Omeros announced that the Centers for Medicare and Medicaid Services (CMS) confirmed its preliminary decision to assign a permanent product-specific Healthcare Common Procedure Coding System (HCPCS) J-code for Omidria (phenylephrine and ketorolac intraocular solution) 1% / 0.3%.
Omidria is Omeros’ commercial drug used during cataract surgery to prevent miosis and reduce postoperative pain, improving patient outcomes and safety. The new J-code for Omidria—J1097—will become effective October 1, 2019, according to a company news release.
J-codes are reimbursement codes used by commercial insurance plans, Medicare, Medicare Advantage, and other government payers for Medicare Part B drugs like Omidria that are administered by a physician. Claims submission and payment are standardized with a J-code, facilitating and streamlining billing and reimbursement. In addition, some commercial insurers require a J-code for payment, so insurers who would not reimburse providers for Omidria under the drug’s current temporary HCPCS C-code should be able to provide reimbursement with the newly awarded permanent J-code. Commercially insured patients represent a growing segment of the Omidria user base.
“Having a permanent J-code will simplify billing and payment, further enhancing patient access to Omidria,” Gregory A. Demopulos, MD, chairman and chief executive officer of Omeros, said in the news release. “With the expanding body of evidence demonstrating the clinical benefits of Omidria—from prevention of IFIS to reduction in both cystoid macular edema and opioid use—physician demand continues to grow, and the J-code makes appropriate reimbursement of Omidria even more reliable.”