Health Information Management

Healthcare News: CMS grants four drugs and biologicals to pass-through status

JustCoding News: Outpatient, April 18, 2012

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Providers will receive pass-through payment for four additional drugs and biologicals as part of the April OPPS update.

CMS granted pass through status for these four HCPCS codes:
• C9288, injection, centruroides (scorpion) immune f(ab)2 (equine), 1 vial
• C9289, injection, asparaginase erwinia chrysanthemi, 1,000 international units (IU)
• C9290, injection, bupivicaine liposome, 1 mg
• C9291, injection, aflibercept, 2 mg vial

CMS published specific instructions about reporting and reimbursement for code C9291 in MLN Matters 7784:

Eylea (aflibercept) is packaged in a sterile, 3 mL single use vial containing a 0.278 mL fill of 40 mg/mL Eylea (NDC 61755-0005-02). As approved by the Food and Drug Administration (FDA), the recommended dose for Eylea is 2 mg every 4 weeks, followed by 2 mg every 8 weeks. Payment for HCPCS code C9291 is for the entire contents of the single-use vial, which is labeled as providing a 2 mg dose of aflibercept. As indicated in 42 CFR § 414.904, CMS calculates an ASP [average sales price] payment limit based on the amount of product included in a vial or other container as reflected on the FDA-approved label, and any additional product contained in the vial or other container does not represent a cost to providers and is not incorporated into the ASP payment limit. In addition, no payment is made for amounts of product in excess of that reflected on the FDA-approved label.

CMS notes that the approved FDA dose is 2 mg and by HCPCS code description, that dosage is the lowest reportable unit. CMS further notes that this is the maximum amount of this product that may be reported and reimbursed for this single-use vial. Facilities should not report a wasted amount for any overfill that might be noted on the vial. CMS could create a medically unlikely edit for this HCPCS code.

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