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Physician's Offices Can Now Officially Get Reimbursed for CAR T by Medicare FFS

A Change Request to the CAR T NCD Clarifies Billing Requirements for Outpatient Physician's Offices Administering CAR T Cell Therapy

The Medicare Learning Network (MLN) published a revision to change request (CR) 12928 (see MLN Matters Number: MM12928 Revised) on December 30, 2022. The key takeaway is that Part B physician offices now have a way to bill for Chimeric Antigen Receptor (CAR) T-cell Therapy and actually get reimbursed. Prior to this CR revision, issues with billing had to do with the number of dollar digits the Multi-Carrier System (MCS) system allowed (the field length for the dollar amount in MCS is only 7 digits per line item or total maximum is 99999.99). MCS is the Medicare Part B claims processing system used by a majority of Medicare Part B contractors to process Medicare claims related to non-hospital based physician care. Since the HCPCS amounts for CAR Ts have more than 7 digits (think Q2041 = 1 unit = $448,316.40), claims were getting rejected by the system.

Depending on the price of the CAR T, providers will need to bill in fractional units; that is, divide the price by 10 and append the bill with:

  1. the new modifier -LU, fractionated payment CAR T-cell therapy,

  2. modifier -76, repeat procedure or service by same physician or other qualified healthcare professional, and modifier -KX,

  3. requirements specified in the medical policy have been met, to attest they are a REMS-approved facility.

So, 3 modifiers will be needed on any CAR T-cell claim. Note that MACs have received the transmittal and may have specific coding guidances.

The issue on patient out-of-pocket exposure persists, however, when the CAR T-cell therapy is administered in the physician's office. When CAR-T is provided in a physician's office, the beneficiary is financially responsible for cost-sharing for the physician’s service, which is generally 20% of the Medicare approved amount under the Physician Fee Schedule and the hospital outpatient co-payment under the Outpatient Prospective Payment System. In the hospital outpatient setting (HOPD, distinct from a physician's office), copayment is capped at the inpatient deductible (which is $1,600 in 2023).

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