CAR T Reimbursement Updates Proposed in 2021 Hospital Inpatient Payment Rule

May 12, 2020

On May 11, the Centers for Medicare & Medicaid Services (CMS) released the Hospital Inpatient Prospective Payment System (IPPS) proposed rule for 2021. Of particular note, CMS is proposing a new Medicare Severity-Diagnosis Related Group (MS-DRG) for chimeric antigen receptor T-cell therapy (CAR T-cell therapy).

In response to multiple stakeholder requests for a new MS-DRG for procedures involving CAR T-cell therapy and given the additional claims data now available on these procedures, CMS proposes to create the MS-DRG 018 (Chimeric Antigen Receptor (CAR) T-cell Immunotherapy). Any cases reporting the existing CAR-T ICD-10-PCS procedure codes (XW033C3 or XW043C3) would be assigned to the new MS-DRG, should the proposal become final.

If CMS approves and finalizes additional procedure codes describing CAR T-cell therapies, CMS will use its established process to assign these procedure codes to the most appropriate MS-DRG. As these CAR T cases would no longer be assigned to MS-DRG 016, CMS proposes to revise the title for MS-DRG 016 from “Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy” to “Autologous Bone Marrow Transplant with CC/MCC.”

CMS is also proposing to discontinue the new technology add-on payments (NTAPs) for two CAR-T products: Yescarta and Kymriah.

While the final IPPS rule would usually be published in early August, CMS has stated that, due to the Covid-19 pandemic, this year’s final rule may not be released until September 1. The final rule’s provisions will go into effective October 1, 2020. The Association for Clinical Oncology is assessing the proposed rule and will submit feedback to CMS during the open comment period.

Read CMS’ press release and fact sheet on the proposed rule.

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