Defining Administration Complexity by the Drug, Not the Diagnosis

The ACR is working to keep biologic drugs accessible to rheumatology patients, defending the ability of rheumatology practices to use the complex chemotherapy codes for administration of biologics. Those codes take into account the complexity of these drugs and the additional time needed for their delivery.

Dr. Snow

“If there is not appropriate reimbursement for the administration of biologic drugs, practices may not be able to continue offering these critical therapies in office,” says Marcus Snow, MD, chair of the ACR Committee on Rheumatologic Care (CORC).

Currently, a number of Medicare contractors (MACs) do not recognize certain biologic drugs as reimbursable under complex administration codes. Instead, they require rheumatology practices to code administration of these drugs under simple/therapeutic codes.

Such policies fail to recognize that biologics, regardless of the disease they are used to treat, are inherently complex and therefore should be reimbursed at the higher rate under the complex administration codes.

An ACR position statement, presented by CORC and sent to key stakeholders in 2019, details the reasons biologics should be reimbursed under complex administration codes, regardless of the specialty using them.

Complexity Determined by the Drug, Not the Diagnosis

According to both Current Procedural Terminology (CPT) and Centers for Medicare & Medicaid Services (CMS) manuals, biologics meet the definitions for chemotherapy services and are reimbursed under complex chemotherapy codes (CPT 96401–96413). As detailed in the ACR’s position statement, the higher reimbursement based on these complex codes takes into account the comprehensive work required to approve, administer and monitor biologics, usually requiring direct physician supervision.

Administration of biologics in rheumatology and other specialties entails the same level of expertise as in oncology to ensure proper and safe use. “The determination of whether it is appropriate to use the complex chemotherapy administration codes is based on the complexity of the drug, not the patient’s diagnosis,” says Dr. Snow.

The ACR’s statement lists the following key positions on biologics:

• Use of biologics should be supervised and carried out by specially trained practitioners with knowledge, training, and experience to properly handle, administer, and monitor biological agents;
• All providers and payers should follow consistent policies for documentation of medical necessity, complex administration protocols, and proper coding and reimbursement for the infusion and injection of biologics;
• All biological agents should be considered highly complex for administration, monitoring, coding, and reimbursement purposes and be covered at an appropriate level by health plans;
• Unique CPT codes are warranted for biologics with separate formulations (such as those administered subcutaneous versus intravenous) given their distinct indications, risks and target populations; and
• Policies on where biologics are administered should promote the highest standards of safety and allow patients to receive treatments in facilities with specialty trained practitioners overseeing their infusion.

To date, however, certain MACs have set policy on coding and reimbursement of biologics in rheumatology by issuing Local Coverage Articles (LCAs) that require rheumatology practices to use the simple/therapeutic code (CPT 96365) for administering biologics, in effect barring the use of complex coding for these drugs. This move by the MACs appears to define complexity more by a patient’s diagnosis (e.g., cancer) than by the complexity of the drug itself.