OPPS Medical Coding and Billing UpdatesKey coding and billing changes to the Hospital Outpatient Prospective Payment System (OPPS) came into force on July 1, 2016. Medical billing and coding companies are taking note of these updates which are designed to improve the quality of care for Medicare patients by better supporting their physicians and other health care providers. The major updates made by Centers for Medicare & Medicaid Services (CMS) are as follows:

  • Intensity Modulated Radiation Therapy (IMRT) Code Revision: This is to confirm that payment for services identified by Radiology CPT codes 77014, 77280, 77285, 77290, 77295, 77306-77321, 77331, and 77370 are included in the Ambulatory Payment Classification (APC) payment for CPT code 77301 Intensity modulated radiotherapy plan. These codes must not be reported separately when provided prior to, or as part of, the development of an IMRT plan.
  • Clarifications on eyelid surgery: Medicare does not allow separate payment for a blepharoplasty procedure (CPT codes 15822-15823) in addition to a blepharoptosis procedure (CPT codes 67901-67908) on the ipsilateral upper eyelid. In the case of bilateral eyelid surgery, CMS will not permit operating on the left and right eyes on different days. Providers should not
    • bill additionally for a cosmetic blepharoplasty when a blepharoptosis repair is performed
    • perform these procedures on a different date of service in order to unbundle the blepharoplasty or bill the patient for a cosmetic surgery
    • charge an additional amount for removing orbital fat done during a blepharoplasty or a blepharoptosis repair

    If eyelid surgery is performed on one eye and a blepharoptosis repair is performed on the other eye, the appropriate Right or Left modifier should be used to bill each service.

  • Revised status indicators (SI) for Pathology CPT codes:
    • The SI for 85396 and 88141 has changed from Q4 to N.
    • The SI for 88174 and 88175 has changed from N to Q4.
  • Reporting of non-therapy outpatient department services: Non-therapy outpatient department services that are “adjunctive,” or similar to a comprehensive APC (C-APC) procedure (SI J1), or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI J2), should not be reported with therapy CPT codes. Examples of these services include: outpatient physical therapy, outpatient speech-language pathology, and outpatient occupation therapy furnished either by therapists or non-therapists, and included on the same claim as the C-APC procedure.
  • Introduction of 9 new Category III codes: HCPCS Level II code C9743 Injection/implantation of bulking or spacer material (any type) with or without image guidance will be replaced by Category III code 0438T Transperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple, includes image guidance.
  • Quarterly updates of payment for drugs, biologicals and radiopharmaceuticals: Providers should take note of the changes in payments for drugs, biologicals and radiopharmaceuticals which are based on average sales price (ASP) and updated on a quarterly basis. Claims affected by adjustments to previous quarter’s payment files should be resubmitted.

Starting July 1, five drugs and biologicals described by HCPCS Level II injection codes C0476-C9480 have been granted OPPS pass-through status. Many other changes have also been made with regard to HCPCS Level II codes.

Implemented in 2000, the OPPS significantly affects the way hospitals are reimbursed for outpatient services under Medicare. Medical billing and coding outsourcing is the best way for providers to keeping track of the updates to the OPPS and secure optimal reimbursement.