National Infusion Center Association and National Organization of Rheumatology Managers Fight Downcoding of Biologic Drugs
The National Infusion Center Association (NICA) and the National Organization of Rheumatology Managers (NORM) submitted joint comments to UnitedHealthcare (UHC) regarding a change in the Injection and Infusion Services Policy to require that therapeutic infusion codes be reimbursed instead of chemotherapy codes when reported for specific medications.
NICA is a nonprofit advocacy organization, established to represent patients requiring provider-administered intravenous or injectable medications and the providers who treat them. NORM is a 501(c)(6) nonprofit advocacy organization that represents rheumatology managers, physicians, and patients.
Both organizations acted on behalf of their respective stakeholders due to a policy change outlined in UHC’s September Network Bulletin (Table 1).
“NICA and NORM are deeply concerned that such a change would drive inappropriate utilization of administrative coding inconsistent with medical coding guidelines directed by the American Medical Association (AMA), the Centers for Medicare & Medicaid Services (CMS), and the Government Accountability Office,” wrote Brian Nyquist, MP, executive director of NICA and Andrea Zlatkus, president of NORM.
Table 1: UHC Coordinated Commercial Reimbursement Policy Announcement
If implemented, the administrative codes for these complex biologics will be “downcoded” or reimbursed as simple, therapeutic codes, rather than complex, chemotherapy administration codes, which contradicts the CMS Medicare Claims Processing Manual that states in Chapter 12, Section 30.5, Subsection D, “[c]hemotherapy administration codes apply to parenteral administration of […] substances such as monoclonal antibody agents, and other biologic response modifiers.” This section of the manual continues with the statement, “The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes.”
Regarding the complex nature of biologic administration, Nyquist and Zlatkus wrote, “Biologics are highly complex, large molecule medications used to treat very complex, chronic conditions and autoimmune disease. Due to the complexity of the preparation, administration, and monitoring, the high level of skill required, CMS and AMA support complex administration codes for complex biologic agents, like Entyvio, Orencia, Actemra, and Simponi Aria.”
During NORM’s annual conference, which took place October 4-5, 2018 in Tampa, FL, over 200 rheumatology managers, representing 129 rheumatology practices across the country, signed the joint letter to express their concern of the further reduction in reimbursement of biologic drugs.
The petition has received over 350 signatures from practice managers, physicians, and clinicians across specialties.
Complex coding and appropriate reimbursement of biologic drugs continue to be a priority for NICA and NORM. There are currently no available codes or supplemental fee structure to reimburse office-based infusion providers for the cost of medical supplies or equipment utilized for the administration of intravenous biologics. In addition, administrative reimbursement does not fully cover the costs associated with patient observation/assessments before, during, and after treatment, as well as the countless hours spent on case management and care coordination.
The letter recognized and commended UHC’s efforts to reducing overall healthcare costs and its efforts in site of care optimization for biologics and expensive specialty medications to shift these beneficiaries into office-based care settings, but implored UHC to reconsider its decision to downcode biologics that require complex preparation and administration.
NICA and NORM are dedicated to conveying the importance of appropriate reimbursements and hope to deter other insurers from implementing similar downcoding strategies for the repayment of biologic drugs.
If you are experiencing problems with downcoding in your practice, NICA and NORM want to hear from you!
Please contact us at email@example.com
NICA is a nonprofit advocacy organization, established in 2010, to represent patients requiring provider-administered intravenous or injectable medications and the providers that treat them. NICA was formed to ensure that some of our nation’s sickest and most vulnerable patients can access the in-office infusion therapy they rely upon to manage their complex, chronic condition(s).
NORM is a 501(c)(6) nonprofit advocacy organization representing rheumatology managers, physicians and patients. Our mission proclaims we are a forum by which we promote and support education, expertise and advocacy for access to care of our rheumatology practices and their patients.
 UnitedHealthcare. Network Bulletin. September 2018; pg.22.
 CMS. Medicare Claims Processing Manual, Chapter 12, Section 30.5, Subsection D. Bolded for emphasis. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf