Drug Reimbursement – Mitosol

Mitosol® (mitomycin for solution) is an antimetabolite indicated as an adjunct to ab externo glaucoma surgery.  It was approved by the Food and Drug Administration (FDA) in February 2012, and subsequently approved by CMS for pass-through reimbursement within Part B Medicare under the Outpatient Prospective Payment System (OPPS) that governs reimbursement for HOPDs and ASCs.   A HCPCS code, J7315 (mitomycin, ophthalmic, 0.2 mg), was assigned to this drug.  The Medicare reimbursement rate depends on the manufacturer’s average selling price, and is revised quarterly.  For Q1 2015, CMS published an allowed amount of $372.80 per vial.  It is important to note that pass-through payments are not subject to the 20% Medicare copayment. 

It should be noted that HCPCS code J7315 should only be used for Mitosol and should not be used for compounded mitomycin or other forms of mitomycin.  Under longstanding CMS regulations contained in CMS Transmittal 1759, no separate reimbursement is made for compounded medications used in a procedure performed in a HOPD or ASC – reimbursement for compounded medications is included in the facility fee. 

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