Final FY 2022 Hospital Inpatient Payment Proposal Sets Reimbursement for CAR-T, Removes Measures for Oncology Plan of Care for Pain

August 3, 2021

On August 2, the Centers for Medicare & Medicaid Services (CMS) released updates to the Inpatient Prospective Payment System (IPPS) for fiscal year (FY) 2022 final rule, including updates to Medicare payment policies and payment rates for most acute care hospitals.

Reimbursement for CAR-T and Other Immunotherapies

In 2021, CMS established a Medicare Severity Diagnosis Related Group (MS-DRG) 018 for Chimeric Antigen Receptor T-cell (CAR-T) services. CMS finalized its proposal to add 16 new procedure codes to MS-DRG-018 for FY 2022 and subsequently rename the MS-DRG “Chimeric Antigen Receptor (CAR) T-cell and Other Immunotherapies.” As additional data becomes available for new CAR-T and other immunotherapies procedure codes, CMS will continue to evaluate and determine if further modifications to MS-DRG 018 are needed. The Association for Clinical Oncology (ASCO) will continue to monitor and engage with CMS and other stakeholders.

The national, unadjusted payment amount for MS-DRG-018 will be $246,957 for those hospitals that submitted quality data, an increase of $7,025 from FY 2021 to FY 2022. For hospitals that do not submit quality data, payments will increase by $6,171.87 for a national unadjusted payment rate of $240,889 in FY 2022. While we commend CMS for establishing an MS-DRG for CART-T, we remain concerned that the reimbursement rate will be insufficient to cover the cost of the CAR-T therapy and associated services and could therefore restrict access to this lifesaving therapy. We will continue to advocate for adequate reimbursement for new cancer treatments.

Oncology Plan of Care for Pain

CMS is moving forward with its proposal to remove the Oncology Plan of Care for Pain – Medical Oncology and Radiation Oncology (NQF #0383) (PCH-15) measure in the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program beginning with the FY 2024. CMS is removing the measure because the agency states it is not feasible to implement as it is meant to be paired with the Medical and Radiation—Pain Intensity Quantified (PCH –16/NQF #0384) measure (78 FR 50843), which was removed beginning with the FY 2021 program year. In its comment letter to CMS in June 2021, ASCO  strongly recommended that CMS maintain the Oncology Plan of Care for Pain measure in the program and to reinstate the Pain Intensity Quantified measure; however, despite those recommendations, CMS will remove the Oncology: Plan of Care for Pain – Medical Oncology and Radiation Oncology (NQF #0383) (PCH-15) measure beginning with the FY 2024 program year.

The Association for Clinical Oncology (ASCO) will continue to work with CMS to make sure patients continue to have access to quality oncology care, and that practices have the resources they need to continue to care for patients.

Read the full IPPS Final Rule.

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