OPPS July update: Six drugs receive pass-through status, payment allowed for new Hepatitis B vaccine
CMS announced revised pricing for covered drugs and biologicals in the July 2018 update to the OPPS, released June 1. The new payment rates will be effective July 1.
Nonpass-through drugs, biologicals, and therapeutic radiopharmaceuticals that are not acquired through the 340B drug program are paid at average sales price (ASP) plus 6%. The ASP is updated quarterly to reflect any changes to prices. Hospitals can review the updated payment rates and prepare for any necessary adjustments in pricing.
Six drugs and biologicals were given pass-through status, effective July. These are reported with HCPCS codes:
- C9030, injection, copanlisib, 1 mg
- C9031, Lutetium Lu 177, dotatate, therapeutic, 1 mCi
- C9032 injection, voretigene neparvovec-rzyl, 1 billion vector genome
- Q9991, injection, buprenorphine extended-release (Sublocade), less than or equal to 100 mg
- Q9992, injection, buprenorphine extended-release (Sublocade), greater than 100 mg
- Q9995, injection, emicizumab-kxwh, 0.5 mg
In addition, the status indicator (SI) of 90739 (Hepatitis B vaccine [hepb], adult dosage, two dose schedule, for intramuscular use) was changed from E1 (not paid by Medicare when submitted on outpatient claims [any outpatient bill type]) to F (not paid under OPPS; paid at reasonable cost). This change was made to reflect the vaccine’s FDA approval in November 2017. Organizations should note that the effective date for the SI change is April 1.
Other changes outlined in the July OPPS update include replacing HCPCS code C9469 (injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg) with Q9993 (Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg).
Hospitals should thoroughly review all of the updates detailed in Transmittal 4064 to ensure any required changes are in place by the stated effective dates.