CMS: CAR-T provided to MA beneficiaries to be paid under traditional Medicare

Chimeric antigen receptor T-cell (CAR-T) therapy provided to Medicare Advantage (MA) beneficiaries will be paid for by traditional Medicare for calendar years 2019 and 2020. The policy, issued through Special Edition MLN Matters 19024, is retroactively effective on August 7, 2019.

SE19024 instructs hospitals on how to report CAR-T provided to MA beneficiaries. Hospitals may use revenue codes 087X (cell/gene therapy) and 089X (pharmacy). If CAR-T is provided in the hospital outpatient setting, organizations may track these services by billing them separately using the following HCPCS/revenue code combinations:

• HCPCS 0537T with revenue code 0871
• HCPCS 0538T with revenue code 0872
• HCPCS 0539T with revenue code 0873

These codes will receive reason code W7111.

Providers are reminded that Medicare pays for CAR-T in the hospital outpatient setting separately under CPT® code 0540T with revenue code 0874, assigned to status indicator “S”. Payment for collection and preparation is included in payment for the biological. Charges for collection and preparation may be included in the charge submitted for biological or providers may report these charges separately for tracking purposes. Hospitals cannot include charges for pre-infusion steps in the drug revenue code (0891) and separately listed for the pre-infusion revenue codes (0871, 0872, and 0873).

SE19024 also includes three scenarios demonstrating how to apply the instructions and properly report the codes.

CMS approved nationwide coverage of CAR-T in August. The therapy will be covered when performed in facilities enrolled in the FDA’s risk evaluation and mitigation strategies program for FDA-approved indications, as well as for off-label uses that are recommended by CMS-approved compendia.