First time posting, but I could really use some help.
I've read everything I can get my hands on, but I need someone to explain to me the usage of the JW or JZ for biological material.
Our LCD L36690, the Article for wound care A56696 nor the IOM state that there is an exclusion in the guidelines for billing wasted product in wound care scenarios on biological material.
Scenario-1
Provider identifies product used and details whole procedure, the amount is stated to have used 7 of 8 units of total single use product. 1 unit of waste/discarded.
Billing-
HCPCS CODE- NO MODIFIER- UNITS USED- COST = LINE 1
HCPCS CODE-JW MODIFIER- UNITS WASTED- COST = LINE 2
HCPCS CODE FOR APPLICATION - NO MODIFIER- UNIT = LINE 3
Scenario -2
Provider identifies product used and details whole procedure, the amount is stated to have used 8 of 8 units of total single use product. 0 unit of waste/discarded.
Billing-
HCPCS CODE- NO MODIFIER- UNITS USED- COST = LINE 1
HCPCS CODE FOR APPLICATION - NO MODIFIER- UNIT = LINE 3
These are 2 examples of how we'd normally code/bill for grafts in office outpatient setting for chronic wound after 6 + weeks of conservative treatment.
Almost Every claim was processed under these conditions and paid per medical necessity under our MAC.
Except a handful. Now each was billed similarly - diagnosis and providers and locations changed as indicated
But the "how" of the billing was always as listed above.
In December and January - I reached out to CGS for those denials and asked for details on the reason for denial. (I'd already sent the PWK forms and extra information usually requested)
I was told the PWK forms were not received and I needed to send the invoices and notes. I did this again, they turned back a denial same reasons.
I called again, was told this time, that it denied in error and they'd send it back again, "everything looked correct and to be in order on the claim and documentation"
Denied again.
This time when I called beginning of February 2023, I was told that it was denied because of the JW modifier, and that modifier is "only for drugs, not biologics" - But the IOM clearly states it is for use on discarded biologics.
The L36690 clearly directs us to reference the IOM chapter 17, section 40 for discarded drugs and biologicals
I referenced this and the rep stated that I needed to provide her with these documents from CMS for Kentucky on the usage. So I did, she said she'd take it back to review and they'd be in contact.
Fastforward to February 14th
I receive a call from CMS - "yes, your use is proper please rebill and we'll get it processed, sorry for the confusion"
Billed Again. Denied Again. Total Confusion here. What in the world is happening?
Search and dig and find a random "News" Note posted on CGS website on 2.13.2023 - please note that since February updates have been made to the IOM as well.
February 13, 2023
HCPCS modifier JW, used in wound care services, is not considered an injectable drug, so the guidelines on wastage for single dose vials do not apply.
Codes identified with the JW modifier for wound care services will be denied.
Reference:
This is Literally the only place that this is stated in anything I have read. Also - is this "official"?
A random blurb on the website when it's not stated anywhere else?
It feels like changing the rules halfway through the "game" because you don't like something.
Someone please advise because this feels hinky.
If I am missing something - tell me, I want to learn. But this?
I know this is long, but any help at all is appreciated.
Thank you.
I've read everything I can get my hands on, but I need someone to explain to me the usage of the JW or JZ for biological material.
Our LCD L36690, the Article for wound care A56696 nor the IOM state that there is an exclusion in the guidelines for billing wasted product in wound care scenarios on biological material.
Scenario-1
Provider identifies product used and details whole procedure, the amount is stated to have used 7 of 8 units of total single use product. 1 unit of waste/discarded.
Billing-
HCPCS CODE- NO MODIFIER- UNITS USED- COST = LINE 1
HCPCS CODE-JW MODIFIER- UNITS WASTED- COST = LINE 2
HCPCS CODE FOR APPLICATION - NO MODIFIER- UNIT = LINE 3
Scenario -2
Provider identifies product used and details whole procedure, the amount is stated to have used 8 of 8 units of total single use product. 0 unit of waste/discarded.
Billing-
HCPCS CODE- NO MODIFIER- UNITS USED- COST = LINE 1
HCPCS CODE FOR APPLICATION - NO MODIFIER- UNIT = LINE 3
These are 2 examples of how we'd normally code/bill for grafts in office outpatient setting for chronic wound after 6 + weeks of conservative treatment.
Almost Every claim was processed under these conditions and paid per medical necessity under our MAC.
Except a handful. Now each was billed similarly - diagnosis and providers and locations changed as indicated
But the "how" of the billing was always as listed above.
In December and January - I reached out to CGS for those denials and asked for details on the reason for denial. (I'd already sent the PWK forms and extra information usually requested)
I was told the PWK forms were not received and I needed to send the invoices and notes. I did this again, they turned back a denial same reasons.
I called again, was told this time, that it denied in error and they'd send it back again, "everything looked correct and to be in order on the claim and documentation"
Denied again.
This time when I called beginning of February 2023, I was told that it was denied because of the JW modifier, and that modifier is "only for drugs, not biologics" - But the IOM clearly states it is for use on discarded biologics.
The L36690 clearly directs us to reference the IOM chapter 17, section 40 for discarded drugs and biologicals
I referenced this and the rep stated that I needed to provide her with these documents from CMS for Kentucky on the usage. So I did, she said she'd take it back to review and they'd be in contact.
Fastforward to February 14th
I receive a call from CMS - "yes, your use is proper please rebill and we'll get it processed, sorry for the confusion"
Billed Again. Denied Again. Total Confusion here. What in the world is happening?
Search and dig and find a random "News" Note posted on CGS website on 2.13.2023 - please note that since February updates have been made to the IOM as well.
February 13, 2023
Reminder: HCPCS Modifier JW "Drug or Biological Amount Discarded/Not Administered to Any Patient"
Use HCPCS modifier JW for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded.HCPCS modifier JW, used in wound care services, is not considered an injectable drug, so the guidelines on wastage for single dose vials do not apply.
Codes identified with the JW modifier for wound care services will be denied.
Reference:
- IOM
- Change Request 9603
- L36690 – Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities
- A56696 – Billing and Coding: Wound Application of Cellular and / or Tissue Based Products (CTPs), Lower Extremities
This is Literally the only place that this is stated in anything I have read. Also - is this "official"?
A random blurb on the website when it's not stated anywhere else?
It feels like changing the rules halfway through the "game" because you don't like something.
Someone please advise because this feels hinky.
If I am missing something - tell me, I want to learn. But this?
I know this is long, but any help at all is appreciated.
Thank you.