Status Update: CMS "Pause" on Downcoding

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.

Utilization Management Survey: Alliance of Specialty Medicine

As a long-time member of the Alliance of Specialty Medicine (ASM), CSRO is asking the rheumatology community to provide feedback to help better understand the impact of utilization management practices through ASM’s brief survey.

Your participation will ensure the perspective of the rheumatology community is represented and is appreciated!

Take Survey

RDAM: Advocate by Creating Awareness 

In honor of Rheumatic Disease Awareness Month (RDAM), we are calling on those in the rheumatology community to join us in our advocacy work by creating awareness with state legislators about how rheumatology patients suffer because they are not protected from utilization management practices.

Awareness = Advocacy – take action today.  

Take Action
Legislation Around the Country

What's Happening in the States

CSRO tracks legislative activity relevant to the rheumatology community and their patients – click here to view a full status report.

Be sure to check out our interactive legislative map tool for additional information about current policy in your state.


Step Therapy

  • AB 1880: Transmitted to the Governor


Step Therapy & Prior Authorization

  • SB 225: Reported by House Insurance Committee 
Upcoming Events

Join Us

  • Exclusive: Member Breakfast at ACR Convergence
  • November 13, 2022 – Philadelphia, PA
  • Information has been shared directly with member societies

Save the Date

Find all of CSRO's event dates by visiting our Upcoming Events page, and check out past events and webinars in our Library.

Please visit the CSRO website for other news and updates, and do not hesitate to contact us with any questions at
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