Updates and Changes in US ABA Medical Billing for 2023

With the start of each new year, there are often changes to policies around coding and billing made by various health organizations. Due to the number of changes that can occur, it can become quite confusing to understand the policies of the suppliers and the providers. Below we go through all of the changes to policies for coding and billing and take you through step by step so it becomes much clearer.

New Modifier JZ-Effective the 1st of January, 2023

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Since the 1st of January, 2017, the Center for Medicare and Medicaid Services (CMS) has made a requirement for providers to utilize the modifier JW for ABA billing. This can essentially be described as the total amount of discarded drug or any amount of drug that was not administered to a patient. More specifically, the number of drugs discarded from containers that are described as single-dose. This is done to receive payment for any amount of drug that has been discarded. Prescriptions that are provided in a single-dose container and have been administered to a Medicare Beneficiary by a provider can receive payment for any medication discarded or administered.

Drugs that have been discarded include any medication that did not make up the total prescribed amount and is also not meant to have any therapeutic impact on the patients it has been prescribed to. The easiest way to calculate the discarded amount of drug is to take the amount of the drug labeled on the container and take it away from how much should have been administered. You are then left with the discarded amount of the drug, which you can then put into the JW modifier. 

Since the introduction of the JW modifier, it has not been used as intended, with very low compliance rates. To improve this, the CMS has created another modifier known as the JZ modifier. This modifier refers to no amount of drug discarded or medication that has not been administered to patients. The JZ modifier is specifically for drugs in single-dose containers and is made for when no drugs have been discarded.  

From the 1st of January, 2023, the implementation of the JZ modifier has been put into effect; however, it won’t be until the 1st of July, 2023, that providers will be required to use it. After this time, any claim for drugs in single-dose containers that haven’t used either the JZ or JW modifier may face provider audits. By the 1st of October 2023, any claims with no report using the modifiers may be at risk of being returned due to problems with processing. 

Applicable Settings for the JW & JZ Modifiers

The Center for Medicare and Medicaid Services (CMS) has made it mandatory for all suppliers and providers to use the JZ and JW modifiers. More specifically, those buying and billing drugs are payable separately and also fall under part B of Medicare. Usually, this happens in places like an outpatient setting, a physician’s office, or hospitals used for critical access. 

The requirements mentioned above do not apply to a number of different institutions. These include federally qualified health centers, health clinics in a rural setting, and admissions of patients to hospitals. In this case, the provider will bill through the Inpatient Prospective Payment System.

Appropriate Use of Modifier JW

When making a claim using a JW modifier, two lines must be completed for it to be processed properly. A JW modifier is used when a provider administers a single-dose container where there will be discarded amounts of drugs. The first line in the claim will state the payment and billing code. This line does not contain the modifier but will include the total units of drugs administered.

The billing and payment code is still required in the second line of the claim. However, it will also include the modifier JW. In addition to this, you will also write the total amount of units that have been discarded.

Appropriate Use of Modifier JZ

The modifier JZ is used when there are no amounts of discarded drugs. In this case, the claim will only require one line. In this line, the payment and billing code will be included, as well as the JZ modifier and the total number of units that have been administered.

The Bottom Line

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The most important thing to remember while billing is to be consistent. This will allow the process to run much more smoothly and reduce the chance of mistakes or delays in coding and billing. If you keep up to date with policy changes and bill correctly, you should have no issues. 

Tony Bennett

Tony Bennett

Tony Benett makes his living in the insurance industry by teaching and consulting. He is also recognized by the legal profession as an expert on insurance coverages. His insurance experience includes having worked at the company level, owned an independent general agency and having worked for an insurance association. He has received various certificates over the past few years and helps his clients and readers by giving them a realistic outlook on what they can expect to achieve within their set targets. At Insurance Noon, he is known for his in-depth analysis and attention to details with accuracy. He has been published as one of the most referred agents by his peers in the insurance community. Tony loves the outdoors and most sport events. His passion other than providing excellent advice is playing golf.

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