Outpatient Facility Coding Alert

Plus: New drugs codes for hemophilia, asthma, arrhythmia and cancer

Get ready to learn more new C-codes for your outpatient services as the HCPCS update goes into effect. Remember, CMS approved C-code coverage under the Hospital Outpatient Prospective Payment System (HOPPS) effective October 1, 2016.

Background: “C-codes generally mean reimbursement for a drug or procedure and often apply to new technology items or services,” says Sarah Goodman, MBA, CHCAF, CPC-H, CCP, FCS, president of the consulting firm SLG, Inc., in Raleigh, N.C. The new codes include OPPS pass-through drug codes and a radiology procedure code. Most of the new drug codes reflect recent FDA approvals.

Abdominal Ultrasound Gets a New Code

Now, liver and/or abdominal ultrasound procedures with contrast can be assigned HCPCS code C9744 (Ultrasound, abdominal, with contrast), when performed in the hospital outpatient setting.

This is a new code, which CMS will reimburse. “Obtaining approval for coding and coverage for contrast enhanced ultrasound is a milestone in the evolution of ultrasound in radiology,” said Vittorio Puppo, President and CEO, Bracco Diagnostics Inc. in a Sept. 23 Bracco Diagnostics Inc release, (http://imaging.bracco.com/sites/braccoimaging.com/files/technica_sheet_pdf/us-2016-09-23-pr-lumason.pdf).

LUMASON is a contrast agent made up of gas-filled microspheres that reflect sound waves to enhance the image in ultrasonography, according to the Bracco Diagnostics Inc release. It is used:

• in echocardiography to opacify the left ventricular chamber better visualization of the left ventricular endocardial border in adult patients with suboptimal echocardiograms
• in ultrasound of the liver to find focal lesions in both adults and pediatric patients

“Be sure that the use of contrast is specifically ordered and supported by medical necessity,” says Joanne Schade-Boyce, MS, BSDH, CPC, ACS, AHIMA Approved ICD-10-CM / PCS Trainer and Ambassador, FairCode Associates, LLC, Marco Island, FL. “In addition, be sure that the correct units of LUMASON are reported.”

Remember: Medicare does not pay for Contrast material to outpatient hospitals unless the product has “pass-through” status, under outpatient prospective payment systems (OPPS). LUMASON got its pass through status in October 2015, as outlined in MLN article MM9310 (www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9310.pdf).

Soak In the New Drug Supply Codes

You also have several new HCPCS codes you can report for your pharmacy services. The following drugs and biologicals got an OPPS pass-through status effective Oct. 1:

You’ll report Idelvion injections with HCPCS code C9139 (Injection, Factor IX, albumin fusion protein [recombinant], Idelvion, 1 i.u.). Idelvion is used to treat children and adults with hemophilia B (congenital Factor IX deficiency) for:

• Prevention and Control of bleeding
• Managing of bleeding preoperatively
• Routine prophylaxis to prevent or reduce the frequency of bleeding episodes.

New code C9481 (Injection, reslizumab, 1 mg) is used to report Reslizumab injection, which is an interleukin 5 antagonist monoclonal antibody used to treat adult patients with severe asthma.

Use new code C9482 (Injection, sotalol hydrochloride, 1 mg) to report sotalol injections for treatment of rhythm disorders such as atrial fibrillation or flutter, or life threatening ventricular arrhythmia, for patients who are not able to take sotalol orally.

New code C9483 (Injection, atezolizumab, 10 mg) reports injections of atezolizumab a newly approved drug with a programmed death-ligand 1 (PD-L1) blocking antibody used for the treatment of patients with urothelial carcinoma.

“All hospitals should explore the impact of these codes with all their payors. Just because it’s on the HOPPS approved list, doesn’t mean that all payors are on board for payment,” Boyce says.

Tip: Take time to give both NCDs and LCDs a thorough review “for any updates that might impact the medical necessity requirements of these drugs and/or procedure,” Boyce recommends.

Note: Refer to the October 2016 OPPS update at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9768.pdf or the October 2016 Update of the Ambulatory Surgical Center (ASC) Payment System change request (CR) document at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9773.pdf for payment and other information about these HCPCS C-codes. 

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