CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPO17

Wasted / Discarded Drugs and Biologicals Policy

Governance for billing, documentation, and reimbursement of wasted or discarded drugs and biologicals for Blue Cross Blue Shield - Oklahoma members and providers submitting claims under BCBSOK plans.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyWasted / Discarded Drugs and Biologicals Policy

Policy CodePolicy CPCPO17

Change TypeNo material change

Effective DateFeb 13, 2023

Next Review Date

Key ActionProviders must submit documentation, bill units per CPT/HCPCS definitions, and append JW modifier on a separate line for discarded amounts in non-inpatient settings.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

JW requiredmodifier requirement for non-inpatient places of service

JZmodifier to indicate zero discarded amount

3 examplesillustrative billing scenarios

>=10 itemsexamples when reimbursement is denied

Reimbursement Criteria and Exclusions

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Reimbursement criteria and exclusions for wasted/discarded drugs

Reimbursement is allowed for discarded amounts of drugs or biologicals from single‑use vials or single‑use packages when all documentation, billing, and unit rules are met. The following criteria, billing rules, and exclusions apply.

ALL of the following

ALL of the following
ALL of the following
ALL of the following

ALL of the following

Modifiers, Units, and Billing Codes

JW/JZ modifier usageModifierCovered

JW	CPT/HCPCS modifier to report discarded drug/biological amount (non-inpatient).
JZ	Modifier appended when there is no discarded drug amount of a single dose or single use package.

inv-03: Units billed — billing, rounding, and total units guidance

Units must match CPT/HCPCS unit definitionsUnits of service must be billed in multiples of the dosage specified in the full CPT/HCPCS description.

Rounding rule for administered amountIf the amount administered is not a multiple of the CPT/HCPCS code, round to the next highest unit in the CPT/HCPCS description for that code.

Total dose limit (administered + wasted)Total dose, administered and wasted, must not exceed the vial amount.

NDC and unit correspondenceNDC units billed should correspond to the CPT/HCPCS units billed and reflect the numeric quantity and unit of measure (e.g., mL for filled vials).

Bill discarded amount on separate lineDiscarded amount must be billed on a separate line than the administered amount with correct CPT/HCPCS code and units when applicable.

Provider Billing and Documentation Responsibilities

Documentation Required

Provider billing and documentation responsibilities

Providers must submit accurate documentation of services performed and be prepared to provide additional documentation upon request. Claims must be coded using valid HIPAA-approved code sets and industry coding guidelines. Discarded amounts must be billed on a separate line with the correct CPT/HCPCS code, correct units, and the JW modifier for all non-inpatient places of service. Suppliers and providers are required to document the amount of discarded drugs or biologicals in the member's medical record and retain documentation supporting the dose administered, discarded amount, exact date and time of administration, and the reason for wastage.

Submit claims using valid HIPAA-approved code sets (CPT/HCPCS, NDC, ICD-10, etc.) and follow industry coding guidelines.
Bill discarded amount on a separate line with correct CPT/HCPCS code, units, and JW modifier for non-inpatient places of service.
Document amount discarded, dose administered, exact date/time, and reason for wastage in the medical record and provide upon request.

Billing Rule

Rounding and unit billing rule

When the amount administered is not an exact multiple of the CPT/HCPCS code unit, round to the next highest unit in the CPT/HCPCS description. Ensure that the total dose (administered plus discarded/wasted) does not exceed the vial or package amount.

Units of service must be billed in multiples of the dosage specified in the full CPT/HCPCS description; if not a multiple, round up to the next highest unit.
Total administered dose plus wasted/discarded amount must not exceed the vial/package labeled amount.

Key Definitions

inv-06: Drug Waste — definition and qualifying conditions

Definition of Drug WasteThe partial vial, package, or product of drug or biologic that is discarded and not administered to any member.

Discarded product requirementDiscarded drugs or biologicals must not be administered to another member/patient.

Single-use packaging requirementThe drug or biological must be available only in a single-use vial or single-use package to qualify for discarded reimbursement.

Documentation requirementDose administered, discarded amount, exact date/time of administration, and reason for wastage must be clearly and acceptably documented in the medical record.