ModifiedHumanaPolicy CP2011102

Modifiers JW and JZ

Humana's billing and reimbursement requirements for reporting discarded (JW) and zero-discard (JZ) amounts for drugs from single-dose vials/packages for Medicare Advantage and Commercial products; applies to providers submitting drug claims to Humana.

Policy Summary

PayerHumana

PolicyModifiers JW and JZ

Policy CodePolicy CP2011102

Change TypeClarification and requirement added

Effective DateSep 1, 2017

Next Review Date

Key ActionEnsure claims meet plan requirements including medical necessity, reasonableness, and any referral or authorization requirements prior to submission.

SourceLink

POLICY UPDATE CHANGES

For dates of service beginning July 1, 2023, modifier JZ is required when no amount is discarded for drugs where JW would have been required if there had been a discarded amount.

Humana reimburses discarded drug amounts only when the drug is covered, the discarded amount is remainder of a single-dose vial or package used to treat the patient, and the drug is billed as described.

2billing lines required when discarded amount reimbursable (administered + JW line)

7/1/2023effective date when JZ is required for no-discard reporting

4conditions causing Humana to deny a JW line

2conditions causing Humana to deny a JZ line

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2defined billing modifiers

Coverage and Reimbursement Criteria

Modifiers JW/JZ billing and denial criteria

Humana reimburses and denies JW/JZ reporting according to the following criteria and billing rules for discarded or non-discarded drug amounts from single‑dose vials/packages.

ALL of the following

ALL of the following
- The drug is a covered expense
- The discarded amount is the remainder of a single‑dose vial or package used to treat the patient
- The drug is billed according to Humana billing instructions (see billing rules below)
ALL of the following
- Humana reimburses no more, for the total administered plus total discarded, than the amount appropriate in dollars for the efficient administration amount

ALL of the following

When a discarded amount is reimbursable, submit two claim lines using the HCPCS code for the drug
Line 1: number of base units for amount administered (fractions rounded up)
Line 2: modifier JW appended; number of base units equal to (efficient administration base units minus administered base units)
Combined charge for both lines must not exceed the charge appropriate for the efficient administration amount

ALL of the following

If administered base units equal the efficient administration base units, submit one line with modifier JZ instead of two lines
For dates of service beginning July 1, 2023, modifier JZ is required when no amount was discarded for drugs where JW would have been required if there had been discarded amount
Suppliers who prepare but do not administer must report JZ when no amount was discarded during preparation

Denials for JW lines

Submitted line uses a procedure code that is not a drug code
Line reports a multi‑dose vial or package
No accompanying administered line (without JW) for the same drug code and date of service
Combined number of units for both lines exceeds the total base units for the efficient administration amount

Denials for JZ lines

Submitted line uses a procedure code that is not a drug code
Line reports a multi‑dose vial or package

ALL of the following

A charge for a drug from a single‑dose vial or package that requires JW or JZ will be denied if neither modifier is reported

ALL of the following

Suppliers who dispense but do not administer must report JW when drug is discarded during preparation and JZ when no amount is discarded during preparation

ALL of the following

Calculate base units per the HCPCS code description (base unit defined by code, e.g., '10 mg' means one base unit = 10 mg)
Example: choose vial combination that minimizes discarded drug; reimbursement follows efficient administration amount rather than arbitrary vial selection

Discarded drug billing context and resources

Definitions and resources to support implementation and claims processing for reporting discarded and zero‑discard drug amounts.

ALL of the following

Base unit: For billing purposes, the specific amount of a drug defined in the unit measurement in the drug code's long descriptor (example: '10 mg' = one base unit)
Efficient administration amount: The total amount from vials/packages that, in combination, represent the minimum amount necessary for use given available vial/package sizes
Modifier JW: Drug amount discarded/not administered to any patient
Modifier JZ: Zero drug amount discarded/not administered to any patient

ALL of the following

Coding and Billing Details

ModifiersModifierCovered

JW	Modifier indicating drug amount discarded/not administered to any patient
JZ	Modifier indicating zero drug amount discarded/not administered to any patient

Discarded drug modifiersModifierCovered

JW	Drug amount discarded/not administered to any patient (modifier)
JZ	Zero drug amount discarded/not administered to any patient (modifier)

inv-05: Billing unit math and combined charge limit

Billing unit submissionSubmit units per the HCPCS code's base unit; calculate base units using the unit size indicated in the HCPCS long descriptor and round fractions up for the administered line.

Two-line requirement when discarded amount reimbursableWhen a discarded amount is reimbursable, submit two lines using the HCPCS code: first line = units for amount administered; second line = same HCPCS code with modifier JW for the discarded units.

Charge calculation per lineFor each line, submit a charge equal to the per-base-unit charge multiplied by the number of base units on that line.

Combined charge limitThe combined charge for the administered line plus the JW line must not exceed the total charge appropriate for the efficient administration amount (i.e., charge as if the efficient administration amount were administered).

Single-line exception with JZIf administered base units equal the efficient administration base units, submit one line with modifier JZ instead of two lines.

Provider Actions and Notices

Documentation Required

Provider obligations

In addition to the policy, claims payments are subject to other plan requirements for the processing and payment of claims, including, but not limited to, requirements of medical necessity and reasonableness and applicable referral or authorization requirements. Humana expects each healthcare provider to administer drugs and biologicals efficiently and in a clinically appropriate manner. This includes using multi-dose vials or packages when available and clinically appropriate and using the combination of available single-dose vials or packages that results in the least amount of discarded drug.

Ensure claims meet plan requirements including medical necessity, reasonableness, and any referral or authorization requirements prior to submission.
When administering drugs/biologicals, use multi-dose vials or packages when clinically appropriate and combine single-dose vials/packages to minimize discarded product.

Note

Provider resources and claim notice channels

Humana provides multiple resources and channels for providers to obtain eligibility, benefits, referrals, authorizations, claims status, and electronic remittances information. Providers are encouraged to register for and use Humana's online tools and regularly review provider communications for claims processing updates.

Definitions and Key Terms

inv-08: Base unit

DefinitionBase unit = the specific amount defined in the drug code's long descriptor (example: '10 mg' means one base unit = 10 mg).

Billing useCalculate and submit units using the HCPCS base unit; round fractions up on the administered line.

ExampleIf HCPCS long descriptor = 10 mg, then 14 mg administered = 2 base units submitted for the administered line (fractions rounded up).

inv-09: Efficient administration amount

DefinitionEfficient administration amount = the total amount from vials/packages that, in combination, results in the minimum discarded drug given available vial/package sizes.

Billing implicationDetermine efficient administration amount to compute the JW units as the difference between efficient administration base units and administered base units.

Policy Summary

PayerHumana

PolicyModifiers JW and JZ

Policy CodePolicy CP2011102

Change TypeClarification and requirement added

Effective DateSep 1, 2017

Next Review Date

Key ActionEnsure claims meet plan requirements including medical necessity, reasonableness, and any referral or authorization requirements prior to submission.

SourceLink

On This Page

Federal Register Final Rule CMS‑1784‑F and CMS Medicare Claims Processing Manual Chapter 17, Section 40 (Discarded Drugs and Biologicals)

CMS FAQ: Discarded Drugs and Biologicals – JW and JZ Modifier Policy

HCPCS Level II and associated publications

ALL of the following

Availity: register for eligibility, benefits, referrals, authorizations, claims and electronic remittances
Claims processing edit notifications: posted first Friday each month
Claims resources, educational pages, medical and pharmacy coverage policies and publications available on Humana website

ALL of the following

For dates of service beginning July 1, 2023, Humana requires modifier JZ when no amount was discarded for drugs where JW would have been required if there had been a discarded amount

ALL of the following

If administered units equal efficient administration units, submit one line with JZ indicating the appropriate number of base units

Availity — Providers can register for access to eligibility, benefits, referrals, authorizations, claims and electronic remittances.
Claims processing edit notifications — Alerts of upcoming claims payment changes are posted on the first Friday of each month.
Claims resources — Information on referrals, authorizations, electronic claim submissions and related topics.
Making it easier — Educational series and resources for providers and healthcare professionals.
Medical and pharmacy coverage policies — Published determinations of coverage for procedures, devices and medications; coverage may vary by plan.
Publications — Quarterly newsletter, provider manual and other resources to support doing business with Humana.
Note: Links to external sources are verified at publication; please report broken links.

ExampleIf efficient administration amount = 30 mg (3 base units) and 14 mg administered (2 base units), JW units = 1 base unit representing 10 mg.

inv-10: Modifier JW

DefinitionModifier JW indicates a drug amount discarded/not administered to any patient.

When to appendAppend JW on the second line when a discarded amount from a single-dose vial/package is reimbursable and reported as a separate line.

Processing noteJW lines are subject to combined charge limits and other Humana denial criteria if billing rules are not met.

inv-11: Modifier JZ

DefinitionModifier JZ indicates zero drug amount discarded/not administered to any patient.

When to useSubmit a single line with modifier JZ when administered base units equal the efficient administration base units (no discarded amount).

Effective requirementAs of July 1, 2023, JZ is required when no amount was discarded for drugs where JW would have been required if there had been a discarded amount.

inv-12: Base unit (duplicate inventory entry)

Billing definitionBase unit (billing) = the specific amount of a drug defined in the HCPCS long descriptor used to calculate units for claim lines (e.g., '10 mg' = 1 base unit).

Use in mathBoth administered and discarded (JW) units are calculated using this billing base unit; efficient administration base units are derived from the same unit size.

Rounding ruleFractions of a base unit on the administered line are rounded up to the next whole base unit for submission.

inv-13: Efficient administration amount (duplicate inventory entry)

DefinitionEfficient administration amount (billing) = the minimum total amount from vials/packages, in combination, necessary to administer the appropriate dose while minimizing discard.

Use to compute JW unitsJW units = efficient administration base units minus administered base units; the efficient administration amount determines the combined charge limit.

ExampleIf efficient administration = 30 mg (3 base units) and administered = 14 mg (2 base units), JW units = 1 base unit.

inv-14: Modifier JW (duplicate inventory entry)

DefinitionModifier JW = indicates a discarded drug amount not administered to any patient.

Billing applicationUsed on the second line when reporting reimbursable discarded amounts from single-dose vials/packages; combined charges subject to limits.

Denial risksJW lines may be denied if billing rules are not followed (e.g., no accompanying administered line, multi-dose vial reported, combined units exceed efficient administration units).

inv-15: Modifier JZ (duplicate inventory entry)

DefinitionModifier JZ = indicates zero drug amount discarded/not administered to any patient.

Billing applicationSubmit one line with JZ when no amount was discarded and administered units equal the efficient administration units; required as of 7/1/2023 in applicable cases.

Denial risksJZ lines may be denied if the procedure code is not a drug code or if a multi-dose vial/package is reported.