taurus7694
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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:
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!!
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
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!!