LCD and Policy Article Revisions Summary for May 22, 2025 - JD DME

Joint DME MAC Publication
Posted May 22, 2025

Outlined below are the principal changes to the DME MAC Local Coverage Determination (LCD) and Policy Articles (PAs) that have been revised and posted. The policies included are External Infusion Pumps, Immunosuppressive Drugs, Intravenous Immune Globulin, and Nebulizers. Please review the entire LCDs and PAs for complete information.

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.

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

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.

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.

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.

Note: The information contained in this article is only a summary of revisions to the LCDs and/or PAs. For complete information on any topic, you must review the LCDs and/or PAs.

With the update(s) listed above, Noridian would like to remind users how to find the policy that was previously effective. When billing, the supplier should follow guidance that was effective on the date of service. The below steps can be followed to find all previous policies:

1. Open the currently effective policy on the Medical Coverage Database (MCD)
   1. Links to the MCD can be found on the Active LCDs page on the Noridian website
      1. There is a link at the top of the Active LCD page that goes to a full list of the LCDs or PAs, depending on which link is selected OR
      2. There are direct links to all LCDs under the ‘LCD ID number and Effective Date’ column
2. Scroll down to the bottom of the policy
3. Find the section labeled Public Version(s)
4. Look for the link to the policy that was effective on the dates of service in question.
5. Click on hyperlink to go to the policy.