Ongoing Advocacy Efforts Seek Use of Complex Administration Codes for Biologics

The ACR and other advocacy organizations continue to work with the Centers for Medicare & Medicaid Services (CMS) to advocate for appropriate reimbursement of the administration of complex biologic therapies.

Over the past several years,  Medicare Administrative Contractors (MACs) have implemented Local Coverage Articles (LCAs) prohibiting the use of the chemotherapy administration codes (CPT 96401–96549) when coding for the administration of certain complex biologic drugs, instead requiring use of the diagnostic or therapeutic codes (CPT 96360–96379). The ACR has spoken with leaders from each of the MACs; however, they are unyielding in their opinion that this policy is accurate and appropriate.

In June, the ACR led a multispecialty sign-on letter asking the CMS to review the policymaking process used to implement these policy changes. The ACR was joined by nine other specialty societies in arguing that the MACs are using LCAs to bypass the more rigorous Local Coverage Determination process and subvert the transparency and stakeholder engagement intended by the 21st Century Cures Act. The letter asks the CMS to invalidate all current LCAs that restrict coverage or patient access.

In its response, the CMS acknowledged the concerns raised and suggested this specific issue may fall under the purview of its Center for Program Integrity (CPI). The ACR has subsequently reached out to the CPI and will pursue additional opportunities for dialogue.

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