April OPPS Additions, Changes, Deletions

The Centers for Medicare & Medicaid Services (CMS) has posted April 2012 changes to billing instructions for payment policies implemented in the hospital Outpatient Prospective Payment System (OPPS). The April 2012 updated Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer will reflect the HCPCS Level II, ambulatory payment classification (APC), HCPCS modifier, and revenue code additions, changes, and deletions as identified in change request (CR) 7748. The April 2012 revisions to I/OCE data files, instructions, and specifications are provided in CR 7751, “April 2012 Integrated Outpatient Code Editor (I/OCE) Specifications Version 13.1.”

Noteworthy Changes

1. For services provided on or after Jan. 1, 2012, the descriptor for CPT® 33249 has been changed to read “Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber.” Due to clinical inappropriateness, this has prompted the removal of HCPCS Level II code C1882 Cardioverter-defibrillator, other than single or dual chamber (implantable) from the list of device codes required to be billed with CPT® code 33249 on the procedure-to-device edit list. This change is retroactive to Jan. 1, 2012.

2. For new service (fluorescent vascular angiography), HCPCS Level II code C9733 Non-ophthalmic fluorescent vascular angiography (SI = Q2 and APC = 0397, vascular imaging) is assigned for $154.87 payment (minimum unadjusted copayment = $30.98) under the OPPS, effective April 1, 2012. HCPCS Level II code C9733, assigned to APC 0397, describes SPY® Fluorescence Vascular Angiography and other types of non-ophthalmic fluorescent vascular angiography.

3. Drugs and biologicals with OPPS pass-through status, effective April 1, 2012, are:

C9288 Injection, centruroides (scorpion) immune f(ab)2 (equine), 1 vial

C9289 Injection, asparaginase Erwinia chrysanthemi, 1,000 international units (I.U.)

C9290 Injection, bupivacaine liposome, 1 mg

C9291 Injection, aflibercept, 2 mg vial

4. Payment rates for certain HCPCS Level II codes effective July 1- Sept. 30, 2011 are:

HCPCS Code Status Indicator APC Short Descriptor Corrected Payment Rate Corrected Min. Unadjusted Copayment
J0735 K 0935 Clonidine hydrochloride $35.67 $7.13
J1212 K 1221 Dimethyl sulfoxide 50% 50 ML $84.55 $16.91
J1756 K 9046 Iron sucrose injection $0.34 $0.07
J9245 K 0840 Inj melphalan hydrochl 50 MG $1,308.97 $261.79

5. The following HCPCS Level II codes describe products that can be used as skin substitutes (They will be separately paid only when used with one of the CPT® codes describing the application of a skin substitute (15271-15278)):

HCPCS Level II Code APC Short Descriptor Status Indicator
C9358 9358 SurgiMend, fetal K
C9360 9360 SurgiMend, neonatal K
C9363 9363 Integra Meshed Bil Wound Mat K
C9366 9366 EpiFix wound cover G
C9367 9367 Endoform Dermal Template G
Q4100 N/A Skin substitute, NOS N
Q4101 1240 Apligraf K
Q4102 1241 Oasis wound matrix K
Q4103 1242 Oasis burn matrix K
Q4104 1243 Integra BMWD K
Q4105 1244 Integra DRT K
Q4106 1245 Dermagraft K
Q4107 1246 Graftjacket K
Q4108 1247 Integra matrix K
Q4110 1248 Primatrix K
Q4111 1252 Gammagraft K
Q4112 1249 Cymetra injectable K
Q4113 1250 Graftjacket xpress K
Q4114 1251 Integra flowable wound matri K
Q4115 1287 Alloskin K
Q4116 1270 Alloderm K
Q4118 1342 Matristem micromatrix K
Q4119 1351 Matristem wound matrix K
Q4121 1345 Theraskin K
Q4122 1419 Dermacell K
Q4124 9365 Oasis Ultra Tri-Layer Matrix G
Q4130 N/A Strattice TM N

For the complete CR, see CMS Transmittal 2418.

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