January 2015 OPPS Update

on Wednesday, 07 January 2015. All News Items | Outpatient Services | Coding | Billing

Tell Me Once, Tell Me Twice…

Some things are so interesting or enjoyable that you like to hear them over and over – like re-reading a good book or watching a good movie a second or third time (or maybe the hundredth time if you have small children and the video Frozen). Sometimes the subject matter is just so complicated that it requires multiple reviews of the information to completely understand it. Since I can’t claim the “enjoyable” angle for Medicare information, I have to conclude it is the “need to comprehend” reason that justifies the re-telling of Medicare regulations.

Medicare publishes quarterly updates to the Outpatient Prospective Payment System (OPPS) but none is quite as voluminous as the annual January update that reiterates and explains many of the new regulations from the OPPS Final Rule for that year. Here is a brief summary of some of the key points from the January 2015 OPPS Update. For more detailed information, see the MLN Matters at the prior link or the corresponding CMS Transmittal.

Comprehensive APCs

Beginning January 1, 2015, Medicare will make a single payment for selected (device-dependent) primary services with payment for all adjunctive services reported on the same claim packaged into the payment for the primary service. HCPCS codes assigned to comprehensive APCs are designated with a status indicator of “J1”. The following table describes the services that are packaged with the comprehensive APCs. Some services such as preventive services, mammography, ambulance services, and some vaccinations are excluded from packaging. A complexity adjustment to a higher rated APC may occur when multiple J1 services or a combination of J1 and add-on services are reported on a claim.

Comprehensive APC Packaged ServicesStatus Indicator(s)
major OPPS procedure P, S, T or V
lower ranked comprehensive procedure J1
drugs K
blood products R
therapy service reported with therapy revenue codes A
normally packaged OPPS service N, Q1, Q2, or Q3


Sometimes Therapy Codes

“Sometimes therapy” services are paid as therapy services if they are performed by a therapist under a certified therapy plan of care and billed with a therapy revenue code (042x, 043x, or 044x) and appended with a therapy modifier (GP, GO, or GN). Outpatient hospital therapy services are reimbursed by Medicare based on the Medicare Physician Fee Schedule (MPFS). When “sometimes therapy” services are provided in an outpatient hospital setting by a non-therapist (and not under a therapy plan of care), the services may be paid as OPPS services. To receive payment under OPPS the services should be submitted without a therapy modifier or therapy revenue code. Two new codes were designated as “sometimes therapy” services for 2015 - CPT codes 97607 and 97608 for disposable, non-DME negative pressure wound therapy (these codes replaced HCPCS codes G0456 and G0457).

Skin substitutes

Beginning in 2014, CMS made the following changes to skin substitute products:

  • Packaged payment for skin substitute products into the application procedures
  • Classified skin substitutes as low or high cost
  • Created new HCPCS codes for application of low cost skin substitutes (C5271-C5278) to correlate with current CPT application codes to be used for high cost skin substitutes (15271-15278)
  • Implemented differential payment for application of low or high cost skin substitutes
  • Developed OPPS edits that require hospitals to report skin substitute products in combination with an applicable skin substitute application code (i.e. low cost product with low cost application code, high cost product with high cost application code)

This continues for 2015 with possible revisions to the classifications of the skin substitutes. See the MLN Matters article for a listing of the 2015 skin substitute codes, descriptions, and cost designations.

Other Reminders and Cautions

  • Corneal tissue is paid on a cost basis and not under the OPPS. To receive cost based reimbursement for corneal tissue, hospitals must bill charges for corneal tissue using HCPCS code V2785.
  • Hospitals should report CPT code 93229 only when they have provided continuous outpatient cardiovascular monitoring as described by the code definition that includes up to 30 consecutive days of real-time cardiac monitoring.
  • Compounded drug combinations, including combinations of anti-inflammatory drugs and antibiotics given as intraocular or periocular injections during ocular surgery, should be reported with HCPCS code J3490 (not C9399). These drugs are a covered part of the ocular surgery, but are packaged as surgical supplies. The injections are also not separately reportable - per the NCCI Manual, “no separate procedure code may be reported for any type of injection during surgery or in the perioperative period. Injections are a part of the ocular surgery and are included as a part of the ocular surgery and the HCPCS code used to report the surgical procedure.” Since these services are packaged covered services, the patient is not liable and should not be given an Advance Beneficiary Notice (ABN) for the drug(s) and/or the injections.

New / Revised Codes

The update also includes several lists of new or revised HCPCS codes. These include:

  • A new service - C9742, Laryngoscopy, flexible fiberoptic, with injection into vocal cord(s), therapeutic, including diagnostic laryngoscopy, if performed
  • A new pass-through device – C2624, Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components
  • New Laboratory HCPCS codes, G6030-G6058, to replace deleted CPT codes for laboratory drug testing
  • New 2015 HCPCS codes for drugs, biologicals and radiopharmaceuticals
  • Revised 2015 HCPCS codes for drugs, biologicals and radiopharmaceuticals

Refer to the MLN Matters Article to see these lists. It is important to notice that the following revised HCPCS codes contain a change in the unit description, as an error in reporting of units could result in over or underpayment.

2015 HCPCS CodeDescriptionReplaces
J0153 Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) J0150 - 6 mg
J0151 - 1 mg
J1071 Injection, testosterone cypionate, 1mg J1070 - up to 100 mg
J1080 - 200 mg
J2274 Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10mg J2271 - 100 mg
J2275 - 10 mg
J3121 Injection, testosterone enanthate, 1mg J3120 - up to 100 mg
J3130 - up to 200 mg
J7336 Capsaicin 8% patch, per square centimeter J7335 - per 10 sq cm
J9267 Injection, paclitaxel, 1 mg J9265 - 30 mg

Now you have been told twice, but you may want to keep this article and a copy of the MLN Matters article in case you decide to read one more time, or twice or …even more.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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