Continuation of System Changes to Automate Processing of Inpatient Claims for Chimeric Antigen Receptor (CAR) T-Cell and Other Immunotherapy Cases

CMS recently became aware that there are other instances in which the immunotherapy product is not purchased in the usual manner, such as provided at no cost. Beginning in FY 2026, in cases where the immunotherapy product is not purchased in the usual manner, such as provided at no cost, the payment adjustment will be applied.

To notify the Medicare Administrative Contractor (MAC) of a case where the immunotherapy product is not purchased in the usual manner, such as provided at no cost, the provider may enter billing note "PROD NO COST" on the electronic claim 837I or a remark "PROD NO COST" on a paper or Direct Data Entry (DDE) claim, and the Shared System Maintainer (SSM) shall populate condition code ZD so that the Inpatient Prospective Payment System (IPPS) Pricer will apply the payment adjustment in calculating the payment for the case.

Refer to CMS Change Request (CR) 14028 for details.

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