July OPPS Update Features Many Code Changes

The Centers for Medicare & Medicaid Services (CMS) has released the July 2024 Outpatient Prospective Payment System (OPPS) update. The MLN Matters number is MM13632, and the Change Request Number is CR13632.

This update takes effect on July 1.

On March 22, the Food and Drug Administration (FDA) released an Emergency Use Authorization (EUA) for emergency use of PEMGARDA (pemivibart) for pre-exposure prophylaxis of COVID-19. The HCPCS code is Q0224, and the administration code is M0224. The status indicator is “L” for Q0224, and it is not paid under the OPPS, but at “reasonable cost,” and the status indicator for M0224 is “S,” which means that it receives separate payment. The Ambulatory Payment Classification (APC) is 1506 (New Technology – Level 6) and pays $401-$500. Patient cost-sharing does not apply to either code.

There are 26 new Proprietary Laboratory Analyses codes (0450U-0475U). The list can be found in Table 2 of the Change Request.

There are two new devices introduced for pass-through status under the OPPS:

• C1605 (Pacemaker, leadless, dual-chamber (right atrial and right ventricular, implantable components), rate-responsive, including all necessary components for implantation); and

• C1606 (Adapter, single-use (i.e., disposable) for attaching ultrasound system to upper gastrointestinal endoscope).

There are two key clarifications on devices. C1601 (endoscope, single-use (i.e., disposable), pulmonary, imaging/illumination device) does not include reprocessed devices or reprocessed single-use devices. C1602 (orthopedic/device/drug matrix/absorbable bone void filler, anti-microbial eluting (implantable) became effective on Jan. 1.

The device offset for 0505T when billed with C1604 is now $0, effective at the start of this year. See transmittal 12421 or Change Request 13488 for more details. The pass-through status for C1761 (Catheter, transluminal intravascular lithotripsy, coronary) will expire on June 30.

There are 34 new CPT® Category III codes that were released in January and are effective as of July 1. The list of codes can be found in Table 5 of CR 13632.

The status indicator for 0621T (Trabeculostomy ab interno by laser) changes from “E1” to “J1” (Hospital Part B Services Paid through a Comprehensive APC, paid under the OPPS), effective at the start of this year. This code is assigned to APC 5492.

There is a new HCPCS code, C9901 (endoscopic defect closure within entire gastrointestinal tract, including upper endoscopy (including diagnostic, if performed) and colonoscopy (including diagnostic, if performed), with all system and tissue anchoring components, with status indicator “J1”. This code took effect on Jan. 1, and is assigned to APC 5362.

There are six new HCPCS codes for drugs and biologicals, which are listed in Table 9 of the change request. These new codes have been assigned status indicator “G” (pass-through drugs and biologicals, with a separate APC payment). HCPCS J7353 (Anacaulase-bcdb, 8.8-percent gel) had a change in status indicator from “N” to “G”. Pass-through status is ending for 11 HCPCS codes, effective June 30. These codes can be found in Table 11 of the change request. There are 49 new drug, biological, and radiopharmaceutical HCPCS codes established as of July 1. Table 12 provides a list of the codes, the descriptor, status indicator, and APC.

These HCPCS codes are deleted, effective July 1:

• J2780 – Injection, ranitidine hydrochloride;
• J9371 – Injection, vincristine sulfate liposome;
• Q4210 – Axolotl graft or axolotl dual graft; and
• Q4277 – Woundplus membrane or e-graft.

There are nine HCPCS codes that are changing status indicators, but due to operational issues, the changes were not published in the July OPPS update and will be printed in the October 2024 I/OCE, retroactive to July 1.

There are 23 new skin substitute HCPCS codes effective July 1. The list is printed in Table 17.

It is important that chargemaster coordinators review the quarterly OPPS updates to prepare for the CPT and HCPCS code changes. This update may identify new services to be included in the chargemaster, as well as code changes and deletions.

The changes should be discussed with ancillary areas to validate if a device, drug, or service is planned for each given facility. A current chargemaster promotes clean claims.

Programming note:

Listen to senior healthcare consultant Laurie Johnson report this story live tomorrow on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.

Resources:

July 2024 OPPS Update: MM13632 – Hospital Outpatient Prospective Payment System: July 2024 Update (cms.gov)

July 2024 OPPS Update: r12665cp.pdf (cms.gov)