Down coding is a when a health plan (public or private) reduces the level of service or procedure to a level that is lower than what was actually provided. In the context of rheumatology and drug administration services, the Centers for Medicare & Medicaid Services’ (CMS) Medicare Administrative Contractors (MACs) established “Billing and Coding” articles that erroneously deem many of the medications infused for autoimmune conditions (e.g., rheumatoid arthritis (RA), psoriasis, and other non-oncologic conditions) as non-complex, and require physician offices to use the “therapeutic” drug administration service codes (CPT codes 96360-96379), rather than the “complex” administration service codes (CPT code series 96401-96549).
Down coding inappropriately diminishes the level of service provided, and consequently, the associated reimbursement. For rheumatologists who administer outpatient medications, down coding has significantly impacted their ability to continue providing these services in the office, the lowest cost setting for this level of care.
The Coalition of State Rheumatology Organizations (CSRO) leads efforts to address inappropriate down coding of complex drug administration services. As a result of CSRO’s efforts, the MACs retired their Billing and Coding articles and CMS proposed and finalized revisions to its manual instructions to “provide complex clinical characteristics for the MACs to consider as criteria when determining payment of claims for these services,” which are not currently present.
Use CSRO's Payer Issue Reporting Form to notify us of instances where MACs inappropriately down code complex drug administration services.
