Medicare Approves New Pass-Through PTA Device

on Monday, 30 March 2015. All News Items | Outpatient Services | Coding | Billing

Gains and Losses

There are numerous scams that promise a huge reward if you will only send some upfront money to cover costs. But alas, often the reward never arrives. Medicare is not scamming providers on pass-through device payments. You will receive your “extra” payment. But as explained below, you need to make sure your charge amount is calculated correctly so you do not end up losing more than you gain.

As usual, Medicare announced several code changes in the April 2015 OPPS Update including new codes, new pass-through devices and drugs, changed status indicators, and changes in classification of skin substitutes. See the table at the end of this article for a list of the April changes.

One notable update was the approval of a new pass-through device category for drug-coated, non-laser, transluminal angioplasty catheter effective April 1, 2015. The new category was granted by CMS in response to a request from Medtronic for a new pass-though category for the IN.PACT Admiral Paclitaxel Coated Percutaneous Angioplasty (PTA) Balloon Catheter. The new device has been assigned HCPCS code C2623.

The Social Security Act requires that CMS create additional categories for transitional pass-through payment of new medical devices not described by existing or previously existing categories of devices. Under OPPS, new device categories are eligible for transitional pass-through payment for at least 2, but not more than 3 years while CMS gathers cost data. When pass-through status expires, devices are packaged into the payment for the procedure. A portion of the Medicare payment amount for device-dependent procedures is for the device itself.

Pass-through devices are assigned a Status Indicator (SI) of H and receive separate cost-based reimbursement not subject to a co-payment. To receive the appropriate cost-based payment, providers must calculate the charge amount for the device using their actual acquisition cost for the device and their hospital outpatient charge-to-cost ratio (CCR).

The formula is: Device Acquisition Cost ÷ CCR = Device Charge Amount

Device Cost = $10,000.00

Charge-to-Cost Ratio = 0.75

$10,000 ÷ 0.75 = $13,335.00

Medicare reverses this payment logic when calculating your payment amount, so that your “payment” should effectively be your cost amount.

Since the device-dependent procedures with which this new device will be reported already contain a portion of their payment for devices, the payment of the procedure APC payment amount will be “off-set” when reported with the new HCPCS code C2623. Medicare deducts from pass-through payments for devices an amount that reflects the portion of the APC payment amount that CMS determines is associated with the cost of the device.The C2623 device may be billed with various peripheral transluminal balloon angioplasty codes that are assigned to various peripheral transluminal angioplasty codes in APC 0083, APC 0229, and APC 0319.

APC

APC Title

CY 2015 APC Payment Rate

Device Offset Percentage

Device Offset Dollar Amount

0083 Level I Endovascular Procedures $4,537.45 23.86% $1,082.64
0229 Level II Endovascular Procedures $9,624.10 40.43% $3,891.02
0319 Level III Endovascular Procedures $14,840.64 48.01% $7,124.99

Hospitals should be sure to set the charge for pass-through devices appropriately so they are receiving correct reimbursement. As you can see, if you don’t, the device offset may negatively affect your payment.

Other Coding Updates - Effective April 1, 2015 unless otherwise noted.

HCPCS Code

Descriptor

Status Indicator

Update

Comment

C2623 Catheter, transluminal angioplasty, drug-coated, non-laser H New pass-through device category  
C9445 Injection, c-1 esterase inhibitor (human), Ruconest, 10 units G New pass-through drug  
C9448 Netupitant (300mg) and palonosetron (0.5 mg), oral G New pass-through drug  
C9449 Injection, blinatumomab, 1 mcg G New pass-through drug Monoclonal antibody - bill with chemotherapy injection and infusion codes
C9450 Injection, fluocinolone acetonide intravitreal implant, 0.19 mg G New pass-through drug HCPCS code C9450 is associated with Iluvien® and should not be used to report any other fluocinolone acetonide intravitreal implant (for example, Retisert®). Hospital should note that the dosage descriptor for Iluvien is 0.01 mg. Because each implant is a fixed dose containing 0.19 mg of fluocinlone acetonide, hospitals should report 19 units of C9450 for each implant.
C9451 Injection, peramivir, 1 mg G New pass-through drug  
C9452 Injection, ceftolozane/tazobactam, 5 mg G New pass-through drug  
J0365 Injection, aprotonin, 10,000 kiu E SI change from K SI = E (Not paid by Medicare when submitted on outpatient claims)
J7189 Injection, factor xiii (antihemophilic factor, human), 1 i.u. K SI change from N  
Q4150 Allowrap DS or Dry 1 sq cm N Skin substitute high cost status  
Q4153 Dermavest 1 square cm N Skin substitute high cost status  
Q9975 Injection, factor VIII, FC Fusion protein, (recombinant), per i.u. G Replacing C9136  
90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose schedule, for intramuscular use E New vaccine code effective 2/1/2015 SI = E (Not paid by Medicare when submitted on outpatient claims)
90621 Meningococcal recombinant lipoprotein vaccine, serogroup B, 3 dose schedule, for intramuscular use E New vaccine code effective 2/1/2015 SI = E (Not paid by Medicare when submitted on outpatient claims)
90697 Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP- IPV-Hib-HepB), for intramuscular use E New vaccine code effective 1/1/2015 SI = E (Not paid by Medicare when submitted on outpatient claims)

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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