New Codes, New Rates in OPPS July Update

June 11, 2010

The Centers for Medicare and Medicaid Services (CMS) released May 28 the hospital Outpatient Prospective Payment System (OPPS) July 2010 update, which includes a number of changes to and billing instructions for various Medicare Part B payment policies.

H1N1 Vaccine Administration Code

Under the OPPS, HCPCS Level II code G9142 Influenza a (H1N1) immunization administration (includes the physician counseling the patient/family) is assigned to status indicator “E,” indicating that payment is not made by Medicare when this code is submitted on an outpatient bill type because the H1N1 vaccine is supplied at no cost to providers. However, payment will be made to a provider for the administration of the H1N1 vaccine when reported under HCPCS Level II code G9141, even if the vaccine is supplied at no cost to the provider. Code G9141 is assigned to APC 0350 Administration of Flu and PPV vaccine with a status indicator of “S” and a payment rate of $25.61 for 2010. Beneficiary copayment and deductible do not apply to G9141 (for both OPPS and non-OPPS providers). Providers should report one unit of code G9141 for each administration of the H1N1 vaccine.

Category III CPT® Codes

CMS is implementing 11 Category III CPT® codes in the OPPS, effective July 1, which the American Medical Association (AMA) released Jan. 1. Of the 11 codes listed in the table below, 10 are separately payable under the OPPS.

Code Long Descriptor SI APC
0223T Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; single, with interpretation and report S 0099
0224T Multiple, including serial trended analysis and limited reprogramming of device parameter – AV or VV delays only, with interpretation and report S 0690
0225T Multiple, including serial trended analysis and limited reprogramming of device parameter – AV and VV delays, with interpretation and report S 0690
0226T Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); diagnostic, including collection of specimen(s) by brushing or washing when  performed X 0340
0227T Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); with biopsy(ies) T 0146
0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level T 0207
0229T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure) T 0206
0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level T 0207
0231T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure) T 0206
0232T Injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed X 0340
0233T Skin advanced glycation endproducts (AGE) measurement by multi-wavelength fluorescent spectroscopy A NA

CPT® 0233T will be paid under the Medicare Physician Fee Schedule (MPFS) when billed by OPPS providers. Payment rates for the other 10 codes can be found in Addendum B of the July 2010 OPPS update, posted on the CMS website.

Dermal Injections for LDS Treatment

Effective for claims with dates of service on or after March 23, dermal injections for facial lipodystrophy syndrome (LDS) are covered under Medicare when diagnosed in HIV-infected patients who also have been diagnosed with depression due to HIV treatment.

Medicare will separately pay for the administration and product of dermal filler injections. CMS has created four HCPCS Level II codes to describe the dermal injection procedure and products, as listed in the table below.

Code Long Descriptor SI APC
C9800 Dermal injection procedure(s) for facial lipodystrophy syndrome (LDS) and provision of Radiesse or Sculptra dermal filler, including all items and supplies T 0135
G0429 Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy) B NA
Q2026 Injection, Radiesse, 0.1 mL B NA
Q2027 Injection, Sculptra, 0.1 mL B NA

Physicians should report on dermal filler injections claims HCPCS Level II codes Q2026 or Q2027 and G0429 in addition to the ICD-9-CM diagnosis codes 042 Human immunodeficiency virus (HIV) disease and 272.6 Lipodystrophy.

Outpatient hospitals and ambulatory surgery centers (ASCs) should use temporary HCPCS Level II code C9800 and ICD-9 diagnosis codes 042 and 272.6 until HCPCS Level II codes Q2026 and Q2027 are billable.

Inpatient hospitals should report ICD-9 procedure code 86.99 Other operations on skin and subcutaneous tissue, ie, injection of filler material and ICD-9 diagnosis codes 042 and 272.6.

Note: An ICD-9 diagnosis code for depression is not required by Medicare to be listed in claims but it may be a requirement of your contractor.

Allogeneic Stem Cell Transplant

CMS is revising Pub. 100-04, Medicare Claims Processing Manual, chapter 4, section 231.11 “to clarify that charges for allogeneic stem cell acquisition services billed with revenue code 0819 (Other Organ Acquisition) should be reported on the same date of service as the allogeneic transplant procedure in order to be appropriately packaged for payment purposes.”

Drugs and Biologicals

The updated payment rates for drugs and biologicals based on the Average Sales Price (ASP), effective July 1, will be included in the July 2010 update of the OPPS Addenda A and B, posted on the CMS website.

CMS has created the following six new HCPCS Level II codes with pass-through status, effective July 1.

HCPCS Code Long Descriptor APC SI
C9264 Injection, tocilizumab, 1 mg 9264 G
C9265 Injection, romidepsin, 1 mg 9265 G
C9266 Injection, collagenase clostridium histolyticum, 0.1 mg 9266 G
C9267 Injection, von Willebrand factor complex (human), Wilate, per 100 IU VWF: RCO 9267 G
C9268 Capsaicin, patch, 10 cm2 9268 G
C9367 Skin substitute, Endoform Dermal Template, per square centimeter 9367 G

Also new for the second half of 2010 is HCPCS Level II code Q2025 Fludarabine phosphate, oral, 1 mg. Beginning July 1, report this code in place of code C9262.

Payment Rate Corrections

The payment rates for three HCPCS Level II codes were incorrect in the April 2010 OPPS Pricer. The corrected payment rates are listed in the table below and have been incorporated into the reissued Pricer, effective for services furnished on April 1, through implementation of the July 2010 update. According to CMS, affected claims that were already processed/paid prior to the reissued Pricer have been reprocessed (or are in the process of being reprocessed).

Code SI APC Short Descriptor Corrected Payment Rate Corrected  Minimum Unadjusted Copayment
C9258 G 9258 Telavancin injection $2.12 $0.42
C9262 G 9262 Fludarabine phosphate, oral $8.18 $1.61
J1540 K 0923 Gamma globulin 9 CC inj $141.64 $28.33

Status Indicator Change for 90670

Effective April 1, the status indicator for CPT® code 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use will change from SI=E (not paid by Medicare when submitted on outpatient claims (any outpatient bill type) to SI=K (paid under OPPS; separate APC payment). For the remainder of 2010, 90670 will be separately paid and the price will be updated on a quarterly basis.

Source: CMS Transmittal 1980, Change Request (CR) 6996, issued June 4.

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3 Responses to “New Codes, New Rates in OPPS July Update”

  1. Diane J. Silas says:

    I would like to confirm what exactly Q2026 and Q2027 are. Would they be considered a pharmacutical/drug? We are trying to establish how to price them, but pharmacy is telling us they are not drugs and to price according to DME???

    Along that same line of thought, G0429 is the ADMINISTRATION code for Q2026 abd Q2027 (?)

    Kind regards,
    Diane J. Silas

  2. Rocelyn says:

    I am wondering if you ever found out the answers to your question?? If so, may I ask what the answer was?
    Thank You

  3. Howard says:

    Q2026 is Injection, Radiesse, 0.1 ml
    Q2027 is Injection, Sculptra, 0.1 ml

    G0429 is specific to Dermal Filler injections for the treatment of facial lipodystrophy syndrome (LDS).

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