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July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Published on 

Tuesday, June 16, 2020

 | RAC Information 
 | FAQ 

Q:

Has CMS released information about the July 2020 Hospital Outpatient Prospective Payment System update? 


A:

Yes. On June 5th CMS released Change Request 11814 - Transmittal R10166CP and related MLN Article MM1184. This recurring update notification describing changes to and billing instructions for various payment policies implemented in the July 2020 OPPS update. This update includes changes in response to the COVID-19 pandemic and the secretary declaring a public health emergency (PHE). Following is a list of key updates for July 1, 2020:

  • COVID-19 Laboratory Tests and Services and Other Laboratory Tests Coding Update
  • Status Indicator Changes for Certain Virtual Services (Telephone services)
  • New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) Only
  • Other Telehealth Distant Site Codes for RHCs and FQHCs in the OPPS Addendum B and I/OCE
  • New CPT Category III Codes Effective July 1, 2020
  • The American Medical Association (AMA) released CPT Category III codes twice a year: In January, for implementation beginning the following July, and in July, for implementation beginning the following January. CMS is implementing 25 CPT Category III codes on July 1, 2020.
  • CPT Proprietary Laboratory Analyses (PLA) Coding Changes Effective July 1, 2020
  • The AMA CPT Editorial Panel deleted five PLA codes (CPT codes 0124U through 0128U) and established 30 new PLA codes (CPT codes 0172U through 0201U)
  • Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes C9754 and C9755
  • New Device Pass-Through Categories
  • New CY 2020 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals Receiving Pass-Through Status
  • There are eleven new HCPCS codes for reporting drugs and biologicals in the hospital outpatient setting, where there have not previously been specific codes available (i.e., C9059 Injection, meloxicam, 1mg).
  • Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals That Will Start To Receive Pass-Through Status
  • Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals With Pass-Through Status Ending on June 30, 2020
  • Drugs and Biologicals that have Changes to Status Indicators 
  • Newly Established HCPCS Codes for Drugs, Biologicals, and Radiopharmaceuticals as of July 1, 2020
  • Skin Substitutes – New Products
  • New Separately Payable Procedure Codes – Surgical Procedures
  • New HCPCS Codes Describing Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI)
  • New HCPCS Codes Describing Peripheral Intravascular Lithotripsy
  • Supervision of Outpatient Therapeutic Services
  • This section discusses several changes that have been made in response to the COVID-19 outbreak and the Secretary declaring the existence of a public health emergency (PDE).

Finally, CMS reminds providers that “the fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.”

Resources:

Link to Transmittal: https://www.cms.gov/files/document/r10166cp.pdf

Link to MLN Article MM11814: https://www.cms.gov/files/document/mm11814.pdf

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

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.