The Centers for Medicare & Medicaid Services (CMS) recently released October 2011 updates of the hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center Payment System (ASC PS). The updates include two new device pass-through categories, a new C code, and a payment rate correction for an injection code. Providers and billing staff submitting claims to Medicare for services paid under the OPPS or ASC PS should be aware of these changes.
Changes to Device Edits
Although device code C1778 Lead, neurostimulator is not a required device for procedure code 64569 Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator, CMS is adding 64569 as an appropriate procedure for C1778. The procedure may be appropriately reported on the same claim with the device code. This change is effective Jan. 1, 2011, so any claims for C1778 without 64569, when the service was furnished between Jan. 1 and Oct. 1, may be resubmitted.
New Device Pass-through Categories
Effective Oct. 1, outpatient facilities and ASCs have two new Category III CPT® codes created as payable ancillary procedures. New coding and payment information is shown in Table 1.
||Device Offset from Payment
||Powered bone marrow biopsy needle
||Lens, intraocular (telescopic)
C1840 may be billed when provided with CPT® codes 66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage), or 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification). Both of these codes are assigned to APC 0246.
Drugs and Biological with OPPS Pass-through Status
The two drugs/biologicals shown in Table 2 have been granted OPPS pass-through status, effective Oct. 1. Note that C9286—also granted ASC payment status—is a new code.
||Injection, belatacept, 1 mg
||Injection, canakinumab, 1 mg
Updated Payment Rate for J9185
The payment rate for HCPCS Level II code J9185 Injection, fludarabine phosphate, 50 mg was incorrect in the July 2011 OPPS Pricer and ASC Drug file. The corrected rate, which is effective for services furnished between July 1 and Sept. 30, is listed in Table 3.
||Corrected Payment Rate
||Corrected Minimum Unadjusted Copayment
||Fludarabine phosphate inj
Refer to CMS Transmittal 2296, CR 7545, issued Sept. 2 or MLN Matters® MM7545 for further information about these updates to the OPPS; and CMS Transmittal 2296, CR 7545, issued Sept. 2, for more information regarding the ASC October update.
Also see CMS Transmittal 2277, CR 7541, issued Aug. 19, for the October 2011 Integrated Outpatient Code Editor (I/OCE) Specifications Version 12.3. This version includes many diagnosis and procedure codes changes, as well as the addition of modifier 92, valid effective Jan. 1, 2008.
September 16th, 2011