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I. Background
A. Authority for the Outpatient Prospective Payment System
When the Medicare statute was originally enacted, Medicare payment for hospital outpatient services was based on hospital-specific costs. In an effort to ensure that Medicare and its beneficiaries pay appropriately for services and to encourage more efficient delivery of care, the Congress mandated replacement of the cost-based payment methodology with a prospective payment system (PPS). The Balanced Budget Act of 1997 (BBA) (Pub. L. 105–33), enacted on August 5, 1997, added section 1833(t) to the Social Security Act (the Act) authorizing implementation of a PPS for hospital outpatient services. The Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106–113), enacted on November 29, 1999, made major changes that affected the hospital outpatient PPS (OPPS). The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106–554), enacted on December 21, 2000, made further changes in the OPPS. The OPPS was first implemented for services furnished on or after August 1, 2000.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (DIMA) (Pub. L. 108–173), enacted on December 8, 2003, made additional changes to the Act relating to the OPPS and calendar year 2004 payment rates to be implemented January 1, 2004.
We would ordinarily publish a notice of proposed rulemaking in the
Federal Register
and invite public comment on the proposed rule. This procedure can be waived, however, if an agency finds good cause that a notice-and-comment procedure is impracticable, unnecessary, or contrary to the public interest and incorporates a statement of the finding and its reasons in the rule issued. We find good cause to waive notice and comment procedures for this correction notice as set forth in section IV, “Waiver of Proposed Rulemaking and Waiver of 30-Day Delay in the Effective Date,” below.
B. Summary of Relevant Provisions of the DIMA
The DIMA, enacted December 8, 2003, made the following changes to the Act that relate to the OPPS:
1. Transitional Corridor Payments Extended
Section 411 of the DIMA amends section 1833(t)(7)(D)(i) of the Act and extends the hold-harmless provision for small rural hospitals. The hold harmless
transitional corridor payments will continue through December 31, 2005 for small rural hospitals having 100 or fewer beds. Section 411 of the DIMA further amends section 1833(t)(7) of the Act to provide that hold-harmless transitional corridor payments shall apply to sole community hospitals as defined in section 1886(d)(5)(D)(iii) of the Act and will continue through December 31, 2005.
2. Payment for “Specified Covered Outpatient Drugs”
Section 621(a)(1) of the DIMA amends the Act by adding section 1833(t)(14) that requires classification of separately paid radiopharmaceutical agents and drugs or biologicals that had transitional pass-through status on or before December 31, 2002, into 3 categories: innovator multiple source drugs; noninnovator multiple source drugs; and sole source drugs. Payment levels based on the reference average wholesale price are specified for each category.
3. Payment for Drug or Biological Before HCPCS Code Assigned
Section 621(a)(1) of the DIMA amends the Act by adding section 1833(t)(15), which requires that payment be made at 95 percent of the average wholesale price (AWP) for new drugs and biologicals until a HCPCS code is assigned.
4. Payment for Pass-Through Drugs
Section 303(b) of the DIMA amends section 1842(o) of the Act. As a result, certain pass-through drugs are to be paid at 95 percent, and others at 85 percent, of the AWP. Drugs and biologicals furnished during 2004 for which pass-through payment was first made on or after January 1, 2003 (which removes them from application of section 621 of the DIMA) and were approved by the FDA for marketing as of April 1, 2003, will be paid 85 percent of AWP pursuant to section 1842(o)(1)(B) and 1842(o)(4)(A), unless sections 1842(o)(4)(B), (C) or (D) apply. Blood clotting factors furnished during 2004, drugs or biologicals furnished during 2004 that were not available for payment as of April 1, 2003, vaccines furnished on or after January 1, 2004, and drugs or biologicals furnished during 2004 in connection with the renal dialysis services if billed by renal dialysis facilities, are paid at 95 percent of the reference AWP. Drugs or biologicals that were paid on a pass-through basis under the OPPS on or after January 1, 2003 and that were available for payment as of April 1, 2003 are paid at 85 percent of the reference AWP rather than 95 percent as was previously the policy under section 1842(o) of the Act.
5. Exclude Separately Payable Drugs and Biologicals From Outlier Payments
Section 621(a)(3) amends section 1833(t)(5) of the Act to require that separately paid drugs and biologicals be excluded from outlier payments.
6. Brachytherapy Sources Are To Be Paid Separately
Section 621(b) amends the Act by adding section 1833(t)(16)(C) which requires that all devices of brachytherapy consisting of a seed or seeds (or radioactive source) be paid based on the hospital's charge for each device adjusted to cost. Also included in the new provision is a requirement that all such brachytherapy sources be excluded from outlier payments.
Payment Methodology That Applied Prior To Enactment
In the hospital outpatient prospective payment update final rule published in the
Federal Register
on November 7, 2003, CMS announced payments for 2004 under the Medicare hospital outpatient prospective payment system (68 FR 63398). The provisions of that final rule with regard to payment for brachytherapy sources, for separately payable drugs, biologicals and radiopharmaceutical agents and for pass-through drugs and biologicals is superceded in part with enactment of the DIMA, effective for services furnished on or after January 1, 2004. This interim final rule with comment presents the payment amounts that apply in 2004 that result from the changes made by DIMA.
The following is a summarization of the payment policies that we published for the 2004 OPPS before enactment of the new law.
Drugs and biologicals that were within the 2–3 year pass-through payment period were paid amounts as specified in section 1842(o) of the Act. Under the November 7 final rule, that payment was 95 percent of AWP.
Under the provisions of the November 7 OPPS final rule, payment for non-pass-through drugs, biologicals and radiopharmaceutical agents with per day median costs greater than $50 was based on data compiled from hospital claims submitted on or after April 1, 2002 through December 31, 2002. Those data were used to set median costs which were converted to relative weights, scaled for budget neutrality, and multiplied by the 2004 conversion factor, the same methodology used to set relative weights for procedural ambulatory payment classifications (APCs) under the OPPS. A detailed discussion of the rate setting methodology for the 2004 OPPS update is provided in the November 7, 2003 final rule (68 FR 63416).
Payment for drugs, biologicals and radiopharmaceutical agents that had per day median costs less than $50 and drugs, biologicals and radiopharmaceutical agents for which there was no HCPCS code, was included in the rate for the service in which the item was used. There were no separate payments for these drugs, biologicals and radiopharmaceutical agents.
Changes Required Under the DIMA
a. Changes in Payment for “specified covered outpatient drugs”: radiopharmaceutical agents and drugs or biologicals that were paid as pass-throughs under the OPPS on or before December 31, 2002.
The DIMA amends the Act by adding section 1833(t)(14) which states that payment for specified covered outpatient drugs is to be based on its “reference average wholesale price,” that is, the average wholesale price for the drug as determined under section 1842(o) of the Act as of May 1, 2003 (1833(t)(14)(G)).
Under new section 1833(t)(14)(B)(i) a “specified covered outpatient drug” is a covered outpatient drug as defined in 1927(k)(2) of the Act, for which a separate ambulatory payment classification group (APC) exists and that is a radiopharmaceutical agent or a drug or biological for which payment was made on a pass-through basis on or before December 31, 2002.
Under section 1833(t)(14)(B)(ii) of the Act, certain drugs and biologicals are designated as exceptions, which are not included in the definition of “specified covered outpatient drugs.” These exceptions are the following:
• A drug or biological for which payment is first made on or after January 1, 2003 under the transitional pass-through payment provision in section 1833(t)(6) of the Act.
• A drug or biological for which a temporary HCPCS code has not been assigned.
• During 2004 and 2005, an orphan drug (as designated by the Secretary).
Section 1833(t)(14)(A)(i) specifies payment limits for 3 categories of “specified covered outpatient drugs” in 2004. Section 1833(t)(14)(F) defines the 3 categories of “specified covered outpatient drugs” based on sections 1861(t)(1) and 1927(k)(7)(A)(ii), (iii) and (iv) of the Act. The categories of drugs are “sole source drugs”, “innovator multiple source drugs” and “noninnovator multiple source drugs.”
b. Definitions and payment rates for DIMA-specified categories for drugs, biologicals, and radiopharmaceutical agents.
Section 1927(k) of the Act pertains to the Medicaid drug rebate program. In order to administer the Medicaid drug rebate program, CMS gathers information from manufacturers and classifies drugs into categories that are defined in sections 1927(k)(7)(A)(ii), (iii) and (iv) of the Act. We are using these category designations to guide our classification of covered OPPS drugs in order to implement the changes in payment under the OPPS that are required by DIMA in section 1833(t)(14) of the Act. The classifications are listed in the Medicaid average manufacturer price (AMP) database, which can be found at
http://www.cms.gov/medicaid/drugs/drug6.asp.
In cases when the AMP database does not provide a classification for an affected drug or biological, we relied on our clinical and pharmaceutical experts to determine the appropriate classification. Further, when there are conflicting or incomplete designations in the AMP, we assigned drugs to the noninnovator multiple-source category for payment effective January 1, 2004, until we can resolve the conflicts and make a definitive classification. Classification changes will be implemented April 1, 2004 effective for services furnished on or after January 1, 2004. We invite comments regarding the appropriate classification of the drugs listed in Table 2.
The Medicaid AMP database is updated on a quarterly basis. However, we believe that midyear changes in the classification of drugs could be confusing and burdensome for providers to administer. Therefore, the final category designations used to determine 2004 OPPS drug payments for the “specified covered outpatient drugs” to which section 1833(t)(14)(A)(i) of the Act applies, will remain in effect through December 31, 2004. We will update the category designations through rulemaking as part of the annual OPPS update for 2005.
The sole source category is defined in section 1833(t)(14)(F)(i) of the Act as a biological product (as defined under section 1861(t)(1) of the Act) or a single source drug (as defined in section 1927(k)(7)(A)(iv)) of the Act). Section 1927(k)(7)(A)(iv) of the Act defines the term “single source drug” to mean a covered outpatient drug which is produced or distributed under an original new drug application (NDA) approved by the Food and Drug Administration (FDA), including a drug product marketed by any cross-licensed producers or distributors operating under the NDA. Based on this definition, in effect, single source drugs are brand name drugs for which there is no FDA generic approval, and the term is used interchangeably with “sole source drug” in this preamble.
Section 621(a) of the DIMA, amends the Act by adding section 1833(t)(14)(A)(i)(I), which provides that a sole source drug shall, in 2004, be paid no less than 88 percent and no more than 95 percent of the reference AWP.
Innovator multiple source drugs are defined in section 1833(t)(14)(F)(ii) of the Act according to the definition provided in section 1927(k)(7)(A)(ii) of the Act. Section 1927(k)(7)(A)(ii) of the Act defines an innovator multiple source drug as a multiple source drug that was originally marketed under an original NDA approved by the FDA. Under this definition, these drugs were originally sole source drugs for which FDA subsequently approved a generic alternative(s). An innovator multiple source drug first must be a sole source drug.
Section 621(a) of the DIMA, amends the Act by adding section 1833(t)(14)(A)(i)(II), which provides that an innovator multiple source drug shall, in 2004, be paid no more than 68 percent of the reference AWP.
Section 1833(t)(14)(F)(III) defines a noninnovator multiple source drug according to the definition of the term in 1927(k)(7)(A)(iii). Section 1927(k)(7)(A)(iii) defines noninnovator multiple source drug as a multiple source drug that is not an innovator multiple source drug. Under this definition, noninnovator multiple source drugs are, in effect, generic drugs approved by the FDA.
Section 621(a) of the DIMA, amends the Act by adding section 1833(t)(14)(A)(i)(III), which provides that a noninnovator multiple source drug shall, in 2004, be paid no more than 46 percent of the reference AWP.
There are several drugs that are classified in the AMP database as qualifying for all three categories. A drug that meets the criteria for all 3 categories has FDA approval as an innovator drug. A generic version of the drug, the noninnovator, also has received FDA approval. In addition, there is an FDA approval for a different indication for use under a different NDA for which the drug is the sole source. When a single drug, biological or radiopharmaceutical agent that meets the definition of a single HCPCS code qualifies for all of the 3 categories in the AMP file, we are recognizing the product only as an innovator multiple source and noninnovator multiple source drug. That is, once a drug qualifies as a multiple source drug, we will not recognize it as a sole source drug for payment under the OPPS. We believe that it would be impossible to operationalize a system in which the same drug would be paid differently according to the clinical indication for its use. Medicare makes payment for a drug or biological that is reasonable and necessary to treat an illness or disease. Medicare does not base payment for drugs and biologicals according to their indicated uses, except when required by a national coverage decision. Further, to do so would circumvent the payment limitation that the law requires for drugs, biologicals and radiopharmaceutical agents that have generic competition by allowing payment for a drug that has generic competition at the sole source rate (88 to 95 percent of AWP) rather than at the limit for innovator multiple source (68 percent of AWP) or noninnovator multiple source (46 percent of AWP) drugs.
c. Definition of “reference AWP” and determination of payment amounts.
Section 1833(t)(14)(G) of the Act defines reference AWP as the AWP determined under section 1842(o) as of May 1, 2003. We interpret this to mean the AWP set under the CMS single drug pricer (SDP) based on prices published in the Red Book on May 1, 2003.
We determined the payment amount for specified covered outpatient drugs under the provisions of the DIMA by comparing the payment amount calculated under the median cost methodology in effect prior to enactment of the DIMA to the percentages specified in new section 1833(t)(14)(A) of the Act.
Specifically, for sole source drugs, we compared the payments established in the November 7, 2003 final rule for the HCPCS code for the drug to its reference AWP. When the payment fell below 88 percent of the reference AWP, we increased the payment to 88 percent of the reference AWP. When the payment exceeded 95 percent of the reference AWP, we reduced the payment to 95 percent of the reference AWP. When the payment was no lower than 88 percent and no higher than 95 percent of reference AWP, we made no change. To receive payment for sole source drugs on or after January 1, 2004, hospitals should continue to bill the appropriate HCPCS code for the drug. Table 1 lists the payment amounts for sole source drugs, biologicals and radiopharmaceutical agents effective January 1, 2004 through December 31, 2004.
There are a few drugs for which we cannot find an AWP rate. We are working to resolve this on a case-by-case basis for each of the drugs. The drugs are: Technetium TC 99M Sodium Glucoheptonate (C1200), Cobalt Co 57 cobaltous chloride (C9013), I–131 tositumomab, diagnostic (C1080) and I–131 tositumomab, therapeutic (C1081).
With regard to C1080 and C1081, there is no AWP available because this drug did not receive FDA approval until June, 2003 and so could not be in the May 1, 2003 Red Book (AWP) that we have identified as the source of the reference AWP. We presented an in-depth discussion of our policy for payment of this drug, Bexxar, in our November 7 final rule. In that rule we explain our rationale for making payment for Bexxar parallel to that for another radiopharmaceutical called Zevalin. In order to set the payment rate for Bexxar in accordance with DIMA, we also have adhered to the policy regarding the pricing of Bexxar established in the November 7 final rule.
For the remaining drugs for which we could not identify a May 1, 2003 AWP amount, we will continue our research to find an AWP. If we are able to identify the AWP established on dates other than May 1, 2003, we will use whichever is closest to May 2003. In the interim, we will implement the payment rates published in the November 7 final rule to make payments for these drugs for January 1, 2004 through March 31, 2004. We will address our findings regarding development of payment rates for these drugs in our April update.
APC 9024 is made up of 3 sole source drugs: Amphotericin B lipid complex (J0287); Amphotericin B cholesteryl sulfate (J0288); and Amphotericin B liposome injection (J0289). To comply with the statute, these 3 drugs must all be paid separately under the OPPS and that will require that we create an APC for each of the drugs. Due to the limited time available to implement the changes required for January 1, 2004, we will not be able to implement the new APCs until April 1, 2004. We will continue to pay for these drugs in APC 9024 at the rate published in the November 7 final rule. The new APCs will be implemented April 1, 2004 and will be effective for services furnished on or after January 1, 2004.
Table 1.—Sole Source Drugs
HCPCS
Status indicator
Description
APC
OPPS CY 2004 November 7, 2003 rate
DIMA final rate
A4642
K
Satumomab pendetide per dose
0704
$124.46
$1,474.00
A9500
K
Technetium TC 99m sestamibi
1600
64.28
112.73
A9502
K
Technetium TC99M tetrofosmin
0705
58.06
665.28
A9507
K
Indium/111 capromab pendetid
1604
687.71
2,030.60
A9511
K
Technetium TC 99m depreotide
1095
37.87
704.00
A9521
K
Technetiumtc-99m exametazine
1096
210.65
825.00
A9524
K
Iodinated I–131 serumalbumin, per 5uci
9100
0.36
48.58
A9600
K
Strontium-89 chloride
0701
402.85
892.43
C1079
K
CO 57/58 per 0.5 uCi
1079
68.51
235.14
C1080
K
I–131 tositumomab, dx
1080
2,260.00
2,565.55
C1081
K
I–131 tositumomab, tx
1081
19,565.00
22,210.19
C1082
K
In-111 ibritumomab tiuxetan
9118
2,260.00
2,565.55
C1083
K
Yttrium 90 ibritumomab tiuxetan
9117
19,565.00
22,210.19
C1092
K
IN 111 pentetate per 0.5 mCi
1092
217.45
237.60
C1122
K
Tc 99M ARCITUMOMAB PER VIAL
1122
534.77
1,144.00
C1166
K
CYTARABINE LIPOSOMAL, 10 mg
1166
278.99
344.08
C1167
K
EPIRUBICIN HCL, 2 mg
1167
20.43
25.60
C1178
K
BUSULFAN IV, 6 Mg
1178
299.70
27.87
C1200
K
TC 99M Sodium Glucoheptonat
1200
30.28
30.28
C1201
K
TC 99M SUCCIMER, PER Vial
1201
80.24
125.66
C1305
K
Apligraf
1305
822.19
1,199.00
C9003
K
Palivizumab, per 50 mg
9003
344.15
611.24
C9008
K
Baclofen Refill Kit-500mcg
9008
6.90
73.92
C9009
K
Baclofen Refill Kit-2000mcg
9009
40.92
40.92
C9010
K
Baclofen Refill Kit—4000mcg
9010
42.22
79.82
C9109
K
Tirofiban hcl, 6.25 mg
9109
118.60
218.33
C9202
K
Octafluoropropane
9202
118.60
137.28
J0130
K
Abciximab injection
1605
289.44
475.22
J0207
K
Amifostine
7000
289.40
419.59
J0287
K
Amphotericin b lipid complex
9024
20.86
20.86
J0288
K
Ampho b cholesteryl sulfate
9024
20.86
20.86
J0289
K
Amphotericin b liposome inj
9024
20.86
20.86
J0350
K
Injection anistreplase 30 u
1606
1,516.46
2,495.31
J0585
K
Botulinum toxin a per unit
0902
3.21
4.58
J0587
K
Botulinum toxin type B
9018
6.98
8.14
J0637
K
Caspofungin acetate
9019
29.64
30.52
J0850
K
Cytomegalovirus imm IV /vial
0903
291.18
659.60
J1327
K
Eptifibatide injection
1607
7.99
11.88
J1438
K
Etanercept injection
1608
102.37
143.73
J1440
K
Filgrastim 300 mcg injection
0728
123.48
172.20
J1441
K
Filgrastim 480 mcg injection
7049
175.96
290.93
J1565
K
RSV-ivig
0906
48.61
16.55
J1626
K
Granisetron HCl injection
0764
5.70
17.18
J1830
K
Interferon beta-1b / .25 MG
0910
100.51
67.22
J1950
K
Leuprolide acetate /3.75 MG
0800
182.92
479.20
J2020
K
Linezolid injection
9001
15.12
34.09
J2353
K
Octreotide injection, depot
1207
65.74
73.62
J2354
K
Octreotide inj, non-depot
7031
1.44
3.94
J2788
K
Rho d immune globulin 50 mcg
9023
1.69
32.21
J2790
K
Rho d immune globulin inj
0884
10.16
92.93
J2792
K
Rho(D) immune globulin h, sd
1609
9.76
19.03
J2820
K
Sargramostim injection
0731
16.32
26.92
J2941
K
Somatropin injection
7034
41.18
297.79
J2993
K
Reteplase injection
9005
568.33
1,263.90
J3100
K
Tenecteplase injection
9002
1,296.75
2,492.60
J3245
K
Tirofiban hydrochloride
7041
227.85
436.66
J3305
K
Inj trimetrexate glucoronate
7045
61.36
132.00
J3395
K
Verteporfin injection
1203
897.20
1,350.80
J7191
K
Factor VIII (porcine)
0926
1.52
1.89
J7195
K
Factor IX recombinant
0932
1.01
1.04
J7320
K
Hylan G–F 20 injection
1611
123.46
215.97
J7504
K
Lymphocyte immune globulin
0890
127.89
258.17
J7505
K
Monoclonal antibodies
7038
320.84
792.33
J7507
K
Tacrolimus oral per 1 MG
0891
1.34
3.24
J7511
K
Antithymocyte globuln rabbit
9104
163.56
331.23
J7520
K
Sirolimus, oral
9020
2.89
6.60
J7525
K
Tacrolimus injection
9006
5.72
110.04
J8510
K
Oral busulfan
7015
1.57
1.93
J8520
K
Capecitabine, oral, 150 mg
7042
1.65
3.14
J8700
K
Temozolmide
1086
3.76
6.81
J9001
K
Doxorubicin hcl liposome inj
7046
256.34
364.49
J9010
K
Alemtuzumab injection
9110
424.88
541.46
J9017
K
Arsenic trioxide
9012
26.91
34.32
J9020
K
Asparaginase injection
0814
16.13
58.00
J9045
K
Carboplatin injection
0811
86.47
137.79
J9098
K
Cytarabine liposome
1166
278.99
344.08
J9151
K
Daunorubicin citrate liposom
0821
163.55
64.60
J9170
K
Docetaxel
0823
220.97
331.53
J9178
K
Inj, epirubicin hcl, 2 mg
1167
20.43
25.60
J9185
K
Fludarabine phosphate inj
0842
205.74
329.83
J9201
K
Gemcitabine HCl
0828
80.43
112.09
J9202
K
Goserelin acetate implant
0810
285.16
413.59
J9206
K
Irinotecan injection
0830
100.55
135.00
J9213
K
Interferon alfa-2a inj
0834
20.61
32.31
J9214
K
Interferon alfa-2b inj
0836
10.93
13.78
J9215
K
Interferon alfa-n3 inj
0865
79.65
8.17
J9216
K
Interferon gamma 1-b inj
0838
180.15
290.70
J9217
K
Leuprolide acetate suspnsion
9217
312.37
576.47
J9219
K
Leuprolide acetate implant
7051
3,666.71
5,001.92
J9245
K
Inj melphalan hydrochl 50 MG
0840
254.90
389.14
J9268
K
Pentostatin injection
0844
965.98
1,784.64
J9270
K
Plicamycin (mithramycin) inj
0860
15.42
86.89
J9293
K
Mitoxantrone hydrochl / 5 MG
0864
173.68
332.87
J9310
K
Rituximab cancer treatment
0849
306.40
464.20
J9320
K
Streptozocin injection
0850
65.19
131.05
J9350
K
Topotecan
0852
433.41
739.80
J9355
K
Trastuzumab
1613
40.56
53.85
J9357
K
Valrubicin, 200 mg
1614
461.78
487.87
J9390
K
Vinorelbine tartrate/10 mg
0855
64.79
100.97
J9600
K
Porfimer sodium
0856
1,594.30
2,411.82
Q0136
K
Non esrd epoetin alpha inj
0733
9.83
11.76
Q0137
K
Darbepoetin alfa, non esrd
0734
3.24
3.88
Q0166
K
Granisetron HCl 1 mg oral
0765
34.49
171.78
Q0180
K
Dolasetron mesylate oral
0763
41.00
152.38
Q0187
K
Factor viia recombinant
1409
1,083.93
1,495.30
Q2003
K
Aprotinin, 10,000 kiu
7019
1.17
13.26
Q2005
K
Corticorelin ovine triflutat
7024
224.91
375.00
Q2006
K
Digoxin immune fab (ovine)
7025
271.14
1.79
Q2007
K
Ethanolamine oleate 100 mg
7026
27.82
67.10
Q2008
K
Fomepizole, 15 mg
7027
7.23
10.65
Q2009
K
Fosphenytoin, 50 mg
7028
4.88
5.63
Q2011
K
Hemin, per 1 mg
7030
0.64
6.86
Q2013
K
Pentastarch 10% solution
7040
26.40
139.94
Q2017
K
Teniposide, 50 mg
7035
137.41
238.49
Q2018
K
Urofollitropin, 75 iu
7037
63.48
63.48
Q3000
K
Rubidium-Rb-82
9025
143.89
162.63
Q3003
K
Technetium tc99m bicisate
1620
183.69
392.93
Q3005
K
Technetium tc99m mertiatide
1622
20.63
1,650.00
Q3008
K
Indium 111-in pentetreotide
1625
449.84
1,144.00
Q4052
K
Octreotide injection, depot
1207
65.74
73.62
Table 2.—Multisource Drugs
HCPCS
Status indicator
Description
APC
OPPS CY 2004 November 7, 2003 rate
DIMA final rate
A9505
K
Thallous chloride TL 201/mci
1603
$19.89
$18.29
A9508
K
Iobenguane sulfate I–131, per 0.5 mCi
1045
165.82
165.82
A9517
K
Th I131 so iodide cap millic
1064
5.48
5.48
A9528
K
Dx I131 so iodide cap millic
1064
5.48
5.48
A9529
K
Dx I131 so iodide sol millic
1065
6.49
6.49
A9530
K
Th I131 so iodide sol millic
1065
6.49
6.49
A9605
K
Samarium sm153 lexidronamm
0702
874.44
493.89
C1091
K
IN111 oxyquinoline, per0.5mCi
1091
224.52
224.52
C1775
K
FDG, per dose (4–40 mCi/ml)
1775
324.48
324.48
C9013
K
Co 57 cobaltous chloride
9013
56.67
56.67
C9105
K
Hep B imm glob, per 1 ml
9105
71.33
65.58
J1190
K
Dexrazoxane HCl injection
0726
112.48
112.48
J1563
K
Immune globulin, 1 g
0905
43.96
37.95
J1564
K
Immune globulin 10 mg
9021
0.44
0.41
J1745
K
Infliximab injection
7043
38.86
31.81
J1825
K
Interferon beta-1a
0909
184.79
123.77
J2430
K
Pamidronate disodium /30 MG
0730
174.32
128.74
J7190
K
Factor viii
0925
0.51
0.42
J7192
K
Factor viii recombinant
0927
1.01
0.61
J7193
K
Factor IX non-recombinant
0931
0.51
0.51
J7194
K
Factor ix complex
0928
0.51
0.18
J7198
K
Anti-inhibitor
0929
1.01
0.69
J7310
K
Ganciclovir long act implant
0913
86.54
86.54
J7317
K
Sodium hyaluronate injection
7316
138.78
67.16
J7502
K
Cyclosporine oral 100 mg
0888
2.56
2.41
J7517
K
Mycophenolate mofetil oral
9015
2.04
1.36
J8560
K
Etoposide oral 50 MG
0802
27.37
21.91
J9000
K
Doxorubic hcl 10 MG vl chemo
0847
6.61
4.69
J9031
K
Bcg live intravesical vac
0809
103.75
77.54
J9040
K
Bleomycin sulfate injection
0857
160.56
88.32
J9060
K
Cisplatin 10 MG injection
0813
21.74
7.73
J9065
K
Inj cladribine per 1 MG
0858
37.82
24.84
J9070
K
Cyclophosphamide 100 MG inj
0815
4.74
2.77
J9093
K
Cyclophosphamide lyophilized
0816
4.50
2.36
J9100
K
Cytarabine hcl 100 MG inj
0817
5.07
1.55
J9130
K
Dacarbazine 100 mg inj
0819
5.31
5.31
J9150
K
Daunorubicin
0820
73.97
35.94
J9181
K
Etoposide 10 MG inj
0824
4.56
0.83
J9200
K
Floxuridine injection
0827
114.19
66.24
J9208
K
Ifosfomide injection
0831
106.04
72.81
J9209
K
Mesna injection
0732
28.43
17.66
J9211
K
Idarubicin hcl injection
0832
178.21
178.21
J9218
K
Leuprolide acetate injection
0861
43.60
14.48
J9265
K
Paclitaxel injection
0863
112.14
79.04
J9280
K
Mitomycin 5 MG inj
0862
53.03
30.91
J9340
K
Thiotepa injection
0851
59.93
45.31
Q2022
K
VonWillebrandFactr CmplxperIU
1618
1.01
0.46
Q3002
K
Gallium ga 67
1619
11.22
11.22
Q3007
K
Sodium phosphate p32
1624
70.61
66.44
Q3011
K
Chromic phosphate p32
1628
98.52
81.27
Q3012
K
Cyanocobalamin cobalt co57
1089
57.07
47.38
Q3025
K
IM inj interferon beta 1-a
9022
61.60
13.36
Coding for Specified Outpatient Drugs
In order to implement these provisions timely on January 1, 2004, we are instructing hospitals to use the existing HCPCS code that describes the drug for services furnished on or after January 1, 2004. For sole source drugs, the existing HCPCS code is priced in accordance with the provisions of section 1833(t)(14)(A)(i) of the Act as indicated in Table 1. However, existing HCPCS codes do not allow us to differentiate payment amounts for innovator multiple source and noninnovator multiple source forms of the drug.
Therefore, for implementation January 1, 2004, we set payment rates for all multiple source innovator and noninnovator drugs, biologicals and radiopharmaceutical agents at the lower of the payment rate in the November 7, 2003 final rule or 46 percent of the reference AWP. These rates are shown in Table 2.
Initially, we will implement sections 1833(t)(14)(A)(i)(II) and (III) of the Act in this manner because we are unable to compile a definitive list of the innovator multiple source drugs in time for January 1, 2004 implementation. On April 1, 2004, CMS will implement new HCPCS codes that providers may use to bill for innovator multiple source drugs in order to receive appropriate payment in accordance with section 1833(t)(14)(A)(i)(II) of the Act, that is, the payment amount established in the November 7, 2003 final rule or 68 percent of the reference AWP, whichever is lower. The new codes will be effective January 1, 2004 so that providers may submit adjustment bills after April 1, 2004 to receive appropriate payment for multiple source innovator drugs furnished on or after January 1, 2004 through March 31, 2004.
Beginning April 1, 2004, innovator multiple source drugs will be paid at the statutory rate as long as the new codes are used. The multiple source noninnovator rate will be the default payment rate for the existing HCPCS code assigned to the drug, and providers will continue to use the current HCPCS codes to bill for noninnovator multiple source drugs after March 31, 2004. The new HCPCS codes will be very similar to the current codes with only the distinction that the drug being billed is an innovator multiple source drug eligible for payment of as much as 68 percent of the AWP.
We recognize that creation and use of a new code to designate a drug to be an innovator multiple source drug creates burden for hospitals. However, the law provides different payment rules based on the category into which the drug falls and therefore, to ensure correct payment, hospitals must report a code for the drug that identifies the category into which it falls. We request comments on ways that we can reduce the reporting burden on hospitals that results from the law's imposing different payment limitations on brand name and generic versions of the same drug.
Table 2 lists the drugs for which the new HCPCS codes will be implemented April 1, 2004 to distinguish innovator multiple source from noninnovator multiple source drugs.
Other changes in payment methodology effective January 1, 2004 as a result of enactment of the Medicare Prescription Drug, Improvement and Modernization Act of 2003
Payment for Pass-Through Drugs, Biologicals, and Radiopharmaceuticals
Drugs and biologicals that are within the 2–3 year pass-through payment period in 2004 continue to be paid pursuant to section 1842(o) of the Act. However, section 1842(o) of the Act has been revised by section 303(b) of the DIMA and those revisions change the way that these drugs are paid.
Drugs and biologicals furnished during 2004 that are approved for pass-through payment under the OPPS and that were not approved by the FDA for marketing as of April 1, 2003 will be paid 95 percent of AWP pursuant to section 1842(o)(1)(A)(iii).
See
Table 3b for a list of these pass-through drugs.
Drugs and biologicals furnished during 2004 for which pass-through payment was first made on or after January 1, 2003 (which removes them from application of section 621 of the DIMA) and were approved by the FDA for marketing as of April 1, 2003, will be paid 85 percent of AWP pursuant to section 1842(o)(1)(B) and 1842(o)(4)(A), unless sections 1842(o)(4)(B), (C) or (D) apply. See Table 3a for a list of these pass-through drugs.
Table 3c lists 10 drugs and biologicals with pass-through status in 2004 that also meet the criteria for “specified covered outpatient drugs” under section 1833(t)(14). That is, the drugs in Table 3c are pass-through drugs in 2004 that were available for payment before April 1, 2003 and would therefore be paid 85 percent of AWP (determined as of April 1, 2003) under the cross reference in section 1833(t)(6)(D)(i) to section 1842(o). Separate APCs have been established for these drugs and they were paid as pass-through drugs on or before December 31, 2002. Therefore, these pass-through drugs qualify under section 1833(t)(14)(B) as “specified covered outpatient drugs.” As specified covered outpatient drugs, the ten drugs would be categorized as “sole source” drugs.
Sole source drugs, under section 1833(t)(14)(A)(i)(I) are paid no less than 88 percent nor more than 95 percent of the reference AWP. To the extent that the ten drugs listed in Table 3c qualify as both pass-through drugs and sole source drugs under the DIMA, it appears that they are subject to two different payment provisions. We have reconciled the two apparently conflicting payment provisions in a way that we believe results in the fewest anomalies. The drugs will retain their pass-through status, and therefore, the rules and policies that otherwise apply to pass-through drugs continue to apply to them. They will also be considered sole source drugs for purposes of section 1833(t)(14). We will pay for the drugs as follows.
First, because the drugs are pass-through drugs, we will give them pass-through payments. The pass-through payments will equal 85 percent of AWP (determined as of April 1, 2003) under section 1833(t)(6)(D)(i). However, because the drugs are also sole source drugs, we will also apply the payment methodology set forth in section 1833(t)(14)(A)(i)(I), and raise the payment to 88 percent of the reference AWP (the AWP determined as of May 1, 2003).
Under the payment methodology that we are applying to sole source drugs, we look at the payment that would otherwise be made and if it is less than 88 percent or greater than 95 percent of reference AWP, we adjust it as minimally as necessary to ensure that it is within the required range. In the case of these drugs, absent the provisions of 1833(t)(14)(i)(I), we would pay 85 percent of AWP (determined as of April 1, 2003). Therefore adjusting the payment that would otherwise be made results in payment at 88 percent of reference AWP.
In light of the total revamping of the methodology for payment for drugs and biologicals under OPPS, we revisited the adjustment that we made under our authority in section 1833(t)(2)(E) of the Act to ensure equitable payments in 2003 and in the November 7 final rule for the 2004 update of the OPPS. After considering the nature of the DIMA payment changes, we have concluded that it is still appropriate to apply this adjustment to the methodology discussed in the previous two paragraphs for the reasons we stated in the OPPS rulemaking during the past two years. Therefore, for darbepoetin alpha (Q0137 and C1774), we are
making an adjustment in accordance with section 1833(t)(2)(E) of the Act (which was unaffected by DIMA) to the combined pass-through amount and 3 percent additional payment provided under section 1833(t)(14)(A)(i)(I) of DIMA, resulting in a payment rate of $3.88 per unit. This payment rate is budget neutral.
Table 3a.—Pass-Through Drugs Reimbursed at 85% of AWP
HCPCS
APC
Long description
2004 Payment amount
2004 Co-payment amount
J9395
9120
Injection, Fulvestrant, per 25 mg
$78.36
$13.09
C9121
9121
Injection, Argotroban, per 5 mg
14.63
2.44
C9123
9123
TransCyte, per 247 sq cm
689.78
115.23
C9205
9205
Injection, Oxaliplatin, per 5 mg
8.45
1.41
C9203
9203
Injection, Perflexane lipid microspheres, per single use vial
127.50
21.30
J3315
9122
Injection, Triptorelin pamoate, per 3.75 mg
356.66
59.58
J3486
9204
Injection, Ziprasidone mesylate, per 10 mg
18.60
3.11
C9211
9211
Injection, IV, Alefacept, per 7.5 mg
595.00
99.40
C9212
9212
Injection, IM, Alefacept, per 7.5 mg
422.88
70.65
Table 3b.—Pass-Through Drugs Paid at 95% of AWP
HCPCS
APC
Long description
Amount
Amount
C9207
9207
Injection, IV, Bortezomib, per 3.5 mg
1,039.68
155.40
C9208
9208
Injection, IV, Agalsidase beta, per 1 mg
123.78
18.50
C9209
9209
Injection, IV, Laronidase, per 2.9 mg
644.10
96.28
C9210
9210
Injection, IV, Palonosetron HCI, per 0.25 mg (250 micrograms)
307.80
46.01
Table 3c.—Pass-Through Drugs Paid as Sole Source Drugs at 88% of AWP
HCPCS
APC
Long description
OPPS CY2004 November 7 rate
DIMA final rate
J0583
9111
Injection, Bivalirudin, per 1 mg
$1.43
$1.61
C9112
9112
Injection, Perflutren lipid microsphere, per 2 ml
132.60
137.28
C9113
9113
Injection, Pantoprazole sodium, per vial
22.44
23.23
J1335
9116
Injection, Ertapenem sodium, per 500 mg
21.24
21.99
J2505
9119
Injection, Pegfilgrastim, per 6 mg single dose vial
2,507.50
2,596.00
C9200
9200
Orcel, per 36 sqare centimeters
1,015.75
1,051.60
C9201
9201
Dermagraft, per 37.5 square centimeters
516.80
535.04
J2324
9114
Injection, Nesiritide, per 0.5 mg
135.66
140.45
J3487
9115
Injection, Zoledronic acid, per 1 mg
194.52
211.07
Payment for New Drugs and Biologicals Before a HCPCS Code Is Assigned
Under new section 1833(t)(15) of the Act, as added by section 621(a)(1) of the DIMA a drug or biological that is furnished as part of covered outpatient department services for which a HCPCS codes has not been established, is to be paid at 95 percent of the AWP for the drug or biological.
We are in the process of determining how hospitals would bill Medicare for a drug prior to assignment of a HCPCS code. We will issue instructions once we have determined how to make this requirement operational.
Payment for Orphan Drugs as Designated by the Secretary
Section 1833(t)(14)(C) as added by section 621(a)(1) of the DIMA, provides that the amount of payment for orphan drugs designated by the Secretary shall, for 2004 and 2005, equal the amount the Secretary shall specify. We have determined that single indication orphan drugs as designated by the Secretary will be paid at the rates published in the November 7, 2003
Federal Register
(68 FR 63398). Neither the definition nor the 2004 payment amounts for single indication orphan drugs under the OPPS have changed from what was published in the November 7 final rule.
Brachytherapy
Section 621(b)(1) of the DIMA of 2003 amends the Act by adding section 1833(t)(16)(C) and section 1833(t)(2)(H) which establish separate payment for devices of brachytherapy consisting of a seed or seeds (or radioactive source) based on a hospital's charges for the service, adjusted to cost. Further, charges for the brachytherapy devices shall not be used in determining any outlier payments and consistent with our practice under OPPS to exclude items paid at cost from budget neutrality consideration, these items will be excluded from budget neutrality as well. The period of payment under this provision is for brachytherapy sources furnished from January 1, 2004 through December 31, 2006.
We will pay for the brachytherapy sources listed in Table 4 on a cost basis, as required by the statute. The status indicator for brachytherapy sources is changed to “H.” The definition of status indicator “H” is currently for pass-through payment for devices, but the brachytherapy sources affected by new sections 1833(t)(16)(C) and 1833(t)(2)(H) are not pass-through device categories. Therefore, we are also changing, for 2004, the definition of payment status indicator “H” to include non-pass-through brachytherapy sources paid for on a cost basis. This use of status indicator “H” is a pragmatic decision that allows us to pay for brachytherapy sources in accordance with new section 1833(t)(16)(C) effective January 1, 2004
without having to modify our claims processing systems. We will revisit the use and definition of status indicator “H” for this purpose for the OPPS update for 2005. Table 4 provides a complete listing of the HCPCS codes, descriptors, APC assignments and status indicators for brachytherapy sources.
Table 4.—Brachytherapy Sources To Be Paid Separately, Using Charges Reduced to Cost
HCPCS
Descriptor
APC
APC title
New status indicator
C1716
Brachytx source, Gold 198
1716
Brachytx source, Gold 198
H
C1717
Brachytx source, HDR Ir-192
1717
Brachytx source, HDR Ir-192
H
C1718
Brachytx source, Iodine 125
1718
Brachytx source, Iodine 125
H
C1719
Brachytx sour, Non-HDR Ir-192
1719
Brachytx source, Non-HDR Ir-192
H
C1720
Brachytx source, Paladium 103
1720
Brachytx source, Paladium 103
H
C2616
Brachytx source, Yttrium-90
2616
Brachytx source, Yttrium-90
H
C2632
Brachytx solution, I–125, per mCi
2632
Brachytx sol, I–125, per mCi
H
C2633
Brachytx source, Cesium-131
2633
Brachytx source, Cesium-131
H
C2632
Brachytx sol, I–125, per mCi
2632
Brachytx sol, I–125, per mCi
H
As indicated in Table 4, brachytherapy source in HCPCS code C1717 will be paid based on the hospital's charge reduced to cost beginning January 1, 2004. Prior to enactment of DIMA, these sources were paid as packaged services in APC 0313. As a result of the requirement to pay for C1717 separately, we are adjusting the payment rate for APC 0313 to reflect the unpackaging of the brachytherapy source. The new rate is listed in Addendum A.
Section 1833(t)(2)(H) is added by section 621(b)(2)(C) of DIMA, mandating the creation of separate groups of covered OPD services that classify brachytherapy devices separately from other services or groups of services. The additional groups shall be created in a manner reflecting the number, isotope and radioactive intensity of the devices of brachytherapy furnished, including separate groups for palladium-103 and iodine-125.
We invite the public to submit recommendations for new codes to describe brachytherapy sources in a manner reflecting the number, radioisotope, and radioactive intensity of the sources. We request that commenting parties provide a detailed rationale to support recommended new codes. We will propose appropriate changes in codes for brachytherapy sources in the 2005 OPPS update.
Continuation of Transitional Corridor Payments for CY 2004
Since the inception of the OPPS, providers have been eligible to receive additional transitional payments if the payments they received under the OPPS were less than the payments they would have received for the same services under the payment system in effect before the OPPS. Under 1833(t)(7) of the Act, most hospitals that realize lower payments under the OPPS received transitional corridor payments based on a percent of the decrease in payments. However, rural hospitals having 100 or fewer beds, as well as cancer hospitals and children's hospitals described in section 1886(d)(1)(B)(iii) and (v) of the Act, were held harmless under this provision and paid the full amount of the decrease in payments under the OPPS.
Transitional corridor payments were intended to be temporary payments to ease providers' transition from the prior cost-based payment system to the prospective payment system. In accordance with section 1833(t)(7) of the Act, transitional corridor payments were to be eliminated January 1, 2004, for all providers other than cancer hospitals and children's hospitals. Cancer hospitals and children's hospitals are held harmless permanently under the transitional corridor provisions of the statute.
Section 411 of the DIMA amends section 1833(t)(7) of the Act to provide that hold harmless transitional corridor payments will continue through December 31, 2005 for rural hospitals having 100 or fewer beds.
Section 411 of the DIMA further amends section 1833(t)(7) of the Act to provide that hold harmless transitional corridor payments shall apply to sole community hospitals, as defined in section 1886(d)(5)(D)(iii) of the Act, which are located in rural areas, with respect to services furnished during cost reporting periods beginning on or after January 1, 2004, and continuing through December 31, 2005. For purposes of this provision, a sole community hospital's location in a rural area will be determined as it is under the inpatient PPS, in 42 CFR 412.63(b).
II. Provisions of the Interim Final Rule With Comment Period
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (DIMA), enacted December 8, 2003 makes changes to the Social Security Act (the Act) relating to calendar year 2004 payments under the Hospital Outpatient Prospective Payment System. This interim final rule with comment period implements changes resulting from enactment of the DIMA that are effective January 1, 2004, as follows:
Transitional Corridor Payments Extended
Hold harmless transitional corridor payments are continued through December 31, 2005 for small rural hospitals having 100 or fewer beds. In addition, hold-harmless transitional corridor provisions shall apply to sole community hospitals as defined in section 1886(d)(5)(D)(iii) of the Act with respect to cost reporting periods beginning on or after January 1, 2004 and will continue through December 31, 2005.
Payment for “Specified Covered Outpatient Drugs”
Separately paid radiopharmaceutical agents and drugs or biologicals that had transitional pass-through status on or before December 31, 2002, are classified into 3 categories: innovator multiple source drugs; noninnovator multiple source drugs; and sole source drugs. Payment levels based on the reference average wholesale price as of May 1, 2003 are specified for each category.
Payment for Pass-Through Drugs
Drugs and biologicals furnished during 2004 for which pass-through payment was first made on or after January 1, 2003 (which removes them from application of section 621 of the
DIMA) and were approved by the FDA for marketing as of April 1, 2003, will be paid 85 percent of AWP pursuant to section 1842(o)(1)(B) and 1842(o)(4)(A), unless sections 1842(o)(4)(B), (C) or (D) apply.
Certain drugs, biologicals and radiopharmaceutical agents that are pass-through drugs in 2004 and that also meet the definition of “specified covered outpatient drugs”, except as otherwise specified, are paid 88 percent of the reference AWP. Those drugs, biologicals, and radiopharmaceutical agents remain pass-through drugs and all policies that apply to them as pass-through drugs continue to apply.
Exclude Separately Payable Drugs and Biologicals From Outlier Payments
Separately paid drugs and biologicals are excluded from outlier payments.
Brachytherapy Sources Are To Be Paid Separately
All devices of brachytherapy consisting of a seed or seeds (or radioactive source) are paid based on the hospital's charge for the device adjusted to cost. All such brachytherapy sources are excluded from outlier payments.
III. Collection of Information Requirements
This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995.
IV. Waiver of Notice of Proposed Rulemaking and the 30-Day Delay in the Effective Date
We ordinarily publish a notice of proposed rulemaking in the
Federal Register
and invite public comment on the proposed rule in accordance with 5 U.S.C. section 553(b) of the Administrative Procedure Act (APA). The notice of proposed rulemaking includes a reference to the legal authority under which the rule is proposed, and the terms and substances of the proposed rule or a description of the subjects and issues involved. This procedure can be waived, however, if an agency finds good cause that a notice-and-comment procedure is impracticable, unnecessary, or contrary to the public interest and incorporates a statement of the finding and its reasons in the rule issued.
In this case, we believe that it is in the public interest to comply with the statutory requirement to implement these changes effective January 1, 2004. Failure to meet this deadline would cause a delay in payment increases for many drugs and biologicals and brachytherapy sources.
Section 1871 of the Act also provides for publication of a notice of proposed rulemaking and opportunity for public comment before CMS issues a final rule. However, section 1871(b)(2)(B) provides an exception when a law establishes a specific deadline for implementation of a provision and the deadline is less than 150 days after the law's date of enactment. The DIMA was enacted by the Congress on November 25, 2003 and signed into law by the President on December 8, 2003. The provisions of this rule that amend the Medicare hospital outpatient prospective payment system are required to be implemented January 1, 2004. Therefore, these provisions are subject to waiver of proposed rulemaking in accordance with section 1871(b)(2)(B) of the Act.
In addition, we ordinarily provide a 30-day delay in the effective date of the provisions of an interim final rule. Section 553(d) of the APA (5 U.S.C. section 553(d)) ordinarily requires a 30-day delay in the effective date of final rules after the date of their publication in the
Federal Register
. This 30-day delay in effective date can be waived, however, if an agency finds for good cause that the delay is impracticable, unnecessary, or contrary to the public interest, and the agency incorporates a statement of the finding and its reasons in the rule issued.
In this case, we believe that it is in the public interest to comply with the statutory requirement to implement these changes effective January 1, 2004 without the 30-day delay in effective date. Failure to meet this deadline would cause a delay in payment increases for many drugs and biologicals and brachytherapy sources.
In addition to the APA requirements, section 1871(e)(1), as amended by section 903(b)(1) of DIMA also requires that a substantive change in a regulation shall not become effective before the end of the 30-day period that begins on the date that the Secretary has issued or published the substantive change. Section 903(b)(1) provides an exception to the requirement of a 30-day delay in the effective date if the Secretary finds that the waiver of such 30-day period is necessary to comply with statutory requirements or that the application of such 30-day period is contrary to the public interest.
For purposes of DIMA, we believe that it is in the public interest to comply with the statutory requirement to implement these changes effective January 1, 2004 without the 30-day delay in effective date for the same reasons stated above—failure to meet this deadline would cause a delay in payment increases for many drugs and biologicals and brachytherapy sources. In addition, we find it is necessary to waive the 30-day delay period in order to timely comply with the statutory requirement that new payment rates be effective on January 1, 2004. We are providing a 60-day public comment period.
V. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA) (September 16, 1980, Pub. L. 96–354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104–4), and Executive Order 13132.
Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year).
We estimate the effects of the provisions that will be implemented by this final rule will result in expenditures exceeding $100 million in any 1 year. Our Office of the Actuary estimates that the total change in expenditures under the OPPS for CY 2004 as a result of the changes made by DIMA to be approximately $150 million. Therefore, this final rule with comment is an economically significant rule under Executive Order 12866, and a major rule under 5 U.S.C. 804(2). Therefore the discussion below, in combination with the rest of this final rule constitutes a regulatory impact analysis. The RFA requires agencies to analyze options for regulatory relief of small businesses. However a regulatory flexibility analysis is not required for an interim final rule because no proposed rule is being issued.
Therefore the discussion below constitutes a regulatory impact analysis but no regulatory flexibility analysis is provided.
Unfunded Mandates
Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in expenditure in any 1 year by State, local, or tribal governments, in the aggregate, or by the private sector, of $110 million. This interim final rule will not mandate any requirements for State, local or tribal governments. This interim final rule will not impose unfunded mandates on the private sector of more than $110 million dollars.
Federalism
Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications.
We have examined this interim final rule in accordance with Executive Order 13132, Federalism, and have determined that it will not have an impact on the rights, roles, and responsibilities of State, local or tribal governments.
B. Anticipated Effects of Changes in This Interim Final Rule and Alternatives Considered for Each Change
All of the changes made in this interim final rule with comment are required by DIMA. We are required under section 621 of the DIMA to revise payments for certain drugs and biologicals and for radiopharmaceuticals. We are also required under section 621 of the DIMA to pay for brachytherapy sources on the basis of application of a cost to charge ratio to the charges for the sources. In addition, we are required under section 621 of the DIMA to continue transitional outpatient payment for certain hospitals.
Impact on Drugs and Biologicals That Will Be Paid Under Pass-Through Provisions in 2004
Four of the drugs and biologicals that will be paid under pass-through provisions in 2004 will be paid at 95 percent of AWP. Nine of the drugs and biologicals that will be paid under pass-through provisions in 2004 will be paid at 85 percent of AWP in 2004. This is a reduction of 10 percent of AWP compared to the payment that would have been made for these drugs and biologicals before passage of the DIMA.
As discussed previously in this rule, some pass-through drugs and biologicals also meet the criteria for “specified covered outpatient drugs” under 1833(t)(14) and, except as specified in this rule, will be paid 88 percent of the reference AWP. Notwithstanding the payment amount, however, they remain pass-through drugs.
Hospitals that provide drugs paid at 85 percent of AWP will be paid less than they would have been paid absent passage of the new law.
It is unclear whether the reduction in payments for these drugs will have any effect on beneficiary access to them. Hospitals consider many factors when they determine whether they choose to provide the drugs and it is unclear whether the reduction in payment for Medicare will result in impaired access. However, reduction in the payment amounts for some drugs means that beneficiaries will have lower copayments for those drugs and that they, and complementary insurers who pay beneficiary cost sharing, will have reduced expenses. Hospitals, however, will clearly be paid reduced amounts by Medicare for these drugs compared to the amounts that would be paid had the statute not imposed these changes. Manufacturers and distributors of the pass-through drugs that will be paid at 85 percent of AWP will be under increased pressure to reduce the price of the drugs since the hospitals to which they sell the items will be paid lower amounts by Medicare for them when used in hospital outpatient departments.
We considered setting payment at 85 percent for pass-through drugs that also meet the definition of “specified covered outpatient drugs” as allowed in the cross reference from 1833(t)(6) to 1842(o). However, given that the drugs are eligible for payment under both sets of criteria, we chose to increase their payment to 88 percent of reference AWP, except as otherwise specified. We believe that this choice will result in the least possible disruption to beneficiary access to these drugs.
We considered no alternatives with regard to payment for pass-through drugs that did not meet the definition of “specified covered outpatient drugs” because the law provides only one payment methodology for these drugs.
Impact of Changes for “Specified Covered Outpatient Drugs”
Radiopharmaceutical agents and drugs or biologicals for which payment was made on a pass-through basis on or before December 31, 2002, are now to be paid under section 1833(t)(14) of the Act as added by DIMA. Under these provisions, radiopharmaceuticals and drugs and biologicals that meet the criteria, are paid amounts that must be limited as specified in the law. Specifically, items that meet the definition of sole source drugs must be paid no less than 88 percent of reference AWP nor more than 95 percent of reference AWP. Items that meet the definition of innovator multiple source drugs must be paid no more than 68 percent of AWP and items that meet the definition of noninnovator multiple source drugs must be paid no more than 46 percent of AWP.
As described previously, these categories are defined in section 1927(k)(7) of the Act. That section classifies drugs, biologicals and radiopharmaceuticals for purposes of the Medicaid drug rebate program. CMS has a database in which these items are categorized to which we looked to seek the classification of each drug, biological and radiopharmaceutical paid under pass-through provisions before December 31, 2002. Table 1 shows those items that we believe meet the definition of sole source drug. Table 2 shows those items for which it is not clear to us whether the item should be classified as a sole source drug or as both an innovator multiple source and a noninnovator multiple source drug and which we will pay as noninnovator multiple source drugs until we receive comments and determine the classification into which the drug falls. Paying for those drugs with questionable classification as noninnovator multiple source drugs allows payment to be made to hospitals for these drugs when they are furnished and also protects hospitals from incurring overpayments. Once we review the public comments and establish the correct classification and codes for the billing of innovator multiple source drugs, hospitals may subject adjustment bills to be paid the additional amounts due.
We will pay the 121 drugs in Table 1 at the amounts shown, as previously discussed. Six of these drugs will have no payment change from the payment announced in the November 7, 2003 final rule. Six of these drugs will receive decreases in payment compared to the final rule because the payment established in the November 7, 2003 final rule exceeded 95 percent of the reference AWP. The payment amounts for these drugs are now set at 95 percent of the reference AWP in accordance with the law. One hundred nine of these drugs will receive increases in payment compared to the final rule because the payment established in the November 7, 2003 final rule was less than 88 percent of reference AWP. The payment amounts for these drugs, biologicals and radiopharmaceuticals is now set at 88 percent of the reference AWP.
We will temporarily pay the 52 drugs in Table 2 at the amounts shown, as previously discussed. Thirteen of these items will be paid the amount that was published in the November 7, 2003 final rule. Thirty-eight of these items will receive payment decreases. One of these items did not have a reference AWP under the SDP and will require further research to determine the correct payment amount. Until we determine a reference AWP for this item it will be paid at the amount that was published in the November 7, 2003 final rule.
It is unclear what the final overall impact of these changes will be because we are, as yet, unable to determine into which categories 52 items in dispute will fall. Moreover, once they are categorized, we do not anticipate that we will know the frequency with which hospitals will use the innovator multiple source drug versus the noninnovator multiple source drug in the outpatient department. Moreover, it is not clear to what extent hospitals may change their behavior with regard to which type of a drug they choose to purchase and whether their purchasing decisions will be affected by whether they furnish the item to hospital outpatient departments or inpatient departments.
We considered whether to classify the 52 items with questionable category assignment as both innovator multiple source and noninnovator multiple source drugs and to create HCPCS codes to be used when innovator multiple source drugs are administered. However, we believe that public comment is necessary to determine the correct classification of these items. Similarly, we believe that, given the burden the law imposes on hospitals for reporting drugs by the category into which they fall, it was important to receive public comment regarding whether new codes should be created and regarding ways we can reduce the reporting burden on hospitals. Hence, until we receive and review the comments, we will not be able to assess the impact of these requirements of the law.
We do acknowledge, however, that for the 52 drugs that are not sole source drugs, the temporary payments to hospitals at the noninnovator multiple source drug rate will be less than the payment that would have been made under the November 7, 2003 final rule. For those drugs that are sole source drugs, the payment will increase in most cases.
Hospitals that provide sole source drugs will be paid more for these drugs under these provisions than they would have been paid before enactment of the DIMA. Hospitals that provide innovator multiple source drugs and noninnovator multiple source drugs will be paid less for these items than they would have been before enactment of the DIMA. This may encourage use of sole source drugs and discourage use of multiple source drugs. As a result, beneficiaries may have greater access to sole source drugs but will also incur greater copayments because those payment rates are higher than they would have been before enactment of DIMA. In turn, there may be increased payment by complementary insurers for these items. Manufacturers of sole source drugs may realize increased sales and manufacturers of generic drugs may see reduced sales.
We considered whether to permit a drug that is classified by AMP as a sole source drug, an innovator multiple source drug and a noninnovator multiple source drug to be paid under all three classifications. We decided not to pay a drug as a sole source drug if it is also a multiple source drug for reasons described previously in this interim final rule. We considered no alternatives because the law is quite specific with regard to the classification of drugs and the payment rules that apply to each class of drug.
Impact of Cost-Based Payment for Sources of Brachytherapy
The law provides that sources of brachytherapy will be paid an amount equal to the hospital's charge for the source adjusted by the applicable cost to charge ratio. It is unclear whether this will result in an increase or decrease in payment for brachytherapy sources. However, removing the brachytherapy source from packaged payment for the services with which it is furnished removes incentives for using the least number of sources needed for the therapeutic purpose. There is no evidence that packaged payment for brachytherapy sources resulted in inappropriately low utilization of brachytherapy, nor that separate payment will result in any change in availability of the service. We are unable to estimate the impact of this change on utilization and program payment.
We considered no alternatives to this policy because the statute was specific with regard to how payment for brachytherapy sources must be made.
Impact of Continuation of Transitional Outpatient Payments for Certain Hospitals
The law provides that transitional outpatient payments must continue for rural hospitals with 100 or fewer beds and be provided for sole community hospitals in rural areas through December 31, 2005. There are approximately 600 sole community hospitals and approximately 1150 rural hospitals with 100 beds or fewer that may be affected by this provision. These hospitals will continue to receive transitional corridor payments in addition to the payments they will receive under OPPS. These payments should continue to strengthen the ability of these hospitals to furnish services to beneficiaries who reside in the areas served by these hospitals. Beneficiaries should be better assured of access to services in these hospitals. These hospitals will be assured of payment for the reasonable costs of providing outpatient services.
We considered no alternatives because the statute is quite directive with regard to the extension of hold harmless protection to these hospitals.
C. Conclusion
We have prepared the analysis above because we have determined that this interim final rule will have a significant economic impact. In accordance with the provisions of Executive Order 12866, this interim final rule was reviewed by the Office of Management and Budget.
Publication of Addenda
The addenda included in this interim final rule, Addenda A and D1 replace the addenda in the November 7, 2003
Federal Register
(68 FR 63478). The revised addenda reflect changes required by the DIMA as well as corrections to minor errors contained in the addenda published November 7, 2003.
In addition to the addenda included here, we will post the updated Addenda B and C on our Web site at
http://www.cms.hhs.gov/regulations/hopps/.
List of Subjects in 42 CFR Part 419
Hospitals, Medicare, Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services amends 42 CFR chapter IV as set forth below:
PART 419—PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES
1. The authority citation for part 419 continues to read as follows:
Authority:
Secs. 1102, 1833(t), and 1871 of the Social Security Act (42 U.S.C. 1302, 1395l(t), and 1395hh).
Subpart C—Basic Methodology for Determining Prospective Payment Rates for Hospital Outpatient Services
2. Section 419.32 is amended by revising paragraph (d) to read as follows:
§ 419.32
Calculation of prospective payment rates for hospital outpatient services.
(d)
Budget neutrality.
(1) CMS adjusts the conversion factor as needed to ensure that updates and adjustments under § 419.50(a) are budget neutral.
(2) In determining adjustments for 2004 and 2005, CMS will not take into account any additional expenditures per section 1833(t)(14) of the Act that would not have been made but for enactment of section 621 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
Subpart D—Payments to Hospitals
3. Section § 419.43 is amended as follows:
A. Paragraph (d)(1) introductory text is revised.
B. Paragraph (e) is revised.
C. New paragraph (f) is added.
The revisions and additions read as follows:
§ 419.43
Adjustments to national program payments and beneficiary copayment amounts.
(d)
Outlier adjustment
—(1)
General rule.
Subject to paragraph (d)(4) of this section, CMS provides for an additional payment for a hospital outpatient service (or group of services) not excluded under paragraph (f) of this section for which a hospital's charges, adjusted to cost, exceed the following:
(e)
Budget neutrality.
CMS establishes payment under paragraph (d) of this section in a budget-neutral manner excluding services and groups specified in paragraph (f) of this section.
(f)
Excluded services and groups.
Drugs and biologicals that are paid under a separate APC and devices of brachytherapy, consisting of a seed or seeds (including a radioactive source) are excluded from qualification for outlier payments.
Subpart G—Transitional Pass-Through Payments
4. Section 419.64 is amended by revising paragraph (d).
§ 419.64
Transitional pass-through payments: Drugs and biologicals.
(d)
Amount of pass-through payment.
(1) Subject to any reduction determined under § 419.62(b), the pass-through payment for a drug or biological as specified in section 1842(o)(1)(A) and (o)(1)(D)(i) of the Act is 95 percent of the average wholesale price of the drug or biological minus the portion of the APC payment CMS determines is associated with the drug or biological.
(2) Subject to any reduction determined under § 419.62(b), the pass-through payment for a drug or biological as specified in section 1842(o)(1)(B) and (o)(1)(E)(i) of the Act is 85 percent of the average wholesale price, determined as of April 1, 2003, of the drug or biological minus the portion of the APC payment CMS determines is associated with the drug or biological.
Subpart H—Transitional Corridors
5. Section 419.70 is amended as follows:
A. Paragraph (d)(1) is amended by removing “2004” and adding “2006” in its place.
B. A new paragraph (d)(3) is added to read as follows:
§ 419.70
Transitional adjustment to limit decline and payment.
(d) * * *
(3)
Temporary treatment for sole community hospitals located in rural areas.
For covered hospital outpatient services furnished during cost reporting periods beginning on or after January 1, 2004, and continuing through December 31, 2005, for which the prospective payment system amount is less than the pre-BBA amount, the amount of payment under this part is increased by the amount of that difference if the hospital—
(i) Is a sole community hospital, under § 412.92 of this chapter; and
(ii) Is located in a rural area as defined in § 412.63(b) of this chapter or is treated as being located in a rural area under section 1886(d)(8)(E) of the Act.
(Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplementary Medical Insurance Program)
Dated: December 23, 2003.
Dennis G. Smith,
Acting Administrator, Centers for Medicare & Medicaid Services.
Approved: December 23, 2003.
Tommy G. Thompson,
Secretary.
Note:
The following addenda will not appear in the Code of Federal Regulations.
Addendum A.—List of Ambulatory Payment Classifications (APCS) With Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts Calendar Year 2004
APC
Group title
Status
indicator
Relative
weight
Payment
rate
National
unadjusted
copayment
Minimum
unadjusted
copayment
0001
Level I Photochemotherapy
S
0.4237
$23.12
$7.09
$4.62
0002
Level I Fine Needle Biopsy/Aspiration
T
0.8083
$44.10
$8.82
0003
Bone Marrow Biopsy/Aspiration
T
2.3229
$126.74
$25.35
0004
Level I Needle Biopsy/ Aspiration Except Bone Marrow
T
1.5882
$86.65
$22.36
$17.33
0005
Level II Needle Biopsy/Aspiration Except Bone Marrow
T
3.2698
$178.40
$71.59
$35.68
0006
Level I Incision & Drainage
T
1.6527
$90.17
$23.26
$18.03
0007
Level II Incision & Drainage
T
11.8633
$647.27
$129.45
0008
Level III Incision and Drainage
T
19.4831
$1,063.02
$212.60
0009
Nail Procedures
T
0.6652
$36.29
$8.34
$7.26
0010
Level I Destruction of Lesion
T
0.6480
$35.36
$10.08
$7.07
0011
Level II Destruction of Lesion
T
2.2217
$121.22
$27.88
$24.24
0012
Level I Debridement & Destruction
T
0.7612
$41.53
$11.18
$8.31
0013
Level II Debridement & Destruction
T
1.1302
$61.66
$14.20
$12.33
0015
Level III Debridement & Destruction
T
1.5968
$87.12
$20.35
$17.42
0016
Level IV Debridement & Destruction
T
2.5724
$140.35
$57.31
$28.07
0017
Level VI Debridement & Destruction
T
16.3697
$893.15
$227.84
$178.63
0018
Biopsy of Skin/Puncture of Lesion
T
0.9178
$50.08
$16.04
$10.02
0019
Level I Excision/ Biopsy
T
3.9493
$215.48
$71.87
$43.10
0020
Level II Excision/ Biopsy
T
7.0842
$386.52
$113.25
$77.30
0021
Level III Excision/ Biopsy
T
14.3594
$783.46
$219.48
$156.69
0022
Level IV Excision/ Biopsy
T
18.7932
$1,025.38
$354.45
$205.08
0023
Exploration Penetrating Wound
T
2.8141
$153.54
$40.37
$30.71
0024
Level I Skin Repair
T
1.6850
$91.94
$33.10
$18.39
0025
Level II Skin Repair
T
5.1912
$283.24
$107.00
$56.65
0027
Level IV Skin Repair
T
15.8990
$867.47
$329.72
$173.49
0028
Level I Breast Surgery
T
17.6584
$963.46
$303.74
$192.69
0029
Level II Breast Surgery
T
30.1167
$1,643.20
$632.64
$328.64
0030
Level III Breast Surgery
T
37.3083
$2,035.58
$763.55
$407.12
0032
Insertion of Central Venous/Arterial Catheter
T
11.4907
$626.94
$125.39
0033
Partial Hospitalization
P
5.2569
$286.82
$57.36
0035
Placement of Arterial or Central Venous Catheter
T
0.1691
$9.23
$2.79
$1.85
0036
Level II Fine Needle Biopsy/Aspiration
T
1.5170
$82.77
$16.55
0037
Level III Needle Biopsy/Aspiration Except Bone Marrow
T
9.8921
$539.72
$237.45
$107.94
0039
Implantation of Neurostimulator
S
235.1866
$12,832.02
$2,566.40
0040
Level II Implantation of Neurostimulator Electrodes
S
52.1002
$2,842.64
$568.53
0041
Level I Arthroscopy
T
27.3819
$1,493.98
$298.80
0042
Level II Arthroscopy
T
43.0808
$2,350.53
$804.74
$470.11
0043
Closed Treatment Fracture Finger/Toe/Trunk
T
1.9074
$104.07
$20.81
0045
Bone/Joint Manipulation Under Anesthesia
T
13.5889
$741.42
$268.47
$148.28
0046
Open/Percutaneous Treatment Fracture or Dislocation
T
32.5581
$1,776.40
$535.76
$355.28
0047
Arthroplasty without Prosthesis
T
29.9582
$1,634.55
$537.03
$326.91
0048
Arthroplasty with Prosthesis
T
51.4609
$2,807.76
$695.60
$561.55
0049
Level I Musculoskeletal Procedures Except Hand and Foot
T
19.6046
$1,069.65
$213.93
0050
Level II Musculoskeletal Procedures Except Hand and Foot
T
24.8651
$1,356.66
$271.33
0051
Level III Musculoskeletal Procedures Except Hand and Foot
T
34.5144
$1,883.14
$376.63
0052
Level IV Musculoskeletal Procedures Except Hand and Foot
T
42.7126
$2,330.44
$466.09
0053
Level I Hand Musculoskeletal Procedures
T
14.8831
$812.04
$253.49
$162.41
0054
Level II Hand Musculoskeletal Procedures
T
24.2456
$1,322.86
$264.57
0055
Level I Foot Musculoskeletal Procedures
T
18.7205
$1,021.41
$355.34
$204.28
0056
Level II Foot Musculoskeletal Procedures
T
25.3930
$1,385.47
$405.81
$277.09
0057
Bunion Procedures
T
25.5035
$1,391.50
$475.91
$278.30
0058
Level I Strapping and Cast Application
S
1.0931
$59.64
$11.93
0060
Manipulation Therapy
S
0.2788
$15.21
$3.04
0068
CPAP Initiation
S
1.0807
$58.96
$29.48
$11.79
0069
Thoracoscopy
T
28.9392
$1,578.95
$591.64
$315.79
0070
Thoracentesis/Lavage Procedures
T
3.0717
$167.60
$33.52
0071
Level I Endoscopy Upper Airway
T
0.8799
$48.01
$12.89
$9.60
0072
Level II Endoscopy Upper Airway
T
1.7613
$96.10
$26.68
$19.22
0073
Level III Endoscopy Upper Airway
T
3.4541
$188.46
$73.38
$37.69
0074
Level IV Endoscopy Upper Airway
T
13.9480
$761.02
$295.70
$152.20
0075
Level V Endoscopy Upper Airway
T
20.3815
$1,112.04
$445.92
$222.41
0076
Level I Endoscopy Lower Airway
T
9.2346
$503.85
$189.82
$100.77
0077
Level I Pulmonary Treatment
S
0.2837
$15.48
$7.74
$3.10
0078
Level II Pulmonary Treatment
S
0.7917
$43.20
$14.55
$8.64
0079
Ventilation Initiation and Management
S
2.1494
$117.27
$23.45
0080
Diagnostic Cardiac Catheterization
T
36.0160
$1,965.07
$838.92
$393.01
0081
Non-Coronary Angioplasty or Atherectomy
T
35.0285
$1,911.19
$382.24
0082
Coronary Atherectomy
T
110.2196
$6,013.69
$1,293.59
$1,202.74
0083
Coronary Angioplasty and Percutaneous Valvuloplasty
T
59.2047
$3,230.27
$646.05
0084
Level I Electrophysiologic Evaluation
S
10.5226
$574.12
$114.82
0085
Level II Electrophysiologic Evaluation
T
35.4126
$1,932.15
$426.25
$386.43
0086
Ablate Heart Dysrhythm Focus
T
44.9389
$2,451.91
$833.33
$490.38
0087
Cardiac Electrophysiologic Recording/Mapping
T
39.8161
$2,172.41
$434.48
0088
Thrombectomy
T
34.6942
$1,892.95
$655.22
$378.59
0089
Insertion/Replacement of Permanent Pacemaker and Electrodes
T
117.1896
$6,393.98
$1,722.59
$1,278.80
0090
Insertion/Replacement of Pacemaker Pulse Generator
T
96.8284
$5,283.05
$1,651.45
$1,056.61
0091
Level II Vascular Ligation
T
28.8326
$1,573.14
$348.23
$314.63
0092
Level I Vascular Ligation
T
25.0959
$1,369.26
$505.37
$273.85
0093
Vascular Reconstruction/Fistula Repair without Device
T
21.3104
$1,162.72
$277.34
$232.54
0094
Level I Resuscitation and Cardioversion
S
2.6345
$143.74
$48.58
$28.75
0095
Cardiac Rehabilitation
S
0.5994
$32.70
$16.35
$6.54
0096
Non-Invasive Vascular Studies
S
1.7176
$93.71
$46.85
$18.74
0097
Cardiac and Ambulatory Blood Pressure Monitoring
X
1.0635
$58.03
$23.80
$11.61
0098
Injection of Sclerosing Solution
T
1.0729
$58.54
$14.06
$11.71
0099
Electrocardiograms
S
0.3703
$20.20
$4.04
0100
Cardiac Stress Tests
X
1.5862
$86.54
$41.44
$17.31
0101
Tilt Table Evaluation
S
4.4040
$240.29
$105.27
$48.06
0103
Miscellaneous Vascular Procedures
T
11.6202
$634.01
$223.63
$126.80
0104
Transcatheter Placement of Intracoronary Stents
T
82.6713
$4,510.63
$902.13
0105
Revision/Removal of Pacemakers, AICD, or Vascular
T
19.1898
$1,047.01
$370.40
$209.40
0106
Insertion/Replacement/Repair of Pacemaker and/or Electrodes
T
58.9719
$3,217.57
$643.51
0107
Insertion of Cardioverter-Defibrillator
T
337.1304
$18,394.17
$3,699.14
$3,678.83
0108
Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads
T
452.6995
$24,699.74
$4,939.95
0109
Removal of Implanted Devices
T
7.4705
$407.60
$131.49
$81.52
0110
Transfusion
S
3.6718
$200.34
$40.07
0111
Blood Product Exchange
S
13.1719
$718.67
$200.18
$143.73
0112
Apheresis, Photopheresis, and Plasmapheresis
S
37.5832
$2,050.58
$612.47
$410.12
0113
Excision Lymphatic System
T
19.9322
$1,087.52
$217.50
0114
Thyroid/Lymphadenectomy Procedures
T
37.5963
$2,051.29
$485.91
$410.26
0115
Cannula/Access Device Procedures
T
25.6437
$1,399.15
$459.35
$279.83
0116
Chemotherapy Administration by Other Technique Except Infusion
S
0.7996
$43.63
$8.73
0117
Chemotherapy Administration by Infusion Only
S
3.0360
$165.65
$42.54
$33.13
0119
Implantation of Infusion Pump
T
134.7194
$7,350.43
$1,470.09
0120
Infusion Therapy Except Chemotherapy
T
1.9114
$104.29
$28.21
$20.86
0121
Level I Tube changes and Repositioning
T
2.1114
$115.20
$43.80
$23.04
0122
Level II Tube changes and Repositioning
T
8.8621
$483.53
$99.16
$96.71
0123
Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant
S
6.1499
$335.54
$67.11
0124
Revision of Implanted Infusion Pump
T
23.8050
$1,298.82
$259.76
0125
Refilling of Infusion Pump
T
2.1606
$117.88
$23.58
0130
Level I Laparoscopy
T
32.7724
$1,788.09
$659.53
$357.62
0131
Level II Laparoscopy
T
40.8064
$2,226.44
$1,001.89
$445.29
0132
Level III Laparoscopy
T
57.2045
$3,121.13
$1,239.22
$624.23
0140
Esophageal Dilation without Endoscopy
T
6.4525
$352.05
$107.24
$70.41
0141
Upper GI Procedures
T
7.8206
$426.70
$143.38
$85.34
0142
Small Intestine Endoscopy
T
8.7959
$479.91
$152.78
$95.98
0143
Lower GI Endoscopy
T
8.2957
$452.62
$186.06
$90.52
0146
Level I Sigmoidoscopy
T
3.9826
$217.29
$64.40
$43.46
0147
Level II Sigmoidoscopy
T
7.6808
$419.07
$83.81
0148
Level I Anal/Rectal Procedure
T
3.8320
$209.08
$63.38
$41.82
0149
Level III Anal/Rectal Procedure
T
17.1425
$935.31
$293.06
$187.06
0150
Level IV Anal/Rectal Procedure
T
22.1919
$1,210.81
$437.12
$242.16
0151
Endoscopic Retrograde Cholangio-Pancreatography (ERCP)
T
17.9462
$979.16
$245.46
$195.83
0152
Percutaneous Abdominal and Biliary Procedures
T
9.1474
$499.09
$125.28
$99.82
0153
Peritoneal and Abdominal Procedures
T
20.8723
$1,138.81
$410.87
$227.76
0154
Hernia/Hydrocele Procedures
T
26.9636
$1,471.16
$464.85
$294.23
0155
Level II Anal/Rectal Procedure
T
10.0809
$550.02
$188.89
$110.00
0156
Level II Urinary and Anal Procedures
T
2.4747
$135.02
$40.52
$27.00
0157
Colorectal Cancer Screening: Barium Enema
S
2.5693
$140.18
$28.04
0158
Colorectal Cancer Screening: Colonoscopy
T
7.4244
$405.08
$101.27
0159
Colorectal Cancer Screening: Flexible Sigmoidoscopy
S
2.7823
$151.81
$37.95
0160
Level I Cystourethroscopy and other Genitourinary Procedures
T
6.8801
$375.39
$105.06
$75.08
0161
Level II Cystourethroscopy and other Genitourinary Procedures
T
16.8407
$918.85
$249.36
$183.77
0162
Level III Cystourethroscopy and other Genitourinary Procedures
T
21.9098
$1,195.42
$239.08
0163
Level IV Cystourethroscopy and other Genitourinary Procedures
T
33.8805
$1,848.55
$369.71
0164
Level I Urinary and Anal Procedures
T
1.2021
$65.59
$17.59
$13.12
0165
Level III Urinary and Anal Procedures
T
14.6838
$801.16
$160.23
0166
Level I Urethral Procedures
T
16.7918
$916.18
$218.73
$183.24
0167
Level III Urethral Procedures
T
30.0186
$1,637.84
$555.84
$327.57
0168
Level II Urethral Procedures
T
30.0147
$1,637.63
$405.60
$327.53
0169
Lithotripsy
T
45.1150
$2,461.52
$1,115.69
$492.30
0170
Dialysis
S
5.9678
$325.61
$65.12
0180
Circumcision
T
18.6176
$1,015.79
$304.87
$203.16
0181
Penile Procedures
T
29.4217
$1,605.28
$621.82
$321.06
0183
Testes/Epididymis Procedures
T
21.6724
$1,182.47
$236.49
0184
Prostate Biopsy
T
3.8995
$212.76
$96.27
$42.55
0187
Miscellaneous Placement/Repositioning
X
4.4288
$241.64
$90.71
$48.33
0188
Level II Female Reproductive Proc
T
1.1365
$62.01
$12.40
0189
Level III Female Reproductive Proc
T
1.4232
$77.65
$18.09
$15.53
0190
Level I Hysteroscopy
T
19.6922
$1,074.43
$424.28
$214.89
0191
Level I Female Reproductive Proc
T
0.1853
$10.11
$2.93
$2.02
0192
Level IV Female Reproductive Proc
T
2.7121
$147.97
$39.11
$29.59
0193
Level V Female Reproductive Proc
T
15.0453
$820.89
$171.13
$164.18
0194
Level VIII Female Reproductive Proc
T
18.4286
$1,005.48
$397.84
$201.10
0195
Level IX Female Reproductive Proc
T
25.6950
$1,401.94
$483.80
$280.39
0196
Dilation and Curettage
T
16.1219
$879.63
$338.23
$175.93
0197
Infertility Procedures
T
4.8280
$263.42
$52.68
0198
Pregnancy and Neonatal Care Procedures
T
1.3578
$74.08
$32.19
$14.82
0199
Obstetrical Care Service
T
17.2831
$942.98
$188.60
0200
Level VII Female Reproductive Proc
T
17.9920
$981.66
$307.83
$196.33
0201
Level VI Female Reproductive Proc
T
16.8660
$920.23
$329.65
$184.05
0202
Level X Female Reproductive Proc
T
38.9821
$2,126.90
$1,042.18
$425.38
0203
Level IV Nerve Injections
T
11.5969
$632.74
$276.76
$126.55
0204
Level I Nerve Injections
T
2.1711
$118.46
$40.13
$23.69
0206
Level II Nerve Injections
T
5.2875
$288.49
$75.55
$57.70
0207
Level III Nerve Injections
T
6.4554
$352.21
$123.69
$70.44
0208
Laminotomies and Laminectomies
T
40.2830
$2,197.88
$439.58
0209
Extended EEG Studies and Sleep Studies, Level II
S
11.5435
$629.82
$280.58
$125.96
0212
Nervous System Injections
T
2.9739
$162.26
$74.67
$32.45
0213
Extended EEG Studies and Sleep Studies, Level I
S
2.9055
$158.53
$65.74
$31.71
0214
Electroencephalogram
S
2.2176
$120.99
$58.12
$24.20
0215
Level I Nerve and Muscle Tests
S
0.6457
$35.23
$15.76
$7.05
0216
Level III Nerve and Muscle Tests
S
2.8535
$155.69
$67.98
$31.14
0218
Level II Nerve and Muscle Tests
S
1.1404
$62.22
$12.44
0220
Level I Nerve Procedures
T
16.5554
$903.28
$180.66
0221
Level II Nerve Procedures
T
24.8875
$1,357.89
$463.62
$271.58
0222
Implantation of Neurological Device
T
232.2024
$12,669.20
$2,533.84
0223
Implantation or Revision of Pain Management Catheter
T
26.7610
$1,460.11
$292.02
0224
Implantation of Reservoir/Pump/Shunt
T
34.1770
$1,864.73
$453.41
$372.95
0225
Level I Implementation of Neurostimulator Electrodes
S
206.0034
$11,239.75
$2,247.95
0226
Implantation of Drug Infusion Reservoir
T
136.2989
$7,436.60
$1,487.32
0227
Implantation of Drug Infusion Device
T
160.8363
$8,775.39
$1,755.08
0228
Creation of Lumbar Subarachnoid Shunt
T
52.2880
$2,852.89
$639.03
$570.58
0229
Transcatherter Placement of Intravascular Shunt
T
61.9895
$3,382.21
$771.23
$676.44
0230
Level I Eye Tests & Treatments
S
0.7619
$41.57
$14.97
$8.31
0231
Level III Eye Tests & Treatments
S
2.1883
$119.40
$50.94
$23.88
0232
Level I Anterior Segment Eye Procedures
T
4.9206
$268.47
$103.17
$53.69
0233
Level II Anterior Segment Eye Procedures
T
14.4205
$786.80
$266.33
$157.36
0234
Level III Anterior Segment Eye Procedures
T
21.4631
$1,171.05
$511.31
$234.21
0235
Level I Posterior Segment Eye Procedures
T
5.0749
$276.89
$72.04
$55.38
0236
Level II Posterior Segment Eye Procedures
T
18.6701
$1,018.66
$203.73
0237
Level III Posterior Segment Eye Procedures
T
34.1784
$1,864.81
$818.54
$372.96
0238
Level I Repair and Plastic Eye Procedures
T
3.1954
$174.34
$58.96
$34.87
0239
Level II Repair and Plastic Eye Procedures
T
6.1331
$334.63
$66.93
0240
Level III Repair and Plastic Eye Procedures
T
17.4535
$952.28
$315.31
$190.46
0241
Level IV Repair and Plastic Eye Procedures
T
22.1969
$1,211.09
$384.47
$242.22
0242
Level V Repair and Plastic Eye Procedures
T
29.4294
$1,605.70
$597.36
$321.14
0243
Strabismus/Muscle Procedures
T
21.7323
$1,185.74
$431.39
$237.15
0244
Corneal Transplant
T
37.6284
$2,053.04
$803.26
$410.61
0245
Level I Cataract Procedures without IOL Insert
T
12.2973
$670.95
$222.22
$134.19
0246
Cataract Procedures with IOL Insert
T
22.9755
$1,253.57
$495.96
$250.71
0247
Laser Eye Procedures Except Retinal
T
4.9482
$269.98
$104.31
$54.00
0248
Laser Retinal Procedures
T
4.8223
$263.11
$95.08
$52.62
0249
Level II Cataract Procedures without IOL Insert
T
27.7406
$1,513.55
$524.67
$302.71
0250
Nasal Cauterization/Packing
T
1.4697
$80.19
$28.07
$16.04
0251
Level I ENT Procedures
T
1.7880
$97.56
$19.51
0252
Level II ENT Procedures
T
6.4469
$351.75
$113.41
$70.35
0253
Level III ENT Procedures
T
15.2249
$830.69
$282.29
$166.14
0254
Level IV ENT Procedures
T
21.8901
$1,194.35
$321.35
$238.87
0256
Level V ENT Procedures
T
35.1548
$1,918.08
$383.62
0258
Tonsil and Adenoid Procedures
T
20.6265
$1,125.40
$437.25
$225.08
0259
Level VI ENT Procedures
T
392.8622
$21,434.95
$9,394.83
$4,286.99
0260
Level I Plain Film Except Teeth
X
0.7802
$42.57
$21.28
$8.51
0261
Level II Plain Film Except Teeth Including Bone Density Measurement
X
1.3176
$71.89
$14.38
0262
Plain Film of Teeth
X
0.7540
$41.14
$9.82
$8.23
0263
Level I Miscellaneous Radiology Procedures
X
2.1883
$119.40
$43.58
$23.88
0264
Level II Miscellaneous Radiology Procedures
X
3.0287
$165.25
$79.41
$33.05
0265
Level I Diagnostic Ultrasound Except Vascular
S
1.0289
$56.14
$28.07
$11.23
0266
Level II Diagnostic Ultrasound Except Vascular
S
1.6117
$87.94
$43.97
$17.59
0267
Level III Diagnostic Ultrasound Except Vascular
S
2.4586
$134.14
$65.52
$26.83
0268
Ultrasound Guidance Procedures
S
1.3081
$71.37
$14.27
0269
Level III Echocardiogram Except Transesophageal
S
3.2309
$176.28
$87.24
$35.26
0270
Transesophageal Echocardiogram
S
5.8546
$319.43
$146.79
$63.89
0271
Mammography
S
0.6499
$35.46
$16.80
$7.09
0272
Level I Fluoroscopy
X
1.4184
$77.39
$38.36
$15.48
0274
Myelography
S
3.5931
$196.04
$93.63
$39.21
0275
Arthrography
S
3.2775
$178.82
$69.09
$35.76
0276
Level I Digestive Radiology
S
1.5906
$86.78
$41.72
$17.36
0277
Level II Digestive Radiology
S
2.4444
$133.37
$60.47
$26.67
0278
Diagnostic Urography
S
2.7012
$147.38
$66.07
$29.48
0279
Level II Angiography and Venography except Extremity
S
10.7073
$584.20
$174.57
$116.84
0280
Level III Angiography and Venography except Extremity
S
19.1015
$1,042.20
$353.85
$208.44
0281
Venography of Extremity
S
6.6031
$360.27
$115.16
$72.05
0282
Miscellaneous Computerized Axial Tomography
S
1.6834
$91.85
$44.51
$18.37
0283
Computerized Axial Tomography with Contrast Material
S
4.6543
$253.94
$126.27
$50.79
0284
Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contras
S
7.1165
$388.28
$194.13
$77.66
0285
Myocardial Positron Emission Tomography (PET)
S
14.1508
$772.08
$334.45
$154.42
0287
Complex Venography
S
6.4923
$354.23
$111.33
$70.85
0288
Bone Density:Axial Skeleton
S
1.2726
$69.43
$13.89
0289
Needle Localization for Breast Biopsy
X
3.4900
$190.42
$44.80
$38.08
0296
Level I Therapeutic Radiologic Procedures
S
2.8635
$156.24
$69.20
$31.25
0297
Level II Therapeutic Radiologic Procedures
S
7.7145
$420.91
$172.51
$84.18
0299
Miscellaneous Radiation Treatment
S
5.7618
$314.37
$62.87
0300
Level I Radiation Therapy
S
1.4912
$81.36
$16.27
0301
Level II Radiation Therapy
S
2.1340
$116.43
$23.29
0302
Level III Radiation Therapy
S
6.3268
$345.20
$130.77
$69.04
0303
Treatment Device Construction
X
2.8835
$157.33
$66.95
$31.47
0304
Level I Therapeutic Radiation Treatment Preparation
X
1.6742
$91.35
$41.52
$18.27
0305
Level II Therapeutic Radiation Treatment Preparation
X
3.6767
$200.60
$91.38
$40.12
0310
Level III Therapeutic Radiation Treatment Preparation
X
13.7165
$748.39
$325.27
$149.68
0312
Radioelement Applications
S
3.6637
$199.90
$39.98
0313
Brachytherapy
S
13.8073
$753.34
$150.67
0314
Hyperthermic Therapies
S
4.6041
$251.20
$101.77
$50.24
0320
Electroconvulsive Therapy
S
5.3785
$293.46
$80.06
$58.69
0321
Biofeedback and Other Training
S
1.4817
$80.84
$21.78
$16.17
0322
Brief Individual Psychotherapy
S
1.2802
$69.85
$13.97
0323
Extended Individual Psychotherapy
S
1.8689
$101.97
$21.26
$20.39
0324
Family Psychotherapy
S
2.4473
$133.53
$26.71
0325
Group Psychotherapy
S
1.4865
$81.10
$18.27
$16.22
0330
Dental Procedures
S
0.5745
$31.35
$6.27
0332
Computerized Axial Tomography and Computerized Angiography without Contras
S
3.3936
$185.16
$91.27
$37.03
0333
Computerized Axial Tomography and Computerized Angio w/o Contrast Material
S
5.4241
$295.94
$146.98
$59.19
0335
Magnetic Resonance Imaging, Miscellaneous
S
6.3499
$346.46
$151.46
$69.29
0336
Magnetic Resonance Imaging and Magnetic Resonance Angiography without Cont
S
6.3897
$348.63
$174.31
$69.73
0337
MRI and Magnetic Resonance Angiography without Contrast Material followed
S
9.2075
$502.37
$240.77
$100.47
0339
Observation
S
6.6961
$365.35
$73.07
0340
Minor Ancillary Procedures
X
0.6314
$34.45
$6.89
0341
Skin Tests
X
0.1365
$7.45
$3.03
$1.49
0342
Level I Pathology
X
0.2162
$11.80
$5.88
$2.36
0343
Level II Pathology
X
0.4617
$25.19
$12.55
$5.04
0344
Level III Pathology
X
0.6291
$34.32
$17.16
$6.86
0345
Level I Transfusion Laboratory Procedures
X
0.2550
$13.91
$3.10
$2.78
0346
Level II Transfusion Laboratory Procedures
X
0.3866
$21.09
$5.32
$4.22
0347
Level III Transfusion Laboratory Procedures
X
0.9610
$52.43
$13.20
$10.49
0348
Fertility Laboratory Procedures
X
0.8194
$44.71
$8.94
0352
Level I Injections
X
0.1230
$6.71
$1.34
0353
Level II Allergy Injections
X
0.3982
$21.73
$4.35
0355
Level III Immunizations
K
0.2749
$15.00
$3.00
0356
Level IV Immunizations
K
0.7698
$42.00
$8.40
0359
Level II Injections
X
0.8000
$43.65
$8.73
0360
Level I Alimentary Tests
X
1.7313
$94.46
$42.45
$18.89
0361
Level II Alimentary Tests
X
3.5510
$193.75
$83.23
$38.75
0362
Level III Otorhinolaryngologic Function Tests
X
2.6984
$147.23
$29.45
0363
Level I Otorhinolaryngologic Function Tests
X
0.8641
$47.15
$17.44
$9.43
0364
Level I Audiometry
X
0.4459
$24.33
$9.06
$4.87
0365
Level II Audiometry
X
1.2132
$66.19
$18.95
$13.24
0367
Level I Pulmonary Test
X
0.5887
$32.12
$15.16
$6.42
0368
Level II Pulmonary Tests
X
0.9319
$50.85
$25.42
$10.17
0369
Level III Pulmonary Tests
X
2.4984
$136.32
$44.18
$27.26
0370
Allergy Tests
X
0.9185
$50.11
$11.58
$10.02
0371
Level I Allergy Injections
X
0.4105
$22.40
$4.48
0372
Therapeutic Phlebotomy
X
0.5607
$30.59
$10.09
$6.12
0373
Neuropsychological Testing
X
2.3288
$127.06
$25.41
0374
Monitoring Psychiatric Drugs
X
1.1252
$61.39
$12.28
0375
Ancillary Outpatient Services When Patient Expires
T
$1,150.00
$230.00
0376
Level II Cardiac Imaging
S
4.4510
$242.85
$121.42
$48.57
0377
Level III Cardiac Imaging
S
6.8830
$375.54
$187.76
$75.11
0378
Level II Pulmonary Imaging
S
5.4852
$299.28
$149.63
$59.86
0379
Injection adenosine 6 Mg
K
0.2078
$11.34
$2.27
0380
Dipyridamole injection
K
0.2525
$13.78
$2.76
0384
GI Procedures with Stents
T
36.5400
$1,993.66
$433.01
$398.73
0385
Level I Prosthetic Urological Procedures
S
67.1530
$3,663.93
$732.79
0386
Level II Prosthetic Urological Procedures
S
116.2382
$6,342.07
$1,268.41
0387
Level II Hysteroscopy
T
28.1480
$1,535.78
$655.55
$307.16
0388
Discography
S
11.6347
$634.80
$303.19
$126.96
0389
Non-imaging Nuclear Medicine
S
1.6328
$89.09
$44.54
$17.82
0390
Level I Endocrine Imaging
S
2.7907
$152.26
$76.13
$30.45
0391
Level II Endocrine Imaging
S
3.1956
$174.36
$87.18
$34.87
0393
Red Cell/Plasma Studies
S
4.4354
$242.00
$121.00
$48.40
0394
Hepatobiliary Imaging
S
4.3714
$238.51
$119.25
$47.70
0395
GI Tract Imaging
S
3.9536
$215.71
$107.85
$43.14
0396
Bone Imaging
S
4.1883
$228.52
$114.26
$45.70
0397
Vascular Imaging
S
2.2183
$121.03
$60.51
$24.21
0398
Level I Cardiac Imaging
S
4.5091
$246.02
$123.01
$49.20
0399
Nuclear Medicine Add-on Imaging
S
1.5273
$83.33
$41.66
$16.67
0400
Hematopoietic Imaging
S
3.8242
$208.65
$104.32
$41.73
0401
Level I Pulmonary Imaging
S
3.3736
$184.07
$92.03
$36.81
0402
Brain Imaging
S
5.4063
$294.97
$147.48
$58.99
0403
CSF Imaging
S
3.8402
$209.53
$104.76
$41.91
0404
Renal and Genitourinary Studies Level I
S
3.7303
$203.53
$101.76
$40.71
0405
Renal and Genitourinary Studies Level II
S
4.3432
$236.97
$118.48
$47.39
0406
Tumor/Infection Imaging
S
4.3955
$239.82
$119.91
$47.96
0407
Radionuclide Therapy
S
3.5841
$195.55
$97.77
$39.11
0409
Red Blood Cell Tests
X
0.1390
$7.58
$2.32
$1.52
0410
Mammogram Add On
S
0.1523
$8.31
$1.66
0411
Respiratory Procedures
S
0.4367
$23.83
$4.77
0412
IMRT Treatment Delivery
S
5.3904
$294.11
$58.82
0415
Level II Endoscopy Lower Airway
T
20.7348
$1,131.31
$459.92
$226.26
0600
Low Level Clinic Visits
V
0.9278
$50.62
$10.12
0601
Mid Level Clinic Visits
V
0.9816
$53.56
$10.71
0602
High Level Clinic Visits
V
1.5041
$82.07
$16.41
0610
Low Level Emergency Visits
V
1.3691
$74.70
$19.57
$14.94
0611
Mid Level Emergency Visits
V
2.3967
$130.77
$36.16
$26.15
0612
High Level Emergency Visits
V
4.1476
$226.30
$54.12
$45.26
0620
Critical Care
S
8.9992
$491.01
$142.30
$98.20
0648
Breast Reconstruction with Prosthesis
T
54.0165
$2,947.19
$589.44
0651
Complex Interstitial Radiation Source Application
S
10.2314
$558.24
$111.65
0652
Insertion of Intraperitoneal Catheters
T
27.0364
$1,475.13
$295.03
0653
Vascular Reconstruction/Fistula Repair with Device
T
30.0334
$1,638.65
$327.73
0654
Insertion/Replacement of a permanent dual chamber pacemaker
T
112.6957
$6,148.79
$1,229.76
0655
Insertion/Replacement/Conversion of a permanent dual chamber pacemaker
T
142.7039
$7,786.07
$1,557.21
0656
Transcatheter Placement of Intracoronary Drug-Eluting Stents
T
103.4907
$5,646.56
$1,129.31
0657
Placement of Tissue Clips
S
1.5102
$82.40
$16.48
0658
Percutaneous Breast Biopsies
T
5.5779
$304.34
$60.87
0659
Hyperbaric Oxygen
S
3.0228
$164.93
$32.99
660
Level II Otorhinolaryngologic Function Tests
X
1.7353
$94.68
$30.66
$18.94
0661
Level IV Pathology
X
3.2576
$177.74
$88.87
$35.55
0662
CT Angiography
S
5.8775
$320.68
$156.47
$64.14
0664
Proton Beam Radiation Therapy
S
9.7295
$530.85
$106.17
0665
Bone Density: Appendicular Skeleton
S
0.7257
$39.59
$7.92
0668
Level I Angiography and Venography except Extremity
S
10.2660
$560.12
$237.76
$112.02
0669
Digital Mammography
S
0.9009
$49.15
$9.83
0670
Intravenous and Intracardiac Ultrasound
S
27.4483
$1,497.61
$542.37
$299.52
0671
Level II Echocardiogram Except Transesophageal
S
1.6384
$89.39
$44.69
$17.88
0672
Level IV Posterior Segment Procedures
T
38.9476
$2,125.02
$988.43
$425.00
0673
Level IV Anterior Segment Eye Procedures
T
26.8390
$1,464.36
$649.56
$292.87
0674
Prostate Cryoablation
T
119.9733
$6,545.86
$1,309.17
0675
Prostatic Thermotherapy
T
49.3452
$2,692.32
$538.46
0676
Level II Transcatheter Thrombolysis
T
2.7315
$149.03
$40.30
$29.81
0677
Level I Transcatheter Thrombolysis
T
2.1805
$118.97
$23.79
0678
External Counterpulsation
T
2.0659
$112.72
$22.54
0679
Level II Resuscitation and Cardioversion
S
5.4887
$299.47
$95.30
$59.89
0680
Insertion of Patient Activated Event Recorders
S
62.8252
$3,427.81
$685.56
0681
Knee Arthroplasty
T
98.1613
$5,355.78
$2,131.36
$1,071.16
0682
Level V Debridement & Destruction
T
8.0790
$440.80
$174.57
$88.16
0683
Level II Photochemotherapy
S
1.5489
$84.51
$30.42
$16.90
0685
Level III Needle Biopsy/Aspiration Except Bone Marrow
T
4.8100
$262.44
$115.47
$52.49
0686
Level III Skin Repair
T
7.9247
$432.38
$198.89
$86.48
0687
Revision/Removal of Neurostimulator Electrodes
T
20.4416
$1,115.31
$513.05
$223.06
0688
Revision/Removal of Neurostimulator Pulse Generator Receiver
T
46.7347
$2,549.89
$1,249.45
$509.98
0689
Electronic Analysis of Cardioverter-defibrillators
S
0.5533
$30.19
$6.04
0690
Electronic Analysis of Pacemakers and other Cardiac Devices
S
0.4074
$22.23
$10.63
$4.45
0691
Electronic Analysis of Programmable Shunts/Pumps
S
2.8066
$153.13
$76.56
$30.63
0692
Electronic Analysis of Neurostimulator Pulse Generators
S
1.1057
$60.33
$30.16
$12.07
0693
Level II Breast Reconstruction
T
39.0111
$2,128.48
$798.17
$425.70
0694
Mohs Surgery
T
2.9752
$162.33
$64.93
$32.47
0695
Level VII Debridement & Destruction
T
19.1849
$1,046.75
$266.59
$209.35
0697
Level I Echocardiogram Except Transesophageal
S
1.4415
$78.65
$39.32
$15.73
0698
Level II Eye Tests & Treatments
S
0.9599
$52.37
$18.72
$10.47
0699
Level IV Eye Tests & Treatments
T
2.2303
$121.69
$47.46
$24.34
0700
Antepartum Manipulation
T
2.4306
$132.62
$37.13
$26.52
0701
SR 89 chloride, per mCi
K
$892.43
$178.49
0702
SM 153 lexidronam, 50 mCi
K
$493.89
$98.78
0704
IN 111 Satumomab pendetide per dose
K
$1,474.00
$294.80
0705
Technetium TC99M tetrofosmin
K
1.0642
$665.28
$133.06
0726
Dexrazoxane hcl injection, 250 mg
K
2.0616
$112.48
$22.50
0728
Filgrastim 300 mcg injection
K
$172.20
$34.44
0730
Pamidronate disodium , 30 mg
K
$128.74
$25.75
0731
Sargramostim injection
K
$26.92
$5.38
0732
Mesna injection 200 mg
K
$17.66
$3.53
0733
Non esrd epoetin alpha inj, 1000 u
K
$11.76
$2.35
0734
Injection, darbepoetin alfa (for non-ESRD), per 1 mcg
K
$3.88
$0.78
0763
Dolasetron mesylate oral
K
$152.38
$30.48
0764
Granisetron HCl injection
K
$17.18
$3.44
0765
Granisetron HCl 1 mg oral
K
$171.78
$34.36
0800
Leuprolide acetate, 3.75 mg
K
$479.20
$95.84
0802
Etoposide oral 50 mg
K
$21.91
$4.38
0807
Aldesleukin/single use vial
K
$680.35
$136.07
0809
Bcg live intravesical vac
K
$77.54
$15.51
0810
Goserelin acetate implant 3.6 mg
K
$413.59
$82.72
0811
Carboplatin injection 50 mg
K
$137.79
$27.56
0813
Cisplatin 10 mg injection
K
$7.73
$1.55
0814
Asparaginase injection
K
$58.00
$11.60
0815
Cyclophosphamide 100 MG inj
K
$2.77
$0.55
0816
Cyclophosphamide lyophilized
K
$2.36
$0.47
0817
Cytarabine hcl 100 MG inj
K
$1.55
$0.31
0819
Dacarbazine 100 mg inj
K
0.0974
$5.31
$1.06
0820
Daunorubicin 10 mg
K
$35.94
$7.19
0821
Daunorubicin citrate liposom 10 mg
K
$64.60
$12.92
0823
Docetaxel, 20 mg
K
$331.53
$66.31
0824
Etoposide 10 MG inj
K
$0.83
$0.17
0827
Floxuridine injection 500 mg
K
$66.24
$13.25
0828
Gemcitabine HCL 200 mg
K
$112.09
$22.42
0830
Irinotecan injection 20 mg
K
$135.00
$27.00
0831
Ifosfomide injection 1 gm
K
$72.81
$14.56
0832
Idarubicin hcl injection 5 mg
K
3.2663
$178.21
$35.64
0834
Interferon alfa-2a inj
K
$32.31
$6.46
0836
Interferon alfa-2b inj recombinant, 1 million
K
$13.78
$2.76
0838
Interferon gamma 1-b inj, 3 million u
K
$290.70
$58.14
0840
Melphalan hydrochl 50 mg
K
$389.14
$77.83
0842
Fludarabine phosphate inj 50 mg
K
$329.83
$65.97
0844
Pentostatin injection, 10 mg
K
$1,784.64
$356.93
0847
Doxorubic hcl 10 MG vl chemo
K
$4.69
$0.94
0849
Rituximab, 100 mg
K
$464.20
$92.84
0850
Streptozocin injection, 1 gm
K
$131.05
$26.21
0851
Thiotepa injection
K
$45.31
$9.06
0852
Topotecan, 4 mg
K
$739.80
$147.96
0855
Vinorelbine tartrate, 10 mg
K
$100.97
$20.19
0856
Porfimer sodium, 75 mg
K
$2,411.82
$482.36
0857
Bleomycin sulfate injection 15 u
K
$88.32
$17.66
0858
Cladribine, 1mg
K
$24.84
$4.97
0860
Plicamycin (mithramycin) inj
K
$86.89
$17.38
0861
Leuprolide acetate injection 1 mg
K
$14.48
$2.90
0862
Mitomycin 5 mg inj
K
$30.91
$6.18
0863
Paclitaxel injection, 30 mg
K
$79.04
$15.81
0864
Mitoxantrone hcl, 5 mg
K
$332.87
$66.57
0865
Interferon alfa-n3 inj, human leukocyte derived, 2
K
$8.17
$1.63
0884
Rho d immune globulin inj, 1 dose pkg
K
$92.93
$18.59
0888
Cyclosporine oral 100 mg
K
$2.41
$0.48
0890
Lymphocyte immune globulin 250 mg
K
$258.17
$51.63
0891
Tacrolimus oral per 1 mg
K
$3.24
$0.65
0900
Alglucerase injection, per 10 u
K
$37.13
$7.43
0901
Alpha 1 proteinase inhibitor, 10 mg
K
$3.43
$0.69
0902
Botulinum toxin a, per unit
K
$4.58
$0.92
0903
Cytomegalovirus imm IV/vial
K
$659.60
$131.92
0905
Immune globulin, 1g
K
$37.95
$7.59
0906
RSV-ivig, 50 mg
K
$16.55
$3.31
0907
Ganciclovir sodium injection
K
0.5918
$32.29
$6.46
0909
Interferon beta-1a, 33 mcg
K
$123.77
$24.75
0910
Interferon beta-1b /0.25 mg
K
$67.22
$13.44
0911
Streptokinase per 250,000 iu
K
1.5733
$85.84
$17.17
0913
Ganciclovir long act implant
K
1.5861
$86.54
$17.31
0916
Imiglucerase injection/unit
K
$3.71
$0.74
0917
Adenosine injection
K
1.0393
$56.71
$11.34
0925
Factor viii per iu
K
$0.42
$0.08
0926
Factor VIII (porcine) per iu
K
$1.89
$0.38
0927
Factor viii recombinant per iu
K
$0.61
$0.12
0928
Factor ix complex per iu
K
$0.18
$0.04
0929
Anti-inhibitor per iu
K
$0.69
$0.14
0931
Factor IX non-recombinant, per iu
K
$0.51
$0.10
0932
Factor IX recombinant, per iu
K
$1.04
$0.21
0949
Plasma, Pooled Multiple Donor, Solvent/Detergent
K
$124.31
$24.86
0950
Blood (Whole) For Transfusion
K
$87.93
$17.59
0952
Cryoprecipitate
K
$29.31
$5.86
0954
RBC leukocytes reduced
K
$119.26
$23.85
0955
Plasma, Fresh Frozen
K
$95.00
$19.00
0956
Plasma Protein Fraction
K
$92.98
$18.60
0957
Platelet Concentrate
K
$41.44
$8.29
0958
Platelet Rich Plasma
K
$53.56
$10.71
0959
Red Blood Cells
K
$86.41
$17.28
0960
Washed Red Blood Cells
K
$160.69
$32.14
0961
Infusion, Albumin (Human) 5%, 50 ml
K
0.2802
$15.29
$3.06
0963
Albumin (human), 5%, 250 ml
K
1.0901
$59.48
$11.90
0964
Albumin (human), 25%, 20 ml
K
0.3741
$20.41
$4.08
0965
Albumin (human), 25%, 50ml
K
0.8869
$48.39
$9.68
0966
Plasmaprotein fract,5%,250ml
K
$464.90
$92.98
1009
Cryoprecip reduced plasma
K
$37.39
$7.48
1010
Blood, L/R, CMV-neg
K
$121.78
$24.36
1011
Platelets, HLA-m, L/R, unit
K
$499.77
$99.95
1013
Platelet concentrate, L/R, unit
K
$49.52
$9.90
1016
Blood, L/R, froz/deglycerol/washed
K
$301.68
$60.34
1017
Platelets, aph/pher, L/R, CMV-neg, unit
K
$393.15
$78.63
1018
Blood, L/R, irradiated
K
$132.40
$26.48
1019
Platelets, aph/pher, L/R, irradiated, unit
K
$406.28
$81.26
1020
Pit, pher,L/R,CMV,irrad
K
$495.22
$99.04
1021
RBC, frz/deg/wsh, L/R, irrad
K
$336.04
$67.21
1022
RBC, L/R, CMV neg, irrad
K
$201.12
$40.22
1045
Iobenguane sulfate I-131per 0.5 mCi
K
3.0392
$165.82
$33.16
1064
I-131 sodium iodide capsule
K
0.1004
$5.48
$1.10
1065
I-131 sodium iodide solution
K
0.1189
$6.49
$1.30
1079
CO 57/58 per 0.5 uCi
K
$235.14
$47.03
1080
I-131 tositumomab, dx
K
$2,565.55
$513.11
1081
I-131 tositumomab, tx
K
$22,210.19
$4,442.04
1084
Denileukin diftitox, 300 MCG
K
$1,232.88
$246.58
1086
Temozolomide,oral 5 mg
K
$6.81
$1.36
1089
Cyanocobalamin cobalt co57
K
$47.38
$9.48
1091
IN 111 Oxyquinoline, per .5 mCi
K
4.1151
$224.52
$44.90
1092
IN 111 Pentetate, per 0.5 mCi
K
$237.60
$47.52
1095
Technetium TC 99M Depreotide
K
$704.00
$140.80
1096
TC 99M Exametazime, per dose
K
$825.00
$165.00
1122
TC 99M arcitumomab, per vial
K
$1,144.00
$228.80
1166
Cytarabine liposome
K
$344.08
$68.82
1167
Epirubicin hcl, 2 mg
K
$25.60
$5.12
1178
Busulfan IV, 6 mg
K
$27.87
$5.57
1200
TC 99M Sodium Glucoheptonat
K
$30.28
$6.06
1201
TC 99M SUCCIMER, PER Vial
K
$125.66
$25.13
1203
Verteporfin for injection
K
$1,350.80
$270.16
1207
Octreotide injection, depd
K
$73.62
$14.72
1305
Apligraf
K
$1,199.00
$239.80
1409
Factor viia recombinant, per 1.2 mg
K
$1,495.30
$299.06
1501
New Technology - Level I ($0–$50)
S
$25.00
$5.00
1502
New Technology - Level II ($50–$100)
S
$75.00
$15.00
1503
New Technology - Level III ($100–$200)
S
$150.00
$30.00
1504
New Technology - Level IV ($200–$300)
S
$250.00
$50.00
1505
New Technology - Level V ($300–$400)
S
$350.00
$70.00
1506
New Technology - Level VI ($400–$500)
S
$450.00
$90.00
1507
New Technology - Level VII ($500–$600)
S
$550.00
$110.00
1508
New Technology - Level VIII ($600–$700)
S
$650.00
$130.00
1509
New Technology - Level IX ($700–$800)
S
$750.00
$150.00
1510
New Technology - Level X ($800–$900)
S
$850.00
$170.00
1511
New Technology - Level XI ($900–$1000)
S
$950.00
$190.00
1512
New Technology - Level XII ($1000–$1100)
S
$1,050.00
$210.00
1513
New Technology - Level XIII ($1100–$1200)
S
$1,150.00
$230.00
1514
New Technology - Level XIV ($1200–$1300)
S
$1,250.00
$250.00
1515
New Technology - Level XV ($1300–$1400)
S
$1,350.00
$270.00
1516
New Technology - Level XVI ($1400–$1500)
S
$1,450.00
$290.00
1517
New Technology - Level XVII ($1500–$1600)
S
$1,550.00
$310.00
1518
New Technology - Level XVIII ($1600–$1700)
S
$1,650.00
$330.00
1519
New Technology - Level IXX ($1700–$1800)
S
$1,750.00
$350.00
1520
New Technology - Level XX ($1800–$1900)
S
$1,850.00
$370.00
1521
New Technology - Level XXI ($1900–$2000)
S
$1,950.00
$390.00
1522
New Technology - Level XXII ($2000–$2500)
S
$2,250.00
$450.00
1523
New Technology - Level XXIII ($2500–$3000)
S
$2,750.00
$550.00
1524
New Technology - Level XIV ($3000–$3500)
S
$3,250.00
$650.00
1525
New Technology - Level XXV ($3500–$4000)
S
$3,750.00
$750.00
1526
New Technology - Level XXVI ($4000–$4500)
S
$4,250.00
$850.00
1527
New Technology - Level XXVII ($4500–$5000)
S
$4,750.00
$950.00
1528
New Technology - Level XXVIII ($5000–$5500)
S
$5,250.00
$1,050.00
1529
New Technology - Level XXIX ($5500–$6000)
S
$5,750.00
$1,150.00
1530
New Technology - Level XXX ($6000–$6500)
S
$6,250.00
$1,250.00
1531
New Technology - Level XXXI ($6500–$7000)
S
$6,750.00
$1,350.00
1532
New Technology - Level XXXII ($7000–$7500)
S
$7,250.00
$1,450.00
1533
New Technology - Level XXXIII ($7500–$8000)
S
$7,750.00
$1,550.00
1534
New Technology - Level XXXIV ($8000–$8500)
S
$8,250.00
$1,650.00
1535
New Technology - Level XXXV ($8500–$9000)
S
$8,750.00
$1,750.00
1536
New Technology - Level XXXVI ($9000–$9500)
S
$9,250.00
$1,850.00
1537
New Technology - Level XXXVII ($9500–$10000)
S
$9,750.00
$1,950.00
1538
New Technology - Level I ($0–$50)
T
$25.00
$5.00
1539
New Technology - Level II ($50–$100)
T
$75.00
$15.00
1540
New Technology - Level III ($100–$200)
T
$150.00
$30.00
1541
New Technology - Level IV ($200–$300)
T
$250.00
$50.00
1542
New Technology - Level V ($300–$400)
T
$350.00
$70.00
1543
New Technology - Level VI ($400–$500)
T
$450.00
$90.00
1544
New Technology - Level VII ($500–$600)
T
$550.00
$110.00
1545
New Technology - Level VIII ($600–$700)
T
$650.00
$130.00
1546
New Technology - Level IX ($700–$800)
T
$750.00
$150.00
1547
New Technology - Level X ($800–$900)
T
$850.00
$170.00
1548
New Technology - Level XI ($900–$1000)
T
$950.00
$190.00
1549
New Technology - Level XII ($1000–$1100)
T
$1,050.00
$210.00
1550
New Technology - Level XIII ($1100–$1200)
T
$1,150.00
$230.00
1551
New Technology - Level XIV ($1200–$1300)
T
$1,250.00
$250.00
1552
New Technology - Level XV ($1300–$1400)
T
$1,350.00
$270.00
1553
New Technology - Level XVI ($1400–$1500)
T
$1,450.00
$290.00
1554
New Technology - Level XVII ($1500–$1600)
T
$1,550.00
$310.00
1555
New Technology - Level XVIII ($1600–$1700)
T
$1,650.00
$330.00
1556
New Technology - Level XIX ($1700–$1800)
T
$1,750.00
$350.00
1557
New Technology - Level XX ($1800–$1900)
T
$1,850.00
$370.00
1558
New Technology - Level XXI ($1900–$2000)
T
$1,950.00
$390.00
1559
New Technology - Level XXII ($2000–$2500)
T
$2,250.00
$450.00
1560
New Technology - Level XXIII ($2500–$3000)
T
$2,750.00
$550.00
1561
New Technology - Level XXIV ($3000–$3500)
T
$3,250.00
$650.00
1562
New Technology - Level XXV ($3500–$4000)
T
$3,750.00
$750.00
1563
New Technology - Level XXVI ($4000–$4500)
T
$4,250.00
$850.00
1564
New Technology - Level XXVII ($4500–$5000)
T
$4,750.00
$950.00
1565
New Technology - Level XXVIII ($5000–$5500)
T
$5,250.00
$1,050.00
1566
New Technology - Level XXIX ($5500–$6000)
T
$5,750.00
$1,150.00
1567
New Technology - Level XXX ($6000–$6500)
T
$6,250.00
$1,250.00
1568
New Technology - Level XXXI ($6500–$7000)
T
$6,750.00
$1,350.00
1569
New Technology - Level XXXII ($7000–$7500)
T
$7,250.00
$1,450.00
1570
New Technology - Level XXXIII ($7500–$8000)
T
$7,750.00
$1,550.00
1571
New Technology - Level XXXIV ($8000–$8500)
T
$8,250.00
$1,650.00
1572
New Technology - Level XXXV ($8500–$9000)
T
$8,750.00
$1,750.00
1573
New Technology - Level XXXVI ($9000–$9500)
T
$9,250.00
$1,850.00
1574
New Technology - Level XXXVII ($9500–$10000)
T
$9,750.00
$1,950.00
1600
Technetium TC 99m sestamibi
K
$112.73
$22.55
1603
Thallous chloride TL 201/mci
K
$18.29
$3.66
1604
IN 111 capromab pendetide, per dose
K
$2,030.60
$406.12
1605
Abciximab injection, 10 mg
K
$475.22
$95.04
1606
Anistreplase, 30 u
K
$2,495.31
$499.06
1607
Eptifibatide injection, 5mg
K
$11.88
$2.38
1608
Etanercept injection
K
$143.73
$28.75
1609
Rho(D) immune globulin h, sd, 100 iu
K
$19.03
$3.81
1611
Hylan G-F 20 injection, 16 mg
K
$215.97
$43.19
1612
Daclizumab, parenteral, 25 mg
K
$393.78
$78.76
1613
Trastuzumab, 10 mg
K
$53.85
$10.77
1614
Valrubicin, 200 mg
K
$487.87
$97.57
1615
Basiliximab, 20 mg
K
$1,425.06
$285.01
1618
Vonwillebrandfactrcmplx, per iu
K
$0.46
$0.09
1619
Gallium ga 67
K
0.2056
$11.22
$2.24
1620
Technetium tc99m bicisate
K
$392.93
$78.59
1622
Technetium tc99m mertiatide
K
$1,650.00
$330.00
1624
Sodium phosphate p32
K
$66.44
$13.29
1625
Indium 111-in pentetreotide
K
$1,144.00
$228.80
1628
Chromic phosphate p32
K
$81.27
$16.25
1716
Brachytx source, Gold 198
H
1717
Brachytx source, HDR Ir-192
H
1718
Brachytx source, Iodine 125
H
1719
Brachytx source,Non-HDR Ir-192
H
1720
Brachytx source, Palladium 103
H
1775
FDG, per dose (4-40 mCi/ml)
K
5.9471
$324.48
$64.90
1783
Ocular implant, aqueous drain device
H
$-
1814
Retinal Tamp, silicone oil
H
$-
1818
Integrated keratoprosthesis
H
$-
1819
Tissue localization-excision dev
H
$-
1884
Embolization Protect syst
H
$-
1888
Catheter, ablation, non-cardiac, endovascular (implantable)
H
$-
1900
Lead coronary venous
H
$-
2614
Probe, percutaneous lumbar disc
H
$-
2616
Brachytx source, Yttrium-90
H
2632
Brachytx sol, I-125, per mCi
H
$-
2633
Brachytx source, Cesium-131
H
7000
Amifostine, 500 mg
K
$419.59
$83.92
7007
Inj milrinone lactate, per 5 mg
K
0.2129
$11.62
$2.32
7011
Oprelvekin injection, 5 mg
K
$248.16
$49.63
7015
Busulfan, oral, 2 mg
K
$1.93
$0.39
7019
Aprotinin, 10,000 kiu
K
$13.26
$2.65
7024
Corticorelin ovine triflutat
K
$375.00
$75.00
7025
Digoxin immune FAB (ovine)
K
$1.79
$0.36
7026
Ethanolamine oleate 100 mg
K
$67.10
$13.42
7027
Fomepizole, 15mg
K
$10.65
$2.13
7028
Fosphenytoin, 50 mg
K
$5.63
$1.13
7030
Hemin, per 1 mg
K
$6.86
$1.37
7031
Octreotide acetate injection
K
$3.94
$0.79
7034
Somatropin injection
K
$297.79
$59.56
7035
Teniposide, 50 mg
K
$238.49
$47.70
7036
Urokinase 250,000 iu inj
K
3.7855
$206.54
$41.31
7037
Urofollitropin, 75 iu
K
1.1634
$63.48
$12.70
7038
Muromonab-CD3, 5 mg
K
$792.33
$158.47
7040
Pentastarch 10% solution
K
$139.94
$27.99
7041
Tirofiban hydrochloride 12.5 mg
K
$436.66
$87.33
7042
Capecitabine, oral, 150 mg
K
$3.14
$0.63
7043
Infliximab injection 10 mg
K
$31.81
$6.36
7045
Trimetrexate glucoronate
K
$132.00
$26.40
7046
Doxorubicin hcl liposome inj 10 mg
K
$364.49
$72.90
7048
Alteplase recombinant
K
0.2856
$15.58
$3.12
7049
Filgrastim 480 mcg injection
K
$290.93
$58.19
7051
Leuprolide acetate implant, 65 mg
K
$5,001.92
$1,000.38
7316
Sodium hyaluronate injection
K
$67.16
$13.43
9001
Linezolid injection
K
$34.09
$6.82
9002
Tenecteplase, 50mg/vial
K
$2,492.60
$498.52
9003
Palivizumab, per 50mg
K
$611.24
$122.25
9004
Gemtuzumab ozogamicin inj,5mg
K
$2,022.90
$404.58
9005
Reteplase injection
K
$1,263.90
$252.78
9006
Tacrolimus injection
K
$110.04
$22.01
9008
Baclofen Refill Kit-500mcg
K
$73.92
$14.78
9009
Baclofen refill kit - per 2000 mcg
K
0.7499
$40.92
$8.18
9010
Baclofen refill kit - per 4000 mcg
K
$79.82
$15.96
9012
Arsenic Trioxide
K
$34.32
$6.86
9013
Co 57 cobaltous chloride
K
$56.67
$11.33
9015
Mycophenolate mofetil oral 250 mg
K
$1.36
$0.27
9018
Botulinum toxin B, per 100 u
K
$8.14
$1.63
9019
Caspofungin acetate, 5 mg
K
$30.52
$6.10
9020
Sirolimus tablet, 1 mg
K
$6.60
$1.32
9021
Immune globulin 10 mg
K
$0.41
$0.08
9022
IM inj interferon beta 1-a
K
$13.36
$2.67
9023
Rho d immune globulin 50 mcg
K
$32.21
$6.44
9024
Amphotericin B, lipid formulation
K
$20.86
$4.17
9025
Radiopharms Used to Image Perfusion of Heart
K
$162.63
$32.53
9100
Iodinated I-131albumin, per 5 uci
K
$48.58
$9.72
9104
Anti-thymocycte globulin rabbit
K
$331.23
$66.25
9105
Hep B imm glob, per 1 ml
K
$65.58
$13.12
9108
Thyrotropin alfa, per 1.1 mg
K
$572.00
$114.40
9109
Tirofliban hcl, per 6.25 mg
K
$218.33
$43.67
9110
Alemtuzumab, per 10 mg
K
$541.46
$108.29
9111
Inj, bivalirudin, per 250 mg vial
G
$1.61
$0.32
9112
Perflutren lipid micro, per 2ml
G
$137.28
$27.46
9113
Inj, pantoprazole sodium, vial
G
$23.23
$4.65
9114
Nesiritide, per 0.5 mg vial
G
$140.45
$28.09
9115
Inj, zoledronic acid, per 1 mg
G
$211.07
$42.21
9116
Inj, Ertapenem sodium, per 500 mg
G
$21.99
$4.40
9117
Yttrium 90 ibritumomab tiuxetan
K
$22,210.19
$4,442.04
9118
In-111 ibritumomab tiuxetan
K
$2,565.55
$513.11
9119
Pegfilgrastim, per 1 mg
G
$2,596.00
$519.20
9120
Inj, Fulvestrant, per 50 mg
G
$78.36
$13.09
9121
Inj, Argatroban, per 5 mg
G
$14.63
$2.44
9122
Inj, Triptorelin pamoate, per 3.75 mg
G
$356.66
$59.58
9123
Transcyte, per 247 sq cm
G
$689.78
$115.23
9200
Orcel, per 36 cm2
G
$1,051.60
$210.32
9201
Dermagraft, per 37.5 sq cm
G
$535.04
$107.01
9202
Octafluoropropane
K
$137.28
$27.46
9203
Perflexane lipid micro
G
$127.50
$21.30
9204
Ziprasidone mesylate
G
$18.60
$3.11
9205
Oxaliplatin
G
$8.45
$14.12
9207
Injection, bortezomib
G
$1,039.68
$155.40
9208
Injection, agalsidase beta
G
$123.78
$18.50
9209
Injection, laronidase
G
$644.10
$96.28
9210
Injection, palonosetron HCL
G
$307.80
$46.01
9211
Inj, alefacept, IV
G
$595.00
$99.40
9212
Inj, alefacept, IM
G
$422.88
$70.65
9217
Leuprolide acetate suspnsion, 7.5 mg
K
$576.47
$115.29
9500
Platelets, irradiated
K
$74.79
$14.96
9501
Platelets, pheresis
K
$408.81
$81.76
9502
Platelet pheresis irradiated
K
$443.68
$88.74
9503
Fresh frozen plasma, ea unit
K
$69.74
$13.95
9504
RBC deglycerolized
K
$183.44
$36.69
9505
RBC irradiated
K
$108.65
$21.73
9506
Granulocytes, pheresis
K
$1,248.66
$249.73
Addendum D1.—Payment Status Indicators for the Hospital Outpatient Prospective Payment System
Indicator
Item/Code/Service
Explanation
A
Services furnished to a Hospital Outpatient that are paid under a Fee Schedule/Payment System other than OPPS, e.g.:
• Ambulance Services
• Clinical Diagnostic Laboratory Services
• Non-Implantable Prosthetic and Orthotic Devices
• EPO for ESRD Patients
• Physical, Occupational and Speech Therapy
• Routine Dialysis Services for ESRD Patients Provided in a Certified Dialysis Unit of a Hospital
• Screening Mammography
Not paid under OPPS. Paid by Intermediaries under a Fee Schedule/Payment System other than OPPS.
B
Codes that are not recognized by OPPS when submitted on an Outpatient Hospital Part B bill type (12x, 13x, and 14x)
Not paid under OPPS.
• May be paid by Intermediaries when submitted on a different bill type, e.g., 75x (CORF), but not paid under OPPS.
• An alternate code that is recognized by OPPS when submitted on an Outpatient Hospital Part B bill type (12x, 13x, and 14x) may be available.
C
Inpatient Procedures
Not paid under OPPS. Admit patient; Bill as Inpatient.
D
Deleted Codes
Not paid under OPPS. Not paid under Medicare.
E
Items, Codes, and Services:
• That are not covered by Medicare based on Statutory Exclusion
• That are not covered by Medicare for reasons other than Statutory Exclusion
• That are not recognized by Medicare but for which an alternate code for the same item or service may be available
• For which separate payment is not provided by Medicare Not paid under OPPS
F
Corneal Tissue Acquisition; Certain CRNA Services
Not paid under OPPS. Paid at reasonable cost.
G
Drug/Biological Pass-Through
Paid under OPPS; Separate APC payment includes Pass-Through amount.
H
Device Category Pass-Through and Brachytherapy Source
Paid under OPPS; Separate cost-based
K
Non Pass-Through Drugs and Biologicals; Radiopharmaceutical Agents
Paid under OPPS; Separate APC payment.
L
Influenza Vaccine; Pneumococcal Pneumonia Vaccine
Not paid under OPPS. Paid at reasonable cost; Not subject to deductible or coinsurance.
N
Items and Services packaged into APC Rates
Paid under OPPS. However, payment is packaged into payment for other services, including Outliers. Therefore, there is no separate APC payment.
P
Partial Hospitalization
Paid under OPPS; Per diem APC payment.
S
Significant Procedure, Not Discounted when Multiple
Paid under OPPS; Separate APC payment.
T
Significant Procedure, Multiple Procedure Reduction Applies
Paid under OPPS; Separate APC payment.
V
Clinic or Emergency Department Visit
Paid under OPPS; Separate APC payment.
Y
Non-Implantable Durable Medical Equipment
Not paid under OPPS. All institutional providers other than Home Health Agencies bill to DMERC.
X
Ancillary Service
Paid under OPPS; Separate APC payment.