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July 2008 Update to the Ambulatory Surgical Center (ASC) Payment System; Summary of Payment Policy Changes (ASC)
Posted July 2, 2008
MLN Matters Number: MM6095
Related Change Request (CR) #: 6095
Related CR Release Date: June 20, 2008
Related CR Transmittal #: R1540CP
Effective Date: July 1, 2008
Implementation Date: July 7, 2008
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Provider Types Affected
Providers (ambulatory surgical centers (ASCs)) who submit claims to Part A/B Medicare Administrative Contractors (A/B 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) 6095, which describes changes to, and billing instructions for, payment policies implemented in the July 2008 ASC update. This update provides updated payment rates for selected separately payable drugs and biologicals, descriptors for newly created Level II Healthcare Common Procedure Coding System (HCPCS) codes for drugs and biologicals, and payment rates and descriptors for three newly created Category III Common Procedural Terminology (CPT) codes that are added to the list of payable procedures. Code deletions are also identified in this notification. Be sure billing staff is aware of these changes.
Key Points of CR 6905
Billing for Drugs and Biologicals
The Centers for Medicare & Medicaid Services (CMS) strongly encourages ASCs to report charges for all separately payable drugs and biologicals, using the correct HCPCS codes for the items used. ASCs billing for these products should make certain that the reported units of service of the reported HCPCS code are consistent with the quantity of the drug or biological that was used in the care of the patient. ASCs should not report HCPCS codes and separate charges for drugs and biologicals that receive packaged payment through the payment for the associated covered surgical procedure.
Remember that under the Outpatient Prospective Payment System (OPPS), 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.
Unless otherwise specified in the long description, HCPCS descriptions refer to the non-compounded, FDA-approved final product. If a product is compounded and a specific HCPCS code does not exist for the compounded product report an appropriate unlisted code such as J9999 or J3490.
Drugs and Biologicals with Payment Based on Average Sales Price (ASP) Effective July 1, 2008
- Payments for separately payable drugs and biologicals based on the ASP will be updated on a quarterly basis as later quarter ASP submissions become available. In cases where adjustments to payment rates for previous quarter(s) are necessary based on the most recent ASP submissions, CMS will incorporate changes to the payment rates in the July 2008 release of the ASC drug file.
- Your Medicare contractors will make available to the ASCs the list of any newly added codes and previous quarter payment rate changes as identified in CR 6095.
- Providers take note that, if your claims were processed prior to the installation of the revised January or April 2008 ASC drug file, your Medicare A/B MAC or carrier will adjust, as appropriate, claims you bring to their attention that have dates of service on or after January 1, 2008, but prior to July 1, 2008.
New HCPCS Drugs and Biologicals Separately Payable under the ASC Payment System Effective July 1, 2008
The four HCPCS codes that are newly payable in ASCs and their descriptors are listed in Table 1 below.
Table 1
New Drugs and Biologicals Separately Payable under the ASC Payment System as of July 1, 2008
| C9242 |
Injection, fosaprepitant |
| C9356 |
TendoGlide Tendon Prot, cm2 |
| C9357 |
Flowable Wound Matrix, 1 cc |
| C9358 |
SurgiMend, per 0.5 cm2 |
The payment rates for these drugs in Table 1 are included in the July 2008 update of the ASC Addendum BB which will be posted at the end of June at www.cms.hhs.gov/ASCPayment/04_CMS-1517-F.asp on the CMS Web site.
No HCPCS codes are being deleted from the ASC drug file for July 2008.
Updated Payment Rates for Certain HCPCS Codes Effective January 1, 2008, through March 31, 2008
The payment rates for several HCPCS codes were incorrect in the January 2008 ASC drug file. The corrected payment rates are listed below in Table 2 and have been included in the revised January 2008 ASC drug file, effective for services furnished on January 1, 2008, through March 31, 2008. Your Medicare contractor will adjust claims affected by these corrections if you bring such claims to their attention.
Table 2
Updated Payment Rates for Certain HCPCS Codes Effective January 1, 2008, through March 31, 2008
| 90675 |
Rabies vaccine, im |
K2 |
150.27 |
| J2820 |
Sargramostim injection |
K2 |
25.02 |
| J9010 |
Alemtuzumab injectionn |
K2 |
549.29 |
| J9015 |
Aldesleukin/single use vial |
K2 |
764.56 |
| J9226 |
Supprelin LA implant |
K2 |
14694.12 |
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 in Table 3 and have been corrected in the revised April 2008 ASC drug file effective for services furnished on April 1, 2008, through June 30, 2008. Your Medicare contractor will adjust claims affected by these corrections if you bring such claims to their attention.
Table 3
Updated Payment Rates for Certain HCPCS Codes Effective April 1, 2008, through June 30, 2008
| J2323 |
Natalizumab injection |
K2 |
7.51 |
| J2778 |
Ranibizumab inj |
K2 |
406.18 |
| J3350 |
Urea Injection |
K2 |
23.23 |
| J3488 |
Reclast injection |
K2 |
216.61 |
Correct Reporting of Units for Drugs
ASCs are reminded to ensure that units of drugs administered to patients are accurately reported in terms of the dosage specified in the full HCPCS code descriptor. That is, units should be reported in multiples of the units included in the HCPCS descriptor.
- For example, if the drug's HCPCS code descriptor specifies 6 mg, and 6 mg of the drug were administered to the patient, the units billed should be 1.
- As another example, if the drug's HCPCS descriptor specifies 50 mg and 200 mg of the drug were administered to the patient, the units billed should be 4.
- ASCs should not bill the units based on how the drug is packaged, stored, or stocked. That is, if the HCPCS descriptor for the drug code specifies 1 mg and a 10 mg vial of the drug was administered to the patient, 10 units should be reported on the bill, even though only 1 vial was administered.
- HCPCS short descriptors are limited to 28 characters, including spaces, so short descriptors do not always capture the complete description of the drug. Therefore, before submitting Medicare claims for drugs and biologicals it is extremely important to review the complete long descriptors for the applicable HCPCS codes.
Payment for Brachytherapy Sources as of July 1, 2008
The Medicare, Medicaid, and SCHIP Extension Act of 2007 requires CMS to pay for brachytherapy sources for the period of January 1 through June 30, 2008, at hospitals' charges adjusted to costs. Consistent with CMS policy to pay ASCs at contractor-priced rates if prospective OPPS rates are not available for brachytherapy sources, for the period January 1 through June 30, 2008, ASCs are paid at contractor-priced rates for these sources. The prospective payment rates for each source, which are listed in Addendum BB to CMS CY 2008 final rule dated November 27, 2007, will be used for payment from July 1 through December 31, 2008. These payment rates are also included in the revised ASCFS effective for dates of service beginning July 1, 2008. The "H7" payment indicators assigned to brachytherapy source HCPCS codes in the April 2008 Addendum BB on the CMS Web site will change to "H2" to reflect the policy to pay for brachytherapy sources at prospectively determined rates, as in Addendum BB published with the CY 2008 OPPS/ASC final rule with comment period.
The HCPCS codes for separately payable brachytherapy sources, long descriptors, and payment indicators for CY 2008 are listed in Table 4 below.
Note that when billing for stranded sources, providers should bill the number of units of the appropriate source HCPCS C code according to the number of brachytherapy sources in the strand, and not bill as one unit per strand. The payment rates for these brachytherapy sources will be available in Addendum BB posted on the CMS Web site at the end of June.
Table 4
Comprehensive List of Brachytherapy Sources Payable as of July 1, 2008
| A9527 |
Iodine I-125 sodium iodide |
H2 |
| C1716 |
Brachytx, non-str, Gold-198 |
H2 |
| C1717 |
Brachytx, non-str, HDR Ir-192 |
H2 |
| C1719 |
Brachytx, NS, Non-HDR Ir-192 |
H2 |
| C2616 |
Brachytx, non-str, Yttrium-90 |
H2 |
| C2634 |
Brachytx, non-str, HA, I-125 |
H2 |
| C2635 |
Brachytx, non-str, HA, P-103 |
H2 |
| C2636 |
Brachy linear, non-str, P-103 |
H2 |
| C2638 |
Brachytx, stranded, I-125 |
H2 |
| C2639 |
Brachytx, non-stranded, I-125 |
H2 |
| C2640 |
Brachytx, stranded, P-103 |
H2 |
| C2641 |
Brachytx, non-stranded, P-103 |
H2 |
| C2642 |
Brachytx, stranded, C-131 |
H2 |
| C2643 |
Brachytx, non-stranded, C-131 |
H2 |
| C2698 |
Brachytx, stranded, NOS |
H2 |
| C2699 |
Brachytx, NOS |
H2 |
Category III CPT Codes
CMS is implementing three new Category III CPT codes that are appropriate for payment in ASCs, effective July 1, 2008. The new Category III codes and their ASC payment indicators are shown in Table 5 below. Payment rates for these services can be found in Addendum AA of the July 2008 ASC Update that will be posted on the CMS Web site at the end of June. These new Category III CPT codes and their payment rates are included in the July release of the ASC Fee Schedule.
Table 5
Category III CPT Codes Implemented as ASC Covered Surgical Procedures as of July 1, 2008
| 0190T |
Place intraoc radiation src |
G2 |
| 0191T |
Insert ant segment drain int |
G2 |
| 0192T |
Insert ant segment drain ext |
G2 |
ASC Payment for Office-Based Procedures and Radiology Services
ASC payment for office-based procedures and radiology services are made at the lesser of the nonfacility practice expense (PE) relative value units (RVU) amount under the Medicare Physician Fee Schedule or the ASC rate for the service calculated according to the standard ASC methodology. The provisions of §109(b) of the Medicare, Medicaid and SCHIP Extension Act of 2007 expire after June 30, 2008, and, therefore, the MPFS payment rates for July 1 through December 31, 2008, will be those issued by CMS in the MPFS final rule (72 FR 66410). The changes to those rates result in changes to rates for some covered office-based surgical procedures and covered ancillary radiology services paid under the ASC payment system.
Beginning July 1, 2008, ASC payment amounts for office-based procedures and radiology services will be equal to the rates displayed in Addenda AA and BB to the OPPS/ASC final rule with comment period (72 FR 66945 and 67165) and will be included in Addenda AA and BB that will be posted on the CMS Web site at the end of June. These revised rates are included in the July release of the ASCFS.
Additional Information
To see the official instruction (CR 6095) issued to your Medicare carrier or A/B MAC, visit www.cms.hhs.gov/Transmittals/downloads/R1540CP.pdf on the CMS Web site. Your Medicare contractor will make the July 2008 ASC fee schedule data for their localities available on their Web site.
If you have questions, please contact your Medicare carrier or A/B MAC at their toll-free number, which may be found at www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip 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 2007 American Medical Association.
April 2008 Update to the Ambulatory Surgical Center (ASC) Payment System; Summary of Payment Policy Changes (ASC)
Posted April 22, 2008
MLN Matters Number: MM5994
Related Change Request (CR) #: 5994
Related CR Release Date: April 9, 2008
Related CR Transmittal #: R1488CP
Effective Date: April 1, 2008
Implementation Date: April 7, 2008
The Ambulatory Surgical Center Fee Schedule Fact Sheet, which provides general information about the Ambulatory Surgical Center (ASC) Fee Schedule, ASC payments, and how ASC payment amounts are determined, is now available in downloadable format from the Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network at www.cms.hhs.gov/MLNProducts/downloads/AmbSurgCtrFeepymtfctsht508.pdf on the CMS Web site, and is also available in print format. To place your order for the printed version, visit www.cms.hhs.gov/mlngeninfo/, scroll down to "Related Links Inside CMS," and select "MLN Product Ordering Page."
Provider Types Affected
Providers (ambulatory surgical centers (ASCs)) who submit claims to Part A/B Medicare Administrative Contractors (A/B MACs) and carriers, for services provided to Medicare beneficiaries which are paid under the ASC payment system.
Provider Action Needed
This article is based on Change Request (CR) 5994 which describes changes to, and billing instructions for, payment policies implemented in the April 2008 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.
Key Points
Billing for Drugs and Biologicals
- ASCs are strongly encouraged to report charges for all separately payable drugs and biologicals, using the correct HCPCS codes for the items used. ASCs billing for these products must make certain that the reported units of service of the reported HCPCS code are consistent with the quantity of the drug or biological that was used in the care of the patient. ASCs should not report HCPCS codes and separate charges for drugs and biologicals that receive packaged payment through the payment for the associated covered surgical procedure.
- If commercially available drug and biological products are being mixed together to facilitate their concurrent administration, the ASC should report the quantity of each product (reported by HCPCS code) that is separately payable in the ASC used in the care of the patient. Alternatively, if the ASC is compounding drugs that are not a mixture of commercially available products, but are a different product that has no applicable HCPCS code, the payment is packaged and no HCPCS coding is required. In these situations, ASCs should not report HCPCS code C9399. HCPCS code C9399, Unclassified drug or biological, is for new drugs and biologicals that are approved by the Food and Drug Administration (FDA) on or after January 1, 2004, for which a HCPCS code has not been assigned.
Drugs and Biologicals with Payment Based on Average Sales Price (ASP) Effective April 1, 2008
- Payments for separately payable drugs and biologicals based on the average sales price (ASP) will be updated on a quarterly basis as later quarter ASP submissions become available. In cases where adjustments to payment rates for previous quarters (January 2008) are necessary based on the most recent ASP submissions, the Centers for Medicare & Medicaid Services (CMS) will incorporate changes to the payment rates in the April 2008 release of the ASC drug file.
- Your Medicare contractors will make available to the ASCs the list of any newly added codes and previous quarter payment rate changes as identified in CR 5994. The April 2008 ASC payment rates are available at www.cms.hhs.gov/ASCPayment/.
- Providers take note that if your claims were processed prior to the installation of the revised January 2008 ASC drug file, your Medicare A/B MAC or carrier will adjust, as appropriate, claims you bring to their attention that have dates of service on or after January 1, 2008, but prior to April 1, 2008.
New HCPCS Drug Codes Separately Payable Under the ASC Payment System as of April 1, 2008
Four new HCPCS codes have been created effective April 1, 2008. These new HCPCS codes and their descriptors are listed in Table 1 below.
Table 1
New Drugs Separately Payable Under the ASC Payment System as of April 1, 2008
| C9241 |
Injection, doripenem, 10 mg |
| Q4096 |
Injection, Von Willebrand Factor Complex, human, Ristocetin Cofactor (Not otherwise specified), per I.U. VWF:RCO |
| Q4097 |
Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg |
| Q4098 |
Injection, iron dextran, 50 mg |
The payment rates for the drugs in Table 1 can be found in the April 2008 update of the ASC Addendum BB, which will be posted on the CMS Web site at the end of March.
HCPCS Drug Codes No Longer Payable Under the ASC Payment System Effective April 1, 2008
The following drug codes have been deleted and are no longer payable by Medicare, effective April 1, 2008.
Table 2
Drugs HCPCS Codes No Longer Eligible for Payment Under Medicare as of April 1, 2008
| J1751 |
Injection, iron dextran 165, 50 mg |
Not payable by Medicare |
| J1752 |
Injection, iron dextran 267, 50 mg |
Not payable by Medicare |
Correct Reporting of Units for Drugs
ASCs are reminded to ensure that units of drugs administered to patients are accurately reported in terms of the dosage specified in the full HCPCS code descriptor. That is, units should be reported in multiples of the units included in the HCPCS descriptor.
- For example, if the drug's HCPCS code descriptor specifies 6 mg, and 6 mg of the drug were administered to the patient, the units billed should be 1.
- As another example, if the drug's HCPCS descriptor specifies 50 mg and 200 mg of the drug were administered to the patient, the units billed should be 4.
- ASCs should not bill the units based on how the drug is packaged, stored, or stocked. That is, if the HCPCS descriptor for the drug code specifies 1 mg and a 10 mg vial of the drug was administered to the patient, 10 units should be reported on the bill, even though only 1 vial was administered.
- HCPCS short descriptors are limited to 28 characters, including spaces, so short descriptors do not always capture the complete description of the drug. Therefore, before submitting Medicare claims for drugs and biologicals, it is extremely important to review the complete long descriptors for the applicable HCPCS codes.
Additional Information
To see the official instruction (CR 5994) issued to your Medicare carrier or A/B MAC refer to www.cms.hhs.gov/Transmittals/downloads/R1488CP.pdf on the CMS Web site.
If you have questions, please contact your Medicare A/B MAC or carrier at their toll-free number, which may be found at www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site. For the Upstate Medicare Division (UMD), you can call the toll-free provider line at 877-567-7173.
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 2007 American Medical Association. |
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