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Retinal Physician - Coding Q&A

CPT® 2012 features two temporary codes that describe this emerging technology.

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Twice each year, the AMA issues Category III CPT codes, which the AMA defines as temporary codes for emerging technology, services, and procedures. (In addition, AMA issues mid-year Category I CPT codes for vaccines for which FDA approval is imminent, to ensure timely availability of a code.) The AMA establishes these codes to allow collection of data specific to the service described by the code, as these services could otherwise only be reported using a Category I CPT unlisted code. The AMA releases Category III CPT codes in January, for implementation beginning the following July, and in July, for implementation beginning the following January. Prior to CY 2006, we treated new Category III CPT codes implemented in July of the previous year or January of the OPPS update year in the same manner that new Category I CPT codes and new Level II HCPCS codes implemented in January of the OPPS update year are treated; that is, we provided APC and status indicator assignments or both in the final rule updating the OPPS for the following calendar year. New Category I and Category III CPT codes, as well as new Level II HCPCS codes, were flagged with Comment Indicator “NI” in Addendum B of the final rule to indicate that we were assigning them an interim payment status which was subject to public comment following publication of the final rule that implemented the annual OPPS update.

Boston Keratoprosthesis (KPro) - EyeWiki
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Section 303(h) of exempted radiopharmaceuticals from ASP pricing in the physician office setting where the fewer numbers (relative to the hospital outpatient setting) of radiopharmaceuticals are priced locally by Medicare contractors. Consequently, we do not have ASP data for radiopharmaceuticals. However, the law also requires us to make payments for specified covered outpatient drugs, including radiopharmaceuticals, equal to the average acquisition cost for the drug as determined by the Secretary and subject to any adjustment for overhead costs. We expect hospitals' different purchasing and preparation and handling practices for radiopharmaceuticals to be reflected in their charges. Therefore, for CY 2006, we calculated per day costs of radiopharmaceuticals using mean unit costs from the CY 2004 hospital claims data to determine the items' packaging status similar to the drugs and biologicals with no ASP data. For CY 2006, we implemented a 1-year temporary policy to pay for separately payable radiopharmaceuticals based on the hospital's charge for each radiopharmaceutical adjusted to cost. We clearly stated in our CY 2006 OPPS final rule with comment period that we did not intend to maintain the CY 2006 methodology permanently () and that we would actively seek other methodologies for setting payments for radiopharmaceuticals in CY 2007.

The Boston Keratoprosthesis (KPro) ..

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Twice each year, the AMA issues Category III CPT codes, which the AMA defines as temporary codes for emerging technology, services, and procedures. (In addition, the AMA issues mid-year Category I CPT codes for vaccines for which FDA approval is imminent, to ensure timely availability of a code.) The AMA establishes these codes to allow collection of data specific to the service described by the code, as these services could otherwise only be reported using a Category I CPT unlisted code. The AMA releases Category III CPT codes in January, for implementation beginning the following July, and in July, for implementation beginning the following January. Prior to CY 2006, we treated new Category III CPT codes implemented in July of the previous year or January of the OPPS update year in the same manner that new Category I CPT codes and new Level II HCPCS codes implemented in January of the OPPS update year are treated; that is, we provided APC or status indicator assignments or both in the final rule updating the OPPS for the following calendar year. New Category I and Category III CPT codes, as well as new Level II HCPCS codes, were flagged with comment indicator “NI” in Addendum B of the final rule to indicate that we assigned them an interim payment status which was subject to public comment following publication of the final rule that implemented the annual OPPS update.

CPT code 65770 is a surgical procedure for implantation of a keratoprosthesis, an artificial cornea. The keratoprosthesis device that is required for the implantation is described by HCPCS code C1818 (Integrated keratoprosthesis), a device category that received transitional pass-through payment under the OPPS from July 2003 through December 2005. When the device came off pass-through status for CY 2006 and its costs were packaged into the implantation procedure, CPT code 65770 continued to be assigned to APC 0244 (Corneal Transplant), with a payment rate of about $2,275, despite an increase in the median cost of the implantation procedure of about $1,200 associated with the packaging of the device. There is no 2 times violation in APC 0244 for CY 2006.

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C1818 - Integrated keratoprosthesis Code Information .
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As we indicated in the proposed rule (), we reviewed the presentations to the APC Panel; the APC Panel's recommendations; the CPT code descriptors, introductory explanations, cross-references, and parenthetical notes; the clinical characteristic of the procedures; and the code-specific median costs for all related CPT codes available from our CY 2005 claims data. While we agreed with the APC Panel that the codes currently placed in APC 0024 (Level I Skin Repair) should be assigned to an APC with a higher median cost for CY 2007, we disagreed that these procedures should be placed in APC 0027 (Level IV Skin Repair). The APC Panel presenters reasoned that some of the codes (CPT codes 15170, 15175, 15320, 15340, 15360, 15365, 15420, and 15430) for the first increment of body surface area treated should be placed in APC 0027 because they are similar to CPT code 15300 (Allograft skin for temporary wound closure, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children). Upon further review of the clinical and expected hospital resource characteristics of CPT code 15300, we asserted in the proposed rule that this procedure was not appropriately placed in APC 0027. Split-thickness and full thickness skin autograft procedures currently assigned to APC 0027 were likely to require greater hospital resources, including additional operating room time and special equipment, in comparison to application of a separately paid allograft skin product. Instead, for CY 2007 we proposed to reassign CPT code 15300 to APC 0025 (Level II Skin Repair), with an APC median cost of $314.58. We agreed, in principle, that other CPT codes for the first increment of body surface area treated with a skin replacement or skin substitute were similar clinically and from a hospital resource perspective to CPT code 15300 and, therefore, we proposed to assign these procedures to APC 0025 as well for CY 2007.

Because there was a new, more general HCPCS L-code (L8609) created for the artificial cornea in CY 2006 that may be used to report all keratoprostheses not already described by HCPCS code C1818, we are accepting the APC Panel's recommendation regarding the establishment of device edits for CPT code 65770. We will establish a device edit in CY 2007 for CPT code 65770 that requires reporting of an appropriate device HCPCS code to ensure that all claims for CPT code 65770 in CY 2007 and future years include charges for a required device. However, to the extent that devices with different costs are used to provide the keratoprosthesis procedure, unless the CPT code descriptor for the service is revised or more specific CPT codes are developed, our claims data will continue to reflect highly variable costs for the services that are provided using the full spectrum of keratoprosthesis devices.

Healthcare Common Procedure Coding System Code C1818 (0010),Integrated keratoprosthesis
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Similarly, presenters reasoned that the related add-on codes (CPTs 15171, 15176, 15321, 15342, 15361, 15366, 15421, and 15431) for procedures to treat additional body surface areas are similar to CPT code 15301 (Allograft skin for temporary wound closure, trunk, arms, legs; each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof) in terms of required hospital resources. CPT code 15301 is assigned to APC 0025 for CY 2006. We are proposing to maintain the assignment of CPT code 15301 to APC 0025 for CY 2007 and to reassign the other add-on codes to this APC. Note that APC 0025 has a status indicator of “T,” so that the add-on codes will experience the standard OPPS multiple surgical procedure reduction when properly billed with the first body surface area treatment codes that are assigned to the same clinical APC. We believe that this reduction in payment for the procedural resources associated with the add-on services is appropriate.

C1818 HCPCS Code | Integrated keratoprosthesis | Year: …

At the March 2006 meeting of the APC Panel, following a presentation regarding the procedure to implant a keratoprosthesis that described the clinical and hospital resource characteristics of CPT code 65770, the Panel recommended moving CPT code 65770 to a more appropriate APC in order to make appropriate payment. We agree with the recommendation of the APC Panel. Claims data from CY 2005 demonstrate that the median cost for implantation of a keratoprosthesis of $3,127.51 remains significantly higher than the median costs of other procedures assigned to APC 0244, although there is no 2 times violation. In addition, CPT code 65770 contributes less than 1 percent of the single claims in the APC available for ratesetting, and it is likely to continue to be an uncommon procedure among Medicare beneficiaries, resulting in its persistent small contribution to the median cost of APC 0244. Therefore, for CY 2007 we are proposing to create a new APC 0293 (Level V Anterior Segment Eye Procedures) with a median cost of $3,127.51 and to move CPT code 65770 into that APC in order to more appropriately pay for the procedure and the related device.

ASCRS | American Society of Cataract and Refractive Surgery

We reviewed the presentations to the APC Panel; the APC Panel's recommendations; the CPT code descriptors, introductory explanations, cross-references, and parenthetical notes; the clinical characteristic of the procedures; and the code-specific median costs for all related CPT codes available from our CY 2005 claims data. While we agree with the APC Panel that the codes currently placed in APC 0024 (Level I Skin Repair) should be assigned to an APC with a higher median cost for CY 2007, we disagree that these procedures should be placed in APC 0027 (Level IV Skin Repair). APC Panel presenters reasoned that some of the codes (CPTs 15170, 15175, 15320, 15340, 15360, 15365, 15420, and 15430) for the first increment of body surface area treated should be placed in APC 0027 because they are similar to CPT code 15300 (Allograft skin for temporary wound closure, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children). Upon further review of the clinical and expected hospital resource characteristics of CPT code 15300, we believe that this procedure is not appropriately placed in APC 0027. Split-thickness and full thickness skin autograft procedures currently assigned to APC 0027 are likely to require greater hospital resources, including additional operating room time and special equipment, in comparison to application of a separately paid allograft skin product. Instead, for CY 2007 we are proposing to reassign CPT code 15300 to APC 0025 (Level II Skin Repair), with an APC median cost of $314.58. We agree, in principle, that other CPT codes for the first increment of body surface area treated with a skin replacement or skin substitute are similar clinically and from a hospital resource perspective to CPT code 15300 and are, therefore, proposing to assign these procedures to APC 0025 as well for CY 2007.

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