Code and Payment Changes in October Update to OPPS
The October 2016 update to the Outpatient Prospective Payment System (OPPS) includes one new HCPCS Level II code, two deleted HCPCS Level II codes; ambulatory payment classification (APC) and status indicator (SI) changes to several drug codes; and other changes to various payment policies.
New Ultrasound Code
HCPCS Level II code C9744 Ultrasound, abdominal, with contrast is effective Oct. 1, 2016. This new code has been assigned an OPPS SI of S and an OPPS APC of 5571.
Deleted G Codes
Effective Sept. 30, 2016, HCPCS Level II codes G0436 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes and G0437 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes are deleted. For claims with dates of service on or after Oct. 1, 2016, report, instead, CPT codes 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes and 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes. The pricing information is the same.
Non-therapy Outpatient Department Services
Effective for claims received on or after Oct. 1, 2016, with dates of service on or after Jan. 1, 2015, providers may report non-therapy outpatient department services that are adjunctive to a Comprehensive APC procedure (SI=J1) or the specific combination of services assigned to the C-APC 8011 (SI=J2) in one of two ways:
- With revenue code 0940 Other therapeutic services; or
- With the appropriate occurrence codes, CPT codes, modifiers, revenue codes, and functional reporting requirements.
Updates to Drugs, Biologicals, and Radiopharmaceuticals
Four drugs/biologicals granted OPPS pass-through status (SI=G) effective Oct. 1, 2016, are:
C9139 Injection, Factor IX, albumin fusion protein (recombinant), Idelvion, 1 i.u.
C9481 Injection, reslizumab, 1 mg
C9482 Injection, sotalol hydrochloride, 1 mg
C9483 Injection, atezolizumab, 10 mg
Effective July 1, 2016, Q5102 Injection, Infliximab, Biosimilar, 10 mg has been reassigned to SI E (Not paid under OPPS or any other Medicare payment system).
Changes to OPPS Pricer Logic
OPPS drug pricing will now apply the average sales price (ASP) fee schedule amounts from the Fiscal Intermediary Shared System (FISS) and not the OPPS Pricer.
Deleted Codes Due to Internal Requests
Unrelated to the OPPS quarterly update, codes to be discontinued effective Dec. 31, 2016, are:
A9544 Iodine i-131 tositumomab, diagnostic, per study dose
A9545 Iodine i-131 tositumomab, therapeutic, per treatment dose
Rationale: The products have been discontinued by the manufacturer, and are no longer sold.
J0760 Injection, Colchicine, per 1 mg
Rationale: The FDA has removed marketing clearance for this drug.
Q4219 Unite Biomatrix, per square centimeter
Rationale: This product was discontinued by the manufacturer in 2012, and is no longer sold.
MLN Matters Number MM9768, Aug. 26, 2016
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