Summary of the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) payment and coding updates for Q4′ 2019
We’ve summarized the Centers for Medicare and Medicaid Services (CMS) and American Medical Association (AMA) payment and coding updates being implemented October 1, 2019. The updates should be reviewed for possible implementation in your hospital chargemaster and/or reviewed by applicable coding and billing staff.
Drugs and Biologicals
CMS is implementing many changes associated with drugs and biologicals prior to the end of the year. For ease of review, the new codes, terminated codes and revised codes appear in separate tables. The changes are summarized as follows:
- Forty-five new drug and biological HCPCS codes will be effective for use October 1, 2019. See below table with new HCPCS J or Q code and alternate temporary HCPCS C code where applicable. Many of the HCPCS C codes were created for use in 2019 and are being terminated prior to the end of the year. Ensure hospital pharmacy system and chargemasters are updated with applicable HCPCS codes.
- HCPCS code C9042 (Injection, bendamustine hcl (Belrapzo), 1 mg) status indicator of E2 (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type)) will be retroactively changed to G (Pass-through drug paid under OPPS; separate APC payment) for the period of April 1, 2019 to June 30, 2019. Hospitals will want to evaluate claims data to determine if they want to seek payment for Belrapzo during that time. If an outpatient claim containing C9042 was processed and charge was line item denied, then the hospital may be due separate reimbursement.
- HCPCS code Q5107 (Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg) status indicator E2 (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type)) will be retroactively changed to K (Non pass-through drug paid under OPPS; separate APC payment) for the period of July 18, 2019 to September 30, 2019. Hospitals will want to evaluate claims data to determine if they want to seek payment for MVASI during that time. If an outpatient claim containing Q5107 was processed and charge was line item denied, then the hospital may be due separate reimbursement.
- HCPCS code J9356 (Injection, trastuzumab, 10 mg and Hyaluronidase-oysk) added July 1, 2019 will be changed from non pass-through status (SI K) to pass-through status (SI G).
- Several HCPCS codes descriptions are being revised (J0641, J2794, J7311, J7313, Q4122, Q4165, Q4184). Review the description changes to ensure they do not impact code assignments to hospital chargemaster service lines.
| HCPCS Codes Effective for Use October 1, 2019 | ||||
| HCPCS | Action | Prior Code | Short Descriptor | Other drug name |
| J0121 | Add | C9051 | Inj., omadacycline, 1 mg | Nuzyra |
| J0122 | Add | Inj., eravacycline, 1 mg | Xerava | |
| J0222 | Add | C9036 | Inj., patisiran, 0.1 mg | Onpattro |
| J0291 | Add | C9039 | Inj., plazomicin, 5 mg | Zemdri |
| J0593 | Add | Inj., lanadelumab-flyo, 1 mg | Takhzyro | |
| J1096 | Add | C9048 | Dexametha opth insert 0.1 mg | Dextenza (non-surgically inserted) |
| J1097 | Add | C9447 | Phenylep ketorolac opth soln | Omidria (intracameral injection) |
| J1303 | Add | C9052 | Inj., ravulizumab-cwvz 10 mg | Ultomiris |
| J1943 | Add | C9035 | Inj., aristada initio, 1 mg | |
| J1944 | Add | J1942 | Aripirazole lauroxil 1 mg | Aristada |
| J2798 | Add | C9037 | Inj., perseris, 0.5 mg | |
| J3031 | Add | C9040 | Inj., fremanezumab-vfrm 1 mg | Ajovy |
| J3111 | Add | Inj. romosozumab-aqqg 1 mg | Evenity | |
| J7314 | Add | Inj., yutiq, 0.01 mg | ||
| J7331 | Add | Synojoynt, inj., 1 mg | ||
| J7332 | Add | Inj., triluron, 1 mg | ||
| J7401 | Add | S1090 | Mometasone furoate sinus imp | Sinuva |
| J9118 | Add | Inj. Calaspargase pegol-mknl | Asparlas | |
| J9119 | Add | C9044 | Inj., cemiplimab-rwlc, 1 mg | Libtayo |
| J9204 | Add | C9038 | Inj, mogamulizumab-kpkc, 1 mg | Poteligeo |
| J9210 | Add | C9050 | Inj., emapalumab-lzsg, 1 mg | Gamifant |
| J9269 | Add | C9049 | Inj. tagraxofusp-erzs 10 mcg | Elzonris |
| J9313 | Add | C9045 | Inj., lumoxiti, 0.01 mg | |
| Q4205 | Add | Membrane graft or wrap sq cm | ||
| Q4206 | Add | Fluid flow or fluid gf 1 cc | ||
| Q4208 | Add | Novafix per sq cm | ||
| Q4209 | Add | Surgraft per sq cm | ||
| Q4210 | Add | Axolotl graf dualgraf sq cm | ||
| Q4211 | Add | Amnion bio or axobio sq cm | ||
| Q4212 | Add | Allogen, per cc | ||
| Q4213 | Add | Ascent, 0.5 mg | ||
| Q4214 | Add | Cellesta cord per sq cm | ||
| Q4215 | Add | Axolotl ambient, cryo 0.1 mg | ||
| Q4216 | Add | Artacent cord per sq cm | ||
| Q4217 | Add | Woundfix biowound plus xplus | ||
| Q4218 | Add | Surgicord per sq cm | ||
| Q4219 | Add | Surgigraft dual per sq cm | ||
| Q4220 | Add | Bellacell HD, Surederm sq cm | ||
| Q4221 | Add | Amniowrap2 per sq cm | ||
| Q4222 | Add | Progenamatrix, per sq cm | ||
| Q4226 | Add | Myown harv prep proc sq cm | ||
| Q5116 | Add | Inj., trazimera, 10 mg | ||
| Q5117 | Add | Inj., kanjinti, 10 mg | ||
| Q5118 | Add | Inj., zirabev, 10 mg | ||
| HCPCS Codes Being Terminated September 30, 2019 | |||
| HCPCS | Action | Prior Code | Short Descriptor |
| C9035 | D/C | Injection, aristada initio | |
| C9036 | D/C | Injection, patisiran | |
| C9037 | D/C | Injection, risperidone | |
| C9038 | D/C | Inj mogamulizumab-kpkc | |
| C9039 | D/C | Injection, plazomicin | |
| C9040 | D/C | Injection, fremanezumab-vfrm | |
| C9043 | D/C | Injection, levoleucovorin | |
| C9044 | D/C | Injection, cemiplimab-rwlc | |
| C9045 | D/C | Moxetumomab pasudotox-tdfk | |
| C9048 | D/C | Dexamethasone ophth insert | |
| C9049 | D/C | Injection, tagraxofusp-erzs | |
| C9050 | D/C | Injection, emapalumab-lzsg | |
| C9051 | D/C | Injection, omadacycline | |
| C9052 | D/C | Injection, ravulizumab-cwv | |
| C9447 | D/C | Inj, phenylephrine ketorolac | |
| J1942 | D/C | Aripiprazole lauroxil 1mg | |
| S1090 | D/C | Mometasone furoate sinus imp | |
| HCPCS Code Descriptor Updates Effective October 1, 2019 | ||||
| HCPCS | Action | Prior Code | Short Descriptor | Other drug name |
| J0641 | Revise | C9043 | Inj., levoleucovorin, 0.5 mg | Khapzory |
| J2794 | Revise | Inj., risperdal consta, 0.5 mg | ||
| J7311 | Revise | Inj., retisert, 0.01 mg | ||
| J7313 | Revise | Inj., iluvien, 0.01 mg | ||
| Q4122 | Revise | Dermacell, awm, porous sq cm | ||
| Q4165 | Revise | Keramatrix, Kerasorb sq cm | ||
| Q4184 | Revise | Cellesta or duo per sq cm | ||
Guidance Clarification for Intraocular/Periocular Injections
On September 15, 2015, the Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 9298 (Transmittal R3352CP), which provided guidance for “dropless cataract surgery.” This CR is a clarification to CR 9298 on “dropless cataract surgery.” Intraocular or periocular injections of combinations of anti-inflammatory drugs and antibiotics are being used with increased frequency in ocular surgery (primarily cataract surgery). One example of combined or compounded drugs includes, triamcinolone and moxifloxacin with or without vancomycin. Such combinations may be administered as separate injections or as a single combined injection. Because such injections may obviate the need for post-operative anti-inflammatory and antibiotic eye drops, some have referred to cataract surgery with such injections as “dropless cataract surgery.” However, nothing in this CR is intended to preclude physicians or other professionals from discussing the potential benefits and drawbacks of dropless therapy with their patients and prescribing it if the patient so elects.
The original guidance reminds providers that National Correct Coding Policy precludes separate coding of the injection (e.g., 66020, 66030, 67028, 67500, 67515, or 68200) for these drugs when performed pre-, intra- or post a cataract procedure. Providers will use the applicable HCPCS code when a compounded drug is used. HCPCS code C9399 (Unclassified drug or biological) is not appropriate for use to bill for a compounded drug.
The link below is to the original transmittal coding guidance.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3352CP.pdf
| Refer to the October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) change request (CR) document for payment and other information related to these HCPCS code(s). https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4387CP.pdf |
Proprietary Laboratory Analyses CPT Update
The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel established 34 new PLA (Proprietary Laboratory Analyses) CPT codes 0105U – 0138U effective October 1, 2019. These codes are not currently published in the AMA CPT codebook. Staff will need to go to the AMA website for any additional information.
PLA code 0104U (Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (32 genes [sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only]) is being deleted effective October 1, 2019.
| New PLA Codes Effective October 1, 2019 | |
| CPT Code |
Long Descriptor |
| 0105U | Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kidney injury molecule-1 (KIM-1) combined with longitudinal clinical data, including APOL1 genotype if available, and plasma (isolated fresh or frozen), algorithm reported as probability score for rapid kidney function decline (RKFD) |
| 0106U | Gastric emptying, serial collection of 7 timed breath specimens, non-radioisotope carbon-13 (13C) spirulina substrate, analysis of each specimen by gas isotope ratio mass spectrometry, reported as rate of 13CO2 excretion |
| 0107U | Clostridium difficile toxin(s) antigen detection by immunoassay technique, stool, qualitative, multiple-step method |
| 0108U | Gastroenterology (Barrett’s esophagus), whole slide–digital imaging, including morphometric analysis, computer-assisted quantitative immunolabeling of 9 protein biomarkers (p16, AMACR, p53, CD68, COX-2, CD45RO, HIF1a, HER-2, K20) and morphology, formalin-fixed paraffin-embedded tissue, algorithm reported as risk of progression to high-grade dysplasia or cancer |
| 0109U | Infectious disease (Aspergillus species), real-time PCR for detection of DNA from 4 species (A. fumigatus, A. terreus, A. niger, and A. flavus), blood, lavage fluid, or tissue, qualitative reporting of presence or absence of each species |
| 0110U | Prescription drug monitoring, one or more oral oncology drug(s) and substances, definitive tandem mass spectrometry with chromatography, serum or plasma from capillary blood or venous blood, quantitative report with steady-state range for the prescribed drug(s) when detected |
| 0111U | Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis, utilizing formalin-fixed paraffin-embedded tissue |
| 0112U | Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene |
| 0113U | Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score |
| 0114U | Gastroenterology (Barrett’s esophagus), VIM and CCNA1 methylation analysis, esophageal cells, algorithm reported as likelihood for Barrett’s esophagus |
| 0115U | Respiratory infectious agent detection by nucleic acid (DNA and RNA), 18 viral types and subtypes and 2 bacterial targets, amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected |
| 0116U | Prescription drug monitoring, enzyme immunoassay of 35 or more drugs confirmed with LC-MS/MS, oral fluid, algorithm results reported as a patient-compliance measurement with risk of drug to drug interactions for prescribed medications |
| 0117U | Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid), LC- MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain |
| 0118U | Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA in the total cell-free DNA |
| 0119U | Cardiology, ceramides by liquid chromatography–tandem mass spectrometry, plasma, quantitative report with risk score for major cardiovascular events |
| 0120U | Oncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin-fixed paraffin- embedded tissue, algorithm reported as likelihood for primary mediastinal B-cell lymphoma (PMBCL) and diffuse large B-cell lymphoma (DLBCL) with cell of origin subtyping in the latter |
| 0121U | Sickle cell disease, microfluidic flow adhesion (VCAM-1), whole blood |
| 0122U | Sickle cell disease, microfluidic flow adhesion (P-Selectin), whole blood |
| 0123U | Mechanical fragility, RBC, shear stress and spectral analysis profiling |
| 0124U | Fetal congenital abnormalities, biochemical assays of 3 analytes (free beta-hCG, PAPP-A, AFP), time-resolved fluorescence immunoassay, maternal dried-blood spot, algorithm reported as risk scores for fetal trisomies 13/18 and 21 |
| 0125U | Fetal congenital abnormalities and perinatal complications, biochemical assays of 5 analytes (free beta-hCG, PAPP-A, AFP, placental growth factor, and inhibin-A), time-resolved fluorescence immunoassay, maternal serum, algorithm reported as risk scores for fetal trisomies 13/18, 21, and preeclampsia |
| 0126U | Fetal congenital abnormalities and perinatal complications, biochemical assays of 5 analytes (free beta-hCG, PAPP-A, AFP, placental growth factor, and inhibin-A), time-resolved fluorescence immunoassay, includes qualitative assessment of Y chromosome in cell-free fetal DNA, maternal serum and plasma, predictive algorithm reported as a risk scores for fetal trisomies 13/18, 21, and preeclampsia |
| 0127U | Obstetrics (preeclampsia), biochemical assays of 3 analytes (PAPP-A, AFP, and placental growth factor), time-resolved fluorescence immunoassay, maternal serum, predictive algorithm reported as a risk score for preeclampsia |
| 0128U | Obstetrics (preeclampsia), biochemical assays of 3 analytes (PAPP-A, AFP, and placental growth factor), time-resolved fluorescence immunoassay, includes qualitative assessment of Y chromosome in cell-free fetal DNA, maternal serum and plasma, predictive algorithm reported as a risk score for preeclampsia |
| 0129U | Hereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and eletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53) |
| 0130U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in addition to code for primary procedure) |
| 0131U | Hereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code for primary procedure) |
| 0132U | Hereditary ovarian cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code for primary procedure) |
| 0133U | Hereditary prostate cancer–related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure) |
| 0134U | Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure) |
| 0135U | Hereditary gynecological cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition to code for primary procedure) |
| 0136U | ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately in addition to code for primary procedure) |
| 0137U | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) mRNA sequence analysis (List separately in addition to code for primary procedure) |
| 0138U | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) mRNA sequence analysis (List separately in addition to code for primary procedure) |
CPT is a registered trademark of the American Medical Association.
Copyright 2018 American Medical Association. All rights reserved.
Refer to the AMA website for further information regarding new PLA codes https://www.ama-assn.org/system/files/2019-08/cpt-pla-codes-long.pdf
