Wiki J7327 Modifier ?

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LenaM

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Hi Everyone, Lately we are receiving denials from Commercial payers (Humana Medicare Replacement in this question) for J7327. The claim was coded out as 20610, LT qty 1 and J7327 QTY 1 both with dx code M17.11. They paid on the 20610 but have denied the J7327 with the following reason: PAYMENT IS NOT ALLOWED FOR THIS SINGLE DOSE DRUG VIAL WHEN BILLED WITHOUT THE REQUIRED MODIFIER. Would anyone know what Modifier is needed on this? Thank you for the help.
 
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They are looking for information on whether the entire vial was administered or if there was drug waste. If the entire vial was administered, then you would bill JZ-Zero drug amount discarded/not administered to any patient. If the entire vial was not administered, then you need to bill 2 lines for this code with one line for the units administered without a modifier and then bill a second line for the code with the number of units wasted/discarded and append modifier JW-Drug amount discarded/not administered to any patient.

For example, which is based on fictitious information for the units on this J code:
  • if the vial contained 100 units and the patient was administered all 100 units you would bill J7327-JZ 100 units.
  • if the vial contained 100 units and the patient was administered 75 units you would bill 1 line as J7327 75 units and the second line you would bill J7327-JW 25 units.
Effective 07/01/23 for single dose vials were there was no drug waste modifier JZ is required to be billed with the J code to indicate that the patient received the entire contents of the vial, the modifier was effective 01/01/23 and it was optional to use 01/01/23-06/30/23 but as of 7/1/23 it is mandatory.

You can review IOM 100-04 Claims Processing Manual: Chapter 17-Drugs and Biologicals; section 40-40.1 as well as this FAQ regarding Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy Frequently Asked Questions

Hopefully these resources will help you get your claims submitted and processed correctly.
 
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CBLENNIE said:
They are looking for information on whether the entire vial was administered or if there was drug waste. If the entire vial was administered, then you would bill JZ-Zero drug amount discarded/not administered to any patient. If the entire vial was not administered, then you need to bill 2 lines for this code with one line for the units administered without a modifier and then bill a second line for the code with the number of units wasted/discarded and append modifier JW-Drug amount discarded/not administered to any patient.

For example, which is based on fictitious information for the units on this J code:
  • if the vial contained 100 units and the patient was administered all 100 units you would bill J7327-JZ 100 units.
  • if the vial contained 100 units and the patient was administered 75 units you would bill 1 line as J7327 75 units and the second line you would bill J7327-JW 25 units.
Effective 07/01/23 for single dose vials were there was no drug waste modifier JZ is required to be billed with the J code to indicate that the patient received the entire contents of the vial, the modifier was effective 01/01/23 and it was optional to use 01/01/23-06/30/23 but as of 7/1/23 it is mandatory.

You can review IOM 100-04 Claims Processing Manual: Chapter 17-Drugs and Biologicals; section 40-40.1 as well as this FAQ regarding Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy Frequently Asked Questions

Hopefully these resources will help you get your claims submitted and processed correctly.
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Just an FYI. H/A products such as Euflexxa and Synvisc do not come in vials that are drawn from. They come in pre-dosed syringes and the entire syringe is injected. Three injections are performed about a week apart to complete the treatment.
 
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Thank you! I found this morning the description from CMS. That and your descriptions and fictitious dosage info helped clarify it. I am sharing with the team in our morning meeting. Thank you again. :)
 
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Orthocoderpgu said:
Just an FYI. H/A products such as Euflexxa and Synvisc do not come in vials that are drawn from. They come in pre-dosed syringes and the entire syringe is injected. Three injections are performed about a week apart to complete the treatment.
Click to expand...
In reviewing the FAQ from CMS regarding JW & JZ modifier usage the verbiage actually isn't specific to "vials" it states the following:
1709843886924.png
So, I would say that the requirement to use modifier JZ is still applicable to J7327. Based on the fact that the entire syringe is typically administered the claims will still need the JZ modifier to indicate there was no waste from the single dose container.

Additionally, while technically the entire syringe is intended to be administered, there are unique situations where a patient may not receive the entire dose in the syringe, which means there is an off chance that there may be a situation where there is in fact waste for one of these drugs and the guidelines for using modifier JW would be applicable.
 
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CBLENNIE said:
In reviewing the FAQ from CMS regarding JW & JZ modifier usage the verbiage actually isn't specific to "vials" it states the following:
View attachment 6914
So, I would say that the requirement to use modifier JZ is still applicable to J7327. Based on the fact that the entire syringe is typically administered the claims will still need the JZ modifier to indicate there was no waste from the single dose container.

Additionally, while technically the entire syringe is intended to be administered, there are unique situations where a patient may not receive the entire dose in the syringe, which means there is an off chance that there may be a situation where there is in fact waste for one of these drugs and the guidelines for using modifier JW would be applicable.
Click to expand...
I wonder if they are looking for that modifier. I just asked someone in the clinical staff if they had ever not given the entire syringe and she said no. She's been injecting for 8 years. But they might want that modifier !
 
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LenaM said:
Hi Everyone, Lately we are receiving denials from Commercial payers (Humana Medicare Replacement in this question) for J7327. The claim was coded out as 20610, LT qty 1 and J7327 QTY 1 both with dx code M17.11. They paid on the 20610 but have denied the J7327 with the following reason: PAYMENT IS NOT ALLOWED FOR THIS SINGLE DOSE DRUG VIAL WHEN BILLED WITHOUT THE REQUIRED MODIFIER. Would anyone know what Modifier is needed on this? Thank you for the help.
Click to expand...
Maybe it is a typo but, your diagnosis code is RT (M17.11) when you state the modifier was 20610 - LT...?

I agree with the advice above.
"The final rule also established a requirement that you report the new JZ modifier (Zero drug amount discarded/not administered to any patient) when there’s no discarded amounts. We stated that the JW and JZ modifier requirements would apply to separately payable drugs under Part B that are supplied in a single-dose container or single-use package based on FDA approved labeling."
"We’re implementing the JZ modifier in phases:• January 1, 2023: You may report the JZ modifier• July 1, 2023: You’re required to use the JZ modifier on applicable claims• October 2, 2023: Claims editing starts when JW or JZ modifiers aren’t used correctly.

If this has not been done and your practice has a heavy Visco component (talking to you ortho clincs!) you better run a claims query on all the Viscos to make sure they are paid correctly.
 
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