Fourth Quarter ASC Payment Rate Updates Released

October 2018 ~

CMS has released its October addenda, providing fourth quarter updates to the ASC payment system.

These changes, effective as of October 1, include the following:

New Separately Payable Procedure Code

Effective October 1, HCPCS code C9750 has been created. This procedure was previously described by Category III CPT code 0302T and was deleted December 31, 2017.

HCPCS Code: C9750

Short Descriptor: Ins/remreplace compl iims

Long Descriptor: Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation and peri-operative interrogation and programming; complete system (includes device and electrode)

ASC PI C9750: G2

HCPCS Codes and Dosage Descriptors for Certain Drugs and Biologicals

Two new HCPCS codes have been created for reporting drugs and biologicals in the ASC payment system effective October 1, where there have not previously been specific codes available.

HCPCS Code: C9033

Short Descriptor: Inj, akynzeo

Long Descriptor: Injection, fosnetupitant 235 mg and palonosetron 0.25 mg

ASC PI: K2

HCPCS Code: C9034

Short Descriptor: Injection, dexamethasone 9%

Long Descriptor: Injection, dexamethasone 9%, intraocular, 1 mcg

ASC PI: K2

HCPCS Code Payment Indicator Changes to Separately Payable Status

Four HCPCS codes will have their ASC PI change from ASC PI=N1 (Packaged service/item; no separate payment made.) to ASC PI= K2 (Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate.) effective October 1. The HCPCS codes, their July 2018 ASC PI, and there new ASC PI are also effective as of October 1.

HCPCS Code: A9586

Short Descriptor: Florbetapir f18

ASC PI Effective July 1, 2018: N1

ASC PI Effective October 1, 2018: K2

HCPCS Code: C9447

Short Descriptor: Inj, phenylephrine ketorolac

ASC PI Effective July 1, 2018: N1

ASC PI Effective October 1, 2018: K2

HCPCS Code: Q4172

Short Descriptor: Puraply or puraply am

ASC PI Effective July 1, 2018: N1

ASC PI Effective October 1, 2018: K2

HCPCS Code: Q9950

Short Descriptor: Inj sulf hexa lipid microsph

ASC PI Effective July 1, 2018: N1

ASC PI Effective October 1, 2018: K2

Drugs and Biologicals Based on ASP Methodology with Restated Payment Rates

Some drugs and biologicals based on ASP methodology may have payment rates that are corrected retroactively. These retroactive corrections typically occur on a quarterly basis. The list of drugs and biologicals with corrected payments rates can be found on the CMS Web site on the first date of each quarter.

Reassignment of Skin Substitute Product from the Low-Cost Group to the High Cost Group

The payment for skin substitute products that do not qualify for hospital Outpatient Prospective Payment System (OPPS) pass-through status are packaged into the OPPS payment for the associated skin substitute application procedure. This policy is also implemented in the ASC payment system. The skin substitute products are divided into two groups: 1) high cost skin substitute products and 2) low cost skin substitute products for packaging purposes. Table 5 lists the skin substitute product and its assignment as either a high cost or a low-cost skin substitute product, when applicable. ASCs should not separately bill for packaged skin substitutes (ASC PI=N1). High cost skin substitute products should only be used in combination with the performance of one of the skin application procedures described by CPT codes 15271- 15278. Low cost skin substitute products should only be used in combination with the performance of one of the skin application procedures described by HCPCS code C5271- C5278. All OPPS pass-through skin substitute products (ASC PI=K2) should be billed in combination with one of the skin application procedures described by CPT code 15271-15278.

The skin substitute product listed below has been reassigned from the low-cost skin substitute group to the high cost skin substitute group based on updated pricing information. NOTE: this skin substitute product is packaged and should not be separately billed by ASCs.

HCPCS Code: Q4181

Short Descriptor: Amnio wound, per square cm

ASC PI: N1

Low/High Cost Skin Substitute: High

Coverage Determinations

The fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the ASC payment system does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.

For more information, see the Quarterly HCPCS Drug/Biological Code Changes – October 2018 Update

Source(s): CMS’ MLN Matters; ASCA Government Affairs Update (October 4, 2018);