CMS addresses improper payment rates for immunosuppressive drugs

CMS determined the improper payment rate for immunosuppressive drugs was 15.7% in 2023, with a projected improper payment amount of $43.2 million. Organizations should review CMS' guidance on proper billing codes, coverage criteria, common denial reasons, and documentation requirements.

In the 2023 reporting period, approximately 62.2% of improper payments were caused by insufficient documentation, according to CMS. The agency recommends that facilities consider the following factors when submitting immunosuppressive drug claims to Medicare:

• The claim requires dosage, frequency, and administration route
• The claim must conform to generally accepted medical practice and meet medical necessity requirements to prevent or treat an organ transplant rejection
• CMS limits the quantity of immunosuppressive drugs dispensed to a 30-day supply

CMS covers prescription drugs for immunosuppressive therapy under the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) program benefit if the following criteria are met:

• The provider prescribed immunosuppressive drugs for the patient after certain transplant procedures
• The transplant met the Medicare coverage criteria in effect at the time
• The patient has Part A at the time of the transplant
• The patient has Part B at the time the provider dispenses the drugs
• The provider furnished the drugs in compliance with certain requirements

CMS limits immunosuppressive drug coverage to 36 months for patients whose Medicare entitlement is based solely on end-stage renal disease, as well as for those who are enrolled in other types of coverage. Coverage can continue beyond this time period for eligible patients enrolled in the Part B immunosuppressive drug benefit.

Organizations can view Local Coverage Determination L33824 for an up-to-date list of appropriate billing codes. CMS’ guidance also includes information on DMEPOS refill and documentation requirements.