cms-updates-medicare-part-b-drug-pricesRetroactive code pricing updates may require claims lookback.

The Centers for Medicare & Medicaid Services (CMS) has posted a retroactive update to the April Average Sales Price (ASP) pricing file for three Medicare Part B drugs. Also now available are the July ASP and Not Otherwise Classified (NOC) pricing files and the ASP NDC HCPCS crosswalk.

April ASP Update

On June 1, CMS retroactively updated the ASP for three HCPCS Level II codes. The updated payment limits are affective April 1, 2021, through June 30, 2021.

Code Short Description Dosage Payment Limit
J1557 Gammaplex injection 500 mg $49.45
J3315 Triptorelin pamoate injection 3.75 mg $515.49
Q2050 Doxorubicin injection 10 mg $308.82

The ASP for these codes change again in third quarter.

July ASP Update

The following table shows updated payment limits for five HCPCS Level II codes, effective July 1, 2021, through Sept. 30, 2021:

Code Short Description Dosage Payment Limit
J1437 Ferric derisomaltose injection 10 mg $25.815
J1951 Fensolvi injection 0.25 mg $127.748
J3032 Eptinezumab-jjmr injection 1 mg $15.603
J7212 Factor viia (recomb sevenfact) 1 mcg $2.185
Q5123 Riabni injection 10 mg $73.83

 

Take Note

Payment allowance limits subject to the ASP methodology are based on first quarter 2021 (1Q21) ASP data. The absence or presence of a HCPCS Level II code and the payment allowance limits in the pricing files does not indicate whether Medicare covers a drug. Determinations are made by the local Medicare Administrative Contractor processing the claim.

Where applicable, the payment amounts in the quarterly ASP files are 106 percent of the ASP calculated from data submitted by drug manufacturers. The quarter-to-quarter price changes are generally the result of updated data from the manufacturers of these drugs.

According to CMS, comparing the third quarter 2021 payment amounts with the prior quarter reveals that, on average, payment amounts for the top 50 Part B drugs decreased by 0.8 percent. For most of the higher volume drugs (26 out of the top 50), the prices changed 2 percent or less. Overall, the prices for 21 of the top 50 drugs decreased.

HCPCS Quarterly Update Correction

CMS updated on June 9 the July 2021 Alpha-Numeric HCPCS File to make several corrections, as shown below:

HCPCS/MOD Code Action Short Description Long Description Effective Date TOS BETOS Cov Pricing
C9065 Do not terminate
G0327 Revise TOS 7/1/2021 5
J9314 Remove code
M0201 Add COVID-19 vaccine home admin COVID-19 vaccine administration inside a patient’s home; reported only once per individual home per date of service when only COVID-19 vaccine administration is performed at the patient’s home 6/8/2021 V O1G C 54
M0247 Add Sotrovimab infusion Intravenous infusion, sotrovimab, includes infusion and post administration monitoring 5/26/2021 V O1G C 54
M0248 Add Sotrovimab inf, home admin Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency 5/26/2021 V O1G C 54
Q0247 Add Sotrovimab Injection, sotrovimab, 500 mg 5/26/2021 V O1G C 54

For More Information: https://www.aapc.com/blog/75566-cms-updates-medicare-part-b-drug-prices/

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