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1. Fixed-Loss Threshold
- The outlier fixed-loss threshold has now reached an excessive and extremely problematic level. ASTCT encourages CMS to review methodological changes to improve base MS-DRG payment rates that would decrease the number of cases that pull from outlier dollars on a routine basis.
2. New Technology Add-on Payment (NTAP)
- ASTCT believes that the 75 percent of NTAP proposed for the hematopoietic stem cell (HSC) gene therapy products for the treatment of sickle cell disease (SCD) is insufficient and will not support beneficiary access. ASTCT proposes an alternate use of NTAP dollars for cost reimbursement of these products.
- ASTCT supports CMS’ proposal to move the three-year NTAP anniversary date from April 1 to October 1 for the FY 2026 cycle.
3. MS-DRG 018: Chimeric Antigen Receptor (CAR) T-Cell and Other Immunotherapies
- ASTCT recommends that CMS mitigate charge compression for MS-DRG 018 cases by utilizing the “other” cost-to-charge ration (CCR) to reduce CAR-T product charges to cost starting in FY 2025. The agency should utilize this method until CMS implements an alternative payment solution that results in a more appropriate base payment amount.
- ASTCT supports maintaining the current title; we request that CMS not map prademagene zamikeracel to MS-DRG 018 due to the clinical resource differences between it and the other therapies that are currently mapped to this MS-DRG.
4. MS-DRG 014: Allogeneic Bone Marrow (Stem Cell) Transplantation
- ASTCT recommends that CMS instruct MA plans to update their payment methodologies to provide cost-based reimbursement for donor search and cell acquisition costs for allogeneic HSCT as of the effective date of Section 108.
- CMS should also update and clarify cost report instructions for Section 108
- The agency is urged to implement a Medicare Code Editor edit that rejects claims reported with an allogeneic ICD-10-PCS code and without revenue code 0815 reported with charges greater than $0, similar to the long-standing outpatient edit in the Outpatient Code Editor.
5. MS-DRG 016 & 017: Autologous Bone Marrow Transplant with and without CC/MCC
- ASTCT recommends that CMS utilize NTAP dollars and Value Code 90 to provide cost reimbursement for HSC gene therapy products during the 2-3 year NTAP time frame while it develops a longer-term payment mechanism (see NTAP section).
6. Absence of Medicare Advantage (MA) Claims from Rate-Setting
- ASTCT requests that CMS model the inclusion of MA shadow claims on MS-DRGs to understand the impact excluding these data have on case volume and rate-setting now that > 50 percent of Medicare beneficiaries receive their health care through MA plans.
7. MS-DRG Methodological issues and Coding:
- ASTCT is concerned that the proposed market basket increase of 2.6 percent is woefully inadequate to address the significant staffing, drug, and supply costs that hospitals have and will continue to grapple with.
- ASTCT supports CMS’ proposal to delay implementation of the Complications and Comorbidities (CC) and Major Complications and Comorbidities (MCC) split criteria.
- ASTCT supports CMS’ proposals associated with MDC 17, including the creation of a new surgical base MS-DRG (850) for select acute leukemia cases.
- ASTCT supports CMS’ mapping and CC status proposals for the newly created lymphoma, in remission codes.
- ASTCT supports CMS’ ongoing review of the Social Determinants of Health Codes and its proposal to increase the severity level of the ICD-10-CM diagnosis codes that indicate housing instability.
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