April 2023 OPPS Update Comes with New Codes and a New Identity

The document will also be identified as CR 13136.

The April 2023 Outpatient Prospective Payment System (OPPS) Update has been released and is effective April 1, 2023, and implemented on April 3, 2023. This document is also identified as CR 13136.

There are new codes, reimbursement updates, and changes to status indicators found in this release. The following items should be noted:

1. New COVID-19 CPT Vaccine and Administration Codes
   • 91316 – Moderna COVID-19 vaccine, bivalent booster for ages six months through five years.
   • 0164A – Administration of CPT 9131691317 – Pfizer-BioNTech COVID-19 vaccine, bivalent booster for ages six months through four years.
   • 0173A – Administration of CPT 91317
2. With the shutdown of the public health emergency (PHE) which is May 11, treatments for COVID-19 will be paid under a Comprehensive Ambulatory Payment Classification (C-APC) for an outpatient claim.
3. There are twenty-three (23) new proprietary laboratory analyses (PLA) codes beginning 0364U through 0386U effective April 1, 2023. See Addendum B for short descriptors and status indicators.
4. Three new devices have been added to pass-through status:
   • C1747 – endoscope, single use, urinary tract has an offset of $507.69.
   • C1826 – generator, neurostimulator (implantable) includes closed feedback loop leads with rechargeable battery. Its offset is $24,024.04.
   • C1827 – generator, neurostimulator (implantable), non-rechargeable lead and external paired stimulator controller. The offset is also $24,024.04.
5. A single code had its pass-through status expired effective Jan. 1, 2023. The code is C1823 (generator, neurostimulator (implantable) non-rechargeable, with transvenous sensing and stimulation leads).
6. One (1) code was removed from device pass-through status. C1834 (pressure sensor system, includes all components (e.g., introducer, sensor), intramuscular (implantable), excludes mobile (wireless) software application) was approved in error in the October 2022 release. This code was removed effective March 31, 2023.
7. New Drugs, Biologicals, and Radiopharmaceuticals
   • There are twelve (12) new drugs, biologicals, and radiopharmaceuticals effective April 1, 2023. See Table 5 in CR13136 for details.
   • Two (2) drugs, biologicals, and radiopharmaceuticals had a status indicator change effective April 1^st. See Table 6 for details.
8. One (1) item, J1411 (injection, etranacogene dezaparvovec-drib, per therapeutic dose) will require manual adjudication. Payment will be based on average sales price (ASP). The payment for APC 9138 will initially be $0.00 to prompt for the manual adjudication.

Change Request 13136 contains a huge amount of information – especially for chargemaster coordinators and claim auditors. This document should be at the top of your reading list this week.

Programming note: Listen to Laurie Johnson’s live Coding Report every Tuesday on Talk Ten Tuesdays, 10 Eastern, with Chuck Buck and Dr. Erica Remer.

Resources:

CR13136:  MM13136 – Hospital Outpatient Prospective Payment System: April 2023 Update (cms.gov)