July 2015 OPPS Modifier and Code Updates

on Monday, 22 June 2015. All News Items | Outpatient Services | Billing

Off-Campus, Offset, and Off-Kilter

The heat index is hovering around 100° this week, so it seems the hot, lazy days of summer are finally here. With the busy, hectic lives we live, I doubt anyone actually has time to be lazy, but the heat and humidity of summer can drag you down and make you feel off-kilter. The folks at CMS may be feeling a little “off” themselves these days with the latest OPPS update including descriptions for off-campus and offset.

The July 2015 OPPS Update includes a reminder about the use of the new PO modifier to identify services furnished at off-campus provider-based outpatient departments. Although the modifier is not required until January 1, 2016, it may be voluntarily reported in 2015. This modifier is to be reported with every HCPCS code for all outpatient hospital items and services furnished in an off-campus provider-based department of a hospital. This modifier should not be reported for remote locations of a hospital, satellite facilities of a hospital, or for services furnished in an emergency department. Definitions from 42 CFR 413.65(a) (2) and 412.22(h) applicable to this instruction include:

  • Campus means the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider's campus.
  • Remote location of a hospital means a facility or an organization that is either created by, or acquired by, a hospital that is a main provider for the purpose of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section.
  • A satellite facility is a part of a hospital that provides inpatient services in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital.

CMS reversed their April 2015 decision concerning the device-offset for HCPCS code C2623, Catheter, transluminal angioplasty, drug-coated, non-laser. After further review, CMS has determined that a device-offset should not apply to claims billed with C2623. C2623 is to be billed with various peripheral transluminal balloon angioplasty codes that are assigned to APC 0083, APC 0229, or APC 0319. Providers may request an adjustment from their MAC for claims processed on or after April1, 2015 to which an offset was applied.

Other updates to codes, status indicators, etc. from the July 2015 OPPS transmittal are listed below:

HCPCS code

Description

SI

Effective Date

Comment

C26131 Lung biopsy plug with delivery system H 7/1/2015 New pass-through device
0392T2 Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band) T 7/1/2015 new Category III CPT code
0393T Removal of esophageal sphincter augmentation device Q2 7/1/2015 new Category III CPT code
C9453 Injection, nivolumab, 1 mg G 7/1/2015 New pass-through drug
C9454 Injection, pasireotide long acting, 1 mg G 7/1/2015 New pass-through drug
C9455 Injection, siltuximab, 10 mg G 7/1/2015 New pass-through drug
Q9976 Injection, Ferric Pyrophosphate Citrate Solution, 0.01 mg of iron E 7/1/2015 New HCPCS code
Q9977 Compounded Drug, Not Otherwise Classified N 7/1/2015 New HCPCS code
Q51013 Injection, Filgrastim (G-CSF), Biosimilar, 1 microgram E 3/1/2015 New HCPCS code
C93494 PuraPly, and PuraPly Antimicrobial, any type, per square centimeter   7/1/2015 description change
J0365 Injection, aprotonin, 10,000 kiu E 4/1/2015 SI change from 'K'
90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose schedule, for intramuscular use K 2/1/2015 SI change from 'E'
90621 Meningococcal recombinant lipoprotein vaccine, serogroup B, 3 dose schedule, for intramuscular use K 2/1/2015 SI change from 'E'
Q9978 Netupitant 300 mg and Palonosetron 0.5 mg, oral G 7/1/2015 Replaces C9448

1 HCPCS code C2613 (lung biopsy plug with delivery system) should always be billed with CPT Code 32405 (Biopsy, lung or mediastinum, percutaneous needle). There will be a device-offset for C2613 with the APC associated with this procedure.

 

2CPT code 0392T is replacing HCPCS code C9737 (deleted effective June 30, 2015) to report the implantation of a magnetic esophageal ring associated with the LINX Reflux Management System procedure.

 

3Zarxio®, HCPCS code Q5101, is the first biosimilar approved by the FDA. Pricing information is not currently available because Zarxio is not being marketed. Once Zarxio is marketed, CMS will make pricing information available at the soonest possible date on the OPPS payment files and payment for Zarxio will be retroactive to the date the product is first marketed.

 

4The descriptor for HCPCS code C9349 is changing July 1, 2015 from FortaDerm to PuraPly.

 

As the MLN Matters Articles always say, “Make sure your billing staff are aware of these changes” or your claims may end up off-kilter.

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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