OPPS Update Includes Added Coverage, New Codes, and Corrected Pay Rates

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  • September 10, 2012
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The October 2012 update to the Outpatient Prospective Payment System (OPPS) includes added coverage, two new drug/biological codes, and three corrected payment rates. Providers and suppliers paid under the OPPS should take note of these changes to ensure proper reimbursement.

Outpatient Payment for Laparoscopic Bariatric Surgery

Effective Jan. 1, 2012, outpatient hospitals (as well as ambulatory surgical centers (ASCs) paid under the ASC payment system) may perform and be paid for laparoscopic bariatric surgery procedures described by CPT® 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components).

Drugs/Biologicals with OPPS Pass-through Status

Effective Oct. 1, 2012 the following two drugs/biologicals have been granted OPPS pass-through status:

Level II Code
Descriptor APC Status Indicator
C9292 Injection, pertuzumab, 10 mg 9292 G
C9293 Injection, glucarpidase, 10 units 9293 G

These drugs/biologicals have also been granted ASC payment status effective Oct. 1, 2012. The ASC payment indicator is K2 Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate.
Pertuzumab (brand name Perjeta™) was approved by the U.S. Food and Drug Administration (FDA) on June 8, 2012. Pertuzumab is used in combination with trastuzumab and docetaxel to treat certain patients with HER2-positive metastatic breast cancer.
Glucarpidase (Voraxaze) was approved by the FDA on Jan. 17, 2012 for the treatment of toxic plasma methotrexate concentrations in patients with delayed methotrexate clearance due to impaired renal function.

Payment Rate Corrections

The payment rates for three HCPCS Level II codes were incorrect in the July 2012 OPPS Pricer and the July 2012 ASC Drug File. The corrected payment rates have been installed in the October 2012 OPPS Pricer and the revised July 2012 ASC Drug File, but providers and suppliers who submitted claims for the following items under the OPPS/ASC PS between July 1, 2012 and Sept. 30, 2012 will need to act to receive proper reimbursement.

Level II Code
Short Descriptor APC Status Indicator Corrected Payment Corrected Minimum Unadjusted Co-pay
C9368 Grafix Core 9368 G $160.66 $31.53
C9369 Grafix Prime 9368 G $51.84 $10.17
Q2045 Human fibrinogen conc inj 1414 K* $0.89 $0.18

*Status indicator K Non-pass-through drugs and non-implantable biologicals including therapeutic radio pharmaceuticals
Source: MLN Matters® MM8031, released Aug. 24, 2012; MLN Matters® MM8032, released Aug. 24, 2012

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