CMS "Pause" on Downcoding 

Thank you to the practices that have shared with CSRO their challenges and frustrations with the complex vs therapeutic drug administration coding issue occurring with MACs nationwide.

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.

Please continue to send notification of denials to CSRO at info@csro.info. As more information becomes available, we will notify practices immediately.

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