Description
This policy provides direction on drugs and biologicals reimbursement as well as the appropriate use of Modifier JW.
Same group practice is defined as a physician and/or other qualified health care professional of the same group and same specialty with the same Federal Tax ID number.
Policy
Blue Cross Blue Shield North Carolina (Blue Cross NC) will provide reimbursement for drugs and biologicals, according to the criteria outlined in this policy.
Reimbursement Guidelines
Blue Cross NC will limit reimbursement for drugs and biologicals per guidance from the FDA-approved indications and acceptable off-label indications, unless otherwise specified in a separate pharmacy policy. This helps ensure appropriate indications for use, dosing limits, and frequency of use.
Blue Cross NC will only reimburse one claim line of an administered drug or biological per day, per provider or same group practice. If multiple lines of the same drug/code are billed on the same claim or date of se rvice and one line does not contain a JW modifier, the line(s) with an equal or lower quantity will be denied.
Drugs and biologicals with multiple administration routes must be billed with modifiers (JA, JB) to indicate route of administration.
Single Use Vial or Package
Modifier JW is only valid when used to identify discarded/wasted drug or biological from a single use vial or package.
Reimbursement for drug or biological wastage (as indicated by the Modifier JW) will never exceed the units contained in the smallest single use vial or package available for purchase from the manufacturer(s).
Drug or biologic wastage (Modifier JW) must be filed with a separate claim line from the administered drug or biologic in order to be reimbursed. Drug or biologic wastage (Modifier JW) alone is not reimbursable.
Multi-use Vial or Package
Modifier JW cannot be used to indicate drug or biological wastage for multi-use vials. Wastage for multi-use vials is not reimbursable.
Rationale
In alignment with CMS, Blue Cross NC will not provide reimbursement for discarded drugs or biologicals for multi-use vials.
Please refer to the “Drug Wastage” section in Provider Manual for more information related to claim filing.
Billing and Coding
Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.