FDA-approved OMIDRIA qualifies for separate payment by Centers for Medicare & Medicaid Services (CMS) when used in ambulatory surgery centers (ASCs)



OMIDRIA has a unique permanent J-code

J1097

phenylephrine 10.16 mg/mL and ketorolac 2.88 mg/mL ophthalmic irrigation solution, 1 mL 7

OMIDRIA is reimbursed per mL; therefore, providers should always use 1 mL as the billing unit and bill for 4 units.

CMS confirmed that OMIDRIA qualifies for separate payment under the non-opioid pain management policy when used in ASCs. Separate payment is effective retroactively beginning October 1, 2020 26.

  • 20% co-pay in ASCs 27
    • Approximately 90% of Medicare Part B patients have some form of supplemental insurance, which covers co-pays 28
OMIDRIA is covered and paid by 100% of Medicare Administrative Contractors (MACs) across all 50 states and Puerto Rico

Individual plan coverage, payment, policies, and procedures vary and should be confirmed by the facility. Omeros does not guarantee reimbursement.

No effect on physician or facility fees 27

Payment to the surgeon for cataract surgery under Medicare’s Physician Fee Schedule will be unaffected by the use of OMIDRIA.

Learn More About OMIDRIAssure

 

Information contained herein is provided as a reference for obtaining appropriate and accurate reimbursement for the use of OMIDRIA in eligible patients. Omeros Corporation does not guarantee that the use of the recommended codes will result in reimbursement.

Indications and Usage

OMIDRIA® is added to ophthalmic irrigating solution used during cataract surgery or intraocular lens replacement and is indicated for maintaining pupil size by preventing intraoperative miosis and reducing postoperative ocular pain.

Important Safety Information

OMIDRIA must be added to irrigating solution prior to intraocular use.

OMIDRIA is contraindicated in patients with a known hypersensitivity to any of its ingredients.

Systemic exposure of phenylephrine may cause elevations in blood pressure.

Use OMIDRIA with caution in individuals who have previously exhibited sensitivities to acetylsalicylic acid, phenylacetic acid derivatives, and other nonsteroidal anti-inflammatory drugs (NSAIDs), or have a past medical history of asthma.

The most commonly reported adverse reactions at ≥ 2% are eye irritation, posterior capsule opacification, increased intraocular pressure, and anterior chamber inflammation.

Please see the Full Prescribing Information for OMIDRIA.

You are encouraged to report Suspected Adverse Reactions to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

OMEROS®, the OMEROS logo®, OMIDRIA®, the OMIDRIA logo®, and OMIDRIAssure® are registered trademarks of Omeros Corporation.
© Omeros Corporation 2021, all rights reserved. 2019-071

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References
  1. Omeros survey data on file.
  2. Rosenberg ED, Nattis AS, Alevi D, et al. Visual outcomes, efficacy, and surgical complications associated with intracameral phenylephrine 1.0%/ketorolac 0.3% administered during cataract surgery. Clin Ophthalmol. 2017;12:21-28.
  3. OMIDRIA [package insert]. Seattle, WA: Omeros Corporation; 2017.
  4. Lindstrom RL, Loden JC, Walters TR, et al. Intracameral phenylephrine and ketorolac injection (OMS302) for maintenance of intraoperative pupil diameter and reduction of postoperative pain in intraocular lens replacement with phacoemulsification. Clin Ophthalmol. 2014;8:1735-1744.
  5. Hovanesian JA, Sheppard JD, Trattler WB, et al. Intracameral phenylephrine and ketorolac during cataract surgery to maintain intraoperative mydriasis and reduce postoperative ocular pain: integrated results from 2 pivotal phase 3 studies. J Cataract Refract Surg. 2015;41:2060-2068.
  6. Donnenfeld ED, Whitaker JS, Jackson MA, Wittpenn J. Intracameral ketorolac and phenylephrine effect on intraoperative pupil diameter and postoperative pain in cataract surgery. J Cataract Refract Surg. 2017;43:597-605.
  7. HCPCS quarterly update. CMS.gov. Available at: https://www.cms.gov/medicare/coding/hcpcsreleasecodesets/hcpcs-quarterly-update.html. Accessed August 9, 2019.
  8. Al-Hashimi S, Donaldson K, Davidson R, et al. Medical and surgical management of the small pupil during cataract surgery. J Cataract Refract Surg. 2018;44:1032-1041.
  9. Guzek JP, Holm M. Cotter JB, et al. Risk factors for intraoperative complications in 1000 extracapsular cataract cases. Ophthalmol. 1987;94(5):461-466.
  10. Roach L. Strategies for preventing intraoperative miosis. EyeNet. 2015:29-31.
  11. Chang DF, Campbell JR, Colin J, Schweitzer C. Prospective masked comparison of intraoperative floppy iris syndrome severity with tamsulosin versus alfuzosin. Ophthalmol. 2014;121:829-834.
  12. Ackman A, Yilmaz G, Oto S, Akova YA. Comparison of various pupil dilatation methods for phacoemulsification in eyes with a small pupil secondary to pseudoexfoliation. Ophthalmol. 2004;111:1693-1698.
  13. Katsev DA, Katsev CC, Pinnow J, Lockhart CM. Intracameral ketorolac concentration at the beginning and end of cataract surgery following preoperative topical ketorolac administration. Clin Ophthalmol. 2017;11:1897-1901.
  14. Porela-Tiihonen S, Kaarniranta K, Kokki M. Postoperative pain after cataract surgery. J Cataract Refract Surg. 2013;39:789-798.
  15. Omeros data on file.
  16. Silverstein SM, Rana V, Stephens R, et al. Effect of phenylephrine 1.0%-ketorolac 0.3% injection on tamsulosin-associated intraoperative floppy-iris syndrome. J Cataract Refract Surg. 2018;44(9):1103-1108.
  17. Visco D. Effect of phenylephrine/ketorolac on iris fixation ring use and surgical times in patients at risk of intraoperative miosis. Clin Ophthalmol. 2018;12:301-305.
  18. Bucci FA Jr, Michalek B, Fluet AT. Comparison of the frequency of use of a pupil expansion device with and without an intracameral phenylephrine and ketorolac injection 1%/0.3% at the time of routine cataract surgery. Clin Ophthalmol. 2017;11:1039-1043.
  19. Walter K, Delwadia N, Coben J. Continuous intracameral phenylephrine-ketorolac irrigation for miosis prevention in femtosecond laser-assisted cataract surgery: reduction in surgical time and iris manipulation. J Cataract Refract Surg. 2019;45(4):465-469. doi: 10.1016/j.jcrs.2018.11.004.
  20. Matossian C, Teves N. Clinical outcomes of phenylephrine/ketorolac intraocular solution versus epinephrine in cataract surgery in a real-world setting. Manuscript submitted for publication. 2018.
  21. Gayton JL. Effect of early phenylephrine and ketorolac injection 1% / 0.3% (Omidria®) usage on pupil diameter in traditional and femtosecond laser assisted cataract surgery. E-poster presented at: 15th International Congress on Vision Science and Eye; 2017 Aug 10-11; London, UK.
  22. Waterbury LD. Alternative drug delivery for patients undergoing cataract surgery as demonstrated in a canine model. J Ocul Pharmacol Ther. 2018;34:154-160.
  23. Visco D, et al. Study to evaluate patient outcomes following cataract surgery when using OMIDRIA with postoperative topical NSAID administration versus a standard regimen of postoperative topical NSAIDs and steroids. Presented at: 28th Annual Meeting of the American College of Eye Surgeons (ACES), the American Board of Eye Surgery (ABES), and the Society for Excellence in Eyecare (SEE), Caribbean Eye Meeting; February 1-5, 2019; Cancún, Mexico.
  24. Walter K, Kauffman L, Hess J. Rate of pseudophakic cystoid macular edema using intraoperative and topical NSAIDs alone without steroids. Manuscript submitted for publication. 2019.
  25. Data on file.
  26. Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs. Baltimore, MD: Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services; December 2, 2020. CMS publications CMS-1736-FC and 1736-IFC.
  27. Medicare program: changes to hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs. Fed Regist. 2018(83);58818-59179.
  28. Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2010.