Summary of the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) payment and coding updates.
We’ve summarized the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) payment and coding updates that went into effect on July 1, 2019. Below is the list of changes and recommendations for possible implementation in the chargemaster, including what your billing and coding staff should know.
New Code for Lymphatic Mapping of Lymph Node(s) with ICG
New HCPCS code C9756 (Intraoperative near-infrared fluorescence lymphatic mapping of lymph node(s) (sentinel or tumor draining) with administration of indocyanine green (ICG) (List separately in addition to code for primary procedure) effective July 1, 2019. This code is being assigned to OPPS status indicator “N” (Items and Services Packaged into APC Rates). Because this code is conditionally packaged and is considered an add-on code, hospitals may not report this code without a primary procedure code. CMS has given this code a Coverage Indicator of “D” which means special coverage instructions apply. Make sure your coding and billing staff are aware of this new code.
Recommendation: It is important to understand other payer’s coverage criteria for this intraoperative service for applicable coding and billing.
New Code for Transperineal Implantation of Balloon Continence Device
Current HCPCS code C9746 (Transperineal implantation of permanent adjustable balloon continence device, with cystourethroscopy, when performed and/or fluoroscopy, when performed) will be deleted effective June 30, 2019. New Category III code 0548T (Transperineal periurethral balloon continence device; bilateral placement, including cystoscopy and fluoroscopy) will be effective for use as of July 1, 2019.
Recommendation: Make sure your coding staff is aware of this code change.
Myocardial Imaging by Magnetocardiography Update
CMS is updating the OPPS status indicators for Category III codes 0541T (Myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning-derived clinical scoring, and automated report generation, single study;) and 0542T (Myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning-derived clinical scoring, and automated report generation, single study; interpretation and report) in light of recent FDA approval for the device CardioFlux Magnetocardiography (MCG). Code 0541T will be changed from “E1” to “S” (significant procedure) and code 0542T will be changed from “E1” to “M” (items and services not billable to the MAC. Not paid under OPPS).
Recommendation: Staff will want to check other payer coverage requirements for this study.
New HCPCS Codes for Pass-through Drugs
CMS has created HCPCS codes for several drugs that have FDA approval. These drugs are approved for pass-through status under the OPPS.
Recommendation: Make sure pharmacy staff is made aware of these updates. These drugs may already be set up in the hospital chargemaster with an unclassified / not otherwise specified HCPCS code. To ensure pass-through payment for Medicare claims, the new HCPCS code will need to be reported.
| HCPCS | Long Description | Brand Name | Update Comment(s) |
| C9047 | Injection, caplacizumab-yhdp, 1 mg | Cablivi | New OPPS pass-through drug code effective July 1, 2019. |
| C9048 | Dexamethasone, lacrimal ophthalmic insert, 0.1 mg | Dextenza | New OPPS pass-through drug code effective July 1, 2019. |
| C9049 | Injection, tagraxofusp-erzs, 10 mcg | Elzonris | New OPPS pass-through drug code effective July 1, 2019. |
| C9050 | Injection, emapalumab-lzsg, 1 mg | Gamifant | New OPPS pass-through drug code effective July 1, 2019. |
| C9051 | Injection, omadacycline, 1 mg | Nuzyra | New OPPS pass-through drug code effective July 1, 2019. |
| C9052 | Injection, ravulizumab-cwvz, 10 mg | Ultomiris | New OPPS pass-through drug code effective July 1, 2019. |
Drug HCPCS Scheduled for Discontinuation
Medicare is replacing two temporary drug HCPCS codes with permanent HCPCS J codes. These existing codes were just recently added effective April 1, 2019. This is an important update because HCPCS code C9042 is currently assigned OPPS status indicator “E2” (Items, Codes, and Services: For which pricing information and claims data are not available) and will be paid as a pass-through drug with new HCPCS code J9036.
Recommendation: Pharmacy staff will need to ensure smooth transition for reporting the permanent HCPCS codes on claims beginning July 1, 2019.
| HCPCS | Long Description | Effective Date | Termination Date | Update Comment(s) |
| C9042 | Injection, bendamustine hcl (belrapzo), 1 mg | 4/1/2019 | 6/30/2019 | C9042 will be deleted June 30, 2019 and replaced with J9036 (Injection, bendamustine hydrochloride, (belrapzo/bendamustine), 1 mg) effective July 1, 2019. |
| C9141 | Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi), 1 i.u. | 4/1/2019 | 6/30/2019 | C9141 will be deleted June 30, 2019 and replaced with J7208 (Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u.) effective July 1, 2019. |
Other Drug HCPCS Updates
CMS is updating the short and long descriptions for HCPCS code J9355 to Inj trastuzumab excl biosimi and Injection, trastuzumab, excludes biosimilar, 10 mg to ensure appropriate code assignment with the introduction of new HCPCS Q codes for trastuzumab biosimilars.
The table below contains other new drug HCPCS codes and discontinuation of code J9031 with introduction of HCPCS code J9030. Pharmacy staff and billing staff will need to review these drugs for billing and payment. Medicare has assigned a status indicator “E2” to the biosimilars initially. They will gather data for these drugs as it becomes available to make a determination for payment status in future OPPS updates.
| HCPCS | Action | Long Descriptor | Effective Date |
| Q5112 | Add | Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg | 7/1/2019 |
| Q5113 | Add | Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg | 7/1/2019 |
| J7208 | Add | Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u. | 7/1/2019 |
| Q5114 | Add | Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg | 7/1/2019 |
| J7677 | Add | Revefenacin inhalation solution, fda-approved final product, non-compounded, administered through DME, 1 microgram | 7/1/2019 |
| Q5115 | Add | Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg | 7/1/2019 |
| J9036 | Add | Injection, bendamustine hydrochloride, (Belrapzo/bendamustine), 1 mg | 7/1/2019 |
| J1444 | Add | Injection, ferric pyrophosphate citrate powder, 0.1 mg of iron | 7/1/2019 |
| J9030 | Add | BCG live intravesical instillation, 1 mg | 7/1/2019 |
| J9031 | D/C* | Bcg (intravesical) per instillation | 7/1/2019 |
| J9356 | Add | Injection, trastuzumab, 10 mg and Hyaluronidase-oysk | 7/1/2019 |
*J9031 is being discontinued June 30, 2019 with introduction of J9030 effective for reporting July 1, 2019.
Skin Substitute HCPCS Code Update
The following skin substitute HCPCS code is being reassigned from the Low Cost Group to the High Cost Group effective July 1, 2019.
Recommendation: Ensure coding staff are aware of this change so the applicable skin substitute graft application CPT codes (15271-15278) are reported with this HCPCS code.
| HCPCS | Short Description | Effective Date | OPPS SI | Low / High Cost Skin Substitute |
| Q4176 | Neopatch, per square centimeter | 7/1/19 | N | High |
| Refer to the July 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) change request (CR) document for payment and other information related to these HCPCS code(s) and other updates. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4313CP.pdf |
UPDATE: Chimeric Antigen Receptor (CAR) T-Cell Therapy
We published guidance for reporting CAR T-Cell Therapy effective for services April 1, 2019 in our last quarterly newsletter. CMS released an MLN Matters Number SE19009 dated May 28, 2019 stating this article replaces instructions posted in Transmittal 4255, CR11216. They revised the billing instruction when CAR T-cells are administered in the inpatient setting. The hospital may report the steps to collect and prepare the CAR T-cells in revenue codes 871, 872 or 873 or the hospital may include the charges for these steps in the charge reported for the biological using revenue code 891.
Recommendation: We refer readers to the link provided. Make sure the revised guidance is discussed with applicable staff.
Proprietary Laboratory Analyses (PLA) Code Updates
American Medical Association (AMA) is deleting one PLA code (0057U) and adding twenty-one new PLA codes (0084U-0104U) effective for use July 1, 2019. To see the full listing of these new codes, readers can go to the AMA website link provided below. CMS has also published this table in the July 2019 OPPS Update Transmittal.
New Vaccine Code
The AMA releases new Category I codes twice a year for vaccines codes. Medicare has assigned OPPS status indicator “E1” (Items, Codes, and Services: Not covered by any Medicare outpatient benefit category, Statutorily excluded by Medicare, Not reasonable and necessary) to code 90619.
Recommendation: We recommend staff check with other payers regarding coverage and reimbursement for this vaccine.
| HCPCS | Long Description | Effective
Date |
OPPS SI |
| 90619 | Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use | 7/1/19 | E1 |
New Category III Codes
The AMA is releasing twenty new Category III codes (0543T through 0562T) effective for use July 1, 2019. To view the table of new codes, readers can access the link to the July 2019 OPPS Update Transmittal or access the link to the AMA website below.
CPT® is a registered trademark of the American Medical Association.
Copyright 2018 American Medical Association. All rights reserved.
Refer to the AMA website for further information regarding new Category III codes and PLA codes
https://www.ama-assn.org/system/files/2019-03/cpt-category3-codes-long-descriptors.pdf
https://www.ama-assn.org/practice-management/cpt/cpt-pla-codes
To learn more about the changes and our recommendations for possible implementation in the chargemaster, download the summary sheet.