October OPPS Code Changes/Additions

on Monday, 11 September 2017. All News Items | Outpatient Services | Coding

A Code for This, a Code for That

Every year with the annual update of the hospital Outpatient Prospective Payment System (OPPS) and quarterly thereafter, CMS adds or makes changes to procedure codes for billing outpatient services. These additions and changes are described in the quarterly OPPS update transmittals. The October 2017 OPPS Update contains, as usual, a number of code updates. See the table at the end of this article for the new codes with an explanation of exactly what is new or changed. Below is a description of some of the categories of changes to help with understanding the new codes.

Proprietary Laboratory Analyses (PLA) CPT Codes – A new addition to the American Medical Association (AMA) CPT code set, these codes may be requested by labs or manufacturers to more specifically identify their proprietary laboratory tests. They must be performed on human specimens and are provided by either a single (“sole-source”) laboratory or licensed or marketed to multiple providing laboratories (eg, cleared or approved by the Food and Drug Administration [FDA]). These are generally complex laboratory tests such as Multianalyte Assays with Algorithmic Analyses (MAAA) and Genomic Sequencing Procedures (GSP). 

Device Intensive Procedures – Device-intensive status is assigned to procedures requiring the implantation of a medical device, when the individual HCPCS level device offset is greater than 40 percent. Device offset is the portion of the Medicare procedure payment amount that is attributed to the cost of the device. New procedures requiring the insertion of an implantable medical device will be assigned device-intensive status until claims data is available.  When a device-intensive HCPCS code is reported on a claim, the claim must also contain a device code. On claims with pass-through devices that are paid separately by Medicare, the procedure payment is reduced by the device offset amount so that Medicare is not paying twice for the device.

Pass-through Status – Status allowing separate payment for new technology devices and drugs that meet certain criteria.  The payments are only available for 2-3 years until claims data is available to determine appropriate payment. Devices must meet a number of criteria; drugs only need to be new and have significant cost in comparison to the applicable payment rate. When a drug’s pass-through status expires, payment for the drug is packaged or paid separately depending on the estimated per day cost compared to the OPPS drug packaging threshold for that calendar year – drugs with a per day cost exceeding the threshold are paid separately, those below are packaged.

Biosimilar Biological Product – A biosimilar is a biologic medical product or drug that is highly similar to an FDA-approved biological product manufactured by a different company (reference product).  A biosimilar has no clinically meaningful differences in terms of safety and effectiveness from the reference product.  The Affordable Care Act (2010) created an abbreviated approval pathway for biological products to promote development and create competition, with the goals of increasing treatment options and reducing healthcare costs. (FDA Information on Biosimilars)

CMS assigns one HCPCS code to a biosimilar, regardless of the manufacturer.  All biosimilars of that drug will be reported with that one HCPCS code.  For example, you will notice in the table below the HCPCS code for Infliximab Biosimilar is Q5102.  A modifier, assigned by CMS, must be appended to the biosimilar HCPCS code to identify the manufacturer of the biosimilar. (See Transmittal 15420).

October 2017 OPPS Code Updates
CPT CodeLong DescriptorOPPS Status IndicatorEffective DateDescription of Change
0006U Prescription drug monitoring, 120 or more drugs and substances, definitive tandem mass spectrometry with chromatography, urine, qualitative report of presence (including quantitative levels, when detected) or absence of each drug or substance with description and severity of potential interactions, with identified substances, per date of service Q4
(Payment packaged unless only lab tests on claim)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0007U Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of service Q4
(Payment packaged unless only lab tests on claim)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0008U Helicobacter pylori detection and antibiotic resistance, DNA, 16S and 23S rRNA, gyrA, pbp1, rdxA and rpoB, next generation sequencing, formalin-fixed paraffin embedded or fresh tissue, predictive, reported as positive or negative for resistance to clarithromycin, fluoroquinolones, metronidazole, amoxicillin, tetracycline and rifabutin A
(Paid under fee schedule other than OPPS; Clinical Lab Fee Schedule (CLFS) for this test)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0009U Oncology (breast cancer), ERBB2 (HER2) copy number by FISH, tumor cells from formalin fixed paraffin embedded tissue isolated using image-based dielectrophoresis (DEP) sorting, reported as ERBB2 gene amplified or non-amplified Q4
(Payment packaged unless only lab tests on claim)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0010U Infectious disease (bacterial), strain typing by whole genome sequencing, phylogenetic-based report of strain relatedness, per submitted isolate A
(Paid under fee schedule other than OPPS; Clinical Lab Fee Schedule (CLFS) for this test)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0011U Prescription drug monitoring, evaluation of drugs present by LCMS/MS, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug compounds and metabolites Q4
(Payment packaged unless only lab tests on claim)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0012U Germline disorders, gene rearrangement detection by whole genome next-generation sequencing, DNA, whole blood, report of specific gene rearrangement(s)

A
(Paid under fee schedule other than OPPS; Clinical Lab Fee Schedule (CLFS) for this test)

August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0013U Oncology (solid organ neoplasia), gene rearrangement detection by whole genome next-generation sequencing, DNA, fresh or frozen tissue or cells, report of specific gene rearrangement(s) A
(Paid under fee schedule other than OPPS; Clinical Lab Fee Schedule (CLFS) for this test)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0014U Hematology (hematolymphoid neoplasia), gene rearrangement detection by whole genome nextgeneration sequencing, DNA, whole blood or bone marrow, report of specific gene rearrangement(s) A
(Paid under fee schedule other than OPPS; Clinical Lab Fee Schedule (CLFS) for this test)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0015U Drug metabolism (adverse drug reactions), DNA, 22 drug metabolism and transporter genes, real-time PCR, blood or buccal swab, genotype and metabolizer status for therapeutic decision support Q4
(Payment packaged unless only lab tests on claim)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0016U Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation A
(Paid under fee schedule other than OPPS; Clinical Lab Fee Schedule (CLFS) for this test)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
0017U Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected A
(Paid under fee schedule other than OPPS; Clinical Lab Fee Schedule (CLFS) for this test)
August 1, 2017 New Proprietary Laboratory Analyses (PLA) CPT Code
C9747 Ablation of prostate, transrectal, high intensity focused ultrasound (HIFU), including imaging guidance J1
(comprehensive APC; payment for most other services on claim packaged into payment of primary J1 service)
October 1, 2017 New Device Intensive Procedure
C9491 Injection, avelumab, 10 mg G
(Pass-through drug; paid under OPPS)
October 1, 2017 Granted Pass-through status
C9492 Injection, durvalumab, 10 mg G
(Pass-through drug; paid under OPPS)
October 1, 2017 Granted Pass-through status
C9493 Injection, edaravone, 1 mg G
(Pass-through drug; paid under OPPS)
October 1, 2017 Granted Pass-through status
C9494 Injection, ocrelizumab, 1 mg G
(Pass-through drug; paid under OPPS)
October 1, 2017 Granted Pass-through status
Q5102-ZB Injection, Infliximab, Bio similar, 10 mg (Pfizer/Hospira) K
(Nonpass-through drug; paid under OPPS)
April 1, 2017 New Modifier for Biosimilar Biological Product
Q5102-ZC Injection, Infliximab, Bio similar, 10 mg (Merck/Samsung Bioepis) K
(Nonpass-through drug; paid under OPPS)
July 1, 2017 New Modifier for Biosimilar Biological Product
90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use L
(Flu/pneumonia vaccine; paid at reasonable cost)
January 1, 2017 Existing Flu Vaccine with trade name Flucelvax Quadrivalent (Preservative-Free and Antibiotic-Free Flu Vaccine)
Q2039 Influenza virus vaccine, not otherwise specified (Cciiv4 vaccine, nos, intramuscular)

L
(Flu/pneumonia vaccine; paid at reasonable cost)

August 1, 2017 through December 31, 2017 New Flu Vaccine with trade name Flucelvax Quadrivalent (Preservative Flu Vaccine); permanent CPT code to be released on a later date

 

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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