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Outpatient Hospital Covered Services Updates Effective July 1, 2018
Critical care services (CPT 99291 and 99292), pharmaceuticals (HCPCS Q5103 and Q5104), and lactation classes (HCPCS S9443) will be covered in the outpatient hospital (OPH) setting. Vaccine administration services (CPT 90461, 90471 and 90472) and moderate sedation services (CPT 99152, 99153, and G0500) will be covered in the OPH and ambulatory surgical center (ASC) settings. We currently cover other vaccine administration services in the OPH setting but not the ASC setting, so to be consistent, ASC coverage will also be added to CPT/HCPCS 90460, 90473, 90474, G0008, G0009, and G0010.
Coverage of supervision of a hyperbaric oxygen session (CPT 99183) will be end-dated because it is a professional service rather than an outpatient facility service. In addition, prior authorization will be added to some procedure codes (CPT 27096, 59000, 59001) that are already covered in the OPH and ASC settings. Prior authorization will be added to CPT 27096 (injection into sacroiliac joint) and CPTs 59000 and 59001 (amniocentesis diagnostic and therapeutic services) as these procedures can only be safely performed under certain circumstances.
Since 1/1/2016, revenue center codes (RCCs) 25X and 636 have been restricted to all valid J-codes, select Q-codes, and vaccine toxoids in the OPH setting. These procedure code restrictions have prevented other provider-administered drugs (e.g., A-codes, C-codes, etc.) from being submitted with RCCs 25X and 636. Since RCCs 25X and 636 are pharmaceutical RCCs, the procedure code restrictions will be removed so that providers can bill for drugs with appropriate RCCs.
ODM covers trauma response services but the RCC that the procedure code should be submitted with is currently non-covered. Therefore inpatient (IPH) and outpatient hospital contracts will be added to RCCs 681, 682, and 683.
Type of Change
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ASC, IPH, or OPH Contract
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Procedure/Revenue Code/HCPCS Group
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Add Coverage
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OPH
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99152, 99153, G0500, 99291, 99292, 90461, 90471, 90472, S9443, Q5103, Q5104 (Q5103 & Q5104 will pay off the provider-administered pharmaceuticals fee schedule)
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Add Coverage
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ASC
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90460, 90461, 90471, 90472, 90473, 90474, 99152, 99153, G0500, G0008, G0009, G0010
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Remove Coverage
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OPH
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99183
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Add PA = Y
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OPH
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27096, 59000, 59001
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Add PA = Y
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ASC
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59000, 59001
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Remove CPT/HCPCS restriction
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OPH
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25X, 636
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Add coverage RCC
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IPH and OPH
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681, 682, 683
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