CMS has made several changes which affect the reimbursement of drugs and biologics in ambulatory surgery centers, according a report from the ASC Association in its ASCA Government Affairs Update and documentation from CMS.
Here are the four changes.
1. Beginning April 1, Medicare will reimburse ASCs for four new drug codes. The new HCPCS codes are as follows (rate given is for 2011):
- C9280 (Injection, eribulin mesylate, 1 mg) — $901.00
- C9281 (Injection, pegloticase, 1 mg) — $304.75
- C9282 (Injection, ceftaroline fosamil, 10 mg) — $0.72
- Q2040 (Injection, incobotulinumtoxin A, 1 unit) — $5.57
Note: Q2040 replaces the discontinued code C9278, which was paid at the same rate of $5.57.
2. The reimbursement rates of 242 drugs and biologics will change on April 1. The rate change is due to Medicare's process of updating the rates of drugs/biologics quarterly to reflect changes in their average sales prices.
While about 40 percent of the drugs and biologics undergoing a change are revised by less than one percent, the ASCA notes that some changes are significant, ranging from a 67 percent reduction to a 369 percent increase. To view the complete list of the changes, courtesy of the ASCA, click here (pdf).
3. CMS issued corrections to the 2010 fourth quarter reimbursement rates of nine drugs and biologics. Here are the revised HCPCS codes, with the correct rate provided followed by the incorrect fourth quarter rate in parentheses:
- J0833 (Cosyntropin injection NOS) — $51.32 ($69.15)
- J1451 (Fomepizole, 15 mg) — $7.14 ($7.42)
- J3030 Sumatriptan succinate / 6 mg) — $45.71 ($52.88)
- J7502 (Cyclosporine oral 100 mg) — $3.04 ($3.05)
- J7507 (Tacrolimus oral per 1 mg) — $3.18 ($3.22)
- J9185 (Fludarabine phosphate inj) — $162.67 ($136.94)
- J9206 (Irinotecan injection) — $7.45 ($6.01)
- J9218 (Leuprolide acetate injection) — $4.50 ($4.07)
- J9263 (Oxaliplatin) — $4.52 ($4.62)
ASCs may ask that contractors adjust previously paid claims, according to the ASCA.
4. CMS omitted one drug/biologic — Q4119 (Matristem wound Matrix) — on its list of reimbursable ancillary services for the first quarter of 2011. ASCs which provided this drug during the quarter may request an adjustment of previously processed claims to include a $5.62 payment for this drug/biologics.
To download a list of Medicare-covered drugs and biologics for 2011, updated to include the changes noted in this report, courtesy of ASCA, click here (pdf).
Read the CMS document noting the changes discussed in this report by clicking here (pdf).
For more information about these changes, contact Jonathan Beal at the ASCA at jbeal@ascassociation.org.
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