CMS Details Medicare Payment for New COVID-19 Antibody Drug

Just a day after the FDA approved the emergency use of a new COVID-19 antibody drug, CMS updated Medicare payment and billing policies to ensure providers have access to the new treatment for coronavirus patients.

CMS announced yesterday that Medicare payment will be available for both the purchase and administration of bamlanivimab, which can be used to treat mild-to-moderate COVID-19 in certain adult and pediatric patients, according to the FDA’s recent emergency use authorization.

The agency said it plans to pay 95 percent of the average wholesale price for the COVID-19 antibody drug to providers who purchase it. However, the drug is expected to be free for healthcare providers at first, according to the announcement.

But even with free doses, CMS will reimburse providers for the administration of the drug.

The Medicare payment rate for the administration of bamlanivimab will be $309.60. The rate will cover one hour of infusion and post-administration monitoring in the hospital outpatient setting and will be adjusted according to geographic region, the agency explained in an instruction guide accompanying the announcement.

Healthcare providers will be able to bill for the administration of the drug’s infusion on a single claim for COVID-19 monoclonal antibody administration or they can submit claims on a roster bill.

But providers should understand that the administration of the new COVID-19 antibody drug is more complex than other services that are billed using roster billing, CMS warned.

The FDA’s emergency use authorization sets specific criteria for who is eligible to receive the COVID-19 antibody drug and providers will need to provide medical documentation that not only supports the medical necessity of the drug’s administration, but also that it meets the terms of the FDA’s authorization.

For example, providers will need to document that the drug is being used for the treatment of mild-to-moderate COVID-19 in a patient who is at high risk for progressing to severe COVID-19 and/or hospitalization. Medical documentation should also include the name of the practitioner who ordered or made the decision to administer the drug, even when claims for the administration are submitted on roster bills.

Additionally, CMS said healthcare providers should only seek Medicare reimbursement for the administration of the COVID-19 antibody drug if they received the drug for free. In that case, providers should not include the codes for the monoclonal antibody on the claim, the agency stated.

The codes for the COVID-19 antibody drug and its administration are:

• Q0239: Long descriptor: Injection, bamlanivimab-xxxx, 700 mg Short descriptor: bamlanivimab-xxxx
• M0239: Long Descriptor: intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring Short Descriptor: bamlanivimab-xxxx infusion

CMS intends for the updated Medicare billing and payment policy to enable a broad range of providers to administer the drug. The agency expects freestanding and hospital-based infusion centers, home health agencies, nursing homes, and entities with whom nursing homes contract for this to be able to administer the drug under the new policy.

The agency also aims to ensure broad access to the drug. To achieve this, CMS is making the drug free to Medicare beneficiaries. For providers, this means Medicare patients will not pay a copayment, coinsurance, or part of their deductible for the infusion.

“Today, CMS is announcing a historic, first-of-its kind policy that drastically expands access to COVID-19 monoclonal antibodies to beneficiaries without cost sharing,” CMS Administrator Seema Verma said in yesterday’s announcement. “Our timely approach means beneficiaries can receive these potentially life-saving therapies in a range of settings – such as in a doctor’s office, nursing home, infusion centers, as long as safety precautions can be met. This aggressive action and innovative approach will undoubtedly save lives.”

Eli Lilly & Company who developed and will distribute the COVID-19 antibody drug has made a deal with the federal government to provide the first doses to HHS and the Department of Defense. The company will provide 300,000 doses to the federal departments at a price of $375 million. The departments also have the option to purchase up to 650,000 additional doses through the end of June 2021 for $812.5 million.