July 2009 Update to the Ambulatory Surgical Center (ASC) Payment System: Summary of Payment Policy Changes
MLN Matters® Number: MM6496 Revised
Related Change Request (CR) #: 6496
Related CR Release Date: June 19, 2009
Effective Date: July 1, 2009
Related CR Transmittal #: R1759CP
Implementation Date: July 6, 2009
Note: This article was revised on June 22, 2009, to reflect a revision made to CR 6496. That CR was modified because it incorrectly identified HCPCS code Q4115 as a newly payable HCPCS in the ASC setting. This code is not payable in the ASC setting and the CR and this article were adjusted accordingly. The CR release date, transmittal number, and Web address for accessing CR 6496 were also revised. All other information remains the same.
Provider Types Affected
Providers (ASCs) who submit claims to Palmetto GBA, for services provided to Medicare beneficiaries paid under the ASC payment system.
Provider Action Needed
This article is based on Change Request (CR) 6496 which describes changes to, and billing instructions for, payment policies implemented in the July 2009, ASC update. This update provides updated payment rates for selected separately payable drugs and biologicals and provides rates and descriptors for newly created Level II Healthcare Common Procedure Coding System (HCPCS) codes for drugs and biologicals. Be sure your billing staff is aware of these changes.
Background
Final policy under the revised ASC payment system, as set forth in the final rule CMS-1517-F, requires that ASC payment rates for covered separately payable drugs and biologicals be consistent with the payment rates under the Medicare hospital outpatient prospective payment system (OPPS). Those rates are updated quarterly. Therefore, beginning with the update notification (Transmittal R1488CP, CR5994) issued April 9, 2008, the Centers for Medicare & Medicaid Services (CMS) has issued quarterly updates to ASC payment rates for separately paid drugs and biologicals. CMS also updates the lists of covered surgical procedures and covered ancillary services to include newly created HCPCS codes, as appropriate. CR 6496 provides the new HCPCS codes for 12 separately payable drugs and biologicals, and two new Category III Current Procedural Terminology (CPT) codes for surgical procedures that will be added to the ASC list of covered surgical procedures effective July 1, 2009.
In CR 6496, CMS issued instructions to their contractors to modify their systems to include new payment rates for all separately payable drugs and biologicals and to update the payment indicators for payable and non-payable ASC services.
Key Points
CMS reminds ASCs that under the ASC payment system if two or more drugs or biologicals are mixed together to facilitate administration, the correct HCPCS codes should be reported separately for each product used in the care of the patient. The mixing together of two or more products does not constitute a "new" drug as regulated by the Food and Drug Administration (FDA) under the New Drug Application (NDA) process. In these situations, ASCs are reminded that it is not appropriate to bill HCPCS code C9399. HCPCS code C9399, Unclassified drug or biological, is for new drugs and biologicals that are approved by the FDA on or after January 1, 2004, for which a HCPCS code has not been assigned.
CMS also reminds ASCs that updated drug payment rates effective July 1, 2009, are included in the July 1, 2009, updated ASC Addendum BB that will be posted on the CMS Web site at the end of June.
Eleven new HCPCS drug codes have been created that are separately payable for dates of service on or after July 1, 2009. The new HCPCS codes, the long descriptors, and payment indicators (PIs) are identified in the following table:
New Drugs and Biologicals Separately Payable under the ASC Payment System Effective July 1, 2009
|
HCPCS Code
|
Long Descriptor
|
P I
|
|
C9250
|
Human plasma fibrin sealant, vapor-heated, solvent- detergent (Artiss), 2ml
|
K2
|
|
C9251
|
Injection, C1 esterase inhibitor (human), 10 units
|
K2
|
|
C9252
|
Injection, plerixafor, 1 mg
|
K2
|
|
C9253
|
Injection, temozolomide, 1 mg
|
K2
|
|
C9360
|
Dermal substitute, native, non-denatured collagen,
neonatal bovine origin (SurgiMend Collagen Matrix), per
0.5 square centimeters
|
K2
|
|
C9361
|
Collagen matrix nerve wrap (NeuroMend Collagen Nerve
Wrap), per 0.5 centimeter length
|
K2
|
|
C9362
|
Porous purified collagen matrix bone void filler (Integra
Mozaik Osteoconductive Scaffold Strip), per 0.5 cc
|
K2
|
|
C9363
|
Skin substitute, Integra Meshed Bilayer Wound Matrix,
per square centimeter
|
K2
|
|
C9364
|
Porcine implant, Permacol, per square centimeter
|
K2
|
|
Q2023
|
Injection, factor viii (antihemophilic factor, recombinant)
(Xyntha), per i.u.
|
K2
|
|
|
Skin substitute, Alloderm, per square centimeter
|
K2
|
The payment rates for several HCPCS codes were incorrect in the January 2009 ASC DRUG file that CMS supplied to its contractors. Suppliers who think they may have received an incorrect payment between January 1, 2009 and March 31, 2009, may voluntarily submit claims to their contractors for reprocessing after July 6, 2009. The corrected payment rates are shown in the following table:
Updated Payment Rates for Certain HCPCS Codes Effective January 1, 2009 through March 31, 2009
|
HCPCS Code
|
Short Descriptor
|
Payment
Indicator
|
Corrected
Payment Rate
|
|
J1441
|
Filgrastim 480 mcg injection
|
K2
|
$304.27
|
|
J1740
|
Ibandronate sodium injection
|
K2
|
$136.35
|
|
J2505
|
Injection, pegfilgrastim 6mg
|
K2
|
$2,135.12
|
|
J7513
|
Daclizumab, parenteral
|
K2
|
$341.09
|
CMS has determined that two new Category III CPT Codes are appropriate for payment in ASCs, effective July 1, 2008. Payment rates for these services can be found in the July 2009 updated ASC Addendum AA that will be posted on the CMS Web site at the end of June. The new Category III codes, their descriptors and their ASC payment indicators are as follows:
Category III CPT Codes Implemented as ASC Covered Surgical Procedures as of July 1, 2009
|
HCPCS Code
|
Long Descriptor
|
PI
|
|
0200T
|
Percutaneous sacral augmentation (sacroplasty),
unilateral injection(s), including the use of a balloon or
mechanical device (if utilized), one or more needles
|
G2
|
|
0201T
|
Percutaneous sacral augmentation (sacroplasty),
bilateral injections, including the use of a balloon or
mechanical device (if utilized), two or more needles
|
G2
|
CR 6496 also provides reminders about the correct reporting of drugs and biologicals when used as implantable devices and the correct reporting of units for drugs.
Additional Information
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Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.