In order to make sure immediate access during the Coronavirus pandemic, Medicare will cover and pay for these infusions in accordance with section 3713 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). CMS intends to address potential refinements to payment to for bamlanivimab and its administration through future notice and comment rulemaking.
Payment for Infusion
At preliminary, for the infusion of the bamlanivimab product, the Medicare payment rate for the administration of bamlanivimab will be $309.60.
This payment rate is based on the below things:
- One hour of infusion
- Post-administration monitoring in the hospital outpatient setting
This rate will also be adjusted according to geographic location. At a later date, Medicare may use a similar method to fix the payment rate for the infusion of additional monoclonal antibody products based on the expected infusion time, consistent with the FDA emergency use authorization or FDA approval of such products.
Payment for Product
Medicare will not provide reimbursement for the monoclonal antibody products that healthcare providers receive for free of cost, as will be the case upon the product’s initial availability in response to the COVID-19 pandemic. Whenever healthcare providers start purchase monoclonal antibody products, CMS anticipates setting the payment rate in the same way to set the payment rate for coronavirus vaccines.
As an example, Medicare will pay 95 percent of the average wholesale price for coronavirus vaccines furnished in the physician office setting, and pay hospital OPD at a reasonable cost for coronavirus vaccines.
Medicare beneficiaries pay no cost-sharing for this monoclonal antibody infusion:
- No co-payment / co-insurance
- No deductible
Billing for Monoclonal Antibody COVID-19 Infusion Administration
Providers can create a single claim for COVID-19 monoclonal antibody administration or submit a claim on a roster bill, in accordance with the FDA EUA.
The EUA for COVID-19 monoclonal antibody treatment bamlanivimab contains specific requirements for administration that are considerably more complex than for other services that are billed using roster billing. CMS expects that Healthcare providers will keep proper medical documentation that supports the medical requirement of the service.
This includes documentation that supports that the terms of the EUA are met, including that it is being used for the treatment of mild to moderate coronavirus disease 2019 (COVID-19) for a patient that is at high risk for progressing to severe COVID-19 and/or hospitalization.
The documentation should also include the name of the practitioner who ordered or made the decision to administer the infusion, even in cases where claims for these services are submitted on roster bills.
When COVID-19 monoclonal antibody doses are provided by the government without charge, providers should only bill for the administration. Healthcare providers cannot include the monoclonal antibody codes on the claim when the product is provided for free.
Healthcare providers who participate in a Medicare Advantage Plan should submit claims for bamlanivimab administration to Original Medicare for all patients enrolled in Medicare Advantage in 2020 and 2021.
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