PA

External Infusion Pumps PA

Revision Effective Date: 02/19/2025

MODIFIERS:

• Revised: "Effective January 1, 2024, the JZ modifier is also required when billing for drugs and biologicals from single-dose containers that are dispensed by the supplier but self-administered by the beneficiary or the beneficiary's caregiver." to "Effective for claims with dates of service on or after January 1, 2024, the JZ modifier is also required when billing for drugs and biologicals from single-dose containers dispensed by the supplier but have no unused and discarded amounts that are self-administered by the beneficiary or the beneficiary's caregiver."
• Added: "Effective for claims with dates of service on or after January 1, 2025, the JW modifier is also required if a billing supplier is not administering a drug or biological, but there are unused and discarded amounts during the preparation process before supplying the drug or biological to the patient as described in scenario 3 below."
• Revised: "The JW modifier is not required for drugs dispensed by the supplier and self-administered by the beneficiary or the beneficiary's caregiver in the beneficiary's home, as it is not expected that the beneficiary or their caregiver provide discarded drug information to the supplier. The JZ modifier is required in this scenario (effective for claims with dates of service on or after January 1, 2024)." to "The JZ modifier is required for drugs and biologicals that are dispensed by the supplier but have no unused and discarded amounts during the preparation process and are self-administered by the beneficiary or the beneficiary's caregiver in the beneficiary's home."
• Revised: "drug" to "drugs" in "Multi-use vials are not subject to payment for discarded amounts of drugs or biologicals."
• Revised: "Below are two scenarios in regard to the JW modifier." to "Below are three (3) scenarios in regard to the JW and JZ modifiers."
• Added: "claim" to "In this scenario, the JW modifier must be billed on a separate claim line to provide payment for the amount of discarded drug or biological.," as clarification
• Added: "claim" to "The 70 mg dose is billed correctly by rounding up to 1 UOS (representing the entire 100 mg vial) on a single claim line item with the JZ modifier.," as clarification
• Added: "claim" to "The single claim line item of 1 UOS would be processed for payment of the combined total of 100 mg of the administered and discarded amounts.," as clarification
• Added: "claim" to "The discarded 30 mg must not be billed as another 1 UOS on a separate claim line item with the JW modifier.," as clarification
• Added: Scenario 3 billing information and example

05/22/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

LCD

Immunosuppressive Drugs LCD

Revision Effective Date: 04/01/2025

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

• Revised: Quantity of immunosuppressive drugs dispensed from a 30-day supply to a 90-day supply effective for dates of service on or after 01/01/2025

CODING INFORMATION:

• Added: JW and JZ modifiers effective for dates of service on or after 01/01/2025

05/22/2025: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS direction.

PA

Immunosuppressive Drugs PA

Revision Effective Date: 01/01/2025

MODIFIERS:

• Added: JW and JZ modifier guidelines

05/22/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

PA

Intravenous Immune Globulin PA

Revision Effective Date: 01/01/2025

MODIFIERS:

• Revised: "Effective January 1, 2024, the JZ modifier is also required when billing for drugs and biologicals from single-dose containers that are dispensed by the supplier but self-administered by the beneficiary or the beneficiary's caregiver." to "Effective for claims with dates of service on or after January 1, 2024, the JZ modifier is also required when billing for drugs and biologicals from single-dose containers dispensed by the supplier but have no unused and discarded amounts that are self-administered by the beneficiary or the beneficiary's caregiver."
• Added: "Effective for claims with dates of service on or after January 1, 2025, the JW modifier is also required if a billing supplier is not administering a drug or biological, but there are unused and discarded amounts during the preparation process before supplying the drug or biological to the patient as described in scenario 3 below."
• Revised: "The JW modifier is not required for drugs dispensed by the supplier and self-administered by the beneficiary or the beneficiary's caregiver in the beneficiary's home, as it is not expected that the beneficiary or their caregiver provide discarded drug information to the supplier. The JZ modifier is required in this scenario (effective for claims with dates of service on or after January 1, 2024)." to "The JZ modifier is required for drugs and biologicals that are dispensed by the supplier but have no unused and discarded amounts during the preparation process and are self-administered by the beneficiary or the beneficiary's caregiver in the beneficiary's home."
• Revised: "drug" to "drugs" in "Multi-use vials are not subject to payment for discarded amounts of drugs or biologicals."
• Revised: "Below are two scenarios in regard to the JW modifier." to "Below are three (3) scenarios in regard to the JW and JZ modifiers."
• Added: "claim" to "In this scenario, the JW modifier must be billed on a separate claim line to provide payment for the amount of discarded drug or biological.," as clarification
• Added: "claim" to "The 70 mg dose is billed correctly by rounding up to 1 UOS (representing the entire 100 mg vial) on a single claim line item with the JZ modifier.," as clarification
• Added: "claim" to "The single claim line item of 1 UOS would be processed for payment of the combined total of 100 mg of the administered and discarded amounts.," as clarification
• Added: "claim" to "The discarded 30 mg must not be billed as another 1 UOS on a separate claim line item with the JW modifier.," as clarification
• Added: Scenario 3 billing information and example

05/22/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

PA

Nebulizers PA

Revision Effective Date: 01/01/2025

MODIFIERS:

• Revised: "Effective January 1, 2024, the JZ modifier is also required when billing for drugs and biologicals from single-dose containers that are dispensed by the supplier but self-administered by the beneficiary or the beneficiary's caregiver." to "Effective for claims with dates of service on or after January 1, 2024, the JZ modifier is also required when billing for drugs and biologicals from single-dose containers dispensed by the supplier but have no unused and discarded amounts that are self-administered by the beneficiary or the beneficiary's caregiver."
• Added: "Effective for claims with dates of service on or after January 1, 2025, the JW modifier is also required if a billing supplier is not administering a drug or biological, but there are unused and discarded amounts during the preparation process before supplying the drug or biological to the patient as described in scenario 3 below."
• Revised: "The JW modifier is not required for drugs dispensed by the supplier and self-administered by the beneficiary or the beneficiary's caregiver in the beneficiary's home, as it is not expected that the beneficiary or their caregiver provide discarded drug information to the supplier. The JZ modifier is required in this scenario (effective for claims with dates of service on or after January 1, 2024)." to "The JZ modifier is required for drugs and biologicals that are dispensed by the supplier but have no unused and discarded amounts during the preparation process and are self-administered by the beneficiary or the beneficiary's caregiver in the beneficiary's home."
• Revised: "Below are two scenarios in regard to the JW modifier." to "Below are three (3) scenarios in regard to the JW and JZ modifiers."
• Added: "claim" to "In this scenario, the JW modifier must be billed on a separate claim line to provide payment for the amount of discarded drug or biological.," as clarification
• Added: "claim" to "The 70 mg dose is billed correctly by rounding up to 1 UOS (representing the entire 100 mg vial) on a single claim line item with the JZ modifier.," as clarification
• Added: "claim" to "The single claim line item of 1 UOS would be processed for payment of the combined total of 100 mg of the administered and discarded amounts.," as clarification
• Added: "claim" to "The discarded 30 mg must not be billed as another 1 UOS on a separate claim line item with the JW modifier.," as clarification
• Added: Scenario 3 billing information and example

05/22/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.