Health Information Management

Tip: Following CMS’ payment rate updates

APCs Insider, September 5, 2014

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For the last several years, CMS has updated the payment rates for separately payable drugs based on the average sales price (ASP). As new information becomes available, the ASP may rise or fall, and CMS adjusts the payment rate accordingly with each new quarter’s OPPS files. The new information is included in the quarterly OPPS Pricer files that are loaded into the claims processing system.
One example is HCPCS code J0129 (abatacept injection, 10 mg). This code is assigned status indicator K (nonpass-through drugs and nonimplantable biologicals, including therapeutic radiopharmaceuticals) and receives separate payment for CY 2014. In the January Addendum B, the national unadjusted price for each 10 mg unit was $23.43. Because of changes in the average sales price data, for July 2014 the payment rate per 10 mg is $32.21.
CMS has also updated pricing for some drugs and biologicals from previous quarters. The payment rate for J2788 (Rho d immune globulin, 50 mcg) has been updated for the time period October 1 through December 31, 2013. The payment rate for J0775 (injection, collagenase, clostridium histolyticum, 0.01 mg) has been updated for the time period January 1 through March 31, 2014. CMS instructs contractors to adjust claims brought to their attention.
More information can be found in Transmittal 2971. Addendum B includes a column that contains an asterisk to indicate a change has been made to a specific line item.
This tip is adapted from “This month's coding Q&A” in the September issue of Briefings on APCs.

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