CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP026

Therapeutic, Prophylactic, Diagnostic, Injection and Infusion Administration Coding

Coding and billing guidance for therapeutic, prophylactic, diagnostic injections, infusions, and hydration services affecting providers submitting claims to Blue Cross and Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTherapeutic, Prophylactic, Diagnostic, Injection and Infusion Administration Coding

Policy CodePolicy CPCP026

Change TypeNo material changes

Effective DateAugust 8, 2024

Next Review DateN/A

Key ActionAppend JW for discarded drug amounts and JZ for zero waste; bill discarded amounts on a separate line and include documentation of drug, dosage, and reason.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

2024-08-08effective date

2024-07-30approval date

One initial/service/daybilling rule

JW/JZmodifiers

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Billing and reimbursement criteria

Covered when documentation and coding support separate reimbursement; certain items and services are considered inclusive and are not separately reimbursable.

Plan may request supporting documentation to determine eligible reimbursement. Submission of any code should be fully supported in the medical documentation.

Services, equipment, and supplies that are routine or commonly furnished as part of an injection/infusion visit are included in the general charge and are not separately reimbursed.

Examples of items/services not separately reimbursed: local anesthesia; IV start; access to indwelling IV/subcutaneous catheter or port; flush at conclusion of infusion; standard tubing, syringes, and supplies.

Some HCPCS supply codes are not separately reimbursable when used the same day as an E/M service or procedure in a non‑facility place of service; supplies used during administration are integral to the service and not separately reimbursed.

Hydration codes (96360-96361) describe IV fluids/electrolytes only and require a minimum documented infusion time (see coding thresholds); IV maintenance or IV kept open for other therapy is not separately reported as hydration.

Therapeutic/prophylactic/diagnostic administration codes (e.g., 96365-96377, 96379, and related injection codes) describe administration of drugs/biologics; fluids used solely to deliver drugs are incidental and not separately reimbursed.

Chemotherapy/highly complex administration codes (96401-96459) take precedence for higher‑complexity drug administration and supervision requirements and are primary for hierarchy when applicable.

Only one initial service code may be reported per member encounter per day for both physician/QHP and facility reporting except when documentation supports two separate IV sites or separate same‑day visits (use modifier -59 or other appropriate modifier with documentation).

Administration time for infusion/injection is distinct from E/M time; an E/M may be billed with modifier -25 if a significant, separately identifiable service is performed and documentation supports it.

Modifiers JW and JZ should be used as applicable to report discarded drug amounts (JW) or zero discarded amount from single‑use vial/package (JZ); discarded amounts must be billed on a separate line with JW in non‑inpatient places of service and documentation must identify drug, dosage, and reason.

Certain administration codes are typically included in facility E/M services and are not separately reimbursable when reported by the physician/QHP in a facility setting (see coding section for specific codes).

Billing/documentation rules

Billing and documentation requirements when administering drugs or when a member supplies their own drug:

Append the JW modifier to report the amount of drug or biological discarded; the discarded amount must be billed on a separate line with the JW modifier for all non‑inpatient places of service. Documentation must identify and describe the drug, dosage, and reason for discard.

Append the JZ modifier to indicate there were no discarded amounts from a single‑use vial or single‑use package.

If no applicable code exists to describe the administered drug, service, or procedure, report using the appropriate unlisted/Not Otherwise Classified code and submit a description and supporting documentation with the claim.

If a member supplies their own drug and no E/M service is provided, report the appropriate injection CPT (e.g., 96372) for the administration and include a separate drug line reporting the drug and dosage with a $0.00 charge when applicable; the drug must be administered under direct supervision.

CPT/HCPCS Codes, Modifiers, and Billing Rules

Primary administration codesCPT

96360-96361	Hydration IV infusion initial and add-on
96365-96377, 96379	Therapeutic, prophylactic, diagnostic injection/infusion administration (excluding chemotherapy/highly complex)
96401-96459	Chemotherapy and highly complex drug/biologic administration (range referenced in text)
96372	Therapeutic, prophylactic, or diagnostic injection (SC/IM)
96376	Facility-only same drug sequential injection add-on

Drug wastage modifiersModifier | HCPCS

JW	Amount of drug/biological discarded
JZ	No discarded amount from single-use vial/package

example pairingmixed

J2357	HCPCS example for a drug; report with CPT 96372 for therapeutic, prophylactic, or diagnostic injection
96372	CPT therapeutic, prophylactic, or diagnostic injection, SC/IM

Hydration minimum time

Hydration minimum timeMinimum 31 minutes of hydration infusion is required to report hydration using CPT 96360-96361.

When hydration not reportedDo not report hydration codes when IV fluids are used only to keep an IV line open or as free-flowing IV during chemotherapy or other therapeutic infusions.

Code rangeHydration codes referenced: CPT 96360-96361.

Initial service reporting

One initial service per encounterOnly one initial service code may be reported per member encounter per day for physician/QHP and facility reporting.

Exception — separate IV sitesAn additional initial service may be reported when protocol or the member’s condition requires two separate IV sites; append appropriate modifier to reflect difference in time/effort.

Exception — separate visit same dayIf member returns for a separate visit/encounter the same day, another initial infusion/injection code may be billed with modifier -59.

Billing separate line for discarded drug

Separate line for discarded amountDiscarded amount must be billed on a separate line with the JW modifier for all non-inpatient places of service.

Documentation requiredDocumentation must identify and describe the drug, dosage, and reason for discarded amount when JW is used.

Efficiency encouragedProviders are encouraged to administer and care for members to minimize drug/biologic waste; refer to Plan documents and industry guidelines for additional information.

Provider Responsibilities and Actionable Billing Guidance

Documentation Required

Policy Hierarchy

If a conflict arises between this Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. If a conflict arises between this Clinical Payment and Coding Policy and any provider contract pursuant to which a provider participates in and/or provides Covered Services to eligible member(s) and/or plans, the provider contract will govern. "Plan documents" include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. Blue Cross and Blue Shield of New Mexico may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. BCBSNM has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents.

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid code combinations from HIPAA-approved code sets.
Claims are subject to code edit protocols and claim review, including terms of benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.
Upon request, the provider is urged to submit any additional documentation to support the claim.

Billing Rule

Modifiers JW and JZ

HCPCS Level II codes should be submitted that best describe the drug and dosage administered. If a dosage administered is greater than what is listed, the unit field should be completed to specify the appropriate number of units per the code's description. The JW modifier may be appended to claims to report the amount of drug or biological that is discarded; the discarded amount must be billed on a separate line with the JW modifier for all non-inpatient places of service. The JZ modifier may be appended to reflect there were no discarded amounts from a single-use vial or single-use package. Documentation must identify and describe the drug, dosage, and reason for the discarded or zero-discard amount. Providers are encouraged to administer and care for members in a way that drugs and biologicals are used most efficiently to prevent waste.

Append JW on a separate line reporting the discarded drug/biologic amount (non-inpatient settings).
Append JZ when there were no discarded amounts from a single-use vial/package.
Ensure supporting documentation describes the drug, dosage, exact amounts discarded (if any), and clinical rationale.

Billing Rule

Member-Supplied Drugs Billing

If no E/M service is provided and a member supplies their own drug to a provider for administration under direct supervision, report the appropriate administration CPT code and include a separate drug line with a zero-dollar ($0.00) charge listing the drug and dosage. Example: when no E/M is performed, report CPT 96372 for intramuscular injection administration and include a separate line for the member-supplied drug with a $0.00 charge. For more information on home infusion or related billing practices, refer to Plan documents and industry coding guidelines.

Report the administration CPT (e.g., 96372) when no E/M is provided.
Include a separate drug line showing the drug/service code and dosage with a $0.00 charge for member-supplied drugs.
Ensure documentation demonstrates the drug was supplied by the member and administered under direct supervision.

Key Definitions

Injection — definition and routes

DefinitionInjection: introduction of a substance into the body using a syringe and an attached needle.

RoutesSubcutaneous (under the skin), Intravenous (via a vein), Intramuscular (deep into a muscle), Intrathecal (into the fluid surrounding the spinal cord).

Typical usesUsed to administer therapeutic, prophylactic, or diagnostic substances as part of treatment or diagnosis.

Infusion (initial, concurrent, sequential) and IV/IA Push

Infusion — definitionInfusion: intravenous or subcutaneous administration of therapeutic solutions (e.g., saline, glucose) often referred to as a drip.

SubtypesInitial infusion: primary reason for the encounter; Concurrent infusion: new substance infused at same time as another (reported once per day); Sequential infusion: new substance or IV push following a primary service (may use CPT 96376 for same drug sequential IV push in facilities).

IV/IA PushIntravenous/Intra-arterial (IV/IA) Push: injection where the administrator is continuously present or an infusion lasting 15 minutes or less.

Qualified Health Care Professional — definition

DefinitionQualified Health Care Professional: an individual qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within their scope of practice and independently reports that service.

Scope of practiceMust perform services within their professional scope and have applicable facility privileges when required.

ReportingA QHP independently reports the professional service they perform; reporting rules may differ by provider/location per the policy.

JW — definition of JW modifier

JW modifier — purposeJW may be appended to report the amount of drug or biological that is discarded.

Billing requirementDiscarded amount reported with JW must be billed on a separate line for all non-inpatient places of service.

DocumentationWhen JW is used, documentation must identify and describe the drug, dosage, and reason for discard.

JZ — definition of JZ modifier

JZ modifier — purposeJZ may be appended to indicate there were no discarded amounts from a single-use vial or single-use package.

Use contextUse JZ when zero waste occurred for single-use vial/package administrations.

Documentation expectationDocumentation should identify the drug and dosage; providers are encouraged to minimize waste and follow Plan/industry guidance.

Unlisted/Not Otherwise Classified (NOC) — definition

Unlisted/NOC — when to useUse an appropriate unlisted/Not Otherwise Classified code only when no existing code accurately describes the administered drug, service, or procedure.

Submission requirementsWhen submitting an unlisted code, include a description and supporting documentation to explain the service provided.

Reference guidanceFor additional information, providers should refer to Plan documents.

OpenPayer

Therapeutic, Prophylactic, Diagnostic, Injection and Infusion Administration Coding

Billing and Coverage Criteria

CPT/HCPCS Codes, Modifiers, and Billing Rules

Provider Responsibilities and Actionable Billing Guidance

Key Definitions

Policy Revision History