Please note that the statements below are for informational purposes only and are not coding or billing guidance.
It has been communicated to CSRO from CMS that the "pause" in down-coding of the drug administration codes (from complex to therapeutic) associated with certain rheumatologic medications remains in place following the August 12, 2022 Technical Direction Letter (TDL) to the MACs, and will remain in place until we are notified to the contrary by CMS.
If you have received a denial for the complex administration code based solely on the name of the drug, please email CSRO at email@example.com with a redacted copy of the remittance advice (removing all PHI) showing the denial.
CSRO remains in contact with CMS headquarters regarding challenges with billing and coding for drug administration services. According to CMS, the August 12, 2022 Technical Direction Letter (TDL) remains in effect, although guidance from local Medicare Administrative Contractors (MACs) may continue to direct practices to use “simple” administration codes for complex infusions and injections.
Please continue to contact CSRO at firstname.lastname@example.org with claim denials from your local MAC that are inconsistent with the TDL.
Last week, one Medicare Administrative Contractor (MAC) – WPS Insurance Corporation – formally retired their Local Coverage Article (LCA): “Billing and Coding: Complex Drug Administration Coding” effective August 12, 2022. The retired policy comes after months of CSRO and other stakeholder engagement with the Centers for Medicare and Medicaid Services (CMS) and MAC Contractor Medical Directors (CMDs) about the inappropriateness of these articles, and follows a CMS technical direction letter (TDL) to the MACs directing them to stop making adjustments or edits to claims for CPT codes 96401-96549 based solely on the specific drug or agent being administered.
Reports that other MACs intend to retire their LCAs have been shared with CSRO and other stakeholders; CSRO continues to monitor the Medicare Coverage Database (MCD) and will share any changes in these policies as they occur.
Related, WPS Insurance Corporation initiated a Targeted Probe and Educate (TPE) for Infusion Services in October 2021 that is “focused on those codes that fall under the subsection of hydration, therapeutic, prophylactic, diagnostic injection and infusion, and chemotherapy and other highly complex drug or highly complex biologic administration.” CSRO encourages rheumatology practices, especially in the WPS jurisdiction, to review the documentation and coding guidance that WPS states would represent “a successful review of infusion services.”
CSRO continues to work with CMS and MAC CMDs on a long-term solution to “down coding” of rheumatologic medications when administered in the physician’s office.
Please note that CSRO’s communications are for informational purposes only and are not coding or billing guidance. As always, practices should code and bill items and services based on documentation in the medical record and in accordance with Medicare requirements and policy applicable to that particular item or service.
On August 12, 2022, CMS staff in the Office of the Administrator (OA) shared the following update with CSRO about ongoing efforts to address downcoding by the MACs for certain rheumatologist drugs:
“CMS has continued to work on this issue, and has met multiple times with the Medicare Administrative Contractors (MACs) recently. Today, a technical direction letter (TDL) was issued to all of the MACs that provides instruction regarding the payment for these codes while CMS further considers this matter. The TDL directs that the MACs shall not make claim adjustments or edits to claims for CPT codes 96401-96549 based solely on the specific drug or agent being administered. Claims for these codes that involve administration of monoclonal, complex biological, and rheumatological therapies shall be paid as complex administration, so long as all elements of these codes that are required for appropriate billing are met, using Medicare guidance/policy.”
Because the TDL is a contractual document, CMS explained that it is confidential and not able to be shared with the public. CSRO is monitoring certain submitted claims from rheumatology practices to see how these are processed by their MACs, and CSRO will report on that outcome in a future communication.
CSRO is working collaboratively with CMS officials on a long-term solution to this issue and will share updates as appropriate. Please continue to direct questions and report issues to email@example.com.
Please note that this communication is for informational purposes only and is not coding or billing guidance. As always, practices should code and bill items and services based on documentation in the medical record and in accordance with Medicare requirements and policy applicable to that particular item or service.
Following CMS’ technical direction to MACs on June 10, 2022, which required MACs to temporarily pause medical review (i.e., sending additional documentation request (ADR) letters) when practices bill complex drug administration services associated with the provision of Cimzia® (J0717), Orencia® (J0129), Simponi Aria® (J1602), Stelara® (J3358), and Prolia® (J0897), CMS was concerned to hear from CSRO that the MACs continue to reject claims when the complex drug administration codes are submitted by rheumatology practices.
Since then, CMS has been working across various divisions with the agency to address the discrepancy with the MACs. As of this publication, they have not provided a timeline or any guidance on how practices should proceed in the interim. CSRO's public communication about the technical direction to the MACs was in accordance with the direction of CMS’ Center for Program Integrity (CPI). Like you, CSRO is frustrated by the lack of resolution between the entities.