CMS Proposes HCPCS Coding Changes for IVIG

May 15, 2007

The Centers for Medicare & Medicaid Services (“CMS”) proposed brand-specific Healthcare Common Procedural Coding System (“HCPCS”) code changes for intravenous immune globulin (“IVIG”) that may lead to enhanced reimbursement for the biologic.  The HCPCS coding changes are effective July 1, 2007, and were announced in preliminary decisions for a May 15, 2007 HCPCS Public Meeting Agenda.  The new HCPCS codes coincide with the release of an April 2007 report from the Health and Human Services Office of Inspector General, which examined Medicare reimbursement for IVIG and addressed concerns about the biologic’s availability.

IVIG is a blood plasma derivative that is FDA-approved to treat patients whose immune systems produce insufficient antibodies to fight infection. Patients are infused with IVIG to temporarily replace antibodies to guard against various opportunistic infections that otherwise could be life-threatening.  FDA-approved indications include primary immunodeficiency, and certain immunodeficiency syndromes such as pediatric human immunodeficiency syndrome.  IVIG is also prescribed for many off-label uses, however, including chronic idiopathic demyelinating polyneuropathy, also known as chronic GuillainBarré syndrome.  There are currently two HCPCS codes for IVIG products, depending on whether they are powder or liquid.

Medicare reimbursement for IVIG is based on manufacturer average sales price (“ASP”).  Currently, Medicare Part B IVIG administered in hospital outpatient departments and in physician offices is reimbursed at 106% of the weighted average ASP.  Medicare also makes a separate payment of $75 to physicians and hospital outpatient departments for pre-administration-related services associated with IVIG (HCPCS code G0332) to cover the effort to locate and acquire IVIG for administration.  Even so, some providers believe that Medicare ASP-based reimbursement is not enough to pay acquisition costs for IVIG.  Because reimbursement is based on a weighted average of the ASPs for the various IVIG products, providers that use more expensive IVIG products may be under-reimbursed, since the weighted average incorporates lower-priced products as well.  This has caused some providers to stop furnishing the biologic to Medicare patients.

CMS’s decision to split HCPCS codes for IVIG into brand-specific codes may improve Medicare reimbursement for the biologic.  Brand-specific HCPCS coding will allow Medicare reimbursement to more accurately reflect provider acquisition cost of IVIG.  The new codes will also enable CMS to more readily monitor IVIG claims and access.

By Kirk L. Dobbins

Categories: Reimbursement