RAC study: Providers incorrectly billed multi-use vials with medication wastage

Wednesday, January 29, 2020

Several Medicare claims for trastuzumab multi-dose vials billed over the last three years failed to comply with Medicare requirements in part due to the improper application of modifier -JW (drug amount discarded/not administered to any patient), according to a study reported in the January 2020 Medicare Quarterly Provider Compliance Newsletter.

Medicare Recovery Auditor Contractors (RAC) reviewed claims for trastuzumab (Herceptin)— a chemotherapy drug used to treat breast, stomach, and esophageal cancer— over the last three years (2017-2019) to ensure compliance with Medicare policy. According to the report, claims for trastuzumab were billed incorrectly by providers for one or more of the following reasons:

  • Billed services were not rendered
  • Duplicate payments
  • Insufficient documentation
  • Incorrect coding
  • No documentation
  • Number of units incorrectly billed
  • Record included the wrong date of service

The reviewers determined that, in many cases, providers billed multi-use vials incorrectly with medication wastage. Specifically, providers incorrectly billed for trastuzumab multi-dose vials using one or more units of HCPCS code J9355 (injection, trastuzumab [Herceptin], excludes biosimilar, 10 mg) with HCPCS modifier -JW to identify discarded amounts of the drug.  

Per CMS guidance, modifier -JW is used on a Medicare Part B drug claim to report the amount of a drug that is discarded and should only be used for drugs in single dose or single-use packaging. It would, therefore, not apply in cases involving multi-dose vials.

Healthcare professionals should review the following resources for additional information on billing for drugs and biologicals and the proper application of modifier -JW:

Editor's Note: This article originally appeared on Revenue Cycle Advisor.

Found in Categories: 
Billing and Claims, Revenue Integrity