Part B Insider (Multispecialty) Coding Alert

Drug and biological additions are the highlight of the HCPCS changes.

With the most recent quarterly update, CMS is offering up new HCPCS codes and changes to make your life easier.

Relief for Chemo Patients with New HCPCS Addition

Medicare has added HCPCS code Q9981 (Rolapitant, oral, 1 mg) for “the hospital outpatient setting, where there have not previously been specific codes available,” reports an MLN Matters release from June 28, 2016.

Rolapitant is the generic form of the drug, Varubi, and helps to alleviate nausea and vomiting after emetogenic cancer chemotherapy.

Other Q-Code changes. Medicare will also be adding two other Q-Codes to its payment cycle effective July 1, 2016. The two different contrast agents covered in both codes help to address Alzheimer’s issues and detection. Here is a quick look at the additions:  

• Q9982 (Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries)
• Q9983 (Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries)

Watch for Modifier ZB with Biosimilar Change       

CMS added HCPCS code Q5102 (Injection, Infliximab, Biosimilar, 10 mg) this past April with approval from the FDA. However, the updates included a reminder from CMS to those submitting claims that the biological biosimilar products must include a modifier that distinguishes the manufacturer of the drug.

Remember. Q5102 must have modifier ZB (Pfizer/Hospira) attached to avoid a denial. The appended modifier will not determine payment, but rather is meant to differentiate between biosimilar products.             

Cost change. Of special note, HCPCS code Q4164 (Helicoll, per square centimeter) has been reevaluated by CMS. The skin substitute product has been given a pricing reassignment from the low cost to the high cost skin substitute group slated to affect claims as of July 1, 2016.                              

Take a Look at These C-Codes Updates

CMS has granted Outpatient Prospective Payment System (OPPS) pass-through status to some of its HCPCS C-codes with the quarterly changes effective July 1, 2016. The codes have been given a status indicator (SI) of G—“additional payment for drug or biological pass-through”—from CMS, states the MLN Matters release.

Here is an overview of the codes affected by the changes:

• C9476 (Injection, daratumumab, 10 mg)
• C9477 (Injection, elotuzumab, 1 mg)
• C9478 (Injection, sebelipase alfa, 1 mg)
• C9479 (Instillation, ciprofloxacin otic suspension, 6 mg)
• C9480 (Injection, trabectedin, 0.1 mg)

Reminder. Don’t forget to append modifier JW (Drug amount discarded/not administered to any patient) with HCPCS code C9479 for any part of the installation that is discarded. “Each vial of C9479 contains 60 mg, or 10 doses,” states the “Medicare Claims Processing Manual” in Chapter 17 of the Drugs and Biologicals, Section 40. “If one single use vial is used for both patient’s ears with the remainder of the drug in the vial unused, then two units of C9479 should be reported as administered to the patient; any discarded amount should be reported with the JW modifier.”

Resource: For a closer look at the HCPCS additions and changes, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9658.pdf.

For a more in-depth take on the FY 2016-2017 data related to OPPS, visit  https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1656-P-OPPS-Claims-Accounting.pdf.

---