Status indicator changes in the April OPPS update

April 27, 2016
Medicare Web

Q: You previously talked about drugs with pass-through status beginning in April, but are there any other items with changes in the OPPS update? ​

A: Yes, there are. CMS has published the quarterly average sales price (ASP) pricing update and resulting payment changes for drugs and biologicals in the April 2016 update to Addendum A and B.

In addition, status indicators (SI) for several drugs and biologicals have changed. Unless specified below, the effective date is retroactive to January 1, 2016.

  • CPT code 90653, influenza vaccine inactivated (IIV) subunit, adjuvanted for IM use, is changing from SI of E (not paid by Medicare on OP claim) to SI of L (paid based on reasonable cost). This is effective retroactive to November 24, 2015.
  • HCPCS code J0130, injection abciximab, 10 mg, is changing from SI of K (separate APC payment) to SI of N (packaged)
  • HCPCS code J0583, injection, bivalirudin, 1mg, is changing from SI of K to SI of N
  • HCPCS code J1443, injection, ferric pyrophosphate citrate solution, 0.1mg of iron, is changing from SI of E to SI of N
  • HCPCS code J2704, injection, propofol, 10mg, is changing from SI of E to SI of N

These are listed in Table 3 of Transmittal 3471.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

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