Understanding how to accurately code and bill for medications and radiopharmaceuticals can be a complex process, especially with ongoing changes in Medicare policies. The JZ modifier, in particular, may prove difficult to comprehend as this modifier is one of the newest modifiers approved. This article explores a relevant question answered by our experts that examines the guidelines set by Medicare for coding and billing these scenarios, particularly focusing on the use of the JW and JZ modifiers for documenting discarded drugs. We’ll break down various examples to help clarify these billing practices and ensure compliance with the latest Medicare regulations.
QUESTION: How do we code and bill for adenosine when we do not use the entire vial on a Medicare patient? Also does this policy apply to radiopharmaceuticals or for all single use administered drugs and diagnostic or therapeutic radiopharmaceuticals?
ANSWER:
Medicare only covers discarded drugs for single use vials; multi-use vials are not subject to payment for discarded amounts of drugs. Since adenosine is supplied as a single use vial, there are several scenarios regarding how to code and bill based on the vial used, (60 mg or 90 mg) and the patient administered dose, which is based on the patients’ weight.
Medicare encourages physicians to schedule patients in such a way that they can use drugs or radiopharmaceuticals most efficiently. However, if a physician must discard the remainder of a single use vial, the Medicare program covers the amount of drug or radiopharmaceutical discarded/decayed/wasted along with the amount administered.
Effective July 1, 2023, providers of separately paid drugs or radiopharmaceuticals from single use administrations are now required to report the waste with the JW modifier or if there is no waste to report the JZ modifier. This is important for CMS tracking and for consistency across the Medicare Administrative Contractors (MACs).
Note: There have been many changes to coding for adenosine from 2013 to 2015 for dates of service prior to January 1, 2014, providers use HCPCS level
II code J0152, Injection, Adenosine, for diagnostic use, per 30 mg increments, for dates of service January 1, 2014 to December 31, 2014 providers would report the new in 2014 HCPCS level II code J0151 Injection, Adenosine, for diagnostic use, per milligram and for dates of service on or after January 1, 2015 and beyond use HPCPS level II code J0153 Injection, Adenosine, diagnostic, per milligram
Example 1: Patient receives 45 milligrams of adenosine from a 60-milligram vial. The HCPCS Level II code description is J0153 Injection, adenosine, per mg, therefore code and bill for (45) units of J0153 on one line and drop down to a second line to bill the wasted 15 units of J0153 with the JW modifier.
If the non-Medicare payer does not require the JW modifier it would also be correct to bill 60 mg of J0153. Since the description is per 1-milligram increments, it is appropriate to account for this waste by simply rounding up to the nearest whole vial. The same would hold true if the patient received 64 milligrams that was taken from a 90-milligram vial, the provider would code and bill for (90) units of J0153 or split 64 units on line one with 26 units and document that the rest of the vial was discarded. We expect that providers plan accordingly and not waste 90 milligram vials excessively.
Example 2: Patient receives 45 milligrams of adenosine from a 90-milligram vial. In this instance the provider did not have any 60-milligram vials on hand as the patient was an add-on for that day, or the site did not have a correct weight for the patient upon scheduling. For any Medicare contractor the wasted drugs must be billed on a separate line using the HCPCS modifier JW, description Drug Amount Discarded/Not Administered to Any Patient, the provider would bill for (45) units of J0153 and (45) units of J0153-JW
Example 3: Patient receives 60 milligrams of adenosine from a 60-milligram vial. The HCPCS Level II code description is J0153 Injection, adenosine, per mg, therefore code and bill for (60) units of J0153 with the required by Medicare JZ modifier.
If billing a non-Medicare private payer that does not require the JW or JZ modifier, follow the private payer instructions.
Of note, effective for claims with DOS on or after January 1, 2017, Medicare requires the use of the JW modifier for wasted drugs or radiopharmaceuticals.
Additionally, effective for claims with DOS on or after July 1, 2023, Medicare requires the use of JW and JZ for single use drugs or radiopharmaceuticals for tracking and payment. For more information and CMS Q&A on the JW and JZ modifiers go to https://www.cms.gov/medicare/medicare-fee-forservice- payment/hospitaloutpatientpps/downloads/jw-modifier-faqs.pdf. This excerpt is sourced from our 2024 Nuclear Medicine & PET Coder. Remember to take advantage of our expertly aggregated resources to overcome complex challenges in this area and others.
Note that: The opinions referenced are those of the members of the SNMMI Coding and Reimbursement Committee and their consultants based on their coding experience. They are based on the commonly used codes in Nuclear Medicine, which are not all inclusive. Always check with your local insurance carriers as policies vary by region.
The final decision for the coding of a procedure must be made by the physician considering regulations of insurance carriers and any local, state or federal laws that apply to the physician’s practice. The SNMMI and its representatives disclaim any liability arising from the use of these opinions.
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