April Brings ASC Payment System Updates
- By Stacy Chaplain
- In CMS
- April 11, 2022
- Comments Off on April Brings ASC Payment System Updates
April is upon us. And for those who code and bill for products and services provided in the Ambulatory Surgical Center (ASC) setting, it’s time to familiarize yourself with the quarterly updates to the ASC payment system. The changes to codes and calendar year (CY) 2022 payment rates for ASCs released by the Centers for Medicare & Medicaid Services (CMS) took effect April 1, 2022, unless otherwise specified. Spread the word to make sure your staff is aware of these updates.
Procedure List for C1748 Expands
The list of procedure codes associated with HCPCS Level II code C1748 is expanded. In addition to CPT® codes 43260-43265 and 43274-43278, you may now also bill the device described by C1748 with one of the following CPT® codes:
0652T Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
0653T Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single or multiple
0654T Esophagogastroduodenoscopy, flexible, transnasal; with insertion of intraluminal tube or catheter
43197 Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
43198 Esophagoscopy, flexible, transnasal; with biopsy, single or multiple
All these codes have an offset amount of $0. The codes are assigned to ambulatory payment classification (APC) 5301 (Level 1 Upper GI Procedures) and APC 5302 (Level 2 Upper GI Procedures).
New Code Established for Subacromial Tissue Spacer Implantation
There is a new HCPCS Level II code to describe the implantation of a saline-filled balloon in the subacromial space for arthroscopic treatment of massive, irreparable rotator cuff tears (MIRCTs).
C9781 Arthroscopy, shoulder, surgical; with implantation of subacromial spacer (e.g., balloon), includes debridement (e.g., limited or extensive), subacromial decompression, acromioplasty, and biceps tenodesis when performed
This minimally invasive intervention aims to restore the damaged area without requiring sutures or fixation devices. The ASC Payment Indicator (ASC PI) I for C9781 is J8.
Drugs, Biologicals, and Radiopharmaceuticals
Existing CY 2022 HCPCS Level II Code J9304 Receives Pass-Through Status
One drug with an existing HCPCS Level II code for which pricing information and claims data weren’t previously available receives drug pass-through status starting April 1, 2022.
J9304 Injection, pemetrexed (pemfexy), 10 mg
ASC PI K2 replaces the January 2022 ASC PI (K5).
Newly Established HCPCS Level II Codes
Effective April 1, 2022 are nine new drug, biological, and radiopharmaceutical HCPCS Level II codes. These codes and their descriptors, as well as codes deleted as of March 31, 2022, are:
|New HCPCS Code||Old HCPCS Code||Descriptor|
|J0219||C9085||Injection, avalglucosidase alfa-ngpt, 4 mg|
|J0491||C9086||Injection, anifrolumab-fnia, 1 mg|
(auromedics), 5 mg
|J9359||C9084||Injection, loncastuximab tesirine-lpyl,|
|C9090||N/A||Injection, plasminogen, human-tvmh, 1|
|C9091||N/A||Injection, sirolimus protein-bound|
particles, 1 mg
|C9092||N/A||Injection, triamcinolone acetonide,|
suprachoroidal (xipere), 1 mg
|C9093||N/A||Injection, ranibizumab, via sustained|
release intravitreal implant (susvimo), 0.1
|J9273||N/A||Injection, tisotumab vedotin-tftv, 1 mg|
The ASC PI for all of the codes listed above is K2.
HCPCS Level II code M1145 Most favored nation (mfn) model drug add-on amount, per dose, (do not bill with line items that have the jw modifier is deleted, retroactive to Feb. 28, 2022.
90377 Status Change
CMS revises the ASC PI for HCPCS Level II code 90377 Rabies immune globulin, heat- and solvent/detergent-treated (RIg-HT S/D), human, for intramuscular and/or subcutaneous use from K5 to K2, retroactive to Jan. 1, 2022. This retroactively changes the status of rabies immune globulin from non-payable to payable status.
Hepatitis-B Vaccine Is Retroactively Payable
Effective Jan. 11, 2022, CPT® code 90759 Hepatitis B vaccine (HepB), 3-antigen (S, Pre-S1, Pre-S2), 10 mcg dosage, 3 dose schedule, for intramuscular use is retroactively payable at reasonable cost in the ASC payment system. The ASC PI for 90759 is F4.
UPDATE: Starting July 5, Medicare will process claims for code 90759 and price the vaccine per the average sales price drug pricing file. Coinsurance and deductible don’t apply.
Payments for Drugs and Biologicals
For CY 2022, payment for non-pass-through drugs and biologicals continues at a single rate of average sales price (ASP) plus 6 percent. This provides payment for both the acquisition cost and pharmacy overhead costs associated with the drug or biological. Also, in CY 2022, a single payment of ASP plus 6 percent continues for Outpatient Prospective Payment System (OPPS) pass-through drugs and biologicals. This provides payment for costs associated with acquisition and pharmacy overhead for these pass-through items.
Payments for drugs and biologicals based on ASPs are updated quarterly as later quarter ASP submissions become available. Updated payment rates effective April 1, 2022, are in the April 2022 update of ASC Addendum BB.
Be aware that CMS may correct the payment rates of some drugs and biologicals retroactively based on the ASP methodology. These retroactive corrections typically happen every quarter. The list of drugs and biologicals with corrected payment rates is available on the first date of the quarter at Restated Drug and Biological Payment Rates.
FDA-Approved, Waiting on Product-Specific Code
As in the OPPS, ASCs are allowed to use HCPCS Level II code C9399 Unclassified drugs or biological to bill for new drugs, biologicals, and therapeutic radiopharmaceuticals approved by the FDA on or after Jan. 1, 2004, for which OPPS pass-through status hasn’t been approved and a C-code and APC payment haven’t been assigned.
Whereas diagnostic radiopharmaceuticals and contrast agents are policy packaged under both the OPPS and ASC payment system unless they’ve been granted pass-through status. Therefore, new diagnostic radiopharmaceuticals and contrast agents are an exception to the above policy and shouldn’t be billed with C9399 prior to the approval of pass-through status. These are packaged instead in the ASC setting, with payment already included in the surgical procedure performed, and aren’t billed.
Skin Substitute Specifics
Nine skin substitute HCPCS Level II codes are newly added to the ASC payment system as of April 1, 2022. They are all low-cost skin substitutes with an ASC PI of N1.
A2011 Supra sdrm, per square centimeter
A2012 Suprathel, per square centimeter
A2013 Innovamatrix fs, per square centimeter
A4100 Skin substitute, fda cleared as a device, not otherwise specified
Q4224 Human health factor 10 amniotic patch (hhf10-p), per square centimeter
Q4225 Amniobind, per square centimeter
Q4256 Mlg-complete, per square centimeter
Q4257 Relese, per square centimeter
Q4258 Enverse, per square centimeter
Don’t bill for packaged skin substitutes (ASC PI=N1) separately since packaged codes aren’t reportable under the ASC payment system.
Also note the reassignment of one skin substitute code. HCPCS Level II code Q4199 Cygnus matrix, per square centimeter is reassigned from the low-cost skin substitute group to the high-cost skin substitute group as of April 1, 2022.
Payment and Coverage
CMS wraps up the April ASC payment system update with a few reminders.
- ASC pass-through devices are covered ancillary services, which are paid separately, and are MAC priced based on acquisition cost or invoice. Payable ASC pass-through device codes carry an ASC PI of J7.
- MACs reduce the approved payment amount for specifically identified procedures with an offset amount greater than zero when provided in conjunction with a specific pass-through device. The agency identifies these code pairs as part of the quarterly update to the ASC payment system transmittals. The device offset amount is the device portion in Addendum FF of the quarterly addenda file. To determine the payment rate for the approved surgical procedure billed with an OPPS pass-through device, subtract the device portion from the ASC payment rate.
- The fact that CMS assigns a HCPCS Level II code and a payment rate to a drug, device, procedure, or service under the ASC payment system doesn’t imply coverage by Medicare. This only indicates how the product, procedure, or service may be paid if covered by the program.
See MLN Matters article MM12679 for more information on Change Request 12679.
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