MLN Matters® Number: MM6629
Related Change Request (CR) #: 6629
Related CR Release Date: August 28, 2009
Effective Date: October 1, 2009
Related CR Transmittal #: R1806CP
Implementation Date: October 5, 2009

Provider Types Affected
This article is for providers, i.e., ASCs, who submit claims to Medicare contractors, i.e., Medicare Administrative Contractors (MACs) and carriers, for services provided to Medicare beneficiaries paid under the ASC payment system.

Provider Action Needed
This article is based on Change Request (CR) 6629 which describes changes to, and billing instructions for, payment policies implemented in the October 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 6629 provides the new HCPCS code for one separately payable drug that will be added to the ASC list of covered ancillary items effective October 1, 2009.

Key Points of CR6629
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 October 1, 2009 are included in the October 1, 2009 updated ASC Addendum BB that will be posted at www.cms.hhs.gov/ASCPayment/11_Addenda_Updates.asp#TopOfPage on the CMS Web site at the end of September.

New Drugs and Biologicals Separately Payable under the ASC Payment System Effective October 1, 2009
One new HCPCS drug code has been created that is separately payable for dates of service on or after October 1, 2009. The new HCPCS code, the long descriptor, and payment indicator (PI) are identified in the following table: 

HCPCS code Q2024 is included in the October 2009 quarterly updates transmittals for the OPPS and ASC payment system. However, this code is not on the 2009 HCPCS file. CMS issued instructions to your Medicare contractors to manually add this code to their systems.

ASC Payment Rate for Certain Newly Payable HCPCS Codes Effective October 1, 2009
For dates of service beginning October 1, 2009, HCPCS code Q4115 (Skin substitute, alloskin, per square centimeter) is eligible for separate payment under the ASC payment system when it is provided integral to a covered surgical procedure. HCPCS code Q4115, the long descriptor, and the updated PI are displayed in the following table: 

Updated Payment Rates for Certain HCPCS Codes Effective April 1, 2008 through June 30, 2008
The payment rates for several HCPCS codes were incorrect in the April 2008 ASC DRUG file. The corrected payment rates are listed below. Suppliers who think they may have received an incorrect payment between April 1, 2008 and June 30, 2008, may voluntarily submit those claims to their Medicare contractors for reprocessing.  

Updated Payment Rates for Certain HCPCS Codes Effective July 1, 2008 through September 30, 2008
The payment rates for several HCPCS codes were incorrect in the July 2008 ASC DRUG file. The corrected payment rates are listed below. Suppliers who think they may have received an incorrect payment between July 1, 2008 and September 30, 2008, may voluntarily submit those claims to their contractors for reprocessing. 

Updated Payment Rates for Certain HCPCS Codes Effective October 1, 2008 through December 31, 2008
The payment rates for several HCPCS codes were incorrect in the October 2008 ASC DRUG file. The corrected payment rates are listed below. Suppliers who think they may have received an incorrect payment between October 1, 2008 and December 31, 2008, may voluntarily submit those claims to their contractors for reprocessing.

Updated Payment Rates for Certain HCPCS Codes Effective July 1, 2009 through September 30, 2009
The payment rates for several HCPCS codes were incorrect in the July 1, 2009 ASC DRUG file. The corrected payment rates are listed below. Suppliers who think they may have received an incorrect payment between July 1, 2009 and September 30, 2009, may voluntarily submit those claims to their contractors for reprocessing. 

Correct Reporting of Drugs
CR 6629 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
If you have questions, please contact our Provider Contact Center at our toll-free number (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).

The official instruction (CR 6629) issued to your Medicare MAC and/or carrier is available at www.cms.hhs.gov/Transmittals/downloads/R1806CP.pdf (PDF, 384 KB) on the CMS Web site.

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.

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