2 Important CMS Updates for GI Practices: Biosimilar Changes and Medicare Appeals Guidance

Medicare Part B Biosimilar Payment and Required New Codes: Dates of Service on or after April 1, 2018

Pursuant to a recent CMS update, the “Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – April 2018,” please note that there is a coding change when administering the biosimilar of infliximab.  HCPCS Q5102 will be replaced with two codes: Q5103 and Q5104, effective this month.  Effective for Medicare Part B claims with dates of service on or after April 1, 2018, ACG members need to use the two biosimilars codes noted below:

Q5103: Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg
Q5104: Injection, infliximab-abda, biosimilar, (renflexis), 10 mg

Read the CMS Transmittal guidance here

Please note: HCPCS code Q5102 and the requirement to use biosimilar modifiers remain in effect for dates of service prior to April 1, 2018.

Medicare Part B Appeal Process: CMS Releases Revised Guidance

CMS also revised guidance to assist ACG members and GI practices when considering to appeal to a recent Medicare Part B reimbursement denial or coverage decision.  Please see the revised guidance here.  CMS breaks down the guidance through the 5 levels of the appeals process, and also provides helpful tips throughout each step:

1. 1. Redetermination by a Medicare Administrative Contractor (MAC)
      1. When you need to file a request (within 120 days)
      2. How to file a request (in writing per MAC instructions or Form CMS-20027 or CMS20031)
      3. Who make this decision (the MAC)
      4. How long does the decision take (60 days)
   2. When you disagree with the MAC decision: Reconsideration by a Qualified Independent Contractor (QIC)
      1. When you need to file a request (within 180 days)
      2. How to file a request (in writing per MAC instructions or Form CMS-20033)
      3. Who make this decision (the QIC)
      4. How long does the decision take (within 60 days)
   3. When you disagree with the QIC reconsideration: Administrative Law Judge Hearing or Review of Office of Medicare Hearings and Appeals
      1. When you need to file a request (within 60 days)
      2. How to file a request (per instructions or Form OMHA-100 or OMHA-100A)
      3. Who make this decision (the ALJ or attorney adjudicator)
      4. How long does the decision take (there are significant delays, but you can seek to elevate your dispute to the next level)
   4. When you disagree with the decision of the ALJ or Office of Medicare Hearings and Appeals: Medicare Appeals Council (Council)
      1. When you need to file a request (within 60 days)
      2. How to file a request (per instructions or Form DAB-101)
      3. Who make this decision (the Council)
      4. How long does the decision take (within 90 days)
   5. Judicial Review: U.S. District Court
      1. When you need to file a request (within 60 days)
      2. How to file a request (file a claim in the U.S. District Court)
      3. Who make this decision (the Court)
      4. How long does the decision take (there is no statutory time limit)

Louis J. Wilson, MD, FACG

Chair, ACG Practice Management Committee