.
When NOT to Use the JW Modifier
“When the billing unit is equal to or greater than the total actual dose and the amount discarded, you may not use the JW modifier,” says Buckholtz.
Take another example from WPS GHA, in which a single-use vial contains one billing unit of 10 mg and a 7 mg dose is administered. In this case, you would simply bill the one unit of 10 mg. “Billing another unit on a separate line item with the JW modifier for the discarded 3 mg of drug is not permitted because it would result in overpayment,” the MAC reasons.
CMS won’t compensate you for any overfill a vial may contain—CMS considers overfill as included by the drug manufacturer at no cost to you. Ditto for wastage from complementary (sample) vials provided by a manufacturer.
Feds Focus Eagle Eyes on Wastage Costs
HHS OIG’s 2017 Work Plan contains a clue about why CMS wants providers to use JW. It would help government watchdogs track drug wastage more precisely. It could also potentially control rising drug costs by putting the heat on manufacturers. So far, most of CMS’ plans to reduce drug costs have focused on providers rather than manufacturers. And that has drawn much criticism from the medical community.
In 2016, a British Medical Journal study found that Medicare and private payers combined waste almost $3 billion each year on cancer medicines that providers simply discard. Critics point to drug manufacturer’s use of single-use cancer vials. These vials contain a greater quantity of medicine than most patients need. These “oversized” containers encourage more wastage than is necessary. They also rake in big profits for manufacturers of drugs billed to Medicare Part B in the U.S.
“Savings might be realized if single vial sizes currently available in other countries were available in the United States and if manufacturers were to market these smaller vials at lower prices,” the Work Plan notes.
Tips for Documenting Intravitreal Injections
Intravitreal injections are one of the most heavily billed Medicare procedures for ophthalmologists. Some practices even schedule “injection afternoons” that consist entirely of back-to-back injection appointments. These appointments have very little procedural variance, it can be tempting to standardize your EHR records for these visits.
Also known as cloning, cut and paste, and copy forward, misuse of this function might temporarily boost your physicians’ efficiency. But it can also lead to big mistakes like erroneous health records, misdiagnoses, dosing mistakes, and unintentional fraud. So much so, that some EHRs are choosing to disable the copy and paste function altogether.
Injections may be routine, but “this is a surgical procedure and payers expect to see a formal operative report,” Suzanne Corcoran, COE, of Corcoran Consulting Group told Retinal Physician. What should that op report include? Corcoran provides this list:
- Date of service
- Patient’s name
- Pre-and Post-op diagnoses (even if they’re the same)
- Indications to show medical necessity
- Description of surgery
- A note that discharge instruction were provided
- Surgeon’s signature
And documentation doesn’t stop with an op report, says Corcoran. “Because of the high expense, it’s important to have good records of ordering, inventory-on-hand, injection logs, and billing. Your records should allow you to track specific vials or syringes to a specific patient and date of service in order to facilitate reconciling those vials/syringes with purchase invoices and claims submitted to payers if they should be required later.”