Revisions to Intensity Modulated Radiation Therapy (IMRT) Codes Transparent by CMS
The July 2016 update to the Outpatient Prospective Payment System (OPPS) includes key changes to, and billing instructions for, various payment policies, as indicated in the 2016 OPPS final rule. Effective January 1, 2016, The Centers for Medicare & Medicaid Services (CMS) revised Intensity Modulated Radiation Therapy (IMRT) planning billing instructions, per the 2016 OPPS final rule. Instructions are being revised to clarify that payment for services identified by Radiology CPT codes 77014, 77280, 77285, 77290, 77295, 77306-77321, 77331, and 77370 are included in the Ambulatory Payment Classification (APC) payment for CPT code 77301 Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications. One should not separately report these codes when provided prior to, or as part of, the development of an Intensity Modulated Radiation Therapy plan.
It must be noted that:
The Centers for Medicare & Medicaid Services (CMS) payment policy will not allow separate payment for a blepharoplasty procedure (CPT codes 15822, 15823) in addition to a blepharoptosis procedure (CPT codes 67901-67908) on the ipsilateral upper eyelid. Any removal of upper eyelid skin in the context of an upper eyelid blepharoptosis surgery is considered a part of the blepharoptosis surgery.
? When a blepharoptosis repair is performed, patient should not be charged an additional amount for a cosmetic blepharoplasty.
? When a blepharoplasty or a blepharoptosis repair is performed, patient should not be charged an additional amount for removing orbital fat.
? For the purpose of unbundling the blepharoplasty or charging the patient for a cosmetic surgery; when a blepharoplasty is perfomed on a different date of service than the blepharoptosis procedure.
? Performing blepharoplasty as a staged procedure, either by one or more surgeons. It should be noted that under certain circumstances a blepharoptosis procedure could be a staged procedure.
? Billing for two procedures when two surgeons divide the work of a blepharoplasty performed with a blepharoptosis repair.
? Using modifier 59 to unbundle the blepharoplasty from the ptosis repair on the claim form; this applies to both physicians and facilities
? For the purpose of charging the beneficiary for a cosmetic surgery, treating medically necessary surgery as a cosmetic one
? For a service that would be bundled into another service if billed to Medicare, using an Advance Beneficiary Notice (ABN) of non – coverage.
It should be noted that : In cases, where a blepharoplasty is performed on one eye and a blepharoptosis repair is performed on the other eye, each service should be billed with the appropriate RT Right or LT Left modifier.
Revision for Status Indicators (SIs) For Pathology Codes:
The CMS also revises a handful of status indicators (SI) for Pathology CPT codes.
From July 1st, the SI for 85396 Coagulation/fibrinolysis assay, whole blood (e.g., viscoelastic clot assessment), including use of any pharmacologic additive(s), as indicated, including interpretation and written report, per day and 88141 Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician will change from Q4 Conditionally packaged laboratory tests to N No additional payment, payment included in line items with APCs for incidental service; and the SI for 88174 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision and 88175 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescrubbing or review under physician supervision will change from N to Q4.
CMS is revising its policy to clarify providers should not separately report non-therapy outpatient department services that are ?adjunctive,? or similar, to a comprehensive APC (C-APC) procedure (SI J1), or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI J2), with therapy CPT codes ? namely, outpatient physical therapy, outpatient speech-language pathology, and outpatient occupation therapy furnished either by therapists or non-therapists, and included on the same claim as the C-APC procedure.
Effective July 1, non-therapy outpatient department services should be reported that are adjunctive to J1 or J2 procedures with revenue code 0940 Other therapeutic services.
The SI for 0940 is changing from B not allowed item or service for OPPS to N.
This policy revision shall be effective for claims received on or after July 1, 2016, with dates of service on or after January 1, 2015.
New Category III Codes:
There are also nine new Category III codes, effective July 1st. Category III code 0438T Transperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple, includes image guidance, which will replace HCPCS Level II code C9743 Injection/implantation of bulking or spacer material (any type) with or without image guidance (not to be used if a more specific code applies).
Payments for Drugs, Biologicals and Radiopharmaceuticals:
Updated payment rates effective July 1 and drug price restatements are available in the July 2016 update of the OPPS Addendum A and Addendum B. Providers should resubmit claims affected by adjustments to previous quarter?s payment files.
Effective July 1st, five drugs and biologicals have been granted OPPS pass-through status. They are described by HCPCS Level II injection codes C0476-C9480.
Effective July 1st, the update also implements HCPCS Level II code Q9981 Rolapitant, oral, 1 mg, SI K, APC 1761.
And on April 5, Inflectra was approved by the FDA. This is reported with Q5102 Injection, Infliximab, Biosimilar, 10 mg, and modifier ZB. Modifier ZA should be appended to its biosimilar biological product, Q5101 Injection, Filgrastim (G-CSF), Biosimilar, 1 mc.
Effective July 1, HCPCS Level II code Q4164 Helical, per sq cm is being reassigned, from the low-cost skin substitute group to the high cost skin substitute group.
Effective July 1, HCPC C9458 will be replaced by HCPCS Level II code Q9982 Flutemetamol f1 8, diagnostic, per study dose, up to 5 millicuries replaces C9459, and Q9983 Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries.
Lastly, HCPCS Level II codes C1713 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) and C1817 Septal defect implant system, intracardiac are added to the list of devices allowed for the device intensive procedure edit in the July release and will make it retroactive to January 2016.
Note: CPT is a registered trademark of the American Medical Association.