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March 27, 2018

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Medical Coding News Archives

OPPS Final Rule Has G Codes, Discount Drug Payment in Its Sights

November 30, 2017:

In the HCPCS Level II update for 2018, the biggest hit section is the G codes. In all, 141 codes are new in the update, 50 descriptors have been revised, and 38 codes have been deleted. Of the modifiers, two have been deleted, two changed, and 10 created. The outpatient prospective payment system final rule, which updates the HCPCS codes, also slashes payment for drugs hospitals acquire through the 340B discount program.

New and revised codes: For the most part, revisions were minor, many focusing on correcting grammar or punctuation. New codes will have a larger impact on reporting services. The Centers for Medicare and Medicaid Services (CMS) added two C codes of note for the coming year: C9738 and C9748. Code C9738 (Adjunctive blue light cystoscopy with fluorescent imaging agent) describes the use of blue-light cystoscopy, which improves tumor detection in nonmuscle invasive bladder cancer (NMIBC). It can be performed only after a white-light cystoscopy has been completed. Hexaminolevulinate HCL, an optical imaging agent, is instilled into the bladder via an intravesical catheter and retained in the bladder for 1 hour. The bladder is then evacuated, and the blue-light cystoscopy is performed. This is an add-on code and must be reported in conjunction with the appropriate CPT© codes for cystourethroscopy.

Code C9748 (Transurethral destruction of prostate tissue; by radiofrequency water vapor [steam] thermal therapy) describes thermal therapy to treat benign prostatic hypertrophy (BPH). The procedure involves thermal therapy, which generates water vapor by radiofrequency and directs it to the obstructing prostatic tissue through a device similar to a cystoscope. This process denatures the cell membranes, causing near-instant death of the cells. The denatured cells are absorbed by the body over time, reducing the hypertrophic tissue and improving the flow of urine.

The G code section (Procedures/professional services [temporary codes]) gained 89 new codes in the update and 36 revised long code descriptors, and 18 codes were deleted. Codes in this section are being considered for permanent inclusion in the coding system, and payment is decided by local payers. Of the new G codes, eight (G9902-G9909) pertain to tobacco use screening and cessation intervention. Five new codes (G9922-G9926) describe safety screening provision and documentation, as well as any corresponding mitigation steps taken, and new codes G9941-G9947 are to be used to report back pain measurement using the visual analog scale (VAS) and spinal procedures.

As it did last year, CMS, which maintains the HCPCS Level II codes, added some codes with identical descriptors to other codes. For example, new codes G9890 and G9974, G9891 and G9975, G9892 and G9976, and G9893 and G9977 have the same descriptors related to macular examinations, and codes G9898, G9901, G9910, and G9938 have the descriptor “Patient age 65 or older in institutional special needs plans (SNP) or residing in long-term care with POS code 32, 33, 34, 54, or 56 any time during the measurement period.” CMS has explained this overlap by saying that each code is appropriate for a particular specialty.

Deleted codes: Among the deletions are a few of note that crosswalk to CPT codes. Deleted x-ray codes G0202, G0204, and G0206 for screening and diagnostic mammography crosswalk to CPT codes 77065-77067, which were new last year. Behavioral health codes G0502-G0505 and G0507 crosswalk to new 2018 CPT codes 99492-99494, which describe initial and subsequent collaborative care management for psychiatric conditions.

Modifiers: Among the new modifiers are five that describe the scope and duration of clinical services. Level II HCPCS modifiers X1-X5, indicating patient relationship categories, were finalized for 2018. Acknowledging that clinicians may not be ready to use these modifiers January 1, 2018, CMS is making their use voluntary. In 2018, there will be no impact on payment for codes with these modifiers appended.

X1 Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care

X2 Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services

X3 Episodic/broad services: for reporting services by clinicians who have broad responsibility for the comprehensive needs of the patient that is limited to a defined period and circumstance such as a hospitalization; reporting clinician service examples include but are not limited to the hospitalist's services rendered providing comprehensive and general care to a patient while admitted to the hospital

X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period

X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician

Two of the modifiers (JG and TB) added for 2018 pertain to CMS’s decision to alter its payment formula for drugs and biologicals hospitals acquire under the 340B program that discounts drug prices. In the outpatient prospective payment system final rule released November 1, 2017, CMS detailed its intention to reimburse hospitals for drugs bought through the 340B program at 22.5 percent less than the average sales price. Currently, Medicare pays the ASP plus 6 percent for such drugs. The 340B program enables covered entities to buy drugs from pharmaceutical companies at deep discounts and then to use the revenue generated when they get paid for the drugs by Medicare any way they like, but ideally to reach more eligible patients and provide more comprehensive services. CMS’s plan to drastically reduce this source of revenue for hospitals would be such a major financial hit that two hospital associations and one medical college association have joined to sue CMS over the payment plan.

Hospitals will be required to add modifier JG (Drug or biological acquired with 340b drug pricing) to codes for separately payable drugs acquired through the 340B program, which will trigger the 22.5 percent payment discount off the ASP. Some providers—children’s hospitals, some cancer hospitals, and rural sole community hospitals—will be exempt from this steep payment reduction, however. They instead will add modifier TB (Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes) to provide information only and will continue to be reimbursed at ASP plus 6 percent.

CMS is basing its payment reduction on a 2015 estimate by the Health Resources and Services Administration (HRSA), which is under the Department of Health and Human Services, that hospitals saved an average of at least 22.5 percent off the ASP of drugs acquired under the 340B program. There are no claims data to support this figure, however. The agency plans to reallocate Medicare savings from drug payments to all hospitals paid under OPPS. Consumers would also benefit—those buying 340B drugs would pay a copayment of 20 percent of the OPPS payment rate, in this case 22.5 percent below ASP.

The final rule can be accessed online at https://www.federalregister.gov/documents/2017/11/13/2017-23932/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment.

CPT copyright 2017 American Medical Association. All rights reserved.


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