CMS Changes Effective April 4, 2014

Here are a few highlights of the changes effective April 2014.  New services have been released in attachment A and are assigned for payment under the Outpatient Perspective Payment System.

Table 1: New services payable under OPPS Effective April 1, 2014

  • C9739 Cystrourethrsocopy, with insertion of transprostatic implant; 1-3 implants
  • C9740 Cystrourethroscopy, with insertion of transprostatic implant; 4 or more implants

Both of these services have been assigned a status indicator T and the APC for C9739 is 0162 with a national payment rate of $2,007.32.  HCPCS code C9740 has been assigned APC 1564 and has a national payment rate of $4,750.00.

Table 2 has indicated drug and biologicals changes or additions with OPPS Pass -Through status.

C9021 is a new code for Injection, Obinutuzumab, 10mg and has a status indicator of G and an APC assignment of 1476.  The national payment rate is $54.70.

  • Q4121 Theraskin, per square centimeter has been assigned APC 1479 and status indicator of G.  The national payment amount is $23.18.

Table 3: Indicative of drugs and biologicals with revision of the status indicators.

  • A9545 Iodine I-131 tositumomab, therapeutic, per treatment dose has been assigned a status indicator E and there is not an APC associated.  This treatment is no longer payable under the OPPS on any outpatient bill type.
  • J1446 Injection, TBO-Filgrastim, 5 micrograms has been assigned APC 1477 with a status indicator K.  National payment rate is $4.22.
  • J7178 Injection, human fibroinogen concentrate, 1 mg has also been assigned APC 1478 with a status indicator K.  National payment amount is $0.96.
  • Q0181 Unspecified oral dosage form, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen, has been changed to status indicator N and is packaged.

Table 4 and Table 5:  The following have updated payment rates for certain HCPCS codes and are effective April 1, 2013-June 30, 2013 and July 1, 2013-September 30, 2013.  The amount for HCPCS code Q4127 Talymed had previously been priced incorrectly at $0.55.  This code carries a status indicator G and APC 1449.  The payment amount has been corrected to $13.78.  The instruction given by the MLN Matters is to bring these claims to the attention of the MAC so they can be reprocessed.  Adjustments to the claims will not be performed automatically, the facility must request it.

Table 6 is indicative of updated payment rates for the following HCPCS code effective October 1, 2013-December 31, 2013

  • A9600 Sr89 strontium had a payment rate of $1,368.27 nationally and has been updated to reflect the corrected rate of $1,196.47.
  • J25323 Natalizumab injection was at a payment rate of $12.90 and has been corrected to $12.99.
  • Q4127 Talymed was at $0.55 and has been updated to $13.78.

It is important to note the MLN matters did not give instruction on how these HCPCS codes for this time frame would be adjusted or what action the facility should take.

Table 7:  This table is indicative of the Reassignment of Skin Substitute Products that are new for CY 2014 from the Low Cost Group to the High Cost Group.

For CY 2014 OPPS/ASC final rule, CMS finalized a policy to package payment for skin substitute products into the associated skin substitute application procedures.  For packaging purposes, CMS has created two groups of application procedures.  One for high cost skin substitutes products billed using CPT codes 15271-15278 and application procedures that use low cost skin substitute products, which are billed using HCPCS codes C5271-C5278.  The assignment of skin substitute products to the high cost or low cost groups was dependent upon a comparison of the July 2013 payment rate for skin substitute product to $32.00 per square centimeter.  This was a weighted average payment per unit for all skin substitute products using the skin substitute utilization from the CY 2012 claims data and the July 2013 payment rate for each product.  The skin substitute products paid within the July 2013 payment rate that was above $32.00 per square centimeter are paid through the high cost group and those that were paid with an equal too or lesser than $32.00 per square centimeter were put in the low cost group category.   There were some products that did not have any claims data or payment data available at the time of assignment for the low cost or high cost category.  Table 7 has listed the updated payment rates for the following skin substitutes:

  • Q4143 Repriza, Per square centimeter, this is a status indicator N and is in the low cost category.
  • Q4147 Architect Extracellular Matrix, Per square centimeter is status indicator N and in is in the high cost category.
  • Q4148 Neox 1k, Per square centimeter is status indicator N and has been listed in the high cost category

Special coding and billing instructions apply to these services and I wanted to bring to your attention that there are a few skin substitute products that are applied as either liquids or powders per milliliter or per milligram that are currently employed outside of the procedures described by CPT 15271-15278. These services are not designated as either high or low cost, and should be billed with the applicable surgical procedures that use them rather than the skin application procedures noted in CPT as 15271-15278 or C5271-C5278.  Payment for those skin substitutes will be packaged into payment for the related surgical procedures.

Effective April 1, 2014 the reassignment of the two skin substitutes products Q4147 and Q4148 from the low to high cost group. Hospitals need to revise the billing policies to ensure that these skin substitute products are billed with the applicable skin application procedures.  In addition, hospitals need to keep an eye out for potential reassignment of the remaining six new skin application procedures so that the billing policies can be changed appropriately and implemented as needed.

For more information go to and see Change Request CR 8653 and Medicare Learning Network MLN Matters MM8653.

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