The CAP Advocates to Reverse CAR-T Payment Policy

CAP Economic Affairs Committee members met with officials from the Centers for Medicare & Medicaid Services (CMS) to advocate for appropriate physician recognition and reimbursement for providing care and management to Chimeric Antigen Receptor T-cell (CAR-T) therapy patients on February 3. The CAP disagreed with the CMS' 2025 finalized policy to recognize CAR-T services as part of the drug product manufacturing process and to not pay individually for each CAR-T service through the Medicare Physician Fee Schedule.

The CMS had finalized a policy in its final 2025 physician fee schedule rule to bundle payment for harvesting and preparation of CAR-T cells into the drug code and to not pay individually for CPT codes 38225, 38226, and 38227 through the Medicare Physician Fee Schedule or Hospital Outpatient Prospective Payment System (OPPS).

The CAP led a multispecialty effort to create and value four new category I CPT codes for CAR-T therapy (CPT codes 38225, 38226, 38227, and 38228). Specifically, these codes recognize the harvesting of blood derived T lymphocytes, the preparation and preservation of these collected lymphocytes for transportation to a manufacturing facility, the subsequent receipt and preparation of the modified lymphocytes for infusion into the patient, and finally the administration of the modified lymphocytes to the patient.

The CAP explained that the CPT codes associated with CAR-T therapy represent separate and distinct processes. Each step is labor intensive and requires the expertise of physicians and professional oversight and monitoring. CAR-T patients are very sick and must be monitored for specific treatment related complications such as fainting, allergic reaction, seizures, and abnormal heart rate. By not reimbursing physicians separately for each of the CAR-T services, the CMS is failing to recognize the medical decision making and physician work associated with managing these complex and extremely sick patients. CPT codes 38225, 38226, 38227, and 38228 represent patient care and management. Providing life-saving emergency care in response to significant treatment specific complications should never be considered part of the drug manufacturing process.

CAR-T services should reasonably be expected to follow similar payment policies used for other gene and cell therapies. The CAP specifically modeled the CAR-T coding after gene therapy with the expectation that it would follow the same payment pathway. In a comment letter, CAP urged the CMS to reevaluate their payment policies related to CAR-T therapy and to make appropriate edits to ensure that the physician work is appropriately recognized and compensated.