Pharmacy Question for the Week of September 25, 2017

Pharmacy Compliance Question of the Week

Question:

Last week you said that the new modifier ZC (Merck/Samsung Bioepis) would be effective on July 1, 2017 for the code reporting an injection of the biosimilar drug infliximab. However, I think that is the wrong date. Instead, it should be October 1, 2017, according to transmittal 3850. Can you verify?

Answer:

It appears that the Centers for Medicare & Medicaid Services (CMS) have published two different effective dates for new modifier ZC in two different transmittals that were issued on the same date of August 25, 2017. It is likely that CMS will issue a clarification in the near future, which will be published here. What we have so far is as follows:

Transmittal 3853 (CR 10236) includes the following information: Q5102 can be reported with either the existing modifier ZB or new modifier ZC effective July 1, 2017. The table accompanying this directive also lists July 1, 2017 as the effective date for modifier ZC.

For the above, go to https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017-Transmittals-Items/R3853CP.html.

However, transmittal 3850 (CR 10234) states the following:

The ZC modifier will become effective (that is, valid) for claims submitted beginning October 1, 2017 and applies retroactively to dates of service on or after July 24, 2017. Contractors shall add modifier ZC (Merck/Samsung Bioepis) to the required modifiers that must be used when HCPCS code Q5102 is billed on a claim.

A second biosimilar version of infliximab was marketed on July 24, 2017, creating a situation where products from two manufacturers may appear on claims. In order to allow the identification of the manufacturer of the specific biosimilar biological product that was administered to a patient, either existing HCPCS modifier ZB, or new modifier ZC is required when HCPCS code Q5102 is billed on a claim that is submitted after October 1, 2017.

For this information, go to https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3850CP.pdf.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.