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Introduction:
The Centers for Medicare & Medicaid Services (CMS) has released a comprehensive update to the Hospital Outpatient Prospective Payment System (OPPS), effective April 2025, as outlined in Transmittal 13135. This update introduces significant changes to billing codes, payment policies, and coverage determinations, aiming to enhance the accuracy and efficiency of outpatient services billing.
Key Highlights from the April 2025 OPPS Update:
1. Introduction of New Proprietary Laboratory Analyses (PLA) Codes
- Effective April 1, 2025, CMS has added 21 new PLA codes (CPT codes 0531U through 0551U) to the Integrated Outpatient Code Editor (I/OCE).
- These codes, established by the AMA CPT Editorial Panel, are designed to capture emerging diagnostic technologies and specialized laboratory tests.
- Detailed descriptors and status indicators for these codes are available in the April 2025 OPPS Addendum B.
2. Status Indicator Revisions
Several existing codes have undergone status indicator changes to reflect updated payment policies:
- PLA Code 0464U: Status indicator changed from "E1" to "A," retroactive to October 3, 2024.
- CPT Code 83718: Status indicator changed from "Q4" to "A," effective April 1, 2025.
These adjustments aim to ensure appropriate reimbursement and align with current clinical practices.
3. Introduction of New HCPCS Codes
CMS has established several new HCPCS codes to describe innovative medical services and technologies:
- G0567: Screening DNA/RNA test for Hepatitis C Virus, effective June 27, 2024.
- G0183: Software reporting cardiac chamber volumes and left ventricular wall mass, effective April 1, 2025.
- C8004: Simulation angiogram for radioembolization of tumors, effective April 1, 2025.
- C8005: Transbronchial ablation of lung tumors using pulsed electric field energy, effective April 1, 2025.
- G0566: 3D image generation for surgical planning and navigation for the placement of implants and devices in the spine and pelvis, effective April 1, 2025.
These additions reflect CMS's commitment to incorporating cutting-edge medical advancements into the OPPS framework.
4. Deletion of Certain COVID-19 Monoclonal Antibody Therapy Codes
In response to the FDA's revocation of emergency use authorizations, CMS is deleting 19 HCPCS codes related to COVID-19 monoclonal antibody therapies and their administration.
- Notably, codes M0245, M0246, and Q0245 are deleted effective December 31, 2023.
- Codes M0220 through Q0247 are deleted effective December 31, 2024.
5. Updates to Device Pass-Through Payments
CMS has updated the long descriptor for HCPCS code C1739 to "Tissue marker, probe detectable any method (implantable), with delivery system," effective January 1, 2025. This change is part of the ongoing device pass-through payment process, ensuring appropriate reimbursement for new medical devices.
6. Revisions to Implantable Glucose Sensor System Codes
CMS is deleting G codes G0564 and G0565, which describe 365-day implantable glucose monitoring systems. These have been replaced by CPT codes 0446T and 0448T, revised to reflect the updated APC assignments, aligning with the previous G-code descriptors.
7. Adjustments to Drug and Biological Payment Rates
CMS has made several changes to the payment status indicators and descriptors for specific drugs and biologicals:
- HCPCS Code J9074: Status indicator restored to "E2" for services from July 1, 2024, through September 30, 2024.
- HCPCS Code J1171: Status indicator corrected to "N," effective January 1, 2025.
Additionally, payment rates for many drugs and biologicals have been updated based on the Average Sales Price (ASP), with adjustments incorporated into the April 2025 Fiscal Intermediary Shared System (FISS) release.
8. Skin Substitute Product Updates
CMS has introduced 14 new skin substitute HCPCS codes effective April 1, 2025. These products are categorized into high-cost and low-cost groups for payment packaging purposes. One existing skin substitute product code has been deleted as of March 31, 2024, and another has been reassigned from the low-cost to the high-cost group effective April 1, 2025.
Implications for Healthcare Providers:
These updates underscore CMS's commitment to adapting the OPPS to reflect current medical practices and technologies. Healthcare providers should review these changes carefully to ensure compliance with billing and coding requirements. Staying informed about such updates is crucial for accurate reimbursement and optimal patient care. For a comprehensive understanding of all changes, providers are encouraged to review the full transmittal document available on the CMS website.
Reference:
Transmittal 13135 (April 2025 Update of the Hospital Outpatient Prospective Payment System (OPPS)
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