April quarterly OPPS update affects pricing for skin substitute products, billing for CAR-T therapy

Wednesday, March 27, 2019

The April 2019 OPPS quarterly update reassigned specific skin substitute products from the low-cost group to the high-cost group, and clarified billing and reporting for chimeric antigen receptor T-cell (CAR-T) therapy procedures performed in the outpatient setting.

According to Transmittal 4255, CMS reassigned the following HCPCS codes from the low-cost skin substitute group to the high-cost skin substitute group, effective April 1, based on updated pricing information:

  • Q4183, Surgigraft, per sq. cm
  • Q4184, Cellesta, per sq. cm
  • Q4194, Novachor per sq. cm
  • Q4203, Derma-gide, per sq. cm

In its update, CMS reminds billing professionals that it is continuing pass-through payment status under the OPPS for CAR-T therapy HCPCS codes Q2041 (axicabtagene ciloleucel, up to 200 million autologous anti-cd19 CAR positive viable T-cells, including leukapheresis and dose preparation procedures, per therapeutic dose) and Q2042 (tisagenlecleucel, up to 600 million CAR-positive viable T-cells, including leukapheresis and dose preparation procedures, per therapeutic dose).

According to the update, the following HCPCS codes for CAR-T therapy dosing and preparation services were assigned to status indicator B, meaning they are not recognized by the OPPS when submitted on outpatient hospital Part B bill types:

  • 0537T, CAR-T therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR-T cells, per day
  • 0538T, CAR-T therapy; preparation of blood-derived T lymphocytes for transportation (e.g., cryopreservation, storage)
  •  0539T, CAR-T therapy; receipt and preparation of CAR-T cells for administration

However, as noted in the update, it will be possible for Medicare to track utilization and cost data from hospitals reporting these services, even for HCPCS codes reported for services in which no separate payment is made under the OPPS. Accordingly, effective April 1, hospitals may report HCPCS codes 0537T, 0538T, and 0539T, as noncovered items or services to allow for Medicare to track these services when they’re furnished in the outpatient setting.

More information, including examples for the accurate reporting and billing of CAR-T therapy services, can be found in Transmittal 4255 and MLN Matters MM11192.

Editor's note: This article was originally published on Revenue Cycle Advisor.

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Position Paper: April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) [CR11216]