Medicare Updates

  • 0
  • January 23, 2017

On Thursday, December 15, the Obama administration announced that the proposed Medicare Part B Drug Model would not move forward at this time. The decision to halt the program came after much criticism, for the scope and design of the program, from public comments on the proposed rule to a letter signed by more than 170 members of the House to CMS and the Centers for Medicare & Medicaid Innovation (CMMI). In their letter, the congressional members state that CMMI models should be implemented in a voluntary, limited-scale basis, and that the CMMI has exceeded its authority with the development of the mandatory Part B Drug Payment Model.

In a statement explaining the decision to halt the proposed program, a CMS spokesperson said, “While CMS was working to address these concerns, the complexity of the issues and the limited time available led to the decision not to finalize the rule at this time.”

Reminder: Effective January 1, 2017, providers are required to report the JW modifier on Part B drug claims for discarded drugs and biologicals. Providers must also document the amount of discarded drugs or biologicals in Medicare beneficiaries’ medical records.

Discarded drug is to be reported on the claim on a separate line with the JW modifier, and the amount of drug discarded should be entered in the unit field.

The JW modifier is only to be reported when you are reporting discarded drug, from a single dose vial, which is eligible for payment under Medicare’s discarded drug policy. The JW modifier is not to be used to report overfill wastage as Medicare expressly prohibits billing for overfill.

The JW modifier should not be used when the actual dose of the drug administered and the amount discarded is equal to or less than the HCPCS billing unit. Chapter 17, Section 40 of the CMS Medicare Claims Processing Manual provides details and examples on properly billing for discarded drug.

The JW modifier policy applies to providers who buy and bill drugs in the physician’s office and the hospital outpatient setting. However, the JW modifier is not required for drugs that are not separately payable, such as packaged OOPS drugs or those administered in a Federally Qualified Health Center (FQHC) or in a Rural Health Clinic (RHC) setting.

MLN Matters MM9603 Learning-Network-MLN/MLNMattersArticles/Downloads/MM9603.pdf

Chapter 17 of the CMS Medicare Claims Processing Manual (Section 40) – Guidance/Guidance/Manuals/downloads/clm104c17.pdf

January 1, 2017 starts the first reporting period for Medicare’s new Quality Payment Program (QPP). Read our newsletter on the final rule (links below) and monitor the CMS QPP website for tools and resources for this program,

Oplinc’s Best Practice Review Volume 11 Issue 3:
html version: MACRA Final Rule iBook version: MACRA Final Rule