October 2010 OPPS Update

on Thursday, 23 September 2010. All News Items

CMS released the October 2010 OPPS Update (Transmittal 2050 CR 7117) on September 17, 2010. The update includes the following information:

  • The transmittal clarified that hospitals cannot backdate observation services. Regarding the start time for observation services when Condition Code 44 is used, the transmittal states: “When Condition Code 44 is appropriately used, the hospital reports on the outpatient bill the services that were ordered and provided to the patient for the entire patient encounter. However, in accordance with the general Medicare requirements for services furnished to beneficiaries and billed to Medicare, even in Condition Code 44 situations, hospitals may not report observation services using HCPCS code G0378 (Hospital observation service, per hour) for observation services furnished during a hospital encounter prior to a physician's order for observation services. Medicare does not permit retroactive orders or the inference of physician orders. Like all hospital outpatient services, observation services must be ordered by a physician. The clock time begins at the time that observation services are initiated in accordance with a physician’s order.” (emphasis added) Per this update, providers may report hours for nursing care and monitoring that occurred prior to the observation order under revenue 0762 but without a HCPCS code (such as G0378).
  • CMS clarified that when a radiolabeled product is administered in one hospital and the nuclear medicine scan is subsequently performed at another hospital, the hospital administering the nuclear medicine scan should bill for both the scan and the radiolabeled product in accordance with OPPS policy requiring that radiolabeled products be reported and billed with nuclear medicine scans. The hospitals may enter into an arrangement where the hospital that administers the nuclear medicine scan pays the appropriate amount for the radiolabeled product to the hospital that administers the radiolabeled product.
  •  The following drugs and biologicals have been granted OPPS pass-through status effective October 1, 2010.

 

HCPCS Code

Long Descriptor

APC

Status Indicator effective 10/1/10

C9269*

Injection, C-1 esterase inhibitor (human), Berinert, 10 units

9269

G

C9270*

Injection, immune globulin (Gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg

9270

G

C9271*

Injection, velaglucerase alfa, 100 units

9271

G

C9272*

Injection, denosumab, 1 mg

9272

G

C9273*

Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF in 250 mL of Lactated Ringer's, including leukapheresis and all other preparatory procedures, per infusion

9273

G

NOTE: The “*” indicate that these are new codes effective October 1, 2010.

  •  The Status Indicator (SI) for two vaccines is being changed to “L” which means these vaccines will be paid at reasonable cost and not subject to deductible or coinsurance. Effective April 1, 2010, the SI for CPT code 90670 (Pneumococcal vacc, 13 val im) will be changed to “L” (Change due to error in April SI assignment). Effective December 23, 2009, the SI for CPT code 90662 (Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use) will be changed to “L” (Change due to FDA approval)
  • Effective for claims with dates of service on and after June 3, 2010, CMS permits local Medicare contractors to cover (or not cover) all indications of MRA that are not specifically addressed by national coverage rules. Due to the OPPS requirement that imaging services with and without contrast be paid through separate APCs, CMS has created six new HCPCS codes for MRA services that may now be covered at local Medicare contractor discretion. Specifically, HCPCS codes C8931, C8932, and C8933 replace CPT code 72159 (Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)), while HCPCS codes C8934, C8935, and C8936 replace CPT code 73225 (Magnetic resonance angiography, upper extremity, with or without contrast material(s)).   The SI for CPT codes 72159 and 73225 will be changed to “B” to indicate that these codes are not recognized by OPPS when submitted on an outpatient hospital Part B bill type 12x or 13x. The SI for the new C codes will be “Q3” indicating these codes will be paid under the composite rate when performed on the same date of services as other procedures in the same imaging family.

 The new MRA codes are:

HCPCS Code

Long Descriptor

Composite APC

Standard

(Non-Composite) APC

C8931

Magnetic resonance angiography with contrast, spinal canal and contents

8008

 

0284

C8932

Magnetic resonance angiography without contrast, spinal canal and contents

8007 or 8008

0336

 

C8933

Magnetic resonance angiography without contrast followed by with contrast, spinal canal and contents

8008

0337

C8934

Magnetic resonance angiography with contrast, upper extremity

8008

0284

C8935

Magnetic resonance angiography without contrast, upper extremity

8007 or 8008

0336

C8936

Magnetic resonance angiography without contrast followed by with contrast, upper extremity

8008

0337

For more information on the October OPPS update see the transmittal at the link above or the MLN Matters Article MM7117.

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