CMS has released coding changes and policy updates for OPPS 2023

Coding changes and policy updates for OPPS

You won’t find these codes in your 2023 code books, but they are effective April 1.

The Centers for Medicare & Medicaid Services (CMS) has released coding changes and policy updates for the Outpatient Prospective Payment System (OPPS). The updates include the addition of many new HCPCS Level II codes, the deletion of a few codes, and several status indicator changes for existing codes. These changes are effective April 1 and Medicare Administrative Contractors (MACs) were instructed to implement the changes by April 3.

New CPT® Codes

In addition to new CPT® codes for reporting COVID-19 vaccination that were released after publication of CPT® 2023, the American Medical Association’s CPT® Editorial Panel has established 23 new proprietary laboratory analyses (PLA) codes (0364U-0386U).

Only one of these codes (0368U) has a status indicator “E1” (not covered). The other 22 codes have a status indicator of “A” (not paid under OPPS) or “Q4” (conditionally packaged; paid under OPPS or CLFS).

Device Pass-through Status Changes

After determining that the conditional approval for C1834 Pressure sensor system, includes all components (e.g., introducer, sensor), intramuscular (implantable), excludes mobile (wireless) software application was in error, CMS deleted the code on March 31, 2023. CMS says that since there is no claims data for C1834 there should be no need to reprocess claims. HCPCS Level II codes J0610 and J0611 also are deleted as of March 31.
In the OPPS final rule for calendar year 2023, CMS approved HCPCS Level II codes C1747, C1826, and C1827 for pass-through status effective Jan. 1, 2023 until Dec. 31, 2025.

Several HCPCS Level II codes have pass-through status with earlier expiration dates:

Dec. 31, 2024

C1832 Autograft suspension, including cell processing and application, and all system components
C1833 Monitor, cardiac, including intracardiac lead and all system components (implantable)

Sept. 30, 2024

C1831 Interbody cage, anterior, lateral or posterior, personalized (implantable)

Dec. 31, 2023

C1825 Generator, neurostimulator (implantable), non-rechargeable with carotid sinus baroreceptor stimulation lead(s)
C1052 Hemostatic agent, gastrointestinal, topical
C1062 Intervertebral body fracture augmentation with implant (e.g., metal, polymer)
C1824 Generator, cardiac contractility modulation (implantable)
C1982 Catheter, pressure-generating, one-way valve, intermittently occlusive
C1839 Iris prosthesis
C1734 Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)
C2596 Probe, image-guided, robotic, waterjet ablation

June 30, 2023

C1761 Catheter, transluminal intravascular lithotripsy, coronary
C1748 Endoscope, single-use (i.e. disposable), Upper GI, imaging/illumination device (insertable)
Additionally, pass-through status ended March 31 for HCPCS Level II codes J0179, J0223, J0791, J1201, J7331, Q5114, Q5115, Q5120. The status indicator for these codes has changed from “G” (pass-through status; separate APC payment) to either “K” (non-pass-through status; paid under OPPS; separate APC payment) or “N” (paid under OPPS; packaged into payment for other services).
The status indicator for J3399 is also changed from “A” to “K” and APC 9141 is assigned; this code will be manually priced by MACs, so a $0.00 payment rate is assigned to APC 9141.

Drugs, Biologicals, and Radiopharmaceuticals

There are 12 new injection codes added for drugs, biologicals, and radiopharmaceuticals receiving pass-through status under the OPPS starting April 1: C9145-C9149, J0218, J1411, J1747, J2403, Q5128, and Q5130 and another 10 new codes in this category with various status indicators.

New Skin Substitute Products

Seven new skin substitute HCPCS Level II codes (Q4265-Q4271) are effective April 1 under the OPPS. These codes have a status indicator “N.”
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