Q&A: Does Inflectra Get Paid Under the OPPS?

September 14, 2016
Medicare Web

Q: One of our physicians is talking about a new biological called Inflectra that he is interested in using. Do you have any information on how this is handled under the OPPS?

A: Inflectra is a new biosimilar biological product that was approved by the FDA in April 2016. CMS created a new HCPCS code Q5102 (injection, infliximab, biosimilar, 10 mg) for reporting this product. It was originally assigned status indicator of K (separately payable nonpass-through drug or biological) effective July 1, 2016.

In the October OPPS update, CMS notes that there is no available pricing information for this product, so they are changing the status indicator to E (services not paid, non-allowed item or service), effective retroactively to July 1. This is CMS’ usual process – assignment of a product to status indicator E until pricing information is available, as separately paid drugs and biologicals are reimbursed at average sales price plus 6%. Once pricing information is available, the status indicator will be changed and the OPPS rate will be effective.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

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