Drug Wastage – Modifier JW

Reimbursement Policy:

Effective Date:

March 18, 2019

Last Reviewed Date:

March 23, 2023

Purpose:

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

Scope:

All products are included, except

Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
COB

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

Modifier JW reports the drug amount discarded/not administered to any patient.

Drug Wastage is the discarded drug amount not administered to patient.

Single-dose/Single-use Vials are 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 Vials are intended for administration by injection or infusion containing more than one medication dose. Manufacturer labels vials as multi-dose.

Policy:

Horizon BCBSNJ shall consider for reimbursement single-dose/single-use vial drug waste appended with Modifier JW, along with the amount of the drug that was administered, when the amount billed as drug wastage is not administered to another patient.

Horizon BCBSNJ shall consider for reimbursement multi-dose vials that are administered to the patient.

Horizon BCBSNJ 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 along with the amount of drug administered to the patient, Horizon BCBSNJ shall reimburse drug codes appropriately appended with modifier JW for single-dose/single-use vials only.

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

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
In instances where the provider is not participating, member liability shall be up to the provider's charge.

Limitations and Exclusions:

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

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
Mandated or legislative required criteria will always supersede.

History:

10/22/2018: Policy approved

Policy122_v2.0_03232023