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.