Wiki Documentation for JW/JZ Modifier

[taurus7694]

CMS guidance for JW/JZ modifiers states: Providers and suppliers must document the amount of discarded drugs in Medicare beneficiaries' medical records.
As a coder/auditor, I believe the amount administered and discarded should be documented in the provider's procedure note in order to charge the appropriate units. The provider's note should stand alone is a saying that I have utilized in my career as a coder/auditor. CMS guidance doesn't specify that it needs to be documented in the actual procedure note, it simply states it just needs to be documented in the medical record.

JW
Question #1 - As a coder/auditor, would you code/charge medication waste if it was only documented in the MAR and not in the provider's note?
Question #2 - If the discarded amount is documented in the provider's note, would you code/charge if the waste was documented as:

• The proximal interphalangeal joint cord of the right long finger was injected with 0.58mg of Xiaflex. The rest of the vial was discarded.
• The proximal interphalangeal joint of the right ring finger was injected with 0.58mg of Xiaflex. The appropriate amount was discarded

JZ
Question #1 - When applying JZ modifier, do you require the provider to document a statement such as, "The entire vial was used to treat the patient" or "No medication waste"?
Question #2 - Do you apply the JZ based on the NDC, which tells you the vial size/strength, and the amount administered per documentation?


Please share any guidance you may have found in addition to CMS guidance. Thank you!!

 

[lgardner]

here is an FAQ from CMS : https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/downloads/jw-modifier-faqs.pdf

Q15. Does CMS have specific requirements regarding documentation for discarded amounts of drugs, such as who is required to document the amount that is discarded, the format for whether calculated values are acceptable, or where the documentation should be stored? Is there a specific area in the medical record where the administered/discarded amounts should be documented?
A15. Other than the expectation that providers and suppliers will maintain accurate (medical and/or dispensing) records for all beneficiaries as well as accurate purchasing and inventory records for all drugs that were purchased and billed to Medicare2 , CMS has no specific requirements regarding the method, format, the medical staff responsible for making the record, or location of discarded amount data in a patient's medical record. Providers and suppliers should also check with the MAC that processes their Part B drug claims in case additional information on billing and documentation is available at the local level.

Q16 Will CMS accept an “automatic” calculation of discarded amounts, for example, a calculation done by software, as documentation of discarded amounts within the medical record?
A16. As long as the discarded amount is accurately documented, CMS does not dictate how it is calculated.
________________________________________________

Also, Noridian has a couple of LCAs (I haven't checked all other MACs), here is the link to one: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55932

I hope these help you find your answers.

 

[taurus7694]

here is an FAQ from CMS : https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/downloads/jw-modifier-faqs.pdf

Q15. Does CMS have specific requirements regarding documentation for discarded amounts of drugs, such as who is required to document the amount that is discarded, the format for whether calculated values are acceptable, or where the documentation should be stored? Is there a specific area in the medical record where the administered/discarded amounts should be documented?
A15. Other than the expectation that providers and suppliers will maintain accurate (medical and/or dispensing) records for all beneficiaries as well as accurate purchasing and inventory records for all drugs that were purchased and billed to Medicare2 , CMS has no specific requirements regarding the method, format, the medical staff responsible for making the record, or location of discarded amount data in a patient's medical record. Providers and suppliers should also check with the MAC that processes their Part B drug claims in case additional information on billing and documentation is available at the local level.

Q16 Will CMS accept an “automatic” calculation of discarded amounts, for example, a calculation done by software, as documentation of discarded amounts within the medical record?
A16. As long as the discarded amount is accurately documented, CMS does not dictate how it is calculated.
________________________________________________

Also, Noridian has a couple of LCAs (I haven't checked all other MACs), here is the link to one: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55932

I hope these help you find your answers.

Thank you! I appreciate the information. The coder in me still thinks it needs to be in the provider's note because the coder has to rely on the dose the provider documents, not what a nurse documents in MAR. At the very least, if the provider doesn't have to document the waste in the procedure note, I think they should make reference to the MAR. Something like, "For medication administered and/or discarded, please see MAR".

 

[lgardner]

Thank you! I appreciate the information. The coder in me still thinks it needs to be in the provider's note because the coder has to rely on the dose the provider documents, not what a nurse documents in MAR. At the very least, if the provider doesn't have to document the waste in the procedure note, I think they should make reference to the MAR. Something like, "For medication administered and/or discarded, please see MAR".

I agree with you.

 

[csperoni]

I didn't realize you posted twice (which shouldn't be done for this exact reason) and answered in your other post. My copied/pasted below:
No official references here, but I'll weigh in since no one else has. The "note should stand alone" to me does not mean only the document called note. For example, sometimes my clinicians draw a diagram for the patient that is scanned in and contains some additional information. The "note" doesn't have the diagram, but does reference it - it is a separate document. But both documents together make up the record for the day. Or maybe at 8pm the physician speaks with the patient's cardiologist that he/she tried to reach earlier in the day. If they create a new document instead of adding/amending the existing document, I don't know why you couldn't count the information. The same would apply here to me. As long as it's in the chart as part of the records signed by the physician for the day, I would not have a problem with it.
My practice does not currently supply/bill drugs, so I am not 100% up to date with the JW/JZ requirements. I will say I absolutely prefer rather than "rest of the vial" or "appropriate amount" to state the amount. There are meds that come in various sized vials. This is too vague for me, even if the NDC is noted. "0.42mg discarded" is not any harder than "The appropriate amount was discarded." but leaves zero room for a misinterpretation or ding on an audit.

 

[thomas7331]

Thank you! I appreciate the information. The coder in me still thinks it needs to be in the provider's note because the coder has to rely on the dose the provider documents, not what a nurse documents in MAR. At the very least, if the provider doesn't have to document the waste in the procedure note, I think they should make reference to the MAR. Something like, "For medication administered and/or discarded, please see MAR".

I can see that this might be the case if the physician is the one administering the drug during the procedure. However, the majority of drug administrations (especially in the facility setting) are done by nursing staff, acting under the orders of a physician, and there is no reason that I can see why a physician would need to duplicate that information in their own note. Nurse documentation is routinely used for billing of drugs throughout the industry. I've never seen a case where an auditor would disqualify documentation just because it's in the MAR and not in the physician note. I think it would be a great waste of physician time to require them to add documentation to either repeat what the nursing staff has already recorded or even just to state that the information is located in the MAR. I really don't think that's necessary at all.