Reimbursement for Dextenza (Ocular Therapeutix)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR DEXTENZA
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Q What is DEXTENZA®?
A DEXTENZA (dexamethasone ophthal-mic insert) 0.4mg is a corticosteroid intracanalicular insert placed into the canaliculus via the punctum. The insert is designed to deliver dexamethasone, without preservatives, to the ocular surface for up to 30 days. Following treatment, the insert resorbs and exits the nasolacrimal system without the need for removal.1 The Food and Drug Administration2 (FDA) approved DEXTENZA in November, 2018.
Q What is the indication for DEXTENZA?
A DEXTENZA is indicated for the treatment of ocular inflammation and pain following ophthalmic surgery.
Q What CPT code describes insertion of DEXTENZA in the lower lacrimal canaliculus?
A To report insertion of DEXTENZA, use Category III CPT code 0356T (insertion of drug-eluting implant including punctal dilation and implant removal when performed into lacrimal canaliculus, each). Use the RT or LT location modifiers to indicate which side.
Q How is the supply of DEXTENZA coded?
A Use HCPCS code J1096 (Dexamethasone, lacrimal ophthalmic insert, 0.1mg) to report the supply of DEXTENZA. On your claim, report 4 units. This code became effective October 1, 2019.
Q Do Medicare and other third party payers cover placement of the insert (0356T) and the supply (DEXTENZA)?
A Maybe. However, even when coverage is secured, the payer might not make separate payment; payer policies differ.
Q What is the surgeon’s reimbursement for 0356T?
A Unknown. In the 2020 Medicare Physician Fee Schedule, the allowed amount is indeterminate. Since there is no national coverage policy for this Category III CPT code, each Medicare Administrative Contractor (MAC) will determine coverage and payment for the surgeon. Medicare does not bundle 0356T with most ophthalmic procedures, including cataract surgery.
If your MAC defines 0356T as not covered, ask the patient to assume financial responsibility using a financial waiver. A financial waiver can take several forms depending on insurance.
Q What is the Medicare facility reimbursement for 0156T?
A Effective July 1, 2019, CMS assigned DEXTENZA to APC 9308 within the national OPPS payment schedule for facilities (HOPD or ASC).5 Each unit is allowed $138.749; so, 4 units is allowed $555. The reimbursement rate changes periodically and depends on the manufacturer’s average selling price as reported to CMS.
Q What is the Medicare facility reimbursement for 0356T?
A In the ASC, the allowed amount for 0356T is zero; no separate payment applies. In the HOPD, payment of APC 5733 depends on how the allied procedure is categorized. When the procedure performed is cataract surgery with IOL, the payment for 0356T is bundled within the comprehensive APC 5491 ($1,917) so there is no additional payment. In neither case is the facility allowed to hold the beneficiary financially responsible, even with a financial waiver or ABN.
Q Is there separate payment to the HOPD or ASC for DEXTENZA?
A Sometimes. For Medicare Part B beneficiaries, there is separate payment for the supply of DEXTENZA because it qualifies as a pass-through drug under the Outpatient Prospective Payment System (OPPS) that governs reimbursement to HOPDs and ASCs.3 In the Medicare payment schedule for HOPD and ASC, this is represented by status indicator “G” in the OPPS files.
Other payers may follow CMS’ policy but are not obliged to do so.
Q What is the Medicare facility reimbursement for DEXTENZA?
A Effective July 1, 2019, CMS assigned DEXTENZA to APC 9308 within the national OPPS payment schedule for facilities (HOPD or ASC).4 As of 7/1/20, each unit is allowed $139.814; so, 4 units allows $559.26. The reimbursement rate changes periodically and depends on the manufacturer’s average selling price as reported to CMS.
Q Is DEXTENZA subject to the Medicare coinsurance rule?
A Yes. DEXTENZA is subject to Medicare coinsurance. 81% of Medicare beneficiaries with Part B coverage have supple-mental insurance to cover some or all cost-sharing requirements.5
Q Is DEXTENZA an important consideration within MIPS?
A It could be important going forward. For eligible clinicians, under the Resource Use component of the Merit-Based Incentive Payment System (MIPS), lower cost of an average episode of routine cataract surgery earns points while higher cost loses points. Only covered items and services used during routine cataract surgery are counted toward the surgeon’s 2020 MIPS score, which is a factor in determining future Medicare payments in 2022. Clinicians who achieve a final composite score of 85 or higher will be eligible for the exceptional performance adjustment, while those with a score below 45 will be penalized.
Importantly, the use of DEXTENZA in complex cataract surgery, non-routine cases, or within Medicare Advantage is not counted toward the MIPS composite score.
1 Directions for use. Link here. Accessed 05/28/20.
2 FDA. NDA 208742. Approval letter for DEXTENZA. November 30, 2018. Link here. Accessed 05/28/20.
3 Social Security Act §1833(t)(6). Link here. Accessed 05/28/20.
4 OPPS Addendum B, July 2019. Link here. Accessed 05/28/20.
5 Henry J Kaiser Family Foundation. Nov 2018. Link here. Accessed 05/28/20
Provided Courtesy of Ocular Therapeutix (877) 628-8998
Last updated August 24, 2020
The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, and other sources. The reader is strongly encouraged to review federal and state laws, regulations, code sets, and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. Although we believe this information is accurate at the time of publication, the reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.
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