Health Information Management

CMS adds new radiopharmaceutical, modifier

JustCoding News: Outpatient, November 30, 2011

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CMS reclassified HCPCS code C9406 (iodine I-123 ioflupane, diagnostic, per study dose, up to 5 millicuries) as a radiopharmaceutical as part of the October updates to the Integrated Outpatient Code Editor (I/OCE). The change is retroactively effective to July 1.

The change is significant for two reasons, says Dave Fee, MBA, product marketing manager of outpatient products at 3M Health Information Systems in Murray, UT. First, if a hospital receives the radiopharmaceutical at no charge, it must append modifier -FB (item provided without cost to provider, supplier or practitioner, or credit received for replacement device [Examples, but not limited to: covered under warranty, replaced due to defect, free samples]) to the procedure code.

Second, C9406 now satisfies edit 78 (claim lacks required radiopharmaceutical). When coders report a nuclear medicine procedure, they must also report the radiopharmaceutical. Because C9406 is now classified as a radiopharmaceutical, claims that pair it with a nuclear medicine procedure will not trigger the edit.

Modifier -92
CMS also added modifier -92 (alternative laboratory platform testing) to the list of valid modifiers in October, though the modifier is retroactive to January 1, 2008.

When laboratory testing for HIV is performed using a kit or transportable instrument that wholly or in part consists of a single-use, disposable analytical chamber, coders can now identify the service by adding modifier -92 to the usual laboratory procedure code.

This modifier will indicate point-of-service testing for HIV and applies only to these three laboratory procedure codes:

  • 86701 (antibody; HIV-1)
  • 86702 (antibody; HIV-2)
  • 86703 (antibody; HIV-1 and HIV-2, single assay)


The test does not require permanent dedicated space, so providers may transport the kit or disposable instrument to the patient for immediate testing. Note, however, that the location of the testing alone does not determine whether coders should append this modifier.

New device offset
Effective October 1, HCPCS code C1840 (telescopic ¬intraocular lens) will be subject to the device offset. When a facility receives a replacement device at no or reduced cost, CMS subtracts a device "offset percentage" from the payment for the HCPCS procedure code for implanting the device.
Fee notes that C1840 satisfies the requirement related to the offset, but is not included in the device-to-procedure edits, meaning it is not subject to edits 71 (claim lacks required device code) and 77 (claim lacks allowed procedure code).

ICD-9-CM code changes
In conjunction with the release of the new ICD-9-CM codes for 2012, CMS added 168 new diagnosis codes to the I/OCE and deleted 33 codes that are no longer valid. The changes are effective ¬October 1. For a complete list of the new codes, view Transmittal 2277.
CMS also added the following codes to the list of ¬maternity diagnoses for patients 12–55 years old:

  • 631.0, inappropriate change in quantitative human chorionic gonadotropin (hCG) in early pregnancy
  • 631.8, other abnormal product of conception
  • 649.81, onset (spontaneous) of labor after 37 completed weeks of gestation but before 39 completed weeks gestation, with delivery by (planned) cesarean section, delivered, with or without mention of antepartum condition
  • 649.82, onset (spontaneous) of labor after 37 completed weeks of gestation but before 39 completed weeks gestation, with delivery by (planned) cesarean section, delivered, with mention of postpartum complication
  • V23.42, pregnancy with history of ectopic pregnancy
  • V23.87, pregnancy with inconclusive fetal viability

CMS also added the new maternity codes to the female-only list, along with the following other diagnosis codes:

  • 516.4, lymphangioleiomyomatosis (LAM)
  • 629.31, erosion of implanted vaginal mesh and other prosthetic material to surrounding organ or tissue
  • 629.32, exposure of implanted vaginal mesh and ¬other prosthetic materials into vagina 
  • V12.21, personal history of gestational diabetes

In addition, CMS added two codes to the list of adult-only ¬diagnoses, age 15–124 years old:

  • 379.27, vitreomacular adhesion
  • 516.5, adult pulmonary Langerhans cell histiocytosis

These four new codes now appear on the list of mental health diagnoses:

  • 294.20, dementia, unspecified, without behavioral disturbances
  • 294.21, dementia, unspecified, with behavioral disturbances
  • 310.81, pseudobulbar affect (PBA)
  • 310.89, other specified nonpsychotic mental disorders following organic brain damage

HCPCS code changes
CPT code 64561 (percutaneous implantation of neuro¬stimulator electrodes; sacral nerve [transforaminal placement]) is now conditionally bilateral, meaning that use of modifier -50 (bilateral procedure) is appropriate, Fee says.
CMS also added three new HCPCS codes to the I/OCE ¬effective October 1:

  • C1830, power bone marrow biopsy needle
  • C1840, telescopic intraocular lens
  • C9286, injection, belatacept

All three codes are subject to edit 55 (non-¬reportable for site of service). HCPCS codes beginning with the letter C are only valid for bill types 12x, 13x, and 14x.

HCPCS code 92015 (refraction) is now subject to edit 50 (noncovered based on statutory exclusion). Code J0638 (Canakinumab injection) now has status indicator G (pass-through drugs and biologicals).
CMS removed two procedures from the female-only list, effective October 1:

  • 46715, repair of low imperforate anus; with anoperineal fistula (cut-back procedure)
  • 46716, repair of low imperforate anus; with transposition of anoperineal or anovestibular fistula

APC changes


CMS added three new APCs, effective October 1:

  • 01830, power bone marrow biopsy needle
  • 01840, telescopic intraocular lens
  • 09286, injection, belatacept

APC 01311 now has a status indicator of G. Previously it had a status indicator of K (non-pass-through drugs and biologicals).

Payment adjustment values
CMS added two new payment adjustment values for preventive services, 9 and 10, as part of the August update to the I/OCE. Although CMS did not change the payment adjustments in October, "it's really important for people to understand how to use these payment adjustments for preventative care," Fee says.

The coinsurance is waived for some preventive services, while both the coinsurance and deductible are waived for others. Currently, no CPT codes fall into payment adjustment 10 for situations when only coinsurance is waived.

The I/OCE includes a very specific list of which codes have the coinsurance and deductible waived and which have only the deductible or co-insurance waived. CMS added the administration of the hepatitis B vaccine to the list of services with coinsurance and deductible waived.

Rural sole community hospitals will lose the 7.1% payment rate adjustment for bill type 14X, which is used to report nonpatient laboratory specimens. These are specimens that are sent to a reference laboratory for testing and with whom the laboratory has no actual patient contact.

The pricer doesn't know which bill type is being submitted, Fee says, so it will look for claims that exclusively contain codes in the laboratory range (codes 80000–89999). "If that's all that's on the claim, CMS will not apply the adjustment," Fee says.

Editor’s note: This article was originally published in the November issue of Briefings on APCs. E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at

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