“October 2006 Update of the Hospital Outpatient Prospective Payment System (OPPS): Summary of Payment Policy Changes”

Change Request (CR) #5304 originally stated the following about Current Procedural Terminology (CPT) code 90736:

e. Payment Rate for CPT 90736, Zoster (Shingles) Vaccine, Live, for Subcutaneous Injection, Becomes Effective on Its Date of FDA Approval

Currently, CPT code 90736 is not payable under OPPS and is assigned to status indicator “E.” The product described by this code was approved by the Food and Drug Administration (FDA) on May 25, 2006. Therefore, in the October 2006 OCE update, the status indicator for CPT 90736 will be changed from “E” to “K” to become payable under OPPS effective May 25, 2006.

CPT 90736 will map to APC 0745. The payment rate for APC 0745 can be found in the October 2006 update of OPPS Addendum A and Addendum B, which will posted on the Centers for Medicare & Medicaid Services (CMS) Web site at the end of September.

Update: CMS has determined that CPT code 90736 is not covered and should be “rejected” if billed on any claim whether it is for an OPPS or a non-OPPS hospital.

If CPT code 90736 is submitted on a claim, it will be rejected with either reason code 76132 (provider liability) or 76133 (beneficiary liability based on the presence of an Occurrence Code 32).

Following is the narrative for reason codes 76132 and 76133 :

CMS CR5304 included misinformation on CPT code 90736. Originally, CMS was going to assign CPT code 90736 to an APC in the OPPS OCE. CMS has revisited this and has decided that this service should be rejected and not allowed. Per CMS, this rejection is for all bill types.

Pub. 100-4, Transmittal# R1060CP, CR# 5304

Posted: 11/27/2006

CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.