Learn About OPPS Changes in July Update

Please be mindful that several coding and billing alterations pertaining to outpatient claims have been backdated to either April or January.

Numerous modifications to Medicare’s Outpatient Prospective Payment System (OPPS) in the July update closely mirror those in the Medicare Physician Fee Schedule Database (MPFSDB) update for the same quarter. These include the introduction of fresh COVID-19 CPT® vaccine and administration codes, novel CPT® proprietary laboratory analyses (PLA) codes, and innovative CPT® Category III codes for drugs and biologicals. However, differences in payment methodologies necessitate distinct coding and billing instructions for outpatient claims.

Outlined below are the alterations in claims processing featured in the July update to the OPPS. For further information, relevant links are provided as needed.

COVID-19 Vaccine and Test Coding

CPT® codes 91309 (Moderna booster) and 0094A (administration) received emergency use authorization from the FDA on March 29, arriving too late for the April OPPS update. Both codes will appear in the July 2022 Integrated Outpatient Code Editor (I/OCE) with a retroactive effective date of March 29. Code 91309 is designated as status indicator L, denoting it’s not paid under OPPS but rather at a reasonable cost, exempt from deductible or coinsurance. Code 0094A bears status indicator ‘S’, indicating it’s a procedure or service that isn’t discounted when assigned to multiple, separate APCs. It falls under Ambulatory Payment Classification (APC) 9398 for COVID-19 vaccine administration dose 2 of 2, single dose product, or additional dose.

Over-the-counter (OTC) COVID-19 tests, present for a few months, are payable through HCPCS Level II code K1034. Eligible providers can bill for these tests under the Medicare Payment for OTC COVID-19 Tests Demonstration from April 4 throughout the public health emergency (PHE). This code carries OPPS status indicator ‘A’, signifying it’s not paid under OPPS but rather through MACs under an alternative fee schedule or payment system. The code is on the C-APC exclusion list.

Medicare Administrative Contractor (MAC) Novitas Solutions recommends utilizing suggested diagnosis code Z20.822 (contact with and suspected exposure to COVID-19) if no other diagnoses apply to the OTC COVID-19 tests. If an attending physician isn’t present for the OTC test claim, input “OTC” and a billing provider NPI in the corresponding name field.

Additional billing information for professional, institutional, and Medicare Advantage claims for Jurisdiction H can be found on its website.

Advanced Diagnostic Lab Tests

It’s important to note that advanced diagnostic lab test (ADLT) code 0108U, labeled with status indicator ‘A,’ has retroactively come into effect on March 24 rather than July 1.

New Codes for Drugs and Biologicals

Don’t overlook the introduction of new CPT® Category III codes 0714T-0737T and 16 new HCPCS Level II codes for reporting drugs and biologicals, with nine having pass-through status as of July 1.

Additionally, three new skin substitute codes (Q4259-Q4261) are introduced, and four skin substitute codes (A2001, A2002, Q4229, Q4258) are reassigned from the low-cost skin substitute group to the high-cost skin substitute group from July 1 (retroactive to April 1 for A2001). A2004’s short descriptor has been altered from “Xcellistem, per sq cm” to “Xcellistem, 1 mg,” retroactive to Jan. 1. It’s no longer assigned to either the low- or high-cost skin substitute group.

Moreover, difelikefalin injection code J0879’s status indicator will change in July from ‘E2’ to ‘K,’ retroactive to April 1.

Updated payment rates, effective July 1, for drugs and biologicals will be included in the July 2022 Fiscal Intermediary Standard System (FISS) release. Detailed information can be found in the July 2022 update of the OPPS Addendum A and Addendum B on the CMS website. Furthermore, certain drugs and biologicals paid based on ASP methodology will have retroactively corrected payment rates available from July 1. Claims impacted by adjustments to previous quarter’s payment files may be resubmitted, as stated in Transmittal 11435, Change Request 12761 from the Centers for Medicare & Medicaid Centers (CMS).

New Technology APCs

The July update also introduces new technology codes, commencing with 0721T, describing quantitative computed tomography tissue characterization using the Optellum LCP for lung cancer risk assessment. This code is marked with status indicator ‘S’ and assigned to APC 1508, New Technology – Level 8 ($600-$700).

Additionally, code 0723T portrays quantitative magnetic resonance cholangiopancreatography (QMRCP), producing an evaluation of the biliary tree and gallbladder. With status indicator ‘S’, it’s placed in APC 1511, New Technology – Level 11 ($900-$1,000).

Please take note that APC assignments for codes 0100T, 0473T, and C1841 are no longer applicable. Also, code C9782 (CardiAMP cell therapy IDE study) established on April 1 has seen its APC revised to 1590 – Level 39 ($15,000-$20,000) from the initial 1574, with status indicator ‘T’, to accommodate the device.

For a comprehensive understanding of coding and billing instructions ensuring accurate adjudication of claims paid under OPPS, make sure to consult the official July 2022 I/OCE data files.