CMS announces new HCPCS and CPT codes, issues modifier –FY clarification

March 14, 2018
Medicare Web

Changes to HCPCS and CPT® codes, drug and biological payments, and a new separately payable procedure code are coming in April. CMS announced the changes in the April 2018 update of the outpatient prospective payment system (OPPS), published in Transmittal 3988 on March 2. The changes are effective April 1.

CMS is introducing a new, separately payable HCPCS code, C9749 (repair of nasal vestibular lateral wall stenosis with implant[s]). Hospitals should ensure that the new code and charge are set up and ready to go into effect for April 1. Physicians must be briefed on the new code to ensure that documentation captures the elements required to support the charge. Coders and billers also must be informed of the new code, and any updates to coding and billing software should be completed prior to the effective date.

A delayed CPT code is also rolling out on April 1. The American Medical Association CPT Editorial Panel released a new multianalyte assays with algorithmic analyses code, 0011M (oncology, prostate cancer, mRNA expression assay of 12 genes [10 content and 2 housekeeping], RT-PCR test utilizing blood plasma and/or urine, algorithms to predict high-grade prostate cancer risk). The code was released in December 2017, too late to be included in the January OPPS update and was pushed out to the April update. Organizations should ensure that charges are updated in the chargemaster, coding and billing software is updated, and providers and HIM staff are aware of the new code. Organizations should also be aware that although the code is being officially released on April 1, it is retroactively effective to January 1.

The transmittal describes a number of updates to drugs and biologicals. Updated payments for nonpass-through drugs, biologicals, and therapeutic radiopharmaceuticals that were not acquired through the 340B program go into effect April 1. They will be paid at a single rate of the average sales price (ASP) plus 6%. In addition, the payment rate for some ASP drugs and biologicals will be retroactively corrected. The list of effected drugs and biologicals will be posted on the OPPS page on April 1. Be prepared to update charges in a timely fashion once new rates are posted.

Finally, the transmittal clarifies the application of the modifier –FY (X-ray taken using computed radiography technology/cassette-based imaging) payment reduction. The payment reduction for these services will be phased in, with a reduction of 7% for calendar years 2018–2022, and 10% starting in 2023. CMS clarifies that the payment reduction should only be applied if an image is taken using traditional computed radiography technology. If multiple images are taken using computed radiography technology and digital radiography, CMS does not believe the payment reduction would apply.

See Transmittal 3988 for more on the April 2018 OPPS update.