The July 2010 update to the Ambulatory Surgical Center (ASC) payment system adds seven new ancillary service codes and eight new surgical procedure codes. ASC staff also should note that the payment rates for three codes were incorrect in the April 2010 ASC DRUG file.

New Ancillary Service Codes

Seven new HCPCS Level II codes have been created for drugs that are payable as covered ancillary services for dates of service on or after July 1. The following new separately payable drug and biological codes and their payment rates are included in the July 2010 ASC DRUG file.

*C9262 is discontinued after June 30 and replaced by Q2025 effective July 1.

CPT® Code Payment Indicator Change

Effective April 1, the payment for CPT® code 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use will change from ASC PI=Y5 (non-surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made) to ASC PI=K2 (drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on Outpatient Prospective Payment System (OPPS) rate). The payment rate effective April 1 is: $106.70. Suppliers who think they may have received an incorrect payment determination between April 1 and June 30 should request contractor adjustment of previously processed claims.

New Surgical Procedure Codes

Seven new Category III CPT® codes have been created for surgical procedures that are payable for dates of service on or after July 1. and one new HCPCS Level II surgical procedure code has been created and is payable for dates of service on or after March 23.

The following new separately payable codes and their payment rates are included in the July 2010 ASC Fee Schedule (ASCFS) file.

*Temporary office-based status

Updated Payment Rates

The corrected payment rates that follow appear in the revised April 2010 ASC DRUG file effective for services furnished on April 1 through implementation of the July 2010 update (July 6).

Medicare contractors will adjust claims for these three HCPCS Level II codes that have dates of service on or after April 1 through July 1, and were originally processed prior to the installation of the revised April 2010 ASC DRUG File, only if brought to their attention.

MLN Matters MM7008 notifies providers submitting claims payable under the ASC payment system to Medicare of these important changes.

A new treatment therapy for men with advanced prostate cancer is being heralded as revolutionary because it the first of its kind to use a patient’s own immune system to fight the disease. Provenge (sipuleucel-T), recently approved by the U.S. Food and Drug Administration (FDA), is indicated for the treatment of asymptomatic or minimally symptomatic prostate cancer that has spread to other parts of the body and is resistant to standard hormone treatment.

Provenge is an autologous cellular immunotherapy, designed to stimulate a patient’s own immune system to respond against the cancer. Each dose of Provenge is manufactured by obtaining a patient’s immune cells from the blood, using a machine in a process known as leukapheresis. To enhance the patient’s response against the cancer, the immune cells are then exposed to a protein that is found in most prostate cancers, linked to an immune stimulating substance. After this process, the patient’s own cells are returned to the patient to treat the prostate cancer.

Provenge, manufactured by Seattle-based Dendreon Corp., is administered intravenously in a three-dose schedule given at about two-week intervals.

Physicians who treat Medicare patients with cancer or a particular HIV-related illness will soon have three additional HCPCS Level II codes they can report on claims for the drugs used in treating their patients.

The following HCPCS Level II code is payable under Medicare effective July 1, 2010, when documentation shows medical necessity:

Effective for claims with dates of service on or after March 23, 2010, dermal injections for facial lipodystrophy syndrome (LDS) are payable under Medicare in HIV-infected beneficiaries when facial LDS caused by antiretroviral HIV treatment is a significant contributor to their depression. In this instance only, the following two HCPCS Level II codes may be used to claim the drug payment.

Report the diagnosis of LDS with ICD-9-CM code 272.6 Lipodystrophy. Report the administration of the drug with one of the following CPT® codes:

11951  Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc

11952  Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc

11954  Subcutaneous injection of filling material (eg, collagen); over 10.0 cc

Tip: When reporting units, note that 0.1 cc is equal to 0.1 mL

The Centers for Medicare & Medicaid Services (CMS) released the July update for quarterly HCPCS Level II changes May 21 in Transmittal 1972, Change Request (CR) 6809.

The Average Sales Price (ASP) files are now available for the second quarter of 2010, which you can download from the Centers for Medicare & Medicaid Services (CMS) website. Where applicable, the payment amounts in the quarterly ASP files are 106 percent of the ASP, calculated from data submitted by drug manufacturers.

Comparing the second quarter 2010 payment amounts with the previous quarter reveals that, for the most part, average drug prices in the market remain stable. On average, CMS says, prices for the top part B drugs increased by 0.7 percent. For most of the higher volume drugs (35 out of the top 50), the prices changed 2 percent or less. Overall, the prices for 12 of the top 50 drugs decreased, while four remained the same.

Subscribers to Part B News can download an 11-page document that details all price changes from first to second quarter. You will find it in the Hot Documents folder, labeled “ASP_chart_Q210.”

Here’s a snapshot of drug price changes included in Part B News’ list:

• Prices for 248 drugs will decrease from the amounts paid in the first quarter of 2010;
• Prices for 67 drugs will not change;
• Prices for 270 drugs will increase; and,
• CMS issued payments for the first time for two drugs – C1 esterase inhibitor injection (J0598, $42.746) and Temozolomide injection (J9328, $4.899).

Codes J9093-J9097 for Cyclophosphamide lyophilized no longer appear on the list.

The U.S. Food and Drug Administration (FDA) and Edwards Lifesciences notified health care professionals, Nov. 9, about the Class 1 recall of CardioVations EndoClamp™ Aortic Catheter, model numbers EC1001 and EC65. The recall was initiated because the balloon catheters may spontaneously rupture during surgery.

This product was manufactured from August 2008 through August 2009 and distributed from November 2008 through September 2009.

The device blocks off the aorta, monitors aortic pressure, and delivers solution to stop the heart during cardiopulmonary bypass procedures.

On Oct. 29, 2009, the manufacturer sent a follow-up letter to their customers instructing them to:

• Check their inventory and identify any unused product; and 
• Return unused products to the company.

Class 1 recalls are the most serious type of recall and involve situations in which there is a reasonable probability that use of the product will cause serious adverse health consequences or death.

Health care professionals and consumers may report adverse reactions or quality problems experienced with the use of this product to the FDA’s MedWatch Adverse Event Reporting program.

The Food and Drug Administration (FDA) advised health care professionals Oct. 1 that a new version of heparin due to start shipping Oct. 8 is 10 percent less potent, and that this reduced potency could weaken its ability to prevent blood clots. Read more »

The Food and Drug Administration (FDA) issued a Public Health Advisory on transdermal drug patches after learning a warning was missing on certain patches containing aluminum or other metals in their non-adhesive backing. Such patches can cause burns if worn while undergoing magnetic resonance imaging (MRI) scans.

Read more »

Physicians will soon have a new treatment option to offer patients with overactive bladder (OAB). The Food and Drug Administration (FDA) approved a new topical gel designed to treat the symptoms of OAB Jan. 27.

Read more »

Health care professionals have an additional choice for treating patients with moderate to severe acute pain. The U.S. Food and Drug Administration (FDA) has approved Tapentadol hydrochloride, according to a Nov. 24 press release. Read more »

The U.S. Food and Drug Administration (FDA) seized 11 lots of contaminated heparin—a blood thinner drug—from Celsus Laboratories Inc. on Nov. 6, according to an FDA news release.

The 11 lots consisted of five lots of Heparin Sodium Active Pharmaceutical Ingredient (API) and six lots of Heparin Lithium. These products were manufactured in China and found to be contaminated with over-sulfated chondroitin sulfate (OSCS)—a substance that mimics heparin’s anticoagulant activity. Read more »