Monoclonal Antibodies – New Codes and Rates for COVID-19 Therapeutics

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New Codes, Rates for COVID-19 Therapeutics

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Healthcare providers administering monoclonal antibodies to Medicare patients with COVID-19 will soon see an increase in reimbursement, especially if providing this service in an unconventional setting.

For dates of service (DOS) on or after May 6, the national average payment rate for administering monoclonal antibodies is increased from $310 to $450 in most healthcare settings. The Centers for Medicare & Medicaid Services (CMS) is also establishing two new HCPCS Level II codes (M0244 and M0246) for treatment provided in the patient’s home or temporary lodging (e.g., hotel/motel, cruise ship, hostel, or homeless shelter) with a national payment rate of $750.

Latest Codes and Payment Rates

CMS has updated its COVID-19 Vaccines and Monoclonal Antibodies website to reflect the new codes and payment rates, as shown here:

Code Descriptor Labeler National Payment Allowance for DOS 5/6/2021 or after National Payment Allowance for DOS through 5/5/2021 Effective Dates
Q0239 Injection, bamlanivimab-xxxx, 700 mg Eli Lilly N/A $0.010 11/10/2020 – 04/16/2021
M0239 Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring Eli Lilly N/A $309.600 11/10/2020 – 04/16/2021
Q0243 Injection, casirivimab and imdevimab, 2400 mg Regeneron $0.010 $0.010 11/21/2020 – TBD
M0243 Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring Regeneron $450.00 $309.600 11/21/2020 – TBD
M0244 Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency Regeneron $750.00 N/A 5/6/2021 – TBD
Q0245 Injection, bamlanivimab and etesevimab, 2100 mg Eli Lilly $0.010 $0.010 2/9/2021 – TBD
M0245 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring Eli Lilly $450.00 $309.600 2/9/2021 – TBD
M0246 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency Eli Lilly $750.00 N/A 5/6/2021 – TBD
N/A – not applicable after May 5, 2021

Important Coverage Update

The Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for bamlanivimab on Nov. 9 2020, and for casirivimab and imdevimab, when administered together, on Nov. 21, 2020, for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and requiring hospitalization.

On April 16, however, the FDA revoked the EUA that allowed for bamlanivimab to be used alone for such treatment. Due to this revocation, Medicare will not pay for claims with HCPCS Level II codes M0239 or Q0239 with DOS after April 16.

Monoclonal antibody products are not eligible for the New COVID-19 Treatments Add-on Payment under the Inpatient Prospective Payment System.

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