August 31, 2016

CMS Issues Notification of July OPPS Update

The Centers for Medicare and Medicaid Services (CMS) has issued an update notification regarding a number of changes to billing instructions for payment policies effective July, as a part of the July 2016 Outpatient Prospective Payment System (OPPS) update. These instructions include information regarding updated payment rates, changes to HCPCS (Healthcare Common Procedure Coding System) codes for certain drugs, biological and radiopharmaceuticals, and changes to the OPPC Pricer Logic.

As part of the July OPPS Update HCPCS code Q9982 (flutemetamol f18 diagnostic) will replace HCPCS code C9459 (Flutemetamol f18) and HCPCS code Q9983 (florbetaben f18 diagnostic) will replace HCPCS code C9458 (Florbetaben f18). The status indicators for both of those codes will remain G, “Pass-Through Drugs and Biologicals”.

Additionally, effective July 1, 2016 four diagnostic radiopharmaceuticals and one contrast agent will begin receiving pass-through payment in the OPPS Pricer logic. Pass-through payments are provided by statute for items that are generally too new to be represented in the data used to set payment rates. For the APCs containing nuclear medicine procedures CMS will reduce the amount of pass-through diagnostic radiopharmaceutical or contrast agent payments by the wage-adjusted offset for the APC with the highest offset amount when the radiopharmaceutical or contrast agent with pass-through appears on a claim with a nuclear procedure.

The OPPS payment files are updated quarterly to account for mid-year changes , including average sales price (ASP) data. For CY 2016 payments for drugs, biologicals and therapeutic radiopharmaceuticals are made at a single rate of ASP + 6 percent. Those payment rates can be found in the July 2016 Update of the OPPS Addendum A and B.