Effective Date: November 1, 2019

Purpose:
This policy provides guidelines for the reimbursement of drug wastage. This policy applies to professional and institutional providers.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Modifier -JW: Reports the drug amount discarded/not administered to any patient.\
• Drug Wastage: Discarded drug amount not administered to patient.
• Single-dose/Single-use Vial: Intended for administration by injection or infusion for use in a single patient for a single procedure. Manufacturer labels vial as single-dose/single-use vial.
• Multi-dose Vial: Intended for administration by injection or infusion containing more than one medication dose. Manufacturer labels vials as multi-dose.

Policy:
As per the CMS, physicians, hospitals and other providers and suppliers should care for and administer drugs and biologicals to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.

When a provider must discard the remainder of a single use vial or other single use package after administering a dose/quantity of the drug or biological, the drug wastage may be eligible for reimbursement as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label.

When submitting a claim, providers shall report the drug amount administered on one (1) line and on a separate line, report the single-dose/single-use vial drug waste amount with modifier –JW appended to the associated HCPCS code. Modifier –JW is only applicable to the amount of the drug discarded or wasted, and not the amount administered to the patient. Medical records must clearly indicate the amount of drug administered to the member and the amount wasted. Providers are expected to use the drug or biological in a responsible way to avoid drug wastage.

Horizon NJ Health shall not consider for reimbursement:

• Multi-dose vial drug wastage
• Drug wastage billed when none of the drug was administered to the patient
• Drugs billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose

Procedure:
When billed on a claim along with the amount of drug administered to the patient, Horizon NJ Health shall reimburse drug codes appropriately appended with modifier -JW for single-dose/single-use vials only for drug wastage.

Horizon NJ Health shall deny drug codes appended with modifier -JW for multi-dose vial drug waste.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:
Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals
CMS.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c17.pdf

CMS MNL Matters Number MM9603
CMS.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9603.pdf

Medicare –JW Modifier Frequently Asked Questions
CMS.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services