October OPPS quarterly update includes billing and reimbursement changes for drugs

Wednesday, September 11, 2019

The October 2019 OPPS quarterly update reassigned certain injections from non-payable to separately payable. CMS also revised the status indicators for several recently approved advanced diagnostic laboratory tests (ADLT).

According to Transmittal 4387, CMS gave J3111 (Injection, romosozumab-aqqg, 1 mg) and J9356 (Injection, trastuzumab, 10 mg and Hyaluronidase-oysk) pass-through status in hospital outpatient settings.

Several non-payable HCPCS codes were made payable for specified periods of time. C9042 (Injection, bendamustine hcl [belrapzo]) has received pass-through status retroactively for April 1, 2019 through June 30, 2019, and Q5107 (Injection, bevacizumab-awwb, biosimilar, [mvasi], 10 mg) received separately payable status retroactively for claims dating back to July 18, 2019 –September 30, 2019.

In May, CMS announced that three tests received ADLT approval, but the agency was not able to update the CPT® codes in time for the July 2019 OPPS quarterly update. CPT codes 0080U (Oncology [lung], mass spectrometric analysis of galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors [age, smoking status, nodule diameter, nodule-spiculation status and nodule location], utilizing plasma, algorithm reported as a categorical probability of malignancy) and 81599 (Unlisted multianalyte assay with algorithmic analysis) are assigned to status indicator “A” effective July 1, 2019.

Transmittal 4387 also notes that J9030 (BCG live intravesical instillation, 1 mg) has been reassigned from APC 0809 to APC 9322 effective July 1, 2019.

The update also includes new HCPCS codes for drugs, biologicals, and radiopharmaceuticals, and it implements new and deleted proprietary laboratory analyses (PLA) codes and CPT Category II codes. For more information on the newly released HCPCS codes, see Transmittal 4387, Addendum A. More information on the PLA codes and CPT Category II codes will be included in the October 2019 OPPS Addendum B.