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Update to ‘Single-Dose Vial Unused Portion Reimbursement Policy for Clinician-Administered Drugs’

Last updated on 8/10/2020

This is an update to the articles titled “Single-Dose Vial Unused Portion Reimbursement Policy for Clinician Administered Drugs,” published on the TMHP website on June 12, 2020, and “Single-Dose Vial Unused Portion Reimbursement Policy for Clinician Administered Drugs,” published on TMHP’s Children with Special Health Care Needs (CSHCN) Services Program webpage on June 19, 2020.

The update is that effective September 1, 2020, claims submitted for the unused portion and discarded portion of weight-based or variable dosing clinician-administered drugs (CADs) manufactured only in single-dose vials, with dates of service on or after September 1, 2020, must include the modifier JW for consideration of reimbursement.

The JW modifier on the claim identifies the unused portion and discarded portion of the vial contents. This applies to Medicaid, the Children’s Health Insurance Program (CHIP), and the CSHCN Services Program.

This only applies to medical claims for weight-based or variable dosing CADs billed with Healthcare Common Procedure Coding System (HCPCS) procedure codes, manufactured only in single-dose vials, and provided in a professional or outpatient setting.

Claims Filing

Providers must enter the dose administered (used portion) line item detail of the CAD and enter the dose discarded (unused portion) line item detail of the CAD on the same claim. The dose discarded (unused portion) line item detail must include the JW modifier to be considered for reimbursement.

When billing for reimbursement of wastage on an outpatient claim, the HCPCS and Current Procedural Terminology (CPT) code should always be provided along with the revenue code.

Note: Providers must not use the JW modifier when the actual dose of the drug or biological administered is less than the billing unit. The package size submitted on the claim must not exceed the package size of the vial used for preparation of the dose. Providers must not bill for vial contents overfill.

Beginning September 1, 2020, providers can refer to the Texas Medicaid Provider Procedure Manual, and the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.