Warning: Opdivo is New RAC Target

Opdivo is an immunotherapy treatment for advanced cancer.

What is Opdivo? It’s a new target for Recovery Audit Contractors (RACs), specifically Performant Recovery. Opdivo is an immunotherapy treatment for advanced cancer or cancers that have been resistant to other treatments. While this is a newer drug, Medicare will still cover the cost of cancer treatment with Opdivo.

• Medicare covers cancer treatment under parts A, B, and C, depending on which phase of treatment you’re in, where you receive treatment, and the plan you have.
• Medicare pays for Opdivo as an outpatient infusion: the consumer will pay a 20-percent copayment for each infusion after the Part B deductible has been met.

Opdivo is fairly new, having been approved by the Food and Drug Administration (FDA) in 2015. Despite this, cancer treatments are covered under original Medicare. Original Medicare is made up of two main parts: Part A and Part B. J9299 is a valid 2020 HCPCS code for Injection, nivolumab, 1 mg or just “Injection, nivolumab” for short, used in medical care J9299 has been in effect since Jan. 1, 2016.

The reason that I think Opdivo will be one of the upcoming RAC audit targets is because the dollar amount is high, per injection. If an auditor finds no medical necessity or a documentation error for even just 10 dates of service, we are already talking about high costs. Then add in an extrapolation here and there.

The cost of Opdivo depends on the dosage you receive and how long you receive treatment. Opdivo is considered a specialty medication in both its brand name and generic forms.

Depending on the dose, Opdivo can cost $6,580 per infusion.

Performant Recovery Inc., which is covering New York, Maine, New Hampshire, Massachusetts, Rhode Island, Connecticut, Ohio, Kentucky, Indiana, and Michigan, has been instructed by CMS to review and audit for drugs and biologicals with excessive use, or insufficient drug units billed. Performant is also in Region 5 – the national U.S. contract for durable medical equipment (DME) and home health and hospice (HHH).

Opdivo should be billed in multiples of the dosage specified in the HCPCS code long descriptor.

The number of units billed should be assigned based on the dosage increment specified in that HCPCS long descriptor and should correspond to the actual amount of the drug administered to the patient, including any appropriate discarded drug waste. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Claims billed with excessive or insufficient units will be reviewed by a nurse, registered pharmacist, certified pharmacy technician, or certified coder to determine the actual amount administered and the correct number of billable/payable units.

If you do not, beware of upcoming audits. Self-audit. Self-report.

Programming Note: Knicole Emanuel, Esq. is a permanent panelist on Monitor Mondays. Listen to her RAC Report every Monday at 10 a.m. EST.