Medicare payment for outpatient services and ambulatory surgical center (ASC) services in practices is based on set rates under Medicare Part B. ASC Payment System covers surgical procedures done in ASC facilities. CMS updates the OPPS (Outpatient Prospective Payment System)/ASC regulations together in one rule annually, with comment periods open prior to implementation of the final rule. For 2022, major ASC payment updates were announced that are effective from the 1st of April and July months. Being an established medical coding company in U.S ., we’re up-to-date with the changing billing and coding regulations.
ASC payment updates – April 2022
- Expansion of Procedure List – C1748
Effective April 1, 2022, the list of procedure codes associated with HCPCS Level II code C1748 is expanded.
- C1748 Endoscope, single-use (i.e. disposable) Upper GI, imaging/illumination device (insertable)
Now, medical billing companies can bill the device described by device category HCPCS code C1748 with 1 of the following CPT codes: 0652T, 0653T, 0654T, 43197, or 43198.
- CPT code 0652T – Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
- CPT code 0653T – Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single or multiple
- CPT code 0654T – Esophagogastroduodenoscopy, flexible, transnasal; with insertion of intraluminal tube or catheter
- CPT code 43197 – Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
- CPT code 43198 – Esophagoscopy, flexible, transnasal; with biopsy, single or multiple
All these codes have an offset amount of $0. The codes are assigned to ambulatory payment classification (APC) 5301 (Level 1 Upper GI Procedures) and APC 5302 (Level 2 Upper GI Procedures).
- New Code for In Space Subacromial Tissue Spacer System Procedure
A new HCPCS code, C9781, has been added to describe the implantation of a saline-filled balloon for the shoulder to treat irreparably torn rotator cuff tendons.
- C9781 Arthroscopy, shoulder, surgical; with implantation of subacromial spacer (e.g., balloon), includes debridement (e.g., limited or extensive), subacromial decompression, acromioplasty, and biceps tenodesis when performed
New Codes for Drugs, Biologicals, and Radiopharmaceuticals
Existing CY 2022 HCPCS Level II Code J9304 Receives Pass-Through Status
- J9304 Injection, pemetrexed (pemfexy), 10 mg
New codes added
| New HCPCS Code | Old HCPCS Code | Descriptor |
| J0219 | C9085 | Injection, avalglucosidase alfa-ngpt, 4 mg |
| J0491 | C9086 | Injection, anifrolumab-fnia, 1 mg |
| J9071 | C9087 | Injection, cyclophosphamide, (auromedics), 5 mg |
| J9359 | C9084 | Injection, loncastuximab tesirine-lpyl, 0.075 mg |
| C9090 | N/A | Injection, plasminogen, human-tvmh, 1 mg |
| C9091 | N/A | Injection, sirolimus protein-bound particles, 1 mg |
| C9092 | N/A | Injection, triamcinolone acetonide, suprachoroidal (xipere), 1 mg |
| C9093 | N/A | Injection, ranibizumab, via sustained release intravitreal implant (susvimo), 0.1 mg |
| J9273 | N/A | Injection, tisotumab vedotin-tftv, 1 mg |
https://www.aapc.com/blog/84669-april-brings-asc-payment-system-updates/
https://www.cms.gov/files/document/r11303cp.pdf#page=13
HCPCS Code M1145 Deleted Retroactive to February 28, 2022
- M1145 Most favored nation (mfn) model drug add-on amount, per dose, (do not bill with line items that have the jw modifier)
90377 Status Change
CMS revises the ASC PI for HCPCS Level II code 90377, from K5 to K2, retroactive to Jan. 1, 2022.
- 90377 Rabies immune globulin, heat- and solvent/detergent-treated (RIg-HT S/D), human, for intramuscular and/or subcutaneous use
Skin Substitutes
New Skin Substitute Products Low-Cost Group/High-Cost Group Assignment
Nine skin substitute HCPCS codes that are newly added to the ASC payment system as of April 1, 2022.
- A2011 Supra sdrm, per sq cm
- A2012 Suprathel, per sq cm
- A2013 Innovamatrix fs, per sq cm
- A4100 Skin sub fda clrd as dev nos
- Q4224 Hhf10-p per sq cm
- Q4225 Amniobind, per sq cm
- Q4256 Mlg complet, per sq cm
- Q4257 Relese, per sq cm
- Q4258 Enverse, per sq cm
Skin Substitute Products Reassigned to the High-cost Skin Substitute Group
Skin substitute HCPCS code Q4199 is reassigned from the low-cost skin substitute group to the high-cost skin substitute group.
- Q4199 Cygnus matrix, per sq cm
Read more here.
ASC payment updates – July 2022
Make sure your billing staff knows about these changes:
- A new CPT Category III Code effective July 1, 2022
CMS is implementing 1 new CPT Category III code that the AMA released in January 2022 for implementation on July 1, 2022.
- 0714T – Transperineal laser ablation of benign prostatic hyperplasia, including imaging guidance
- ASC drugs, biologicals, and radiopharmaceuticals
CMS established 14 new drug and biological HCPCS codes for ASC drugs, biologicals, and radiopharmaceuticals, effective July 1, 2022 and the old HCPCS codes in this table were deleted, effective June 30, 2022.
14 new drug and biological HCPCS codes
- A9596 Gallium ga-68 gozetotide, diagnostic, (illuccix), 1 millicurie
- C9094 Inj, sutimlimab-jome, 10 mg
- C9095 Inj, tebentafusp-tebn, 1 mcg
- C9096 Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram
- C9097 Inj, faricimab-svoa, 0.1 mg
- J1306 Injection, inclisiran, 1 mg
- J1551 Injection, immune globulin (cutaquig), 100 mg
- J2356 Injection, tezepelumab-ekko, 1 mg
- J2779 Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg
- J2998 Injection, plasminogen, human-tvmh, 1 mg
- J3299 Injection, triamcinolone acetonide (xipere), 1 mg
- J9331 Injection, sirolimus protein-bound particles 1 mg
- J9332 Injection, efgartigimod alfa-fcab, 2mg
- 90739 Hepatitis B vaccine (HepB), CpG-adjuvanted, adult dosage, 2 dose or 4 dose schedule, for intramuscular use
Drugs and Biologicals with Payments Based on Average Sales Price (ASP)
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- For Calendar Year (CY) 2022, CMS will continue to pay for non-pass-through drugs and biologicals at a single rate of ASP + 6%. This provides payment for both the acquisition cost and pharmacy overhead costs associated with the drug or biological.
- CMS will also continue to make a single payment of ASP + 6% for the OPPS pass-through drugs and biologicals to provide payment for both the acquisition cost and pharmacy overhead costs of these pass-through items.
Drugs and Biologicals Based on ASP Methodology with Restated Payment Rates
- Some drugs and biologicals with payment rates based on ASP methodology may have their payment rates corrected retroactively. These retroactive corrections typically occur on a quarterly basis.
- Retroactive Payment for HCPCS J1437
On January 1, 2021, HCPCS code J1437 was granted pass-through status in the OPPS, but due to a technical error, didn’t pass to the ASC payment system properly, which may have resulted in a denial when billed in the ASC setting.
CMS has now corrected the payment indicator assignment for J1437 to ASC PI=K2 (Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate) retroactive to January 1, 2021.
- J1437 Injection, ferric derisomaltose, 10 mg
- Skin Substitutions
The skin substitute products are divided into 2 groups for packaging purposes – High-cost skin substitute products and Low-cost skin substitute products
- Only use high-cost skin substitute products in combination with the performance of 1 of the skin application procedures described by CPT codes 15271-15278.
- Use Low-cost skin substitute products in combination with the performance of the skin application procedures described by HCPCS codes C5271-C5278.
- Bill all OPPS pass-through skin substitute products (ASC PI=K2) in combination with 1 of the skin application procedures described by CPT codes 15271-15278.
New skin substitute products and low-cost/high-cost group assignment
3 new skin substitute HCPCS codes are added –
- Q4259 Celera per sq cm
- Q4260 Signature apatch, per sq cm
- Q4261 Tag, per square centimeter
ASCs should not separately bill for packaged skin substitutes (ASC PI=N1) since packaged codes aren’t reportable under the ASC payment system.
Skin Substitute Products Reassigned to the High-cost Skin Substitute Group
4 skin substitute HCPCS codes are reassigned from the low-cost skin substitute group to the high-cost skin substitute group.
- A2001 Innovamatrix ac, per sq cm
- A2002 Mirragen adv wnd mat per sq
- Q4229 Cogenex amnio memb per sq cm
- Q4258 Enverse, per sq cm
Read more details here.
Practices must make sure their billing staff is current with these changes. Experienced medical billing outsourcing companies stay up-to-date with such changes and would implement these on time to ensure accurate coding and billing.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.