Learn About OPPS Changes in July Update


But be aware that some of the changes for coding and billing outpatient claims are retroactive to April or January.

Many of the changes to Medicare’s Outpatient Prospective Payment System (OPPS) in the July update mirror those in the Medicare Physician Fee Schedule Database (MPFSDB) update for the same quarter — such as the new COVID-19 CPT® vaccine and administration codes; new CPT® proprietary laboratory analyses (PLA) codes, and new CPT® Category III codes for drugs and biologicals. But differences between the two payment methodologies require separate coding and billing instructions for outpatient claims.

Here’s a quick look at the claims processing changes in the July update to the OPPS, with links for where you can find more information as necessary.

COVID-19 Vaccine and Test Coding

CPT® codes 91309, for the Moderna booster, and 0094A, for the administration, received emergency use authorization from the Food and Drug Administration on March 29 — too late to make it into the April update to the OPPS. Both codes will appear in the July 2022 Integrated Outpatient Code Editor (I/OCE), with an effective date of March 29. Code 91309 is assigned status indicator L Not paid under OPPS. Paid at reasonable cost; not subject to deductible or coinsurance and code 0094A is assigned status indicator ‘S’ Procedure or service, not discounted when multiple, separate APC assignment and Ambulatory Payment classification (APC) 9398 COVID-19 vaccine admin dose 2 of 2, single dose product or additional dose.

Over-the-counter (OTC) COVID-19 tests have also been available for a few months and HCPCS Level II code K1034 is payable for all eligible providers who provide these tests to patients under the Medicare Payment for OTC COVID-19 Tests Demonstration as of April 4 and through the end of the public health emergency (PHE). This code is assigned OPPS status indicator ‘A’ Not paid under OPPS. Paid by MACs under a fee schedule or payment system other than OPPS and is on the C-APC exclusion list.

Medicare Administrative Contractor (MAC) Novitas Solutions says, “If you have no other diagnoses for the OTC COVID-19 tests, use suggested diagnosis code Z20.822: contact with and (suspected) exposure to COVID-19.

“If you don’t have an attending physician for the OTC tests claim, enter: OTC

A billing provider NPI

‘Self-referred’ in the corresponding name field.”

The MAC for Jurisdiction H includes additional billing information for professional, institutional, and Medicare Advantage claims on its website.

Advanced Diagnostic Lab Tests

Note that advanced diagnostic lab test (ADLT) code 0108U, assigned status indicator ‘A,’ is now retroactively effective March 24, rather than July 1.

New Codes for Drugs and Biologicals

Don’t miss the new CPT® Category III codes 0714T-0737T and 16 new HCPCS Level II codes for reporting drugs and biologicals, nine of which have pass-through status, available July 1.

There are also three new skin substitute codes (Q4259-Q4261). And four skin substitute codes (A2001, A2002, Q4229, Q4258) will be reassigned from the low cost skin substitute group to the high cost skin substitute group beginning July 1 (retroactive to April 1 for A2001). Also note that the short descriptor for A2004 is changing from Xcellistem, per sq cm to Xcellistem, 1 mg, retroactive to Jan. 1, and no longer assigned to either the low- or high-cost skin substitute group.

Also note the status indicator for difelikefalin injection code J0879 will change in July from ‘E2’ to ‘K,’ retroactive to April 1.

Updated payment rates effective July 1 for drugs and biologicals will be incorporated in the July 2022 Fiscal Intermediary Standard System (FISS) release, and can be found in the July 2022 update of the OPPS Addendum A and Addendum B on the CMS website. As well, some drugs and biologicals paid based on ASP methodology will have payment rates corrected retroactively. These correct payment rates will be available July 1. Claims affected by adjustments to a previous quarter’s payment files may be resubmitted, the Centers for Medicare & Medicaid Centers (CMS) states in Transmittal 11435, Change Request 12761.

New Technology APCs

There are also new technology codes in the July update, starting with 0721T, which describes quantitative computed tomography tissue characterization using the Optellum LCP for qualifying the risk of lung cancer. This code is assigned status indicator ‘S’ Procedure or service, not discounted when multiple, separate APC assignment and APC 1508 New Technology – Level 8 ($600-$700).

New code 0723T describes quantitative magnetic resonance cholangiopancreatography (QMRCP). This service produces an assessment of the biliary tree and gallbladder. Status indicator ‘S,’ APC 1511 New technology – Level 11 ($900-$1,000).

Also note that APC assignments for codes 0100T, 0473T, and C1841 are no longer applicable; and code C9782 CardiAMP cell therapy IDE study — established April 1 and assigned APC 1574, status indicator ‘T’ has been revised to include the device and change the APC to 1590 – Level 39 ($15,000-$20,000).

Be sure to review the official July 2022 I/OCE data files for complete coding and billing guidance to ensure proper adjudication of your claims paid under the OPPS.

For More Information: https://www.aapc.com/blog/85185-learn-about-opps-changes-in-july-update/


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