July 2018 OPPS Updates

on Tuesday, 19 June 2018. All News Items | Outpatient Services | Billing

A Segment of Time

Today, the Gregorian calendar is the most widely used calendar in the world. It is a refinement of the Julian calendar, dividing the year into 12 months with one extra day every four years for leap year. At one time, the old Roman calendar only had 10 months before the addition of January and February. A ten-month year is hard to divide equally into smaller portions of time – ten is only easily divisible by two. On the other hand, 12 months is easy to segment into halves, quarters, or thirds. Quarterly events are commonplace because every three months is a fitting amount of time for reminders, resets, repeat occurrences, and updates. Common examples in healthcare are the numerous quarterly Medicare updates.

The Medicare Outpatient Prospective Payment System (OPPS) runs the calendar year, so quarterly updates occur in January, April, July and October. Medicare recently released the July 2018 OPPS Update transmittal at the first of June, giving healthcare providers a month to prepare for any changes. The main points of the article are new lab, Category III, and pass-through drug codes plus a few code assignment revisions. You can find a summary of these changes in the table below.

There were no major policy revisions in this update, but in addition to the coding updates, a few minor clarifications:

  • HCPCS code C9749 (Repair of nasal vestibular lateral wall stenosis with implant(s), was established in the April update, effective April 1, 2018. CMS clarified that this is an inherently bilateral procedure. Unilateral procedures should be reported by hospital outpatient departments with modifier 73 or modifier 74. It seems modifier 74 would be more commonly used, as these modifiers are only to be used when anesthesia was planned or provided. Modifier 74 is used for a discontinued procedure after the administration of anesthesia. Modifier 73 is used if the procedure is discontinued prior to the administration of anesthesia.
  • CPT code 01402 describes anesthesia for total knee arthroplasty and is an inpatient-only procedure (SI = C). Since CPT code 27447 (total knee arthroplasty) was removed from the inpatient-only list this year, CPT 01402 can be reported with this procedure on an OPPS claim retroactively effective back to January 1, 2018. The payment for 01402 will be packaged into the payment for 27447. If 01402 is reported on a claim without 27447, it is an inpatient-only procedure and is not paid under OPPS.
  • Alloderm (HCPCS code Q4116) can be used as either an applied skin substitute or as an implanted biologic used in breast reconstruction. Therefore, it can be billed with either revenue code 0278 (Other implants) or revenue code 0636 (Drugs requiring detailed coding).
July 2018 OPPS Code Updates
HCPCS Code Long Descriptor OPPS Status IndicatorEffective DateDescription of Change
0012M Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma  A April 1, 2018 New Multianalyte Assays with Algorithmic Analyses (MAAA) CPT Code
0013M Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma  A April 1, 2018 New Multianalyte Assays with Algorithmic Analyses (MAAA) CPT Code
0035U Neurology (prion disease), cerebrospinal fluid, detection of prion protein by quaking-induced conformational conversion, qualitative  Q4 April 1, 2018 New Proprietary Laboratory Analyses (PLA) CPT Code
0036U Exome (i.e., somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses  A April 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0037U Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden  A April 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0038U Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative  Q4 April 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0039U Deoxyribonucleic acid (DNA) antibody, double stranded, high avidity  Q4 April 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0040U BCR/ABL1 (t (9;22)) (e.g., chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative  A April 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0041U Borrelia burgdorferi, antibody detection of 5 recombinant protein groups, by immunoblot, IgM  Q4 April 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0042U Borrelia burgdorferi, antibody detection of 12 recombinant protein groups, by immunoblot, IgG  Q4 April 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0043U Tick-borne relapsing fever Borrelia group, antibody
detection to 4 recombinant protein groups, by immunoblot, IgM 
Q4 April 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0044U Tick-borne relapsing fever Borrelia group, antibody
detection to 4 recombinant protein groups, by immunoblot, IgG 
Q4 April 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0045U Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score   A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0046U FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative   A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0047U Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score   A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0048U Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s)   A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0049U NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative   A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0050U Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements   A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0051U Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, urine, 31 drug panel, reported as quantitative results, detected or not detected, per date of service   Q4 July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0052U Lipoprotein, blood, high resolution fractionation and quantitation of lipoproteins, including all five major lipoprotein classes and subclasses of HDL, LDL, and VLDL by vertical auto profile ultracentrifugation  Q4 July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0053U Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsy specimen, algorithm reported as probability of higher tumor grade  A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0054U Prescription drug monitoring, 14 or more classes of drugs and substances, definitive tandem mass spectrometry with chromatography, capillary blood, quantitative report with therapeutic and toxic ranges, including steady-state range for the prescribed dose when detected, per date of service  Q4 July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0055U Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma  A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0056U Hematology (acute myelogenous leukemia), DNA, whole genome next-generation sequencing to detect gene rearrangement(s), blood or bone marrow, report of specific gene rearrangement(s)  A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0057U Oncology (solid organ neoplasia), mRNA, gene expression profiling by massively parallel sequencing for analysis of 51 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a normalized percentile rank  A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0058U Oncology (Merkel cell carcinoma), detection of antibodies to the Merkel cell polyoma virus oncoprotein (small T antigen), serum, quantitative  Q4 July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0059U Oncology (Merkel cell carcinoma), detection of antibodies to the Merkel cell polyoma virus capsid protein (VP1), serum, reported as positive or negative  Q4 July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0060U Twin zygosity, genomic targeted sequence analysis of chromosome 2, using circulating cell-free fetal DNA in maternal blood  A July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0061U Transcutaneous measurement of five biomarkers (tissue oxygenation [StO2], oxyhemoglobin [ctHbO2], deoxyhemoglobin [ctHbR], papillary and reticular dermal hemoglobin concentrations [ctHb1 and ctHb2]), using spatial frequency domain imaging (SFDI) and multi-spectral analysis   Q4 July 1, 2018 New Proprietary Laboratory Analyses (PLA) Code
0505T Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural road mapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion  J1 July 1, 2018 New Category III CPT Code
0506T Macular pigment optical density measurement by heterochromatic flicker photometry, unilateral or bilateral, with interpretation and report  Q1 July 1, 2018 New Category III CPT Code
0507T Near-infrared dual imaging (i.e., simultaneous reflective and trans-illuminated light) of meibomian glands, unilateral or bilateral, with interpretation and report  Q1 July 1, 2018 New Category III CPT Code
0508T Pulse-echo ultrasound bone density measurement resulting in indicator of axial bone mineral density, tibia  S July 1, 2018 New Category III CPT Code
C9030 Injection, copanlisib, 1 mg G July 1, 2018 New Pass-Through Drug
C9031 Lutetium Lu 177, dotatate, therapeutic, 1 mCi  G July 1, 2018 New Pass-Through Drug
C9032 Injection, voretigene neparvovec-rzyl, 1 billion vector genome  G July 1, 2018 New Pass-Through Drug
Q9991 Injection, buprenorphine extended-release (Sublocade), less than or equal to 100 mg  G July 1, 2018 New Pass-Through Drug
Q9992 Injection, buprenorphine extended-release (Sublocade), greater than 100 mg  G July 1, 2018 New Pass-Through Drug
Q9995 Injection, emicizumab-kxwh, 0.5 mg G July 1, 2018 New Pass-Through Drug
Q9993 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg G July 1, 2018 Replacing code C9469
Q9994 (In-line cartridge containing digestive enzyme(s) for enteral
feeding, each
E1 July 1, 2018 New HCPCS Code  
90739 Hepatitis b vaccine (hepb), adult dosage, 2 dose schedule, for intramuscular use  F April 1, 2018 SI changed from E1 to F due to FDA approval
Q4178 Floweramniopatch, per sq cm N July 1, 2018 Reassignment from low cost group to high cost group (skin substitute product)
Q5105 Injection, epoetin alfa, biosimilar, (Retacrit) (for esrd on dialysis), 100 units   K July 1, 2018 New HCPCS code for Retacrit
Q5106 Injection, epoetin alfa, biosimilar, (Retacrit) (for non-esrd use), 1000 units   K July 1, 2018 New HCPCS code for Retacrit
J9216 Injection, interferon, gamma 1-b, 3 million units  E2 July 1, 2018 SI changed from K to E2
Q2049  Injection, doxorubicin hydrochloride, liposomal, imported lipodox, 10 mg  E2 July 1, 2018 SI changed from K to E2

 

Providers need to make additions and adjustments based on this transmittal soon, because in three months there will be another one.

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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