July Outpatient Editor Update Includes NCCI Changes

July 2012 updates to the Integrated Outpatient Code Editor (I/OCE), the Centers for Medicare & Medicaid Services’ (CMS) system for filing and adjudicating claims paid under the Outpatient Prospective Payment System (OPPS), include a change to bring it in line with correct coding guidelines. The OCE is used for outpatient services in hospitals and ambulatory surgical centers (ASCs).

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June 1st, 2012

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Carriers Hold Claims for Codes 33249, C1882

The Centers for Medicare & Medicaid Services (CMS) has instructed fiscal intermediaries (FIs) and Medicare administrative contractors (MACs) to hold claims for the device described by HCPCS Level II code C1882 Cardioverter-defibrillator, other than single or dual chamber (implantable) when reported with the procedure described by CPT^® code 33249 Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber.

Only Medicare claims containing both C1882 and 33249 with dates of service between Jan. 1, 2012 and June 30, 2012 are affected.

CMS recently discovered that the procedure-to-device edit files included in the January 2012 (V13.0) and April 2012 (V13.1) Integrated Outpatient Code Editor (I/OCE) do not allow C1882 to satisfy the edit in place for 33249.

According to CMS, the July 2012 I/OCE (V13.2) will be updated with a new procedure-to-device edit file that will allow HCPCS Level II code C1882 to be billed with CPT^® code 33249, and carriers will begin processing held claims beginning July 2, 2012.

April 12th, 2012

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April OPPS Additions, Changes, Deletions

The Centers for Medicare & Medicaid Services (CMS) has posted April 2012 changes to billing instructions for payment policies implemented in the hospital Outpatient Prospective Payment System (OPPS). The April 2012 updated Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer will reflect the HCPCS Level II, ambulatory payment classification (APC), HCPCS modifier, and revenue code additions, changes, and deletions as identified in change request (CR) 7748. The April 2012 revisions to I/OCE data files, instructions, and specifications are provided in CR 7751, “April 2012 Integrated Outpatient Code Editor (I/OCE) Specifications Version 13.1.”

Noteworthy Changes

1. For services provided on or after Jan. 1, 2012, the descriptor for CPT® 33249 has been changed to read “Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber.” Due to clinical inappropriateness, this has prompted the removal of HCPCS Level II code C1882 Cardioverter-defibrillator, other than single or dual chamber (implantable) from the list of device codes required to be billed with CPT® code 33249 on the procedure-to-device edit list. This change is retroactive to Jan. 1, 2012.

2. For new service (fluorescent vascular angiography), HCPCS Level II code C9733 Non-ophthalmic fluorescent vascular angiography (SI = Q2 and APC = 0397, vascular imaging) is assigned for $154.87 payment (minimum unadjusted copayment = $30.98) under the OPPS, effective April 1, 2012. HCPCS Level II code C9733, assigned to APC 0397, describes SPY® Fluorescence Vascular Angiography and other types of non-ophthalmic fluorescent vascular angiography.

3. Drugs and biologicals with OPPS pass-through status, effective April 1, 2012, are:

C9288 Injection, centruroides (scorpion) immune f(ab)2 (equine), 1 vial

C9289 Injection, asparaginase Erwinia chrysanthemi, 1,000 international units (I.U.)

C9290 Injection, bupivacaine liposome, 1 mg

C9291 Injection, aflibercept, 2 mg vial

4. Payment rates for certain HCPCS Level II codes effective July 1- Sept. 30, 2011 are:

5. The following HCPCS Level II codes describe products that can be used as skin substitutes (They will be separately paid only when used with one of the CPT® codes describing the application of a skin substitute (15271-15278)):

For the complete CR, see CMS Transmittal 2418.

March 16th, 2012

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Updated IOCE Includes Substantial Changes

Medicare contractors received updated instructions and specifications in December for the January 2012 Integrated Outpatient Code Editor (IOCE). They’ll use version 13.0 to edit claims paid under the Outpatient Prospective Payment System (OPPS) and non-OPPS for hospital outpatient departments, community mental health centers, and for all non-OPPS providers; and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness.

The update includes a number of ambulatory payment classifications (APCs) and HCPCS Level II and CPT^® code changes, most of which are effective Jan. 1, 2012, and all of which outpatient facilities should be aware.

APC Changes

There are 28 new APCs, 25 deleted APCs, 26 APCs with description changes, and 15 APCs with status indicator changes.

New APCs range from 00331 Combined abdomen and pelvis CT without contrast to 09366 EpiFix wound cover.

Deleted APCs begin with 00245 Level I cataract procedures without IOL insert and end with 09364 Porcine implant, Permacol.

Many of the description changes to APCs are meant to enhance specificity and some greatly change the meaning of the code. Here are a few examples:

Other description changes have little or no effect. For example:

As for status indicator changes: With the exception of APC 00668, which went from ‘S’ to ‘T,’ APCs 01236, 01238, 01290, 01296, 01297, 09249, 09250, 09251, 09252, 09253, 09255, 09256, 09360, and 09363 went from a status indicator of ‘G’ to ‘K.’

Code Changes

Added to the January I/OCE are six HCPCS Level II ‘G’ codes for preventive screening services. The following codes are effective Oct. 1, 2011:

Deleted from the IOCE, effective July 1, 2011 is HCPCS Level II code S3628 PAMG-1 rapid assay for ROM.

For the complete list of HCPCS Level II and CPT^® procedure codes that are either added or deleted effective Jan. 1, 2011, and for description and status indicator changes and other code edits, please see the Centers for Medicare & Medicaid Services’ (CMS) Transmittal 2370.

December 30th, 2011

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New Codes, Payment Corrections, and More in Oct. Updates

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.

Table 1

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.

Table 2

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.

Table 3

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

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