This week, CSRO was notified by CGS Administrators that it will retire a problematic “billing and coding” article – Complex Drug Administration Coding – that conflicts with a directive issued by the Centers for Medicare and Medicaid Services (CMS) through an August 12, 2022, Technical Direction Letter (TDL), of which the substance was made public through Change Request 13468, Payment of Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions.

The communication from CGS states the following: “The CGS article: Local Coverage Article (LCA) on billing complex drug administration services (Article ID: A59272) will be retired. This will be visible in Medicare Coverage Database by the end of next week.”  

CSRO is preparing to submit comments in response to the CY 2025 Medicare Physician Fee Schedule (PFS) that, as reported earlier, includes a proposal to update the Medicare Claims Processing Manual, Chapter 12, section 30.5, to include language consistent with CPT code definitions for the complex non-chemotherapy infusion code series, which state that the administration of infusion for particular kinds of drugs and biologics can be considered complex and may be appropriately reported using the chemotherapy administration CPT codes 96401-96549. CMS explains that the addition of this language would allow the Medicare Administrative Contractors (MACs) to consider:

• the need for staff with advanced practice training and competency, such as, a physician or other qualified health care professional to monitor the patient during these infusions due to the incidence of severe adverse reactions, and
• special considerations for preparation, dosage, or disposal for these infusion drugs.

CSRO will continue to provide updates as appropriate.

As part of the ongoing implementation of the Inflation Reduction Act (IRA), CMS recently announced the “negotiated price” for therapies used to treat rheumatologic diseases under Part D – Enbrel and Stelara – beginning January 1, 2026. A fact sheet explains that the discount of negotiated price for these drugs from the 2023 list price (based on Wholesale Acquisition Costs (WACs)) is approximately 67% and 66%, respectively.

As part of the FAQs included in the fact sheet, CMS states that “A participating drug company with a selected drug is required to ensure the negotiated price is made available to eligible individuals and to the pharmacies, mail-order services, and other entities that dispense the selected drug to such individuals” and that “CMS will use its comprehensive formulary review process for Medicare prescription drug plans to assess any practices that may undermine access to negotiated prices for selected drugs for people with Medicare.” In March 2025, CMS intends to “make public an explanation of the agreed-upon negotiated prices.”

Days earlier, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a report that found “Medicare and some enrollees paid substantially more when Stelara injections were covered under Part D (i.e., self-administered) versus under Part D (i.e., administered by a physician),” highlighting a change in coverage when Medicare Administrative Contractors (MACs) moved Stelara to the Self-Administered Drug (SAD) Exclusion List. A graph from the report is included below and explains that the Medicare program and enrollees paid 80% more for Stelara under Part D compared to Part B. The report also highlights OIGs second evaluation focused on utilization patterns by setting that will be included in a forthcoming report.

The recent FTC report confirmed what CSRO has known for a long time - PBMs profit at the expense of patients. CSRO's Vice President of Advocacy & Government Affairs Dr. Madelaine Feldman shared her expert perspective on these findings in this article with Medscape Medical News.

What's Happening in the States

CSRO tracks legislative activity relevant to the rheumatology community and their patients. Check out the list below to see the status of CSRO priority bills from the past two weeks, and click here to view a full status report of CSRO priority bills.

Be sure to check out our interactive legislative map tool for additional details.

California

Rebate Pass Through

• SB 966: Ordered to third reading

Rheumatic Disease Awareness Month: September

Help create awareness about how rheumatology patients suffer because they are not protected from utilization management practices. Stay tuned for more details.

CSRO Advocacy Conference: September 20-22, 2024

Gather with others in the rheumatology community in Nashville for CSRO's annual Advocacy Conference! 

CSRO Fellows Conference: February 21-23, 2025

An annual event to help rheumatology fellows prepare for their future roles as practicing rheumatologists. Registration launching this fall.

State Society Conferences:

CSRO's state rheumatology society members host their own annual meetings throughout the year. Find a listing of these state-specific conferences on our website.

Action Center

Use CSRO's convenient online platform to easily find out who your elected officials are and engage with them directly.

Advocacy Council

Amplify your voice by assembling with other like-minded individuals to enhance CSRO’s advocacy initiatives.

Career Center

Locate the perfect fit whether you're looking for new career opportunities or trying to find the right candidate.

Explanatory Statement: “Underwater” Biosimilars

To aid in addressing the issue of "underwater" biosimilars with payers, CSRO has created a document to illustrate the extent of the problem.

Legislative Map Tool

Find your state on our interactive map tool to learn about current or proposed policy and ways you can take action to make an impact.

Payer Issues Reporting Form

Request assistance with any payer relation issues that may be impacting your patients or office.

Policy Correspondence

Easily access all of CSRO’s policy letters submitted to payers, state, and federal governments as an informational resource.

Rheum for Action

Learn about the latest advocacy issues in CSRO's advocacy column authored by Dr. Madelaine Feldman and produced in partnership with Rheumatology News.

Step Therapy Cover Sheets

Review CSRO's state-specific step therapy materials that help guide practices in gaining an exemption from step therapy protocols.

Questions?

Please visit the CSRO website for other news and updates, and do not hesitate to contact us with any questions at info@csro.info.