October 2014 OPPS Coding Updates
Why, why, why?
If you have ever been around young children, you may remember the “why?” phase. Everything you say and every answer you give to the question “Why?” is followed by another question of “Why?” Of course, this curiosity for “why” is a critical part of the development of children, to expand their understanding of the world around them. I am sometimes sad to realize that this need to understand things does not follow everyone into their adult life. Sometimes it may be because it is just too much work to determine the answer.
As I prepared this week to write about the new coding updates for Medicare from the October 2014 OPPS Update (MM8873), I wanted to know why. Why is there a new service code, why isn’t Medicare covering Mircera, why are two drugs no longer covered by Medicare…? And finding the answers was not easy – in fact, I still don’t have all the answers. Does it matter if I know why or not? Probably not, but I believe the pursuit of knowledge is never a waste of time. So, here are the coding updates effective for October 1, 2014 and the “whys” as I was able to determine them.
New Service: Impl Pressure Sensor w/ Angio
|Long Description:||Right heart catheterization with implantation of wireless pressure sensor in the pulmonary artery, including any type of measurement, angiography, imaging supervision, interpretation, and report, includes provision of patient home electronics unit|
|Reason:||New technology. In May 2014, the FDA approved the first implantable wireless device with remote monitoring to measure pulmonary artery pressure in certain heart failure patients. The FDA Press Release can be viewed at this link.|
New Pass-Through Drugs
|Injection, testosterone undecanoate, 1 mg
Injection, ramucirumab, 5 mg
Injection, vedolizumab, 1 mg
Factor ix (antihemophilic factor, recombinant), Alprolix, per i.uStatus Indicator:G (Paid under OPPS; Separate APC payment includes pass-through amount.)Reason: All drugs recently approved by the FDA.
|Status Indicator:||G (Paid under OPPS; Separate APC payment includes pass-through amount.)|
|Reason:||All drugs recently approved by the FDA.|
New Drugs: Not pass-through drugs
|Q9972||Injection, Epoetin Beta, 1 microgram, (For ESRD On Dialysis)|
|Q9973||Injection, Epoetin Beta, 1 microgram, (Non-ESRD use)|
|Status Indicator:||E (Not paid under OPPS or any other Medicare payment system)|
|Reason:||Not determined. These are the HCPCS codes for the drug Mircera which is an erythropoiesis-stimulating agent (ESA).|
Revised Status Indicator for Drugs
|J9160||Injection, denileukin diftitox, 300 micrograms|
|J9300||Injection, gemtuzumab ozogamicin, 5 mg|
|Status Indicator:||Changed to E (not covered by Medicare) from K (paid under OPPS)|
|Reason:||The products associated with these HCPCS codes are no longer marketed.|
Skin Substitute Reassignment
|Q4137||Amnioexcel or Biodexcel, Per Square Centimeter|
|Q4138||BioDfence DryFlex, Per Square Centimeter|
|Q4140||BioDfence, Per Square Centimeter|
|Assignment:||Changed to High Cost Skin Substitute from Low Cost|
|Reason:||Pricing is now available for these new skin substitute products and is greater than Medicare threshold of $32 per square centimeter.|
Note: Q4137 assignment to high-cost effective July 1, 2014. Others effective October 1, 2014
Now you know what is new and why. View the MLN Matters Article MM8873 for complete information on the October 2014 OPPS updates.
Article by Debbie Rubio
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.