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News & Advocacy

State Update: OAR Leads Downcoding Discussion with CGS

posted: January 1, 2017

CGS Administrators, the Medicare Contractor for Ohio and Kentucky, issued a report that seems to justify downcoding complex drugs to simple coding by explaining that classifying these biologics as complex in the first place was erroneous under the Current Procedural Terminology Professional Edition.

The OAR believes that arbitrarily moving the administrative coding for provider-administered biologics from complex to simple is unacceptable. In response, the OAR along with the Kentuckiana Rheumatology Alliance (KRA) and the American College of Rheumatology (ACR) held a meeting with CGS Medical Director Dr. Earl Berman to discuss the issue in detail. Dr. Berman and his team continued to express CGS’s position that they believe current definitions for complex coding in the Current Procedural Terminology Professional Edition do not meet the specifications for coding Orenica, Iiaris, Cimzia, Prolia, Simponi, Xolair, Arcalyst, Actemra and Stelera as complex.

The OAR along with the KRA and ACR are combating this belief with a follow-up comment letter expressing how the CPT Guide definition for coding complex meets the standards for these biological drugs.


Email CGS and OPPOSE the downcode.