OPPS Proposed Rule CY 2022: Coding and Regulatory Updates

• Presented by:

Panacea Healthcare Solutions Revenue Integrity Division

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Agenda

01

OPPS Summary of Major Provisions

05

Nonrecurring Policy

02

Specific APC Group Policies

06

Other CY 2022 Highlights

03

OPPS Device Payments

07

Proposed & Final Coding Updates

04

OPPS Drugs, Biologicals & Radiopharmaceuticals

08

Q&A

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Meet Your Speakers

Tiffani Bouchard, CCS

Jennifer Daniels, MHSA, CPC

Vice President Revenue Integrity

Director Revenue Integrity

Panacea Healthcare Solutions, Inc.

Panacea Healthcare Solutions, Inc

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Key Objectives for Today Better understand the details of the proposed rule impacting  Comprehensive APCs  Assignments for New Technology APCs  OPPS APC-specific Policies  Device, drugs and biologicals Pass-through payments  Several Nonrecurring Policy Changes  Coding changes for CY 2022

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OPPS Summary of Major Provisions

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OPPS Summary of Major Provisions  Data used in CY 2022 OPPS Ratesetting: To set CY 2022 OPPS and ASC payment rates, CMS would normally use the most updated claims and cost report data available. Because the CY 2020 claims data includes services furnished during the COVID-19 PHE, which significantly affected outpatient service utilization, CMS determined that CY 2019 data would better approximate expected CY 2022 outpatient service utilization than CY 2020 data. As a result, CMS is proposing to utilize CY 2019 data to set CY 2022 OPPS and ASC payment rates.

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OPPS Summary of Major Provisions  Changes to the Inpatient Only (IPO) List: For 2022, CMS is proposing to halt the elimination of the IPO list and, after clinical review of the services removed from the IPO list in CY 2021 against longstanding criteria for removal, they propose to add the 298 services removed from the IPO list in CY 2021 back to the IPO list beginning in CY 2022. CMS is also proposing to codify in regulation the five longstanding criteria used to determine whether a procedure or service should be removed from the IPO list.

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OPPS Summary of Major Provisions  Device Pass-Through Payment Applications: For CY 2022, CMS received eight applications for device pass-through payments. One of these applications (the Shockwave C2 Coronary Intravascular Lithotripsy (IVL) catheter) received preliminary approval for passthrough payment status through our quarterly review process. CMS is soliciting public comment on all eight of these applications and final determinations on these applications will be made in the CY 2022 OPPS/ASC final rule.

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OPPS Summary of Major Provisions  Equitable Adjustment for Device Category, Drugs, and Biologicals with Expiring Pass-through Status: As a result of CMS’ proposal to use CY 2019 claims data, rather than CY 2020 claims data, to inform CY 2022 ratesetting, they are proposing to use our equitable adjustment authority under 1833(t)(2)(E) to provide up to four quarters of separate payment for 27 drugs and biologicals and one device category whose pass-through payment status will expire between December 31, 2021 and September 30, 2022.

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OPPS Summary of Major Provisions  Updates to Requirements for Hospitals to Make Public a List of Their Standard Charges: CMS is proposing to amend several hospital price transparency policies codified at 45 CFR part 180 in order to encourage compliance. They propose to: (1) increase the amount of the penalties for noncompliance through the use of a proposed scaling factor based on hospital bed count; (2) deem state forensic hospitals that meet certain requirements to be in compliance with the requirements of 45 CFR part 180; and (3) prohibit certain conduct that we have concluded are barriers to accessing the standard charge information. CMS clarifies the expected output of hospital online price estimator tools when hospitals choose to use an online price estimator tool in lieu of posting its standard charges for the required shoppable services in a consumer-friendly format. They are seeking stakeholder comment on a variety of issues that CMS may consider in future rulemaking, including improving standardization of the data disclosed by hospitals.

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OPPS Summary of Major Provisions  Comment Solicitation on Temporary Policies for the PHE for COVID-19: In response to the COVID-19 pandemic, CMS undertook emergency rulemaking to implement a number of flexibilities to address the pandemic, such as preventing spread of the infection and supporting diagnosis of COVID-19. While many of these flexibilities will expire at the conclusion of the PHE, they are seeking comment on whether there are certain policies that should be made permanent. Specifically, CMS is seeking comment on services furnished by hospital staff to beneficiaries in their homes through use of communication technology, direct supervision when the supervising practitioner is available through two-way, audio/video communication technology, and code and payment for COVID-19 specimen collection.

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OPPS Summary of Major Provisions  Changes to Beneficiary Coinsurance for Colorectal Cancer Screening Test: Section 122 of the Consolidated Appropriations Act (CAA) of 2021 amends section 1833(a) of the Act to offer a special coinsurance rule for screening flexible sigmoidoscopies and screening colonoscopies regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure, that is furnished in connection with, as a result of, and in the same clinical encounter as the colorectal cancer screening test. CMS proposes that all surgical services furnished on the same date as a planned screening colonoscopy or planned flexible sigmoidoscopy could be viewed as being furnished in connection with, as a result of, and in the same clinical encounter as the screening test for purposes of determining the coinsurance required of Medicare beneficiaries for planned colorectal cancer screening tests that result in additional procedures furnished in the same clinical encounter.

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Specific APC Group Policies

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Specific APC Group Policies  Retinal Prosthesis Implant Procedure CPT code 0100T – continue to assign the Argus® II procedure to New Technology APC 1908. National average payment of $152,500.  Administration of Subretinal Therapies Requiring Vitrectomy HCPCS code C9770 – continue HCPCS code in New Technology APC payment band, APC 1561 for a national average payment rate of $3,250.50.  Bronchoscopy with Transbronchial Ablation of Lesion(s) by Microwave Energy HCPCS code C9751 – continue to assign to APC 1562 with a proposed national payment rate of $3,750.50.

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Specific APC Group Policies  Fractional Flow Reserve Derived From Computed Tomography (FFRCT) CPT code 0503T – continue to use equitable adjustment authority under section 1833(t)(2)(E) of the Act to assign to same New Technology APC 1511 with a national average payment rate of $950.50.  Cardiac Positron Emission Tomography (PET)/Computed Tomography (CT) Studies CPT codes 78431, 78432, and 78433 – continue to assign CPT code 78431 to APC 1522 with a national average payment rate of $2,250.50 and continue CPT codes 78432 and 78433 with assignment to APC 1523 for a national average payment rate of $2,750.50.  V-Wave Medical Interatrial Shunt Procedure HCPCS code C9758 – continue to assign HCPCS to New Technology APC 1590 with a national average payment rate of $17,500.50.

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Specific APC Group Policies  Corvia Medical Interatrial Shunt Procedure HCPCS code C9760 – the difference in the payment for HCPCS codes C9760 and C9758 is based on how often the interatrial shunt is implanted when each code is billed. The Corvia Medical interatrial shunt is implanted every time HCPCS code C9760 is billed. Continue to assign HCPCS code C9760 to New Technology APC 1592 for a national average payment rate of $27,500.50.  Supervised Visits for Esketamine Self-Administration HCPCS codes G2082 and G2083 – continue to assign HCPCS code G2082 to New Technology APC 1508 for a national average payment of $650.50 and to assign HCPCS code G2083 to New Technology APC 1511 for a national average payment of $950.50.

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Specific APC Group Policies  Stromal Vascular Fraction (SVF) Therapy CPT codes 0565T and 0566T – CPT code 0565T is assigned to APC 5733 (Level 3 Minor Procedures) with a payment rate of $55.66, and CPT code 0566T is assigned to APC 5441 (Level 1 Nerve Injections) with a payment rate of $261.17. Based on recent information from the FDA, we found there is no current FDAapproved autologous cellular product derived from autologous body fat (referred to in CPT code 0565T and 0566T as “autologous cellular implant”) associated with SVF therapy. In addition, review of the clinical trials.gov website indicate that SVF therapy is currently under clinical trial (ClinicalTrials.gov Identifiers: NCT04440189 and NCT02726945) and has not received CMS approval as investigational device exemption (IDE) studies. Proposing not to pay under the OPPS for either code. Specifically, we are revising the status indicator for CPT code 0565T from “Q1” (conditionally packaged; separately payable) to “E1” to indicate that the code is not payable by Medicare. Similarly, we are revising the status indicator for CPT code 0566T from “T” (separately payable) to “E1” to indicate that the code is not payable by Medicare and deleting the APC assignment for this code.

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OPPS Device Payments

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OPPS Device Payments  Shockwave C2 Coronary Intravascular Lithotripsy (IVL) catheter (estimated average reasonable cost is $5,640) – CMS is inviting public comment on whether the Coronary IVL should continue to receive transitional pass-through payment under the alternative pathway for devices that are FDA market authorized and that have an FDA Breakthrough Device designation. The Coronary IVL catheter is a proprietary lithotripsy device delivered through the coronary arterial system of the heart to the site of an otherwise difficult to treat calcified stenosis, including calcified stenosis that is anticipated to exhibit resistance to full balloon dilation or subsequent uniform coronary stent expansion.  The revascularization / stenting procedure CPT/HCPCS codes eligible for reporting with this catheter are 92928, 92929, 92933, 92934, 92941, 92943, 92944, C9600, C9601, C9602, C9603, C9606, C9607, C9608.

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OPPS Device Payments  RECELL System (the cost of the RECELL is $7,500) – CMS is inviting public comment on whether the RECELL meets the device pass-through payment criteria, including the cost criterion for device pass-through payment status. The system is a stand-alone, single-use, battery-powered device used to process and apply an autologous skin cell suspension. Category III medical device indicated for the treatment of acute partial-thickness and full-thickness / mixed depth thermal burn wounds and is not categorized as a skin substitute.  If device receives approval for pass-through payment, the eligible procedure CPT/HCPCS codes are Epidermal autograft 15110-15116, Skin split graft 1510015101, 15120-15121, and Wound preparation 15002-15004.

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OPPS Device Payments  AngelMed Guardian® System (Guardian®) (estimated average reasonable cost is 126 percent of the applicable APC payment amount for the service related to the category of devices of $8,152.58) – CMS is inviting public comment on whether the Guardian® meets the device pass-through payment criteria discussed in this section, including the cost criterion for device pass-through payment status. System is a proactive diagnostic technology that monitors a patient's heart's electrical activity for changes that may indicate an Acute Coronary Syndrome (ACS) event (that is, STEMI, NSTEMI, or unstable angina) related to blockage of a coronary artery which prevents the heart muscle from receiving sufficient oxygen.  If device receives approval for pass-through payment, the procedure CPT/HCPCS codes eligible for reporting with this cardiac device are 0525T, 0526T, 0527T, 0528T, 0529T, 0530T, 0531T, 0532T.

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OPPS Device Payments  BONEBRIDGE Bone Conduction Implant System (cost of the BONEBRIDGE is $11,500) – CMS invites public comment on whether BONEBRIDGE meets the device pass-through payment criteria discussed in this section, including the cost criterion for device pass-through payment status. System is a transcutaneous, active auditory osseointegrated device that replaces the function of the damaged outer or middle ear and can help people for whom hearing aids are ineffective or not recommended.  If device receives approval for pass-through payment, the implant procedure CPT/HCPCS codes eligible for reporting with this conduction system are 69714, 69715, 69717, 69718.

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OPPS Device Payments  EluviaTM Drug-Eluting Vascular Stent System (estimated average reasonable cost is 56 percent of the applicable APC payment amount for the service related to the category of devices of $10,042.94) – CMS invites public comment on whether the EluviaTM system meets the device passthrough payment criteria discussed in this section, including the cost criterion for device passthrough payment status. System is a combination product composed of an implantable endoprosthesis, a non-bonded freely dispersed drug layer (a formulation of paclitaxel contained in a polymer matrix), and a stent delivery system indicated for the treatment of symptomatic de novo or restenotic lesions in the native superficial femoral artery (SFA) and/or proximal popliteal artery (PPA).  If device receives approval for pass-through payment, the revascularization / stenting procedure CPT/HCPCS codes eligible for reporting with this stent are 37226, 37227.

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OPPS Device Payments  Cochlear™ Osia® 2 System (estimated average reasonable cost is 136 percent of the cost of the device-related portion of the APC payment amount for the related service of $7,742.60) – CMS invites public comment on whether the Osia® 2 system meets the device pass-through payment criteria discussed in this section, including the cost criterion for device pass-through payment status. System is a transcutaneous, active auditory osseointegrated device that replaces the function of the middle ear by providing mechanical energy to the cochlea.  If device receives approval for pass-through payment, the procedure CPT/HCPCS codes eligible for reporting with this cochlear system are 69714, 69715, 69717, 69718.

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OPPS Device Payments  Pure-Vu® System (estimated average reasonable cost is $975) – CMS is inviting public comment on whether the Pure-Vu® meets the device pass-through payment criteria discussed in this section, including the cost criterion for device pass-through payment status. System helps to avoid aborted and delayed colonoscopy procedures due to poor visualization of the colon mucosa by creating a unique High Intensity, Pulsed Vortex Irrigation Jet that consists of a mixture of air and water to break-up fecal matter, blood clots, and other debris, and scrub the walls of the colon while simultaneously removing the debris through two suction channels.  If device receives approval for pass-through payment, the eligible procedure CPT/HCPCS codes for use with this system are 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45388, 45390.

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OPPS Device Payments  Xenocor Xenoscope™ (cost of is $1,500) – CMS invites public comment on whether the Xenoscope™ meets the device pass-through payment criteria discussed in this section, including the cost criterion. Disposable laparoscope which consists of a highdefinition camera chip on the tip of a composite shaft, paired with led lights with a handle comprised of a clamshell design and made with molded plastic. The Xenoscope™ provides visualization in the abdominal and thoracic cavities through small, minimally invasive incisions for diagnostic and therapeutic laparoscopic procedures in a similar fashion to established, reusable versions of laparoscopes. It is paired with an image processing unit, the Xenobox, that can plug into any HD monitor to display anatomy in the abdomen, pelvis or chest and uses pre-installed firmware that is upgradable.  If device receives approval for pass-through payment, the eligible procedure CPT/HCPCS codes for use with this scope are 43281, 43282, 49320, 49321, 47562, 44970, 49650, 49651, 49652, 58661, 58570.

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OPPS Drugs, Biologicals & Radiopharmaceuticals

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OPPS Drugs, Biologicals & Radiopharmaceuticals  This table represents drugs and radiopharmace uticals for which pass-through payment status will expire December 31, 2021

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CY 2021 HCPCS Code

Long Descriptor

CY 2021 Status Indicator

Pass-Through CY 2021 Payment APC Effective Date

A9590

Iodine i-131 iobenguane, therapeutic, 1 millicurie

G

9339

01/01/2019

J0291

Injection, plazomicin, 5 mg

G

9183

01/01/2019

J1943

Injection, aripiprazole lauroxil, (aristada initio), 1 mg

G

9179

01/01/2019

J2798

Injection, risperidone, (perseris), 0.5 mg

G

9181

01/01/2019

J9204

Injection, mogamulizumabkpkc, 1 mg

G

9182

01/01/2019

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OPPS Drugs, Biologicals & Radiopharmaceuticals CY 2021 CY 2022 HCPCS Code HCPCS Code

Long Descriptor

J7169

J7169

Injection, coagulation factor Xa (recombinant), inactivated (andexxa), 10mg

C9046

C9046

J0642

J0642

J1095

J1095

Cocaine hydrochloride nasal solution for topical administration, 1 mg Injection, levoleucovorin (khapzory), 0.5 mg Injection, dexamethasone 9 percent, intraocular, 1 microgram

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CY 2022 Status Indicator G

Pass- Through Pass- Through Payment Payment End Effective Date Date 9198 04/01/2019 03/31/2022

CY 2022 APC

G

9307 04/01/2019

03/31/2022

G

9334 01/01/2020

03/31/2022

G

9172 04/01/2019

03/31/2022

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OPPS Drugs, Biologicals & Radiopharmaceuticals CY 2021 CY 2022 HCPCS Code HCPCS Code J3031

J3031

J3245

J3245

J7208

J7208

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Long Descriptor Injection, fremanezumab-vfrm, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is selfadministered) Injection, tildrakizumab, 1 mg Injection, factor viii, (antihemophilic factor, recombinant), pegylated- aucl (jivi) 1 i.u.

CY 2022 Status Indicator G

Pass- Through Pass- Through Payment Payment End Effective Date Date 9197 04/01/2019 03/31/2022

CY 2022 APC

G

9306 04/01/2019

03/31/2022

G

9299 04/01/2019

03/31/2022

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OPPS Drugs, Biologicals & Radiopharmaceuticals CY 2021 CY 2022 HCPCS Code HCPCS Code

Long Descriptor

CY 2022 Status Indicator G

Pass- Through Pass- Through Payment Payment End Effective Date Date 9304 04/01/2019 03/31/2022

CY 2022 APC

J9119

J9119

Injection, cemiplimab- rwlc, 1 mg

J9313

J9313

Injection, moxetumomab pasudotox-tdfk, 0.01 mg

G

9305 04/01/2019

03/31/2022

Q5108

Q5108

G

9173 04/01/2019

03/31/2022

Q5110

Q5110

Injection, pegfilgrastim- jmdb, biosimilar, (fulphila), 0.5 mg Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram

G

9193 04/01/2019

03/31/2022

Q5111

Q5111

Injection, pegfilgrastim- cbqv, biosimilar, (udenyca), 0.5 mg

G

9195 04/01/2019

03/31/2022

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OPPS Drugs, Biologicals & Radiopharmaceuticals CY 2021 CY 2022 HCPCS Code HCPCS Code

Long Descriptor

CY 2022 Status Indicator G

Pass- Through Pass- Through Payment Payment End Effective Date Date 9199 07/01/2019 06/30/2022

CY 2022 APC

C9047

C9047

Injection, caplacizumab- yhdp, 1 mg

J0121

J0121

Injection, omadacycline, 1 mg

G

9311 07/01/2019

06/30/2022

J1096

J1096

G

9308 07/01/2019

06/30/2022

J1303

J1303

Dexamethasone, lacrimal ophthalmic insert, 0.1 mg Injection, ravulizumab- cwvz, 10 mg

G

9312 07/01/2019

06/30/2022

G

9313 07/01/2019

06/30/2022

J9036

J9036

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Injection, bendamustine hydrochloride (belrapzo/bendamustine), 1 mg

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OPPS Drugs, Biologicals & Radiopharmaceuticals CY 2021 CY 2022 HCPCS Code HCPCS Code

Long Descriptor

CY 2022 Status Indicator G

Pass- Through Pass- Through Payment Payment End Effective Date Date 9310 07/01/2019 06/30/2022

CY 2022 APC

J9210

J9210

Injection, emapalumab- lzsg, 1 mg

J9269

J9269

Injection, tagraxofusp- erzs, 10 micrograms

G

9309 07/01/2019

06/30/2022

J3111

J3111

G

9327 10/01/2019

09/30/2022

J9356

J9356

Injection, romosozumab- aqqg, 1 mg Injection, trastuzumab, 10 mg and hyaluronidase-oysk

G

9314 10/01/2019

09/30/2022

C9054

J0691

Injection, lefamulin (xenleta), 1 mg

G

9332 01/01/2020

12/31/2022

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OPPS Drugs, Biologicals & Radiopharmaceuticals CY 2021 CY 2022 HCPCS Code HCPCS Code

Long Descriptor

CY 2022 Status Indicator G

Pass- Through Pass- Through Payment Payment End Effective Date Date 9333 01/01/2020 12/31/2022

CY 2022 APC

C9055

J1632

Injection, brexanolone, 1mg

J9309

J9309

Injection, polatuzumab vedotin-piiq, 1 mg

G

9331 01/01/2020

12/31/2022

Q5107

Q5107

G

9329 01/01/2020

12/31/2022

Q5117

Q5117

Injection, bevacizumab- awwb, biosimilar, (mvasi), 10 mg Injection, trastuzumab- anns, biosimilar, (kanjinti), 10 mg

G

9330 01/01/2020

12/31/2022

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OPPS Drugs, Biologicals & Radiopharmaceuticals CY 2022 HCPCS Code

CY 2022 Short Descriptor

CY 2021 High/Low Cost Assignment

Proposed CY 2022 High/Low Cost Assignment

Q4182

Transcyte, per sq centimeter

Low

High

Q4188

Amnioarmor 1 sq cm

Low

High

Q4190

Artacent ac 1 sq cm

Low

High

Q4193

Coll-e-derm 1 sq cm

Low

High

Q4198

Genesis amnio membrane 1 sq cm

Low

High

Q4200

Skin te 1 sq cm

Low

High

Q4201

Matrion 1 sq cm

Low

High

Q4209

Surgraft per sq cm

Low

High

Q4211

Amnion bio or axobio sq cm

Low

High

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OPPS Drugs, Biologicals & Radiopharmaceuticals CY 2022 HCPCS Code

CY 2022 Short Descriptor

CY 2021 High/Low Cost Assignment

Proposed CY 2022 High/Low Cost Assignment

Q4219

Surgigraft dual per sq cm

Low

High

Q4222

Progenamatrix, per sq cm

Low

High

Q4227

Amniocore per sq cm

Low

High

Q4232

Corplex, per sq cm

Low

High

Q4237

Cryo-cord, per sq cm

Low

High

Q4238

Derm-maxx, per sq cm

Low

High

Q4239

Amnio-maxx or lite per sq cm

Low

High

Q4249

Amniply, per sq cm

Low

High

Q4219

Surgigraft dual per sq cm

Low

High

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OPPS Drugs, Biologicals & Radiopharmaceuticals  CMS proposes to continue to pay for pass-through drugs and biologicals at ASP+6 percent, equivalent to the payment rate these drugs and biologicals would receive in the physician’s office setting in CY 2022. They propose that a $0 pass-through payment amount would be paid for passthrough drugs and biologicals that are not policy-packaged as described in Section V.B.1.c. under the CY 2022 OPPS because the difference between the amount authorized under section 1842(o) of the Act, which is proposed at ASP+6 percent, and the portion of the otherwise applicable OPD fee schedule that the Secretary determines is appropriate, which is proposed at ASP+6 percent, is $0.

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OPPS Drugs, Biologicals & Radiopharmaceuticals  In the case of policy-packaged drugs (which include the following: anesthesia drugs; drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure (including contrast agents, diagnostic radiopharmaceuticals, and stress agents); and drugs and biologicals that function as supplies when used in a surgical procedure), CMS proposes that their pass-through payment amount would be equal to ASP+6 percent for CY 2022 minus a payment offset for the portion of the otherwise applicable OPD fee schedule that the Secretary determines is associated with the drug or biological as described in section V.A.6. of the proposed rule. CMS proposes this policy because, if not for the pass-through payment status of these policy-packaged products, payment for these products would be packaged into the associated procedure.

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OPPS Drugs, Biologicals & Radiopharmaceuticals  CMS is proposing to continue our payment policy that has been in effect since CY 2013 to pay for separately payable drugs and biologicals, with the exception of 340Bacquired drugs, at ASP+6 percent in accordance with section 1833(t)(14)(A)(iii)(II) of the Act (the statutory default). They propose to pay for separately payable nonpassthrough drugs acquired with a 340B discount at a rate of ASP minus 22.5 percent (as described in section V.B.6). The CY 2018 OPPS/ASC final rule with comment period (82 FR 59353 through 59371), and the CY 2021 OPPS/ASC final rule with comment period (85 FR 86042 through 86055) contains more information about the current payment policy for drugs and biologicals acquired with a 340B discount.

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OPPS Drugs, Biologicals & Radiopharmaceuticals  CMS proposes to continue to utilize a 3-percent add-on instead of a 6-percent add-on for drugs that are paid based on WAC pursuant to our authority under section 1833(t)(14)(A)(iii)(II) of the Act, which provides, in part, that the amount of payment for a SCOD is the average price of the drug in the year established under section 1847A of the Act. They also propose to apply this provision to non-SCOD separately payable drugs.

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44

Nonrecurring Policy

45

Beneficiary Coinsurance for Colorectal Cancer Screening Test  The phased in Medicare payment percentages for colorectal cancer screening services described in the amendments we propose in the CY 2022 PFS proposed rule to our regulation at section 410.37(j) (and the corresponding reduction in coinsurance) are as follows: • 80 percent payment for services furnished in CY 2022 (with coinsurance equal to 20 percent); • 85 percent payment for services furnished in CY 2023 (with coinsurance equal to 15 percent); • 90 percent payment for services furnished in 2027 through 2029 (with coinsurance equal to 10 percent); and • 100 percent payment for services furnished from CY 2030 onward (with coinsurance equal to zero percent).

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46

Equitable Adjustment for Device Category, Drugs, and Biologicals HCPCS Code

C1823 A9590

Long Descriptor

Generator, neurostimulator (implantable), nonrechargeable, with transvenous sensing and stimulation leads) Iodine i-131 iobenguane, therapeutic, 1 millicurie

Proposed Adjustment Equivalent to an Pass- Through Status Pass- Through Status Extension of PassEffective Date Expiration Date through Status (number of quarters 1/1/2019

12/31/2021

4

1/1/2019

12/31/2021

4

J0222

Injection, Patisiran, 0.1 mg

1/1/2019

12/31/2021

4

J0291

Injection, plazomicin, 5 mg

1/1/2019

12/31/2021

4

J1943

Injection, aripiprazole lauroxil, (aristada initio), 1 mg

1/1/2019

12/31/2021

4

J2798

Injection, risperidone, (perseris), 0.5 mg

1/1/2019

12/31/2021

4

J9204

Injection, mogamulizumab-kpkc, 1 mg

1/1/2019

12/31/2021

4

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47

Equitable Adjustment for Device Category, Drugs, and Biologicals HCPCS Code

J7169 C9046 J0642 J1095 J3031

Long Descriptor

Injection, coagulation factor Xa (recombinant), inactivated (andexxa), 10mg Cocaine hydrochloride nasal solution for topical administration, 1 mg Injection, levoleucovorin 0(khapzory), 0.5 mg Injection, dexamethasone 9 percent, intraocular, 1 microgram

Injection, fremanezumab-vfrm, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)

Software. Consulting. Education. Results.

Proposed Adjustment Equivalent to an Pass- Through Status Pass- Through Status Extension of PassEffective Date Expiration Date through Status (number of quarters 4/1/2019

3/31/2022

3

4/1/2019

3/31/2022

3

1/1/2020

3/31/2022

3

4/1/2019

3/31/2022

3

4/1/2019

3/31/2022

3

© 2021 Panacea Healthcare Solutions, Inc.

48

Equitable Adjustment for Device Category, Drugs, and Biologicals HCPCS Code

Long Descriptor

Proposed Adjustment Equivalent to an Pass- Through Status Pass- Through Status Extension of PassEffective Date Expiration Date through Status (number of quarters

J3245

Injection, tildrakizumab, 1 mg

4/1/2019

3/31/2022

3

J7208

Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi) 1 i.u.

4/1/2019

3/31/2022

3

J9119

Injection, cemiplimab-rwlc, 1 mg

4/1/2019

3/31/2022

3

4/1/2019

3/31/2022

3

4/1/2019

3/31/2022

3

4/1/2019

3/31/2022

3

J9313 Q5108 Q5110

Injection, moxetumomab pasudotox-tdfk, 0.01 mg Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram

Software. Consulting. Education. Results.

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49

Equitable Adjustment for Device Category, Drugs, and Biologicals HCPCS Code

Long Descriptor

Q5111

Injection, Pegfilgrastim-cbqv, biosimilar, (udenyca), 0.5 mg

C9047

Proposed Adjustment Equivalent to an Pass- Through Status Pass- Through Status Extension of PassEffective Date Expiration Date through Status (number of quarters 4/1/2019

3/31/2022

3

Injection, caplacizumab-yhdp, 1 mg

7/1/2019

6/30/2022

2

J0121

Injection, omadacycline, 1 mg

7/1/2019

6/30/2022

2

J1096

Dexamethasone, lacrimal ophthalmic insert, 0.1 mg

7/1/2019

6/30/2022

2

J1303

Injection, ravulizumab-cwvz, 10 mg

7/1/2019

6/30/2022

2

J9036

Injection, bendamustine hydrochloride (belrapzo/bendamustine), 1 mg

7/1/2019

6/30/2022

2

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50

Equitable Adjustment for Device Category, Drugs, and Biologicals HCPCS Code

Long Descriptor

Proposed Adjustment Equivalent to an Pass- Through Status Pass- Through Status Extension of PassEffective Date Expiration Date through Status (number of quarters

J9210

Injection, emapalumab-lzsg, 1 mg

7/1/2019

6/30/2022

2

J9269

Injection, tagraxofusp-erzs, 10 micrograms

7/1/2019

6/30/2022

2

J3111

Injection, romosozumab-aqqg, 1 mg

10/1/2019

9/30/2022

1

J9356

Injection, trastuzumab, 10 mg and hyaluronidase-oysk

10/1/2019

9/30/2022

1

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51

Other CY 2022 Highlights

52

Inpatient New Technology Add-on Payments (NTAP) New Technology Add-on Payment FY 2022 Maximum NTAP Amount for FY 2022 $6,405.89

Technology RYBREVANT™

Coding Used to Identify Cases Eligible for NTAP XW033B7 or XW043B7

HCPCS Code(s)

C9399 or amivantamab J9999

COSELA™

$5,526.30

XW03377 or XW04377

ABECMA®

$272,675.00

XW033K7 or XW043K7

$44,200.00

XHRPXF7

Q4100

$259,350.00

XW033M7 or XW043M7

Q2053

StrataGraft

TM

Skin Tissue

TECARTUS® VEKLURY®

Software. Consulting. Education. Results.

$2,028.00

XW033E5 or XW043E5

Other name

C9078

trilaciclib

HCPCS Procedure 96413, 96417 96365, 96367

C9399 or idecabtagene J3490 vicleucel brexucabtagene autoleucel

C9399 or remdesivir J3490

0540T

0540T 96365

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53

Inpatient New Technology Add-on Payments (NTAP) New Technology Add-on Payment FY 2022 Technology ZEPZELCA™ Aprevo™ Intervertebral Body Fusion Device aScope™

Software. Consulting. Education. Results.

Maximum NTAP Amount for FY 2022 $8,622.90

Coding Used to Identify Cases Eligible for NTAP

HCPCS Code(s)

XW03387 or XW04387

J9223

$20,475.00 XRGA0R7, XRGA3R7, XRGA4R7, XRGB0R7, XRGB3R7, XRGB4R7, XRGC0R7, XRGC3R7, XRGC4R7, XRGD0R7, XRGD3R7 or XRGD4R7 $1,715.59 XFJB8A7 or XFJD8A7

Other name lurbinectedin

HCPCS Procedure 96413, 96417

C1062

22558, 22853, 22854, 22859

C1748

43260, 43261, 43262, 43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278

© 2021 Panacea Healthcare Solutions, Inc.

54

Inpatient New Technology Add-on Payments (NTAP) New Technology Add-on Payment FY 2022 Technology Caption Guidance™ EXALT™ Model D Single-Use Duodenoscope

Harmony™ Transcatheter Pulmonary Valve (TPV) System INTERCEPT Fibrinogen Complex (PRCFC)

Software. Consulting. Education. Results.

Maximum NTAP Amount for FY 2022 $1,868.10

Coding Used to Identify Cases Eligible for NTAP

HCPCS Code(s)

X2JAX47

C1889

93319 (new code for 2022)

$1,715.59

XFJB8A7 or XFJD8A7

C1748

$26,975.00

02RH38M (02RH38Z)

C1889

43260, 43261, 43262, 43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278 33477

$2,535.00

30233D1 or 30243D1 in combination with D65 or D68.2

P9070, P9071 or P9073

Other name

HCPCS Procedure

36430

© 2021 Panacea Healthcare Solutions, Inc.

55

Inpatient New Technology Add-on Payments (NTAP) New Technology Add-on Payment FY 2022 Technology Shockwave C2 Coronary Intravascular Lithotripsy (IVL) System CONTEPO™

Software. Consulting. Education. Results.

Maximum NTAP Amount for FY 2022 $3,666.00 $2,625.00

Coding Used to Identify Cases Eligible for NTAP

HCPCS Code(s)

02F03ZZ, 02F13ZZ, 02F23ZZ, 02F33ZZ

C1761

XW033K5 or XW043K5

Other name

HCPCS Procedure 92928-92944, C9600-C9608

C9399 or fosfomycin J3490

96365, 96367

© 2021 Panacea Healthcare Solutions, Inc.

56

Therapy Assistant Modifiers CMS finalized a de minimis standard to identify when the CQ/CO modifiers apply and when they do not apply as follows:  Portions of a service furnished by the PTA/OTA independent of the physical therapist/occupational therapist, as applicable, that do not exceed 10 percent of the total service (or 15-minute unit of a service) are not considered to be furnished in whole or in part by a PTA/OTA, so are not subject to the payment reduction;  Portions of a service that exceed 10 percent of the total service (or 15-minute unit of a service) when furnished by the PTA/OTA independent of the therapist must be reported with the CQ/CO modifier, alongside of the corresponding GP/GO therapy modifier; are considered to be furnished in whole or in part by a PTA/OTA, and are subject to the payment reduction; and  Portions of a service provided by the PTA/OTA together with the physical therapist/ occupational therapist are considered for this purpose to be services provided by the therapist.

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57

Therapy Assistant Modifiers  The PTA/OTA or PT/OT first needs to determine how many 15-minute units can be billed in a single treatment day for a patient (chart in section 20.2.C of Chapter 5 of the Medicare Claims Processing Manual (MCPM) describes how to count minutes for timed codes defined by 15-minute units). The therapist or assistant should use the same counting rule, commonly known as the “8-minute rule,” that they have used previously.  CMS has provided general examples for 8 different billing scenarios in which multiple units of 15-minute codes are provided by PTs/OTs and PTAs/OTAs and one billing example that used the untimed code for group therapy performed for equal minutes by a PT and a PTA.  https://www.cms.gov/medicare/therapy-services/billing-examples-using-cqcomodifiers-services-provided-ptas-otas

Software. Consulting. Education. Results.

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58

Therapy Assistant Modifiers  Billing Scenario Examples Where CQ/CO Modifier Applies Billing Scenario

Stakeholders’ Rules

Scenario 1

PT/OT (6 minutes) + PTA/OTA (8 minutes) - for a total of 14 minutes.

The PTA/OTA provided 8 minutes or more and the PT/OT provided less than 8 minutes; therefore, the de minimis standard is exceeded. Bill with the CQ/CO modifier.

Scenario 2

PT (5 minutes) + PTA/OTA (5 minutes) for a total of 10 minutes.

Both the PT/OT and the PTA/OTA provided less than 8 minutes; so the de minimis standard is exceeded. Bill with the CQ/CO modifier

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59

Therapy Assistant Modifiers  Billing Scenario Examples Where the Midpoint Rule Applies Billing Scenario Scenario 1

PT (8 minutes) + PTA/OTA (7 minutes) — for a total of 15 minutes.

Scenario 2

PT (11 minutes) + PTA/OTA (11 minutes) - for a total of 22 minutes.

Software. Consulting. Education. Results.

Therapy Stakeholder Midpoint Rule The PT/OT bills without the CQ/CO modifier because they provided enough minutes on their own (8 minutes or more) without the PTA’s/OTA’s time to bill the one unit.

Disregard PTA/OTA minutes.

The PT/OT bills without the CQ/CO modifier because they provided enough minutes on their own (8 minutes or more) without the PTA’s/OTA’s time to bill the one unit.

Disregard PTA/OTA minutes. © 2021 Panacea Healthcare Solutions, Inc.

60

Appropriate Use Criteria (AUC)  The EDUCATIONAL AND OPERATIONS TESTING PERIOD for the AUC Program has been extended through CY 2021. There are no payment consequences associated with the AUC program during CY 2020 and CY 2021. CMS is encouraging stakeholders to use this period to learn, test and prepare for the AUC program.  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Appropriate-Use-Criteria-Program  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf

Software. Consulting. Education. Results.

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61

Proposed & Final Coding Updates Managing year-end updates with Panacea’s CDM Coding Compliance Tool Powered by ChargeAssist™ & PHARMauditor®

62

Panacea’s CDM Coding and Compliance Module

Software. Consulting. Education. Results.

© 2021 Panacea Healthcare Solutions, Inc.

63

Panacea’s CDM Coding and Compliance Module

Software. Consulting. Education. Results.

© 2021 Panacea Healthcare Solutions, Inc.

64

Panacea’s CDM Coding and Compliance Module

Software. Consulting. Education. Results.

© 2021 Panacea Healthcare Solutions, Inc.

65

Panacea’s PHARMauditor

Software. Consulting. Education. Results.

© 2021 Panacea Healthcare Solutions, Inc.

66

PHARMauditor™Report

Software. Consulting. Education. Results.

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67

Proposed & Final Code Deletions A / Proposed M / HCPCS D Code

Short Descriptor

2021 SI

2021 2021 Payment APC

Replacement Code(s)

D

01935

Anesth perc img dx sp proc

N

See code(s) 01937, 01938, 01939, 01940, 01941, 01942

D

01936

Anesth perc img tx sp proc

N

See code(s) 01937, 01938, 01939, 01940, 01941, 01942

D

21310

T

D

33470

Closed tx nose fx w/o manj Revision of pulmonary valve

D

33722

D D

5111 $

206.19

No replacement; see code(s) 21315, 21320

C

No replacement code identified; see code 33999 if performed

Repair of heart defect

C

No replacement code identified; see code 33999 if performed

43850

Revise stomachbowel fusion

C

No replacement code identified; see code 43999 if performed

43855

Revise stomachbowel fusion

C

No replacement code identified; see code 43999 if performed

Software. Consulting. Education. Results.

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68

Proposed & Final Code Deletions A / Proposed M / HCPCS D Code

Short Descriptor

2021 SI

2021 2021 Payment APC

Replacement Code(s)

D

59135

Treat ectopic pregnancy

C

No replacement code identified; see code 59899 if performed

D

63194

Incise spine & cord cervical

C

See code(s) 63197

D

63195

C

See code(s) 63197

D

63196

Incise spine & cord thoracic Incise spine&cord 2 trx crvl

C

See code(s) 63197

D

63198

Incise spin&cord 2 stgs crvl

C

See code(s) 63197

D

63199

Incise spin&cord 2 stgs thrc

C

See code(s) 63197

D

69715

Temple bne implnt w/stimulat

J1

Software. Consulting. Education. Results.

5116 $15,868.13

See code(s) 69716

© 2021 Panacea Healthcare Solutions, Inc.

69

Proposed & Final Code Deletions A / Proposed M / HCPCS D Code

Short Descriptor

2021 SI

2021 2021 Payment APC

Replacement Code(s)

D

69718

Revise temple bone implant

J1

D

72275

Epidurography

N

D

76101

Q1

5522 $

108.97

D

76102

Complex body section x-ray Complex body section x-rays

S

5522 $

108.97

D

80500

Lab pathology consultation

Q1

5671 $

49.76

See code(s) 80503, 80504, 80505, 80506

D

80502

Lab pathology consultation

Q1

5672 $

149.16

See code(s) 80503, 80504, 80505, 80506

D

92559

Group audiometric testing

E1

Software. Consulting. Education. Results.

5115 $12,314.76

See code(s) 69719 No replacement code identified; see code 76496 if performed No replacement code identified; see code 76499 if performed No replacement code identified; see code 76499 if performed

No replacement code identified; see code 92700 if performed © 2021 Panacea Healthcare Solutions, Inc.

70

Proposed & Final Code Deletions A / Proposed M / HCPCS D Code

Short Descriptor

2021 SI

2021 2021 Payment APC

Replacement Code(s)

D

92560

Bekesy audiometry screen

E1

D

92561

Bekesy audiometry diagnosis

Q1

5734 $

111.95

No replacement code identified; see code 92700 if performed

D

92564

Sisi hearing test

Q1

5731 $

24.67

D

93530

Rt heart cath congenital

J1

5191 $ 2,899.02

No replacement code identified; see code 92700 if performed See code(s) 93593, 93594

D

93531

R & l heart cath congenital

J1

5191 $ 2,899.02

See code(s) 93595, 93596, 93597

D

93532

R & l heart cath congenital

J1

5191 $ 2,899.02

See code(s) 93595, 93596, 93597

D

93533

R & l heart cath congenital

J1

5191 $ 2,899.02

See code(s) 93595, 93596, 93597

Software. Consulting. Education. Results.

No replacement code identified; see code 92700 if performed

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71

Proposed & Final Code Deletions A / Proposed M / HCPCS D Code

Short Descriptor

2021 SI

2021 2021 Payment APC

Replacement Code(s)

D

93561

Cardiac output measurement

N

See code(s) 93598

D

93562

Card output measure subsq

N

See code(s) 93598

D

95943

S

5721 $

D

0191T

Parasymp&symp hrt rate test Insert ant segment drain int

J1

5492 $ 3,917.74

D

0376T

Insert ant segment drain int

N

See code(s) 0671T

D

0290T

Laser inc for pkp/lkp recip

N

No replacement code identified

D

0355T

Gi tract capsule endoscopy

J1

Software. Consulting. Education. Results.

139.55

5302 $ 1,625.02

No replacement code identified; see code 95999 if performed See code(s) 0671T

See code(s) 91113

© 2021 Panacea Healthcare Solutions, Inc.

72

Proposed & Final Code Deletions A / Proposed M / HCPCS D Code

Short Descriptor

2021 SI

2021 2021 Payment APC

Replacement Code(s)

D

0356T

Insrt drug device for iop

Q1

D

0423T

Assay secretory type ii pla2

A

No replacement code identified

D

0451T

C

No replacement code; see 37799 if performed

D

0452T

Insj/rplcmt aortic ventr sys Insj/rplcmt dev vasc seal

C

No replacement code; see 37799 if performed

D

0453T

Insj/rplcmt mech-elec ntrfce

J1

5222 $ 8,152.58

No replacement code; see 37799 if performed

D

0454T

Insj/rplcmt subq electrode

J1

5222 $ 8,152.58

No replacement code; see 37799 if performed

D

0455T

Remvl aortic ventr cmpl sys

C

Software. Consulting. Education. Results.

5692 $

61.97

See code(s) 68841

No replacement code; see 37799 if performed

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73

Proposed & Final Code Deletions A / Proposed M / HCPCS D Code

Short Descriptor

2021 SI

2021 2021 Payment APC

Replacement Code(s)

D

0456T

Remvl aortic dev vasc seal

C

D

0457T

Remvl mech-elec skin ntrfce

Q2

5221 $ 3,440.37

No replacement code; see 37799 if performed

D

0458T

Q2

5221 $ 3,440.37

No replacement code; see 37799 if performed

D

0459T

Remvl subq electrode Relocaj rplcmt aortic ventr

D

0460T

Repos aortic ventr dev eltrd

T

D

0461T

Repos aortic contrpulsj dev

C

D

0462T

Prgrmg eval aortic ventr sys

S

Software. Consulting. Education. Results.

No replacement code; see 37799 if performed

C

No replacement code; see 37799 if performed 5221 $ 3,440.37

No replacement code; see 37799 if performed No replacement code; see 37799 if performed

5743 $

272.47

No replacement code; see 93799 if performed

© 2021 Panacea Healthcare Solutions, Inc.

74

Proposed & Final Code Deletions A / Proposed M / HCPCS D Code

Short Descriptor

2021 SI

2021 2021 Payment APC

Replacement Code(s)

D

0463T

Interrog aortic ventr sys

S

D

0466T

Insj ch wal respir eltrd/ra

N

D

0467T

J1

5461 $ 3,275.30

See code(s) 64583

D

0468T

Revj/rplmnt ch respir eltrd Rmvl ch wal respir eltrd/ra

J1

5461 $ 3,275.30

See code(s) 64584

D

0548T

Tprnl balo cntnc dev bi

J1

5377 $11,488.02

See code(s) 53451

D

0549T

Tprnl balo cntnc dev uni

J1

5375 $ 4,413.90

See code(s) 53452

D

0550T

Tprnl balo cntnc dev rmvl ea

J1

5374 $ 3,076.34

See code(s) 53453

Software. Consulting. Education. Results.

5743 $

272.47

No replacement code; see 93799 if performed See code(s) 64582

© 2021 Panacea Healthcare Solutions, Inc.

75

Proposed & Final Code Deletions A / Proposed M / HCPCS D Code

Short Descriptor

2021 SI

2021 2021 Payment APC

D

0551T

Tprnl balo cntnc dev adjmt

T

5371 $

266.14

D

G0424

Pulmonary rehab w exer

S

5733 $

55.66

D

G2064

M

D

G2065

Md mang high risk dx 30 Clin mang h risk dx 30

Software. Consulting. Education. Results.

S

Replacement Code(s)

See code(s) 53454 See code(s) 94625, 94626 See code(s) 99424, 99425, 99437

5822 $

74.87

See code(s) 99426, 99427

© 2021 Panacea Healthcare Solutions, Inc.

76

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

A

01XX2

01937

Anes drg/aspir crv/thrc

A

01XX3

01938

Anes drg/aspir lmbr/sac

N

A

01XX4

01939

Anes nulyt agt crv/thrc

N

A

01XX5

01940

Anes nulyt agt lmbr/sac

N

A

01XX6

01941

Anes neuromd/ntrvrt crv/thrc

N

A

01XX7

01942

Anes neuromd/ntrvrt lmbr/sac

N

A

33XXX

33370

Tcat plmt&rmvl cepd perq

N

A

338X0

33897

Perq trluml angp nt/recr coa

C

Software. Consulting. Education. Results.

N

APC

Relative Weight

Payment Rate

© 2021 Panacea Healthcare Solutions, Inc.

77

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

APC

Relative Weight

A

338X1

33894

Evasc st rpr thrc/aa acrs br

A

338X2

33895

Evasc st rpr thrc/aa x crsg

C

A

33XX3

33267

Open excl laa any method

C

A

33XX4

33268

Opn excl laa oth px any meth

C

A

33XX5

33269

Thrscp excl laa any method

C

A

35XX0

33509

Ndsc hrv uxtr art 1 sgm cab

C

A

42XXX

42975

Dise eval slp do brth flx dx

T

5151

1.9988

A

434XX

43497

Transorl lwr esophgl myotomy

J1

5303

37.4245

Software. Consulting. Education. Results.

C

Payment Rate

$

168.81

$ 3,160.76

© 2021 Panacea Healthcare Solutions, Inc.

78

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

APC

Relative Weight

Payment Rate

A

53XX1

53451

Tprnl balo cntnc dev bi

J1

5377

A

53XX2

53452

Tprnl balo cntnc dev uni

J1

5375

53.6040

$ 4,527.23

A

53XX3

53453

Tprnl balo cntnc dev rmvl ea

J1

5374

37.3892

$ 3,157.78

A

53XX4

53454

Tprnl balo cntnc dev adjmt

T

5371

3.2328

A

617X1

61736

Litt icr 1 traj 1 smpl les

C

A

617X2

61737

Litt icr mlt trj mlt/cplx ls

C

A

630X1

63053

Lam factc&frmt arthrd lum ea

N

A

630XX

63052

Lam facetc&frmt arthrd lum 1

N

Software. Consulting. Education. Results.

139.5079

$11,782.42

$

273.03

© 2021 Panacea Healthcare Solutions, Inc.

79

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

APC

Relative Weight

Payment Rate

A

645X1

64582

Opn mpltj hpglsl nstm ary pg

J1

5465

A

645X2

64583

Rev/rplct hpglsl nstm ary pg

J1

5463

136.5674

$11,534.07

A

645X3

64584

Rmvl hypglsl nstim ary pg

Q2

5432

69.2827

$ 5,851.41

A

646X0

64628

Trml dstrj ios bvn 1st 2 l/s

J1

5115

149.5497

$12,630.52

A

646X1

64629

Trml dstrj ios bvn ea addl

N

A

669X1

66989

Xcpsl ctrc rmvl cplx insj 1+

J1

5492

47.5842

$ 4,018.82

A

669X2

66991

Xcapsl ctrc rmvl insj 1+

J1

5492

47.5842

$ 4,018.82

A

68XXX

68841

Insj rx elut implt lac canal

Q1

5692

0.7533

Software. Consulting. Education. Results.

357.6792

$30,208.51

$

63.62

© 2021 Panacea Healthcare Solutions, Inc.

80

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

APC

Relative Weight

Payment Rate

A

69X50

69716

Impltj oi implt skl tc esp

J1

5115

A

69X51

69719

Revj/rplcmt oi implt tc esp

J1

5115

149.5497

$12,630.52

A

69X52

69726

Rmvl oi implt skl perq esp

J1

5113

34.4169

$ 2,906.75

A

69X53

69727

Rmvl oi implt skl tc esp

J1

5113

34.4169

$ 2,906.75

A

77X01

77089

Tbs dxa cal w/i&r fx risk

M

A

77X02

77090

Tbs techl prep&transmis data

S

5521

0.9829

$

83.01

A

77X03

77091

Tbs techl calculation only

S

5521

0.9829

$

83.01

A

77X04

77092

Tbs i&r fx rsk qhp

M

Software. Consulting. Education. Results.

149.5497

$12,630.52

© 2021 Panacea Healthcare Solutions, Inc.

81

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

APC

Relative Weight

Payment Rate

A

801XX

80220

Drug asy hydroxychloroquine

Q4

A

80XX0

80503

Path clin consltj sf 5-20

Q1

5671

0.6036

$

50.98

A

80XX1

80504

Path clin consltj mod 21-40

Q1

5672

1.8119

$

153.03

A

80XX2

80505

Path clin consltj high 41-60

Q1

5672

1.8119

$

153.03

A

80XX3

80506

Path clin consltj prolng svc

N

A

812X0

81349

Cytog alys chrml abnr lw-ps

A

A

815X0

81560

Trnsplj med meas cd154+ cell

Q4

A

815X1

81523

Onc brst mrna 70 cnt 31 gene

A

Software. Consulting. Education. Results.

© 2021 Panacea Healthcare Solutions, Inc.

82

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

A

826X0

82653

El-1 fecal quantitative

Q4

A

8352X

83521

Ig light chains free each

Q4

A

835X1

83529

Asay of interleukin-6 (il-6)

Q4

A

860X1

86052

Aquaporin-4 antb cba each

Q4

A

860X2

86053

Aqaprn-4 antb flo cytmtry ea

Q4

A

860XX

86051

Aquaporin-4 antb elisa

Q4

A

863X2

86362

Mog-igg1 antb cba each

Q4

A

863X3

86363

Mog-igg1 antb flo cytmtry ea

Q4

Software. Consulting. Education. Results.

APC

Relative Weight

Payment Rate

© 2021 Panacea Healthcare Solutions, Inc.

83

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

A

862X0

86231

Ema each ig class

Q4

A

862X1

86364

Tiss trnsgltmnase ea ig clas

Q4

A

862XX

86258

Dgp antibody each ig class

Q4

A

863X4

86381

Mitochondrial antibody each

Q4

A

865X0

86596

Voltage-gtd ca chnl antb ea

Q4

A

86X00

86036

Anca screen each antibody

Q4

A

86X01

86037

Anca titer each antibody

Q4

A

86XX0

86015

Actin antibody each

Q4

Software. Consulting. Education. Results.

APC

Relative Weight

Payment Rate

© 2021 Panacea Healthcare Solutions, Inc.

84

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

A

8715X

87154

Cultyp id bld pthgn 6+ trgt

Q4

A

9074X

90759

Hep b vac 3ag 10mcg 3dos im

E1

A

9111X

91113

Gi trc img intral colon

T

A

933X0

93319

3d echo img cgen hrt anomal

N

A

93X1X

93593

R hrt cath chd nml nt cnj

A

93X2X

93594

A

93X3X

A

93X4X

APC

Relative Weight

Payment Rate

5311

9.6432

J1

5191

35.2365

$ 2,975.97

R hrt cath chd abnl nt cnj

J1

5191

35.2365

$ 2,975.97

93595

L hrt cath chd nm/abn nt cnj

J1

5191

35.2365

$ 2,975.97

93596

R&l hrt cath chd nml nt cnj

J1

5191

35.2365

$ 2,975.97

Software. Consulting. Education. Results.

$

814.44

© 2021 Panacea Healthcare Solutions, Inc.

85

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

APC

Relative Weight

Payment Rate

A

93X5X

93597

R&l hrt cath chd abnl nt cnj

J1

A

93X6X

93598

Car outp meas drg cath chd

N

A

946X1

94625

Phy/qhp op pulm rhb w/o mntr

S

5733

0.6763

$

57.12

A

946X2

94626

Phy/qhp op pulm rhb w/mntr

S

5733

0.6763

$

57.12

A

989X1

98975

Rem ther mntr 1st setup&edu

V

5012

1.4436

$

121.92

A

989X2

98976

Rem ther mntr dev sply resp

Q1

5741

0.4521

$

38.18

A

989X3

98977

Rem ther mntr dv sply mscskl

Q1

5741

0.4521

$

38.18

A

989X4

98980

Rem ther mntr 1st 20 min

Software. Consulting. Education. Results.

5191

35.2365

$ 2,975.97

B

© 2021 Panacea Healthcare Solutions, Inc.

86

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

A

989X5

98981

Rem ther mntr ea addl 20 min

A

99X21

99437

Chrnc care mgmt phys ea addl

M

A

99X22

99424

Prin care mgmt phys 1st 30

M

A

99X23

99425

Prin care mgmt phys ea addl

M

A

99X24

99426

Prin care mgmt staff 1st 30

S

A

99X25

99427

Prin care mgmt staff ea addl

N

A

050XT

0674T

Laps insj nw/rpcmt prm isdss

E1

A

051XT

0675T

Laps insj nw/rpcmt isdss 1ld

E1

Software. Consulting. Education. Results.

B

APC

5822

Relative Weight

0.9085

Payment Rate

$

76.73

© 2021 Panacea Healthcare Solutions, Inc.

87

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

A

052XT

0680T

Insj/rplcmt pg only isdss

E1

A

053XT

0683T

Prgrmg dev eval isdss ip

E1

A

054XT

0684T

Peri-px dev eval isdss ip

E1

A

055XT

0685T

Interrog dev eval isdss ip

E1

A

060XT

0676T

Laps insj nw/rpcmt isdss ea

E1

A

061XT

0677T

Laps repos lead isdss 1st ld

E1

A

062XT

0678T

Laps repos lead isdss ea add

E1

A

063XT

0679T

Laps rmvl lead isdss

E1

Software. Consulting. Education. Results.

APC

Relative Weight

Payment Rate

© 2021 Panacea Healthcare Solutions, Inc.

88

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

A

064XT

0681T

Rlcj pulse gen only isdss

E1

A

065XT

0682T

Removal pulse gen only isdss

E1

A

056XT

0686T

Histotripsy mal hepatcel tis

A

057XT

0692T

Therapeutic ultrafiltration

E1

A

058XT

0687T

Tx amblyopia dev setup 1st

E1

A

059XT

0688T

Tx amblyopia assmt w/report

E1

A

06X0T

0672T

Ndovag cryg rf remdl tiss

E1

A

0X12T

0671T

Insj ant sgm aq drg dev 1+

J1

Software. Consulting. Education. Results.

T

APC

Relative Weight

5311

9.6432

5491

25.2347

Payment Rate

$

814.44

$ 2,131.25

© 2021 Panacea Healthcare Solutions, Inc.

89

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

A

0X32T

0697T

Quan mr tis wo mri mlt orgn

A

0X33T

0689T

A

0X34T

A

SI

APC

Relative Weight

S

5523

Quan us tis charac w/o dx us

S

5521

0.9829

0690T

Quan us tis charac w/dx us

N

0X36T

0691T

Auto alys xst ct std vrt fx

E1

A

0X37T

0698T

Quan mr tiss w/mri mlt orgn

N

A

0X45T

0673T

Abltj b9 thyr ndul perq lasr

J1

5072

17.0957

A

0X47T

0702T

Rem ther mntr ol tech sprt

Q1

5741

0.4521

A

0X57T

0704T

Rem tx amblyopia setup&edu

E1

Software. Consulting. Education. Results.

2.7960

Payment Rate

$

236.14

$

83.01

$ 1,443.85 $

38.18

© 2021 Panacea Healthcare Solutions, Inc.

90

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

A

0X58T

0705T

Rem tx amblyopia tech sprt

E1

A

0X59T

0706T

Rem tx amblyopia i&r phy/qhp

E1

A

0X60T

0693T

Compre ful bdy 3d mtn alys

Q1

A

0X65T

0700T

Molec fluor img sus nev 1st

M

A

0X66T

0701T

Molec fluor img sus nev ea

M

A

0X68T

0708T

Id ca immntx prep & 1st njx

E1

A

0X69T

0709T

Id ca immntx each addl njx

E1

A

0X70T

0710T

N-invas artl plaq alys

M

Software. Consulting. Education. Results.

APC

5721

Relative Weight

1.6957

Payment Rate

$

143.21

© 2021 Panacea Healthcare Solutions, Inc.

91

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

APC

Relative Weight

5521

0.9829

$

83.01

$

38.18

A

0X71T

0711T

N-nvs artl plaq alys dat prp

A

0X72T

0712T

N-nvs artl plaq alys quan

S

A

0X73T

0713T

N-nvs artl plaq alys rvw i&r

M

A

0X74T

0694T

3d vol img&rcnstj brst/ax

N

A

0X75T

0695T

Bdy srf mpg pm/cvdfb tm impl

N

A

0X76T

0696T

Bdy surf mapg pm/cvdfb f/up

Q1

5741

0.4521

A

0X78T

0699T

Njx pst chmbr eye medication

J1

5491

25.2347

A

0X79T

0707T

Njx b1 sub mtrl sbchdrl dfct

T

5111

2.5039

Software. Consulting. Education. Results.

N

Payment Rate

$ 2,131.25 $

211.47

© 2021 Panacea Healthcare Solutions, Inc.

92

Proposed & Final Code Additions A / Proposed M / HCPCS D AMA Code Code

Short Descriptor

SI

A

0X81T

A

GXXAB

Skin syn sub graft trnk/arm/leg

B

A

GXXAC

Skin syn sub graft t/a/l add-on

B

A

GXXAD

Skin syn sub grft t/arm/lg child

B

A

GXXAE

Skn syn sub grft t/a/l child add

B

A

GXXAF

Skin syn sub graft face/nk/hf/g

B

A

GXXAG

Skin syn sub graft f/n/hf/g add

B

A

GXXAH

Skn syn sub grft f/n/hf/g child

B

A

GXXAI

Skn syn sub grft f/n/hf/g ch add

B

0703T

Software. Consulting. Education. Results.

Rem ther mntr ol mgmt svc

B

APC

Relative Weight

Payment Rate

© 2021 Panacea Healthcare Solutions, Inc.

93

Panacea’s CDM Review Services  Multiple levels of review • Desk • Intermediate

– including pharmacy – fee schedule price comparison

• Comprehensive – including pharmacy and supplies – fee schedule price comparison, hospital peer benchmark pricing analysis

 Optional add-ons

• Charge Capture audits • Professional fee services

Software. Consulting. Education. Results.

© 2021 Panacea Healthcare Solutions, Inc.

94

CDM Diagnostic Review • Process your chargemaster through our CDM Coding and Compliance tool • Flag potential areas where coding issues or opportunities may exist.

• Senior level consultants will analyze the output and summarize the results during a one-hour consultation • Recommend whether to proceed or not with a limited scope or more comprehensive review based on the results.

Audit Name

Audit Issue

Action Item(s)

Results

Invalid (obsolete) HCPCS

Assigned HCPCS code is invalid/obsolete.

Utilizing these within your billing system may cause non-reimbursed charges from Medicare, delayed claims processing, or other payer issues.

1) Check to see if charge is utilized.

2) Confirm the specific service/item is defined clearly by the description.

3) Update ancillary applications and/or forms.

4) Assess past claims submitted with invalid coding for decision on appropriate action.

12

CPT/HCPCS Code to Description Mismatch

Description in CDM does not match the description for the CPT/HCPCS code assigned.

1) Confirm if charge is being utilized.

2) Check with ancillary department to determine if another code is more appropriate based on what is being charged.

3) Assess past claims to ensure paid appropriately.

14

Missing HCPCS

Item or device needs to be reviewed to determine if eligible for HCPCS code assignment.

1) Confirm if charge is being utilized.

2) Review item/device in more detail to confirm if HCPCS code available for billing purposes.

Revenue Code to CPT/HCPCS mismatch

Revenue code assigned may be valid; however, to ensure appropriate processing for payment another revenue code may be needed.

1) Confirm if revenue code assigned is based on Medicare or other payer requirements.

2) Assess paid claims to ensure the item/service was paid accordingly.

OPPS SI E1 or E2 Code Assigned

Non-Covered for Medicare Outpatient claims under OPPS.

1) Check to see if charge is utilized.

2) Confirm other payer coding/claims restrictions for these codes.

3) Assess past claims submitted with E status code for decision on appropriate action.

62

OPPS SI Y Code Assigned

Codes signified as non-implantable Durable Medical Equipment (DME) to assist hospitals in identifying codes that they must bill directly to the Durable Medical Equipment Regional Carrier (DMERC) rather than to the Medicare MAC.

1) Check to see if charge is utilized.

2) Confirm that the item is utilized for home use or whether it is for hospital facility use.

3) Check other payers' policies for claims submission requirements for DME items.

4

Questionable Charge

Item or service appears to be considered nonchargeable (e.g., routine versus nonroutine).

1) Check to see if charge is utilized.

2) Confirm with staff how charge is being used.

3) Check other payer policies to determine if item or service may be separately reported on the claim.

1392

Totals

Software. Consulting. Education. Results.

© 2021 Panacea Healthcare Solutions, Inc.

1879

6

3,369

95

Join us for our next webinar IPPS Final Rule: Key Updates for FY2022 Wed. October 20 | 1:00 PM ET – 2:30 PM ET Presented by: Sandy Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer Senior Healthcare Consultant

Attendees at the live event are eligible to receive 1.5 AHIMA CEUs. Email invites will be sent to all attendees

Software. Consulting. Education. Results.

© 2021 Panacea Healthcare Solutions, Inc.

96

Q&A

© 2021 Panacea Healthcare Solutions, Inc.

Software. Consulting. Education. Results.

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