July 2025 OPPS update includes vaccine, skin substitute coding changes
CMS released the July 2025 update of the Outpatient Prospective Payment System (OPPS) to communicate coding and billing changes that took effect on July 1. The changes include status indicator (SI) adjustments, new vaccine and skin substitute codes, and more.
The American Medical Association recently released six new Current Procedural Terminology (CPT®) codes associated with COVID-19, influenza, and respiratory syncytial virus vaccines. CPT codes 90382, 90612, 90613, 90635, 91323, and 90631 will be available once they receive FDA approval, and CMS assigned them to SI “E1.” Effective December 31, 2024, the agency also deleted COVID-19 monoclonal antibody therapy administration Healthcare Common Procedure Coding System (HCPCS) code M0248, as the FDA revoked its emergency use authorization. These changes are all reflected in the July 2025 Integrated Outpatient Code Editor (I/OCE).
The July 2025 OPPS update also includes several coding changes for drugs, biologicals, and radiopharmaceuticals. Along with coding changes related to pass-through status, CMS established 34 and deleted eight HCPCS codes for these products. The agency also changed the SI for HCPCS codes Q5136 and Q9998 from “E2” to “K.”
Revenue integrity professionals should take note of several HCPCS coding changes for drugs, biologicals, and radiopharmaceuticals that will change payment status retroactively. CMS changed the SI for HCPCS codes J9038, Q5151, and Q5152 to “K” in the July 2025 I/OCE update effective April 1, 2025.
In addition, CMS inadvertently had two active HCPCS codes for the same drug in the April 2025 OPPS update. Effective April 1, 2025, through June 30, 2025, the SIs for HCPCS codes C9173 and Q5148 were changed to “E1” and “G,” respectively. The agency deleted C9173 from the July 2025 I/OCE.
CMS established 13 new HCPCS codes (Q4368–4380, Q4382) for skin substitute products and assigned them all to SI “N,” as it did not have pricing data that demonstrated their costs are above the mean unit cost of $50 or the per-day cost of $833 for calendar year 2025. The agency also reassigned HCPCS code Q4309 from the low-cost skin substitute group to the high-cost group.
The July 2025 OPPS update also includes changes to proprietary laboratory analyses codes, CPT Category III codes, and device categories. Revenue integrity professionals can view Medicare Claims Processing Transmittal 13258 for more information.