March 20, 2012 | | Comments 0
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New procedure, drugs and edits in the April quarterly hospital outpatient guidance

CMS released the April quarterly OPPS and I/OCE updates, and there are several items of interest that may require updates to your chargemasters.

CMS has adopted a new HCPCS code C9733, effective April 1, for non-ophthalmic fluorescent vascular angiography.  CMS indicates the code is used to report SPY ® Fluorescence Vascular Angiography.

CMS also added four new pass-through drugs, effective April 1:

  • C9288 (injection, centruroides (scorpion) immune f(ab)2 (equine), 1 vial)
  • C9289 (injection, asparaginase erwinia chrysanthemi, 1,000 iu)
  • C9290 (injection, bupivacaine liposome, 1 mg)
  • C9291 (injection, aflibercept (Eylea), 2mg vial)

Additionally, CMS adjusted payment rates for four drugs for the July 1, 2011–September 30, 2011 timeframe and four drugs for the October 1, 2011–December 31, 2011 timeframe.  If providers wish to receive any additional amounts due to the corrected rates, they must request reprocessing of their claims.

The April OPPS transmittal also discusses a new edit for skin substitutes which requires providers report them with certain application procedures (CPT codes 15271–15278) in order to be paid separately.  See the transmittal or the I/OCE for the updated list of 27 skin substitute codes.   In the special processing logic of the April I/OCE, it makes clear that if the skin substitute codes are reported without one of the application procedure codes, they will be packaged rather than the claim being returned to the provider for correction.

This is actually implementing edits for longstanding, but confusing guidance CMS had given for biologicals that could be used either in an application procedure or implanted during a surgical procedure.  As with other implants, when the skin substitute is implanted, it is packaged into the surgical procedure implanting it, but when applied as a skin substitute it is paid separately.

Previously, the guidance relied on hospitals properly reporting the HCPCS codes, and in some cases not reporting a HCPCS code, to ensure separate payment was not made inappropriately.  This edit ensures that skin substitute will get packaged appropriately by packaging it whenever the application procedure is not present.   This new edit is effective April 1, but providers should review prior claims submission and coding policies to ensure they have been submitting claims appropriately prior to implementation of the new edit.

One final edit that was updated related to cardioverter-defibrillator system implants.  Formerly, when CPT code 33249 (Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber) was billed there was an edit allowing device code C1882 (Cardioverter-defibrillator, other than single or dual chamber (implantable)).  However, due to a January 1 change in the description of the procedure code, this is no longer correct, and CMS is removing the edit effective retroactively to January 1.

Entry Information

Filed Under: OPPS


Kimberly Hoy About the Author:

Kimberly Anderwood Hoy is director of Medicare and compliance for HCPro, Inc.

As a hospital compliance officer, Kimberly regularly provided research and guidance on coding, billing, and reimbursement issues for a wide range of hospital services. She has a particular expertise in charge description master operation, development, and maintenance. She has experience conducting billing compliance audits and internal investigations. Kimberly also has had primary responsibility for HIPAA privacy regulation compliance, including risk assessment, program development, implementation of policies and procedures, and ongoing operations.

As In-House Legal Counsel, Kimberly had oversight of expense contracting and regulatory compliance, including federal and state laws and regulations. Kimberly regularly provided legal advice on such complex topics as consents, EMTALA, Stark, anti-kickback and anti-inducement laws, physician recruiting, and tax exemption regulations.

Kimberly has served as a speaker at compliance-related conferences in the areas of compliance program effectiveness and physician education. Kimberly is an active member of the American and California Bar Associations, the American Health Lawyers Association and the Health Care Compliance Association.

Kimberly earned her Juris Doctor degree from the University of Montana School of Law, where she received the Corpus Juris Secundum Award for Excellence in Contracts. She also holds a Bachelor of Arts degree in Philosophy from Yale University.

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