Monoclonal antibody products are paid under the Medicare Part B COVID-19 vaccine benefit and therefore are not eligible for a New COVID-19 Treatments Add-on Payment.
A version of this article was first published December 16, 2020, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.
CMS released new and updated FAQs on Medicare Part B billing and reimbursement for COVID-19 treatments and vaccines. The information updated December 9 is included in Section BB, Drugs and Vaccines under Part B of CMS’ COVID-19 billing FAQs.
For the duration of the public health emergency, CMS will pay for monoclonal antibody treatments authorized or approved by the FDA. For payment purposes, CMS is treating these products as vaccines covered under Medicare Part B.
If the product is acquired for free, CMS will only pay for the administration. If the provider or supplier purchases the product, CMS will pay for the product and the administration separately. Monoclonal antibody products are paid under the Medicare Part B COVID-19 vaccine benefit and therefore are not eligible for a New COVID-19 Treatments Add-on Payment.
Payment for administration of an infusion of bamlanivimab or an infusion of casirivimab and imdevimad is approximately $310. The payment rate is based on one hour of infusion and post-infusion monitoring in the hospital outpatient setting. CMS may change the payment rate based on additional information from providers and suppliers. When organizations begin purchasing monoclonal antibody products, CMS plans to set the payment rate in the same way it will set the payment rate for COVID-19 vaccines. The payment rate will be reasonable cost or 95% of the average wholesale price. A chart on p. 123 of the FAQ document shows payments rates by setting.
Currently, there is no separate payment for preparation of monoclonal antibodies, even if prepared for another provider or supplier.
Monoclonal antibody products administered at a nonexcepted off-campus, provider-based department (PBD) will be paid at the full Outpatient Prospective Payment System (OPPS) rate. They will not be subject to the reduced rate (40% of the OPPS) that applies to other services provided at these facilities.
Documentation must support the medical necessity of the treatment as well as demonstrate that the terms of the applicable FDA emergency use authorization are met. The documentation must include the name of the practitioner who ordered the infusion.
Other new and updated FAQs in Section BB include payment for monoclonal antibody treatment provided:
By skilled nursing facilities, mass immunizers, and home health agencies
On the same day as evaluation and management services
To beneficiaries dually eligible for Medicare and Medicaid
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