This information replaces the reimbursement guidelines posted in the December 2019 bulletin, New Coverage, Prior Approval and Billing Requirement for CAR-T Cell Therapy (KYMRIAH & YESCARTA). Clinical coverage policy 11A-17 CAR T-Cell Therapy is available to view on the Stem Cell Transplant Clinical Coverage Policies website.
Inpatient Hospital Services: Institutional Claim (UB-04 form/837I transaction)
In accordance with the State Plan, inpatient services for CAR T-Cell Therapy will be reimbursed using the existing DRG payment methodology and will be based on the primary diagnosis code and grouped to the appropriate DRG. Since this will be a covered service, the cost of the CAR T-Cell Therapy will be an allowable cost on the cost report.
Outpatient Hospital Services: Institutional Claim (UB-04 form/837I transaction)
If the CAR T-Cell Therapy is administered during an outpatient hospital encounter, the infusion is billed on the claim, along with the appropriate HCPCS and NDC codes. If the CAR T-Cell Therapy is billed under 340B pricing, the UD modifier must be used. The outpatient hospital claim will be reimbursed according to Medicaid Outpatient Hospital billing guidelines.
Contact
NCTracks Call Center: 800-688-6696