(Medicare Claims Processing Manual)

61.4.5 - Payment for New Brachytherapy Sources (Rev. 2718, Issued: 06- 07-13, Effective: 07 -01-13, Implementation: 07- 01-13)  Not otherwise specified (NOS) brachytherapy source codes are available for payment of new brachytherapy sources for which source codes have not yet been established: C2698 (Brachytherapy source, stranded, not otherwise specified, per source), and C2699 (Brachytherapy source, non- stranded, not otherwise specified, per source).  The payment rates for these NOS codes are based on a rate equal to the lowest stranded or non -stranded payment rate for such sources, respectively, on a per source basis (as opposed, for example, to per mCi).  Once CMS establishes a new HCPCS code for a new source, the new code will be assigned to its own APC, with the payment rate set based on consideration of external data and other relevant information, until claims data are availab le for the standard OPPS rate making methodology.  61.5 - Billing for Intracoronary Stent Placement  (Rev. 2611, Issued: 12- 14-12, Effective: 01 -01-13, Implementation, 01- 07-13)  Since CY 2003, under the OPPS, we assign coronary stent placement procedures to separate APCs based on the use of nondrug- eluting or drug- eluting stents (APC 0104 (Transcatheter Placement of Intracoronary Stents) or APC 0656 (Transcatheter Placement of Int racoronary Drug- Eluting Stents), respectively).  In order to effectuate this policy, we created HCPCS G -codes G0290 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method;  single vessel) and G0291 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel) for drug -eluting intracoronary stent placement procedures that pa rallel existing CPT codes 92980 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and 92981 (Transcatheter placement of an intracoronary stent(s), percutaneous, w ith or without other therapeutic intervention, any method; each additional vessel), which are used to describe nondrug- eluting intracoronary stent placement procedures. For CY 2012 and years prior, CPT codes 92980 and 92981 have been assigned to APC 0104, while HCPCS codes G0290 and G0291 have been assigned to APC 0656.  Effective January 1, 2013, the AMAs CPT Editorial Panel is deleting CPT codes 92980 and 92981 and replacing them with the following new CPT codes:    CPT code 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)    CPT code 92929 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));    CPT code 92933 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch);    CPT code 92934 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));    CPT code 92937 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed;  single vessel);    CPT code 92938 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performe d; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));    CPT code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);    CPT code 92943 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty;  single vessel); and    CPT code 92944 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty;   each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).   In order to maintain the existing policy of differentiating payment for intracoronary stent placement procedures involving nondrug- eluting and drug- eluting stents, we are deleting HCPCS codes G0290 and G0291 and replacing them with the following new HCPCS C -codes to parallel the new CPT codes:    HCPCS code C9600 (Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch);    HCPCS code C9601 (Percutaneous transcatheter placement of drug- eluting intracoronary stent(s), with coronary angioplasty when performed;  each additional branch of a major coronary artery (List separately in addition to code for primary procedure));    HCPCS code C9602 (Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch);    HCPCS code C9603 (Percutaneous transluminal coronary atherectomy, with drug- eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) );   HCPCS code C9604 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug- eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);    HCPCS code C9605 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug- eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed;  each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));    HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);    HCPCS code C9607 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty; single ves sel); and    HCPCS code C9608 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty;  each addi tional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).   CPT codes 92928, 92933, 92929, 92934, 92937, 92938, 92941, 92943, and 92944 should be used to describe nondrug- eluting intracoronary stent placement procedures and are assigned to APC 0104.  HCPCS codes C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, and C9608 are assigned to APC 0656.  70 - Transitional Corridor Payments  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) established transitional payments to limit providers losses under the OPPS; the additional payments are for 3 1/2 years for community mental health centers (CMHCs) and most hospitals, and permanent for cancer hospitals effective August 1, 2000.  Section 405 of BIPA provides that childrens hospitals described in 1886(d)(1)(B)(iii) are held harmless permanently for purposes of calculating TOP amounts, retroactive to August 1, 2000.  Some rural hospitals are also held harmless for several years after the implementation of the OPPS, as discussed in detail below.  Contractors determine  TOPs eligibility and calculate interim TOPs.   Beginning September 1, 2000, and every month thereafter until further notice, the shared system maintainers must provide contractors with software that gathers all data required to calculate a TOP amount for each hospital and CMHC.  The software must calcu late and pay the TOP amount for OPPS services on claims processed during the preceding month, maintain an audit trail (including the ability to generate a hardcopy report) of these TOP amounts, and transfer to the PS&R system any necessary data.  TOP amounts should be paid before the next month begins and they are not subject to normal payment floor requirements.  Several items contained in the Inpatient or Outpatient Provider Specific File (IPSF or OPSF) are needed to determine TOP eligibility for each hospital or CMHC.  They are:    The provider number;    Fiscal year begin date;    The provider type;    Actual geographic location -  CBSA  (from the IPSF);    Wage index location -  CBSA  (from the IPSF); and    Bed size (from the IPSF)   Pursuant to 403 of BIPA, a TOP may be made to hospitals and CMHCs that did not file a cost report for the cost reporting period ending in calendar year 1996.  The law was amended to provide that if a hospital did not file a cost report for a cost reporting period ending in calendar year 1996, the payment -to-cost ratio used in calculating a TOP will be based on the hospitals first cost report for a period ending after calendar year 1996 and before calendar year 2001.  This provision is effective retroactively to August 1, 2000.  Future updates will be issued in a Recurring Update Notification.   70.1 - Transitional Outpatient Payments (TOPs) for CY 2000 and CY 2001  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Monthly TOPs calculations that contractors are required to calculate are described below.  This calculation is effective for services provided between August 1, 2000, and December 31, 2001.   Step 1 -  Compute the pre -BBA amount for each month by first multiplying the total charges for covered services for all OPPS services on claims paid during the month and reduce the total charges to cost by multiplying them by the outpatient cost to charge r atio and then multiplying this amount by the provider -specific payment -to-cost ratio (PSPCR).   Step 2 -  Add together the total Medicare program payments, unreduced coinsurance and deductible applied for all APCs, as well as all outlier payments and transitional pass-through payments for drugs, biologicals and/or devices for those same claims paid during the month as those used in Step 1.  If the result is greater than the result of step 1, go to step 9.  No transitional payment is due this month.