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Reimbursement for DEXYCU (EyePoint)

FREQUENTLY ASKED QUESTIONS: 

REIMBURSEMENT FOR DEXYCU®

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Q  What is DEXYCU®?

A  DEXYCU (dexamethasone intraocular suspension 9%) is administered as a 0.005 ml dose after preparation from the product kit. DEXYCU, when injected, administers 517 micrograms of the drug. It may help reduce the frequency or need for other post-operative anti-inflammatory agents.

 

Q  What is the indication for DEXYCU?

A  It is indicated for the treatment of postoperative inflammation after eye surgery.1,2

 

Q  When during eye surgery might an injection of DEXYCU be considered?

A  It is injected into the posterior chamber of the eye inferiorly behind the iris “at the end of surgery”.1

Per instructions from the manufacturer, the drug vial is first vigorously agitated for a minimum of 30 seconds to ensure suspension. The suspended drug must be used immediately after agitation. It is drawn up from the vial into a special syringe using an 18 gauge needle, following specific instructions to ensure proper dosing. The needle is then exchanged for a 25 gauge bent cannula and the drug is injected.

 

Q  What HCPCS code describes the supply of DEXYCU?

A  For dates of service on or after January 1, 2019, use J1095 (Injection, dexametha-sone 9 percent, intraocular, 1 microgram) to report the supply of DEXYCU.3

On your claim, bill 517 units to ensure proper payment. Use the 11-digit NDC code (71879-0001-01) in Box 19 of the claim.

 

Q  Is there separate payment to the HOPD or ASC for DEXYCU?

A  For Part B Medicare, there is separate payment for DEXYCU because it qualifies as a pass-through drug in 2021 under the Outpatient Prospective Payment System (OPPS) that governs reimbursement to hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs).4

In the Medicare payment schedule for HOPDs and ASCs, this is represented by status indicator “G” in the OPPS file.

Other payers may follow CMS’ policy but are not obliged to do so.

 

Q  What is the Medicare facility reimbursement for DEXYCU?

A  Effective January 1, 2021, CMS assigned a payment of $1.11 per microgram, so 517 units is allowed $573.87. This reimbursement rate changes periodically and depends on the manufacturer’s average selling price (ASP) as reported to CMS.

 

Q  What is the surgeon’s reimbursement for DEXYCU?

A  There is none. The surgeon is not reimbursed for the drug or its injection.

 

Q  Is DEXYCU subject to copayment rules?

A  It depends on where it is used. For Part B beneficiaries, drugs that have pass-through status are subject to the 20% Medicare copayment in an ASC. There is no copayment if the surgery takes place in a HOPD. More than 80% of Medicare beneficiaries with Part B coverage have supplemental insurance to cover some or all cost-sharing requirements.5

 

Q  Is DEXYCU an important consideration within MIPS in 2021?

A  No. MIPS payment adjustments in 2021 depend on the 2019 performance period. There are no physician reporting requirements for the cost category including the cataract measure;6 CMS determines cost scores. Acumen, the CMS contractor, developed the episode-based cost measure for cataract surgery. Some separately payable drugs are included in the measurement of cost, such as Omidria (C9447), but DEXYCU is not one of them.7 In subsequent performance periods, the set of included drugs may change. The importance of resource use, or cost, within MIPS will also grow.

 

1 Eye Point Pharmaceuticals. Full prescribing information. Link here. Accessed 03/30/21.
2 FDA. NDA 208912. Approval letter for DEXYCU. February 19, 2018. Link here. Accessed 03/30/21.
3 MedLearn Matters MM11099. Effective date 01/01/19. Link here. Accessed 03/30/21.
4 Social Security Act §1833(t)(6). Link here. Accessed 03/30/21.
5 Henry J Kaiser Family Foundation. Nov 2018. Link here. Accessed 03/30/21.
6 A list of ICD-10 codes that result in exclusion from the cataract episode measure can be found in measure 191. Link here. Accessed 03/30/21.
7 ASCRS/ASOA. MIPS Program: 2020 Cost Category

 

Provided Courtesy of EyePoint Pharmaceuticals  (833) 393-7646

Last updated April 8, 2021

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.

© 2021 Corcoran Consulting Group. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system, without the written permission of the publisher. CPT is a registered trademark of the American Medical Association.

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