New HCPCS Codes for Drugs and Biologicals Separately Payable under the ASC Payment System Effective October 1, 2010
b. Supplemental Information for HCPCS Code C9273

CMS has opened a national coverage determination analysis (NCD) for HCPCS code C9273, Provenge (Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF in 250mL of Lactated Ringer’s, including leukapheresis and all other preparatory procedures, per infusion). A final decision on coverage is forthcoming in 2011. As with other drugs and biologicals, at this time, local contractors will retain the discretion to make individual claim determinations for Provenge based on the medical necessity of the service(s) being provided.

Additionally, we clarify that the language given in the long descriptor of Provenge states that “all other preparatory procedures” refers to the transportation process of collecting immune cells from a patient during a non-therapeutic leukapheresis procedure, subsequently sending the immune cells to the manufacturing facility, and then transporting the immune cells back to the site of service to be administered to the patient.

c. Updated Payment Rate for HCPCS Code 90476 Effective April 1, 2010 through June 30, 2010

The payment rate for one HCPCS code was incorrect in the April 2010 ASC DRUG file. The corrected payment rate is listed in Table 2 below and has been included in the revised April 2010 ASC DRUG file effective for services furnished on April 1, 2010 through implementation of the July 2010 update. Suppliers who think they may have received an incorrect payment between April 1, 2010 and June 30, 2010 may request contractor adjustment of the previously processed claims.

Table 2-Updated Payment Rates for Certain HCPCS Codes Effective April 1, 2010 through
June 30, 2010

HCPCS Code             Short Descriptor                      ASC Payment Rate   ASC PI
90476                         Adenovirus vaccine, type 4      $72.17                       K2