The Centers for Medicare & Medicaid Services (CMS) released the July 2020 update of the Ambulatory Surgical Center Payment System (ASC PS) last month. Providers and suppliers billing Medicare Administrative Contractors (MACs) for services subject to the ASC PS need to be aware of the changes to and billing instructions for various payment policies implemented in the July 2020 ASC PS update.
The recently released updates to the ASC PS are effective July 1, 2020, (except where noted). Make sure to review the Calendar Year (CY) 2020 payment rates for separately payable procedures/services, drugs, and biologicals, and familiarize yourself with descriptors for the newly created CPT® and HCPCS Level II codes.
New CPT® Category III Codes
CMS is implementing 11 CPT® Category III codes in the ASC PS. The updated payment rates, effective July 1, 2020, are available in the July 2020 update of ASC Addendum BB. These codes, along with their long descriptors and ASC payment indicators (PIs), are shown in the table below.
|CPT® Code||Long Descriptor||ASC PI|
|0594T||Osteotomy, humerus, with insertion of an externally controlled intramedullary lengthening device, including intraoperative imaging, initial and subsequent alignment assessments, computations of adjustment schedules, and management of the intramedullary lengthening device||J8|
|0596T||Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement||P2|
|0597T||Temporary female intraurethral valve-pump (ie, voiding prosthesis); replacement||P2|
|0598T||Noncontact real-time fluorescence wound imaging, for bacterial presence, location, and load, per session; first anatomic site (eg, lower extremity)||Z2|
|0600T||Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous||J8|
|0601T||Ablation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance, when performed, open||J8|
|0614T||Removal and replacement of substernal implantable defibrillator pulse generator||J8|
|0616T||Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens||J8|
|0617T||Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with removal of crystalline lens and insertion of intraocular lens||J8|
|0618T||Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with secondary intraocular lens placement or intraocular lens exchange||J8|
|0619T||Cystourethroscopy with transurethral anterior prostate commissurotomy and drug delivery, including transrectal ultrasound and fluoroscopy, when performed||J8|
Hemodialysis AVF Procedures: Replacement Codes for HCPCS Level II Codes C9754 and C9755
The July 2020 update introduces replacement codes for arteriovenous fistula (AVF) procedures. CMS is deleting HCPCS Level II codes C9754 and C9755 and replacing them with codes G2170 and G2171, respectively, effective July 1, 2020.
|HCPCS Code||Long Descriptor|
|C9754||Creation of arteriovenous fistula, percutaneous; direct, any site, including all imaging and radiologic supervision and interpretation, when performed and secondary procedures to|
redirect blood flow (e.g., transluminal balloon angioplasty, coil embolization, when performed)
|G2170||Percutaneous arteriovenous fistula creation (AVF), direct, any site, by tissue approximation using thermal resistance|
energy, and secondary procedures to redirect blood flow (e.g., transluminal balloon angioplasty, coil embolization) when performed, and includes all imaging and radiologic guidance, supervision and interpretation, when performed
|C9755||Creation of arteriovenous fistula, percutaneous using magnetic-guided arterial and venous catheters and radiofrequency energy, including flow-directing procedures (e.g., vascular coil|
embolization with radiologic supervision and interpretation, when performed) and fistulogram(s), angiography, venography,
and/or ultrasound, with radiologic supervision and interpretation, when performed
|G2171||Percutaneous arteriovenous fistula creation (AVF), direct, any site, using magnetic-guided arterial and venous catheters and radiofrequency energy, including flow-directing procedures (e.g., vascular coil embolization with radiologic supervision and interpretation, when performed) and fistulogram(s), angiography, enography, and/or ultrasound, with radiologic supervision and interpretation, when performed|
New HCPCS Level II Codes Describing Strain-Encoded Cardiac MRI
CMS is establishing two new codes to describe the technology associated with strain-encoded cardiac magnetic resonance imaging (MRI). HCPCS Level II codes C9762 and C9763 describe the strain imaging and stress imaging associated with strain-encoded cardiac MRI, effective July 1, 2020.
|HCPCS Code||Long Descriptor||ASC PI|
|C9762||Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging||Z2|
|C9763||Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging||Z2|
New Device Pass-Through Category
One new device pass-through category has been created: HCPCS Level II code C1748, effective July 1, 2020.
|Long Descriptor||ASC PI|
|C1748||Endoscope, single-use (i.e.disposable), upper gi, imaging/illumination device (insertable)||J7|
Device Offset From Payment Updates:
- Application of Offset for C1734 – CMS reversed their earlier decision regarding applying an offset to C1734. They have determined that the costs associated with C1734 are not already reflected in APCs 5115 or 5116. Therefore, they are not applying an offset to C1734. This decision also impacts ASCs and is retroactive to Jan. 1, 2020.
- Your MAC will reprocess the impacted ASC claims.
- Correction to the Device Offset Amount and Procedure Payment Rates for 0548T and 0549T – For CY 2020, the ASC device offset percentage for C9746 based on CY 2018 claims data was 69.20 percent. For CPT® codes 0548T and 0549T, a device offset percentage of 69.20 percent results in device offset amounts of $5,472.11 for CPT®code 0548T and $2,706.54 for CPT® code 0549T for CY 2020.
- The device offset amounts when a partial credit (FC modifier) applies to the device identified on the claim is $2736.06 for CPT® code 0548T and $1353.27 for CPT® code 0549T.
- This determination to apply the device offset percentage for C9746 to CPT® codes 0548T and 0549T is retroactive to Jan. 1, 2020.
- This determination also changes the ASC procedure payment rates for 0548T and 0549T.
HCPCS Level II Codes for Certain Drugs and Biologicals
There are 18 new HCPCS Level II codes, effective July 1, 2020, for reporting drugs and biologicals in the ASC setting.
|New HCPCS Code||Old HCPCS Code||2020 Long Descriptor||CY 2020 SI|
|C9059||Injection, meloxicam, 1 mg||K2|
|J9358||Injection, fam-trastuzumab deruxtecan-nxki, 1 mg||K2|
|J7204||Injection, factor VIII, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per IU||K2|
|J9177||Injection, enfortumab vedotin-ejfv, 0.25 mg||K2|
|J0742||Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg||K2|
|C9061||Injection, teprotumumab-trbw, 10 mg||K2|
|J1429||Injection, golodirsen, 10 mg||K2|
|C9063||Injection, eptinezumab-jjmr, 1 mg||K2|
|C9122||Mometasone furoate sinus implant, 10 micrograms (Sinuva)||K2|
|J0896||Injection, luspatercept-aamt, 0.25 mg||K2|
|J7169||C9041||Injection, coagulation factor xa (recombinant), inactivated-zhzo (andexxa), 10 mg||K2|
|J0791||C9053||Injection, crizanlizumab-tmca, 5 mg||K2|
|J0691||C9054||Injection, lefamulin, 1 mg||K2|
|J0223||C9056||Injection, givosiran, 0.5 mg||K2|
|J1201||C9057||Injection, cetirizine hydrochloride, 0.5 mg||K2|
|Q5120||C9058||Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg||K2|
|J1558||Injection, immune globulin (xembify), 100 mg||K2|
|J9246||Injection, melphalan (evomela), 1 mg|
Other Changes to CY 2020 Drugs and Biologicals
CPT® Code Changes
- The ASC PI for CPT®code 90694 Influenza virus vaccine, quadrivalent (aiiv4), inactivated, adjuvanted, preservative free, 0.5 ml dosage, for intramuscular use changes from ASCPI = “Y5” to ASCPI = “M6” effective July 1, 2020, as the vaccine described by CPT®code 90694 may be covered by Medicare, but is payable outside of the ASC payment system.
- Suppliers who think they may have received an incorrect payment for drugs and biologicals impacted by the corrections in CR11842 may request their MAC adjustment of previously processed claims.
HCPCS Level II Code Changes
- The ASC PI for HCPCS Level II code Q5116 Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg for the period of Feb. 23, 2020, through June 30, 2020, will be changed retroactively from ASCPI = Y5 to ASCPI = K2. Q5116 will continue to carry an ASCPI of K2 beginning July 1, 2020.
- The ASC PI for HCPCS Level II code Q5113 Injection, trastuzumab-pkb, biosimilar, (herzuma), 10 mg will be changed retroactively from ASCPI = Y5 to ASCPI = K2 for the period of March 16, 2020, through June 30, 2020. Q5113 will continue to carry an ASCPI of K2 beginning July 1, 2020.
- HCPCS Level II code Q5119 Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg will be separately payable in the ASC payment system beginning Feb. 3, 2020, and will have an ASCPI = K2. Q5119 will continue to carry an ASCPI of K2 beginning July 1, 2020.
- HCPCS Level II code C9058 Injection, pegfilgrastim-bmez, biosimilar, (Ziextenzo) 0.5 mg became effective and separately payable with an ASCPI = K2 effective April 1, 2020. It is now retroactively separately payable from Nov. 15, 2019, through March 31, 2020, with an ASCPI = K2. C9058 will continue to carry an ASCPI of K2 beginning July 1, 2020.
- CMS is adding HCPCS Level II code Q4206 Fluid flow or fluid GF, 1 cc retroactively to the ASC PI file, effective Oct. 1, 2019.
New Skin Substitute Products Low-Cost Group/High-Cost Group Assignment
The July 2020 update provides assignments to skin substitute products as either low-cost or high-cost, effective July 1, 2020. This assignment guides payment for skin substitute products that do not qualify for hospital OPPS pass-through status and are instead packaged into the OPPS payment for the associated skin substitute application procedure. This policy is also implemented in the ASC payment system.
|HCPCS Code||2020 Short Descriptor||CY 2020 SI||Low/High-Cost Skin Substitute|
|C1849||Skin substitute, synthetic||N1||High|
|Q4227||Amniocore per sq cm||N1||Low|
|Q4228||Bionextpatch, per sq cm||N1||Low|
|Q4229||Cogenex amnio memb per sq cm||N1||Low|
|Q4232||Corplex, per sq cm||N1||Low|
|Q4234||Xcellerate, per sq cm||N1||Low|
|Q4235||Amniorepair or altiply sq cm||N1||Low|
|Q4236||Carepatch per sq cm||N1||Low|
|Q4237||Cryo-cord, per sq cm||N1||Low|
|Q4238||Derm-maxx, per sq cm||N1||Low|
|Q4239||Amnio-maxx or lite per sq cm||N1||Low|
|Q4247||Amniotext patch, per sq cm||N1||Low|
|Q4248||Dermacyte Amn mem allo sq cm||N1||Low|
Skin substitute products are divided into two groups for packaging purposes:
- High-cost skin substitute products, which should only be utilized in combination with the performance of one of the skin application procedures described by CPT® codes 15271-15278.
- Low-cost skin substitute products, which should only be utilized in combination with the performance of one of the skin application procedures described by HCPCS Level II codes C5271-C5278.