Pass-through Devices

This page contains the process and information required to apply for transitional pass-through payment status for drugs and biologicals, or for assignment and payment for new pass-through device categories.

Background

Status is determined on an individual basis. Some examples would be:

  • Certain new drugs and biologicals
  • Biosimilar drugs
  • Newly approved devices

When status is granted, CMS designates HCPCS to use for billing. This allows payment for pass-through products for 2-3 years.

Once this period expires, they will either be removed from the list, or assigned a permanent HCPCS code, at which time it may be considered under the Facility payment for the procedure.

Per CMS Change Request CR 5680, pass-through device pricing is based on acquisition cost or invoice

Deduction

Under the Outpatient Prospective Payment System (OPPS), there is a deduction from the Ambulatory Payment Classification (APC) payment from new device pass-through payments.

In the update for Ambulatory Surgical Center ASC Payment System CR 12129, CMS added HCPCS codes J0390, J0745, J5260, 0583T, and Q5118 to the list of New Pass-Through Devices

Payment Indicators

Ambulatory Surgical Centers (ASCs) payment indicators are assigned to all procedures. This information can be located on CMS ASC Payment Rates - Addenda Next click on the correct quarters ASC Approved HCPCS Code and Payment Rates. Addenda DD1 and DD2 has the definition and comments about the payment indicators.

ASC Fee Schedule

  • Review Fee Schedule for your state and core based statistical areas (CBSA) for your county.
  • Download file from Fee Schedule page
  • Look for your code and see if a fee is listed for your procedure.
  • If the fee isn’t listed in the PROC IND column or has a $0 amount, then you will need to submit invoice information.

CMS-1500 Claim Form

When required invoice information is required to be listed in Box 19/ loop 2400, segment NTE02, using the following format: Include the name of the device, number of units, and the total cost.

In certain situations, contractors must reduce the payment for certain procedures in conjunction with a specific pass-through device. This reduction is only applicable for certain code combinations provided on the same day, by the same provider.

CMS will inform contractors of impacted code pairs quarterly:

CMS Pass-Through Payment Status and New Technology Ambulatory Payment Classification

Place of Service for ASC claims will be 24.

Resources

 

Last Updated Wed, 20 Apr 2022 13:58:28 +0000