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On December 19, CSRO led a multispecialty group of physicians and infusion providers in a discussion with CMS’ Center for Medicare (CM) and Center for Clinical Standards and Quality (CCSQ) on longstanding challenges with drug administration service payment and policy. Most of the conversation centered on “down coding” of complex drug administration, which the Medicare Administrative Contractors (MACs) had implemented through “local coverage articles” without input from clinicians.
As a result of CSRO advocacy, CMS issued Technical Direction Letters (TDLs) which “paused” the down coding temporarily while CMS works toward a long-term solution. The TDLs will not expire until CMS has promulgated rulemaking or program instruction (e.g., updates to its policy manuals) that permanently addresses the issue. CSRO has pushed for robust criteria that would account for AMA CPT requirements, Medicare valuation, and other clinical factors, including complexity of the patient population, all of which demonstrate that the administration of these medications warrant use of the chemotherapeutic administration codes.
The multispecialty group also raised concerns about the Self-Administered Drug (SAD) Exclusion List, which they contend is discriminatory and hinders access to therapies for beneficiaries that are unable to administer themselves due to their condition. As rheumatologists know, medications often have two formulations; one that is administered in a physician’s office and reimbursed under Part B, and one that is self-administered by the patient and paid under Part D. However, when a medication is “usually” (i.e., 50% of the time) administered “by the patient,” CMS’ current policy manual directs MACs to place the drug on the SAD List, meaning Medicare will no longer pay for the provider-administered formulation under Part B.
CSRO described issues with CMS’ definitions and criteria, which discriminate against Medicare beneficiaries who are unable to self-inject a medication. For example, CSRO raised concern that CMS uses a weighted average across all indications to determine Part D use, disregarding the fact that certain disease states make it more difficult for the patient to self-inject. CSRO also noted that many patients who utilize a self-injected Part D medication, are not self-administering; instead, they have a relative, friend, or clinical staff in the physician’s office, administer the drug. In fact, a survey conducted by Global Healthy Living Foundation (GHLF) revealed that 40% of Medicare patients fall into this category. Given all of these concerns, the groups urged CMS to revise SAD List criteria, as outlined in the Medicare Benefit Policy Manual, and offered ideas to help ensure more beneficiaries are able to access in-office medications.
CMS recognizes the challenges with both of these issues and asked to meet with CSRO again in the beginning of January.
Earlier in the day, CSRO leadership met with CMS CM staff to discuss concerns about neuromuscular ultrasound coding and billing following CMS’ recent consolidation of CPT 76881. CSRO noted that eliminating the professional and technical components mean that many rheumatology practices will no longer be able to provide this service to Medicare patients given they outsource the ultrasound interpretation and report in order to keep appointment wait times down. CMS did not commit to any “fix” by January 1, 2023, but acknowledged the complexity of the issue and committed to ongoing dialogue with stakeholders to better understand the issue.
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