July 2009 OPPS Update Changes Policies

The July 2009 update of the hospital Outpatient Prospective Payment System (OPPS) implements a number of changes to and billing instructions for various Medicare policies. The most affected areas of note are drugs and biologicals and Part B hospital outpatient services.

The Centers for Medicare & Medicaid Services (CMS) Transmittal 1745, Change Request 6492, issued May 22, outlines the July 2009 update to the OPPS. In it, you will find changes to the following policies:

  1. Procedure and device edits;
  2. Outlier reconciliation;
  3. Updated pricer logic for certain blood products;
  4. Category III CPT® codes;
  5. Billing for drugs, biologicals, and radiopharmaceuticals;
  6. Clarification of HCPCS Level II code C9399 Unclassified drugs or biologicals use;
  7. Nuclear medicine procedure-to-radiolabeled product;
  8. Observation services;
  9. Condition code 44 use; and
  10. Coverage determinations.

Whereas some of the changes are simply clarifications, others are definitive revisions. For example, CMS implemented as of July 1 in the OPPS four Category III CPT® codes that the American Medical Association (AMA) released in January. The codes are:

HCPCS Long Descriptor

0199T Physiologic recording of tremor using accelerometer(s) and gyroscope(s), (including frequency and amplitude) including interpretation and report

0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device (if utilized), one or more needles

0201T Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device (if utilized), two or more needles

0202T Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine

In Pub. 100-04, Medicare Claims Processing Manual, chapter 17, Drugs and Biologicals, you will find the average sales price for nonpass-through and pass-through drugs and biologicals. The updated payment rates, effective July 1, will appear in the July 2009 update of the OPPS Addendum A and Addendum B, which you will find posted on the CMS Web site.

Also worth noting are nine new drugs and biologicals granted OPPS pass-through status effective July 1. These items are as follows:

HCPCS Long Descriptor

C9250 Human plasma fibrin sealant, vapor-heated, solvent-detergent (Artiss), 2 ml

C9251 Injection, C1 esterase inhibitor (human), 10 units

C9252 Injection, plerixafor, 1 mg

C9253 Injection, temozolomide, 1 mg

C9360 Dermal substitute, native, non-denatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters

C9361 Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 centimeter length

C9362 Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold Strip), per 0.5 cc

C9363 Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter

C9364 Porcine implant, Permacol, per square centimeter

Look for the following three new HCPCS Level II codes, effective July 1, for reporting drugs and biologicals in the hospital outpatient setting:

HCPCS Long Descriptor

Q2023 Injection, factor viii (antihemophilic factor, recombinant) (Xyntha), per i.u.
Q4115 Skin substitute, alloskin, per square centimeter
Q4116 Skin substitute, alloderm, per square centimeter

Also in the July 2009 update are several corrections to Drugs and Biologicals policy. One such correction affects the payment rates for several HCPCS Level II codes that were incorrect in the January 2009 OPPS Pricer. The corrected payment rates, effective for services furnished on Jan. 1, through implementation date of the April 2009 update, are as follows:

HCPCS Short Descriptor Corrected Rate

J1441 Filgrastim 480 mcg injection $304.27

J1740 Ibandronate sodium injection $136.35

J2505 Injection, pegfilgrastim 6mg $2,135.12

J7513 Daclizumab, parenteral $341.09

For changes to hospital outpatient services and billing instructions, read “Insurers Clarify Inpatient vs. Outpatient Status” in this issue of EdgeBlast.

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