Overview of Changes in Quarterly OPPS Update
by Kimberly Anderwood Hoy Baker, JD
This week CMS released the April 2016 Update of the OPPS containing several important updates and corrections. The transmittal includes updates for laboratory codes, drug codes, and radiation therapy billing. Some of these updates will correct issues that have caused claims processing issues for providers, but they won’t be in place for another month, and providers should consider what they will do in the remaining time before corrections are installed.
One of the most significant retroactive changes relates to several laboratory drug testing codes that were not added to the January version of the OCE. The codes are in the range G0477 to G0483 and represent presumptive and definitive drug-testing codes adopted by CMS to replace CPT codes for these services. The codes have been added to the April release, retroactive to January 1. Because the codes were not in the January release, claims with these codes were returned to the provider for having invalid codes. This occurrence was particularly troubling for providers because the laboratory codes themselves have status indicator “Q4,” meaning they are not separately payable but rather packaged to other services on the claim. Unfortunately, the payable services on the claim could not be processed because of the return of the entire claim for the unrecognized laboratory codes.
CMS discovered the error and announced they would hold submitted claims with these codes until the system was corrected in April and the claims could be processed. As a result, there is a significant delay in revenue for some providers, causing some to elect to strip off the laboratory codes in order to get claims to process. This represents a problem from a rate-setting perspective because the costs of these labs will now be missing from the data used to set rates for the other payable services on the claims. CMS has indicated the claims can be adjusted to add the laboratory charges, which represents no additional reimbursement for providers but adds significant administrative burden, making it unlikely that all the providers who stripped the lab codes from their claims will submit adjustments to add them simply for data purposes. In turn, this situation may impact rates for ED and other services frequently provided with these drug testing codes.
Two drug codes had similar issues. A flu vaccine (90653, Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use) and a common surgical anesthetic (J2704, Injection, Propofol, 10mg) were designated in January with the status indicator “E” for excluded from coverage. The flu vaccine has been corrected to status indicator “L,” similar to other flu vaccines paid on a reasonable cost basis. Propofol was corrected to status indicator “N” for packaged. Similar to the laboratory codes that caused errors, the propofol code is considered packaged and not paid but may have delayed processing of the remainder of the claim, including expensive separately paid surgeries.
Providers may have elected to strip off the propofol or reflect it as a noncovered service to get claims to process. For those claims, the costs of the propofol will not be considered in rate setting for the surgeries they accompanied because they were not reported. For the propofol, the provider has an additional option of stripping off the HCPCS code only and reporting the charge under the general pharmacy revenue code[1] provided it was a covered, packaged delivery of the drug (i.e., used as an anesthetic supply to surgery), which would allow reporting of the costs of the propofol without delaying the processing of the claim.
Other changes for drug codes may mean recoupments for providers. Two drugs were changed from status indicator “K” for separately paid to status indicator “N” for packaged retroactive to January 1. CMS finalized packaging of these drugs in the CY 2016 OPPS Final Rule under a policy to package drugs that function as supplies to surgeries, but they were inadvertently published in January with a payment rate and payable status indicator. The drugs are anticoagulants ReoPro® (J0130, Injection abciximab, 10 mg), published with a payment rate of $1015.54, and Angiomax® or Angiox® (J0583, Injection, bivalirudin, 1 mg), published with a payment rate of $3.01 for 1 mg, but dosages may be over 100 mgs, yielding a significant total payment rate. Due to the high reimbursement rates for these drugs, providers may expect any payments after January 1 and before the April correction to be recouped by contractors, although there is no specific instruction in the transmittal requiring the contractors to reprocess these claims and recoup the payments.
To view the complete article that appeared on Medical Compliance Watch, click here.
[1] Unfortunately, because the revenue codes for lab require HCPCS codes, this option was not available for the invalid laboratory codes.