Wiki Denials of high dollar drugs with JW for wastage

[sarah8873]

Updated regulations for JW modifier in addition to now having to apply JZ mod to single use drug charges without wastage.

We now have to contend with wastage putting the charges over MUE edits and denials of all the drug charges.
This is happening with straight Medicare and at least one of our Medicare replacement plans.
I understand the importance of reporting wastage. We have always reported wastage.
Historically, the units over MUE would be put to contractual/denied if billed. Which we adjusted on our end because of course they aren't going to pay for anything over MUEs.

However, we are now running into payers rolling up all the charges for the drug and denying all of the drug charges due to the wastage putting the charges over MUE of 150 (for example)
The billing department has taken variance adjustments on these. This is around $11k every month for a pt getting this monthly.

Billing high cost drugs such as J9173 where there is wastage due to vial sizes:
J9173 150 units
J9173 JW 6 units
The wastage is what puts this over the MUE. The only thing I can find is that we would have to appeal all of these.

I am wondering if anyone else has run into this issue? I have read countless articles, federal registrar, CMS mln, etc and no one addresses what to do with these denials and why a payer can just deny what was given vs only denying the units over MUE.

I get the feeling that since they are technically able to go back to the manufacturer for the wastage (probably only if under the MUE amount) they are trying to push us to use different package/vial sizes.

 

[kathleeng]

Whenever you bill over the MUE, as long as it has an indicator of 3, you will more than likely, always need to provide the supporting documentation to justify the need of billing over the MUE, per Medicare guidelines, and/or appeal it. It's not a guaranteed payment, but part of the requirement to justify the need.

 

[shanamarie]

Updated regulations for JW modifier in addition to now having to apply JZ mod to single use drug charges without wastage.

We now have to contend with wastage putting the charges over MUE edits and denials of all the drug charges.
This is happening with straight Medicare and at least one of our Medicare replacement plans.
I understand the importance of reporting wastage. We have always reported wastage.
Historically, the units over MUE would be put to contractual/denied if billed. Which we adjusted on our end because of course they aren't going to pay for anything over MUEs.

However, we are now running into payers rolling up all the charges for the drug and denying all of the drug charges due to the wastage putting the charges over MUE of 150 (for example)
The billing department has taken variance adjustments on these. This is around $11k every month for a pt getting this monthly.

Billing high cost drugs such as J9173 where there is wastage due to vial sizes:
J9173 150 units
J9173 JW 6 units
The wastage is what puts this over the MUE. The only thing I can find is that we would have to appeal all of these.

I am wondering if anyone else has run into this issue? I have read countless articles, federal registrar, CMS mln, etc and no one addresses what to do with these denials and why a payer can just deny what was given vs only denying the units over MUE.

I get the feeling that since they are technically able to go back to the manufacturer for the wastage (probably only if under the MUE amount) they are trying to push us to use different package/vial sizes.

Are you sure your units and waste are correct? It seems odd to me that waste would put you over the MUE. I work with infusions daily and have never run in to this issue so it has me curious. What dose was the patient given and how much of the drug was wasted?

 

[rahulbhaleraog@gmail.com]

Hello All, I have been noticing Drug code are getting denied by BCBS Michigan stating PR167. E.G. J9173 billed with DX C23. Medicare is paying for the same however BCBS Michigan is not. If anyone has any idea about this please help. NCD states the coding is correct. I have checked on availity's clear claim connection and that is also saying the code is correct.

 

[rachaelwilleford]

Hello All, I have been noticing Drug code are getting denied by BCBS Michigan stating PR167. E.G. J9173 billed with DX C23. Medicare is paying for the same however BCBS Michigan is not. If anyone has any idea about this please help. NCD states the coding is correct. I have checked on availity's clear claim connection and that is also saying the code is correct.

If this is a commercial member and not a Medicare Part B member, you can't look at the NCD for Medicare. You have to go to BCBS Michigan's clinical policy for the drug. If you go to the clinical policy for BCBS Michigan, it shows non-small cell lung cancer, small cell lung cancer, biliary tract, and hepatocellular carcinoma as covered cancerous conditions for Imfinzi. Always go to the payer's clinical policies when it's a medically administered drug.