Several CMS-designated permanent and product-specific J-codes recently went into effect, allowing three ophthalmology-minded pharmaceutical companies to expand reimbursement through commercial and Medicare insurance plans.
J-codes were activated Oct. 1 for FDA-approved products manufactured by EyePoint Pharmaceuticals, Ocular Therapeutix and Omeros.
In the past, J-codes were announced once a year; now, CMS is issuing certain J-codes quarterly, Lisa Nijm, MD, JD, founder and medical director of Warrenville EyeCare & LASIK, told Healio/OSN.
Nijm said the window between J-code announcement to activation is helpful because payers then have an opportunity to incorporate the codes into their systems for implementation once the codes go into effect.
For EyePoint, the J-code was activated for Yutiq (fluocinolone acetonide intravitreal implant 0.18 mg), its 3-year micro-insert for chronic, noninfectious uveitis, following its issuance in July.
For Omeros, J-code activation was for Omidria (phenylephrine 1% and ketorolac 0.3% intraocular solution), which is used during cataract surgery to prevent miosis and inhibit postoperative pain.
In Ocular Therapeutix’s case, the J-code replaced the temporary C-code for Dextenza (dexamethasone ophthalmic insert 0.4 mg), approved for treatment of ocular inflammation and pain after ophthalmic surgery.
Some commercial payer plans as well as some state Medicaid plans would recognize J-codes but not C-codes for reimbursements, while some would recognize C-codes only for hospitals but not ASCs, Nijm said.
“By having a J-code, that streamlines the process. You can use one code across all payers for reimbursement,” she said. “The simpler the system is to get reimbursed, the better it is for patients because it allows for smoother utilization and fewer billing errors that may impact patients.”
The codes, issued through the CMS Healthcare Common Procedure Coding System, allow for obtaining pass-through payments under Medicare Part B.
“All three companies have pass-through status right now for their products, so it is important for ophthalmologists to understand how pass-through status works,” Nijm said.
Pass-through is budget neutral, and the cost set for each product is determined by CMS using a complex formula, she explained. Reimbursement is separate from the procedure and does not affect the physician’s or the ASC’s reimbursement.
“In fact, ASCs and hospitals can be reimbursed above the cost of the product,” she said.
During a fiscal year, if pass-through funds intended to reimburse new products, whether for ophthalmology or otherwise, go unused, then that money is “lost to the system,” Nijm said. “So, it is advantageous for physicians to utilize these new drugs during the pass-through time period to provide greater access to patients to cutting-edge innovations and technologies that can help improve outcomes in cataract surgery.”
All three companies have support centers for questions about coding and billing, as well as programs for providing assistance to patients who cannot afford the medication, Nijm said. – by Earl Holland Jr.
Disclosure: Nijm reports she receives consultant fees from EyePoint, Ocular Therapeutix and Omeros.