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OPPS Update: New Services, Retroactive Payment Corrections

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  • April 1, 2011
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The Centers for Medicare & Medicaid Services (CMS) announced, March 18, updates for the Hospital Outpatient Prospective Payment System (OPPS), effective April 1. If your facility or ambulatory surgical center (ASC) submits outpatient claims to Medicare, you’ll want to know about these changes, which include code additions and deletions, payment status changes and corrections, too.

Pass-through Status Changes

Three new drug supply HCPCS Level II codes have been granted pass-through status:
C9280 Injection, eribulin mesylate, 1 mg (APC 9280)
C9281 Injection, pegloticase, 1 mg (APC 9281)
C9282 Injection, ceftaroline fosamil, 10 mg (APC 9282)
CMS grants pass-through status to some new medications, allowing hospitals to receive additional reimbursement for the supply. Pass-through status is effective for at least two years, but no more than three years.

Code Additions

The update also includes one new code for use in the hospital outpatient setting. HCPCS Level II Q2040 Injection, incobotulinumtoxin A, 1 unit (APC 9278) replaces C9278 as of April 1. Incobotulinumtoxin A (trade name Xeomin®) is used in treatment of cervical dystonia to decrease the severity of abnormal head position and neck pain, and may be indicated to treat blepharospasm (abnormal contractions/twitching of the eyes).
A new service, C9729 Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with ligamentous resection, discectomy, facetectomy and/or foraminotomy, when performed) any method under indirect image guidance, with the use of an endoscope when performed, single or multiple levels, unilateral or bilateral; lumbar (APC 0208) has been assigned for payment under OPPS effective April 1, with a payment rate of $3,535.92 and a minimum unadjusted copayment of $707.19.


The update further includes retroactive payment corrections for nine HCPCS Level II codes reported from Oct. 1, 2010 to Dec. 31, 2010. The affected codes (with short descriptors) include:
J0833 Cosyntropin injection NOS
J1451  Fomepizole, 15 mg
J3030 Sumatriptan succinate / 6 mg
J7502 Cyclosporine oral 100 mg
J7507 Tacrolimus oral per 1 mg
J9185 Fludarabine phosphate injection
J9206 Irinotecan injection
J9218 Leuprolide acetate injection
J9263 Oxaliplatin
Payment corrections apply to Q4118 Matristem micromatrix for claims filed between Jan. 1 and March 31.
HCPCS Level II Q4419 Matristem wound matrix, per square centimeter has been granted a “K” status indicator retroactively, allowing separate payment for all such claims on or after Jan. 1. Previously, the code was assigned an “E” status indicator, indicating that the code was not paid when submitted on outpatient claims.
Similarly, G0010 Administration of hepatitis B vaccine was erroneously assigned a “B” status indicator (not recognized by OPPS) in the January update. The April update corrects the status indicator for G0010 to an “S” (Significant procedure, not discounted when multiple), retroactive to Jan. 1, 2011. To ensure correct waiver of coinsurance and deductable under OPPS, G0010 must be used in place of CPT® 90471 or 90472 to report administration of hepatitis B vaccine.
Action point: Review your claims going back to Oct. 1, 2010 to determine if your facility is due payment adjustments related to any of the code payment/status indicator changes noted above.

Code Deletions

Codes 90663 and 90470, removed from the CPT® code set on Dec. 31, 2010, are no longer eligible for OPPS payment. And HCPCS Level II Q1003 New technology intraocular lens category 3 is packaged under OPPS, and will be deleted beginning April 1.
Policy reminders in the April 2011 update review proper reporting of biologicals used as implantable devices, drug units, outpatient diagnostic nuclear medicine procedures, and C9399 for unclassified drug or biological. Also included is a review of device-to-procedure edits. The complete list may be found on the CMS website. These reviews do not reflect any change in OPPS policy.
For additional information related to the April 1 OPPS update, see Transmittal 2174.

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