Physician groups want unique codes for billing and payment of biosimilar drugs

Under current law, reimbursement for biosimilars is calculated by a single code. Six physician groups that represent a wide swath of biologic-prescribing physicians, want to change that by urging Congress to press the Centers for Medicare and Medicaid Services to make unique codes for biosimilar medicines for billing and payment purposes.

The groups drafted and sent a collaborative letter to Senator Orrin Hatch, R-Utah, who has already voiced opposition to a single code system for biosimilars, asking him to press their case to CMS that every biosimilar drug should have its own Healthcare Common Procedure Coding System reimbursement rate and code.

The groups include Alliance for Patient Access, American Association of Clinical Endocrinologists, American College of Rheumatology, American Gastroenterological Association, Biologics Prescribers Collaborative, and Coalition of State Rheumatology Organizations.

Because CMS policy as laid out in its 2016 Physician Fee Schedule placed all biosimilars under the same billing and payment code, the groups argued reimbursement could then be based on average sales, reducing manufacturer incentives to make improved versions of the drugs. 

They also said using a single code inhibits the tracking and tracing of each drug's use/outcomes, potentially jeopardizing patient safety. In their collective letter to Sen. Hatch, who is chairman of the Finance Committee, they wrote:

"We urge you and other Members of Congress to direct CMS to adhere to current law that states that the calculation for reimbursing biosimilars shall be made separately, strongly implying that each biosimilar should have its own unique payment rate and HCPCS code. As physicians who make complex medical decisions daily, we are committed to principles of patient-centered care and a clinically sound prescribing process for biological products, including biosimilars. A single HCPCS billing code and reimbursement rate for all biosimilars of a single reference product seriously jeopardizes these principles, undermining innovation, science and safety."

The letter to Sen. Hatch was sent on December 9. The 2016 Fee Schedule will take effect January 1, 2016.

Twitter: @BethJSanborn