Final

Issued by: Centers for Medicare & Medicaid Services (CMS)

CMS issued an Interim Final Rule with Comment Period that established the New COVID-19 Treatments Add-on Payment (NCTAP) under the Medicare Inpatient Prospective Payment System (IPPS). The NCTAP, designed to mitigate potential financial disincentives for hospitals to provide new COVID-19 treatments, is effective from November 2, 2020, until September 30, 2023.

Through the NCTAP, Medicare will provide an enhanced payment through September 30, 2023, for eligible inpatient cases that use certain new products with current FDA approval or emergency use authorization (EUA) to treat COVID-19, including the following:

• Convalescent plasma: On August 23, 2020, the FDA issued (latest update December 28, 2021) an EUA for the use of COVID-19 convalescent plasma for treating COVID-19 in hospitalized patients.
• GOHIBIC (vilobelimab): On April 4, 2023, the FDA issued (latest update April 12, 2023) an EUA for the use of GOHIBIC to treat certain hospitalized adult patients with severe COVID-19 illness. 
• Kineret® (anakinra): On November 8, 2022, the FDA issued an EUA for Kineret injection for the treatment of COVID-19 in hospitalized adults with positive results of direct SARS-CoV-2 viral testing with pneumonia requiring supplemental oxygen (low- or high-flow oxygen) who are at risk of progressing to severe respiratory failure and likely to have an elevated plasma soluble urokinase plasminogen activator receptor (suPAR). Review the Fact Sheet for Healthcare Providers: EUA for Kineret for more information about the limits and conditions for pharmacists prescribing Kineret.
• Lagevrio (molnupiravir): On December 23, 2021, the FDA issued (latest update February 1, 2023) an EUA for molnupiravir for the treatment of mild-to-moderate COVID-19 in certain adults who are at high-risk for progression to severe COVID-19, including hospitalization or death.

• Olumiant® (baricitinib): On November 19, 2020, the FDA issued (latest update October 27, 2022) an EUA for the use of Olumiant for the treatment of suspected or laboratory confirmed COVID-19 in certain hospitalized patients.
• PAXLOVID^TM (nirmatrelvir co-packaged with ritonavir): 
  • On December 23, 2021, the FDA issued an EUA for PAXLOVID for the treatment of mild-to-moderate COVID-19 in certain adults and pediatric patients at high risk for progression to severe COVID-19, including hospitalization or death. 
  • On July 6, 2022, the FDA revised the EUA to let pharmacists prescribe and dispense PAXLOVID to eligible patients without seeing a doctor or other clinician. Review the Fact Sheet for Health Care Providers: EUA for PAXLOVID for more information about the limits and conditions for pharmacists prescribing PAXLOVID.
  • On May 25, 2023, the FDA approved PAXLOVID to treat eligible adult patients. PAXLOVID remains available under the EUA to treat eligible pediatric patients.
• VEKLURY® (remdesivir): On January 21, 2022, the FDA approved a supplemental New Drug Application (NDA) for VEKLURY, which expanded its use from adults and pediatric patients (12 years of age and older and weighing at least 40 kg) for the treatment of COVID-19 requiring hospitalization to certain non-hospitalized adults and pediatric patients for the treatment of mild-to-moderate COVID-19 disease. See the Federal Register announcement for more information about the revoked EUA and NDA approval.

For eligible cases, the NCTAP is equal to the lesser of these:

• 65% of the operating outlier threshold for the claim
• 65% of the amount by which the costs of the case exceed the standard Diagnosis-Related Group (DRG) payment (including the adjustment to the relative weight under Section 3710 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act)

Coding for NCTAP

NCTAP claims are those that are eligible for the 20% add-on payment under Section 3710 of the CARES Act. Eligible claims have an ICD-10-CM diagnosis code U07.1 (COVID-19) and 1 of the following:

• ICD-10-PCS codes for VEKLURY (remdesivir), COVID-19 convalescent plasma, or Olumiant (baricitinib)
• National Drug Codes (NDC) for PAXLOVID (nirmatrelvir co-packaged with ritonavir), Lagevrio (molnupiravir), Kineret, and GOHIBIC

Codes for COVID-19 Convalescent Plasma for Hospital Discharges On or After November 2, 2020

ICD-10-PCS Code	Description
XW13325	Transfusion of convalescent plasma (nonautologous) into peripheral vein, percutaneous approach, new technology group 5
XW14325	Transfusion of convalescent plasma (nonautologous) into central vein, percutaneous approach, new technology group 5

Codes for GOHIBIC for Hospital Discharges On or After April 4, 2023

National Drug Code	Description
08300011004	GOHIBIC

NDCs are listed as 11-digit codes for hospital institutional billing

Codes for Kineret for Hospital Discharges On or After November 8, 2022

National Drug Code	Description
06665823407	Kineret (anakinra)

NDCs are listed as 11-digit codes for hospital institutional billing

Codes for Lagevrio for Hospital Discharges On or After December 23, 2021

National Drug Code	Description
00006505506	Lagevrio (molnupiravir)
00006505507	Lagevrio (molnupiravir)

NDCs are listed as 11-digit codes for hospital institutional billing

Codes for Olumiant

ICD-10-PCS Code	Description
For Hospital Discharges between November 19, 2020 and December 31, 2020
XW0DXF5	Introduction of other new technology therapeutic substance into mouth and pharynx, external approach, new technology group 5
3E0G7GC	Introduction of other therapeutic substance into upper G.I. via natural or artificial opening
3E0H7GC	Introduction of other therapeutic substance into lower G.I. via natural or artificial opening
For Hospital Discharges On or After January 1, 2021
XW0DXM6	Introduction of baricitinib into mouth and pharynx, external approach, new technology group 6
XW0G7M6	Introduction of baricitinib into upper GI, via natural or artificial opening, new technology group 6
XW0H7M6	Introduction of baricitinib into lower GI, via natural or artificial opening, new technology group 6

 

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