Medicare rates cover hospital outpatient services. OPPS covers hospital outpatient X-rays, emergency department visits, and partial hospitalization. Medicare rates determine ASC payment.
The ASC Payment System pays for covered surgical procedures and ASC facility services. CMS updates OPPS/ASC regulations annually in one rule, with comment periods before implementation. The ACS is interested in CMS; OPPS and ASC Payment System and quality improvement efforts because hospital outpatient departments and ASCs provide much surgical care.
New device pass-through categories are in effect
In accordance with Section 1833(t)(6)(B) of the Social Security Act (the Act), categories of devices must be eligible for transitional pass-through payments under the Outpatient
Prospective Payment System (OPPS) for at least two but no more than three years. Section 1833(t)(6)(B)(ii)(IV) of the Act mandates that CMS establish additional transitional pass- through payment categories for new medical devices that are not described by existing or formerly existing device categories.
For the January 2023 update, CMS approved 3 new OPPS pass-through devices and created new device categories in the ASC payment system. In 2023, HCPCS codes C1747, C1826, and C1827. HCPCS, code descriptors, and ASC Payment Indicators are in CR 13041. (PI).
New Device Offset from the HCPCS 2023 Codes
The Act requires us to deduct the device portion of the ambulatory payment classification (APC)
payment from OPPS pass-through device payments. The device offset is the APC amount that covers pass-through device costs. Offsets are linked to the costs of the new device categories described by the HCPCS codes in CR 13041. Always use one of the CPT codes when billing ASC devices in these categories. The ASC code pair file for January 2023 contains devices, procedures, and offset percentages.
2023 ASC Procedures
26 new ASC procedures are separately payable. CR 13041 has CPT codes, descriptors, and
ASC PIs. In 2023 ASC Addenda AA and BB contain code payment rates.
Complexity-adjusted comprehensive ambulatory payment classifications ASC
Special Payment Policy for Complexity-Adjusted C–APCs The ASC special payment policy for
OPPS complexity-adjusted C–APCs was finalized as part of the CY 2023 OPPS/ASC final rule.
CMS assigned new HCPCS 2023 codes to primary surgical procedures and packaged add-on
code combinations eligible for complexity adjustments under the OPPS and performed in the
ASC to adjust the payment rate for complexity. CMS billing these new C-codes to give ASCs a
complexity adjustment for these code pairs due to claims processing system limitations. CR
13041 has been updated to reflect the addition of new HCPCS codes, descriptors, and ASC
PIs. These C-codes are now included in the procedures that are covered by the ASC.
CR 13041 lists the new C-code HCPCS code combinations. You must now bill the new C-code
to which the assigned primary procedure and secondary add-on procedure HCPCS codes, and
codes are paired when performing them together during an encounter. (ASC PI=N1).
A supplemental crosswalk table to the CY 2023 OPPS/ASC final rule includes descriptors and
PIs for these code pairs.
Drugs, biologics, and radiopharmaceuticals
New HCPCS Drug and Biological Codes in 2023,
In 2023, CMS added 15 new HCPCS codes for drugs and biological products. These HCPCS
codes, descriptors, and ASC PIs are all contained within CR 13041.
b. Drug HCPCS Codes Deleted on 12/31/202
CMS eliminated two HCPCS codes for separately payable drugs on December 31, 2022. These
are the HCPCS codes C9142 and J9044. CR 13041 has a long descriptor and ASC PI.
HCPCS Code Q5124 Is To Be Paid Independently October 1, 2022,
In the Drug file that was submitted to the ASC in October 2022, there was an error that caused
an ASC PI=K5 value to be assigned to the HCPCS code Q5124 (Injection, ranibizumab-nuna,
biosimilar, (byooviz), 0.1 mg). CMS discovered this error and corrected it (Items, codes, and
services for which pricing information and claims data is unavailable). The correct ASC PI for
this code was K2 as of October 1, 2022.
Starting on the 1st of October 2022. If your service claim was denied by CMS between October
1 and December 31 of 2022, your Part B MAC will have the ability to reprocess this code. CR
13041 lists HCPCS code, ASC PI, and effective date.
Drugs and biologics with payments Average Sales Price (ASP)
CMS pay ASP + 6% for non-pass-through drugs and biologicals in CY 2023. This covers drug
acquisition and pharmacy overhead. As ASP submissions arrive, we’ll update drug and
biological payments quarterly. In January 2023, ASC Addendum BB updated payment rates.
ASP-Based Drugs and Biologicals with Restated Payment Rates
ASP-based drugs and biologicals may be retroactively corrected. Retroactive corrections occur
quarterly. The Restated Drug and Biological Payment Rates list will be available on the first day
of the quarter.
You can ask your MAC to adjust claims for drugs and biologicals affected by these corrections if
you think you received an incorrect payment.
‘JZ’ Modifier Available January 1, 2023
Modifier JZ will be voluntary provider use on January 1, 2023, when no drug is discarded from a
single dose or single-use packaging. ASCs must report the JZ modifier for all applicable drugs
without discarded drug amounts by July 1, 2023. CR 13041 shows modifiers and descriptors.
Skin substitutes
Skin substitute products that don’t qualify for hospital OPPS pass-through status are included in
the skin substitute application procedure’s OPPS payment. ASC payment system follows this
policy. Two groups of skin substitutes are shown:
- Use expensive skin substitute products with one of CPT codes 15271-15278’s skin
application procedures. - Use low-cost skin substitute products for packaging with one of HCPCS code C5271-
C5278’s skin application procedures.
New skin substitute HCPCS codes are placed in the low-cost skin substitute group unless
OPPS pricing data indicates that the product costs more than $47 per unit or $837 per day for
CY 2023. In this case, the new code would be placed in the high-cost skin substitute group.
New Skin Substitute Products in 2023
Since January 1, 2023, there are four new skin substitute HCPCS codes. HCPCS codes
Q4236–Q4264. Packaged codes are assigned to low-cost skin substitutes. New packaged
codes are in CR 13041.
ASCs shouldn’t bill separately for packaged skin substitutes (ASC PI=N1). ASCs cannot
independently bill a physician-reportable (PI=Y1) packed code when the physician is present.
2022 HCPCS Code C1849 deletion (Skin substitute, synthetic, resorbable, per square centimeter).
HCPCS code C1849 (Skin substitute, synthetic, resorbable, per square centimeter) was deleted
on December 31, 2022. CR 13041 has HCPCS code C1849.
CY 2023 Skin Substitute Assignments to High and Low-Cost Groups
Skin substitute products and their high-cost or low-cost assignment, when applicable.
CY2023 ASC PI changes from non-payable to payable HCPCS codes
On January 1, 2023, ASC PIs for 18 HCPCS codes in CR 13041 become payable. These CR
13041 codes are unique.
Coverages
A drug, device, procedure, or service’s HCPCS code and ASC payment rate don’t indicate
Medicare coverage, but rather how the product, procedure, or service may be paid if covered.
MACs determine program coverage for drugs, devices, procedures, and services. MACs decide
if treating the patient’s condition is reasonable and necessary.
Who is Medcare MSO?
Medcare MSO is an industry-leading ASC billing service provider with over 11 years of experience in providing ambulatory surgery centers with in-depth and comprehensive billing services.
Author Bio
Isaac is a highly accomplished healthcare professional with over 13 years of experience in health-care administration, medical billing and coding, and compliance. He holds several AAPC specialty certifications and has a bachelor’s degree in Health Administration. He worked previously at a large multi-physician family care and occupational health practice with two locations in northwestern PA and now works for Medcare in the ICD-10 Editorial department to write articles about medical coding. He enjoys sharing his knowledge and experience as a certified PMCC instructor. She has authored many articles for healthcare publications and has been a featured speaker at workshops and coding conferences across the country.
References:
References: Ssa, ordp. (n.d.). Payment of benefits. Act §1833. From
https://www.ssa.gov/OP_Home/ssact/title18/1833.htm
References: Ambulatory Surgical Center Services Payment Basics Payment System. (n.d.).
Retrieved from https://www.medpac.gov/wp-
content/uploads/2021/11/medpac_payment_basics_21_asc_final_sec.pdf
References: ASC code pairs. CMS. (n.d.). Retrieved from
https://www.cms.gov/medicare/ambulatory-surgical-center-asc-payment/asc-code-pairs
References: HCPCS. 2023 HCPCS ‘J’ Codes. (n.d.). Retrieved from
https://www.hcpcsdata.com/Codes/J
References: License for use of current procedural terminology, Fourth edition ("Cpt®"). CMS.
(n.d.). Retrieved from https://www.cms.gov/license/ama?file=%2Ffiles%2Fzip%2Fcy-2023-final-
asc-code-pair-crosswalk-table.zip
References: Restated drug and biological payment rates. CMS. (n.d.). Retrieved from
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/OPPS-Restated-Payment-Rates
References: HCPCS code – skin substitutes and biologicals Q4100-q4264 – codify by AAPC.
Skin Substitutes and Biologicals Q4100-Q4264 – HCPCS Codes – Codify by AAPC. (n.d.).
Retrieved from https://www.aapc.com/codes/hcpcs-codes-range/369/
References: HCPCS deleted code for skin substitute, synthetic, resorbable, per square
centimeter c1849. Skin substitute, synthetic, resorbable, per square centimeter – C1849-HCPCS
Codes – Codify by AAPC. (n.d.). Retrieved from
https://www.aapc.com/codes/hcpcs_code/deleted_hcpcs_code/C1849
