This afternoon, CSRO was notified by senior staff at the Centers for Medicare and Medicaid Services (CMS) that the agency has given “technical direction” to its Medicare Administrative Contractors (MACs) across the country to stop sending additional documentation requests (ADR) after June 10, 2022, when physician practices submit claims for chemotherapy administration services for the following drugs:

• Cimzia® (J0717)
• Orencia® (J0129)
• Simponi Aria® (J1602)
• Stelara® (J3358)
• Prolia® (J0897)

Throughout this year, CSRO has met with CMS numerous times to discuss this issue and had ongoing, repeated communication with the MAC Contractor Medical Directors (CMDs) and various CMS headquarters staff. After a meeting two weeks ago with a senior staffer at the Center for Program Integrity (CPI), CSRO successfully convinced CMS of the inappropriateness of this policy, resulting in this announcement today.

From a practical standpoint, rheumatology practices nationwide that submit claims for chemotherapy administration services (CPT 96401-96549) when the aforementioned drugs are administered should expect those claims to be processed and paid without receiving ADR letters. Per CMS, “This is a temporary pause in medical review while CMS reviews all of the various manuals and policies and determines the appropriate steps forward.”

Please note, this is a nation-wide pause on downcoding of these drugs, which can now be coded as complex for all MACs.

This temporary pause is a direct result of CSRO advocacy. CSRO continues to work with the agency on a long-term solution.

Practices that receive ADR letters dated after June 10, 2022, when they submit claims for chemotherapy administration services for the aforementioned drugs should notify CSRO at info@csro.info.