October 2026 OPPS Quarterly Update

39 New PLA Codes, 58 Category III Codes and 29 New Drug Codes

Rcmaxis Billing & Policy Update  ·  Posted October 7, 2026  ·  Effective: October 01, 2026 (implementation October 05, 2026)

Summary of the Rule or Edit Change

CMS issued MLN Matters article MM14589 (Change Request 14589, Transmittal R13978CP) on September 29, 2026 for the October 2026 update of the Hospital Outpatient Prospective Payment System. Changes are effective October 1, 2026, and contractors implement them October 5, 2026. The update affects hospitals, physicians and other providers that bill Medicare Administrative Contractors for outpatient hospital services.

On the coding side, the AMA created 39 new proprietary laboratory analysis (PLA) codes, 0660U through 0698U, and CMS is implementing 58 new Category III codes, 1054T through 1111T. Category III code 1091T replaces HCPCS code C8010 for a carotid filter study, and C8010 is deleted. New HCPCS code G0685 describes an algorithm-based assessment of the likelihood of autism spectrum disorder from eye-gaze data. CPT code 1011T, a photobiomodulation therapy during radiation treatment, moves from status indicator E1 (not payable) to separately payable now that the device has FDA approval.

The drug section is the longest. CMS created 6 new pass-through drug codes, ended pass-through status for 9 drug codes on September 30, created 29 new drug, biological and radiopharmaceutical codes, deleted 10 on September 30 and changed status indicators on 21. Payment for most drugs continues at average sales price plus 6%, with rates updated from the new ASP data on October 1. A biosimilar payment rate for HCPCS Q5161 was corrected back to July 1, and MACs will adjust affected claims within 30 days of implementation. For skin substitutes, CMS created new HCPCS codes assigned status indicator S1 or N, and revised several descriptors retroactive to April 1 to add the phrase "add-on, list separately in addition to primary procedure."

Two billing instructions deserve attention. The Claims Processing Manual now defines modifier CA as a procedure payable only in the inpatient setting when performed emergently on an outpatient who dies before admission or transfer. CMS also clarified trauma team activation billing in a new section 160.2. Finally, Stimuplex needles now qualify for temporary additional payment as a non-opioid treatment for pain relief, effective April 30, 2026.

Action Required for Billing Teams