April 2010 OPPS Update Sets the Record Straight

The April 2010 hospital Outpatient Prospective Payment System (OPPS) update, released Feb. 26, adds several HCPCS Level II codes to reflect coverage changes, reiterates billing instructions on several points, and corrects payment rate errors in the January and October 2009 OPPS Pricer.

Here are the highlights of the April 2010 OPPS update …

Warfarin Testing

Under the hospital OPPS, HCPCS Level II code G9143 Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) will be assigned status indicator “A” (not paid under OPPS) effective April 1. Payment for this lab test will be made under the clinical lab fee schedule (CLFS). However, HCPCS code G9143 will not appear in the 2010 CLFS with an assigned rate. Its 2010 payment will be determined by Medicare fiscal intermediaries (FIs) and/or Part A/B Medicare administrative contractors (MACs).

HIV Screening Tests

The following three HCPCS Level II G codes were created to implement changed HIV screening test coverage:

G0432 Infectious agent antigen detection by enzyme immunoassay (EIA) technique, qualitative or semi-quantitative, multiple-step method, HIV-1 or HIV-2, screening

G0433 Infectious agent antigen detection by enzyme-linked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV-2, screening

G0435 Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening

These codes also will be assigned status indicator “A” effective in the April 2010 update, to be paid under the CLFS. Payment rates will be determined by Medicare FIs and/or A/B MACs in the same manner that payment rates for unlisted laboratory CPT® codes are currently determined.

Drugs and Biologicals

The following six drugs and biologicals have been granted OPPS pass-through status, and are effective April 1:

Code Long Descriptor APC SI
C9258 Injection, telavancin, 10 mg 9258 G
C9259 Injection, pralatrexate, 1 mg 9259 G
C9260 Injection, ofatumumab, 10 mg 9260 G
C9261 Injection, ustekinumab, 1 mg 9261 G
C9262 Fludarabine phosphate, oral, 1 mg 9262 G
C9263 Injection, ecallantide, 1 mg 9263 G

HCPCS Level II codes C9258, C9259, C9260, C9261, C9262, C9263, G0432, G0433, and G0435 are currently not on the 2010 HCPCS file, but they will be included with the April 2010 IOCE update and listed on the CMS website.

Pricer Corrections

The payment rate for the HCPCS Level II code J9031 was incorrect in the January 2009 OPPS Pricer. The corrected payment rate has been installed in the April 2010 OPPS Pricer, effective for services furnished on Jan. 1, 2009 through implementation of the April 2009 update.

Code SI APC Short Descriptor Rate Unadjusted Copay
J9031 K 0809 Bcg live intravesical vac $118.96 $23.79

The payment rates for several HCPCS codes also were incorrect in the October 2009 OPPS Pricer. The corrected payment rates listed below have been installed in the April 2010 OPPS Pricer, effective for services furnished on Oct. 1, 2009 through implementation of the January 2010 update.

Code SI APC Short Descriptor Rate Unadjusted Copay
90371 K 1630 Hep b ig, im $113.78 $22.76
J1458 K 9224 Galsulfase injection $333.49 $66.70
J2278 K 1694 Ziconotide injection $6.38 $1.28
J2323 K 9126 Natalizumab injection $7.97 $1.59

Pulmonary Rehab Services

Section 140.4 .1, chapter 32 in the Medicare Claims Processing Manual, Pub. 100-04, is being revised to reflect instructions to hospitals and practitioners’ offices for reporting respiratory or pulmonary services furnished to a patient when those services do not meet the diagnosis and coverage criteria for pulmonary rehabilitation services.

CMS is adding the following language:

“If medically necessary, separately reportable respiratory or pulmonary services are furnished to a patient in a hospital or practitioner’s office and those services do not meet the diagnosis and coverage criteria for pulmonary rehabilitation services, then those services should not be reported using HCPCS code G0424 but should be reported using the appropriate CPT or HCPCS codes.”

Procedure and Device Edits

The updated lists for procedure-to-device and device-to-procedure edits can be found on the CMS website under “Device, Radiolabeled Product, and Procedure Edits.”

Source: The Centers for Medicare & Medicaid Services Transmittal 1924, Change Request 6857.

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