00-8215. Office of Inspector General; Medicare Program; Prospective Payment System for Hospital Outpatient Services
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AGENCY:
Health Care Financing Administration (HCFA), HHS, and Office of Inspector General (OIG), HHS.
ACTION:
Final rule with comment period.
SUMMARY:
This final rule with comment period implements a prospective payment system for hospital outpatient services furnished to Medicare beneficiaries, as set forth in section 1833(t) of the Social Security Act. It also establishes requirements for provider departments and provider-based entities, and it implements section 9343(c) of the Omnibus Budget Reconciliation Act of 1986, which prohibits Medicare payment for nonphysician services furnished to a hospital outpatient by a provider or supplier other than a hospital, unless the services are furnished under an arrangement with the hospital. In addition, this rule establishes in regulations the extension of reductions in payment for costs of hospital outpatient services required by section 4522 of the Balanced Budget Act of 1997, as amended by section 201(k) of the Balanced Budget Refinement Act of 1999.
DATES:
Effective date: July 1, 2000, except that the changes to § 412.24(d)(6), new § 413.65, and the changes to § 489.24(h), § 498.2, and § 498.3 are effective October 10, 2000.
Applicability date: For Medicare services furnished by all hospitals, including hospitals excluded from the inpatient prospective payment system, and by community mental health centers, the applicability date for implementation of the hospital outpatient prospective payment system is July 1, 2000.
Comment date: Comments on the provisions of this rule resulting from the Balanced Budget Refinement Act of 1999 will be considered if we receive them at the appropriate address, as provided below, no later than 5 p.m. on June 6, 2000. We will not consider comments concerning provisions that remain unchanged from the September 8, 1998 proposed rule or that were revised based on public comment.
See section VIII for a more detailed discussion of the provisions subject to comment.
ADDRESSES:
Mail written comments (one original and three copies) to the following address ONLY: Health Care Financing Administration, Department of Health and Human Services, Attention: HCFA-1005-FC, P.O. Box 8013, Baltimore, MD 21244-8013.
If you prefer, you may deliver, by courier, your written comments (one original and three copies) to one of the following addresses:
Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201, or
C5-14-03, Central Building, 7500 Security Boulevard, Baltimore, MD 21244-1850.
Comments mailed to those addresses may be delayed and could be considered late.
Because of staffing and resource limitations, we cannot accept comments by facsimile (FAX) transmission. In commenting, please refer to file code HCFA-1005-FC.
Comments received timely will be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, in Room 443-G of the Department's offices at 200 Independence Avenue, SW., Washington, DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m. (Phone (202) 690-7890).
For comments that relate to information collection requirements, mail a copy of comments to:
Health Care Financing Administration, Office of Information Services, Security and Standards Group, Division of HCFA Enterprise Standards, Room N2-14-26, 7500 Security Boulevard, Baltimore, MD 21244-1850, Attn: John Burke, HCFA-1005-FC; and
Lauren Oliven, HCFA Desk Officer, Office of Information and Regulatory Affairs, Room 3001, New Executive Office Building, Washington, DC 20503.
Copies: To order copies of the Federal Register containing this document, send your request to: New Orders, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date of the issue requested and enclose a check or money order payable to the Superintendent of Documents, or enclose your Visa or Master Card number and expiration date. Credit card orders can also be placed by calling the order desk at (202) 512-1800 or by faxing to (202) 512-2250. The cost for each copy is $8. As an alternative, you can view and photocopy the Federal Register document at most libraries designated as Federal Depository Libraries and at many other public and academic libraries throughout the country that receive the Federal Register.
Start Further InfoFOR FURTHER INFORMATION CONTACT:
Janet Wellham, (410) 786-4510 or Chuck Braver, (410) 786-6719 (for general information)
Joel Schaer (OIG), (202) 619-0089 (for information concerning civil money penalties)
Kitty Ahern, (410) 786-4515 (for information related to the classification of services into ambulatory payment classification (APC) groups)
George Morey (410) 786-4653 (for information related to the determination of provider-based status)
Janet Samen (410) 786-9161 (for information on the application of APCs to community mental health centers)
End Further Info End Preamble Start Supplemental InformationSUPPLEMENTARY INFORMATION:
To assist readers in referencing sections contained in this document, we are providing the following table of contents. Within each section, we summarize pertinent material from our proposed rule of September 8, 1998 (63 FR 47552) followed by public comments and our responses.
Table of Contents
I. Background
A. General and Legislative History
B. Summary of Provisions of the Balanced Budget Act of 1997 (the BBA 1997)
1. Prospective Payment System (PPS)
2. Elimination of Formula-Driven Overpayment
3. Extension of Cost Reductions
C. The September 8, 1998 Proposed Rule
D. Overview of Public Comments
E. Summary of Relevant Provisions in the Balanced Budget Refinement Act of 1999 (the BBRA 1999)
1. Outlier Adjustment
2. Transitional Pass-Through for Additional Costs of Innovative Medical Devices, Drugs, and Biologicals
3. Budget Neutrality Applied to New Adjustments
4. Limitation on Judicial Review
5. Inclusion in the Hospital Outpatient PPS of Certain Implantable Items
6. Payment Weights Based on Mean Hospital Costs
7. Limitation on Variation of Costs of Services Classified Within a Group
8. Annual Review of the Hospital Outpatient PPS Components
9. Coinsurance Not Affected by Pass-Throughs Start Printed Page 18435
10. Extension of Cost Reductions
11. Clarification of Congressional Intent Regarding Base Amounts Used in Determining the Hospital Outpatient PPS
12. Transitional Corridors For Application of Outpatient PPS
13. Limitation on Coinsurance for a Procedure
14. Reclassification of Certain Hospitals
II. Prohibition Against Unbundling of Hospital Outpatient Services
A. Background
B. Office of Inspector General (OIG) Civil Money Penalty Authority and Civil Money Penalties for Unbundling Hospital Outpatient Services
C. Summary of Final Regulations on Bundling of Hospital Outpatient Services
D. Comments and Responses
III. Hospital Outpatient Prospective Payment System (PPS)
A. Hospitals Included In or Excluded From the Outpatient PPS
B. Scope of Facility Services
1. Services Excluded from the Scope of Services Paid Under the Hospital Outpatient PPS
a. Background
b. Comments and Responses
c. Payment for Certain Implantable Items Under the BBRA 1999
d. Summary of Final Action
2. Services Included Within the Scope of the Hospital Outpatient PPS
a. Services for Patients Who Have Exhausted Their Part A Benefits
b. Partial Hospitalization Services
c. Services Designated by the Secretary
d. Summary of Final Action
3. Hospital Outpatient PPS Payment Indicators
C. Description of the Ambulatory Payment Classification (APC) Groups
1. Setting Payment Rates Based on Groups of Services Rather than on Individual Services
2. Packaging Under the APC System
a. Summary of Proposal
b. General Comments and Responses (Supporting or Objecting to Packaging)
c. Packaging of Casts and Splints
d. Packaging of Observation Services
e. Packaging Costs of Procuring Corneal Tissue
f. Packaging Costs of Blood and Blood Products
g. Packaging Costs for Drugs, Pharmaceuticals, and Biologicals
h. Summary of Final Action
3. Treatment of Clinic and Emergency Department Visits
a. Provisions of the Proposed Rule
b. Comments and Responses
4. Treatment of Partial Hospitalization Services
5. Inpatient Only Procedures
6. Modification of APC Groups
a. How the Groups Were Constructed
b. Comments on Classification of Procedures and Services Within APC Groups
c. Effect of the BBRA 1999 on Final APC Groups
d. Summary of APC Modifications
e. Exceptions to the BBRA 1999 Limit on Variation of Costs Within APC Groups
7. Discounting of Surgical Procedures
8. Payment for New Technology Services
a. Background
b. Comments and Responses
D. Transitional Pass-Through for Innovative Medical Devices, Drugs, and Biologicals
1. Statutory Basis
2. Identifying Eligible Pass-Through Items
a. Drugs and Biologicals
b. Medical Devices
3. Criteria to Define New or Innovative Medical Devices Eligible for Pass-through Payments
4. Determination of “Not Insignificant” Cost of New Items
5. Calculating the Additional Payment
6. Process to Identify Items and to Obtain Codes for Items Subject to Transitional Pass-Throughs
E. Calculation of Group Weights and Conversion Factor
1. Group Weights (Includes Table 1, Packaged Services by Revenue Center)
2. Conversion Factor
a. Calculating Aggregate Calendar Year 1996 Medicare and Beneficiary Payments for Hospital Outpatient Services (Pre-PPS)
b. Sum of the Relative Weights
F. Calculation of Coinsurance Payments and Medicare Payments Under the PPS
1. Background
2. Determining the Unadjusted Coinsurance Amount and Program Payment Percentage
a. Calculating the Unadjusted Coinsurance Amount for Each APC Group
b. Calculating the Program Payment Percentage (Pre-deductible Payment Percentage)
3. Calculating the Medicare Payment Amount and Beneficiary Coinsurance Amount
a. Calculating the Medicare Payment Amount
b. Calculating the Coinsurance Amount
4. Hospital Election to Offer Reduced Coinsurance
G. Adjustment for Area Wage Differences
1. Proposed Wage Index
2. Labor-Related Portion of Hospital Outpatient Department PPS Payment Rates
3. Adjustment of Hospital Outpatient Department PPS Payment and Coinsurance Amounts for Geographic Wage Variations
4. Special Rules Under the BBRA 1999
H. Other Adjustments
1. Outlier Payments
2. Transitional Corridors/Interim Payments
3. Cancer Centers and Small Rural Hospitals
I. Annual Updates
1. Revisions to APC Groups, Weights and the Wage and Other Adjustments
2. Annual Update to the Conversion Factor
3. Advisory Panel for APC Updates
J. Volume Control Measures
K. Claims Submission and Processing and Medical Review
L. Prohibition Against Administrative or Judicial Review
IV. Provider-Based Status
A. Background
B. Provisions of the Proposed Rule
C. Comments and Responses
D. Requirements for Payment
V. Summary of and Response to MedPAC Recommendations
VI. Provisions of the Final Rule
VII. Collection of Information Requirements
VIII. Response to Comments
IX. Regulatory Impact Analysis
A. Introduction
B. Estimated Impact on the Medicare Program
C. Objectives
D. Limitations of Our Analysis
E. Hospitals Included In and Excluded From the Prospective Payment System
F. Quantitative Analysis of the Impact of Policy Changes on Payment Under the Hospital Outpatient PPS: Basis and Methodology of Estimates
G. Estimated Impact of the New APC System (Includes Table 2, Annual Impact of Hospital Outpatient Prospective Payment System in CY2000-CY2001)
X. Federalism
XI. Waiver of Proposed Rulemaking Regulations Text
Addenda
Addendum A—List of Hospital Outpatient Ambulatory Payment Classification Groups with Status Indicators, Relative Weights, Payment Rates, and Coinsurance Amounts
Addendum B—Hospital Outpatient Department (HOPD) Payment Rates and Payment Status by HCPCS, and Related Information
Addendum C—Hospital Outpatient Payment for Procedures by APC
Addendum D—1996 HCPCS Codes Used to Calculate Payment Rates That Are Not Active CY 2000 Codes
Addendum E—CPT Codes Which Will Be Paid Only As Inpatient Procedures
Addendum F—Status Indicators
Addendum G—Service Mix Indices by Hospital
Addendum H—Wage Index for Urban Areas
Addendum I—Wage Index for Rural Areas
Addendum J—Wage Index for Hospitals That Are Reclassified
Addendum K—Drugs, Biologicals, and Medical Devices Subject to Transitional Pass-Through Payment
Alphabetical List of Acronyms Appearing in the Final Rule
APC Ambulatory payment classification
APG Ambulatory patient group
ASC Ambulatory surgical center
AWP Average wholesale price
BBA 1997 Balanced Budget Act of 1997
BBRA 1999 Balanced Budget Refinement Act of 1999
CAH Critical access hospital
CAT Computerized axial tomography
CCI [HCFA's] Correct Coding Initiative
CCR Cost center specific cost-to-charge ratio
CCU Coronary care unit
CMHC Community mental health center
CMP Civil money penalty
CORF Comprehensive outpatient rehabilitation facility
CPI Consumer Price Index
CPT [Physicians'] Current Procedural Terminology, 4th Edition, 2000, Start Printed Page 18436copyrighted by the American Medical Association
DME Durable medical equipment
DMEPOS DME, orthotics, prosthetics, prosthetic devices, prosthetic implants and supplies
DRG Diagnosis-related group
DSH Disproportionate share hospital
EACH Essential access community hospital
EBAA Eye Bank Association of America
ED Emergency department
EMS Emergency medical services
EMTALA Emergency Medical Treatment and Active Labor Act
ENT Ear/Nose/Throat
ESRD End-stage renal disease
FDA Food and Drug Administration
FDO Formula-driven overpayment
FQHC Federally qualified health center
HCPCS HCFA Common Procedure Coding System
HHA Home health agency
HRSA Health Resources and Services Administration
ICD-9-CM International Classification of Diseases, Ninth Edition, Clinical Modification
ICU Intensive care unit
IHS Indian Health Service
IME Indirect medical education
IOL Intraocular lens
JCAHO Joint Commission on Accreditation of Healthcare Organizations
LTH Long-term hospital
MDH Medicare-dependent hospital
MedPAC Medicare Payment Advisory Commission
MRI Magnetic resonance imaging
MSA Metropolitan statistical area
NECMA New England County Metropolitan Area
OBRA Omnibus Budget Reconciliation Act
OT Occupational therapy
PPO Preferred provider organization
PPS Prospective payment system
RFA Regulatory Flexibility Act
RHC Rural health clinic
RPCH Rural primary care hospital
RRC Rural referral center
SCH Sole community hospital
SGR Sustainable growth rate
SNF Skilled nursing facility
TEFRA Tax Equity and Fiscal Responsibility Act of 1982
TPA Tissue Plasminogen Activator
Y2K Year 2000
I. Background
A. General and Legislative History
When the Medicare program was first implemented, it paid for hospital services (inpatient and outpatient) based on hospital-specific reasonable costs attributable to serving Medicare beneficiaries. Later, the law was amended to limit payment to the lesser of a hospital's reasonable costs or its customary charges. In 1983, section 601 of the Social Security Amendments of 1983 (Pub. L. 98-21) completely revised the cost-based payment system for most hospital inpatient services by enacting section 1886(d) of the Social Security Act (the Act). This section provided for a prospective payment system (PPS) for acute hospital inpatient stays, effective with hospital cost reporting periods beginning on or after October 1, 1983.
Although payment for most inpatient services became subject to the PPS, Medicare hospital outpatient services continued to be paid based on hospital-specific costs, which provided little incentive for hospitals to furnish outpatient services efficiently. At the same time, advances in medical technology and changes in practice patterns were bringing about a shift in the site of medical care from the inpatient to the outpatient setting. During the 1980s, the Congress took steps to control the escalating costs of providing outpatient care. The Congress amended the statute to implement across-the-board reductions of 5.8 percent and 10 percent to the amounts otherwise payable by Medicare for hospital operating costs and capital costs, respectively, and enacted a number of different payment methods for specific types of hospital outpatient services. These methods included fee schedules for clinical diagnostic laboratory tests, orthotics, prosthetics, and durable medical equipment (DME); composite rate payment for dialysis for persons with end-stage renal disease (ESRD); and payments based on blends of hospital costs and the rates paid in other ambulatory settings such as separately certified ambulatory surgical centers (ASCs) or physician offices for certain surgery, radiology, and other diagnostic procedures. However, Medicare payment for services performed in the hospital outpatient setting remains largely cost-based.
In the Omnibus Budget Reconciliation Act of 1986 (OBRA 1986) (Pub. L. 99-509), the Congress paved the way for development of a PPS for hospital outpatient services. Section 9343(g) of OBRA 1986 mandated that fiscal intermediaries require hospitals to report claims for services under the HCFA Common Procedure Coding System (HCPCS). Section 9343(c) of OBRA 1986 extended the prohibition against unbundling of hospital services under section 1862(a)(14) of the Act to include outpatient services as well as inpatient services. The HCPCS coding enabled us to determine which specific procedures and services were being billed, while the extension of the prohibition against unbundling ensured that all nonphysician services provided to hospital outpatients would be billed only by the hospital, not by an outside supplier, and, therefore, would be reported on hospital bills and captured in the hospital outpatient data that could be used to develop an outpatient PPS.
A proposed rule to implement section 9343(c) was published in the Federal Register on August 5, 1988. However, those regulations were never published as a final rule, so we included them in the hospital outpatient PPS proposed rule published in the Federal Register on September 8, 1998 (63 FR 47552) and will implement them as part of this final rule.
Section 1866(g) of the Act, as added by section 9343(c) of OBRA 1986, and amended by section 4085(i)(17) of the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) (Pub. L. 100-203), authorizes the Department of Health and Human Services' Office of Inspector General to impose a civil money penalty (CMP), not to exceed $2,000, against any individual or entity who knowingly and willfully presents a bill in violation of an arrangement (as defined in section 1861(w)(1) of the Act).
In section 9343(f) of the OBRA 1986 and section 4151(b)(2) of the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508), the Congress required that we develop a proposal to replace the current hospital outpatient payment system with a PPS and submit a report to the Congress on the proposed system.
The Secretary submitted a report to the Congress on March 17, 1995, summarizing the research we conducted searching for a way to classify outpatient services for purposes of developing an outpatient PPS. The report cited ambulatory patient groups (APGs), developed by 3M-Health Information Systems (3M-HIS) under a cooperative grant with HCFA, as the most promising classification system for grouping outpatient services and recommended that APG-like groups be used in designing a hospital outpatient PPS.
The report also presented a number of options that could be used, once a PPS was in place, for addressing the issue of rapidly growing beneficiary coinsurance. As a separate issue, we recommended that the Congress amend the provisions of the law pertaining to the blended payment methods for ASC surgery, radiology, and other diagnostic services to correct an anomaly that resulted in a less than full recognition of the amount paid by the beneficiary in calculating program payment (referred to as the formula-driven overpayment).
Three sections of the Balanced Budget Act of 1997 (the BBA 1997) (Pub. L. 105-33), enacted on August 5, 1997, affect Medicare payment for hospital outpatient services. Section 4521 of the BBA 1997 eliminates the formula-driven overpayment for ambulatory surgical Start Printed Page 18437center procedures, radiology services, and diagnostic procedures furnished on or after October 1, 1997. In November 1998, we issued cost report instructions (Provider Reimbursement Manual, Part II, Chapter 36, Transmittal 4) that implemented this provision for services furnished on or after October 1, 1997. Section 4522 of the BBA 1997 amends section 1861(v)(1)(S)(ii) of the Act by extending cost reductions in payment for hospital outpatient operating costs and hospital capital costs, 5.8 percent and 10 percent respectively, before January 1, 2000. Section 4523 of the BBA 1997 amends section 1833 of the Act by adding subsection (t), which provides for implementation of a PPS for outpatient services. (Under Section 4523 of the BBA 1997 the outpatient PPS does not apply to cancer hospitals before January 1, 2000.) Set forth below in section I.B is a detailed description of the changes made by the BBA 1997.
On November 29, 1999, the Balanced Budget Refinement Act of 1999 (the BBRA 1999), Pub. L. 106-113, was enacted. This Act made major changes that affect the proposed hospital outpatient PPS. The legislative changes are summarized in section I.E, below. More specific details on individual provisions that we are implementing in this final rule with comment period are included under the various sections of this preamble.
B. Summary of Provisions in the Balanced Budget Act of 1997 (the BBA 1997)
1. Prospective Payment System (PPS)
Section 4523 of the BBA 1997 amended section 1833 of the Act by adding subsection (t), which provides for a PPS for hospital outpatient department services. (The following citations reflect the statute as enacted by the BBA 1997.) Section 1833(t)(1)(B) of the Act authorizes the Secretary to designate the hospital outpatient services that would be paid under the PPS. That section also requires that the hospital outpatient PPS include hospital inpatient services designated by the Secretary that are covered under Part B for beneficiaries who are entitled to Part A benefits but who have exhausted them or otherwise are not entitled to them. Section 1833(t)(1)(B)(iii) of the Act specifically excludes ambulance, physical and occupational therapy, and speech-language pathology services, for which payment is made under a fee schedule.
Section 1833(t)(2) of the Act sets forth certain requirements for the hospital outpatient PPS. The Secretary is required to develop a classification system for covered outpatient services that may consist of groups arranged so that the services within each group are comparable clinically and with respect to the use of resources.
Section 1833(t)(2)(C) of the Act specifies data requirements for establishing relative payment weights. The weights are to be based on the median hospital costs determined by 1996 claims data and data from the most recent available cost reports. Section 1833(t)(2)(D) of the Act requires that the portion of the Medicare payment and the beneficiary coinsurance that are attributable to labor and labor-related costs be adjusted for geographic wage differences in a budget neutral manner.
The Secretary is authorized under section 1833(t)(2)(E) of the Act to establish, in a budget neutral manner, other adjustments, such as outlier adjustments or adjustments for certain classes of hospitals, that are necessary to ensure equitable payments. Section 1833(t)(2)(F) of the Act requires the Secretary to develop a method for controlling unnecessary increases in the volume of covered outpatient services.
Section 1833(t)(3) of the Act specifies how beneficiary deductibles are to be treated in calculating the Medicare payment and beneficiary coinsurance amounts and requires that rules be established regarding determination of coinsurance amounts for covered services that were not furnished in 1996. The statute freezes beneficiary coinsurance at 20 percent of the national median charges for covered services (or group of covered services) furnished during 1996 and updated to 1999 using the Secretary's estimated charge growth from 1996 to 1999.
Section 1833(t)(3) of the Act also prescribes the formula for calculating the initial conversion factor used to determine Medicare payment amounts for 1999 and the method for updating the conversion factor in subsequent years.
Sections 1833(t)(4) and (t)(5) of the Act describe the method for determining the Medicare payment amount and the beneficiary coinsurance amount for services covered under the outpatient PPS. Section 1833(t)(5)(B) of the Act requires the Secretary to establish a procedure whereby hospitals may voluntarily elect to reduce beneficiary coinsurance for some or all covered services to an amount not less than 20 percent of the Medicare payment amount. Hospitals are further allowed to disseminate information on any such reductions of coinsurance amounts. Section 4451 of the BBA 1997 added section 1861(v)(1)(T) to the Act, which provides that any reduction in coinsurance must not be treated as a bad debt.
Section 1833(t)(6) authorizes periodic review and revision of the payment groups, relative payment weights, wage index, and conversion factor.
Section 1833(t)(7) of the Act describes how payment is to be made for ambulance services, which are specifically excluded from the outpatient PPS under section 1833(t)(1)(B) of the Act.
Section 1833(t)(8) of the Act provides that the Secretary may establish a separate conversion factor for services furnished by cancer hospitals that are excluded from hospital inpatient PPS.
Section 1833(t)(9) of the Act prohibits administrative or judicial review of the hospital outpatient PPS classification system, the groups, relative payment weights, wage adjustment factors, other adjustments, calculation of base amounts, periodic adjustments, and the establishment of a separate conversion factor for those cancer hospitals excluded from hospital inpatient PPS.
Section 4523(d) of the BBA 1997 made a conforming
amendment to section 1833(a)(2)(B) of the Act to provide for payment under the hospital outpatient PPS for some services described in section 1832(a)(2) that are currently paid on a cost basis and furnished by providers of services, such as comprehensive outpatient rehabilitation facilities (CORFs), home health agencies (HHAs), hospices, and community mental health centers (CMHCs). This amendment provides that partial hospitalization services furnished by CMHCs be paid under the PPS.
2. Elimination of Formula-Driven Overpayment
Before enactment of section 4521(b) of the BBA 1997, using the blended payment formulas for ASC procedures, radiology, and other diagnostic services, the ASC or physician fee schedule portion was calculated as if the beneficiary paid 20 percent of the ASC rate or physician fee schedule amount instead of the actual amount paid, which was 20 percent of the hospital's billed charges. Section 4521(b), which amended sections 1833(i)(3)(B)(i)(II) and 1833(n)(1)(B)(i) of the Act, corrects this anomaly by changing the blended calculations so that all amounts paid by the beneficiary are subtracted from the total payment in the calculation to determine the amount due from the program. Effective for services furnished on or after October 1, 1997, payment for surgery, radiology, and other diagnostic services calculated by blended payment methods is now calculated by Start Printed Page 18438subtracting the full amount of coinsurance due from the beneficiary (based on 20 percent of the hospital's billed charges).
3. Extension of Cost Reductions
Section 1861(v)(1)(S)(ii) of the Act was amended by section 4522 of the BBA 1997 to require that the amounts otherwise payable for hospital outpatient operating costs and capital costs be reduced by 5.8 percent and 10 percent, respectively, through December 31, 1999.
C. The September 8, 1998 Proposed Rule
We published a proposed rule in the Federal Register on September 8, 1998 (63 FR 47552) setting forth the proposed PPS for hospital outpatient services. In that proposed rule, we explained that, due to Year 2000 (Y2K) systems concerns, implementation of the new payment system would be delayed until after January 1, 1999. (The statement in the rule that the statute requires implementation “effective January 1, 1999,” and other similar statements in other rules, were not intended to mean that the statute requires retroactive implementation of the hospital outpatient PPS. As noted elsewhere in this rule, the statute does not impose such a requirement.) As noted in that document, the scope of systems changes required to implement the hospital outpatient PPS is so enormous as to be impossible to accomplish concurrently with the critical work that we, our contractors, and our provider-partners had to perform to ensure that all of our respective systems were Y2K compliant. Section XI of the proposed rule (63 FR 47605) explains in greater detail the reasons for delaying implementation.
The proposed rule originally provided for a 60-day comment period. However, the comment period was extended four times, ultimately ending on July 30, 1999. (See 63 FR 63429, November 13, 1998; 64 FR 1784, January 12, 1999; 64 FR 12277, March 12, 1999; and 64 FR 36320; July 6, 1999.)
On June 30, 1999, we published a correction notice (64 FR 35258) to correct a number of technical and typographical errors contained in the September 8, 1998 proposed rule. The numerical values in the proposed rule reflected incorrect data and data programming. Among other corrections, the notice set forth revised numerical values for the current payment, total services (total units), relative weights, proposed payment rates, national unadjusted coinsurance, minimum unadjusted coinsurance, and service-mix index.
D. Overview of Public Comments
We received approximately 10,500 comments in response to our September 8, 1998 proposed rule. That count includes the numerous requests from hospital and other interested groups and organizations that we extend the public comment period to allow additional time for analysis of the impact of our proposals. As we explain above, we extended the comment period four times, to end finally on July 30, 1999.
In addition to receiving comments from a number of organizations representing the full spectrum of the hospital industry, we received comments from beneficiaries and their families, physicians, health care workers, individual hospitals, professional associations and societies, legal and nonlegal representatives and spokespersons for beneficiaries and hospitals, members of the Congress, and other interested citizens. The majority of comments addressed our proposals regarding payment for: Corneal tissue; payment for high-cost technologies, both existing and future; payment for blood and blood products; and payment for high cost drugs, including chemotherapy agents. We also received numerous comments addressing: Our approach to ratesetting using the ambulatory payment classification (APC) system; our method of calculating the payment conversion factor; and the potentially negative impact of the proposed hospital outpatient PPS on hospital revenues. In addition, we received many comments concerning the proposed regulations for provider-based entities.
We carefully reviewed and considered all comments received timely. The many modifications that we made to our proposed regulations in response to commenters' suggestions and recommendations are reflected in the provisions of this final rule. Comments and our responses are addressed by topic in the sections that follow.
E. Summary of Relevant Provisions in the Balanced Budget Refinement Act of 1999 (the BBRA 1999)
As noted above, subsequent to publication of the proposed rule, the BBRA 1999 was enacted on November 29, 1999. The BBRA 1999 made major changes that affect the proposed hospital outpatient PPS. Because these changes are effective with the implementation of the PPS, we have had to make some revisions from the September 8, 1998 proposed rule. The provisions of the BBRA 1999 that we are implementing in this final rule with comment period follow.
1. Outlier Adjustment
Section 201(a) of the BBRA 1999 amends section 1833(t) by redesignating paragraphs (5) through (9) as paragraphs (7) through (11) and adding a new paragraph (5). New section 1833(t)(5) of the Act provides that the Secretary will make payment adjustments for covered services whose costs exceed a given threshold (that is, an outlier payment). This section describes how the additional payments are to be calculated and caps the projected outlier payments at no more than 2.5 percent of the total projected payments (sum of both Medicare and beneficiary payments to the hospital) made under hospital outpatient PPS for years before 2004 and 3.0 percent of the total projected payments for 2004 and subsequent years.
2. Transitional Pass-Through for Additional Costs of Innovative Medical Devices, Drugs, and Biologicals
Section 201(b) of the BBRA 1999 adds new section 1833(t)(6) to the Act, establishing transitional pass-through payments for certain medical devices, drugs, and biologicals. This provision does the following: Specifies the types of items for which additional payments must be made; describes the amount of the additional payment; limits these payments to at least 2 years but not more than 3 years; and caps the projected payment adjustments annually at 2.5 percent of the total projected payments for hospital outpatient services each year before 2004 and no more than 2.0 percent in subsequent years. Under this provision, the Secretary has the authority to reduce pro rata the amount of the additional payments if, before the beginning of a year, she estimates that these payments would otherwise exceed the caps.
3. Budget Neutrality Applied to New Adjustments
Section 201(c) of the BBRA 1999 amends section 1833(t)(2)(E) of the Act to require that the establishment of outlier and transitional pass-through payment adjustments is to be made in a budget neutral manner.
4. Limitation on Judicial Review
Section 201(d) of the BBRA 1999 amends redesignated section 1833(t)(11) of the Act by extending the prohibition of administrative or judicial review to include the factors for determining outlier payments (that is, the fixed multiple, or a fixed dollar cutoff amount, the marginal cost of care, or applicable total payment percentage), and the determination of additional payments for certain medical devices, Start Printed Page 18439drugs, and biologicals, the insignificant cost determination for these items, the duration of the additional payment or portion of the PPS payment amount associated with particular devices, drugs, or biologicals, and any pro rata reduction.
5. Inclusion in the Hospital Outpatient PPS of Certain Implantable Items
Section 201(e) of the BBRA 1999 amends section 1833(t)(1)(B) of the Act to include as covered outpatient services implantable prosthetics and DME and diagnostic x-ray, laboratory, and other tests associated with those implantable items.
6. Payment Weights Based on Mean Hospital Costs
Section 201(f) of the BBRA 1999 amends section 1833(t)(2)(C) of the Act, which specifies data requirements for establishing relative payment weights, to allow the Secretary the discretion to base the weights on either the median or mean hospital costs determined by data from the most recent available cost reports.
7. Limitation on Variation of Costs of Services Classified Within a Group
Section 201(g) of the BBRA 1999 amends section 1833(t)(2) of the Act to limit the variation of costs of services within each payment classification group by providing that the highest median (or mean cost, if elected by the Secretary) for an item or service within the group cannot be more than 2 times greater than the lowest median (or mean) cost for an item or service within the group. The provision allows the Secretary to make exceptions in unusual cases, such as for low volume items and services.
8. Annual Review of the Hospital Outpatient PPS Components
Section 201(h) of the BBRA 1999 amends redesignated section 1833(t)(8) of the Act to require at least annual review of the groups, relative payment weights, and the wage and other adjustments made by the Secretary to take into account changes in medical practice, the addition of new services, new cost data, and other relevant information and factors. That section of the Act is further amended to require the Secretary to consult with an expert outside advisory panel composed of an appropriate selection of provider representatives who will review the clinical integrity of the groups and weights and advise the Secretary accordingly. The panel may use data other than those collected or developed by the Department of HHS for the review and advisory purposes.
9. Coinsurance Not Affected by Pass-Throughs
Section 201(i) of the BBRA 1999 amends redesignated section 1833(t)(7) of the Act to provide that the beneficiary coinsurance amount will be calculated as if the outlier and transitional pass-throughs had not occurred; that is, there will be no coinsurance collected from beneficiaries for the additional payments made to hospitals by Medicare for these adjustments.
10. Extension of Cost Reductions
Section 201(k) of the BBRA 1999 amends section 1861(v)(1)(S)(ii) of the Act to extend until the first date that the hospital outpatient PPS is implemented, the 5.8 and 10 percent reductions for hospital operating and capital costs, respectively.
11. Clarification of Congressional Intent Regarding Base Amounts Used in Determining the Hospital Outpatient PPS
Section 201(l) of the BBRA 1999 provides that, “With respect to determining the amount of copayments described in paragraph (3)(A)(ii) of section 1833(t) of the Social Security Act, as added by section 4523(a) of the BBA, Congress finds that such amount should be determined without regard to such section, in a budget neutral manner with respect to aggregate payments to hospitals, and that the Secretary of Health and Human Services has the authority to determine such amount without regard to such section.” Pursuant to this provision, we are calculating the aggregate PPS payment to hospitals in a budget neutral manner.
12. Transitional Corridors for Application of Outpatient PPS
Section 202 of the BBRA 1999 amends section 1833(t) of the Act by redesignating paragraphs (7) through (11) as paragraphs (8) through (12), and adding a new paragraph (7), which provides for a transitional adjustment to limit payment reductions under the hospital outpatient PPS. More specifically, for the years 2000 through 2003, a provider, including a CMHC, will receive an adjustment if its payment-to-cost ratio for outpatient services furnished during the year is less than a set percentage of its payment-to-cost ratio for those services in its cost reporting period ending in 1996 (the base year). Two categories of hospitals, rural hospitals with 100 or fewer beds and cancer hospitals, will be held harmless under this provision. Small rural hospitals, for services furnished before January 1, 2004, will be maintained at the same payment-to-cost ratio as their base year cost report if their PPS payment-to-cost ratio is less. The hold-harmless provision applies permanently to cancer centers. Section 202 also requires the Secretary to make interim payments to affected hospitals subject to retrospective adjustments and requires that the provisions of this section do not affect beneficiary coinsurance. Finally, this provision is not subject to budget neutrality.
13. Limitation on Coinsurance for a Procedure
Section 204 of the BBRA 1999 amends redesignated section 1833(t)(8) of the Act to provide that the coinsurance amount for a procedure performed in a year cannot exceed the hospital inpatient deductible for that year.
14. Reclassification of Certain Hospitals
Section 401 of the BBRA 1999 adds section 1886(d)(8)(E) to the Act to permit reclassification of certain urban hospitals as rural hospitals. Section 401 adds section 1833(t)(13) to the Act to provide that a hospital being treated as a rural hospital under section 1886(d)(8)(E) also be treated as a rural hospital under the hospital outpatient PPS.
II. Prohibition Against Unbundling of Hospital Outpatient Services
A. Background
Sections 9343(c)(1) and (c)(2) of OBRA 1986 amended sections 1862(a)(14) and 1866(a)(1)(H) of the Act, respectively. As revised, section 1862(a)(14) of the Act prohibits payment for nonphysician services furnished to hospital patients (inpatients and outpatients), unless the services are furnished by the hospital, either directly or under an arrangement (as defined in section 1861(w)(1) of the Act). As revised, section 1866(a)(1)(H) of the Act requires each Medicare-participating hospital to agree to furnish directly all covered nonphysician services required by its patients (inpatients and outpatients) or to have the services furnished under an arrangement (as defined in section 1861(w)(1) of the Act). Section 9338(a)(3) of OBRA 1986 affected implementation of the bundling mandate by amending section 1861(s)(2)(K) of the Act to permit services of physician assistants to be covered and billed separately. Sections 4511(a)(2)(C) and (D) of the BBA 1997 further revised sections 1862(a)(14) and 1866(a)(1)(H) of the Act, respectively, to exclude services of nurse practitioners Start Printed Page 18440and clinical nurse specialists, described in section 1861(s)(2)(K)(ii) of the Act, from the bundling requirement.
B. Office of Inspector General (OIG) Civil Money Penalty Authority and Civil Money Penalties for Unbundling Hospital Outpatient Services
In order to deter the unbundling of nonphysician hospital services, section 9343(c)(3) of OBRA 1986 added section 1866(g) to the Act to provide for the imposition of civil money penalties (CMPs), not to exceed $2,000, against any person who knowingly and willfully presents, or causes to be presented, a bill or request for payment for a hospital outpatient service under Part B of Medicare that violates the requirement for billing under arrangements specified in section 1866(a)(1)(H) of the Act. In addition, section 1866(g) includes authorization to impose a CMP, in the same manner as other CMPs are imposed under section 1128A of the Act when arrangements should have been made but were not. Section 4085(i)(17) of OBRA 1987 amended section 1866(g) of the Act by deleting all references to hospital outpatient services under Part B of Medicare. The result of this amendment is that the CMP is now applicable for services furnished to hospital patients, whether paid for under Medicare Part A or B.
In order to implement section 1866(g) of the Act, we proposed in our August 5, 1988 proposed rule that the OIG would impose a CMP against any person who knowingly and willfully presents, or causes to be presented, a bill or request for payment for a hospital outpatient service under Part B of Medicare that violates the billing arrangement under section 1866(a)(1)(H) of the Act or the requirement for an arrangement. The amount of the CMP is to be limited to $2,000 for each improper bill or request, even if the bill or request included more than one item or service.
C. Summary of Final Regulations on Bundling of Hospital Outpatient Services
In our September 8, 1998 proposed rule, we proposed to make final most of the provisions of the August 5, 1988 proposed rule but with a number of revisions that we describe in detail in the proposed rule (63 FR 47558 through 47559). We are adopting as final regulations what we proposed in the September 8, 1998 rule with the following additional changes:
- We are adding a new paragraph (b)(7) to § 410.42 (Limitations on coverage of certain services furnished to hospital outpatients) to provide an exception to the hospital bundling requirements for services hospitals furnish to SNF residents as defined in § 411.15(p). (Section 410.42 has been redesignated from § 410.39 in the proposed rule.)
- We are making a minor change to newly redesignated paragraph (m)(2) (this language was formerly included in paragraph (m)(1)) in § 411.15 (Particular services excluded from coverage) to make it clearer that the exclusion discussed in this section is referring to excluding certain services from coverage.
- Except for minor wording changes in introductory paragraph (b) of § 1003.102 (Basis for civil money penalties and assessments), that section remains as it appeared in the August 5, 1988 proposed rule. Paragraph (b)(15) is redesignated from proposed paragraph (b)(4) in the August 5, 1988 proposed rule and (b)(14) in the September 8, 1998 proposed rule. Paragraphs (b)(12) through (b)(14) of § 1003.102 are reserved.
- We are adding a new paragraph (k) to § 1003.103 (Amount of penalty) to indicate that the OIG may impose a penalty of not more than $2,000 for each bill or request for items and services furnished to hospital patients in violation of the bundling requirements.
- We are also amending § 1003.105 (Exclusion from participation in Medicare, Medicaid and other Federal health care programs) by revising paragraph (a)(1)(i) to reflect that the basis for imposition of a CMP is also a basis for exclusion from participation in Medicare, Medicaid and other Federal health care programs.
D. Comments and Responses
Comment: One association requested that we clarify whether lab tests are subject to the bundling requirement or whether those services are included in the definition of diagnostic tests that are not required to be bundled. If lab tests are bundled, the association asked that we seek a legislative change to permit a provider, other than the lab that performs the test, to bill for the test.
Response: Laboratory tests, like all other services furnished to hospital patients, must be provided directly or under arrangements by the hospital and only the hospital may bill the program. Section 1833(h)(5)(A)(iii) of the Act provides an exception to the requirement that payment for a clinical diagnostic lab may be made only to the person or entity that performed or supervised the performance of the test. This section provides that in the case of a clinical diagnostic laboratory test provided under arrangement made by a hospital or CAH, payment is made to the hospital.
All diagnostic tests that are furnished by a hospital, directly or under arrangements, to a registered hospital outpatient during an encounter at a hospital are subject to the bundling requirements. The hospital is not responsible for billing for the diagnostic test if a hospital patient leaves the hospital and goes elsewhere to obtain the diagnostic test.
Comment: The same association asked us to clarify that services billed to skilled nursing facilities (SNFs) under the consolidated billing requirement would be exempt from the bundling requirement for hospital outpatient services.
Response: We agree that in situations where a beneficiary receives outpatient services from a Medicare participating hospital or CAH while temporarily absent from the SNF, the beneficiary continues to be considered a SNF resident specifically with regard to the comprehensive care plan required under § 483.20(b). Such services are, therefore, subject to the SNF consolidated billing provision and should be exempt from the hospital outpatient bundling requirements. The final regulations at § 410.42(b)(7) reflect this exception.
We note that the SNF consolidated billing requirements, under § 411.15(p)(3)(iii), do not apply to a limited number of exceptionally intensive hospital outpatient services that lie well beyond the scope of care that SNFs would ordinarily furnish, and thus beyond the ordinary scope of SNF care plans. The hospital outpatient services that are currently included in this policy are: Cardiac catheterization; computerized axial tomography (CAT) scans; MRIs; ambulatory surgery involving the use of an operating room; emergency room services; radiation therapy; angiography; and lymphatic and venous procedures. When a hospital or CAH provides these services to a beneficiary, the beneficiary's status as a SNF resident ends, but only with respect to these services. The beneficiary is now considered to be a hospital outpatient and the services are subject to hospital outpatient bundling requirements. In November 1998, we issued Program Memorandum transmittal number A-98-37, which provides additional clarification on this exclusion as well as a list of specific HCPCS codes that identify the services that are excluded from SNF consolidated billing but subject to hospital outpatient bundling.
Comment: One commenter understood that the proposed rule Start Printed Page 18441would permit payment for all diagnostic tests that are furnished by a hospital or other entity if the patient leaves the hospital and obtains the service elsewhere; however, the commenter requested clarification as to the treatment of “outsourced” hospital departments. The commenter stated that hospitals are increasingly outsourcing departments to providers that can furnish services efficiently. Often these providers do not operate as “under arrangements” providers to the hospital, but as free-standing providers offering outpatient services on hospital grounds. The commenter specifically asked whether a free-standing entity providing outpatient services on hospital grounds, but operated independently of the hospital is able to bill separately for services furnished or is the entity considered to be part of the hospital and required to furnish services “under arrangement.”
Response: A free-standing entity, that is, one that is not provider-based, may bill for services furnished to beneficiaries who do not meet the definition of a hospital outpatient at the time the service is furnished. Our bundling requirements apply to services furnished to a “hospital outpatient,” as defined in § 410.2, during an “encounter,” also defined in § 410.2.
Comment: One commenter indicated that while the proposed revision to § 1003.102(b) accurately reflected the statutory directive that the basis for imposing a CMP is a “bill or request for payment,” the proposed amendment to § 1003.103(a) regarding the appropriate penalty amount to be imposed for bundling violations was in error. The commenter indicated that the OIG lacks the authority to impose a CMP in the amount of $10,000 for these violations, and that such a penalty should be not more than $2,000 for each violation.
Response: The commenter is correct. While section 231(c) of the Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, increased the CMP maximum amount from $2,000 to $10,000, the statute sets forth “items or services” as the basis upon which a higher CMP amount may be assessed. However, with regard to bundling violations, the Secretary may impose a CMP only on the basis of a “bill or request for payment” rather than “for each item and service” as stated in the proposed revision to § 1003.103. We are correcting this error by adding a new § 1003.103(k) to indicate that the OIG may impose a penalty of not more than $2,000 for each bill or request for items and services furnished to hospital patients in violation of the bundling requirements.
III. Hospital Outpatient Prospective Payment System (PPS)
In this section, we designate the services for which Medicare will make payment under the hospital outpatient PPS, the payment rates set for those services, and the method by which we determined the outpatient PPS payment and coinsurance amounts.
We explain the structure of the hospital outpatient PPS, respond to comments that we received about the proposed PPS, and describe modifications that we made to the proposed PPS in response to comments, such as provisions we are making to expedite appropriate payment for new technologies and provisions to pay for blood and blood products.
In this section, we also discuss how we will implement requirements enacted by the BBRA 1999, including transitional payment corridors and other payment adjustments such as outliers and transitional pass-throughs.
A. Hospitals Included In or Excluded From the Outpatient PPS
This PPS applies to covered hospital outpatient services furnished by all hospitals participating in the Medicare program, except as noted below. Partial hospitalization services in community mental health centers (CMHCs) are also paid under this PPS. Exclusions from outpatient PPS are different and more limited than exclusions from inpatient PPS. Thus, hospitals or distinct parts of hospitals that are excluded from the inpatient PPS are included in the outpatient PPS, to the extent that the hospital or distinct part furnishes outpatient services. For example, we will make payment under the outpatient PPS for outpatient psychiatric services. The outpatient services provided by hospitals of the Indian Health Service (IHS) will continue to be paid under separately established rates which are published annually in the Federal Register. We intend to develop a plan that will help these facilities transition to the PPS and will consult with the IHS to develop this plan.
The following hospitals are excluded from the outpatient PPS:
- Certain hospitals in Maryland qualify under section 1814(b)(3) of the Act for payment under the State's payment system. The excluded services are limited to those paid under the State's payment system as described in section 1814(b)(3) of the Act. Any other outpatient services furnished by the hospital are paid under the outpatient PPS.
- Critical access hospitals that are paid under a reasonable cost based system, as required under section 1834(g) of the Act.
Comment: National and State associations representing children's hospitals and a number of individual children's hospitals located across the country strongly recommended that their hospitals be excluded from the hospital outpatient PPS just as they have been excluded from the hospital inpatient PPS. These commenters argued that the exclusion should apply to outpatient services furnished by children's hospitals because these hospitals treat a unique patient group whose health needs are different from those of adult beneficiaries entitled to Medicare benefits. The commenters further argued that services to Medicare patients are, on average, only 1 percent of the total inpatient and outpatient services that children's hospitals furnish and that these services are largely ESRD services that are already excluded from the hospital outpatient PPS. The commenters were concerned that the resources required to implement and comply with the new system would be disproportionately high relative to the small number of patients who would be affected by the new system. In addition, the impact analysis that accompanied the proposed rule estimated that children's hospitals would lose more than 20 percent of their Medicare revenues under the new system. Commenters expressed great concern about this loss of revenue.
Response: Our most recent analysis of the impact on hospitals of the PPS shows a negative effect for children's hospitals of 11.9 percent, which is significantly less than what we estimated in the proposed rule. However, the transitional corridor payments provided by the BBRA 1999 will protect these hospitals from even this level of loss through 2004. The estimated loss for CY 2000-2001 for children's hospitals is only 3.2 percent. (See Table 2 in section IX of this preamble.) As we discuss in section III.H.2 below, we will conduct extensive analyses during the first years of implementation of the PPS to determine whether we should propose adjustments for certain types of hospitals, including children's hospitals, when the transitional corridor provision expires. In the meantime, we are not excluding any special class of hospital from the PPS.
B. Scope of Facility Services
Section 1833(t)(1)(B)(i) of the Act gives us the authority to designate the services to be covered under the hospital outpatient PPS. In this section of the final rule, we designate the types Start Printed Page 18442of services included or excluded under the hospital outpatient PPS.
1. Services Excluded From the Scope of Services Paid Under the Hospital Outpatient PPS
a. Background
In developing a hospital outpatient PPS, we want to ensure that all services furnished in a hospital outpatient setting will be paid on a prospective basis. We have already been paying, in part, for some hospital outpatient services such as clinical diagnostic laboratory services, orthotics, and end-stage renal disease (ESRD) dialysis services based on fee schedules or other prospectively determined rates that also apply across other sites of ambulatory care. Rather than duplicate existing payment systems that are effectively achieving consistency of payments across different service delivery sites, we proposed to exclude from the outpatient PPS those services furnished in a hospital outpatient setting that were already subject to an existing fee schedule or other prospectively determined payment rate. The similar payments across various settings create a more level playing field in which Medicare makes virtually the same payment for the same service, without regard to where the service is furnished.
We therefore proposed to exclude from the scope of services paid under the hospital outpatient PPS the following:
- Services already paid under fee schedules or other payment systems including, but not limited to: screening mammographies, services for patients with ESRD that are paid for under the ESRD composite rate; the professional services of physicians and non-physician practitioners paid under the Medicare physician fee schedule; laboratory services paid under the clinical diagnostic laboratory fee schedule; and DME, orthotics, prosthetics, and prosthetics devices, prosthetic implants, and supplies (DMEPOS) paid under the DMEPOS fee schedule when the hospital is acting as a supplier of these items. An item such as crutches or a walker that is given to the patient to take home, but that may also be used while the patient is at the hospital, would be billed to the DME regional carrier rather than paid for under the hospital outpatient PPS.
- Hospital outpatient services furnished to SNF inpatients as part of his or her resident assessment or comprehensive care plan (and thus included under the SNF PPS) that are furnished by the hospital “under arrangements” but billable only by the SNF, regardless of whether or not the patient is in a Part A SNF stay.
- Services and procedures that require inpatient care.
The statute excludes from the definition of “covered OPD services” ambulance services, physical and occupational therapy, and speech-language pathology services, specified in section 1833(t)(1)(B)(iii) of the Act (redesignated as section 1833(t)(1)(B)(iv) by section 201(e) of the BBRA 1999). These services are to be paid under fee schedules in all settings.
b. Comments and Responses
Comment: One commenter urged that we exclude services furnished to ESRD patients from the scope of the hospital outpatient PPS.
Response: Services furnished to ESRD patients include dialysis, Epoietin (EPO), drugs, and supplies provided outside the composite rate, surgery specific to access grafts, and many other medical services related to renal disease or to other coexisting conditions. We will continue to base payment for dialysis services on the composite rate, and we will continue to pay for EPO based on the current rate established for that service. The drugs and supplies that are used within a dialysis session, but for which payment is not included in the composite rate, are paid outside that rate. We have to conduct further analyses in order to develop appropriate APC groups upon which to base payment. In the meantime, we will continue to pay on a reasonable cost basis for dialysis related drugs and supplies that are paid outside the composite rate.
Comment: A hospital industry association took exception to the requirement that hospitals obtain a separate supplier number, post a bond, and bill separately to the DME regional carrier for DME supplies such as crutches. They believe that this is an unnecessary requirement that results in additional costs for small rural hospitals. The commenter recommended that we include within the PPS rate supplies such as crutches that are directly related to the provison of the hospital outpatient services or that we permit hospitals to bill under the DME fee schedule without having to obtain a DME supplier number or post a bond.
Response: Section 1834(j)(1)(A) of the Act provides that no payment may be made for items furnished by a supplier of medical equipment and supplies unless the supplier obtains a supplier number. Section 1834(a)(1)(C) of the Act provides that payment for DME can be made only under the DME fee schedule. Therefore, to receive payment for DME under Medicare, a hospital must obtain a supplier number and must meet the other requirements set by applicable Medicare rules and regulations.
Comment: Several major hospital associations and a number of other commenters opposed our proposal to exclude from payment certain procedures that we designate as “inpatient only.” Other commenters, including a physician professional society, agree that many of the procedures that we designated in the proposed rule as “inpatient only” are currently performed appropriately and safely only in the inpatient setting. However, these commenters believe that our explicit exclusion of individual procedures, besides being unnecessary, could have an adverse effect on advances in surgical care. Some commenters alleged that we provided no concrete support for designating procedures as “inpatient only.” A number of commenters argued that medicine is not practiced uniformly across the nation and that some services listed among the exclusions are currently being performed on an outpatient basis in various parts of the country with positive outcomes.
An industry association stated that we failed to consider surgical judgment and patient choice in determining the appropriate treatment setting for certain services that we proposed to exclude from coverage. Other commenters believe that the appropriate site for performing a medical service is best determined by physicians and their patients. One professional society stated that case law including medical malpractice case law is sufficient to ensure that medical services are delivered in the appropriate treatment setting and in conformance with prevailing medical standards.
Response: We recognize and acknowledge that our assigning “inpatient only” status to certain services and procedures raises numerous questions and concerns, and that some individual determinations can be reasonably debated. However, section 1833(t)(1)(B) of the Act explicitly authorizes the Secretary to designate which hospital outpatient services are to be “covered OPD services” subject to payment under the hospital outpatient PPS. Therefore, we have had to select from the universe of possible services those that we determine are reasonable, necessary, and appropriate for Medicare payment under the hospital outpatient PPS. We note that our designation of a service as “inpatient only” does not necessarily preclude the service from being furnished in a hospital outpatient Start Printed Page 18443setting, but means only that Medicare will not make payment for the service were it to be furnished to a Medicare beneficiary in that setting. This unfortunately leaves the beneficiary liable for payment if the procedure is in fact performed in the outpatient setting. We hope that hospitals will advise beneficiaries of the consequences if procedures on the inpatient list are provided as outpatient services (that is, denial of Medicare payment with concomitant beneficiary liability). In section III.C.5 of this preamble, we discuss in greater detail our rationale for designating specific procedures as “inpatient only.” In response to comments, we have removed the “inpatient only” status from a number of services, which will allow them to be paid under the hospital outpatient PPS. We emphasize our intention to review annually, in consultation with hospital and professional societies and associations and the expert outside advisory panel mandated by the BBRA 1999, those procedures classified as “inpatient only” to ensure that the designation remains consistent with current standards of practice.
Comment: One industry association contends that the statutory and regulatory authorities that we cite in the proposed rule (section 1862(a)(1)(A) of the Act and 42 CFR 411.15(k)(1), respectively) do not support the proposed medical services exclusions. The commenter argues that those provisions are the basis for prohibiting coverage for services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The commenter states that these provisions are not the basis upon which we identified services for the “inpatient only” list. The commenter further states that use of these provisions as a basis for denying coverage of the services would be confusing to beneficiaries.
Response: The commenter is correct that the proper citations are not section 1862(a)(1) of the Act and 42 CFR 411.15(k)(1). In fact, the basis for our designating certain procedures as “inpatient only” is dependent on medical judgment regarding the proper site of service, and the proper citation for such designation is section 1833(t)(1)(B) of the Act. In some instances, the identification of services to be included or excluded from this PPS was perfectly clear. For example, emergency departments (EDs) are outpatient departments of hospitals. Thus emergency services rendered in EDs qualify as outpatient services. On the other hand, coronary artery bypass graft surgery (CABG) requires many hours in surgery, part of the time with the patient's life being sustained by artificial means; a period of hours, if not days, in the surgical intensive care unit (ICU); and further care in an inpatient unit with frequent nursing attention. It clearly cannot be an outpatient procedure, and it would not be reasonable to consider it for inclusion in this PPS. There are many procedures which require similar intensity of care, including periods in specialty ICUs and several days of intense nursing attention.
Some procedures formerly performed only in the inpatient setting, however, have moved to the outpatient site of service. This movement has taken place due to new, less-invasive surgical techniques, such as laparoscopy, or new anesthesia agents that clear from the body more rapidly, allowing some patients to have general anesthesia in the morning and return home that afternoon. Thus we have had to decide which procedures may reasonably be performed in the outpatient setting, and which cannot. We have been guided in this decision by our medical advisors' clinical judgment regarding what is reasonable in various settings, comments we received in response to the proposed rule, and bill data which shows movement from one site to another. In section III.C.5, we discuss the criteria we considered in defining “inpatient only” procedures.
Comment: One hospital asked how we would pay a hospital that routinely performs on an outpatient basis a procedure that we proposed to designate as “inpatient only.” The commenter recommended that a specific billing mechanism be used to guarantee payment in these situations.
Response: Services designated as “inpatient only” will be excluded from Medicare payment under the hospital outpatient PPS. If the service is performed on an outpatient basis and a claim is submitted, the claim will be denied, and the beneficiary may be billed for the service. We would consider this a very poor policy on the hospital's part, and would hope that hospitals decide to abide by the constraints of the inpatient list.
Comment: One commenter noted that hospital outpatient departments have never been limited to a list of approved procedures as are Medicare participating ASCs. The commenter stated that the “inpatient only” policy would exclude payment for a significant number of procedures that have traditionally been performed in the hospital outpatient setting. The commenter stated that some of the excluded procedures incorporate an observation stay in a recovery care center. The commenter contended that many of the excluded procedures could be safely performed in the outpatient setting particularly if a 24 to 72 hour recovery care center is part of the outpatient surgical care provided.
Response: Routinely billing an observation stay for patients recovering from outpatient surgery is not allowed under current Medicare rules nor will it be allowed under the hospital outpatient PPS. As we state in section III.C.5 of this preamble, one of the primary factors we considered as an indicator for the “inpatient only” designation is the need for at least 24 hours of postoperative care.
Comment: One commenter asked what option a hospital has if a beneficiary's secondary insurer requires that a procedure included on the Medicare inpatient only list be performed on an outpatient basis.
Response: Upon implementation, the provisions of this final rule will govern payment for Medicare covered outpatient services furnished by hospitals to Medicare beneficiaries. Medicare payment policy and rules are not binding on employer-provided retiree coverage that may supplement Medicare coverage. Medigap insurers, however, must follow Medicare's coverage determinations.
c. Payment for Certain Implantable Items Under the BBRA 1999
In the course of identifying items and services whose costs we proposed to designate for payment under the hospital outpatient PPS, we gave considerable thought to including implantable items and services because these items and services are such an integral part of the procedure by which they are inserted or implanted. However, a number of the more common implants such as aqueous shunts, hallux valgus implants, infusion pumps, and neurostimulators, are classified as implantable prosthetics or DME. The statutory language governing payment for DMEPOS provides that, notwithstanding any other provision of the Medicare statute, DMEPOS must be paid for using the DMEPOS fee schedule. Therefore, under the proposed rule, the scope of services paid under the hospital outpatient PPS did not include implantable prosthetics and DME paid under the DMEPOS fee schedule. However, we did propose to package payment for implanted items such as stents, vascular catheters, and venous ports within the APC payment rate for the procedure related to the insertion of these items because we Start Printed Page 18444define these items as supplies rather than as prosthetic implants or implantable DME.
Section 201(e) of the BBRA 1999 amends section 1833(t)(1)(B) of the Act to provide that “covered OPD services” include implantable items described in paragraph (3), (6), or (8) of section 1861(s) of the Act. The conference report accompanying the BBRA 1999, H. R. Rep. No. 436 (Part I), 106th Cong., 1st Sess. (1999), expresses the belief of the conferees that the current DMEPOS fee schedule is not appropriate for certain implantable medical items such as pacemakers, defibrillators, cardiac sensors, venous grafts, drug pumps, stents, neurostimulators, and orthopedic implants as well as items that come into contact with internal human tissue during invasive medical procedures, but are not permanently implanted. In the conference report agreement, the conferees state their intention that payment for these items be made through the outpatient PPS, regardless of how these products might be classified on current HCFA fee schedules. The implantable items affected by this BBRA 1999 requirement include prosthetic implants (other than dental) that replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care and including replacement of these devices); implantable DME; and implantable items used in performing diagnostic x-rays, diagnostic laboratory tests, and other diagnostic tests.
Comment: A number of commenters disagreed with our proposal to pay under the DMEPOS fee schedule for implantable items and devices that require surgical insertion. We received comments on specific implantable items, including Vitrasert (a drug delivery system that is implanted in the eye); cochlear devices, which allow the profoundly deaf to hear sound and in some cases recognize speech; nerve stimulators that treat intractable epilepsy and other diseases; new technology intraocular lenses implanted following cataract surgery; and access devices for dialysis treatment. Commenters were also concerned that the costs of some implantable devices not paid under the DMEPOS fee schedule, which we packaged in our proposed rule, were not properly recognized in the APC payment.
Response: As we explain above, the amendments made to the statute by section 201(e) of the BBRA 1999 provide for payment to be made under the hospital outpatient PPS for implantable items that are part of diagnostic x-rays, diagnostic laboratory tests, and other diagnostic tests; implantable durable medical equipment; and implantable prosthetic devices (other than dental). This BBRA 1999 provision requires that an implantable item be classified to the group that includes the service to which the item relates. Thus, under this final rule with comment period, we are including within the scope of the hospital outpatient PPS items such as aqueous shunts that would, absent the BBRA 1999 provision, have been paid under the DMEPOS fee schedule. Because implantable items are now packaged into the APC payment rate for the service or procedure with which they are associated, certain items may be candidates for the transitional pass-through payment, which is discussed in detail in section III.D of this preamble. The APC rates may not in every case perfectly recognize the cost of implantable items. We will continue to review the impact of packaging implantables in future updates.
d. Summary of Final Action
We are modifying proposed § 419.22 to remove prosthetic implants from the list of services excluded from payment under the hospital outpatient PPS. We are adding subparagraphs (9), (10), and (11) to proposed § 419.2(b), to include the following in the list of items and services whose costs are included in hospital outpatient PPS payment rates: prosthetic implants (other than dental) that replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), and including replacement of these devices; implantable DME; and implantable items used in performing diagnostic x-rays, diagnostic laboratory tests, and other diagnostic tests.
2. Services Included Within the Scope of the Hospital Outpatient PPS
We proposed to include three categories of services within the scope of the outpatient PPS, as follows:
a. Services for Patients Who Have Exhausted Their Part A Benefits
Section 1833(t)(1)(B)(ii) of the Act provides for Medicare payment under the hospital outpatient PPS for certain services designated by the Secretary that are furnished to inpatients who have exhausted their Part A benefits or who are otherwise not in a covered Part A stay. Examples of services covered under this provision include diagnostic x-rays and certain other diagnostic services and radiation therapy covered under section 1832 of the Act.
b. Partial Hospitalization Services
Section 1833(a)(2)(B) of the Act provides that partial hospitalization services furnished in CMHCs be paid under the hospital outpatient PPS. Partial hospitalization is a distinct and organized intensive psychiatric outpatient day treatment program, designed to provide patients who have profound and disabling mental health conditions with an individualized, coordinated, comprehensive, and multidisciplinary treatment program.
c. Services Designated by the Secretary
We proposed to designate the following services to be paid under the hospital outpatient PPS:
- All hospital outpatient services, except those that are identified as excluded, above, in section III.B.1 of this final rule. The types of services subject to payment under the hospital outpatient PPS include the following: surgical procedures; radiology, including radiation therapy; clinic visits; emergency department visits; diagnostic services and other diagnostic tests; partial hospitalization for the mentally ill; surgical pathology; and cancer chemotherapy.
- Specific hospital outpatient services furnished to a beneficiary who is admitted to a Medicare-participating SNF but who is not considered to be a SNF resident, for purposes of SNF consolidated billing, with respect to those services that are beyond the scope of SNF comprehensive care plans. The specific hospital outpatient services that are excluded from SNF consolidated billing are cardiac catheterization, computerized axial tomography (CAT) scans, MRIs, ambulatory surgery involving the use of an operating room, emergency room services, radiation therapy, angiography, and lymphatic and venous procedures.
- Supplies such as surgical dressings used during surgery or other treatments in the hospital outpatient setting that are also paid under the DMEPOS fee schedule. Payment for these supplies, when they are furnished in a hospital outpatient setting, is packaged into the APC payment rate for the procedure or service with which the items are associated.
- Certain preventive services furnished to healthy persons, such as colorectal cancer screening.
Section 4523(d)(3) of the BBA 1997 amended section 1833(a)(2)(B) of the Act to provide that we discontinue reasonable cost based payment and instead make Part B payment under the hospital outpatient PPS for certain medical and other health services when Start Printed Page 18445they are furnished by other providers such as hospices, SNFs, and HHAs. Specifically, we proposed to pay under the hospital outpatient PPS for the following medical and other health services when they are furnished by a provider of services:
- Antigens (as defined in 1861(s)(2)(G) of the Act);
- Splints and casts (1861(s)(5) of the Act);
- Pneumococcal vaccine, influenza vaccine, hepatitis B vaccine (1861(s)(10) of the Act).
Upon implementation of the hospital outpatient PPS, we would make Part B payment for the above services under the outpatient PPS when they are furnished by an HHA or hospice program. We would also make payment for antigens and the vaccines under the PPS when they are furnished by CORFs. (Splints and casts furnished by CORFs are paid under the rehabilitation fee schedule.) However, this provision would not apply to services furnished by a CORF that fall within the definition of CORF services at section 1861(cc)(1) of the Act. It also would not apply to services furnished by a hospice within the scope of the hospice benefit. Nor would it apply to services furnished by HHAs to individuals under an HHA plan of treatment within the scope of the home health benefit.
d. Summary of Final Action
We received no comments about the services we proposed to include within the scope of the hospital outpatient PPS. As noted in the preceding section III.B.1, we added certain implantable items to § 419.2(b) to implement section 201(e) of the BBRA 1999.
3. Hospital Outpatient PPS Payment Indicators
In the September 8, 1998 proposed rule in the Federal Register, we proposed a payment status indicator for every code in the HCPCS to identify how the service or procedure described by the code would be paid under the hospital outpatient PPS. We received no comments on our proposal to assign a payment status indicator to every HCPCS code. (In section III.C.6, below, we respond to commenters who disagreed with the payment status indicator that we proposed for individual codes.) Therefore, we are implementing payment status indicators as part of the hospital outpatient PPS. Addendum B displays the final payment status indicator for each HCPCS code, including codes for incidental services that are packaged into APC payment rates. Addendum E identifies the HCPCS codes to which we have assigned payment status indicator “C” to identify inpatient services that are not payable under outpatient PPS as implemented by this final rule. We respond below, in section III.C.5, to public comments about the specific codes we classified as inpatient services in the proposed rule and our final determination regarding the payment status of those codes.
The following are the payment status indicators and description of the particular services each indicator identifies:
- We use “A” to indicate services that are paid under some other method such as the DMEPOS fee schedule or the physician fee schedule.
- We use “C” to indicate inpatient services that are not paid under the outpatient PPS.
- We use “E” to indicate services for which payment is not allowed under the hospital outpatient PPS. In some instances, the service is not covered by Medicare. In other instances, Medicare does not use the code in question, but does use another code to describe the service.
- We use “F” to indicate corneal tissue acquisition costs, which are paid separately.
- We use “G” to indicate a current drug or biological for which payment is made under the transitional pass-through.
- We use “H” to indicate a device for which payment is made under the transitional pass-through.
- We use “J” to indicate a new drug or biological for which payment is made under the transitional pass-through.
- We use “N” to indicate services that are incidental, with payment packaged into another service or APC group.
- We use “P” to indicate services that are paid only in partial hospitalization programs.
- We use “S” to indicate significant procedures for which payment is allowed under the hospital outpatient PPS but to which the multiple procedure reduction does not apply.
- We use “T” to indicate surgical services for which payment is allowed under the hospital outpatient PPS. Services with this payment indicator are the only services to which the multiple procedure payment reduction applies.
- We use “V” to indicate medical visits for which payment is allowed under the hospital outpatient PPS.
- We use “X” to indicate ancillary services for which payment is allowed under the hospital outpatient PPS.
The table below lists types of services, the hospital outpatient PPS payment status indicator assigned to each type of service, and the basis for Medicare payment for the service.
Medicare Hospital Outpatient PPS Payment Status Indicators: How Medicare Pays for Various Services When They Are Billed for Hospital Outpatients
Indicator Service Status A Pulmonary Rehabilitation; Clinical Trial Not paid. C Inpatient Procedures Not paid. A Orthotics, and Non-implantable Durable Medical Equipment and Prosthetics DMEPOS Fee Schedule. E Nonallowed Items and Services Not paid. A Physical, Occupational and Speech Therapy Rehab Fee Schedule. A Ambulance Reasonable cost or charge or, when implemented, Ambulance Fee Schedule. A EPO for ESRD Patients National Rate. A Clinical Diagnostic Laboratory Services Lab Fee Schedule. A Physician Services for ESRD Patients Bill to Carrier. A Screening Mammography Lower of Charge or National Rate. N Incidental Services, Packaged into APC Rate Packaged; No Additional Payment Allowed. P Partial Hospitalization Services Paid Per Diem. S Significant Procedure, Not Reduced When Multiple Procedures Performed Paid Under Hospital Outpatient PPS (APC Rate). T Significant Procedure, Multiple Procedure Reduction Applies Hospital Paid Under Outpatient PPS (APC Rate). Start Printed Page 18446 V Visit to Clinic or Emergency Department Paid Under Hospital Outpatient PPS (APC Rate). X Ancillary Service Paid Under Hospital Outpatient PPS (APC Rate). F Acquisition of Corneal Tissue Paid at reasonable cost. G Current Drug/Biological Pass-Through Additional payment. H Device Pass-Through Additional payment. J New Drug/Biological Pass-Through Additional payment. C. Description of the Ambulatory Payment Classification (APC) Groups
1. Setting Payment Rates Based on Groups of Services Rather Than on Individual Services
In our March 17, 1995 report to Congress, we recommended that groups similar to the ambulatory patient groups (APGs) developed by 3M Health Information Systems (3M) be used as the basis for the hospital outpatient PPS. We made this recommendation after examining a number of other payment systems that were already in place or under development, including DRGs that are the basis for Medicare payment for hospital inpatient services, the Medicare physician fee schedule that was implemented in 1992, and the payment groups that have been the basis for Medicare payments for ambulatory surgical center (ASC) facility services since 1982.
As provided by the BBA 1997, section 1833(t)(2)(A) of the Act requires the Secretary to develop a classification system for covered outpatient services. Section 1833(t)(2)(B) provides that this classification system may be composed of groups, so that services within each group are comparable clinically and with respect to the use of resources. The statute refers to “each such service (or group of services),” confirming that the Secretary may choose or not choose to group services.
We explain in our proposed rule that we revised the APGs, based on more recent Medicare data than that used by 3M, to create the ambulatory payment classification (APC) system. We proposed to group services identified by HCPCS codes and descriptors within APC groups as the basis for setting payment rates under the hospital outpatient PPS. We indicated that we organized the APC groups so that the services within each group would be homogeneous both clinically and in terms of resource utilization. We invited comments on our proposal to set rates on the basis of groups of services rather than on individual codes.
Comments: Some commenters claimed that basing payment on APC groups rather than on individual services would result in underpayment for services that are more resource intensive, causing hospitals with a more resource intensive case mix to lose money. An organization representing physicians strongly opposed the use of APCs, because it believes that it is not possible to achieve an incentive-neutral, “level playing field” payment system using groups of codes or services. This organization favored replacing the APC system with a fee schedule based on individual services, similar to the Medicare physician fee schedule, as MedPAC recommends in its 1999 report to Congress. (We address the MedPAC recommendation later in this section.) The same physician organization is concerned that the broad range of services included in each APC will create an incentive for hospitals to provide lower cost services, even though a patient might require higher cost services. This organization expressed concern about the negative impact on physicians if a payment methodology similar to the APC system were applied to payment for physician services. To facilitate pricing new codes using individual services rather than APC groups, the same organization suggested that we establish a “relative value relationship in direct costs” between the new code and a comparable code, or that we consult AMA's Specialty Society RVS Updating Committee (RUC) for advice on relative cost relationships.
One major hospital association expressed its preference for a service-specific fee schedule because of the wide variation in costs represented by groups of codes. Another hospital association advocated using individual services rather than groups of services as the basis for ratesetting, but recommended, if we were to use some form of grouping, that we apply tight limits on the variations of costs for services within a group.
Response: We understand the concerns of commenters that setting payment weights using groups of services rather than individual services could result in payment for particular services that might not fully offset the costs that hospitals incur when they furnish expensive, resource-intensive services. However, we believe these concerns are in large measure addressed by the provisions of this final rule. As we explain in section III.C.6, we significantly restructured the proposed APC groups, first in response to comments and, second, to comply with section 1833(t)(2) of the Act, as amended by the BBRA 1999, which limits the variation of costs of services classified within a group. The result is more APC groups with fewer codes and a narrower range of costs in each group. In addition, other provisions of the BBRA 1999, such as the transitional pass-throughs (see section III.D, below), and outlier payments and transitional corridors (see section III.H, below) protect hospital revenues while hospitals gain experience with the PPS.
Medicare Payment Advisory Commission (MedPAC) Recommendation
In both its March 1998 and March 1999 reports to the Congress on Medicare payment policy, MedPAC recommends that payment rates under the hospital outpatient PPS be based upon costs of individual services rather than groups of similar services to help ensure consistent payments across ambulatory settings. In its March 1999 report, MedPAC asserts its belief that the burden imposed by our proposed APC system outweighs its benefits in ambulatory settings. MedPAC gives several reasons to support its position.
- The use of groups to calculate weights masks questionable cost data for low volume and new procedures.
- Different classes of hospitals face disproportionate impacts, suggesting APC groups may not be as homogeneous as we believe.
- Grouping services will likely create additional administrative burdens for hospitals, because hospitals may have to purchase or develop new software and will experience additional education and training costs.
Response: We carefully reviewed the concerns about using groups of services Start Printed Page 18447expressed by MedPAC in its March 1998 report, and we responded to those concerns in our proposed rule (63 FR 47562). Even though MedPAC concedes in its March 1999 report that using groups to set rates has certain potential advantages, MedPAC continues to oppose using groups because, according to MedPAC, they entail considerable costs and drawbacks and necessitate “a much more complicated design logic” than would be required using a service-level fee schedule.
We do not share MedPAC's concerns. We have a high level of confidence in the ratesetting method using APC groups that we implement in this final rule with comment period. As we explain below, in section III.C.6, we have extensively restructured the APC groups to respond to comments on the proposed rule, to incorporate specific provisions of the BBRA 1999, and to correct some errors that had come to our attention. We believe that by using median costs in the calculation of group weights, we limit the extent to which infrequently performed services with suspect costs can affect the payment rate of an APC group.
As discussed below in the impact analysis (section IX of this preamble), the provisions of this final rule with comment period, which include setting rates using APC groups, alleviate to a large extent the disproportionate impacts on different classes of hospitals estimated in our proposed rule. In addition, as we explain in section III.C.6, when we restructured the APC groups, we were particularly attentive to the degree of provider concentration associated with the individual services within a group in order to avoid biasing the payment system against any subset of hospitals.
Finally, none of the commenters cited increased administrative burden as an argument against using groups. Even though we are using APC groups to set rates under the hospital outpatient PPS, hospitals will bill for services using HCPCS codes (not APCs) using the same claims forms that they use currently. Although to receive payment under the new system, hospitals will have to more fully code the services they furnish, they will not have to know to which APC the service is assigned in order to determine the payment amount. We are publishing the payment rate applicable to each HCPCS code in Addendum B of this final rule. Any burdens on hospitals necessitating additional technical assistance, training, or systems changes are more a function of implementing an entirely new payment system than of our setting rates on the basis of groups of services.
Final Action: The payment rates implemented by this final rule with comment period are determined based on APC groups that use HCPCS codes to describe individual services. The codes assigned to an APC group are comparable clinically and in terms of resource use.
2. Packaging Under the APC System
a. Summary of Proposal
In our proposed rule, we described packaged services as those items or services that we recognized as contributing to the cost of the procedures or services in an APC group, and for which we would not make separate payment. We proposed to include as packaged services use of the operating room and recovery room, anesthesia, medical/surgical supplies, pharmaceuticals, observation, blood, intraocular lenses, casts and splints, the costs of acquiring tissue such as corneal tissue for surgical insertion and various incidental services such as venipuncture. We packaged the services (and their costs) within the APC group of procedures with which they were delivered in the base year. For a list of proposed packaged services grouped by hospital revenue centers, refer to the June 30, 1999 correction notice (64 FR 35258).
b. General Comments and Responses (Supporting or Objecting to Packaging)
Comment: Few commenters disagreed with our proposal to aggregate into one payment the costs for a “package” of services variously related to a procedure or to the principal service being furnished. However, many commenters did object to our packaging costs for certain specific items such as expensive drugs and pharmaceuticals, observation services in the emergency department, blood and blood products, corneal tissue acquisition costs, and chemotherapy and supportive drugs. Commenters, fearful that packaging items and services will result in lower payments that do not offset the high costs of particularly expensive items, raised the prospect of dire consequences such as forcing hospitals to use only the cheapest drugs, being unable to employ oncology nurses, eliminating otherwise clinically necessary ancillary services, or not being able to hold emergency room patients for observation.
Response: We are persuaded by commenters' arguments that packaging payment for certain expensive items and services into an APC group rate could have such a potentially negative impact as to jeopardize beneficiary access to these items and services in the hospital outpatient setting. Therefore, in response to comments, we are not packaging within an APC payment rate the costs associated with certain specified items and services. Instead, we will make a separate APC payment for these particular items and services under the outpatient PPS. However, as we explain in section III.C.2.d, we do not concur with commenters who urge separate payment for observation services; rather, we are packaging the costs in the APC for each service with which observation services were billed in our 1996 database. We discuss in further detail below, in section III.C.2.d through section III.C.2.g, and in section III.C.6, the changes that we are making to the packaging we originally proposed. We address in section III.B.1, above, the BBRA 1999 provision that requires us to package into APC group rates payment for certain implantable items and devices. In section III.D, below, we describe additional payments for certain packaged medical devices, drugs, and biologicals that are provided as transitional pass-throughs under section 201(b) of the BBRA 1999.
As we gain experience with and collect additional cost data under the hospital outpatient PPS, we will review our policy to pay separately for certain items and services that would otherwise be packaged into the APC payment. Should we decide to modify this policy, we will do so through the rulemaking process as part of our annual hospital outpatient PPS update.
MedPAC Recommendation: In its March 1999 report to the Congress, MedPAC cites two models that Medicare uses to define a unit of payment: the DRG-based payment model for hospital inpatient services, and the Medicare physician fee schedule. MedPAC contends that services provided in the hospital outpatient setting more closely parallel those furnished in an office-based setting than those furnished as part of a hospital inpatient admission. Therefore, MedPAC recommends that, in establishing ambulatory care prospective payment systems in general, we define the unit of payment for ambulatory care facilities as an individually coded service, consisting of the primary service that is the reason for the encounter, and the necessary and essential ancillary services and supplies integral to it, including limited follow-up care if it is integral to the primary service, but not including physicians' services. MedPAC further recommends that the unit of payment be defined consistently across all ambulatory care settings. Start Printed Page 18448
Response: The packaging that we proposed as the basis for determining APC payment rates and that we will implement under the hospital outpatient PPS is generally consistent with MedPAC's recommendation. However, we did not propose to include “limited follow-up services” in our packaged groups under the hospital outpatient PPS because of the difficulty of matching in our database the costs of these services with their associated primary encounter. For now, hospitals are to bill follow-up care, such as suture removal, using an appropriate medical visit code. We did not propose, nor have we included in this final rule with comment period, provision for a global period for hospital outpatient services analogous to the global period affecting payments for professional services made under the Medicare physician fee schedule.
c. Packaging of Casts and Splints
Comment: One commenter stated that we should not package costs for casts and splints with other procedures.
Response: We proposed to assign payment status indicator “N” to CPT codes for strapping and casting services (CPT codes 29000-29750) to designate that these are incidental services for which payment is packaged into the APC rate for another service or procedure, in this case, the repair or reduction of a fracture or dislocation. After further review, we determined that strapping and casting services can be performed independently, for example, when a cast placed as a part of a procedure must later be replaced with another cast. Therefore, we have decided that strapping and casting services will not be packaged and we are creating two APCs (0058 and 0059) to pay for these services. The BBA 1997 required that we pay under the outpatient PPS for casting and strapping services furnished in HHAs and hospices, to the extent that these services are provided and are not within the patient's plan of care.
d. Packaging of Observation Services
We received many comments urging us to pay separately for observation services, particularly when patients are seen in the emergency department. Observation service is placing a patient in an inpatient area, adjacent to the emergency department, or, according to some comments, in the intensive care unit (ICU) or coronary care unit (CCU), in order to monitor the patient while determining whether he or she needs to be admitted, have further outpatient treatment, or be discharged. After 1983, many hospitals began to rely heavily on the use of observation services when peer review organizations questioned admissions under the hospital inpatient prospective payment system. However, in some cases, patients were kept in “outpatient” observation for days or even weeks at a time. This resulted in excess payments both from the Medicare program and from beneficiaries who generally paid a higher coinsurance. In response to this practice, in November 1996, we issued instructions limiting covered observation services to no more than 48 hours except in the most extreme circumstances. However, the cost data upon which the APC system is based contain all costs for observation in 1996, including those that exceeded the 48-hour limit imposed at the end of that year. We have packaged those costs into the service with which they were furnished in the base year. Thus, APC payments for emergency room visits include the costs of observation within the payment.
Comment: Some commenters acknowledged that being paid separately for observation following a surgical procedure was not necessary; the packaged recovery room and observation services were sufficient. However, a major concern of commenters was observation of patients with chest pain who had equivocal results on initial diagnostic testing. Commenters were concerned that the APC payment for these cases would not be adequate.
Response: We assume that chest pain patients, such as those described by the commenters, are sent to the CCU or ICU for observation. We believe that, in general, if a patient needs to be monitored in the ICU or CCU for any length of time, then that patient should be admitted as an inpatient. Furthermore, we have never considered care furnished in an ICU or CCU to be outpatient services. Existing cost reporting instructions allow for the use of these specialty beds during a shortage of regular inpatient beds, but charges are to reflect routine care, not intensive care.
Although, as noted above, we received many comments urging that observation services be covered as a separate APC, we continue to believe that these services have been used so inappropriately in the past that we will have to gather data under the PPS before considering constructing a separate APC. We have packaged observation wherever it was billed. Roughly $139 million was identified by revenue code 762 as representing observation services. An additional $253 million was identified in revenue codes 760, 761, and 769, which could be used for either observation or treatment room use. That $253 million is also packaged. (Both figures are in 1996 dollars.)
Further analyses will be necessary on the use of observation as an adjunct to emergency treatment, as in the case of chest pain. In order to ensure that we will have sufficient data for our future analyses, hospitals must continue to bill for observation using revenue center 762 and showing hours in the units field. Observation that is billed must represent some level of active monitoring by medical personnel. It must not be billed as a way to capture room and board for outpatients. During our first review of the APC groups, we will assess whether patients with certain conditions use observation services that should be separately recognized. Thus, correct diagnosis coding is required.
e. Packaging Costs of Procuring Corneal Tissue
Comment: We received about 2,000 comments from physicians, eye banks, and health care associations opposing our proposal to package corneal tissue acquisition costs into the APC payment for corneal transplant procedures. Most commenters argued that the payment for the procedures in proposed APC group 670, Corneal transplant, is grossly inadequate and that we have failed to recognize the high costs associated with tissue screening and testing procedures required by the Food and Drug Administration that are reflected in the fees charged by eye banks. In addition, commenters contended that we failed to recognize the wide variation in tissue acquisition costs resulting from the level of philanthropic contributions in different areas of the country and in different years. Commenters asserted that by packaging corneal tissue acquisition costs with the payment for corneal transplant surgery, we would limit beneficiary access to quality care, force eye banks that are nonprofit, low-cost operations to close, provide disincentives for philanthropic contributions, and impede our goal to increase tissue availability.
As part of their comments, the Eye Bank Association of America (EBAA) submitted a report of a study the EBAA commissioned on corneal tissue acquisition costs. The study was conducted by the Lewin Group which collected and analyzed data on corneal tissue acquisition costs incurred by 74 of EBAA's 100 members that are charitable nonprofit organizations. The report states that these 74 eye banks supplied approximately 82 percent of the corneal tissue distributed Start Printed Page 18449throughout the United States in 1997. Based on the data that they collected, the Lewin Group found that the median gross acquisition cost per transplant is $1,689 in 1999 dollars. Of this amount, approximately $233 represents the national median value of donated in-kind services such as volunteer staff. The Lewin Group concluded that the proposed hospital outpatient PPS payment of $1,583 did not adequately reflect the cost of procuring corneal tissue.
Additionally, the report states that “fund raising and in-kind service values are not as well centered on their median values as the underlying cost data. Variability in fund raising and in-kind contributions not only exists between eye banks, but from year to year, within the same eye bank.” According to the study, charitable contributions in the form of cash and in-kind services represented 28 percent of the eye banks' total gross cost for tissues furnished in 1997. The Lewin Group finds that “If HCFA were to move to fee schedule or other fixed-payment rate, and pays the adjusted median Gross cost Per Transplant * * * payment of $1689, HCFA would overpay some banks and underpay others, depending on philanthropy and in-kind services which varies from community to community and from year to year. The variation is too extreme to determine a fair rate-based system, without destroying the philanthropy the community is built upon.”
Response: Based on the concerns raised by the commenters and the data presented in the Lewin Group study, we have decided not to package payment for corneal tissue acquisition costs with the APC payment for corneal transplant surgical procedures at this time. Instead, we will make separate payment, based on the hospital's reasonable costs incurred to acquire corneal tissue. Final payment will be subject to cost report settlement. To receive payment for corneal acquisition costs, hospitals must submit a bill using HCPCS code V2785, Processing, preserving and transporting corneal tissue, and indicate the acquisition cost rather than the hospital's charge on the bill. We intend to review this policy after we have acquired updated data on corneal procedures.
f. Packaging Costs of Blood and Blood Products
Comment: Many commenters, including the American Red Cross, a major medical association, teaching hospitals, and community oncology centers, believe that the payments we proposed for blood and blood-related products and for APCs that required the use of blood and blood-related products, were too low. Commenters claimed that the proposed payments are so much lower than actual costs that hospitals might be forced to stop providing a range of blood services, especially those more complex than a simple transfusion. The commenters were concerned that our proposed payment would not allow hospitals to furnish the most clinically appropriate blood products and services. The commenters also stated that blood and blood product exchange were not assigned to appropriate APCs, thus skewing payment rates and not recognizing the true costs of services with which blood and blood product exchange are associated. Commenters attributed this deficiency to the fact that certain blood-related products were incorrectly billed in the 1996 data we used as the basis for pricing APCs. Commenters were also concerned that we excluded procedures whose costs fell outside 3 standard deviations of the mean cost. One major organization recommended that we separate payment for blood and blood products from the service with which it is associated. This commenter also recommended separate payment for infusible blood-derived drugs, and that we base payment for transfusable blood products on costs. Some commenters recommended a transition period prior to full implementation of the proposed PPS.
Response: Based on the recommendations of commenters, we have created separate APC groups to pay for blood and blood products. We agree with the commenters that blood use varies enough that packaging blood units with their administration could lead to inequities. Because we were not able to capture enough claims data in the base year to accurately price the blood and blood-product APCs, we have based payment rates for these APCs on data provided by commenters, including suppliers of blood and blood products. We have based payment on current costs rather than 1996 costs so that we recognize the costs of recently developed blood safety tests. The safety of the nation's blood supply is a major concern of the Department of Health and Human Services, and we want to encourage appropriate testing and follow-up care.
g. Packaging Costs for Drugs, Pharmaceuticals, and Biologicals
We proposed to package the cost of drugs, pharmaceuticals, and biologicals with APC groups because we believe drugs are usually provided in connection with some other treatment or procedure. We collected aggregate cost data on all drugs that were billed with HCPCS codes and those billed with revenue center codes, whether or not a HCPCS was entered. By so doing, we captured historical patterns of drug use within the APC groups with which the drugs were billed during the base year. However, because we did not require HCPCS coding of drugs, we could not isolate costs associated with individual drugs, some of which are very expensive even though they are rarely used and may be used by only a few hospitals. As a result, we acknowledge that our proposed APC payment rates may not fully reflect costs of very expensive drugs or biologicals.
We also proposed to create separate drug groups for chemotherapeutic agents because those were separately identified in the APG system designed by 3M. However, because we did not have bills that were coded to identify drugs individually, we were concerned that the APC groups for chemotherapeutic groups may not have completely reflected the costs of these drugs.
Comment: Many commenters criticized the proposed APC payment rates because they were developed using cost data from 1996 that do not reflect the cost of many new drugs, pharmaceuticals, and biologicals. Some commenters expressed particular concern about oncology drugs such as paclitaxil (Taxol) and topotecan. Some advised that Taxol and carboplatin chemotherapy have become the standard treatment for ovarian carcinoma. A number of commenters believe that our proposal did not provide sufficient financial incentives to dissuade hospitals from using the older less effective chemotherapy regimens even though there is significantly greater toxicity and reduced chances of favorable outcomes associated with their use. Many commenters strongly suggested that we carve out new drugs and biologicals and those introduced after 1996 from the PPS and pay for them on a reasonable cost basis. Several commenters asserted that packaging drugs and pharmaceuticals within the APC groups understates their cost to hospitals and their value to patients.
Response: We believe the commenters' concerns have, to a great extent, been addressed by implementation of the BBRA 1999 pass-through provisions for drugs and biologicals. Addendum K includes a complete list of all drugs, biologicals, and medical devices that are eligible for pass-through payments. We encourage interested parties to follow the process outlined below in section III.I.4 of this Start Printed Page 18450preamble to submit requests for consideration of drugs, biologicals, and medical devices that may be eligible for additional payment under the transitional pass-through provision but that are not listed in Addendum K.
h. Summary of Final Action
After consideration of comments received about packaging of services and of the requirements set forth in the amendments made to section 1833(t) of the Act by section 201(b) and section 201(e) of the BBRA 1999, we have revised the package of services directly related and integral to performing a procedure or furnishing a service on an outpatient basis whose costs will determine the national payment rate for that procedure or service under the hospital outpatient PPS.
- We will package into the APC payment rate for a given procedure or service any costs incurred to furnish the following items and services: Use of an operating suite, procedure room or treatment room; use of the recovery room or area; use of an observation bed; anesthesia; medical and surgical supplies and equipment; surgical dressings; supplies and equipment for administering and monitoring anesthesia or sedation; intraocular lenses; capital-related costs; costs incurred to procure donor tissue other than corneal tissue; and, various incidental services such as venipuncture.
- In general, we will package the cost of drugs, pharmaceuticals and biologicals into the APC payment rate for the primary procedure or treatment with which they are used. Additional payment for some drugs, pharmaceuticals, and biologics may be allowed under the transitional pass-through provisions, which we explain below, in section III.D.
- We will not package payment for corneal tissue acquisition costs into the payment rate for corneal transplant surgical procedures at this time. We will make separate payment for these acquisition costs based on the hospital's reasonable costs incurred to acquire corneal tissue.
- We will not package into the APC payment rate for another procedure or service costs incurred to furnish the following items and services: blood and blood products, including anti-hemophilic agents; casting, splinting, and strapping services; immunosuppressive drugs for patients following organ transplant; and certain other high cost drugs that are infrequently administered. We have created new APC groups for these items and services, which allows separate payment to be made for them.
3. Treatment of Clinic and Emergency Department Visits
a. Provisions of the Proposed Rule
As we discussed in our proposed rule, determining payment for hospital clinic and emergency department (ED) visits requires a variety of considerations such as the following:
- The impact of packaging on setting payment rates.
- How to code visits in a manner that recognizes variations in service intensity and levels of resource consumption.
- How to keep the system administratively manageable.
- How to define critical care in terms of facility as opposed to physician input.
- Data problems associated with identifying costs from claims that list multiple services.
- How to move toward greater uniformity of payments across ambulatory settings so as to remove payment as an incentive for determining site of service.
The major issue we faced in determining payment for hospital clinic and ED visits is whether to include diagnosis as well as Physicians' Current Procedural Terminology (CPT) codes in setting payment rates.
In our proposed rule, we considered several approaches to setting prospective payment rates for hospital clinic and ED visits. Potential options included: (1) Using diagnosis codes only; (2) using CPT codes only; and (3) using a CPT-diagnosis code hybrid. We solicited comments on these approaches to setting payment rates for clinic and ED visits as well as comments on alternative approaches that we did not set forth in the proposed rule. In the proposed rule, we discussed in detail our assessment of the advantages and disadvantages of each approach.
In addition, we proposed to create a HCPCS code that would be used to bill when a patient presents to an ED, requests a screening, and is screened in accordance with section 1867(a) of the Act. Payment for this new code would be minimal because we included no treatment costs in the screening service. Payment for the screening APC would be made only when no additional services were furnished by the emergency department. If nonemergency treatment was furnished, the appropriate emergency department visit would be billed, and not the screening. Similarly, if the screening reveals that an emergency does exist and treatment is instituted immediately, the screening would not be billed because we would consider payment to be subsumed into the payment for further treatment.
We proposed paying for critical care as the highest level of “visit.” In our proposed rule, we stated that hospitals would use CPT code 99291 to bill for outpatient encounters in which critical care services are furnished.
We used the CPT definition of “critical care” which is the evaluation and management of the critically ill or injured patient. Under the outpatient PPS, we would allow the hospital to use CPT code 99291 in place of, but not in addition to, a code for a medical visit or for an emergency department service. Although the CPT system allows the physician to bill in 30-minute increments following the first 74-minute period of providing critical care, we proposed to pay separately for only the initial period (CPT code 99291), packaging the few instances in which the 30-minute increments (CPT code 99292) were billed. If other services, such as surgery, x-rays, or cardiopulmonary resuscitation, were furnished on the same day as the critical care services, we would allow the hospital to bill for them separately.
b. Comments and Responses
Comment: The major hospital associations argued that none of our three proposed approaches fully explains facility resource use in connection with clinic and emergency visits. Hospitals did not see a clear benefit in the payment ranges created by using the CPT and diagnosis hybrid approach. A major medical association adamantly opposed the use of diagnosis codes. One major HMO that does not currently use CPT codes was opposed to the use of CPT codes to describe clinic and emergency visits.
Response: In this final rule, we are not using patient diagnosis codes to compute payment rates for medical visits to clinics and emergency departments under the outpatient PPS because a number of concerns were raised about basing payment for medical visits on both HCPCS codes and ICD-9 diagnosis codes. The final payment groups for medical visits are constructed using CPT procedure codes only, which is consistent with our overall PPS grouping strategy and with the approach we have followed to establish payment groups for surgical and diagnostic services. However, we will continue to require hospitals to provide accurate diagnosis coding on claims for payment. We will continue to assess the value of using patient diagnosis for application Start Printed Page 18451to our payment system for possible use in the future.
In developing medical visit APCs based on CPT procedure codes only (a change from the proposed rule), we are collapsing 31 CPT codes that define clinic and emergency visits into six groups, three each for the clinics and the emergency department. The final APC groups for clinic and emergency visits are as follows: APC 0600, Low Level Clinic Visits; APC 0601, Mid-Level Clinic Visits; APC 0602, High Level Clinic Visits; APC 0603, Interdisciplinary Team Conference; APC 0610, Low Level Emergency Visits; APC 0611, Mid-Level Emergency Visits; APC 0612, High Level Emergency Visits; and APC 0620, Critical Care.
When basing payment on CPT codes alone, the range of costs reflects hospitals' billing patterns in increasing level of intensity. However, those increasing increments are due largely to hospitals' use of “chargemaster” systems, which generate bills using predetermined charges for codes. Thus, billing patterns reflect standard bills, not the resources used in any particular case.
We had been concerned that certain hospitals' use of the lowest level code, CPT code 99201, to bill for all clinic visits would distort the data, causing inflation in both the volume and cost of low-level clinic visits, and a corresponding underreporting of mid- and high-level visits. (Costs for mid- and high-level visits would presumably have been correct, because individual hospitals would have reported appropriate charges with these codes; there simply would have been fewer reported visits at those levels.)
We have developed the weights for clinic visits by using claims data only from a subset of hospitals that billed a wider range of visits rather than relying solely on claims with CPT code 99201. We chose to use this subset of hospitals (for this purpose only) because we do not know what CPT code 99201 indicates when hospitals use it exclusively to bill all visits.
We emphasize the importance of hospitals assessing from the outset the intensity of their clinic visits and reporting codes properly based on internal assessment of the charges for those codes, rather than failing to distinguish between low-and mid-level visits “because the payment is the same.” The billing information that hospitals report during the first years of implementation of the hospital outpatient PPS will be vitally important to our revision of weights and other adjustments that affect payment in future years. We realize that while these HCPCS codes appropriately represent different levels of physician effort, they do not adequately describe nonphysician resources. However, in the same way that each HCPCS code represents a different degree of physician effort, the same concept can be applied to each code in terms of the differences in resource utilization. Therefore, each facility should develop a system for mapping the provided services or combination of services furnished to the different levels of effort represented by the codes. (The meaning of “new” and “established” pertain to whether or not the patient already has a hospital medical record number.)
We will hold each facility accountable for following its own system for assigning the different levels of HCPCS codes. As long as the services furnished are documented and medically necessary and the facility is following its own system, which reasonably relates the intensity of hospital resources to the different levels of HCPCS codes, we will assume that it is in compliance with these reporting requirements as they relate to the clinic/emergency department visit code reported on the bill. Therefore, we would not expect to see a high degree of correlation between the code reported by the physician and that reported by the facility.
Hospitals are required to use HCPCS code 99291 to report outpatient encounters in which critical care services are furnished. (See the American Medical Association's CPT 2000 coding manual for the definition of this code.) The hospital is required to use HCPCS code 99291 in place of, but not in addition to, a code for a medical visit or for an emergency department service.
We will work with the American Hospital Association and the American Medical Association to propose the establishment of appropriate facility-based patient visit codes in time for the next proposed rule.
Comment: Several commenters expressed concern that resources expended in the emergency department are not fully explained by the codes at their disposal. One commenter pointed out that some hospitals use internal coding systems to capture differing charges based on whether or not a case requires one-on-one nursing care.
Response: While we share commenters' concerns on this point, we remind hospitals that they can receive additional payment under the outpatient PPS for services such as diagnostic testing and administration of infused drugs, and for therapeutic procedures including resuscitation that are furnished during the course of an emergency visit. We will also pay separately for certain high cost drugs, such as the expensive “clotbuster” drugs that must be given within a short period of time following a heart attack or stroke, if these drugs are furnished during an emergency visit. Even though some ED patients will be transferred to another hospital for inpatient treatment, the hospital that administers the drugs will be paid for them. Cases that fall far outside the normal range of costs will be eligible for an outlier adjustment established by section 201(a) of the BBRA 1999. (See section III.H, below.) In addition, one of the first topics of review to be addressed by the expert outside advisory panel, required by section 201(h)(1)(B) of the BBRA 1999, will be to determine if emergency department visits can be categorized in a way that better recognizes the underlying resources, especially nursing resources, involved in the visit.
Comment: Several commenters expressed concern about the appropriate level of payment for patients who die in the ED. One commenter believes that services furnished to these patients are resource-intensive and recommends that we continue to pay for the services on a reasonable cost basis.
Response: We are directing fiscal intermediaries to use the following guidelines in determining how to make payment when a patient dies in the ED or is sent directly to surgery and dies there.
- If the patient dies in the ED, make payment under the outpatient PPS for services furnished.
- If the ED or other physician orders the patient to the operating room for a surgical procedure, and the patient dies in surgery, payment will be made based on the status of the patient. If the patient had been admitted as an inpatient, pay under the hospital inpatient PPS (a DRG-based payment). If the patient was not admitted as an inpatient, pay under the outpatient PPS (an APC-based payment). If the patient was not admitted as an inpatient and the procedure is designated as an inpatient-only procedure (payment status indicator “C”), no Medicare payment will be made for the procedure, but payment will be made for ED services.
Comment: Some commenters objected to our proposal to restrict payment for critical care services to CPT code 99291 and not allow payment for CPT code 99292. One commenter recommended that we create an APC group for the additional increments of time a physician spends in critical care for which the physician may bill. Start Printed Page 18452
Response: We do not believe that paying hospitals for incremental time as critical care would better reflect facility resources. The most resource-intensive period for the hospital is generally the first hour of critical care. In addition, we believe it would be burdensome for hospitals to keep track of minutes for billing purposes. Therefore, we will pay for critical care as the most resource-intensive visit possible as defined by CPT code 99291. Critical care services will be assigned to APC 0620.
Comment: Several commenters advised that a screening code was not necessary because an emergency visit code could be billed for ED screening services.
Response: We agree with the commenters, and we will instead use the appropriate emergency department codes for screening services (as defined in section 1867(a) of the Act). If no treatment is furnished, we would expect screening to be billed with a low-level emergency department code.
Comment: Some commenters expressed concern about our proposal to allow hospitals to create a separate claim for each visit when two or more medical visits occur on the same day for different diagnoses. Commenters feared that this would result in our paying under the outpatient PPS for clinic care furnished at sites other than hospital outpatient departments, and that we are promoting fragmented care. One commenter was concerned that, to the extent that patients see multiple specialists, tests will be repeated unnecessarily, hospitalizations will rise, and beneficiaries and the Medicare program will be burdened with additional, unnecessary costs.
Response: Our decision not to use diagnosis codes as a factor in determining payment for clinic visits largely negates these concerns because the need to prepare different claims for visits for different diagnoses has been eliminated. When patients are seen in different clinics on the same day, hospitals should bill using the proper codes for the level of the visits, using the units field if appropriate to reflect more than one visit at the same level.
However, we note that the comment did prompt us to develop a code for billing those visits during which numerous physicians see a patient concurrently, for example, a surgeon, medical oncologist, and radiation oncologist for a cancer patient, to discuss treatment options and to ensure that the patient is fully informed. In this instance, each physician is addressing the patient's care from a unique perspective. If several physicians see a patient concurrently in the same clinic for the same reason, the hospital would bill for one clinic visit using an appropriate visit code even though each physician would bill individually for his or her professional services. We have established a code for hospitals to use in reporting a scheduled medical conference with the patient involving a combination of at least three health care professionals, at least one of whom is a physician. That code is G0175, Scheduled interdisciplinary team conference (minimum of three, exclusive of patient care nursing staff) with patient present.
4. Treatment of Partial Hospitalization Services
As we explained in the proposed rule, partial hospitalization is an intensive outpatient program of psychiatric services provided to patients in lieu of inpatient psychiatric care. Partial hospitalization may be provided by a hospital to its outpatients or by a Medicare-certified community mental health center (CMHC). It is important to note that the services of physicians, clinical psychologists, clinical nurse specialists (CNSs), nurse practitioners (NPs), and physician assistants (PAs) furnished to partial hospitalization patients would continue to be billed separately to the carrier as professional services and are not considered to be partial hospitalization services. Thus, payment for partial hospitalization services represents the provider's overhead costs, support staff, and the services of clinical social workers (CSWs) and occupational therapists (OTs), whose professional services are considered to be partial hospitalization services for which payment is made to the provider. Including CSW and OT services reflects historical patterns of treatment billed during the base year.
Because a day of care is the unit that defines the structure and scheduling of partial hospitalization services, we proposed a per diem payment methodology for the partial hospitalization APC. We analyzed the service components billed by hospitals over the course of a billing period and determined the median hospital cost of furnishing a day of partial hospitalization. As noted in the June 30, 1999 correction notice, this analysis resulted in a proposed APC payment rate of $206.71 per day, of which $46.78 is the beneficiary's coinsurance.
We also solicited comments on a number of issues related to partial hospitalization. We asked for information on the mix of services that constitute a typical partial hospitalization day and average duration of a partial hospitalization episode, whether we should impose a minimum number of services for each covered partial hospitalization day, and whether we should establish a limit on routine outpatient mental health services furnished on a given day to equal the partial hospitalization per diem amount. Finally, we indicated that we are considering specifying a timeframe for physician recertification of need for partial hospitalization services as a method of ensuring that a patient's condition continues to require the intensity of a partial hospitalization program.
We did not receive a significant number of public comments on this issue. A summary of the comments we received and our responses follow.
Comment: We received many similar comments from rural hospitals that operate partial hospitalization programs. The hospitals indicated that the proposed per diem amount does not cover their direct cost of providing services. Each commenter included an estimate of their partial hospitalization program cost (without depreciation or allocation of overhead costs). The estimates range from $270 to $325 per patient per day. The commenters indicated that approximately 65 to 70 percent of the costs are personnel-related.
Response: The commenters did not indicate why their costs were higher than the per diem amount, but only that a significant proportion of their costs are related to personnel. In the future, we are committed to assessing the extent to which the per diem reflects special needs of rural hospitals. In the meantime, the BBRA 1999 includes provisions that offer relief to rural hospitals during the early years of the outpatient PPS. (See section III.H of this preamble.)
Comment: We received several other comments regarding the proposed per diem amount. One commenter stated that the proposed per diem rate is equivalent to 3.3 psychotherapy units. The commenter believed this is an inadequate level of therapy for partial hospitalization patients and suggested that a per diem rate equal to 4 psychotherapy units would provide payment for a more appropriate level of service intensity. Several other commenters suggested that we set a single rate using a therapeutic hour of treatment (for example, the group psychotherapy APC rate) as the unit of service coupled with an overall aggregate limit for a course of treatment. These commenters estimated that a typical partial hospitalization day costs $275. Another commenter, a national association, conducted a survey of its Start Printed Page 18453member hospitals which showed that the median cost per day of treatment was approximately $210. Other commenters urged us to establish separate per diem amounts for partial hospitalization programs serving geriatric beneficiaries and those serving disabled beneficiaries under age 65. They indicated that programs designed to serve geriatric beneficiaries consist of different treatment modalities that are costlier than programs that serve younger beneficiaries. One commenter stated that programs serving younger beneficiaries typically average high patient volume and therefore have much lower costs per patient day than do the programs that serve geriatric patients. Other commenters urged us to establish a half day rate, although some stated that a half-day benefit does not reduce administrative costs appreciably.
Response: In accordance with section 1833(t)(2)(C) of the Act, the proposed per diem amount represents the national median cost of providing partial hospitalization services. We used all the data from hospital bills that included the condition code 41, which identifies the claim as partial hospitalization. Because providers do not report on the claim the specific services provided each day, we do not currently have data that would permit us to establish an aggregate limit for a course of treatment or to analyze differences in the mix of services provided to various populations. As discussed in the preamble to the proposed rule and in Transmittal 7 of the CMHC Manual (issued November 1999) and Transmittal 747 of the Hospital Manual (issued December 1999), beginning April 1, 2000, hospitals and CMHCs will be required to indicate line item dates of service on claims. Once we have accumulated these data, we will be better able to determine if refinements to the per diem methodology are warranted, including the extent to which half-days are utilized.
Comment: Several commenters expressed concern that no CMHC data were used to establish the partial hospitalization per diem payment rate. The commenters stated that CMHC costs are significantly different from hospital-based programs and urged us to collect CMHC cost data and base payments to CMHCs on CMHC-specific information. Another commenter stated that implementing PPS for partial hospitalization services provided by CMHCs is intended to contain costs and urged us to track the impact of the PPS on CMHCs. Still another commenter expressed concern that the per diem amount is insufficient for CMHCs to provide quality services. The commenter admitted, however, that historically their service area has had limited resources to provide minimum support for the persistent and chronically mentally ill. Two commenters expressed concern about certification requirements for CMHCs. One urged us to require accreditation by a national accrediting body and another commenter noted that reliance on the statutory definition established for CMHCs under the Public Health Service Act in 1963 is no longer appropriate and urged us to redefine a CMHC for Medicare certification purposes.
Response: Partial hospitalization services are covered services under the hospital outpatient PPS. Section 1833(a)(2)(B) of the Act provides that partial hospitalization services furnished by CMHCs are to be paid under the hospital outpatient PPS. And, section 1833(t)(2)(C) of the Act requires that we establish relative payment weights based on median (or mean, at the election of the Secretary) hospital costs determined by 1996 claims data and data from the most recent available cost reports. As stated above, we are committed to analyzing future data from hospitals and CMHCs to determine if refinements to the per diem are warranted. As we noted in the proposed rule, the Medicare partial hospitalization benefit is designed to furnish services to patients who have been discharged from inpatient psychiatric care, and partial hospitalization services are provided in lieu of continued inpatient treatment, and for patients who exhibit disabling psychiatric/psychological symptoms or experience an acute exacerbation of a severe and persistent mental disorder. Because the statute requires a physician to certify that the patient would otherwise require inpatient psychiatric care in the absence of the partial hospitalization services, we do not believe the Medicare partial hospitalization benefit was intended to provide support for the persistent and chronically mentally ill except when they are in an acute phase of their mental illness. With regard to accreditation requirements for CMHCs and substantively revising the definition of a CMHC, this final rule is not the appropriate vehicle in which to address these issues. We are, however, amending § 410.2 to remove an obsolete provision from the definition of a CMHC.
Comment: Several commenters questioned whether the proposed per diem approach meets the definition of an APC, that is, a group of services that are comparable clinically and in resource use. They believed that partial hospitalizations vary widely in their treatment approach and cost. Therefore, creating one payment amount for all partial hospitalization days is not consistent with our proposed classification system.
Response: We continue to believe that the structure of the average partial hospitalization day is more similar than the commenters believe. We followed the basic analytical methodology used to establish all the APC payment amounts, except that we determined that, for partial hospitalization services, the unit of service is a day. Nonetheless, requiring providers to submit claims by date of service and by service provided will allow for future analysis to determine if the APC grouping for partial hospitalization can be improved.
Comment: One commenter expressed concern about the use of 1996 data as the basis for the per diem amount. They referenced testimony by the Inspector General that indicated a significant improvement in the accuracy of provider billing in 1998 audits. They urged us to use 1997 or 1998 cost reports by region to develop the APC rate.
Response: Section 1833(t)(2)(C) of the Act requires that we use 1996 claims data and the most recent cost reports as the basis for ratesetting under the hospital outpatient PPS. For purposes of the final rule, we primarily used cost reports for periods beginning in FY 1997.
Comment: Several commenters, including national industry associations, expressed concern that partial hospitalization programs are required by their individual fiscal intermediaries to meet different medical necessity and programmatic requirements. For this reason, programs vary widely in program content and resultant cost. The commenters urged us to establish national coverage criteria before implementing a PPS for partial hospitalization services. Another commenter urged us to rely on more recent claims data that identify all services provided on each date of service in order to determine the relative resource cost of various outpatient mental health treatment programs.
Response: Section 1833(a)(2)(B) of the Act provides that partial hospitalization services are paid under section 1833(t). We will refine the system, as needed, based on our review of more specific bill data. Movement to a per diem payment methodology will necessitate changes in the medical review approach used by fiscal intermediaries. It will become necessary to ensure that all patients receive the level of service their Start Printed Page 18454individual condition requires. Some patients will require days of service that cost the provider more than the per diem payment amount. Other patients may require less intensive days of service during an acute episode of partial hospitalization care or as they transition out of the partial hospitalization program. We will be developing medical review guidance for fiscal intermediaries, which we believe will lead to more consistency in medical review.
Comment: One commenter noted that, in the past, a daily or partial-day payment approach was commonly used and was abandoned in favor of component billing for each partial hospitalization service. The commenter now believes that component billing provides a more accurate indication of the services provided to individual patients.
Response: We believe that a per diem payment approach is a more appropriate methodology than billing for each program component. This approach is supported by the major industry groups involved with partial hospitalization and is used by other governmental and private insurers to pay for partial hospitalization program services. A per diem approach also incorporates and recognizes the cost of services that are not separately billable as outpatient psychiatric services, such as nursing services, training and education services, activity therapy, and support staff costs.
Comment: Several commenters requested additional information on the HCPCS codes to which the partial hospitalization indicator applies and questioned how codes will group to APC 20 rather than grouping to psychotherapy APCs 91 through 94. They also asked whether substance abuse day programs will group to APC 20.
Response: We issued revised billing instructions for partial hospitalization services provided by CMHCs in November 1999 and for hospital programs in December 1999. We instructed CMHCs to use HCPCS codes to bill for their partial hospitalization services; we required hospitals and CMHCs to report line item dates of service; and we established new HCPCS codes for occupational therapy and training and educational services furnished as a component of a partial hospitalization treatment program. We included in the instructions a complete listing of the revenue codes and HCPCS codes that may be billed as partial hospitalization services as follows:
Revenue codes Description HCPCS code 43X Occupational Therapy (Partial Hospitalization) G0129. 904 Activity Therapy (Partial Hospitalization) Q0082. 910 Psychiatric General Services 90801, 90802, 90875, 90876, 90899, or 97770. 914 Individual Psychotherapy 90816, 90818, 90821, 90823, 90826, or 90828. 915 Group Psychotherapy 90849, 90853, or 90857. 916 Family Psychotherapy 90846, 90847, or 90849. 918 Psychiatric Testing 96100, 96115, or 96117. 942 Education Training (Partial Hospitalization) G0172. To bill for partial hospitalization services under the hospital outpatient PPS, hospitals are to use these HCPCS and revenue codes and are to specify condition code 41 on the HCFA-1450 claim form. Before assigning a claim for payment to APC 0033 (the final APC for partial hospitalization services), the outpatient code editor (OCE) will check for errors; for example, the OCE will verify that the claim includes a mental health diagnosis, and at least three partial hospitalization HCPCS codes for each day of service, one of which must be a psychotherapy HCPCS code (other than brief). Claims that do not pass the OCE edits will undergo further prepayment review.
With regard to the comments regarding substance abuse day programs, the Medicare benefit category is partial hospitalization services. Because there is no separate benefit category for substance abuse programs, any such program would have to meet requirements established for partial hospitalization programs in order for claims to group to APC 0033, including the requirements that a physician certify that the patient would otherwise require inpatient psychiatric care in the absence of the partial hospitalization services and that the program provides active treatment.
Comment: In regard to physician recertification, we received several comments expressing support for establishing a specific timeframe and recommending a range from 7 to 31 days.
Response: We agree that physicians should initially certify a patient's need for partial hospitalization services and recertify continued need for this intensive level of treatment. Because partial hospitalization is the outpatient substitute for inpatient psychiatric care, we believe it is appropriate to adopt the standard currently used for inpatient psychiatric care. Therefore, in this final rule, we are amending § 424.24(e) to establish physician recertification requirements for partial hospitalization services. The initial physician certification establishing the need for partial hospitalization must be received by the partial hospitalization program upon admission. Thus, services provided to establish a patient's need for partial hospitalization services would continue to be billed to the carrier as professional services. The first recertification is required as of the 18th day of services and subsequent recertifications are required no less frequently than every 30 days. Each recertification must address the patient's response to the intensive, therapeutic interventions provided by the active treatment program which make up partial hospitalization services, changes in functioning and status of the serious psychiatric symptoms that place the patient at risk of hospitalization, and treatment plan and goals for coordination of services such as community supports and less intensive treatment options to facilitate discharge from the partial hospitalization program.
Comment: We received several comments regarding our proposal to limit payment for less intensive outpatient mental health treatment at the partial hospitalization per diem rate. One commenter did not believe the law supports establishment of a payment ceiling and that any such action is arbitrary. Other commenters believe that treatment should be determined by the clinical needs of each patient. However, the commenters conceded that additional requirements may have to be added to the final rule to prevent duplication or overlap of partial Start Printed Page 18455hospitalization and routine outpatient mental health services.
Response: Our rationale for this proposal was that the costs associated with administering a partial hospitalization program represent the most resource intensive of all outpatient mental health treatment and, therefore, we should not pay more for a day of individual services. We are also concerned that a provider may disregard a patient's need for the intensive active treatment offered by a partial hospitalization program and opt to bill for individual services. In addition, the per diem amount represents the cost of an average day of partial hospitalization because the data used to calculate the per diem were derived from all the partial hospitalization data and include the most and the least intensive days. It would not be appropriate for a provider to obtain more payment through component billing.
Comment: Several commenters expressed concern about staffing services that are bundled in the per diem payment and other staffing issues. One commenter stated that due to increased medical review by the fiscal intermediary, no partial hospitalization services may be furnished by unlicensed personnel. The commenter urged that the necessity for upgrades in staffing be taken into consideration in establishing a per diem rate. One commenter believes that all services, except for physician services, should be bundled into the per diem rate.
Response: The list of covered partial hospitalization services is located in section 1861(ff) of the Act. The list includes several services such as patient education and training and activity therapy that may be provided by unlicensed but qualified staff who are specifically trained to work with the mentally ill. We note that the billing instructions issued in November 1999 (for CMHCs) and in December 1999 (for hospitals) announced a new HCPCS code for patient training and education services as a component of a partial hospitalization program. (A HCPCS code for activity therapy as part of a partial hospitalization program has been in place for several years.) Although the list also specifically references the services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients, there are no specific HCPCS codes for these services. Certain other partial hospitalization services, for example, individual and group psychotherapy, family counseling, occupational therapy (OT), and diagnostic services, must be provided by licensed staff, authorized by the State to provide these services.
With regard to the content and staffing of partial hospitalization programs, we believe that all the covered services listed in section 1861(ff) of the Act and the disciplines of the staff who provide the services, that is, the multidisciplinary team, are an important element in creating the therapeutic milieu that distinguishes partial hospitalization programs from other outpatient mental health treatment. We believe it would be inappropriate if providers no longer offered the full range of partial hospitalization services, especially services such as OT that continue to be bundled in the per diem amount. We plan to monitor the extent to which providers change their programming in response to implementation of the PPS. Because the data on which the per diem was based included the full range of services and the use of certain bundled professionals, we will monitor changes in services or increased use of unbundled practitioners to evaluate and update the per diem rate. In response to the comment recommending that we bundle more professional services into the per diem rate, we captured historical patterns of treatment and staffing during the base year. Thus, the partial hospitalization per diem amount is limited to the provider's overhead costs, support staff, and the services of clinical social workers and occupational therapists, whose professional services are defined as partial hospitalization services. We have amended § 410.43(b) to update the list of services that are not paid as partial hospitalization services.
Comment: One commenter took issue with our characterizing partial hospitalization to be the result of an acute exacerbation of a beneficiary's severe and persistent mental illness for which partial hospitalization services are provided in lieu of an inpatient psychiatric admission. They urged us to clarify that admission to a partial hospitalization is based on a physician certification that the patient would otherwise require inpatient psychiatric care, but continued stay in a partial hospitalization program would serve as a maintenance program for the chronically mentally ill. The commenter raised many other concerns about how we described partial hospitalization in the proposed rule, noting specific concern with regard to active treatment, community-based support, and frequency and duration of services.
Response: It was not our intention in the proposed rule to generate public comment on the nature and coverage of partial hospitalization under the Medicare program. Rather, the information presented has appeared in various program memoranda and was included to describe the benefit and explain the per diem payment methodology. We continue to believe that partial hospitalization is a covered Medicare benefit category only when provided as an alternative to inpatient psychiatric care for acutely mentally ill beneficiaries.
Result of Evaluation of Comments
We are adopting as final our proposal to—
- Establish a per diem payment of $202.19 for the partial hospitalization APC (APC 0033); and
- Limit the payment for outpatient mental health treatment furnished on a day of services to the partial hospitalization APC payment amount.
In addition, we are amending § 424.24(e) to establish requirements for physician recertification for partial hospitalization services.
5. Inpatient Only Procedures
In our proposed rule, we assigned payment status indicator “C” to 1,803 codes that represent procedures that our medical advisors and staff determined require inpatient care because of the invasive nature of the procedure, the need for postoperative care, or the underlying physical condition of the patient who would require the surgery. We did not assign these procedures to an APC group, and we proposed to make no payment for these services under the hospital outpatient PPS. Above, in section III.B.1.b of this preamble, we respond to the numerous general comments we received challenging both our classification of various procedures as inpatient procedures and our exclusion of these procedures from the scope of services paid under the hospital outpatient PPS.
Comment: Commenters objected on the grounds that medical practice and new technology have allowed many procedures that formerly were performed only in the inpatient setting to be safely and effectively performed on an outpatient basis. In addition, they believe we are making decisions that should be left to the discretion of surgeons and their patients. Finally, the commenters believe that it is better for the patient if procedures are performed on an outpatient basis whenever possible. Commenters requested that we remove the payment status indicator of “inpatient only” from 195 codes and include them in an appropriate APC.
Response: Under section 1833(t)(1)(B)(i) of the Act, the Secretary has broad authority to designate which Start Printed Page 18456services fall within the definition of “covered OPD [outpatient department] services” that will be subject to payment under the prospective payment system. We believe that certain surgically invasive procedures on the brain, heart, and abdomen, such as craniotomies, coronary-artery bypass grafting, and laparotomies, indisputably require inpatient care, and therefore are outside the scope of outpatient services. Certain other procedures that we proposed as “inpatient only” may not be so clearly classified as such, but they are performed virtually always on an inpatient basis for the Medicare population. We acknowledge that emerging new technologies and innovative medical practice are blurring the difference between the need for inpatient care and the sufficiency of outpatient care for many procedures, although we are concerned that some of the procedures that commenters claim to be performing on an outpatient basis may actually have been performed with overnight postoperative care furnished in observation units. And, regardless of how a procedure is classified for purposes of payment, we expect, as we stated in our proposed rule, that in every case the surgeon and the hospital will assess the risk of a procedure or service to the individual patient, taking site of service into account, and will act in that patient's best interests.
After a careful review of comments by our medical advisors and staff, we have assigned to APC groups certain procedures that we had proposed as inpatient only. We made some changes because we were convinced by commenters' arguments that certain procedures are often performed safely in the outpatient setting; others because we believe that the simplest procedure described by the code may be performed safely in the outpatient setting; and yet others because they were related to codes we moved (for example, the radiologic part of an interventional cardiology procedure). The procedures we moved to the outpatient APCs include codes from within the following families: Explorations of penetrating wounds; repairs of some cranial and facial fractures; planned tracheostomies; diagnostic thoracoscopies; some insertion/removal/replacement of pacemakers, pulse generators, electrodes and cardioverter-defibrillators; embolectomies and thrombectomies; transluminal balloon angioplasty and peripheral atherectomy; transcatheter therapies; bone marrow transplantation; gastrostomies; percutaneous nephrostolithotomy; surgical laparoscopies, including cholecystectomies; ovarian biopsies; and surgeries on the orbit. Although we are moving these procedures into APC groups and they can receive outpatient payment, we emphasize that we expect only the simplest and least resource intensive procedures of each type to be performed in the outpatient setting. For example, several codes could be used to describe initial insertion of a pacemaker or replacement of the pacemaker or its electrodes. We believe most initial pacemaker insertions are performed on an inpatient basis, so codes billed in this range are most likely to be for replacement of a pacemaker, which requires fewer facility resources.
Because of the risk involved with invasive cardiovascular procedures, including angioplasty and atherectomy, we are placing an additional requirement on their performance that we do not think is necessary with other procedures. That is, Medicare will pay for these procedures only in those settings in which the patient can immediately be placed on cardiopulmonary bypass in the event of a complication such as perforation of a coronary artery, which would require an immediate thoracotomy.
When our medical advisors and staff disagreed with the recommendation of commenters to reclassify a particular procedure, they based their decision to retain a procedure as “inpatient only” on several considerations. In general terms, as stated above, we define inpatient procedures as those that require inpatient care because of the invasive nature of the procedure, the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged, or the underlying physical condition of the patient who would require the surgery. In other words, inpatient procedures are those that, in the judgment of our medical advisors and staff, would not be safe, appropriate, or considered to fall within the boundaries of acceptable medical practice if they were performed on other than a hospital inpatient basis.
Among the procedures cited by commenters that we believe should remain as “inpatient only” are: Breast reconstruction using myocutaneous flaps; radical resections of tumors of the mandible; open treatment of certain craniofacial fractures; osteotomies of the femur and tibia; sinus endoscopy with repair of cerebrospinal fluid leaks; carinal reconstruction; surgical thoracoscopies; pacemaker procedures by thoracotomy; certain thromboendarterectomies; excision of mediastinal cysts and tumors; excisions of stomach tumors; enterostomies; hepatotomies; ureterotomies and ureteral endoscopies through ureterotomies; transcranial approaches to the orbit; and laminectomies. Our medical advisors and staff, as well as consulting physicians, believe these procedures are too invasive (for example, thoracotomies), too extensive (for example, breast reconstruction with myocutaneous flaps), or too risky by virtue of proximity to major organs (for example, repairs of spinal fluid leaks and carinal reconstruction) to be performed on an outpatient basis. The procedures that we exclude from outpatient payment because we believe they should be performed on an inpatient basis are listed in Addendum E. This list represents national Medicare policy and is binding on fiscal intermediaries and peer review organizations as well as on hospitals and Medicare participating ASCs. Note, however, that services included in outpatient PPS and assigned to an APC may be performed on an inpatient basis when the patient's condition warrants inpatient admission.
In the future, as part of our annual update process, we will be working with professional societies and hospital associations, as well as with the expert outside advisory panel that we will be convening as required by new section 1833(t)(9)(A) of the Act, to reevaluate procedures on the “inpatient only” list and we will propose to move procedures to the outpatient setting whenever we determine it to be appropriate. For example, a decreasing length of inpatient stay for a procedure may signal that it is appropriate for consideration for payment under the outpatient PPS. If hospitals find that surgeons are discharging patients successfully on the day of surgery, they should bring this to our attention as well, because hospitals may become aware of this trend before our payment data disclose it. Thus, assignment of a “C” payment status indicator in this final rule should not be considered as a permanent or irrevocable designation.
Comment: One professional society recommended that we assign payment status indicator “C” to CPT codes 21343, open treatment of depressed frontal sinus fracture, 42842, radical resection of tonsil, tonsillar pillars, and/or retromolar trigone—without closure, and 69150, radical excision external auditory canal lesion—without neck dissection, because these procedures require inpatient care.
Response: We accepted the commenters' recommendation that these CPT codes should not be performed in an outpatient setting. We also reclassified as an inpatient procedure Start Printed Page 18457CPT code 94762, noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure), because it requires an overnight stay.
Comment: One commenter noted that, to the extent that we require that certain surgical procedures be performed in an inpatient setting in order to receive Medicare payment, the beneficiary will incur the higher deductible associated with a hospital inpatient service.
Response: The commenter is correct that the Part A hospital inpatient deductible amount that a beneficiary will have to pay may be higher than coinsurance and deductibles the beneficiary would have paid as an outpatient for a surgical procedure. However, our decisions concerning whether to pay for certain surgical procedures under the PPS are based on patient safety concerns and the medical appropriateness of performing the procedures in the hospital inpatient versus outpatient setting.
Final Action
Under the hospital outpatient PPS, we will not make payment for procedures that are designated as “inpatient only.” We have, however, revised the list of procedures that are designated as “inpatient only” based on comments. (See Addendum E.)
6. Modification of APC Groups
a. How the Groups Were Constructed
Section 1833(t)(2)(A) of the Act requires the Secretary to develop a classification system for covered outpatient services. Within that classification system, the Secretary is given the authority under section 1833(t)(2)(B) of the Act to establish groups of covered services so that the services within each group are comparable clinically and with respect to the use of resources. In the proposed rule, we explain how we constructed the APC groups that are the basis for ratesetting under the hospital outpatient PPS.
Our medical advisors and staff used the ambulatory patient groups (APGs) developed by 3M-Health Information Systems as a starting point for the APC groups, but we modified the APGs to take into account 1996 outpatient claims data, data collected in a 1994 survey of ambulatory surgical center (ASC) costs and charges, data collected in 1995 and 1996 to establish resource-based practice expense relative values under the Medicare physician fee schedule, and comments offered by a broad range of professional and trade societies and associations. For a more detailed discussion of this process, see section V.B of the proposed rule (63 FR 47561).
b. Comments on Classification of Procedures and Services Within APC Groups
In the proposed rule, we invited comments on the composition of the APC groups, and we requested that commenters support their recommendations for changes with resource cost data and clinical arguments. We received a large number of comments on our proposed grouping of individual procedures and services. The most common comment was that the APC groups generally lacked consistency in terms of clinical characteristics and resource utilization. Below, in section III.C.6.d of this preamble, we address recommendations from commenters that specific HCPCS codes be assigned to a group other than the one we proposed. In addition to reviewing the APC groups that were the subject of comments, our medical advisors and staff reviewed every APC group to take into account the effect across all related groups of commenters' recommended changes.
Criteria for Evaluating Changes Recommended by Commenters
In determining whether or not to accept a recommended change, we focused on five criteria that are fundamental to the definition of a group within the APC system. The decision to accept or decline a modification to an APC group was measured by whether the change enhanced, detracted from, or had no effect on the integrity of an APC group within the context of these five criteria. The five criteria are as follows:
- Resource Homogeneity
The amount and type of facility resources, for example, operating room time, medical surgical supplies, and equipment, that are used to furnish or perform the individual procedures or services within each APC should be homogeneous. That is, the resources used are relatively constant across all procedures or services even though resource use may vary somewhat among individual patients. If the procedures within an APC require widely varying resources, it would be difficult to develop equitable payment rates. Aggregated payments to a facility that performed a disproportionate share of either the expensive or inexpensive procedures within an APC would be distorted. Further, the facility might be encouraged to furnish only the less costly procedures within the APC, resulting in a potential access problem for the more costly services.
It is important to note that procedures within an individual HCPCS code can vary widely in resource use. The coefficient of variation of cost for the procedures within one HCPCS code can be as high as the overall coefficient of variation across all the HCPCS codes that comprise an APC group. Thus, a significant amount of the variability in resource use within some APC groups can be attributed to the variability of resources within individual HCPCS codes. Nevertheless, if resource use is reasonably homogeneous among the HCPCS codes within an APC group, the average pattern of resource use among a group of cases in an APC can be accurately predicted. In section III.C.6.c, below, we discuss the BBRA 1999 provision that sets limits on the variation in resource cost within an APC.
- Clinical Homogeneity
The definition of each APC group should be “clinically meaningful,” that is, the procedures or services included within the APC group relate generally to a common organ system or etiology, have the same degree of extensiveness, and utilize the same method of treatment, for example, surgical, endoscopic, etc. The definition of clinical meaningfulness is, of course, dependent on the goal of the classification system. For APCs, the definition of clinical meaningfulness relates to the medical rationale for differences in resource use. If, on the other hand, classifying patient prognosis were the goal, the definition of patient characteristics that were clinically meaningful might be different.
- Provider Concentration
We considered the degree of provider concentration associated with the individual services that comprise the APC. If a particular service is offered only in a limited number of hospitals, then the impact of payment for the service is concentrated in a subset of hospitals. Therefore, it is particularly important to have an accurate payment level for services with a high degree of provider concentration. Conversely, the accuracy of payment levels for services that are routinely offered by most hospitals does not bias the payment system against any subset of hospitals. Thus, differences in the resource requirements for individual services within an APC are of less significance if all the services within the APC are routinely offered by most hospitals because the impact of the difference should average out at the hospital level.
- Frequency of Service
Unless we found a high degree of provider concentration, we avoided creating separate APC groups for Start Printed Page 18458services that are infrequently performed. It is difficult to establish reliable payment rates for low volume APC groups. Therefore, we assigned the HCPCS codes to the APC that was the most similar in terms of resource use and clinical coherence.
Some procedures, such as craniotomies, are clearly inpatient procedures, and are rarely performed in an outpatient setting. However, there are some procedures that, while they are normally performed on an inpatient basis, can also be safely performed on an outpatient basis. The performance of those procedures on an outpatient basis is infrequent and is limited to the simplest cases. Therefore, when we included these procedures in APC groups, we assumed a level of resource use that would apply only to the simplest cases rather than that typical of more complex cases that would be performed on an inpatient basis.
- Minimal Opportunities for Upcoding and Code Fragmentation
The APC system is intended to discourage using a code in a higher paying group to define a case. That is, putting two related codes, such as the codes for excising a lesion of 1.1 cm and one of 1.0 cm, in different APC groups may create an incentive to exaggerate the size of the lesions in order to justify the incrementally higher payment. APC groups based on subtle distinctions would be susceptible to this kind of upcoding. Therefore, we kept the APC groups as broad and inclusive as possible without sacrificing resource or clinical homogeneity.
In general, HCPCS codes that are nonspecific (such as 20999, “unlisted procedure, musculoskeletal system, general”) were assigned to the lowest paying APC that was consistent with the clinical characteristics of the service. In the case of 20999, the codes to which it is related are in the range 20000-20979. The APCs to which they group range from 0004, with a payment rate of $89.22, to 0050, with a payment rate of $1,024.53. We placed 20999 in the lowest paying, related group, 0004.
c. Effect of the BBRA 1999 on Final APC Groups
Section 201(g) of the BBRA 1999 amends section 1833(t)(2) of the Act to limit the variation in resource use among the procedures or services within an APC group. Specifically, section 1833(t)(2) of the Act now provides that the items and services within a group cannot be considered comparable with respect to the use of resources if the highest cost item or service within a group is more than 2 times greater than the lowest cost item or service within the same group. The Secretary is to use either the mean or median cost of the item or service. We are using the median cost because we have continued to set the relative payment weights for each APC based on median hospital costs in this final rule. (See the discussion in section III.E of this preamble.)
Section 1833(t)(2) of the Act as amended also allows the Secretary to make exceptions to this limit on the variation of costs within each group in unusual cases such as low volume items and services, although we may not make such an exception in the case of a drug or biological that has been designated as an orphan drug under section 526 of the Federal Food, Drug, and Cosmetic Act. See the discussion of the classification of orphan drugs in section II.D of this preamble and the discussion of APC groups that we excepted from the “2 times” limit in section III.C.6.e.
We applied the limit on variation on median costs required by section 201(g) to the revised APC groups. (See section C.6.d, below.) As a result of our analysis of the array of median costs within the revised APC groups, we had to split some otherwise clinically homogeneous APC groups into smaller groups. We are concerned that this further subdivision of groups may create vulnerabilities for upcoding, which conflicts with one of the five criteria described above that we used to evaluate the construction of the APC groups. We will be examining the extent to which the APC reorganization due to the “2 times” rule results in upcoding.
d. Summary of APC Modifications
In this section, we summarize and explain our response to comments on individual or serial APCs. We use the APC number that appeared in the proposed rule to identify a group that was changed. In most instances, we moved a HCPCS code from its proposed APC group to a different APC group either in response to comments or to comply with section 1833(t)(2)(C) of the Act. In some cases, we moved codes when a change in response to a comment or the cost variation limit resulted in a grouping that seriously compromised one of the criteria we used to evaluate changes recommended by commenters. Because we made so many changes in the APC groups, we renumbered all the groups and, in many cases, renamed groups. In our response to comments in connection with an APC, the final designation for a HCPCS code corresponds to the renumbered APC group found in the addenda.
APC 121: Level I Needle Biopsy/Aspiration
Comment: One specialty society commented that there was significant variation in resource consumption for the procedures performed in this APC and that the proposed payment rate of $33.95 for APC 121 does not accurately reflect the preparation, examination, and consultation expenses for a pathologist to thoroughly perform these procedures. The commenter recommended including CPT codes 85095, 85102, 88170, and 88171 in proposed APC 122.
Response: The procedures we proposed to classify in APC 121 were considered sufficiently similar from a clinical perspective. We found no provider concentration associated with the procedures proposed for this APC. Therefore, any variation in cost across the procedures in this APC should average out at the hospital level. However, to be consistent with the BBRA 1999 “two times” provision concerning comparable resources, we have moved CPT codes 85095 and 85102 to final APC 0003, and CPT codes 88170 and 88171 remain in final APC 0002.
APC 122: Level II Needle Biopsy/Aspiration
Comment: A number of commenters indicated that there was significant variation in resource consumption for the procedures proposed in this APC group. For example, one commenter stated that although all the codes within this group are needle biopsies, they range dramatically in complexity, they are quite dissimilar in terms of resource use, they are not clinically similar, and the proposed grouping results in inappropriate payment for the more complex procedures.
Response: We decided that CPT code 67415, Fine needle aspiration of orbital contents, was more appropriately grouped from a clinical perspective with ophthalmic procedures in final APC 0239. We further divided the codes in proposed APC groups 121 and 122 for needle biopsy/aspiration into final APC groups 0002, 0003, 0004, and 0005 to be consistent with the BBRA 1999 “two times” requirement.
APC 131: Level I incision & drainage
Although we received no comments on proposed APC group 131, based on internal review of this APC, we moved CPT code 11976, Removal, implantable contraceptive capsules, to final APC 019 because this procedure represents an excision rather than an incision. We divided proposed APC 131 into final Start Printed Page 18459APC groups 0006, 0007, and 0008 to be consistent with the BBRA 1999 “two times” requirement.
APC 141: Level I Destruction of lesion
APC 142: Level II Destruction of lesion
Comment: One commenter questioned our proposed assignment of CPT codes 17106 through 17108, which describe destruction of cutaneous vascular proliferative lesions, to APC groups 141 and 142.
Response: We moved CPT code 17106 to final APC 0011 because its median cost is significantly higher than the other codes in 0010. However, the median cost for that code is greater than we would have expected it to be. We will review the appropriateness of this placement in the course of future updates of the APC groups.
APC 151: Level I debridement/destruction
APC 152: Level II debridement/destruction
Comment: We received general comments questioning the resource homogeneity of the proposed skin APC groups. One commenter recommended including removal of skin lesion with laser on other body parts in proposed APC 152 rather than restricting the APC to vulva, anus, and penis procedures. The commenter believes that removal of these benign lesions, including papillomas, should include other areas of the body.
Response: We agree with commenters' general concerns about resource homogeneity. We reclassified the codes in proposed APCs 151 and 152 into final APC groups 00012 through 00017 to better differentiate resource use and clinical characteristics and to be consistent with the “two times” BBRA 1999 requirement. We also moved CPT code 42809, Removal of foreign body from pharynx, to final APC 251 because it is an otorhinolaryngology (Ear/Nose/Throat (ENT)) procedure.
APC 161: Level I excision/biopsy
APC 162: Level II excision/biopsy
APC 163: Level III excision/biopsy
Comment: Numerous commenters were concerned about the variation of resource use among the procedures in proposed APC groups 161, 162, and 163. Commenters requested that we consider classifying procedures in these groups based on anatomic location where functionality is of high importance in combination with the size of excision.
Response: We made a number of modifications to the excision APC groups to satisfy the BBRA 1999 “two times” requirement, resulting in final APC groups 0018 through 0022. We reclassified CPT codes 11043 and 11044 to APC groups 0016 and 0017 because these codes describe debridement of skin, subcutaneous tissue, muscle, and bone.
In the final excision/biopsy APC groups, we endeavored to make distinctions based on the location and size of the excision. For example, excisions of malignant lesions from the face, ears, eyelids, nose, lips greater than 4 cm were placed in an APC requiring more resource use than excisions of malignant lesions from the trunk, arms or legs greater than 4 cm because “functionality” is of greater importance when the site is the face, ears, eyelids, nose, or lips. We moved excisions involving the eye to ophthalmic procedure APCs. We did not make grouping distinctions between benign and malignant lesions of the same size and location because resource use for both types is similar.
We moved benign and malignant excisions larger than 2 cm to final APC group 0020 because these excisions require more resources than, for example, excisions smaller than 1 cm.
We moved CPT code 20220, superficial biopsy of bone (e.g., ilium, sternum, spinous process, ribs) with trocar or needle, to final APC 0019, because the resources used in connection with this procedure are similar to those required for excisions of small benign or malignant lesions.
As noted above, we classified two debridement procedures (CPT codes 11043 and 11044) to final APC groups 0016 and 0017, respectively.
We also moved seven codes from proposed APC 162 to the ophthalmic APC groups.
APC 181: Level I skin repair
APC 182: Level II skin repair
APC 183: Level III skin repair
APC 184: Level IV skin repair
Comment: We received numerous comments expressing concern about the consistency of resource use and clinical homogeneity of the procedures in the four proposed skin repair APC groups. Many commenters recommended moving more complex procedures, such as large layer closures, to an APC with a higher payment rate because the procedures require more operating room and recovery time. Some commenters recommended moving some of the skin repair codes to other body systems.
Response: Our review of proposed APC groups 181, 182, 183, and 184 resulted in our regrouping the skin repair codes based more on cost than on clinical considerations. The volume of claims in most of the codes, however, is quite low. In addition, we moved CPT code 33222, Revision or relocation of skin pocket for pacemaker, from proposed APC 360 to final APC 0026, because this procedure is so similar to the other skin repair procedures in terms of clinical content and resource consumption. We will review these groups carefully as data become available.
APC 197: Incision/excision breast
APC 198: Breast reconstruction/mastectomy
Comment: One commenter observed that the procedures in proposed APC group 198 are related both to the definitive treatment of breast cancer and to plastic and reconstructive operations of the breast. The commenter recommended moving CPT code 19162, Mastectomy, partial with axillary lymphadenectomy, and CPT code 19182, Mastectomy, subcutaneous, into an APC group with a higher payment rate because both procedures are more complex and involve more time and resources than the other procedures in proposed APC group 198. Another commenter stated that CPT code 19162, and CPT code 19318, Reduction mammoplasty, require significantly longer operating times than the other procedures in proposed APC group 198. The same commenter further observed that CPT code 19162 essentially involves performing two procedures.
Response: Our medical advisors and staff carefully reviewed the comments submitted in connection with the procedures in proposed APC group 198 within the context of the criteria that we discuss at the beginning of this section. They concluded that, although reduction mammoplasty (CPT code 19318) could require slightly more resources, a reduction mammoplasty is still fundamentally similar to other procedures in proposed APC 198 such as CPT code 19162, Partial mastectomy with axillary lymphadenectomy. Our medical advisors and staff concluded that the procedures in proposed APC groups 197 and 198 were sufficiently similar clinically and in terms of resource use to retain the proposed groupings. Therefore, we are retaining our proposed grouping in final APC groups 0029 and 0030.
APC 207: Closed treatment fracture finger/toe/trunk
Although we did not receive comments about this APC group, our medical advisors and staff determined that treatment of closed fractures Start Printed Page 18460pertaining to the larynx should be moved to the ENT APC groups because they are more similar from a clinical and resource use perspective to ENT procedures. The larynx procedures do not involve casts and, more importantly, they require completely different resources and ancillary personnel than, for example, the setting of a finger fracture. Proposed APC 207 is renumbered final APC 0043.
APC 209: Closed treatment fracture/dislocation except finger/toe/trunk
Comment: One commenter objected to including multiple procedures for dislocation and fractures in proposed APC group 209, when the cost of drugs and supplies alone for these procedures probably exceeds $100. The commenter believed that the proposed payment rate for APC 209 was $71.00.
Response: We note that the proposed payment for APC 209 was $98.75, rather than $71.00, as the commenter quoted. Although we included in proposed APC 209 some procedures that could involve considerable time and resources, only the simplest cases of these potentially more complex procedures would be performed on an outpatient basis, with proportionally lower costs than would be incurred when the procedures are performed in an inpatient setting. Therefore, we retained in final APC 0044 the codes in proposed APC 209, except we moved CPT code 31586, Treatment of closed laryngeal fracture, to final APC 0256, because this is primarily an ENT procedure.
APC 216: Open/percutaneous treatment fracture or dislocation
Comment: Numerous commenters took issue with the variation in resource use among the procedures that include the open treatment of almost all bone fractures, ranging from relatively simple finger and toe fractures to major long bone fractures.
Response: We expect that only the simplest of the procedures proposed in APC group 216 would be performed on an outpatient basis. Therefore, we kept open/percutaneous treatment of fractures in one APC rather than splitting these procedures into multiple APCs. We find it unlikely that one provider would specialize in, for example, only open fractures of fingers or only open fractures of long bones. Because the CPT code descriptors for so many procedures in this APC group indicate “with and/or without internal fixation,” it is impossible to make distinctions based on whether or not internal fixation is applied. Proposed APC 216 is renumbered final APC 0046.
APC 226: Maxillofacial prostheses
APC 231: Level I skull and facial bone procedures
APC 232: Level II skull and facial bone procedures
Although we did not receive specific recommendations for these APCs, our medical advisors and staff determined that the procedures in these groups are more similar to ENT procedures from a clinical and resource use perspective. Therefore, we moved all of the procedures in these proposed APC groups to the final APCs 0251 through 0256, the ENT APCs.
APC 251: Level I Musculoskeletal Procedures
APC 252: Level II Musculoskeletal Procedures
Comment: One commenter expressed concerns about the clinical homogeneity of the codes in these two groups. The commenter stated that proposed APC 251 contains 77 widely disparate procedures, including CPT code 23100 and CPT code 24100, which describe arthrotomies with biopsies, CPT code 25248, Exploration with removal of deep foreign body, forearm or wrist, and CPT code 27704, Removal of ankle implant. The commenter further stated that proposed APC 252 contains equally diverse procedures ranging from: CPT code 20900, Bone graft, any donor area; minor or small, to CPT code 25251, Removal of wrist prosthesis; complicated, including “total wrist,” to CPT codes 27396, 27580, and 27665, which are different types of tendon procedures. The commenter recommended that procedures that require specialized equipment and more operating room time be moved into a group with a higher payment rate.
Response: Our medical advisors and staff, after careful consideration of the commenter's concerns and after reviewing alternative groupings of the numerous codes in these two proposed musculoskeletal APC groups, concluded that splitting these groups to address the disparities cited by the commenter would result in too many small, low-volume groups for which we would be unable to establish reliable payment rates. The broad inclusiveness of these two APC groups is in part a reflection of the magnitude of the musculoskeletal system. Given the homogeneity of resource use across the many procedures within each group, we concluded that the factors supporting retention of the two groups outweighed the concerns raised by the commenter. We did, however, move CPT code 27086, Removal of foreign body, pelvis or hip; subcutaneous tissue, to final APC 0019.
APC 280: Diagnostic Arthroscopy
APC 281: Level I Surgical Arthroscopy
APC 282: Level II Surgical Arthroscopy
Comment: A number of commenters expressed concerns about the homogeneity of codes in the proposed surgical arthroscopy APC groups. In particular, commenters stated that while an arthroscope is needed for all the procedures assigned to proposed APC group 281, the nature of the repair may mandate different additional equipment and differing times to complete. Commenters did not find the procedures in proposed APC 281 to be homogeneous with respect to the time required to perform the procedures nor their associated costs. Commenters specifically recommended transferring complex elbow and wrist procedures represented by CPT codes 29826, 29838, 29839, 29846, 29847, 29848, 29861, 29862, and 29863 into an APC group with a higher payment rate.
Response: Upon revisiting the assignment of codes to proposed APC groups 280, 281, and 282, and considering the concerns expressed by commenters, our medical advisors and staff concluded that collapsing the three proposed APC groups into a single group would result in a more homogeneous grouping in terms of resource use. Hence, final APC 0041 contains the codes proposed as APC groups 280, 281, and 282. The relatively low volume of many of the procedures in the proposed APCs supports combining them into a single group. Further, we found that, from a facility perspective, the resource use for all the codes in final APC 0041 is similar. For example, we had proposed to place CPT code 29881, Arthroscopy, knee, surgical; with meniscectomy (medial or lateral, including any meniscal shaving), and CPT code 29882, Arthroscopy, knee, surgical; with meniscus repair (medial or lateral), in two different APC groups. However, the resources required for these two procedures is sufficiently comparable to warrant placing both into the same APC.
APC 286: Arthroscopically-Aided Procedures
We considered including the procedures in proposed APC group 286 with the other arthroscopic procedures in final APC 0041 because they are so infrequently performed in an outpatient setting for Medicare beneficiaries. However, the resources required to perform the procedures in proposed Start Printed Page 18461APC 286 are so strikingly distinct from those used in connection with the procedures in final APC group 0041 as to warrant being retained in a separate group. Further, it is unlikely that an individual provider specializes in the particular type of arthroscopic procedure contained in this APC, so separating all of the codes in final APC 042 from those in APC 041 should not disadvantage any one hospital.
APC 311: Level I ENT Procedures
APC 312: Level II ENT Procedures
APC 313: Level III ENT Procedures
APC 314: Level IV ENT Procedures
We received numerous comments about the composition of the four proposed ENT APC groups. After careful review of the comments, our medical advisors and staff recognized the need for a major reorganization of the groups we proposed for ENT procedures. The outcome of our review was the creation of five final APC groups for ENT procedures: APC groups 0251, 0252, 0253, 0254, and 0256. We moved a large number of bone procedures involving the facial and ENT areas from musculoskeletal groups to ENT groups. We transferred some codes out of the ENT groups altogether, and we shifted codes among the five final ENT groups to comply with the BBRA 1999 “two times” requirement. We respond to recommendations regarding specific codes below.
Comment: One commenter observed that CPT codes 31603 and 31605, emergency tracheostomy procedures, are risky and life-threatening no matter how quickly they are performed, and, as such, they should not be grouped with procedures for removing a foreign body from the ear canal or removing cerumen (proposed APC 311).
Response: We agree. We created new APC group 0340 to which we assigned CPT code 69200, removal of foreign body from external auditory canal; without general anesthesia, and CPT code 69210, Removal impacted cerumen (separate procedure), one or both ears. We shifted these two procedures to the Minor Ancillary Procedures APC group because of their relative high frequency, their low cost in terms of resource use with low disposable equipment cost, and because these procedures generally do not require scheduling. Removing CPT code 69210 from the final ENT groups also corrects any pricing distortions that may have resulted from the disproportionately high volume of that procedure.
We also moved the tracheostomy emergency procedures to final APC 0254.
We moved several other procedures such as CPT code 41870, Periodontal mucosal grafting, to final APC 0253, a group with higher cost procedures.
We moved several abscess drainage procedures such as CPT code 41800, Drainage of abscess, cyst, hematoma from dentoalveolar structures, to final APC group 0251 because of their relatively low cost.
Comment: One commenter stated that all the procedures in proposed APC 312 appear to be reasonably priced with the exception of CPT code 69436, Tympanostomy (requiring insertion of ventilating tube), general anesthesia. In the view of the commenter, the extra supplies and time required for this procedure necessitate a higher payment.
Response: We moved CPT code 69433, Tympanostomy (requiring insertion of ventilating tube, local or topical anesthesia), to final APC 0252 because of its lower resource use relative to CPT code 69436. CPT code 69436 is assigned to final APC 0253.
We moved a large number of procedures such as CPT code 42335, Sialolithotomy; submandibular (submaxillary), complicated, intraoral from original APC 313 to final APC 0253 to reflect a similarity of resource use. In terms of resource use, CPT code 30115, Excision, nasal polyp(s), extensive, is more similar to CPT code 42300, Drainage of abscess, parotid, simple, than it is to CPT 42410, Excision of parotid tumor or parotid gland; lateral lobe without nerve dissection.
We shifted CPT code 21040, Excision of benign cyst or tumor of mandible, from the musculoskeletal group to final APC 0253 with other ENT procedures.
Comment: One commenter stated that procedures directed towards cancer treatment were inappropriately assigned to proposed APC 313. As examples, the commenter cited CPT codes 30150 and 30160, rhinectomy procedures; CPT code 41120, Glossectomy; less than one-half tongue; and CPT code 69210, Excision external ear, complete amputation. The commenter also indicated concern that proposed APC group 313 includes a disproportionately large percentage of resource-consuming ENT procedures and commonly performed sinus procedures. Other commenters recommended that more complex otorhinolaryngology procedures in the group that have longer operating and recovery room times be moved to a group with a higher payment rate.
Response: We moved CPT code 69210 to final APC group 0340, and we assigned CPT codes 30150, 30160, and 41120 to final APC group 0256. We also moved CPT code 42215, Palatoplasty for cleft palate; major revision to final APC group 0256.
Comment: One commenter suggested placing certain thyroid procedures in the ENT groups.
Response: While we agree that CPT code 60280, Thyroglossal cyst excisions, is somewhat similar to CPT code 42440, Excision of submandibular, submaxillary gland, we nonetheless believe that the former type of excision is more appropriately placed from a clinical perspective with other thyroid procedures.
APC 318: Nasal Cauterization/Packing
Comment: A number of commenters addressed generally the range of resource use among the procedures within this proposed APC. One commenter observed that CPT code 30901 is almost always a simple office procedure within the context of an otolaryngology practice. The same commenter indicated that CPT codes 30903, 30905, and 30906 frequently require several hours of direct physician contact and monitoring and recommended that we consider reclassifying CPT codes 30903, 30905, and 30906 to proposed APC group 332, Level II Endoscopy Upper Airway. Another commenter was concerned that CPT codes 30905 and 30906 stand out as inappropriate for this APC level because they require much more time and expertise and are used in more life-threatening situations than the other codes in the group.
Response: While there is a range of procedures in this APC pertaining to control of nasal hemorrhage, hospitals normally treat the entire range of these procedures, and there is no concentration of certain of these procedures in a subset of hospitals. Our medical advisors and staff also found that there can be a range of resource consumption within many of the procedures themselves as well as across procedures in this APC. We therefore are not reassigning the codes.
We did, however, move CPT codes 30999 and 42999 for unlisted procedures to final APC 0251 and 0252, respectively, to be consistent with our policy of placing unlisted codes in the lowest paid related group.
APC 331: Level I Endoscopy Upper Airway
Comment: One commenter noted that the relative weight and payment rate proposed for APC group 331 approximated the relative weight and payment rate proposed for APC groups 997 or 987. The commenter stated that CPT codes 31575 and 31579 should have a higher relative weight and Start Printed Page 18462payment rate than that proposed for APC 331 because both procedures require more time, higher skill levels, and more equipment than the procedures in APC 997 or 987. A professional association, echoing the first commenter, noted that CPT codes 31575 and 31579 are the most complex of all noninvasive laryngeal diagnostic procedures performed by otolaryngologists and speech language pathologists, further justifying a higher relative weight and payment rate for these procedures.
Response: Proposed APC groups 997 and 987, Manipulation therapy and Subcutaneous chemotherapy, respectively, are clinically very different from proposed APC group 331. The professional skill and expertise of the physician performing the laryngoscopy are recognized separately and are not costs that are packaged with the payment rate for services furnished by the hospital in connection with the procedure. Further, it is very unlikely that there will be systematic differences among facilities with some only doing the most difficult of the basic laryngoscopies that are contained in this group and others only specializing in the simplest variety. However, we have reorganized the proposed endoscopy, upper airway groups into final APC groups 0071 through 0075 to be consistent with the BBRA 1999 “two times” requirement.
APC 341: Level I Needle and Catheter Placement
APC 342: Level II Needle and Catheter Placement
APC 343: Level III Needle and Catheter Placement
APC 347: Injection Procedures for Interventional Radiology
Based on our cost data, our medical advisors and staff determined that the codes in these proposed APC groups should be assigned status indicator “N,” which designates incidental services whose costs are packaged into the APC payment rate. Injection procedures themselves are low cost but, more importantly, they are an integral portion of another procedure. The needle and catheter placement are typically an integral portion of interventional radiology procedures. An exception was made for CPT code 36420, cutdown on a child under age one, which was placed in final APC 0032, to recognize its infrequent use but high median cost.
APC 360: Removal/Revision, Pacemaker/Vascular Device
Comment: Most commenters recommended changing a number of pacemaker codes from “inpatient only” payment status to allow payment under the hospital outpatient PPS. One commenter noted that whereas we proposed to exclude most pacemaker and implantable cardioverter defibrillator (ICD) replacement procedures from the outpatient PPS, we did include pacemaker revision/removal procedures in proposed APC 360 even though both types of procedures require very similar steps to perform. The commenter is concerned that by not paying for pacemaker replacement procedures under the outpatient PPS, we are forcing physicians to perform these replacement procedures on an inpatient basis. By so doing, the commenter suggested that we are adding costs to the entire system that could be saved, because the pacemaker replacement procedures can be safely performed in the outpatient setting, with less inconvenience to the patient.
Response: After careful consideration of commenters' recommendations, our medical advisors and staff agreed that paying for pacemaker insertion or replacement codes under the outpatient PPS is appropriate if the outpatient setting is determined to be reasonable and medically necessary for the individual beneficiary. We assigned procedures for revising or removing implanted infusion pumps and venous access ports in proposed APC 360 and pacemaker insertion or replacement codes payable under the outpatient PPS to final APCs 0089 and 0090. Also, we moved CPT code 33222, Revision or relocation of skin pocket for pacemaker, and CPT code 33223, Revision or relocation of skin pocket for implantable cardioverter-defibrillator, to final APC 0026 because the resource use for these two procedures is similar to that of the skin repair procedures in APC 0027.
APC 367: Vascular Ligation
Comment: One commenter wrote that the procedures in proposed APC 367 include ligation of major arteries and veins, which are usually performed as emergencies in the inpatient setting, and elective ligation and stripping of lower extremity varicose veins of variable complexity. The commenter contended that costs for these procedures vary dramatically, with simple ligation and division of the saphenous vein at the low end of the cost scale, and the stripping of long and saphenous veins at the high end.
Response: We split proposed APC 367 into two groups, final APCs 0091 and 0092, to conform with the BBRA 1999 “two times” requirement. Although we are not sure to which codes the comment refers, codes 37780 and 37730 are now in different groups. These represent ligation and division of the short saphenous vein, and ligation, division and stripping of long and short saphenous veins, respectively.
APC 368: Vascular Repair/Fistula Construction
Comment: Commenters disagreed with the codes assigned to proposed APC 368, especially services related to insertion of implantable hemodialysis access ports. Commenters did not find the services in APC 368 to be comparable clinically. In particular, they recommended moving cannula insertion and declotting procedures to proposed APC groups 341, 342, and 343, which consist of needle and catheter placement procedures.
Response: We split the codes in proposed APC 368 into APC groups 0088, 0090, 0092, and 0093. The resulting classifications are more clinically homogeneous, and they meet the BBRA 1999 “two times” requirement. We also moved CPT code 35875, Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula), into final APC 0088.
APC 369: Blood and Blood Product Exchange
Comments: As we noted in section III.C.2.f, above, many commenters disagreed with both our proposed payment rates and our proposed classification for blood and blood-related products. Most commenters disagreed with our classifying in one APC group therapeutic apheresis, stem cell procedures, and blood transfusion services. The commenters stated that therapeutic apheresis and stem cell procedures are very costly and resource intensive procedures which cost more than 3 times the proposed payment rate for APC 369, yet we are proposing to pay a median amount for these services that is appropriate for blood transfusions only. Commenters questioned whether we had taken into account the costs associated with the specialized equipment, supplies and personnel that are required to perform therapeutic apheresis and stem cell procedures. Commenters stated that the payment rate proposed for APC 369 would not offset the costs hospitals incur to furnish therapeutic apheresis services because outpatient apheresis procedures often combine dissimilar kinds and combinations of plasma replacement products, causing widely differing costs per service.
A major association representing community cancer centers stated that our data for stem cell harvesting claims (CPT 38231) include a range of costs so Start Printed Page 18463large as to suggest that there are errors in the data. The commenter believes that the very small sample of claims (reduced by HCFA's exclusion of multiple procedure claims and claims without codes) further renders the data unreliable. The same commenter cited bone marrow harvesting (CPT 38230) as an example to argue that our data, which indicates a median cost of $18.00 for what is normally a lengthy procedure performed under general anesthesia, are problematic.
Some commenters stated that the proposed payment rate was not sufficient for transfusion services if the rate was supposed to pay for both the blood product and the transfusion procedure, because even though outpatient transfusion services are relatively simple and low-cost, they are associated with a costly blood product that is far more variable.
Commenters expressed concern that the proposed payment rate for APC 369 was insufficient to pay for extracorporeal photopheresis (CPT 36522), whose actual cost is approximately $1,000, and would have an especially negative impact for patients with cutaneous T-cell lymphoma.
A major organization recommended that we separate payment for a service from payment for the blood product associated with that service. The same commenter also recommends separate payment for infusible blood-derived drugs, and that payment for transfusable blood products be based on costs. This organization recommends that APC 369 be split into several APCs because payment for services such as transfusion services, therapeutic apheresis, stem cell collection, Staph column pheresis, and others are distinct, and deserve separate APC payments. The same commenter also recommended that we accelerate the HCPCS coding process for blood-related products.
Response: In response to commenters' recommendations, we are creating different APC groups for blood-related procedures and transfusions, and we are paying for blood and blood products separately, instead of packaging them with the procedures or services with which they are associated. We were convinced by commenters' illustrations of the variability in the use of blood and blood products in various procedures, and by our desire to recognize the costs of tests now being performed on donated blood that were not captured in our 1996 data. The procedures we proposed in APC 369 are split among final APC groups 0109, 0110, 0111, and 0112. We have also created individual APC groups for blood and blood related products. The final APC 0109 that we created to capture bone marrow harvesting and bone marrow/stem cell transplant had a median cost of only $15.00. This is due to the few, highly variable claims in our database. Based on the information available to us at this time, we have assigned a rate of $200.00, and will adjust the rate to reflect actual claims as we collect data under PPS.
APC 407: Esophagoscopy
APC 417: Diagnostic Upper GI Endoscopy
APC 418: Therapeutic Upper GI Endoscopy
Comment: Commenters were concerned about low payment rates set for these three proposed APC groups.
Response: Our medical advisors reviewed the proposed groups and determined that combining the codes into a single APC group for upper gastrointestinal endoscopic procedures conformed with the criteria we used to define APC coherence and resulted in a reasonable payment rate supported by cost data. Resource use for all procedures in final APC 0141 is similar because each procedure involves an endoscopic examination. In addition, most of the procedures involve diagnostic and therapeutic tests such as brushings or fulgurations.
APC 426: Diagnostic Lower GI Endoscopy
APC 427: Therapeutic Lower GI Endoscopy
Comment: Commenters were concerned that the payment rates proposed for APC groups 426 and 427 were too low to offset costs incurred to perform these procedures. One commenter indicated that a diagnostic colonoscopy (CPT code 45379), without any mark up or consideration of room time and equipment use, costs $350, with additional costs if a polyp has to be removed ($155 just for a bicap). The commenter indicated that the current cost of a hot biopsy forceps is $45. Given these costs, the provider would necessarily incur a loss when performing these procedures.
Response: Our medical advisors and staff, after reviewing the cost data for these two proposed groups, combined the diagnostic and therapeutic APCs into a single group, final APC 0143. Resource use for the procedures in this APC is similar because they all involve an endoscopic examination. More importantly, even though resource use may vary relative to the clinical requirements of individual cases, facilities are not likely to specialize in just therapeutic or diagnostic endoscopic services. Therefore, costs should even out across all cases.
Comment: One commenter found the low rate proposed for CPT code 45378, Diagnostic colonoscopy, to be inconsistent with our major policy initiative to screen persons at high risk for colorectal cancer.
Response: We moved HCPCS code G0105, Colorectal Cancer Screening: Colonoscopy,to its own group, final APC 0158, because it is preventive rather than diagnostic or therapeutic in nature.
APC 446: Diagnostic Sigmoidoscopy
APC 447: Therapeutic Proctosigmoidoscopy
APC 448: Therapeutic Flexible Sigmoidoscopy
We reassigned the different types of sigmoidoscopy procedures into two groups, final APC 0146 and final APC 0147. The procedures within each group are similar both clinically and in terms of resource use. We moved HCPCS code G0104, CA screening; flexible sigmoidoscopy, to its own group, final APC 0159, because it is preventive rather than diagnostic or therapeutic in nature.
APC 451: Level I Anal/Rectal Procedures
APC 452: Level II Anal/Rectal Procedures
To conform with the BBRA 1999 “two times” requirement, our medical advisors and staff reclassified procedures in the proposed APC groups resulting in final APC groups 0148 and 0149. We believe the final APC groups are more consistent both clinically and in terms of resource use.
APC 470: Tube Procedures
Comments: We split the codes in proposed APC group 470 into final APC groups 0121, 0122, and 0123 to conform with the BBRA 1999 “two times” requirement. Also, we moved CPT code 50398, Change of nephrostomy or pyelostomy tube, from proposed APC 521 to final APC 0122.
APC 523: Level III Cystourethroscopy and Other Genitourinary Procedures
Comment: A number of commenters recommended moving CPT code 52240, Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; large bladder tumor(s), to the APC for Level IV Cystourethroscopy and other Genitourinary Procedures because the magnitude of the procedure most Start Printed Page 18464closely resembles that of the codes in the higher payment group.
Response: We agree with commenters' recommendations; we moved CPT code 52240 to final APC group 0163 because of the extensive time and equipment required to perform the procedure.
Comment: One commenter recommended placing CPT codes 52335 through 52338 in their own group, given the complexity and technical demands of these ureteroscopic procedures. The same commenter suggested as an acceptable alternative placing these codes in the APC group for Level IV Cystourethroscopy and other Genitourinary Procedures, to reflect more accurately their cost, complexity, and need for expensive single use items such as dilation balloons, baskets and stents. Other commenters recommended moving CPT codes 51020 through 51880 (cystotomy procedures) to the APC group for Level IV Cystourethroscopy and other Genitourinary Procedures.
Response: After a careful review of comments and our cost data, our medical advisors and staff concluded that the cystotomy codes are similar enough in terms of equipment and the time required to perform the procedures to justify keeping them together in final APC 162. Our medical advisors and staff also concluded that the facility equipment and time duration for CPT code 52335, Cystourethroscopy, with ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method), was sufficiently similar to be retained with the other procedures in final APC 0162.
APC 524: Level IV Cystourethroscopy and other Genitourinary Procedures
Comment: Numerous commenters were concerned that the payment rate proposed for APC 524 was insufficient to offset the costs associated with CPT code 53850, Transurethral destruction of prostate tissue, by microwave thermotherapy (TUMT). The commenters argue that TUMT is a very expensive procedure due to its high capital equipment costs and the need to construct a special microwave area, the high cost of disposable probes and other disposable supplies required for the procedure, and the need for specially trained nursing staff. The commenters urged us to establish a unique APC group for this procedure and to provide a payment rate that is consistent with its anticipated costs, which they predict would total approximately $2,200.
Response: After careful consideration of comments and available cost data, our medical advisors and staff determined that CPT code 53850 satisfies the criteria discussed below, in section III.C.8, as a new technology service. Payment for this procedure will be made under new technology APC 0980.
APC 529: Simple Urinary Studies and Procedures
Comment: A number of commenters proposed that we classify CPT code 51726, Complex cystometrogram, to its own unique APC and keep the other urinary study procedures together in proposed APC 529.
Response: After a careful review of comments and our data, our medical advisors and staff agreed with commenters' concerns and subdivided proposed APC group 529. The resulting final APC groups 0164 and 0165 are more homogeneous both in terms of clinical coherence and resource use. We also added simple anal procedures such as CPT code 91122, Anorectal manometry, to final APC 0165 because of the similarity of resource use.
APC 546: Testes/Epididymis Procedures
Comment: A number of commenters disagreed with our classification of scrotal procedures with inguinal procedures in proposed APC group 546. The commenters observed that the scrotal procedures vary considerably from the inguinal procedures in terms of resource usage. The commenters recommended that we move CPT codes 54530, 54550, 54640, 55520, 55530, 55535 and 55540 to proposed APC 466, Hernia/Hydrocele Procedures, because they all involve operating on vessels at the internal ring, and are therefore similar to a hernia repair.
Response: We agree with comments that these procedures are similar to hernia repairs. We moved CPT codes 54530, 54550, 54640, 55535, and 55540 to final APC group 0154.
APC 551: Level I Laparoscopy
APC 552: Level II Laparoscopy
Comment: We received two categories of comments pertaining to laparoscopic procedures: Numerous commenters disagreed with our proposal to define certain laparoscopic procedures as inpatient only, and numerous commenters claimed that the resource costs among the procedures within proposed APC groups 551 and 552 varied too greatly for the groups to be considered homogeneous. Most commenters stated that the costs associated with the procedures in proposed APC groups 551 and 552 exceed their respective proposed payment rates because of the expensive equipment and disposable supplies and the length of time required to perform laparoscopic procedures.
Response: Our medical advisors and staff, after a thorough review and consideration of comments, agreed with commenters who claimed that most laparoscopic procedures can and are being safely and appropriately performed in an outpatient setting. We therefore moved most of the laparoscopic codes to which we proposed to assign a payment status indicator “C,” indicating that the procedures would not be covered under the hospital outpatient PPS, into an APC group with a payment status indicator “T” (significant procedure, multiple procedure reduction applies, payable under the outpatient PPS). In order to absorb these additional procedures within the APC system, we created a third laparoscopic APC group in order to accommodate the wide range of resource use and time that is required to perform the expanded list of laparoscopic procedures.
Although the AMA revised the coding of laparoscopic procedures in CPT 2000, in order to set rates for the laparoscopy APC groups, we used the codes that were in our database of 1996 claims. That is, we moved CPT codes 56362 and 56363 to the Level I laparoscopic group, final APC group 0130, because the resources used in connection with these procedures are less compared to the Level II procedures generally. For example, CPT code 56362, Laparoscopy with guided transhepatic cholangiography, primarily involves the laparoscopy without any associated removal of tissue. Conversely, we shifted CPT codes 56303 and 56304 from Level I to Level II (final APC 0131). CPT code 56303, Laparoscopy, surgical, with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface, requires more resources than, for example, CPT code 56300, Diagnostic laparoscopy, the most common laparoscopic procedure within Level I, final APC group 0130.
The new Level III laparoscopy group, final APC group 0132, consists largely of laparoscopic procedures that we had proposed to classify as inpatient. In addition, we moved CPT code 56312, Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy, and CPT code 56313, Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple, to final APC group 0132 because of the extensive resources and time involved in performing these procedures. Refer to Current Procedural Terminology 2000, published by the American Medical Association, for a summary of coding Start Printed Page 18465changes and crosswalks for laparoscopic procedures.
APC 561: Level I Female Reproductive Procedures
APC 562: Level II Female Reproductive Procedures
APC 563: Level III Female Reproductive Procedures
Comment: One commenter expressed concern that the payment rate for proposed APC group 563 would have a negative effect on certain treatment options for women suffering with incontinence. The commenter contrasted the proposed payment of $848 with a current median cost calculated at $1,931 for CPT code 57288, Sling operation for stress incontinence (e.g., fascia or synthetic).
Response: After reviewing the procedures in proposed APCs 561, 562, and 563, and to be consistent with the BBRA 1999 “two times” requirement, we split the proposed groups into final APCs 0191 through 0195. The cost of CPT code 57288, to which the commenter refers, is still at the high end of the highest weighted group, but the volume of claims for that service is so low that splitting the group again would be problematic. If these more intense surgeries move to the outpatient setting in greater numbers, we will be able to price them more precisely.
APC 601: Level I Nervous System Injections
APC 602: Level II Nervous System Injections
Comment: Commenters contended that there are no similarities among the procedures in the proposed APC groups for nervous system injections.
Response: We disagree. We find the range of services included within each APC group to be generally consistent from a clinical perspective. And, even though an injection into the subarachnoid space may be a more complex injection than some of the others in the group, no institution is likely to specialize solely in one kind of injection. Because all the services within the APC group are offered by most hospitals, the impact of the variation in resource consumption among the different codes should average out at the hospital level. Therefore, we are keeping intact in final APC groups 0211 and 0212 the two levels of nervous system injections that we proposed, with the exception of CPT codes 62194 and 62225, which we moved to final APC group 0121 because they are catheter replacement procedures.
APC 616: Implantation of Neurostimulator Electrodes
APC 617: Revision/Removal Neurological Device
APC 618: Implantation of Neurological Device
Comment: One commenter was concerned that the payment rate proposed for APC group 616 falls far short of the costs incurred to implant a neurostimulator system that embodies a vagus nerve stimulator for the treatment of patients with refractory epilepsy. The commenter estimated that hospitals incur costs between $2,000 and $5,000 to surgically insert the Neurocybernetic Prosthesis system (NCP), which includes an implantable neurostimulator, pulse generator, and implantable electrodes. The commenter stated that the NCP costs $9,100. The commenter recommended that we create a separate APC group for the procedure to ensure appropriate payment. The commenter also expressed concern that the broad range of procedures in proposed APC 618 results in inappropriate payment rates. The commenter noted that the median cost of the procedures in proposed APC group 618 varies from a low of $269.44 to a high of $3,890.70, with a proposed payment rate of $1,274.
Another commenter stated that vagus nerve stimulation, approved by the FDA in 1997, which can sometimes be performed as an outpatient procedure, would be inappropriately paid under our PPS. The commenter stated that the reported cost for the device is $6,900 for the implantable neurostimulator pulse generator and $2,030 for the implantable vagus nerve stimulator leads. A manufacturer of this new system, which is used in treating intractable epilepsy, also expressed concern that the proposed PPS will underpay hospitals for new technologies such as its system and deny beneficiaries access to them.
Response: In response to these and other comments, we made several changes in proposed APC groups 616, 617, and 618. We moved CPT code 63650, Percutaneous implantation of neurostimulator electrodes, peripheral, to final APC 0224 because the procedure is less time intensive and uses fewer facility resources than the implant procedures in final APC 0225. We also shifted CPT codes 64585 and 64595 to final APC 0225. We will re-evaluate APCs 0223, 0224, and 0225 as we accumulate data and will incorporate our findings in a subsequent hospital outpatient PPS rule. Additionally, we will determine whether the implantable neurostimulator system is eligible for treatment as a “pass-through” device under section 201(b) of the BBRA 1999. The criteria for assessing a medical device's eligibility for additional payment under this provision are discussed in section III.D.4, below.
Ophthalmic Procedures: We received numerous comments concerning the APC groups proposed for eye procedures. Based on their analysis of these comments and recommended changes, a review of our data, and consideration of the limit on variation within a group required by section 201(g) of the BBRA 1999, our medical advisors and staff have significantly restructured the ophthalmic APC groups. Eye procedures and services are assigned to final APC groups 0230 through 0248.
APC 930: Minor Eye Examinations
APC 931: Level I Eye Tests
APC 932: Level II Eye Tests
We assigned to final APC groups 0230 and 0231 the procedures in proposed APC groups 930, 931, and 932 in addition to codes from proposed APC groups 681, 682, and 683 that are either tests or minor ophthalmologic procedures requiring relatively low resource use.
APC 651: Level I Anterior Segment Eye Procedure
APC 652: Level II Anterior Segment Procedure
Comment: We received a number of comments about these proposed APC groups. Commenters were primarily concerned that the payment rates proposed for the two levels of anterior segment eye procedures are significantly less than the costs incurred to perform the procedures assigned to these groups, especially those for glaucoma surgery (CPT codes 66150 through 66170). One commenter indicated that the rate proposed for CPT 66180 is acceptable only if separate payment is made for the aqueous shunt and patch graft.
Response: Based on their review of comments and to be consistent with the BBRA 1999 “two times” requirement, our medical advisors and staff added a third APC group for anterior segment eye procedures. The anterior segment eye procedures are assigned to final APC groups 0232, 0233, and 0234. We made a number of code changes among the three groups. We moved CPT codes 66155, 66160, 66165, and 66170 for glaucoma surgery to final APC group 0234. We shifted CPT code 65800, Paracentesis of anterior chamber of eye (separate procedure) with diagnostic aspiration of aqueous, from proposed APC 683 to final APC 0232 because the Start Printed Page 18466instruments used in connection with CPT code 65800 are similar to those used in all procedures that are primarily paracentesis and because operating room time is likewise similar.
APC 667: Cataract Procedures
APC 668: Cataract Procedures With IOL Insert
Based on our data, the median cost for final APC group 0245 (cataract extraction without lens insert) was slightly higher than that for final APC group 0246 (cataract extraction with lens insertion). We attribute the discrepancy to poor coding, and we have increased the payment rate for APC group 0246 to equal the payment rate for APC group 0245. Proper coding in the future should result in better differentiated costs between these two groups.
Comment: One commenter objected to assigning payment status indicator “T,” Significant procedure, multiple procedure reduction applies, to the procedures in proposed APC group 668. The commenter contended that CPT code 66984, Cataract removal with lens insertion, is often performed in conjunction with other procedures such as CPT code 67010, partial removal of eye fluid, CPT code 65875, incise inner eye adhesions, and 66170, Glaucoma surgery, which also have a “T” payment status indicator. The commenter believes that the multiple procedure reduction would undercompensate for these services and that all these procedures should be given an “S” payment status indicator, which would not subject them to the multiple procedure discount.
Response: We disagree. When more than one surgical procedure is performed during a single operative session, full Medicare payment and the full beneficiary coinsurance payment are made for the procedure that has the highest payment rate. The costs associated with anesthesia, operating and recovery room use, and other services for any additional procedures are incremental and are accounted for within the discounted additional payment.
APC 670: Corneal Transplant
Comment: The numerous comments that we received about this proposed APC focused on our proposal to package the cost of procuring corneal tissue as part of the costs associated with corneal transplant surgery. Commenters feared that this fixed payment method would underpay some hospitals while overpaying others because hospitals acquire corneal tissue from eye banks whose charges are dependent upon the amount of philanthropic contributions the bank receives during the course of a year. A national association representing eye banks reported that fee data from different member facilities show that the corneal tissue acquisition fee alone nearly consumes or, in some cases, exceeds, the entire payment rate proposed for APC group 670. Commenters expressed great concern that we would significantly reduce the supply of corneas available for transplant if we were to package corneal tissue acquisition costs within the APC rate.
Response: Given the current basis for pricing corneal tissue, we are accepting commenters' recommendations that corneal tissue acquisition costs be paid separately and in addition to the payment rate for corneal transplant procedures. At least until we gather data regarding costs associated with the acquisition of corneal tissue, this will ensure that individual hospital's reasonable corneal tissue procurement costs are covered under the PPS. Corneal transplant procedures are in final APC group 0244.
APC 676: Posterior Segment Eye Procedures
Comment: Commenters were concerned that the payment rate for proposed APC group 676 was too low given the costs incurred to perform a number of procedures in the group. For example, one commenter noted that CPT code 67005 requires the same draping as a cataract extraction.
Response: In response to commenters' concerns and to be consistent with the BBRA 1999 “two times” requirement, we split the procedures in proposed APC group 676 into final APC groups 0235 through 0237. We also moved procedures such as CPT code 67025, Replace eye fluid, and CPT code 67027, Implant eye drug system, to final APC 0237 because of the similarity of resource use. CPT code 67025 involves injection of a vitreous substitute, usually gas, silicone, or a similar substance, and the procedure may also involve an aspiration.
APC 681: Level I Eye Procedure
APC 682: Level II Eye Procedure
APC 683: Level III Eye Procedure
APC 684: Level IV Eye Procedure
Comment: Commenters were concerned about the wide variation of resource use and clinical characteristics among the procedures within proposed APC groups 681, 682, 683, and 684. Commenters noted that the surgical complexity of individual procedures in proposed APC group 684 ranges from simple suturing (CPT code 67914, Repair of ectropion; suture) to complex eyelid reconstructions with full thickness tarsoconjunctival flap transfer (CPT code 67971). Commenters recommended that these proposed APC groups be revised and that the more complex procedures that require longer operating room time be paid a higher rate.
Response: We agree. Guided by commenters' recommendations as well as the “two times” limit on cost variation required by the BBRA 1999, we created several new groups and we completely reorganized the procedures in proposed APC groups 681, 682, 683, and 684 into the final APC groups 0230 through 0234 and 0238 through 0242.
APC 690: Vitrectomy
Comment: Several commenters were concerned that the cost of an intravitreal implant ($4,000, according to one commenter) would not be adequately recognized if payment for the device were to be packaged with payment for the insertion procedure (CPT code 67027, Implant eye drug system). Commenters were concerned that beneficiary access to this implant would be restricted if we did not make adequate payment. Commenters supported our proposal to make separate payment for the intravitreal implant.
Response: We assigned all of the procedures in proposed APC 690 to final APC group 0237. As we explain in section III.B.1.c, above, section 201(e) of the BBRA 1999 requires us to classify implantable items to the group that includes the service to which the item relates. However, the intravitreal implant that dispenses ganciclovir is an orphan drug that qualifies for a transitional pass-through payment under the BBRA 1999, which is explained in section III.D, below. Thus, we have assigned the entire drug delivery system to its own APC, 0913. We believe that the payment rate set for CPT code 67027 combined with the additional payment for ganciclovir results in an appropriate payment for this service.
APC 700: Plain Film
Comment: We received numerous comments about the structure of proposed APC group 700. Commenters recommended breaking down the proposed APC group into a number of smaller, more congruous groups. For example, one commenter found no justification for the assumption that resource costs are the same for all plain films listed in APC 700, noting that Start Printed Page 18467there is a significant difference in capital costs, room costs, and maintenance costs between an x-ray room that is designed to take chest x-rays compared to an x-ray room with a table used to take abdominal x-rays. The commenter pointed out that there is a substantial increase in cost when cineradiography capabilities are added. The same commenter questioned our assumption that therapeutic radiology port films are clinically similar to diagnostic radiology films or that bone density studies are clinically similar to and have the same resource costs as plain film radiography.
Response: We agree with commenters' concerns about the composition of proposed APC group 700. In response to commenters' recommendations and applying the “two times” limit on cost variation required by the BBRA 1999, we split proposed APC group 700 into final APC groups 0260 through 0262. We assigned CPT code 70300, Radiologic examination, teeth; single view; CPT code 70310, Radiologic examination, teeth; partial examination, less than full mouth; and, CPT code 70320, Radiologic examination, teeth; complete, full mouth, to their own group, final APC group 0262, because these procedures require minimal time and relatively little radiographic film and technical equipment. We classified the remaining codes to final APC groups 0260 and 0261. We believe that these two groups are sufficient to distinguish clinical consistency and similar resource use. Facilities perform, relatively, a similar proportion of the different plain film procedures, and hospitals do not systematically use one type of plain film over another type, with the exception of dental films, which we moved to a separate group. The absolute magnitude of the difference in resource use among different plain films is not as significant as the difference between dental and other types of plain film. Additionally, our data indicate minimal differences in the amount of resource use between bone density measurement tests and plain films.
APC 706: Miscellaneous Radiological Procedures
Comment: A number of commenters found the tests grouped in proposed APC group 706 to vary significantly in the amount of time, effort, and costs required to provide the service.
Response: As a result of applying the “two times” limit on cost variation required by the BBRA 1999, we divided proposed APC 706 into two levels: final APC 0263 and final APC 0264. We also moved CPT code 76075, Bone Density Study, one or more sites, to final APC 0261. We explain below, in section III.C.6.e, why we are making an exception to the BBRA 1999 “two times” limit on cost variation in the case of final APC group 264.
APC 710: Computerized Axial Tomography
APC 720: Magnetic Resonance Angiography
APC 726: Magnetic Resonance Imaging
Comment: A number of commenters believe that assigning all computerized axial tomography (CAT) to a single group and all magnetic resonance imaging (MRI) to a single group results in a lack of homogeneity among the procedures within each group. These commenters were concerned that we ignored the cost of contrast materials, labor, and equipment within proposed APC group 710 and proposed APC group 726 and that combining contrast and non-contrast studies represents an inconsistency in resource use because an examination that uses contrast will be more costly than one without contrast. One commenter observed that an MRI examination with the use of contrast material requires approximately 30 percent more time and effort than an examination performed without contrast material and that a bilateral examination requires 50 percent more staff time and effort to complete. The same commenter expressed concern that proposed APC 720 consists of only one procedure, CPT code 70541, Magnetic image, head (MRA). The commenter recommended that we place this code and the other MRA codes that we now cover into two APC groups, one with and the other without contrast. A number of commenters recommended that we pay separately for contrast material, as a cost pass-through. One commenter believes that including diagnostic studies with placement of radiation therapy fields in proposed APC 710 violates the “clinically similar” criterion.
Response: Our medical advisors and staff carefully reviewed our data for the procedures in proposed APC group 710, proposed APC group 720, and proposed APC group 726 in light of commenters' concerns about the extent to which these groups take into account the costs associated with the use of contrast material. We concluded that costs associated with the use of contrast material are reflected in the payment rate in proportion to its frequency of use. We believe it is reasonable to have the CAT scans and MRIs with and without contrast together in their respective APC groups because facilities do not specialize based on whether or not they use contrast material. Further, the cost of contrast material relative to the overall inherent cost of CAT scans and MRI procedures alone is small. Moreover, the use of contrast material with CAT scans and MRI procedures differs significantly when compared to the use of contrast with plain films. Contrast comprises a significant portion of the cost of plain film services, and not all facilities perform plain films with contrast. A plain film can be ordered without being scheduled, but any plain film with contrast has to be scheduled. This scheduling distinction does not apply to a CAT or MRI scan with or without contrast. We did find that applying the “two times” limit on cost variation required by the BBRA 1999 resulted in the creation of two CAT groups, final APC groups 0282, to which we assigned CPT codes 70486, 76370, 76375, and 76380, and final APC 0283, to which the remaining codes in proposed APC group 710 are assigned. We further eliminated proposed APC group 720 and combined CPT code 70541, Magnetic image, head (MRA), with the other MRI procedures in final APC group 0284 because the base procedure, magnetic resonance imaging, is the same.
APC 716: Fluoroscopy
Comment: A number of commenters recommended that we pay separately for the fluoroscopy portion of procedures that include this radiologic service.
Response: We have assigned payment status indicator “X” to the procedures in final APC groups 0272 and 0273 to indicate that these are ancillary services that are paid separately under the hospital outpatient PPS.
Comment: A professional society commented that CPT code 74340, X-ray guide for GI tube, requires approximately 10 times the amount of radiologic technologist and room time, approximately 15 times the amount of film and many more supplies than does CPT code 71023, Chest x-ray and fluoroscopy. The commenter recommended that we divide proposed APC 716 into three separate and distinct levels based on the extent of the procedures and that we recalculate the relative weight and associated payment rate for the resulting groups.
Response: We disagree with the commenter. Our medical advisors and staff, after reviewing the procedures in proposed APC group 716, concluded that the fluoroscopic portion of these procedures is sufficiently similar in terms of clinical characteristics and resource requirements to be grouped together. However, applying the “two times” limit on cost variation required Start Printed Page 18468by the BBRA 1999 results in the formation of two groups, final APC groups 0272 and 0273.
APC 728: Myelography
Comment: Commenters objected to assigning the same payment amount to procedures regardless of whether or not a contrast agent is used. One commenter was concerned that this payment policy will dissuade hospitals from utilizing contrast agents even in cases where the use of contrast is medically appropriate.
Response: We agree that median costs vary more among the procedures in proposed APC 728 than their clinical similarities would suggest. However, although we found that final APC group 0274 did not satisfy the “two times” limit on cost variation required by the BBRA 1999, we are making an exception in this case as we explain below, in section III.C.6.e., and we are retaining all myelographic procedures in final APC 0274.
APC 730: Arthrography
Comment: Some commenters suggested reassigning various arthrographic procedures that were assigned to proposed APC 730.
Response: We find the procedures in this group to be sufficiently homogeneous in terms of clinical definition and resource use. The procedures are comparable with respect to the use of resources in that the highest median cost procedure is less than twice the lowest median cost procedure, consistent with the standard set by the BBRA 1999. Therefore, we are retaining the proposed grouping of arthrographic procedures in final APC 0275.
APC 736: Digestive Radiology
To be consistent with the limit on cost variation required by section 201(g) of the BBRA 1999, we divided the procedures in proposed APC 736 into final APC groups 0276 and 0277.
APC 738: Therapeutic Radiologic Procedures
To be consistent with the limit on cost variation required by section 201(g) of the BBRA 1999, we split the procedures in proposed APC 738 into final APC groups 0296 and 0297.
APC 739: Diagnostic Angiography and Venography
Comment: Numerous commenters expressed concern about the lack of homogeneity among procedures in proposed APC 739. One commenter recommended that we divide proposed APC 739 into three groups: one for CPT code 75790, Angiography, arteriovenous shunt; one for all other angiography procedures; and one for venography procedures.
Response: In response to these comments, we created final APC group 0281, Venography of Extremity, to reflect the significant clinical and resource consumption differences between venographic procedures performed on extremities and diagnostic angiography and venography performed on other parts of the body. Venographic procedures on the extremities consume less time and fewer resources than other angiography and venography procedures. To be consistent with the limit on cost variation required by the BBRA 1999, we split the other procedures in proposed APC 739 into final APC groups 0279 and 0280. With respect to final APC group 0279, we explain in section III.C.6.e why we are making an exception to the BBRA 1999 limit on cost variation.
APC 747: Diagnostic Ultrasound Except Vascular
Comment: A number of commenters suggested that we restructure proposed APC group 747 according to body site because the APC criterion of clinical homogeneity is violated by including within one group body sites that range from the eye to the pregnant uterus to the scrotum and contents.
Response: Our medical advisors and staff carefully weighed the suggestion of commenters that clinical homogeneity would be better served if the procedures in proposed APC group 747 were divided into groups according to body site. We concluded that resource costs based on the type of technology used are what primarily dictates the definition of groups for various diagnostic services. Thus, we did not assign plain film of the chest in the same APC group with MRI of the chest. Because ultrasound is the type of technology common to all procedures in proposed APC group 747 and because resource use for the various procedures is similar irrespective of body site, we did not break this group up according to body site. However, to be consistent with the limit on cost variation required by the BBRA 1999, we split the procedures in proposed APC 747 into final APC groups 0265 and 0266.
APC 749: Guidance Under Ultrasound
Although there is a range of sites for the procedures in proposed APC group 749, as we explain above in our response to the comments submitted in connection with proposed APC 747, we are keeping this group intact in final APC group 0268 because the base procedure, ultrasonography, is the same for all procedures. Also, the procedures in final APC group 0268 are comparable with respect to the use of resources in accordance with the “two times” limit on cost variation.
APC 750: Therapeutic Radiation Treatment Planning
Comment: Commenters were concerned that radiation physics services are not appropriately recognized in proposed APC group 750. One commenter observed that proposed APC 750 lacks clinical homogeneity by including HCPCS codes for calculations and computer-based treatment planning with codes for the construction of treatment devices. Another commenter objected to including CPT codes 77261, 77262, 77263, 77431, and 77432 in proposed APC 750 because these codes are for professional services only and do not include a technical or facility component. As such, there are no facility costs associated with the codes. The commenter noted that if these codes were removed from proposed APC group 750, three medical physics consultation codes, CPT codes 77336, 77370, and 77399 would remain in the group. The commenter suggested that the resource requirements for two of the three remaining codes are dramatically different.
Response: We agree with commenters' concerns about proposed APC group 750, and we modified this group accordingly. First, we assigned payment status indicator “E,” which designates certain items and services that are not paid under the hospital outpatient PPS, to five codes that describe professional services, which would not be billed by hospitals: CPT code 77261, Therapeutic radiology treatment planning; simple; CPT code 77262, Therapeutic radiology treatment planning; intermediate; CPT code 77263, Therapeutic radiology treatment planning; complex; CPT code 77431, Radiation therapy management with complete course of therapy consisting of one or two factions only; and CPT code 77432, Stereotactic radiation treatment management of cerebral lesion(s) (complete course of treatment consisting of one session).
We renamed the remaining group of codes as final APC 0311, Radiation Physics Services. The codes specific to radiation physics that we classified in this APC are CPT code 77336, Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy; CPT code 77370, Special medical radiation physics Start Printed Page 18469consultation; and CPT code 77399, Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services.
APC 751: Level I Therapeutic Radiation Treatment Preparation
APC 752: Level II Therapeutic Radiation Treatment Preparation
Comment: One commenter objected to including CPT code 77295, Therapeutic radiology simulation-aided field setting; three-dimensional, in proposed APC 752 because this service has dramatically different resource requirements than the other CPT codes in group. Another commenter believes that the resources used in connection with simple intracavitatory applications, which are normally performed with re-usable Cs-137 sources, are totally dissimilar from the resources required for remote afterloading high intensity brachytherapy in proposed APC 751. This commenter noted that the equipment and room costs associated with remote afterloading high intensity brachytherapy may well exceed $500,000.
Response: We agree. In response to commenters' concerns, we made a number of modifications to proposed APC group 751 and proposed APC group 752. First, we assigned payment status indicator “E,” which designates certain items and services that are not paid under the hospital outpatient PPS, to CPT code 77299, Unlisted procedure, therapeutic radiology clinical treatment planning, thereby removing it from an APC group.
We created final APC group 0303, which consists of the following three codes: CPT code 77332, Unlisted procedure, therapeutic radiology clinical treatment planning; CPT code 77333, Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus); and, CPT code 77334, Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts). We created final APC 0303 because the resources needed for device construction are unique. We decided to put these three codes together in one group rather than assigning each to its own individual group because we could make no clear cost distinctions among the three codes and because we expect that facilities do not specialize in one type of device over another, but rather construct all of the types of devices encompassed within the three codes.
We created final APC group 0310, to which we assigned CPT code 77295, Therapeutic radiology simulation-aided field setting, three-dimensional. We assigned CPT code 77295 to its own individual APC group because it requires significantly greater resource consumption than the procedures in either final APC group 0304 or final APC group 0305.
We assigned the codes remaining in proposed APC groups 751 and 752 to final APC groups 0304 and 0305. Both APC groups 0304 and 0305 are comparable with respect to the use of resources in accordance with the “two times” requirement set by the BBRA 1999.
APC 757: Radiation Therapy
Comment: We received a number of comments about the assignment to proposed APC 757 of CPT code 61793, Stereotactic radiosurgery, particle beam, gamma ray or linear accelerator, one or more sessions. Commenters indicated that CPT code 61793 is clinically distinct from other forms of radiation treatment delivery and that this service generally involves significantly greater treatment time and costs. One commenter stated that if we were to keep CPT code 61793 in proposed APC 757, we would be prejudicing use of this new, proven technology. Another commenter contended that radiation therapy is not the same as a surgical procedure. The commenter urged us to separate stereotactic radiation therapy (SRT) and intensity-modulated radiation therapy (IMRT) services from the conventional radiation therapy procedures in APC 757 and to assign them a higher payment rate due to their higher cost.
Response: We created final APC group 0302, to which we assigned stereotactic radiosurgery, which requires significantly more costly resources than the procedures assigned to final APC groups 0300 and 0301. Note that we have created two codes, G0173 and G0174, to use in place of CPT code 61793. They represent stereotactic radiosurgery completed in one session, and that which requires multiple sessions, respectively. We also assigned CPT code 77470 to APC 0302, since we believe it requires resources similar to those required for radiosurgery. We will continue to track the data for these codes to ensure their proper placement. The procedures in final APC group 300 and in final APC group 301 are comparable with respect to the use of resources in accordance with the “two times” limit on cost variation.
APC 759: Brachytherapy and Complex Radioelement Applications
Comment: One commenter expressed concern because we did not identify a payment amount for the radioactive seeds used in brachytherapy. Another commenter referred to low dose rate interstitial brachytherapy that is used to treat complex gynecologic tumors, prostate cancers, and head and neck cancers, noting that this type of radiation therapy employs single-use radioactive sources (iodine, gold, iridium, and palladium seeds) and various disposable applicators. The commenter pointed out that only a limited number of vendors produce these radioactive sources and that the seeds cost as much as $200 each with the number of implants varying depending on the size, stage, and location of the cancer. The commenter stated that some patients with prostate cancer may require as many as 100 to 150 seeds. The commenter asserted that we have not captured the costs of these radiopharmaceuticals in the APC payment.
Response: We have changed how we pay for brachytherapy and the other services we proposed to classify to APC 759 in response both to comments and to the provisions of section 201(b) of the BBRA 1999, which provide for an additional payment to be made for innovative medical devices, including “a (current) device of brachytherapy.” (See section III.D., below.) Within this framework, we recognize the seeds provided during brachytherapy. For bill processing purposes, we have assigned brachytherapy seeds to APC 0918. We will make payment for brachytherapy seeds under the transitional pass-through rules explained in section III.D., below.
Based on commenters' suggestions, a review of our data, and the BBRA 1999 “two times” requirement, we have classified the procedures in proposed APC 759 in final APC 0312, Radioelement Applications, and final APC 0313, Brachytherapy. APC 0313 consists of CPT code 77781, Remote afterloading high intensity brachytherapy; 1-4 source positions or catheters; CPT code 77782, Remote afterloading high intensity brachytherapy; 5-8 source positions or catheters; CPT code 77783, Remote afterloading high intensity brachytherapy; 9-12 source positions or catheters; CPT code 77784, Remote afterloading high intensity brachytherapy; over 12 source positions or catheters; and, CPT code 77799, Unlisted procedure, clinical brachytherapy. Because these Start Printed Page 18470procedures are all different types of brachytherapy, final APC 313 is more coherent clinically than was proposed APC 759.
We moved CPT code 77750, Infusion or instillation of radioelement solution, to final APC 301, Level II Radiation Therapy, and CPT code 77789, Surface application of radioelement, were moved to final APC 300, Level I Radiation Therapy. The remaining procedures from proposed APC 759 constitute final APC 312, Radioelement Applications. The procedures in final APC group 312 and in final APC group 313 are comparable with respect to the use of resources in accordance with the “two times” limit on cost variation.
APC 761: Standard Non-Imaging Nuclear Medicine
APC 762: Complex Non-Imaging Nuclear Medicine
APC 771: Standard Planar Nuclear Medicine
APC 772: Complex Planar Nuclear Medicine
APC 781: Standard SPECT Nuclear Medicine
APC 782: Complex SPECT Nuclear Medicine
APC 791: Standard Therapeutic Nuclear Medicine
APC 792: Complex Therapeutic Nuclear Medicine
Comment: We received numerous comments about the proposed nuclear medicine APC groups. Commenters addressed what they believe to be discrepancies in the payment weights among the proposed groups. Commenters also asserted that the proposed payment levels are inadequate to offset the cost of radiopharmaceuticals. They believe, in part, that our use of single-procedure claims in constructing our database failed to capture the costs associated with the various radiopharmaceuticals that may be used in combination during multiple procedures performed during a single session on various patients. One commenter disagrees with our decision to consider therapeutic radiopharmaceuticals and radionuclides as incidental services, bundling their costs into nuclear medicine and radiation therapy procedures. The commenter recommended that we develop unique APC groups for radiopharmaceuticals and radionuclides. One manufacturer expressed particular concern about our proposed payment for a radiopharmaceutical used to relieve the pain of bone metastasis (CPT code 79400) that we proposed to package into APC 791 for which the proposed payment was $758. The commenter stated that this new radiopharmaceutical, which has generated a very high clinical response rate, costs more than $2,000 per dose.
Response: In response to these and other comments, as well as the changes made by the BBRA 1999 to the outpatient PPS, our medical advisors and staff have reconstructed the nuclear medicine APC groups. First, we have placed radiopharmaceuticals into a separate set of APC groups that are listed in Addendum K. As we state above, new section 1833(t)(6) of the Act provides for additional payment for current and new radiopharmaceuticals. We list in Addendum K those radiopharmaceuticals that are eligible for additional payment effective with services furnished on or after July 1, 2000. In accordance with the process outlined below, in section III.D.4, we invite requests to consider other radiopharmaceuticals as potential candidates for additional pass-through payments.
Next, we reconfigured the nuclear medicine APC groups based on the resources required for the procedures themselves, exclusive of costly radiopharmaceuticals. We took into account the fact that SPECT equipment, which costs significantly more than the non-SPECT equipment that was initially used most frequently for planar medicine, is now commonly used to conduct planar studies. As a final step, we further reorganized the groups to satisfy the requirement set by the BBRA 1999 “two times” requirement, resulting in final APC groups 0286, 0290, 0291, 0292, 0294, and 0295.
Comment: We received a number of comments concerning the clinical efficacy of iodine 131 tositumomab in the treatment of cancer. One commenter stated that iodine 131 tositumomab, which was reported to be pending final FDA approval, has the potential to be the first radioimmunotherapeutic agent to be approved for the treatment of cancer. The commenter expected this pharmaceutical to be the first in its class, and characterized it as neither a chemotherapeutic agent nor a radiopharmaceutical. The commenter stated that the cost of this pharmaceutical will be significantly higher than the payment amount proposed for any of the APC groups containing drugs used for cancer therapies. The commenter believes that we should have proposed an outlier policy to ensure equitable payment for pharmaceuticals such as iodine 131 tositumomab.
Response: If iodine 131 tositumomab receives final FDA approval, we strongly encourage interested parties to submit the appropriate materials to us for determination of this product's eligibility for additional payment under the pass-through provision as described below in section II.D.6.
Comment: One commenter finds our method of paying for new products to be flawed. The commenter sees it as highly probable that a new product will be inserted into an APC procedure category where the payment rate is significantly lower than the actual cost of the newly developed product. The commenter cites our proposed payment for a new product, In-111 Octreo Scan, which is used for tumor imaging. The product costs four times the payment rate for proposed APC 772, Complex Planar Nuclear Medicine. The commenter believes that this enormous discrepancy will discourage hospital outpatient departments from utilizing procedures that require this product and that Medicare beneficiaries may be denied access to the most appropriate care available as a result.
Response: We are firmly committed to ensuring that the provisions of the hospital outpatient PPS do not in any way obstruct or limit Medicare beneficiaries' access to reasonable medically necessary and appropriate care. We further recognize that the development of new technology and products is a highly dynamic enterprise that is constantly evolving and changing the character and cost of current diagnostic and treatment modalities. New section 1833(t)(6) of the Act provides for an additional transitional pass-through payment for certain innovative medical devices, drugs, and biologicals. We are also creating a series of transitional APCs for the express purpose of providing appropriate payment for new technology services when they emerge into the marketplace while we collect data to enable us ultimately to incorporate the new technology service within an APC group, making payment adjustments as needed. We expect to continue working closely with hospitals and their representatives throughout this process to ensure that payment does not inhibit beneficiary access to appropriate care. We discuss the transitional pass-through payment groups in greater detail in section III.D and provisions for payment for new technology in section III.C.8. Start Printed Page 18471
APC 881: Level I Pathology
APC 882: Level II Pathology
APC 883: Level III Pathology
Comment: We received numerous comments on the proposed pathology APC groups. One commenter expressed concern that our proposed assignment of tests among the three groups may create an incentive for physicians to order complex and unnecessary tests when simpler, less comprehensive tests may be adequate, because we have grouped together and are paying the same amount for tests that are clinically similar but that are comprehensively more difficult than one another.
Response: Our medical advisors and staff reviewed and completely reorganized the grouping of pathology tests in light of commenters' concerns and the BBRA 1999 “two times” requirement. Pathology tests are in final APC groups 0342, 0343, and 0344.
APC 906: Infusion Therapy Except Chemotherapy
APC 907: Intramuscular Injections
Comment: We received many comments about proposed APC groups 906 and 907. The commenters were generally concerned that packaging payment for nonchemotherapeutic infused and injected drugs in the payment rates for the administration of nonchemotherapy drugs does not take into account the great variation among these products with regard to their indication/application and cost nor the cost of new drugs that have been introduced since 1996. Commenters fear that we will underpay hospitals and inhibit the introduction of new drugs into the system.
Response: In response to the concerns expressed by commenters, we have created additional groups for certain expensive pharmaceuticals. These high-cost, nonchemotherapy, nonorphan drugs are captured in the following APCs: 0886-0891, 0907, 0908, 0911, 0914, 0915, 0917, 7007, 7036, and 7042. We have set the rates for these high-cost drug APCs based on data we obtained from a contracted study of drug costs. In section III.D, below, we discuss the process for pricing new high cost drugs as they are introduced into the marketplace to assure adequate payment until these new drugs can be assigned to an appropriate APC. Final APC 120, Infusion Therapy Except Chemotherapy, and final APC 359, Intramuscular injections, are priced based on the resources used to perform the procedures, including many less expensive drugs that are packaged into the two APCs.
APC 957: Echocardiography
Comment: Numerous commenters remarked on the lack of homogeneity in resource consumption in this APC. One commenter objected to our not distinguishing between procedures performed with or without contrast agents. Another commenter contends that proposed APC 957 does not account for the diversity of services in costs based on type of equipment, use of conscious sedation medication, and use of contrast agents.
Response: Conscious sedation and contrast media were packaged where they were used in the base year. We believe that packaging of items into the payment amount is appropriate because hospitals do not specialize in providing only services with or only services without sedation or contrast. To the extent that different equipment is used for different procedures, and has different costs, those differing costs are captured and recognized in our payment algorithm.
Comment: Several commenters referred to the fact that some of the echocardiograms are part of more comprehensive codes pertaining to echocardiograms that are in the same APC. For example, one commenter noted that CPT code 93880, the basic vascular ultrasound service, is defined as a “duplex scan.” The commenter stated that all duplex vascular ultrasound codes involve three components and that, to the extent all three components are incorporated into this single vascular code, a provider is paid for only one procedure. On the other hand, CPT code 93307, the basic echocardiography service, incorporates only one of the three types of services included in the basic vascular service, CPT code 93880. Other codes, CPT 93320 and 93325 are used to bill for the other services that are a standard part of all vascular ultrasound procedures like CPT code 93880. This approach results in a provider receiving three separate payments for an echocardiogram with Doppler and color flow mapping as compared to a single payment for an equivalent vascular study.
Response: We agree that duplex vascular ultrasound scanning procedures include two dimensional and doppler signal display. However, for the example cited by the commenter, there is no separate code that includes both the two dimensional and the doppler ultrasound spectral analysis. To report a duplex vascular ultrasound of the heart, the only codes available are CPT codes 93307, 93320 and 93325, unlike the duplex vascular ultrasound scan of the extracranial arteries, which is coded with CPT code 93880. We agree that this limitation of the coding system affects the payment system, since the APC system is based on charges associated with each of the codes. We will bring this issue to the attention of the American Medical Association's CPT Editorial Panel.
However, in those instances where there is a code for the comprehensive service and separate codes for services that are inherent components of the comprehensive service, the Correct Coding Initiative (CCI) edits, which we are incorporating into the hospital outpatient PPS claims processing system, will address this concern. The CCI edits have been in place in the Part B claims processing system since January 1996. These edits detect when codes representing component services are reported with the code for the more comprehensive service. For example, there is an edit that prohibits the payment of CPT code 93875, a doppler study of the extracranial arteries when reported with CPT code 93880, the duplex scan of the extracranial arteries.
APC 960: Cardiac Electrophysiologic Tests/Procedures APC
Comment: Many commenters cited extreme variations in resource use among the procedures in proposed APC 960. One commenter noted that the procedures involve the use of one or more catheters, and argued that the proposed payment does not cover the cost of even one catheter. Another commenter claims that, at a minimum, the total cost of the four diagnostic catheters and one ablation catheter used in performing these procedures is $1,955.
Response: In response to these concerns, we moved CPT code 93660, Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention, to final APC 0101, and CPT code 93724, Electronic analysis of antitachycardia pacemaker system, to final APC 0100. We reclassified the remaining procedures in proposed CPT 960 into final APC groups 0084, 0085, 0086, and 0087 to be consistent with the BBRA 1999 “two times” requirement.
APC 966: Electronic Analysis of Pacemakers/Other Devices
Comment: A number of commenters stated that the procedures in proposed APC 966 are not related clinically or in terms of resource cost. One commenter indicated that analyzing a spine infusion pump or neuroreceiver is a very different process from analyzing a Start Printed Page 18472pacemaker or cardio/defibrillator and hence uses very different resources.
Response: Although the devices that are the subject of electronic analysis in proposed APC group 966 differ, we believe that the resource use among the services in the group is, on average, relatively similar. We determined that the procedures in proposed APC 966 meet the “two times” test for comparability with respect to the use of resources set by the BBRA 1999. In addition, we find it unlikely that facilities will specialize in one particular type of electronic analysis of pacemakers/other devices to the exclusion of others. Therefore, we did not change the procedures in final APC group 102 from what we had proposed.
APC 968: Vascular Ultrasound
Comment: One commenter recommended removing CPT code 93875, Non-invasive physiologic studies of extracranial arteries, complete bilateral study (for example, periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis), from proposed APC 968 because this study is a physiologic procedure and should be in the same group with other noninvasive physiologic vascular studies.
Response: We agree. We moved CPT code 93875 to final APC 0096.
Comment: One commenter recommended creating additional APC groups for CAT, MRI, and general ultrasound procedures to distinguish between diagnostic procedures that utilize contrast media and those that do not. The commenter believes that additional APC groups that properly recognize the resources required for contrast agents will encourage hospitals to use the procedures most suitable for the clinical needs of different patients.
Response: As we explained above, in our response to comments about proposed APC groups 710, 720, and 726, our medical advisors and staff carefully reviewed our data and concluded that costs associated with the use of contrast material are reflected in the payment rate for vascular ultrasound procedures in proportion to its frequency of use. We believe it is reasonable to have vascular ultrasound procedures with and without contrast together in one group because facilities do not specialize based on whether or not they use contrast material. Further, the cost of contrast material is small relative to the overall cost of the ultrasound. Moreover, facilities are not likely to schedule ultrasound according to whether or not contrast is used. Therefore, with the exception of moving CPT code 93875, we did not further change the procedures in final APC group 0267. Final APC group 0267 is within the limit on cost variation required by the BBRA 1999.
APC 969: Hyperbaric Oxygen
Comment: Many commenters were concerned that our cost data for hyperbaric oxygen therapy are flawed because of poor coding, and that the proposed payment rate is, as a consequence, inadequate. One commenter suggested that we did not use a common definition of hyperbaric oxygen therapy across all hospitals and that, due to ambiguity in codes, there is wide variation in how hyperbaric oxygen therapy services are defined for billing purposes.
Response: We cannot subdivide final APC 0031 because we have no mechanism for creating clinically distinct groups related to differences in resource consumption among facilities within a single CPT code. However, we explain below, in section III.H, that we intend to make adjustments in future years to APC group weights, once the hospital outpatient PPS is implemented. If commenters believe that current codes are inadequate to describe these services, they should seek new CPT codes from the American Medical Association.
Comment: One commenter was concerned about not only the low payment rate proposed for hyperbaric oxygen therapy, but also the fact that the proposed national unadjusted coinsurance amount exceeds the proposed total payment rate for the service.
Response: We calculated the payment rate and coinsurance amount for APC 0031 using the same method that we followed for the other APC groups. Charges for hyperbaric oxygen are much higher than their costs, which accounts for the unusually high national unadjusted coinsurance rate relative to the total payment rate for CPT code 99183. Note, however, that hospitals may elect to offer a reduced coinsurance rate for the service as described below in section III.F.4.
APC 971: Level 1 Pulmonary Tests
APC 972: Level II Pulmonary Tests
APC 973: Level III Pulmonary Tests
Comment: Commenters generally questioned the clinical consistency of procedures in the proposed pulmonary test APC groups and expressed concern about the variability of resources required to perform the procedures within each group. One commenter disagreed with our combining procedures before and after medication with procedures before rest and after exercise.
Response: After carefully reviewing the assignment of codes among the three proposed pulmonary test groups, our medical advisors and staff made a number of changes. To better recognize their median costs, we moved CPT code 94060, Bronchospasm evaluation before and after bronchodilator, and CPT code 94260, Thoracic gas volume, to final APC group 0368, and classified CPT code 94720, Carbon monoxide diffusing capacity, to final APC group 0367. We made additional changes among the three groups to ensure comparability of resources within each pulmonary test APC group in accordance with the “two times” standard set by the BBRA 1999.
APC 976: Pulmonary Therapy
Comment: Commenters generally questioned the clinical consistency of procedures in the proposed pulmonary therapy APC group and expressed concern about the variability of resources required to perform the procedures within the group. One professional association wrote that the respiratory therapy procedures in proposed APC group 976 are significantly different in complexity and require significantly different equipment and expertise to perform. The same commenter noted that CPT code 94657, Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing, subsequent days; CPT code 94660, Continuous positive airway pressure ventilation (CPAP), initiation and management; and, CPT code 94662, Continuous negative pressure ventilation (CNP), initiation and management, all require close monitoring, more costly equipment, and, often, more expertise than do other therapies in proposed APC group 976.
Response: We agree with the commenter. We moved the CPT codes describing ventilation initiation and management (CPT codes 94657, 94660, 94662) into their own APC, final APC 0079, Ventilation Initiation and Management, to recognize that these procedures represent a completely different type of clinical service and because they utilize resources that are materially different from those used in connection with other pulmonary therapy procedures. We further divided the procedures in proposed APC 976 to meet the definition of comparable resources required by the BBRA 1999, resulting in final APC groups 0077 and 0078. Start Printed Page 18473
APC 979: Extended EEG Studies and Sleep Studies
APC 980: Electroencephalogram
APC 981: Level I Nerve and Muscle Tests
APC 982: Level II Nerve and Muscle Tests
Comment: One commenter expressed concern about our grouping sleep medicine services in proposed APC 979 with EEG and Epilepsy diagnostic services. Another commenter is concerned about the clinical homogeneity of our proposed groups for the numerous different neurologic and neuromuscular diagnostic codes that are encompassed within the range of services described by CPT code 95805 through CPT code 95958. The commenter believes that our proposed groups do not make appropriate distinctions among the many different tests relating to different parts of the body, taking different amounts of time, using different equipment, and measuring different outcomes. One commenter asked that we add two codes created in 1998 for sleep services to the list of procedures in the APC system. The commenter recommended assigning CPT 95811, Polysomnography with CPAPP, to proposed APC group 979. The commenter also recommended that CPT code 95806, Sleep study, unattended by a technologist, not be assigned to proposed APC group 979 to avoid creating an incentive for hospitals to use that procedure, which the commenter asserts is both less costly and less conclusive than other studies in proposed APC 979, in place of more comprehensive tests. One commenter claimed that the variety of neurological and neuromuscular diagnostic tests warrants an expansion of the number of APCs for these procedures to six, because the resources used vary widely. The commenter prefers that payments be made on a per service rather than on a per group basis. However, if we retain groups, the commenter recommended, on the basis of cost-based practice expenses, separate APCs for sleep and polysomnography services, for EEG studies, for EEG monitoring codes, for EMG codes, for nerve conduction and H reflex tests, and for sensory evoked potential and autonomic nerve function tests.
Response: Our medical advisors and staff decided that CPT codes 95806 and 95811 are both most appropriately assigned to final APC 0213. While sleep studies unattended by a technologist may consume less resources than those studies which involve the presence of a technologist, we believe that physicians are likely to order a mix of sleep studies, and that institutions are unlikely to specialize in sleep studies with or without the presence of a technologist. We added CPT code 95951 to APC group 0213. We believe the codes we proposed in APC groups 979 and 980 are sufficiently comparable clinically and in terms of resource use not to require further subdivision into smaller groups. Therefore, we retained our proposed classification in final APC groups 213 and 214.
We created a third APC group for the nerve and muscle test codes, and we split the codes in proposed APCs 981 and 982 among final APC groups 0215, 0216, and 0217 to ensure comparability of resources within each of the three nerve and muscle test APC groups in accordance with the “two times” requirement set by section 201(g) of the BBRA 1999.
APC 987: Subcutaneous or Intramuscular Chemotherapy
APC 988: Chemotherapy except by Extended Infusion
APC 989: Chemotherapy by Extended Infusion
APC 990: Photochemotherapy
Comments: We received numerous comments that criticized our proposed payments for chemotherapy services. The commenters argued that the proposed payment for chemotherapy and radiation therapy would severely reduce payments to hospitals and create perverse incentives for hospitals to substitute the older, less effective therapies for the newer ones. The commenters asserted that the proposed payment would not cover the costs of supportive care such as drugs to control nausea and vomiting. They expected that low payment rates to hospitals would force them to discontinue chemotherapy services, and that patients would be faced with trips to distant facilities to obtain services.
Response: We believe that the concerns raised by the commenters have been addressed through the transitional pass-through provision set forth in section 1833(t)(6) of the Act, as added by section 201(b) of the BBRA 1999. In accordance with that provision, we have separately identified current drugs and biologicals used in the treatment of cancer. These are listed in Addendum K of this final rule, and are eligible for additional payment under this provision. We have obtained codes for any anticancer, supportive, or adjunctive drugs we could identify. Thus, we will pay for chemotherapy by recognizing the mode(s) of administration and each of the covered drugs given, whether they are to treat the cancer, to protect the patient against the toxic effects of the treatment, or to relieve the side effects of treatment. In section III.D.4, below, we discuss how to request codes for new drugs.
Note that we moved CPT-based chemotherapy infusion codes into the “E” (noncovered) category because HCPCS “Q” codes for these services will be used to identify chemotherapy infusions. Hospitals had been instructed in the past not to bill using the CPT codes.
APC 999: Therapeutic Phlebotomy
Comment: One commenter is concerned that facilities will lose money because the proposed payment rate does not cover the cost incurred to provide the nursing care, phlebotomy bag and other supplies, overhead, scheduling time and disposal of hazardous waste that are all required to furnish this service.
Response: We have carefully reviewed the costs associated with APC 999 and believe that the CPT code 99195 was mistakenly used to report simple venipuncture in some cases, thus lowering the cost of proposed APC 999. However, we believe it is appropriate to base payment for this APC on the median amount billed, since CPT code 99195 was billed more than 20,000 times. Hospitals must use this code only when therapeutic phlebotomy is furnished, and charge an appropriate rate for the resources involved. Appropriate reporting will enable us to determine a more precise weight for this APC in future years.
Final APC 081: Non-Coronary Angioplasty or Atherectomy
Final APC 082: Coronary Atherectomy
Final APC 083: Coronary Angioplasty
We created these three new APC groups to accommodate atherectomy and angioplasty procedures that we originally proposed to classify as inpatient only. We discuss in section III.C.5 our response to commenters' concerns about our proposing to designate certain procedures as “inpatient only” and our final decision to change the status of these atherectomy and angioplasty procedures.
Final APC 058: Strapping
Final APC 059: Casting
We proposed to assign the procedures in these new APC groups a payment status indicator “N” as incidental services for which payment is packaged into the APC rate for another service or procedure. However, we determined Start Printed Page 18474that the procedures in the final APC groups 0058 and 0059 could be performed independently, that is, the procedures for which a strapping has been previously applied and/or a new cast has previously been placed. We explain in more detail in section III.C.2.c our rationale for not packaging the costs associated with these services. We therefore created APC groups 0058 and 0059 for these codes to which we assigned payment status indicator “S” to indicate that these are significant procedures paid under the hospital outpatient PPS to which the multiple procedure discount does not apply.
e. Exceptions to BBRA 1999 Limit on Variation of Costs Within APC Groups
As we note above, section 201(g) of BBRA 1999 amends section 1833(t)(2) of the Act to define what constitutes comparable use of resources among the procedures or services within an ambulatory payment classification group under the hospital outpatient PPS. The standard set by section 1833(t)(2) of the Act is that the items and services within a group cannot be considered comparable with respect to the use of resources if the highest median (elected by the Secretary, as opposed to the mean) cost item or service within a group is more than 2 times greater than the lowest median cost item or service within the same group (the “two-times” requirement).
Section 1833(t)(2) of the Act allows the Secretary to make exceptions to the “two-times” requirement in unusual cases, such as low volume items and services, although the Secretary may not make such an exception in the case of a drug or biological that has been designated as an orphan drug under section 526 of the Federal Food, Drug, and Cosmetic Act. As we explain in the preceding section of this preamble, after we had modified the composition of the APC groups based on the recommendations of commenters, we made numerous additional changes to the APC groups to conform with the BBRA 1999 “two times” requirement. In the resulting groups, we found certain anomalies that were irreconcilable with the principles underlying formation of the APC groups. After carefully evaluating the various combinations resulting from further subdividing groups or reassigning codes to other groups to resolve the anomalies, and after reviewing our data, we decided to maintain the composition of certain APC groups, as exceptions to the “two times” requirement. We based exceptions on factors such as low procedure volume, suspect or incomplete cost data, concerns about inaccurate or incorrect coding, or compelling clinical arguments. We believe that as hospitals gain experience under the hospital outpatient PPS, and as they refine their coding of services, a number of the apparent anomalies within the groups that we are treating as exceptions to the “two times” will be resolved.
Below we list the APC groups that are exceptions to the “two times” requirement, and our reasons for the exception. We use the final APC number to identify the group.
APC 0016: Level IV Debridement and Destruction
We are retaining CPT code 56501 in final APC group 0016, even though its median cost exceeds the “two times limit.” We believe the higher costs that are reflected in the data are the result of incorrect coding. The descriptor for CPT code 56501 defines the procedure as the simple destruction of skin and superficial subcutaneous tissues. In the judgment of our medical advisors, costs associated with simple destruction of skin and superficial subcutaneous tissues are typically within the range of costs associated with the other procedures in final APC group 0016, and the median cost that our data attribute to CPT code 56501 is higher than the code description warrants.
APC 0030: Breast Reconstruction/Mastectomy
Although the range of costs for procedures in final APC group 0030 exceeds the “two times limit,” we believe that only the simplest breast procedures will be done in the outpatient setting. Most of the procedures with median costs over $1000 used observation services in order to provide an overnight stay. We expect these cases to revert to the more appropriate inpatient setting.
APC 0058: Level I Strapping/Casting
The codes in final APC group 0058 are the simpler casting, splinting, and strapping procedures. Costs associated with the more resource-intensive procedures in final APC group 0059 are fairly uniform, but the median costs of procedures in final APC group 0058 vary widely. We are excepting final APC group 0058 from the “two times limit” until we can review the data for the first year of the outpatient PPS.
APC 0060: Manipulation Therapy
Taken collectively, the codes in final APC group 0060 are low in volume and erratically priced. For example, although the number of areas treated increases within the range of CPT codes 98925 through 98929, suggesting progressively increasing resource utilization, our data show median costs associated with the codes in the range 98925-98929 as $38, $11, $16, $17, and $19, respectively. Although costs associated with treating 9 to 10 body regions might not be 5 to 10 times greater than treating one or two regions, we would still expect costs for the more extensive procedures to be higher than those for the less extensive procedures, and certainly not lower as suggested by our data. Nor do we expect a hospital to specialize in treating more or fewer body areas. Therefore, the median payment set for final APC 0060 should average out, providing adequate payment for any number of body areas treated.
APC 0079: Ventilation Initiation and Management
These codes all represent respiratory treatment and support within the outpatient setting. Their costs should be roughly the same, even though our data suggest otherwise. We are excepting final APC group 0079 from the “two times limit” at this time, pending the collection of more conclusive cost data.
APC 0080: Diagnostic Cardiac Catheterization
The data for CPT code 93524 reflect costs that are lower than we would expect. We can find no apparent explanation for the wide variation in costs among the cardiac catheterization codes, although we suspect that the accuracy of the chargemaster system, when assigning charges in other than the surgical suite, may be problematic. We expect costs to even out once hospitals decide which cases may be handled on an outpatient basis without requiring an overnight stay.
APC 0081: Non-Coronary Angioplasty
We are excepting final APC group 0081 from the “two times limit” because of the low volume of cases for the codes in the group. For some of the codes in this group, the data reflect lower than expected median costs, which we attribute to low volume and to miscoding, which would account for the erratic sequences of costs found in our data.
APC 0093: Vascular Repair/Fistula Construction
We believe the median costs for CPT codes 36530 and 36810 are aberrant. These codes are very similar clinically to the other codes in APC 0093, and we would expect their costs to be similar. We believe low volume may account for the variability in cost. Start Printed Page 18475
APC 0094: Resuscitation and Cardioversion
We believe the median costs for CPT codes 92953 and 31500 are aberrant, perhaps due to misuse of the codes. Therefore, we are excepting this APC group from the “two times limit,” until we collect and analyze more accurate data once the hospital outpatient PPS is implemented.
APC 210: Spinal Tap
The two CPT codes that comprise this group are essentially the same procedure, one performed for diagnostic reasons and the other therapeutic. We suspect the disparity in median costs is attributable to the much higher volume of diagnostic spinal taps. Therefore, we are excepting this APC group from the “two times limit,” until we collect and analyze more accurate data once the hospital outpatient PPS is implemented.
APC 0233: Level II Anterior Segment Eye
We are excepting final APC group 233 from the “two times limit” because many of the codes in this APC are low volume and the coding seems erratic. For example, CPT designates a number of codes that are in final APC group 0233 as “relatively small” surgical procedures, which suggests that miscoding may have resulted in inflated cost data.
APC 0251: Level I ENT Procedures
A combination of low volume and unlisted codes obscures the fact that this APC represents the least intense ENT procedures. Because there are so many ENT codes, consistent agreement on what the codes represent may be difficult to achieve. Therefore, we are excepting this APC group from the “two times limit,” until we collect more accurate data under outpatient PPS.
APC 0264: Level II Miscellaneous Radiology Procedures
In the judgment of our medical advisors, the median costs for CPT codes 74740 and 76102 are aberrant. These procedures would be underpaid if they were paid separately and on the basis of what our data show to be their median cost. Therefore, we are excepting this APC group from the “two times limit,” until we collect more accurate cost data under outpatient PPS.
APC 0274: Myelography
In the judgment of our medical advisors, the median costs for CPT codes 70010 and 70015 are aberrant. These codes would be underpaid if they were moved to their own APC and paid on the basis of their median cost. All codes in this APC should cluster around the same cost. Therefore, we are excepting this APC group from the “two times limit,” until we collect more accurate cost data under outpatient PPS.
APC 0279: Level I Diagnostic Angiography
We believe the median costs for the codes at the low end of this APC may be inaccurate, because, clinically, these codes are homogeneous. Therefore, we are excepting this APC group from the “two times limit,” until we collect more accurate cost data under outpatient PPS.
APC 0302: Level III Radiation Therapy
We are retaining CPT code 77470 in final APC group 302, because the median cost seems low for the code description, possibly because this code may have been billed improperly in the past. We are also uncertain of the appropriate median cost of CPT code 61793, because we have been told that CPT code 61793 was used for both single-session gamma knife procedures and for each of multiple sessions of treatment with linear accelerators. Therefore, we have created two codes to be used in place of CPT code 61793, in order to collect more reliable data: G0173 (Stereotactic radiosurgery, complete course of therapy in one session), and G0174 (Stereotactic radiosurgery, requiring more than one session).
We will initially pay both codes at the same rate; however, we expect differences in cost would become apparent during the first year or 18 months of the outpatient PPS.
APC 0311: Radiation Physics Services
We are retaining CPT code 77370 in final APC group 0311, because we believe a special medical radiation physics consultation (outside the weekly management of a patient) is probably more costly than our data indicate.
APC 0341: Immunology Tests
We think the variation in costs among the procedures within final APC group 0341 may be the result of erratic coding. Because these services are so similar clinically, we would expect their individual costs to cluster around the median. Therefore, we are excepting this APC group from the “two times limit,” until we collect more accurate cost data under outpatient PPS.
APC 0371: Allergy Injections
We attribute the variation in median costs among the procedures within final APC group 0371 to erratic coding. Because these services are so similar clinically, we would expect their individual costs to cluster around the median. Therefore, we are excepting this APC group from the “two times limit,” until we collect more accurate cost data under outpatient PPS.
APC 0373: Neuropsychological Testing
With one exception, the codes in final APC group 0373 are billed per hour, so facility costs should all cluster around the median. Therefore, we are excepting this APC group from the “two times limit,” until we collect more accurate cost data under outpatient PPS.
7. Discounting of Surgical Procedures
To be consistent with Medicare policy and regulations governing payment for ambulatory surgical services furnished in a physician's office and in an ASC, we proposed under the hospital outpatient PPS to discount payment amounts when more than one procedure is performed during a single operative session or when a surgical procedure is terminated prior to completion. Specifically, we proposed that when more than one surgical procedure with payment status indicator “T” is performed during a single operative session, we would pay the full Medicare payment and the beneficiary would pay the coinsurance for the procedure having the highest payment rate. Fifty percent of the usual Medicare PPS payment amount and beneficiary coinsurance amount would be paid for all other procedures performed during the same operative session to reflect the savings associated with having to prepare the patient only once and the incremental costs associated with anesthesia, operating and recovery room use, and other services required for the second and subsequent procedures.
We also proposed to require hospitals to use modifiers on bills to indicate procedures that are terminated before completion. Modifier -73 (Discontinued Outpatient Procedure Prior to Anesthesia Administration) would identify a procedure that is terminated after the patient has been prepared for surgery, including sedation when provided, and taken to the room where the procedure is to be performed, but before anesthesia is induced (for example, local, regional block(s), or general anesthesia). Modifier-52 (Reduced Services) would be used to indicate a procedure that did not require anesthesia, but was terminated after the patient has been prepared for the procedure, including sedation when provided and taken to the room where the procedure is to be performed. We proposed to pay 50 percent of the usual Medicare PPS payment amount and Start Printed Page 18476beneficiary coinsurance amount for a procedure terminated before anesthesia is induced. Modifier-74 (Discontinued Procedure) would be used to indicate that a surgical procedure was started but discontinued after the induction of anesthesia (for example, local, regional block, or general anesthesia), or after the procedure was started (incision made, intubation begun, scope inserted) due to extenuating circumstances or circumstances that threatened the well-being of the patient. To recognize the costs incurred by the hospital to prepare the patient for surgery and the resources expended in the operating room and recovery room, the hospital will receive full payment for a procedure that was started but discontinued after the induction of anesthesia or after the procedure was started, as indicated by a modifier-74. The elective cancellation of procedures would not be reported. If multiple procedures were planned, only the procedure actually initiated would be billed.
Comment: Some commenters asked us to clarify how the policy would be applied. For example, one commenter asked whether the surgical discounting methodology would apply in the following situation: Contrast x-ray of lower spine (CPT code 72265) is followed by contrast CAT of the spine (CPT code 72132). Both procedures have related surgical codes (CPT codes 62270 and 62284). Other commenters provided examples that were similar in nature but involved other codes.
Response: We proposed to apply the reduced payment for multiple procedures to surgical procedures only, that is, those CPT codes that have a payment status indicator “T.” Therefore, services such as CPT codes 72265 and 72132 that have a payment status indicator of “S” would not be subject to the multiple procedure discount, whereas CPT codes 62270 and 62284, which are surgical procedures and have a payment status indicator of “T,” would be subject to the multiple procedure discount. Hypothetically, if all four codes were provided in a single operative session, as suggested by this commenter, then the reduced payment would apply only to the surgical procedure with the lower payment rate. (For the record, we have responded to the commenter's example in order to clarify how the multiple procedure discount would apply in a hypothetical situation. However, we question whether the suggested combination of codes would be covered if actually performed during the course of a single patient encounter.)
Comment: Commenters asked what factors guided our assignment of payment status indicator “T” to a code.
Response: We generally assigned the payment status indicator “T” to surgical services. Our medical advisors and staff will continue to review the designation of status indicators and we may propose revisions in the future.
Comment: A variety of commenters stated that the reduced payments for multiple procedures would inappropriately reduce payments for a second procedure. Some were concerned that application of the multiple procedure discount could result in hospitals being less likely to offer procedures assigned the payment status indicator “T.” These commenters recommended that we change all “T” payment indicators to a different indicator such as “S,” which we define as a significant procedure not reduced when multiple, until we have had an opportunity to collect reliable cost data upon which to base payment decisions about discounting.
Response: We continue to believe that the proposed reduced payment for multiple surgical procedures is reasonable. We disagree that hospitals would be less likely to provide these services. We believe there clearly are savings achieved when more than one surgical procedure is performed during a single operative session. The patient has to be prepared for surgery only once, and the costs associated with anesthesia, operating and recovery room use, and other services required for the second procedure are incremental.
Comment: Some commenters questioned whether the reduced payment for multiple procedures applied to the beneficiary coinsurance as well as to the Medicare program payment. Others did not understand how this reduced payment was accounted for in determining the conversion factor.
Response: The reduced payment for multiple procedures would apply to both the beneficiary coinsurance and the Medicare payment. In order to do this in a “budget neutral” manner, we increased the conversion factor to account for the reduced payments for multiple procedures. In this way, total payments in the aggregate are not affected.
Comment: One commenter believes we should exclude from the multiple-procedure discount those procedures that were subject to a 50 percent reduction under the previous cost-based system because those procedures were recognized as being an adjunct to a primary procedure. The commenter believes that we had already factored these discounts into our cost determinations and would therefore be inappropriately reducing payment even further for these procedures.
Response: We disagree with the commenter. In determining the weights for the APC groups, we included only single procedure claims. Multiple procedure reductions existing under the previous cost-based system would not have been reflected in these single procedure claims, and, therefore, do not affect the APC payment weights.
Final Action
Under the hospital outpatient PPS, we will discount payment amounts for surgical procedures when more than one procedure is performed during a single operative session or when a surgical procedure is terminated prior to completion. Parallel discounts will apply to beneficiary coinsurance amounts.
8. Payment for New Technology Services
a. Background
We proposed to price a new item or service that was assigned a new HCPCS code by classifying the new code to whichever existing APC group most closely resembled the item or service in terms of its clinical characteristics and estimated resource use. We proposed to use the group weight, payment rate, and coinsurance amount established for the existing APC to price the new code for at least 2 years to give us an opportunity to collect cost data for the new item or service.
After we published our proposed rule, the Congress expressed concern in the conference report accompanying the BBRA 1999, that our proposed PPS does not adequately address “issues pertaining to the treatment of * * * new technology.” (See H. R. Rep. No. 436 (Part I), 106th Cong., 1st Sess. 868 (1999).) Therefore, the Congress enacted “transitional pass-throughs” in section 201(b) of the BBRA 1999 that provide an additional payment for “new medical devices, drugs, and biologicals” that do not otherwise meet the definition of current orphan drugs, or current cancer therapy drugs and biologicals and brachytherapy, or current radiopharmaceutical drugs and biological products. (See section III.D of this preamble for a discussion of how we are implementing the transitional pass-throughs.)
b. Comments and Responses
Comment: The most frequent commenters regarding our treatment of new technology under the proposed Start Printed Page 18477hospital outpatient PPS were device manufacturers and pharmaceutical companies and their trade associations. Commenters were concerned because the proposed APC payment rates were developed using 1996 cost data that do not reflect the cost of many new technologies introduced subsequent to 1996. Commenters believe that the proposed method of ratesetting under the APC system lacks the flexibility needed to recognize emergent technologies in a timely manner. In the view of the commenters, assigning new technologies to existing APC groups pending the collection of cost data would result in underpayment, thereby discouraging the adoption of new technologies.
Commenters further stated that the proposed payment rates for current yet relatively new devices were too low and would favor continued use of older, less effective regimens on the basis of financial pressures rather than on the improved clinical outcomes of newer technology. Some commenters, concerned that we will not update codes or payment rates quickly enough to allow hospitals to pay for new technologies, recommended that we assign HCPCS codes as soon as products become available and alter APC group weights to account for a new technology. These commenters believe that the time lapse between coding updates is a barrier to innovation because it can take several years for a code to be issued for a new surgical technique, and until a new code is issued, facilities must bill for new surgical techniques as “unlisted procedures” resulting in the lowest payment rate for the category of surgery.
One commenter urged that we implement a payment carve-out for certain drug and biological therapies and pay for these items on a reasonable cost basis in order to provide timely patient access to many new pharmaceutical and biotechnology products. The same commenter recommended that if we reject a complete carve-out, then, at a minimum, we should pay for new products introduced after 1996 on a reasonable cost basis for 1 year to adequately compensate companies for developing new and more effective products. Another commenter recommended that we increase the number of APC groups to better reflect services with similar cost structures.
One professional association recommended abandoning the APC group system altogether and pricing services individually because assigning new technology and most costly procedures to APC groups with established lower cost procedures creates a strong disincentive for hospitals to provide new or improved items or services and, in the case of newer, higher cost drugs, encourages hospitals to develop formularies and practice patterns based on financial considerations rather than on the medical value of drugs.
Technologies that commenters cited as being inadequately addressed by the proposed outpatient PPS include new technologies based on molecular genetics; gamma knife procedures used in radiation surgery; and prostatic microwave thermotherapy (transurethral microwave thermotherapy (TUMT)) which a commenter said has a direct cost of $1,918 and, factoring in indirect costs, a total cost of $2,623.
Response: The concerns expressed by commenters regarding new technology items and services highlight two issues. The first is specific to the data used to construct APC groups and calculate their prices at the start of the PPS. As required by section 1833(t)(2)(C) of the Act, we are using claims data from 1996 as the basis for determining APC group weights and payment rates under the new system. The 1996 data do not capture items and services that have emerged since that time and that are now in use. The second issue relates to new items and services that will be introduced in the future, after the outpatient PPS is implemented. Postponing the adjustment of APC groups and weights for several years to allow for the collection of cost data would potentially inhibit the dissemination of medically desirable innovations.
We recognize the concerns raised by commenters about our proposed treatment of new codes under the hospital outpatient PPS. We therefore have developed a process that we believe will allow us to recognize new technologies on an ongoing basis as expeditiously as our systems permit. We expect that this process, which we explain below, combined with the transitional pass-throughs established by section 201(b) of the BBRA 1999 (which we describe in section III.D of this preamble), will provide additional payment for a significant share of new technologies.
In this final rule, we have created special APC groups to accommodate payment for new technology services. In contrast to the other APC groups, the new technology APC groups do not take into account clinical aspects of the services they are to contain, but only their costs. We will assign new items and services that we determine cannot appropriately be placed in existing APC groups for established procedures and services to the new technology APC groups.
The new technology APC groups, which are now largely unpopulated, are already defined in our claims processing system for the outpatient PPS, and we have established payment rates for the APC groups based on the midpoint of ranges of possible costs, for example, the payment amount for a new technology APC group reflecting a range of costs from $300 to $500 would be set at $400. The cost range for the groups reflects current cost distributions, and we reserve the right to modify the ranges as we gain experience under the outpatient PPS. The final APC groups for new technology are groups 0970 through 0984 and cover a range of costs from less than $50 to $6,000. Upon implementation of the outpatient PPS, we will make payment for the following new technology services under the new technology APCs:
53850 Transurethral destruction of prostate tissue; by microwave thermotherapy
53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy
96570 Photodynamic therapy, first 30 minutes
96751 Photodynamic therapy, each additional 15 minutes
G0125 PET lung imaging of solitary pulmonary nodules, using 2-(Fluorine-18)-Fluoro-2-Deoxy-D-Glucose (FDG), following CT (71250/71260 or 71270)
G0126 PET lung imaging of solitary pulmonary nodules, using 2-(Fluorine-18)-Fluoro-2-Deoxy-D-Glucose (FDG), following CT (71250/71260 or 71270); initial staging of pathologically diagnosed non-small cell lung cancer
G0163 Positron emission tomography (PET), whole body, for recurrence of colorectal metastatic cancer
G0164 Positron emission tomography (PET), whole body, for staging and characterization of lymphoma
G0165 Positron emission tomography (PET), whole body, for recurrence of melanoma or melanoma metastatic cancer
G0166 External counterpulsation, per treatment session
G0168 Wound closure by adhesive
The new technology APC groups give us a mechanism for initiating payment at an appropriate level within a relatively short timeframe, and certainly less than the 2 or 3 years that we contemplated in our proposed rule. As in the case of items qualifying for the transitional pass-through payment, placement in a new technology APC will be temporary. After we gain information about actual hospital costs incurred to furnish a new technology service, we will move it to a clinically-related APC group with comparable resource costs. If we cannot move the new technology service to an existing Start Printed Page 18478APC because it is dissimilar clinically and with respect to resource costs from all other APCs, we will create a separate APC for such service. We will retain a service within a new technology APC group for at least 2 years, but no more than 3 years, consistent with the time duration allowed for the transitional pass-through payments. Movement from a new technology APC to a clinically-related APC would occur as part of the annual update of APC groups. Beneficiary coinsurance amounts for items and services in the new technology APC groups are 20 percent of the payment rate set for the new technology APCs.
We ask that interested parties take the following steps to bring to our attention services that they believe merit consideration for pricing using the new technology APC groups. Mail requests for consideration of possible new technology services that have established HCPCS codes to the following address ONLY: PPS New Tech/Pass-Throughs, Division of Practitioner and Ambulatory Care, Mailstop C4-03-06, Health Care Financing Administration, 7500 Security Boulevard, Baltimore, MD 21244-1850.
To be considered, requests MUST include the following information:
- Trade/brand name of item.
- A detailed description of the clinical application of the item, including HCPCS code(s) to identify the procedure(s) with which the item is used.
- Current cost of the item to hospitals (i.e., actual cost paid by hospitals net of all discounts, rebates, and incentives in cash or in-kind). In other words, submit the best and latest information available that provides evidence of the hospital's actual cost for a specific item.
- If the item is a service, itemize the costs required to perform the procedure, e.g., labor, equipment, supplies, overhead, etc.
- If the item requires FDA approval/clearance, submit information that confirms receipt of FDA approval/clearance and the date obtained.
- If the item already has an assigned HCPCS code, include the code and its descriptor in your submission plus a dated copy of the HCPCS code “recommendation application” previously submitted for this item.
- If the item does not have an assigned HCPCS code, follow the procedure discussed, below, for obtaining HCPCS codes and submit a copy of the application with our payment request.
- Name, address, and telephone number of the party making the request.
- Other information as HCFA may require to evaluate specific requests.
We believe some items not yet known to us do not yet have assigned HCPCS codes. We expect to use national HCPCS codes in the hospital outpatient PPS to the greatest extent possible. These codes are established by a well-ordered process that operates on an annual cycle, starting with submission of information by interested parties due by April 1 and leading to announcement of new codes in October of each year. This process is described, and relevant application forms are available, on the following HCFA website: http://www.hcfa.gov/medicare/hcpcs.htm.
Considering the exigencies of implementing a new system, we intend to establish temporary codes in 2000 to permit implementation of additional payments for other eligible items effective beginning October 1, 2000. The process for submitting information will be the same as for national codes.
For new technology services that DO NOT have established HCPCS codes, submit the regular application for a national HCPCS code in accordance with the instructions found on the internet at http://www.hcfa.gov/medicare/hcpcs.htm. Send applications for national HCPCS codes to: C. Kaye Riley, HCPCS Coordinator, Health Care Financing Administration, Mailstop C5-08-27, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. A fuller discussion of the HCPCS process and schedule is in section III.D.6 of this preamble.
Because of staffing and resource limitations, we cannot accept requests by facsimile (FAX) transmission. Because of claims processing systems constraints, a new technology payment rate can only be initiated at the start of a calendar quarter. Since we will update our outpatient PPS quarterly to include new technology additional services, October 1, 2000 is the earliest date that we will implement payment for additional new technology services other than for those items beginning on July 1, 2000. In general, we expect to be able to complete action on requests to assign an item or service to a new technology APC group in about 6 months from the date we receive the request.
In order to be considered for assignment to a new technology APC group, an item or service must meet the following criteria:
- The item or service is one that could not have been billed to the Medicare program in 1996 or, if it was available in 1996, the costs of the item or service could not have been adequately represented in 1996 data.
- The item or service does not qualify for an additional payment under the transitional pass-through provided for by section 1833(t)(6) of the Act, as amended by section 201(b) of the BBRA 1999, and 42 CFR 419.43(e) as a current orphan drug, as a current cancer therapy drug or biological or brachytherapy, as a current radiopharmaceutical drug or biological product, or as a new medical device, drug, or biological.
- The item or service has a HCPCS code. (See section III.D for additional information about obtaining HCPCS codes.)
- The item or service falls within the scope of Medicare benefits under section 1832(a) of the Act.
- The item or service has been determined to be reasonable and necessary in accordance with section 1862(a)(1)(A) of the Act.
Final Action
We are initiating a method to pay for new technology services that are not addressed by the transitional pass-through provisions of the BBRA 1999.
D. Transitional Pass-Through for Innovative Medical Devices, Drugs, and Biologicals
1. Statutory Basis
Section 201(b) of the BBRA 1999 amended section 1833(t) of the Act by adding a new section 1833(t)(6). This provision requires the Secretary to make additional payments to hospitals for a period of 2 to 3 years for specific items. The items designated by the law are the following: current orphan drugs, as designated under section 526 of the Federal Food, Drug, and Cosmetic Act; current drugs, biologic agents, and brachytherapy devices used for treatment of cancer; current radiopharmaceutical drugs and biological products; and new medical devices, drugs, and biologic agents, in instances where the item was not being paid for as a hospital outpatient service as of December 31, 1996, and where the cost of the item is “not insignificant” in relation to the hospital outpatient PPS payment amount. In this context, “current” refers to those items for which hospital outpatient payment is being made on the first date the new PPS is implemented.
Section 1833(t)(6)(C)(i) of the Act sets the additional payment amounts for the drugs and biologicals as the amount by which the amount determined under section 1842(o) of the Act (95 percent of the average wholesale price (AWP)) exceeds the portion of the otherwise applicable hospital outpatient department fee schedule amount that Start Printed Page 18479the Secretary determines to be associated with the drug or biological. Section 1833(t)(6)(C)(ii) provides that the additional payment for medical devices be the amount by which the hospital's charges for the device, adjusted to cost, exceed the portion of the otherwise applicable hospital outpatient department fee schedule amount determined by the Secretary to be associated with the device. Under section 1833(t)(6)(D), the total amount of pass-through payments for a given year cannot be projected to exceed an “applicable percentage” of total payments. For a year (or a portion of a year) before 2004, the applicable percentage is 2.5 percent; for 2004 and subsequent years, the applicable percentage is 2.0 percent. If the Secretary estimates that total pass-through payments would exceed the caps, the statute requires the Secretary to reduce the additional payments uniformly to ensure the ceiling is not exceeded.
Section 201(c) of the BBRA amended section 1833(t)(2)(E) of the Act to require that these pass-through payments be made in a budget neutral manner. In accordance with section 1833(t)(7) of the Act, as amended by section 201(i) of the BBRA 1999, these additional payments do not affect the computation of the beneficiary coinsurance amount.
Implementation of this pass-through provision requires us to—
- Identify eligible pass-through items;
- Designate a Billing Code for each;
- Determine the term “not insignificant” in the context of determining whether an additional payment is appropriate;
- Determine an appropriate cost-to-charge ratio to use to adjust the hospital's charges for a new medical device to cost;
- Determine the portion of the applicable APC that would be associated with the drug, biological or device; and
- Determine the additional payment amount.
As with other provisions of this final rule that reflect implementation of the BBRA 1999, we are soliciting comments on our implementation of the transitional pass-through payments, as set forth below.
2. Identifying Eligible Pass-Through Items
a. Drugs and Biologicals
Section 1833(t)(6)(A) of the Act establishes definitions and examples of the drugs and biologicals that are candidates for pass-through payments. As indicated above, these drugs and biologicals are characterized as both current and new. Current refers to those drugs and biologicals for which payment is made on the first date the hospital outpatient PPS is implemented, that is, on July 1, 2000. They include the following:
1. Orphan drugs. These are drugs or biologicals that have been designated as an orphan drug under section 526 of the Federal Food, Drug and Cosmetic Act.
2. Cancer therapy drugs, biologicals, and brachytherapy. These items are those drugs or biologicals that are used in cancer therapy, including (but not limited to) chemotherapeutic agents, antiemetics, hematopoietic growth factors, colony stimulating factors, biological response modifiers, bisphosphonates, and a device of brachytherapy.
3. Radiopharmaceutical drugs and biological products. These are radiopharmaceutical drug or biological products used in nuclear medicine for diagnostic, monitoring, or therapeutic purposes.
A new drug or biological is defined as a product that was not paid as a hospital outpatient service prior to January 1, 1997 and for which the cost is not insignificant in relation to the payment for the APC to which it is assigned. These items are not reflected in the 1996 claims data we are required to use in developing the outpatient PPS. Before payment can be made for these new drugs and biologicals, a determination must be made that these items are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member as required by section 1862(a)(1)(A) of the Act. Drugs that can be self-administered are not covered under Part B of Medicare (with specific exemptions for certain oral chemotherapeutic agents and antiemetics, blood-clotting factors, immunosuppressives, and erythropoietin for dialysis patients).
b. Medical Devices
Under section 201(b) of the BBRA 1999, for purposes of making pass-through payments, a new or innovative medical device is one for which payment as a hospital outpatient service was not being made as of December 31, 1996 and for which the cost of the device “is not insignificant” in relation to the hospital outpatient department fee schedule amount payable for the service involved. For the purpose of identifying “new medical devices” that may be eligible for pass-through payments, we are excluding equipment, instruments, apparatuses, implements or items that are generally used for diagnostic or therapeutic purposes, that are not implanted or incorporated into a body part, and that are used on more than one patient (that is, are reusable). This material is generally considered to be hospital overhead costs and the depreciation expenses associated with them are reflected in the APC payments. The unit of payment for the outpatient PPS is a service or procedure. Equipment or instrumentation is a method or means of delivering that service. We are not establishing separate APC payments for equipment, instruments, apparatuses, implements, or items because payment for these types of devices is packaged in the APC payment for the service or item with which they are used. However, as we discuss above in section III.C.8, we have created new technology APCs to accommodate new technology services that may be performed using equipment or instrumentation that is capitalized and depreciated and used on more than one patient. An example of a new technology service is CPT code 53850, Transurethral destruction of prostate tissue; by microwave thermotherapy. We have assigned this procedure to new technology APC 0980. (See section III.C.8 of this preamble for further discussion of payment for new technology under the hospital outpatient PPS.)
Section 201(e) of the BBRA 1999 amends section 1833(t)(1)(B) of the Act to include as “covered OPD services” implantable items described in paragraphs (3), (6), or (8) of section 1861(s) of the Act. Paragraph (3) refers to diagnostic tests including diagnostic x-rays, mammographies, laboratory tests, and other diagnostic tests. Paragraph (6) refers to implantable durable medical equipment (DME), and paragraph (8) refers to prosthetic devices that replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care). Implantables are not mentioned specifically in these paragraphs, but we consider a prosthetic device that replaces all or part of an internal body organ that is mentioned in section 1861(s)(8) to be an implantable. The BBRA 1999 Conference Report lists pacemakers, defibrillators, cardiac sensors, venous grafts, drug pumps, stents, neurostimulators, and orthopedic implants, as well as items that come in contact with human tissue during invasive procedures as examples of implantable items.
Implantable items covered under section 201(e) of the BBRA 1999 may be considered eligible for the transitional pass-through payments allowed under Start Printed Page 18480section 201(b) of the BBRA 1999 to the extent that these implantables meet the statutory requirements set forth in section 201(b) and the criteria established in this final rule for payment of these devices.
Although we are recognizing the implantable items identified in section 201(e) of the BBRA 1999 for possible pass-through payments, we are not applying the pass-through provision to any DME, orthotics, and prosthetic devices that are not covered under section 201(e) of the BBRA 1999. Rather, we will pay for these items under the DMEPOS fee schedule when the hospital is acting as a supplier.
3. Criteria To Define New or Innovative Medical Devices Eligible for Pass-Through Payments
In summary, we will make pass-through payment for new or innovative medical devices that meet the following criteria:
a. They were not recognized for payment as a hospital outpatient service prior to 1997.
b. They have been approved/cleared for use by the FDA.
c. They are determined to be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body part, as required by section 1862(a)(1)(A) of the Act. We recognize that some investigational devices are refinements of existing technologies or replications of existing technologies and may be considered reasonable and necessary. We will consider devices for coverage under the outpatient PPS if they have received an FDA investigational device exemption (IDE) and are classified by the FDA as Category B devices. (See §§ 405.203 to 405.215.) However, in accordance with § 405.209, payment for a nonexperimental investigational device “is based on, and may not exceed, the amount that would have been paid for a currently used device serving the same medical purpose that has been approved or cleared for marketing by the FDA.”
d. They are an integral and subordinate part of the procedure performed, are used for one patient only, are surgically implanted or inserted, and remain with that patient after the patient is released from the hospital outpatient department.
e. The associated cost is not insignificant in relation to the APC payment for the service in which the innovative medical equipment is packaged. (See section III.D.4 below for the definition of “not insignificant.”)
f. They are not equipment, instruments, apparatuses, implements, or such items for which depreciation and financing expenses are recovered as depreciable assets as defined in Chapter 1 of the Medicare Provider Reimbursement Manual (HCFA Pub. 15-1). (As indicated above, these costs are considered overhead expenses that have been factored into the APC payment.)
g. They are not materials and supplies such as sutures, clips, or customized surgical kits furnished incident to a service or procedure.
h. They are not materials such as biologicals or synthetics that may be used to replace human skin.
Comment: Some commenters asked how we would pay for new technology intraocular lenses (IOLs) under the hospital outpatient PPS.
Response: We will use the same criteria established in the June 16, 1999 final rule (64 FR 32198) titled “Medicare Program; Adjustment in Payment Amounts for New Technology Intraocular Lenses Furnished by Ambulatory Surgical Centers” to identify IOLs that may be considered new technology and eligible for pass-through payments. In accordance with that rule, IOLs must first be approved by the FDA before they can be considered as a new technology IOL. The rule establishes only one criterion for distinguishing new technology IOLs from other IOLs. Specifically, all claims of the IOL's clinical advantages and superiority over existing IOLs must have been approved by the FDA for labeling and advertising purposes. For further discussion on the reasons for relying on the FDA's determination, we refer the reader to the IOL proposed rule published on September 4, 1997 (62 FR 46700 through 46701). We recognize that this criterion has been developed to define the characteristics that distinguish a new technology IOL from other IOLs in order to comply with section 141(b) of the Social Security Act Amendments of 1994 (Pub. L. 103-432) that is specific to IOLs furnished in ASCs and not hospital outpatient departments. However, we believe that it is appropriate to rely on an established approach to assist us in distinguishing this new technology since more than 1 million IOLs are inserted annually during or subsequent to cataract surgery performed in the outpatient setting. Moreover, we believe that consistent application of the criterion in both the ASC and hospital outpatient prospective payment systems is less burdensome to those requesting recognition of new technology IOLs. Therefore, when IOLs that are recognized as “new technology IOLs” in accordance with the provisions of the June 16, 1999 final rule are furnished in a hospital outpatient setting, we will pay for such new technology IOLs in accordance with the hospital outpatient PPS method for determining additional payments under the pass-through provision set forth in this final rule.
Comment: We received many comments urging that we establish appropriate payments for brachytherapy seeds used in the treatment of prostate cancer.
Response: In accordance with section 1833(t)(6)(A)(ii), as added by section 201(b) of the BBRA 1999, we will provide additional payments for brachytherapy seeds as an implanted device. The brachytherapy device is assigned to APC 0918.
4. Determination of “Not Insignificant” Cost of New Items
Section 1833(t)(6)(A)(iv)(II) of the Act, as added by section 201(b) of the BBRA 1999 provides that the transitional pass-throughs apply to new drugs, biologicals, and devices whose cost is not insignificant in relation to the hospital outpatient PPS payment amount. Section 1833(t)(6)(C) defines the additional payment as the difference between an amount specified by the law and the portion of the applicable fee schedule amount determined to be associated with the item. The objective of this section is to prevent the hospital outpatient PPS from creating disincentives for the diffusion of valuable new technology by initially paying a rate significantly below the costs of these items. We believe that the “not insignificant” criterion was included in recognition that: (1) The costs of some new technologies would not be large enough relative to the fee schedule amount to provide disincentives for their use in the short run; and (2) that an excessive number of pass-through items could place a substantial burden on the claims processing systems of both HCFA and individual hospitals in a way that could hamper the rapid processing of pass-through payments for those items that would be significantly more costly than the applicable fee schedule amount. Therefore, in order to be consistent with the objectives of this section, we are establishing the following criteria for determining whether the costs of drugs, biologicals, and devices are “not insignificant” relative to the hospital outpatient department fee schedule amount:
(1) Its expected reasonable cost exceeds 25 percent of the applicable fee schedule amount for the associated service. Start Printed Page 18481
(2) The expected reasonable cost of the new drug, biological, or device must exceed the portion of the fee schedule amount determined to be associated with the drug, biological, or device by 25 percent.
(3) The difference between the expected, reasonable cost of the item and the portion of the hospital outpatient department fee schedule amount determined to be associated with the item exceed 10 percent of the applicable hospital outpatient department fee schedule amount.
The following illustrates the application of these three criteria.
Example: Let us assume that the reasonable cost of the new device ZZ is $32.00. ZZ is associated with HCPCS code 00000 assigned to APC 0001. The fee schedule amount for APC 0001 is $100.00. The portion of the fee schedule amount included in APC 0001 that represents the cost associated with the former device is $25.00.
1. (a) Multiply the fee schedule amount for APC 0001 by 25 percent
$100.00 × .25 = $25.00
(b) Compare the reasonable cost for ZZ to the product derived in Step 1
$32.00 > $25.00
Finding: The first criterion is met.
2. (a) Multiply the portion of the fee schedule amount for APC 0001 that is associated with a device by 25 percent
$25.00 × .25 = $6.25
(b) Subtract the portion of the fee schedule amount for APC 0001 attributable to a device from the reasonable cost for ZZ
$32.00 − $25.00 = $7.00
(c) Compare the remainder in Step 4 to the product in Step 2(a)
$7.00 > $6.25
Finding: The second criterion is met.
3. (a) Multiply the fee schedule amount for APC 0001 by 10 percent
$100.00 × .10 = $10.00
(b) Compare the remainder in Step 3 to the product derived in Step 3(a)
$7.00 < $10.00
Finding: The third criterion is not met. Therefore, new device ZZ is not eligible for transitional pass-through payment.
5. Calculating the Additional Payment
Section 1833(t)(6)(C)(i) of the Act requires that for drugs, biologicals, and radiopharmaceuticals, the additional payment be determined as the difference between the amount determined under section 1842(o) of the Act (95 percent of AWP) and the portion of the hospital outpatient department fee schedule amount determined by the Secretary to be associated with those items. For devices, the additional payment is the difference between the hospital's charges adjusted to costs and the portion of the applicable hospital outpatient department fee schedule amount associated with the device. Under section 1833(t)(7) of the Act, as added by section 201(i) of the BBRA 1999, the coinsurance amounts for beneficiaries are not affected by pass-through payments.
We will determine, on an item-by-item basis, the amount of the applicable fee schedule amount associated with the relevant drug, biological, or device. To the extent possible, hospital outpatient department claims data will be used to make these estimates. When necessary, external data pertaining to the costs of the drugs, biologicals and devices already included in the fee schedule amounts will be used to make these determinations.
Before January 1, 2002, charges for devices eligible for pass-throughs will be adjusted to cost on each claim by applying the individual hospital's average cost-to-charge ratio across all outpatient departments. The 1996 data do not allow for determination of which revenue center-specific ratios might be used for this purpose. We will examine claims for the latter half of 2000 and for 2001 in order to determine if a revenue center-specific set of cost-to-charge ratios should be used for 2002 and beyond.
A one-time exception to the general methodology described above pertains to current drugs and biologicals that will be eligible for transitional pass-throughs when the PPS is implemented. For this final rule, we revised many APC groups by removing, to the extent possible, many of these drugs and radiopharmaceuticals. Therefore, the payment rates for the APC groups with which these drugs are associated exclude the costs of these drugs and the total amount paid to hospitals for the drugs will be 95 percent of the applicable AWP. In order to be able to determine a coinsurance amount for these drugs, we needed to estimate what portion of this payment would have been included as part of the APC payment amount associated with these drugs and what portion would be the pass-through amount. Using an external survey of hospitals' drug acquisition costs, we determined the APC payment amount for many of these drugs as their average acquisition cost adjusted to year 2000 dollars. Where valid cost data were not available for individual drugs, we applied the following average ratios of acquisition cost to AWP calculated from the survey to determine the fee schedule amount: .68 for drugs with one manufacturer, .61 for multi-source drugs, and .43 multi-source drugs with generic competitors. In either case, the coinsurance amounts were determined as 20 percent of these fee schedule amounts. It is important to note that these estimates do not affect the total payment to hospitals for these drugs (95 percent of AWP).
Because claims data are not available for most items that will be eligible for transitional pass-through payments for 2000 and 2001, it is extremely difficult to project expenditures under this provision. For this reason, and because many eligible items will be added after the system's implementation, we cannot estimate if, and to what extent, these payments would exceed 2.5 percent of total payments in 2000 and 2001. Therefore, there will be no uniform reduction factor applied to these payments during this period.
6. Process To Identify Items and To Obtain Codes for Items Subject to Transitional Pass-Throughs
We have identified a large number of items subject to the transitional pass-through payment through our own data-gathering activities or through comments on the proposed rule. Many of them already have HCPCS codes, and we are taking steps to establish temporary codes for the remaining items. We will make additional payments for these items when the hospital outpatient PPS system is implemented on July 1. A list of the items already known to us is set forth in Addendum K.
Other items potentially eligible for additional pass-through payments may not be known to us at this time. Because of systems limitations, if we do not know about an item, we will not be able to make additional payments for those items beginning on July 1, 2000. However, we will update our outpatient PPS on a quarterly basis beginning October 1, 2000 to add other items that are eligible for pass-through payments. Therefore, implementation of additional payment for any such item must wait until a later release of systems instructions, that is, in October 2000, January 2001 (annual update), or later.
A manufacturer or other interested party who wishes to bring items that may be eligible for additional transitional pass-through payments to our attention should mail requests for consideration of items to the following address ONLY: PPS New Tech/Pass-Throughs, Division of Practitioner and Ambulatory Care, Mailstop C4-03-06, Health Care Financing Administration, Start Printed Page 184827500 Security Boulevard, Baltimore, MD 21244-1850.
To be considered, requests MUST include the following information:
- Trade/brand name of item.
- A detailed description of the clinical application of the item, including HCPCS code(s) to identify the procedure(s) with which the item is used. If the item replaces or improves upon an existing item, identify the predecessor item by trade/brand name and HCPCS code.
- Current cost of the item to hospitals (i.e., actual cost paid by hospitals net of all discounts, rebates, and incentives in cash or in-kind). In other words, submit the best and latest information available that provides evidence of the hospital's actual cost for a specific item.
- Date of sale of first unit.
- For drugs, submit the most recent average wholesale price (AWP) of the drug and the date associated with the AWP quote.
- If the item requires FDA approval/clearance, submit information that confirms receipt of FDA approval/clearance and the date obtained.
- If the item already has an assigned HCPCS code, include the code and its descriptor in your submission plus a dated copy of the HCPCS code “recommendation application” previously submitted for this item.
- If the item does not have an assigned HCPCS code, follow the procedure discussed, below, for obtaining HCPCS codes and submit a copy of the application with your payment request.
- Name, address, and telephone number of the party making the request.
- Other information as HCFA may require to evaluate specific requests.
We believe some items not yet known to us do not yet have assigned HCPCS codes. We expect to use national HCPCS codes in the hospital outpatient PPS to the greatest extent possible. These codes are established by a well-ordered process that operates on an annual cycle, starting with submission of information by interested parties due by April 1 and leading to announcement of new codes in October of each year. This process is described, and relevant application forms are available, on the following HCFA website: http://www.hcfa.gov/medicare/hcpcs. htm.
Considering the exigencies of implementing a new system, we intend to establish temporary codes in 2000 to permit implementation of additional payments for other eligible items effective beginning October 1, 2000. The process for submitting information will be the same as for national codes.
For items that might be candidates for additional transitional pass-through payments but that DO NOT have established HCPCS codes, submit the regular application for a national HCPCS code in accordance with the instructions found on the internet at http://www.hcfa.gov/medicare/hcpcs.htm. Send applications for national HCPCS codes to: C. Kaye Riley, HCPCS Coordinator, Health Care Financing Administration, Mailstop C5-08-27, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Because of staffing and resource limitations, we cannot accept requests by facsimile (FAX) transmission.
As indicated in the instructions posted at our website address cited above, the deadline for submission of applications for a national HCPCS code for the CY 2001 cycle is April 1, 2000. The HCPCS process will proceed to assign national codes as warranted, and we expect these codes will be used in the hospital outpatient PPS starting January 1, 2001. Because the coding application will contain information vital to determining a specific item or product's eligibility for pass-through payments, we are requesting that a copy of the application be sent concurrently to ATTN: PPS New Tech/Pass-Throughs at the address shown above.
This year, we plan to implement additional payment for appropriate items on October 1, 2000. Requests submitted to us with appropriate information will be evaluated for payment effective October 1. We will use the same submissions made for national HCPCS codes as the basis for making temporary code assignments. However, a very large volume of requests or systems constraints could affect our ability to achieve this goal.
Any applications for HCPCS codes that are received after April 1 will be retained for the next cycle of the national HCPCS code assignment process starting the following April 1. We will also consider these items for assignment of temporary codes that might take effect in January or later in the next year.
How quickly additional payment for a new item can be implemented will depend on processing and systems constraints; it will in general require at least 6 months and may require as many as 9 or more months. Thus, a submission that we receive in May (which is too late for October implementation) might be assigned a temporary code to be used for implementing additional payments starting the following January.
As previously stated, pass-through payment for each item is temporary. After we obtain information about actual hospital costs incurred to furnish a pass-through item, we will package it into the service with which it is clinically associated.
Comment: A number of commenters expressed concern about the extensive amount of time required to obtain HCPCS codes for new items or services. They argued that the lag-time in coding updates creates a barrier to innovation, claiming that it can be several years before a code is issued for a new surgical technique or product. Some commenters noted that when facilities are forced to code new surgical techniques as “unlisted procedures,” pending issuance of a specific code for the procedure, it would result in the facility receiving payment for the lowest related APC group. Some commenters recommended that we assign HCPCS codes as soon as products become available.
Response: We recognize the urgency expressed by commenters. We believe the process we have outlined above will assist interested parties in obtaining HCPCS codes for new items and services in the most expeditious manner possible within the constraints imposed by our system requirements.
E. Calculation of Group Weights and Conversion Factor
1. Group Weights (Includes Table 1, Packaged Services by Revenue Center)
Section 1833(t)(2)(C) of the Act requires the Secretary to establish relative payment weights for covered hospital outpatient services. That section requires that the weights be developed using data on claims from 1996 and data from the most recent available hospital cost reports. Before enactment of the BBRA 1999, we were required to base the relative payment weights on median hospital costs. Section 201(f) of the BBRA 1999 amended section 1833(t)(2)(ii) of the Act to authorize the Secretary to base the relative payment weights on either the median or mean hospital costs. In constructing the database for the outpatient PPS proposed rule group weights and conversion factor, we used a universe of approximately 98 million calendar year 1996 final action claims for hospital outpatient department services received through June 1997 to match to the most recent hospital cost reports available. We have decided to continue to base the relative payments weights in this final rule on median (as opposed to mean) costs because, among other things, reconstructing our database to evaluate the impact of using mean costs after the BBRA 1999 was Start Printed Page 18483enacted would have delayed implementation of the hospital outpatient PPS.
To derive weights based on median hospital costs for services in the hospital outpatient APC groups, we converted billed charges to costs and aggregated them to the procedure or visit level. To accomplish this, we first identified the cost-to-charge ratio that was specific to each hospital's cost centers (“cost center specific cost-to-charge ratios” or CCRs). We then developed a crosswalk to match the hospital's CCRs to revenue centers used on the hospital's 1996 outpatient bills. The CCRs included operating and capital costs but excluded costs associated with direct graduate medical education and allied health education.
To determine the hospital CCRs, the most recent available cost report from each hospital was identified. For the proposed rule, we used cost reports from cost reporting periods beginning on or after October 1, 1994 and before October 1, 1995 (referred to as PPS-12) or earlier. For this final rule, more recent cost reports were available for hospitals. We used cost reports from cost reporting periods beginning on or after October 1, 1996 and before October 1, 1997 (PPS-14) for approximately 94 percent of the hospitals in our database.
If the most recent available cost report for a hospital was one that had been submitted but not settled, we calculated a factor to adjust for the differences that generally exist between settled and “as submitted” cost reports. The adjustment factor was determined by dividing the outpatient department cost-to-charge ratio from the hospital's most recent settled cost report by the outpatient department cost-to-charge ratio from the hospital's “as submitted” cost report for the same period. The resulting ratio was used to adjust each of the CCRs in the hospital's most recent “as submitted” cost report. We repeated this process for every hospital for which the most recent available cost report was a cost report that had not been settled.
The Office of Inspector General (OIG) for DHHS is concerned that the cost reports we are using may reflect some unallowable costs. Therefore, the OIG, in conjunction with HCFA, is proposing to examine the extent to which the cost reports used reflect costs that were inappropriately allowed. If this examination reveals excessive inappropriate costs, we will address this issue in a future proposed rule, or perhaps seek legislation to adjust future payment rates downward.
We next eliminated from the hospital CCR database 258 hospitals that we have identified as having reported charges on their cost reports that were not actual charges (for example, they make uniform charges for all services). These excluded hospitals were Kaiser, New York Health and Hospital Corporation, and all-inclusive rate hospitals. After removing these hospitals, we calculated the geometric mean of the total operating CCRs of hospitals remaining in our CCR database. We identified 58 hospitals whose total operating CCR exceeded the geometric mean by more than 3 standard deviations. These hospitals were also removed from our CCR database.
After assembling and editing our new CCR database, we matched revenue centers from approximately 80 million claims to CCRs of approximately 5,700 hospitals. We excluded from the crosswalk approximately 15 million claims in which the bill type denoted services that would not be covered under the PPS (for example, bill type 72X for dialysis services for patients with ESRD). We also excluded almost 3 million claims from the hospitals that we had removed or trimmed from the hospital CCR database. The table below shows the five cost reporting periods used and the percentage of the cost reports within each PPS period for which we were able to match 1996 claims.
Reporting period Percentage of cost reports matched PPS-15 (cost reporting period beginning on or after 10/1/97 and before 10/1/98) 0.1 PPS-14 (cost reporting period beginning on or after 10/1/96 and before 10/1/97) 94.2 PPS-13 (cost reporting period beginning on or after 10/1/95 and before 10/1/96) 3.7 PPS-12 (cost reporting period beginning on or after 10/1/94 and before 10/1/95) 1.7 PPS-11 (cost reporting period beginning on or after 10/1/93 and before 10/1/94) 0.3 Total 100.0 Next, we took the estimated 80 million claims that we had matched with a cost report and separated them into two distinct groups: Single-procedure claims and multiple-procedure claims. Single-procedure claims were those that included only one HCPCS code (other than laboratory and incidentals such as packaged drugs and venipuncture) that could be grouped to an APC. Multiple-procedure claims included more than one HCPCS code that could be mapped to an APC. There were approximately 45.4 million single-procedure claims and 34.6 million multiple-procedure claims.
To calculate median costs for services within an APC, we used only the single-procedure bills. (Of the roughly 45.4 million single-procedure claims, about 24 million were excluded from the conversion process largely because the only HCPCS codes reported on the claims were for laboratory procedures or other outpatient services not paid under the outpatient PPS.) This approach was taken because the information on claims does not enable us to specifically allocate charges or costs for packaged items and services such as anesthesia, recovery room, drugs, or supplies to a particular procedure when more than one significant procedure or medical visit was billed on a claim. Use of the single-procedure bills minimizes the risk of improperly assigning costs to the wrong procedure or visit. Although we used only single-procedure/visit bills to determine APC relative payment weights, we used multiple-procedure bills in the conversion factor and service mix calculations, regressions, and impact analyses.
For each single-procedure claim, we calculated a cost for every billed line item charge by multiplying each revenue center charge by the appropriate hospital-specific CCR. If the appropriate cost center did not exist for a given hospital, we crosswalked the revenue center to a secondary cost center when possible, or to the hospital's overall cost-to-charge ratio for outpatient department services. We excluded from this calculation all charges associated with HCPCS codes previously defined as not paid under this PPS (for example, laboratory, ambulance, and therapy services).
To calculate the per-procedure or per-visit costs, we used the charges shown in the revenue centers that contained items integral to performing the procedure or visit. These included those items that we previously discussed as being subject to our proposed packaging provision. For instance, in calculating the surgical procedure cost, we included charges for the operating room, treatment rooms, recovery, observation, medical and surgical supplies, pharmacy, anesthesia, casts and splints, and donor tissue, bone, and organ. For medical visit cost estimates, we included charges for items such as medical and surgical supplies, drugs, and observation. A complete listing of the revenue centers that we used is shown below in Table 1, Packaged Services by Revenue Center.Start Printed Page 18484
Table 1.—Packaged Services by Revenue Center
ASC AND OTHER SURGERY 250 PHARMACY 251 GENERIC 252 NONGENERIC 257 NONPRESCRIPTION DRUGS 258 IV SOLUTIONS 259 OTHER PHARMACY 260 IV THERAPY, GENERAL CLASS 262 IV THERAPY/PHARMACY SERVICES 263 IV THERAPY/DRUG/SUPPLY/DELIVERY 264 IV THERAPY/SUPPLIES 269 OTHER IV THERAPY 270 M&S SUPPLIES 271 NONSTERILE SUPPLIES 272 STERILE SUPPLIES 276 INTRAOCULAR LENS 279 OTHER M&S SUPPLIES 370 ANESTHESIA 379 OTHER ANESTHESIA 390 BLOOD STORAGE AND PROCESSING 399 OTHER BLOOD STORAGE AND PROCESSING 630 DRUGS REQUIRING SPECIFIC IDENTIFICATION, GENERAL CLASS 631 SINGLE SOURCE DRUG 632 MULTIPLE SOURCE DRUG 633 RESTRICTIVE PRESCRIPTION 700 CAST ROOM 709 OTHER CAST ROOM 710 RECOVERY ROOM 719 OTHER RECOVERY ROOM 720 LABOR ROOM 721 LABOR 723 CIRCUMCISION 762 OBSERVATION ROOM 810 ORGAN ACQUISITION 819 OTHER ORGAN ACQUISITION 890 OTHER DONOR BANK 891 BONE 892 ORGAN 893 SKIN 899 OTHER DONOR BANK MEDICAL VISIT 250 PHARMACY 251 GENERIC 252 NONGENERIC 257 NONPRESCRIPTION DRUGS 258 IV SOLUTIONS 259 OTHER PHARMACY 270 M&S SUPPLIES 271 NONSTERILE SUPPLIES 272 STERILE SUPPLIES 279 OTHER M&S SUPPLIES 630 DRUGS REQUIRING SPECIFIC IDENTIFICATION, GENERAL CLASS 631 SINGLE SOURCE DRUG 632 MULTIPLE SOURCE DRUG 633 RESTRICTIVE PRESCRIPTION 700 CAST ROOM 709 OTHER CAST ROOM 762 OBSERVATION ROOM OTHER DIAGNOSTIC (BLENDED SERVICES) 254 PHARMACY INCIDENT TO OTHER DIAGNOSTIC 372 ANESTHESIA INCIDENT TO OTHER DIAGNOSTIC 622 SUPPLIES INCIDENT TO OTHER DIAGNOSTIC 710 RECOVERY ROOM 719 OTHER RECOVERY ROOM 762 OBSERVATION ROOM RADIOLOGY SUBJECT TO THE FEE SCHEDULE AND OTHER RADIOLOGY 255 PHARMACY INCIDENT TO RADIOLOGY 371 ANESTHESIA INCIDENT TO RADIOLOGY 621 SUPPLIES INCIDENT TO RADIOLOGY 710 RECOVERY ROOM 719 OTHER RECOVERY ROOM 762 OBSERVATION ROOM ALL OTHER APC GROUPS 250 PHARMACY 251 GENERIC 252 NONGENERIC 257 NONPRESCRIPTION DRUGS 258 IV SOLUTIONS 259 OTHER PHARMACY 260 IV THERAPY, GENERAL CLASS 262 IV THERAPY PHARMACY SERVICES 263 IV THERAPY DRUG/SUPPLY/DELIVERY 264 IV THERAPY SUPPLIES 269 OTHER IV THERAPY 270 M&S SUPPLIES 271 NONSTERILE SUPPLIES 272 STERILE SUPPLIES 279 OTHER M&S SUPPLIES 630 DRUGS REQUIRING SPECIFIC IDENTIFICATION, GENERAL CLASS 631 SINGLE SOURCE DRUG 632 MULTIPLE SOURCE DRUG 633 RESTRICTIVE PRESCRIPTION 762 OBSERVATION ROOM We then applied to these cost estimates an adjustment to calibrate the costs to calendar year 1996 for those services in hospitals whose CCRs were calculated using FY 1997 or later cost reports. On average, hospital charges were rising faster than costs in FY 1997. We therefore made this adjustment for the calculation of the weights, as well as for the hospital costs used in the conversion factor and impact model, to ensure that we did not underestimate costs and payments. We based this hospital specific CCR adjustment on the observed change in each hospital's overall CCR (total operating + total capital) from the proposed rule cost report database to the new final rule database. If applicable, we then calculated a monthly rate of change and applied it based on the number of months past 1996 encompassed in a hospital's cost reporting period; if a hospital's period coincided completely within calendar year 1996, no adjustment was made.
After calibrating the costs to calendar year 1996, we standardized costs for geographic wage variation by dividing the labor-related portion of the operating and capital costs for each billed item by the FY 2000 hospital inpatient prospective payment system wage index published in the Federal Register on July 30, 1999 (64 FR 41585). As in the proposed rule and correction notice, we used 60 percent to represent our estimate of that portion of costs attributable, on average, to labor. A more detailed discussion of wage index adjustments is found below in section III.G of this document.
The standardized labor-related cost and the nonlabor-related cost component were summed for each billed item to derive the total standardized cost for each procedure or medical visit. Extremely unusual costs that appeared to be errors in the data were trimmed from standardized procedure and visit costs. This trimming methodology is analogous to that used in calculating the DRG weights for the inpatient PPS: eliminate any bills with costs outside of 3 standard deviations from the geometric mean. We used the geometric mean and the associated standard deviation because the distribution of costs more closely resembles a lognormal distribution than a normal distribution: There are no negative costs, and the average cost is greater than the median cost. Use of the geometric mean minimizes the impact of the most unusual bills in the determination of the mean. The geometric mean is calculated by taking the mean of the natural logarithm cost. Because the distribution of the natural logarithms of a set of numbers is more compact than the distribution of the numbers themselves, bills with extreme costs do not appear as extreme as they would if non-logged costs were examined. This ensures that only the most aberrant data will be removed from the calculation.
After trimming the procedure and visit level costs, we mapped each procedure or visit cost to its assigned APC and calculated the median cost for each APC weighted by procedure volume. Using the median APC costs, we calculated the relative payment weights for each APC. We scaled all the relative payment weights to APC 601, a mid-level clinic visit, because it is one of the most frequently performed services. This approach is consistent with that used in developing relative value units for the Medicare physician fee schedule. By assigning APC 601 a relative payment weight of 1.0, hospitals can easily compare the relative relationship of one APC to another. Next, we divided the median cost for each APC by the median cost for a mid-level clinic visit, APC 601, to derive the relative payment weight for each APC. Start Printed Page 18485The median cost for APC 601 is $47.00. In the proposed rule, we also used a mid-level clinic visit, APC 91336, which had a median cost of $54.00, as the scaler of APC weights. On average, due to the reduced value of the scaler used for this notice, the final weights will be higher than those published in the proposed rule.
Comment: Some commenters believe that the ratesetting methodology does not reflect complex cases because we eliminate statistical “outlier” claims from the calculation of the median costs and the weights.
Response: As noted above, we trimmed claims with estimated costs that were outside of three standard deviations from the geometric mean. Because we removed claims above or below the mean, we corrected for data errors that would have skewed the estimates of median costs and group weights upward or downward. We believe this trim is a valid method of removing extremely unusual costs that are most likely associated with data submission errors and do not represent actual costs. In addition, it is consistent with the method we use to set inpatient hospital diagnosis-related group (DRG) weights.
Comment: Numerous commenters disagreed with our use of single-procedure claims only in the calculation of the relative payment weights. One commenter was concerned that we could be masking differences in resource use attributable to patient characteristics by using only single-procedure claims to calculate relative weights.
Response: We used single-procedure claims to calculate the relative weight for each APC because we could not accurately allocate costs to a particular procedure when the costs were part of a bill for multiple procedures. Bills with a single major procedure provided are, in most cases, the best estimate of relative procedure costs. It is important to note that for all other calculations, including calculation of the conversion factor, we used both single-procedure and multiple-procedure bills.
We do not believe that using single-procedure bills biases the relative cost of any particular procedure. Although patients with more complex healthcare needs might have several procedures performed, hospital charges for an individual procedure would not be greater. Our most significant concern was that distribution of single bill procedures within an APC would not reflect the correct distribution of those procedure on all bills. However, careful statistical analyses demonstrated that the distribution of procedures within an APC group did not differ when single bill procedure frequencies were compared with all bills. It is also important to note that when items or services were to be packaged with a major procedure, we added their costs to that procedure prior to making the single bill determination. Therefore, the costs of contrast media, for example, are included in the relative weights. In some cases, we agreed with the commenters that this approach needed to be modified. For example, for chemotherapy, we are not grouping drugs, but rather paying for each one separately. Moreover, as a result of the transitional pass-through provisions of the BBRA 1999, radiopharmaceuticals will be paid separately from the nuclear medicine APCs.
Comment: Several commenters expressed concern that the 1996 claims data are insufficient or inadequate to develop the PPS model. For example, some commenters asserted that the 1996 data are not recent enough to reflect the current mix of outpatient services. Some commenters also argued that undercoding in the data would lead to underestimates of median costs. Other commenters recommended that we address alleged inadequacies in the data by gathering cost data on new procedures and by basing payment on these data until we can determine whether to place a new procedure in an existing APC or create a new APC.
Response: While we acknowledge limitations of setting payment rates with historical claims data, section 1833(t)(2)(C) of the Act requires us to use 1996 claims in developing the PPS. We discuss how we will price new procedures that are not reflected in our database in section III.C.8 of this preamble.
Comment: Commenters were concerned about the cost-to-charge ratios used to estimate median APC costs and pre-BBA payments. For example, one medical organization recommended that we account for the capital-intensive nature of radiology services by adjusting the cost-to-charge ratios applicable to these services for the step-down methodology that allocates capital expenses by square footage. The belief is that these allocation methods underestimate radiological equipment costs and certain cost-to-charge ratios, leading to underestimates of the median costs for relevant APC groups.
Response: Although capital-related costs may be allocated to routine and ancillary service cost centers using the step-down methodology based on square footage, as an alternative, the “dollar value” method may be used by hospitals. This method is made available to hospitals in Worksheet B-1 of the hospital cost report (HCFA 2552-96). The dollar value method more accurately distributes the capital costs associated with equipment to the revenue-producing cost center to which the equipment is assigned. We are not able to adjust the cost-to-charge ratios of those hospitals that allocate equipment based on square footage because we have no way of knowing which specific equipment costs should be allocated to revenue-producing cost centers in each hospital.
2. Conversion Factor
Section 1833(t)(3)(C)(i) of the Act requires that we establish a conversion factor for 1999 to determine the Medicare payment amounts for each covered group of services. For the proposed rule as corrected, we derived the conversion factor from a base amount of payments described in section 1833(t)(3)(A) of the Act, as enacted in the BBA 1997. Such base amount was calculated for the services included in the outpatient PPS as an estimate of the sum of (1) total payments that would be payable from the Trust Fund under the current (non-PPS) payment system in 1999, plus (2) the beneficiary coinsurance that would have been paid under the new (PPS) system in 1999. For the final rule, however, we derived the conversion factor from a base amount that includes beneficiary coinsurance that would have been made under the current (non-PPS) system rather than the proposed (PPS) system. Section 201(l) of the BBRA 1999 states: “With respect to determining the amount of copayments described in paragraph (3)(A)(ii) of section 1833(t) of the Social Security Act, as added by section 4523(a) of the BBA, Congress finds that such amount should be determined without regard to such section, in a budget neutral manner with respect to aggregate payments to hospitals, and that the Secretary of Health and Human Services has the authority to determine such amount without regard to such section.”
Section 1833(t)(2)(C) of the Act requires us to project utilization for hospital outpatient services. We were unable to make precise projections of increases in the volume and intensity of services because we were not able to quantify some of the factors that affect utilization. For instance, we would anticipate that Medicare beneficiaries who choose to migrate to managed care plans may be healthier than those who choose to stay in fee-for-service plans. Thus, we could assume a decrease in the volume of services coupled with an increase in the intensity of services Start Printed Page 18486furnished for Medicare beneficiaries in the fee-for-service program. Another factor that we believe will affect future utilization is the incentive to code billed services more accurately. Currently, hospitals are paid for the majority of the outpatient services they furnish on a cost basis, and inaccurate or improper coding does not necessarily affect the amount of payment. In contrast, under the PPS, hospitals are required to use HCPCS codes in order to receive payment. We expect that the frequency of some services may increase as a result of the coding requirements. We believe each of these assumptions will affect the reporting of volume and intensity of services, although we are not able to quantify them individually to project 1999 utilization. Therefore, we used what we believe to be a more reliable and valid approach to computing the conversion factor under the methodology described below.
Comment: A large national trade association commented that the exclusion of claims for unclassified services (for example, those claims for which we cannot identify the service to be paid) from the PPS model could bias the conversion factor downward if the excluded claims have a disproportionate number of services with high payment to cost ratios, such as clinic and emergency room visits.
Response: In order to set the conversion factor as accurately as possible, we used only claims for which the costs and volume of services could be identified on the bill. As noted by the commenter, this decision resulted in the exclusion of claims with unclassifiable services. Upon examination of these claims, we have determined that services with high payment to cost ratios (those that would gain under the PPS system) were not disproportionately represented. Therefore, we believe the exclusion of unclassifiable services does not bias the conversion factor.
Setting the Rates
In order to convert the relative weights determined for each APC (see section III.E.1) into payment rates, we calculated a conversion factor that would result in total estimated payments to hospitals under the PPS in 1999 equal to the total estimated payments that would have been payable from the Trust Fund in 1999 if PPS had not been enacted plus estimated beneficiary coinsurance for the same services during the same period. The prospective payment rate for each APC is calculated by multiplying the APC's relative weight by the conversion factor. For the calculation of the conversion factor, we have excluded all data from the 58 Maryland providers that qualify under section 1814(b)(3) of the Act for payment under the State's payment system. We computed the conversion factor by first adding together the aggregate Medicare hospital outpatient payments made under the cost-based payment system (referred to in this section as pre-PPS payments) for calendar year 1996, plus the estimated beneficiary coinsurance amounts made under pre-PPS law for the same services. We then divided that amount by a wage-adjusted sum of the relative weights for all APCs under the hospital outpatient PPS. The methodology we used to determine current law Medicare hospital outpatient payments and beneficiary coinsurance is discussed below in section III.E.2.a. A discussion of the sum of the relative weights follows in section III.E.2.b.
a. Calculating Aggregate Calendar Year 1996 Medicare and Beneficiary Payments for Hospital Outpatient Services (Pre-PPS)
To calculate Medicare hospital outpatient payment amounts before implementation of the PPS, we first identified calendar year 1996 single and multiple procedure bills for all the services that we will recognize under the outpatient PPS. As we identified services that will be paid under the outpatient PPS, we eliminated invalid or noncovered HCPCS codes.
Hospital payments include both operating and capital costs for the HCPCS coded services for which payment is to be made under the outpatient PPS. We summed these two types of costs by HCPCS code at the provider level. Consolidating the data in this manner allowed us to simulate provider payment on an aggregate basis. Then (as required by section 1861(v)(1)(S)(ii) of the Act as amended by section 201(k) of the BBRA 1999), we applied the capital cost reductions of 10 percent and operating cost reductions of 5.8 percent.
We determined for each HCPCS code the applicable payment methodology under the current system. Payment before implementation of PPS for procedures in the baseline was calculated using one of the following equations, as appropriate:
- For radiology procedures paid for under the radiology fee schedule, we determined payment in the aggregate for each provider as the lower of the cost, charge, or blended amount. We use the following equation to determine the radiology blended amount: (0.42 × lower of cost or charge minus beneficiary coinsurance) + (0.58 × ((0.62 × global physician fee schedule amount) − beneficiary coinsurance)).
- For surgical procedures for which Medicare pays an ASC facility fee, we determined payment in the aggregate for each provider as the lower of the cost, charge, or blended amount. We used the following equation to determine the ASC blended amount: (0.42 × lower of cost or charge minus beneficiary coinsurance) + (0.58 × (ASC payment rate − beneficiary coinsurance)).
- For diagnostic procedures paid for under the diagnostic fee schedule, we determined payment in the aggregate for each provider as the lower of the cost, charge, or blended amount. We used the following equation to determine the blended amount for diagnostic procedures: (0.50 × lower of cost or charge minus beneficiary coinsurance) + (0.50 × ((0.42 × global physician fee schedule amount) − beneficiary coinsurance)).
For all other covered services not subject to one of the blended payment method categories, we determined payment as the lower of costs or charges less beneficiary coinsurance. Because the formula-driven overpayment (FDO) was corrected beginning October 1, 1997, the blended equations eliminate FDO.
We then determined the Medicare payment amount for each provider by summing the aggregate amounts computed for each of the four types of payment methodologies discussed above. In addition, we determined the amount of the beneficiary coinsurance for each provider using the beneficiary coinsurance amounts that would have been paid before implementation of PPS. The total amount (Medicare and beneficiary payments) reflects the amount hospitals would be paid under the PPS and is the numerator in the equation for calculating the unadjusted conversion factor.
b. Sum of the Relative Weights
Next we summed the discounted relative weights for services that are within the scope of the outpatient PPS. (See discussion of discounting for surgical procedures in section III.C.7.) Specifically, we multiplied (using single and multiple procedure claims in a hospital) the discounted volume of procedures or visits in each APC group by the relative weights for each APC group; we wage-adjusted 60 percent of this total by each hospital's wage index, and we then summed the wage-adjusted and nonadjusted weights across all hospitals. (The wage indices used are included in Addenda H, I, and J.) The resulting sum equals the denominator in the calculation of the conversion factor. Start Printed Page 18487We calculated the conversion factor by dividing the sum of the discounted relative weights into the total payment explained in section III.E.2.a, above, including both Medicare payment and beneficiary coinsurance. We then adjusted the conversion factor so that the outlier and pass-through payments are implemented in a budget neutral manner, as described in sections III.H.1 and III.D. The adjusted calendar year 1996 conversion factor is $43.023. To inflate the 1996 conversion factor to 1999, our Office of the Actuary estimated an update factor of 1.106. Therefore, the adjusted 1999 conversion factor is $47.583.
For calendar year 2000, we updated the conversion factor as specified in section 1833(t)(3)(C)(iii) of the Act. The update is the market basket percentage increase applied to hospital discharges occurring during the fiscal year ending in calendar year 2000 minus 1 percentage point. For 2000, the updated conversion factor is $48.487.
Comment: A number of commenters suggested that we remove the behavioral offset that we proposed to apply to the conversion factor. As proposed, the intent of the offset was to adjust for hospital coding changes that take place in response to reductions in beneficiary coinsurance.
Response: We have decided not to include a behavioral offset to the conversion factor in this final rule. Hospital coding changes are expected to occur under the outpatient PPS; however, we believe changes that occur during the first PPS years will result from hospitals billing more accurately under the new system. A behavioral offset implemented in the initial PPS years may distort the incentives to bill accurately. We may reconsider implementation of a behavioral offset in future years as we gather data and gain experience under the new system.
Comment: A large national trade association expressed concern that application of the 5.8 percent and 10.0 percent reduction to costs for all hospital outpatient services included in the PPS model underestimates the conversion factor. They recommended that we exclude the Part B services provided to inpatients who exhaust their Part A benefits from the reductions.
Response: Our analysis shows that fewer than 5,000 of the more than 80 million claims used to set the conversion factor were associated with these types of services. Total costs associated with these claims were less than $1.4 million, which is too small to have a measurable effect on the conversion factor.
Comment: Many commenters strongly argued that we misinterpreted the provisions of section 1833(t)(3) of the Act in calculating beneficiary coinsurance for purposes of setting the base amount of the conversion factor. The commenters noted that this methodology contributed significantly to the estimated 5.7 percent reduction in Medicare outpatient payments to hospitals reflected in the proposed rule. Most commenters further argued that the Congress did not intend for this loss to occur and that we had the authority to interpret the methodology described in the statute so that no net change in payments would result from the conversion factor.
Response: Section 1833(t)(3)(A) of the Act, as added by the BBA 1997, states that, for purposes of calculating the base amount used to determine the conversion factor, the Secretary shall calculate “the total amount of copayments estimated to be paid under this subsection. * * *” (Emphasis added.) For the proposed rule, we estimated the coinsurance that would be paid under PPS. In section 201(l) of the BBRA 1999, the Congress addressed the calculation of the base amount, stating, “With respect to determining the amount of copayments described in paragraph (3)(A)(ii) of section 1833(t) of the Social Security Act, as added by section 4523(a) of the BBA, Congress finds that such amount should be determined without regard to such section, in a budget neutral manner with respect to aggregate payments to hospitals, and the Secretary of Health and Human Services has the authority to determine such amount without regard to such section.” Therefore, for this final rule, we estimated the coinsurance that would have been paid if PPS had not been enacted.
F. Calculation of Coinsurance Payments and Medicare Program Payments Under the PPS
1. Background
In section III.E, above, we explained how we determined APC group weights, calculated an outpatient PPS conversion factor, and determined national prospective payment rates, standardized for area wage variations, for the APC groups. We will now explain how we calculated beneficiary coinsurance amounts for each APC group.
The outpatient PPS established by section 1833(t) of the Act includes a mechanism designed to eventually achieve a beneficiary coinsurance level equal to 20 percent of the prospectively determined payment rate established for the service. As discussed in the proposed rule, for each APC we calculate an amount referred to in section 1833(t)(3)(B) of the Act as the “unadjusted copayment amount.” The unadjusted coinsurance amount is calculated by taking 20 percent of the national median charges billed in 1996 for the services that are in the APC, trended forward to 1999; however, the coinsurance amount cannot be less than 20 percent of the APC payment rate. The unadjusted coinsurance amount for an APC remains frozen, while the payment rate for the APC is increased by adjustments based on the Medicare market basket. As the APC rate increases and the coinsurance amount remains frozen, the unadjusted coinsurance amount will eventually become 20 percent of the payment rate for all APC groups. Once the unadjusted coinsurance amount is 20 percent of the payment amount, both the APC payment rate and the unadjusted coinsurance amount will be updated by the annual market basket adjustment.
In the proposed rule, we proposed to not adopt new APCs for new procedures or services for at least 2 years, but instead assign them to existing groups while accumulating data on their costs. In the final rule we do provide for APCs for new procedures that do not fit well into another APC. When an APC is added that consists of HCPCS codes for which we do not have 1996 charge data upon which to calculate the unadjusted coinsurance amount, coinsurance will be calculated as 20 percent of the APC payment amount.
There is an exception to the coinsurance provisions for screening colonoscopies and screening sigmoidoscopies. Section 4104 of the BBA 1997 provided coverage for colorectal screening. This section, in part, added new sections 1834(d)(2) and (3) to the Act, which provide that for covered screening sigmoidoscopies and colonoscopies performed in hospital outpatient departments and ambulatory surgical centers (ASCs), payment is to be based on the lesser of the hospital or the ASC payment rates and coinsurance for both screening colonoscopies and screening sigmoidoscopies is to be 25 percent of the rate used for payment.
Section 4104 of the BBA 1997 also allows, at the Secretary's discretion, coverage of screening barium enemas as a colorectal cancer screening tool. We are including screening barium enemas as a covered service under the hospital outpatient PPS. The payment rate for screening barium enemas is the same as for diagnostic barium enemas. Coinsurance for a screening barium enema is based on 20 percent of the APC payment rate. Start Printed Page 18488
Sections 201(a) and (b) of the BBRA 1999 amend section 1833(t) of the Act to provide for additional payments to hospitals for outlier cases and for certain medical devices, drugs, and biologicals. These additional payments to hospitals will not affect coinsurance amounts. Redesignated section 1833(t)(8)(D) of the Act, as amended by section 201(i) of the BBRA 1999, provides that the coinsurance amount is to be computed as if outlier adjustments, adjustments for certain medical devices, drugs, and biologicals, as well as any other adjustments we may establish under section 1833(t)(2)(E) of the Act, had not occurred. Section 202 of the BBRA 1999 adds a new section 1833(t)(7) to the Act to provide transitional corridor payments to certain hospitals through calendar year 2003 and indefinitely for certain cancer centers.
Section 1833(t)(7)(H) of the Act provides that the transitional corridor payment provisions will have no effect on determining copayment amounts.
Section 204(a) of the BBRA 1999 amended redesignated section 1833(t)(8)(C) of the Act to provide that the coinsurance amount for a hospital outpatient procedure cannot exceed the amount of the inpatient hospital deductible for that year. The inpatient hospital deductible for calendar year 2000 is $776.00. We will apply the limitation to the wage adjusted coinsurance amount (not the unadjusted coinsurance amount) after any Part B deductible amounts are taken into account. Therefore, although the published unadjusted coinsurance amount for any APC may be higher or lower than $776.00 in 2000, the actual coinsurance amount for an APC, determined after any deductible amounts and adjustments for variations in geographic areas are taken into account, will be limited to the Medicare inpatient hospital deductible. Any reductions in copayments that occur in applying the limitation will be paid to hospitals as additional program payments. (See section III.F.3.a, below, for discussion of calculating the Medicare payment amount.)
MedPAC Comment: In its March 1999 report to the Congress, MedPAC expressed concern that the statute's approach to addressing the reduction in coinsurance could mean that it will be decades before coinsurance is 20 percent of all APC payment rates. MedPAC recommended that the Secretary seek and the Congress legislate a more rapid phase-in and that the cost be financed by increases in program spending, rather than through additional reductions in payments to hospitals. MedPAC agrees that the approach to calculating the coinsurance delineated in section 1833(t) of the Act is methodologically sound, but they recommend a shorter period to complete the coinsurance reduction.
Response: The coinsurance reductions enacted by the BBA 1997 already provide significantly higher levels of financial protection for beneficiaries than have existed in the past. While an acceleration of this protection might be desirable, the costs of such a policy must be balanced against other needs for increased Medicare spending and protection of the trust funds. The President's budget for FY 2001 does not contain such a proposal.
Comment: Three commenters discussed the delay in implementing the outpatient PPS until after January 1, 2000. A hospital association stated that it strongly believes that the outpatient PPS should not be implemented until all systems are ready, and suggested that implementation occur at the start of a calendar year so that Medigap insurers did not receive an unearned windfall by reason of a midyear decrease in beneficiary coinsurance amounts. Stating that the delay in implementation was of serious concern to it, an insurance group strongly urged us to implement the outpatient PPS as soon as possible. Finally, a beneficiary advocacy group stated that it is deeply concerned about the delay in implementation. While stating that it understood the magnitude of the Y2K problem, this group urged us to find a way to proceed with the phase-down of beneficiary coinsurance or, failing that, to offer our assurance that the phase-down will not be delayed beyond January 1, 2000.
Response: As noted elsewhere in this final rule, we intend to implement the outpatient PPS effective for services furnished on or after July 1, 2000. As noted in the proposed rule, we concluded that attempting to make the massive computer changes required to implement PPS at the same time we were trying to ensure that Medicare's computers were Y2K compliant would have jeopardized the compliance effort, which was HCFA's highest priority. Now that HCFA's efforts to make its computer systems, and those of its contractors, Y2K compliant are complete, we believe that July 1, 2000 is the earliest date on which we can feasibly implement the PPS. Pursuant to HCFA's contracts with the contractors responsible for maintaining its computer systems, HCFA makes programming changes such as those required to implement the outpatient PPS at the beginning of fiscal quarters. Thus, pursuant to this practice, after January 1, 2000, there are only three dates in 2000 on which the programming changes necessary to implement outpatient PPS can be put into effect—April 1, 2000, July 1, 2000 and October 1, 2000.
The first step in changing HCFA's computer systems to allow for implementation of the outpatient PPS is to expand the claim record of several HCFA and contractor systems to accept and retain specific information related to how a service is being paid or why it is denied. The claim record expansion is an indispensable prerequisite to implementation of outpatient PPS. Once expansion of the claim form is completed, we can then make the remaining programming changes necessary to implement the outpatient PPS. As we noted in the proposed rule, 63 FR 47605, these are massive changes that will require extensive testing. We anticipate that these software coding changes cannot be completed before the end of the second quarter of 2000. Therefore, the earliest possible date on which they can be installed and made operational is July 1, 2000.
We do not believe that it is technically feasible to complete installation of both the claims-form line item expansion and the coding changes needed to implement PPS any sooner than July 1, 2000. Each of these two stages of preparing HCFA's computer system for PPS constitutes major systems changes in and of itself. To attempt to make both changes simultaneously would be to run the risk that the system would not function properly at all, potentially requiring implementation to be delayed beyond July 1, 2000. We believe that the two-stage approach discussed above is the only feasible way to make the systems changes necessary to implement PPS and to be certain that they will work. The soonest date on which PPS can be implemented after the millennium is therefore July 1, 2000.
Despite one commenter's request that we implement the outpatient PPS at the start of a calendar year, we do not believe it would be appropriate to delay implementation beyond July 1, 2000. We see no reason to delay implementation beyond the time necessary for HCFA to have completed its Y2K efforts and make all the systems changes necessary for PPS. As with all of the other aspects of PPS, we believe that the beneficiary coinsurance reform contained in the outpatient PPS should be put into effect as soon as possible, so that beneficiaries can be subject to the lower coinsurance amounts under the new payment methodology at the Start Printed Page 18489earliest date. We believe that this consideration outweighs any concern that Medigap insurers might receive a windfall because they set premiums for a given year assuming coinsurance amounts would be at one level only to see those amounts decrease in the middle of the year. In addition, we note that, if insurers received a large enough windfall for the reasons described by the commenter, the insurers might be required to refund premiums to beneficiaries or offer them a credit on premiums pursuant to section 1882(r) of the Act.
While none of the commenters specifically requested that we do so, we have considered the possibility of applying the outpatient PPS payment methodology retroactively to services furnished on or after January 1, 1999. We have decided not to make these retroactive payments for the reasons described below.
The first reason is the practical problem that the information needed to implement PPS retroactively does not exist in a usable form. Under current payment methodologies for many outpatient services, hospitals submit bills for furnished services based on their charges for the services. For these services, HCFA does not require hospitals to submit bills containing the HCPCS code for the furnished service and other data (such as the dates of service of multiple services submitted on the same bill) necessary to process bills under the new prospective payment methodology. Without the HCPCS code for a given service, we would be unable to determine retroactively into which APC group the service should be placed for payment under PPS. In turn, that would mean that we could not determine the appropriate payment amount for the service. Thus, given the information currently available to us, we could not now simply reprocess bills for outpatient services that had been furnished between January 1, 1999 and July 1, 2000 and recompute payment and coinsurance amounts for these services. As a result, the data needed to implement PPS retroactively do not exist in a form that would allow for such implementation.
Nor would it have been feasible to attempt to capture the information necessary for retroactive application during 1999. As noted above, we concluded that it would not have been prudent to make the computer programming changes necessary to implement PPS until our Y2K efforts were complete. Those same changes would have been necessary to allow us to capture the more detailed claims data needed to perform a retroactive application of PPS back to January 1, 1999 once the system was implemented prospectively. Because we delayed those changes out of concern that they would interfere with our Y2K efforts, no automated process existed for the period January 1, 1999 through July 1, 2000 by which we could have captured the more detailed claims data necessary to effect an eventual retroactive implementation of PPS. Publication of a final rule before January 1, 1999 would not have altered this situation. Even if we had published such a rule, it could not have become effective until we could make the computer changes necessary to implement PPS—the functional equivalent of what we have done through publication of the proposed rule and this final rule—and until we could make those changes, we could not compile by computer the data needed to later reprocess claims under PPS.
In theory, we might have been able to implement PPS retroactively despite the lack of an automated method of compiling the data necessary to do so. But it simply would not have been practicable to maintain and later process by hand such data for the period between January 1, 1999 and July 1, 2000, given the millions of claims for outpatient services submitted during that period. (Based on the latest data available, we process approximately 160 million claims for outpatient services over an 18-month period.) Neither HCFA nor its contractors have the staff needed to accomplish such a task.
We might also have conceivably required hospitals to maintain the data required for a later retroactive implementation of PPS, but this approach has practical difficulties. First, during the interim period between January 1, 1999 and implementation of PPS, hospitals themselves were exerting significant efforts to ensure the Y2K compliance of their own automated Medicare billing systems, and it is doubtful that those systems could have accommodated the necessary programming changes any more than Medicare's systems could have. Even if hospitals could have maintained the information (or if HCFA could have maintained it by hand or could obtain it from any source now), the burden associated with attempting to implement the new prospective payment methodology both retroactively and prospectively at the same time would have been prohibitive. As noted in the proposed rule and in this final rule, effecting the transition between the old payment methodologies and the new prospective payment methodology constitutes a massive programmatic undertaking. Any effort to reprocess the huge number of bills for outpatient services that would be involved in any attempt to retroactively implement PPS would compete for the same resources needed to implement PPS prospectively, and would compromise our ability to ensure the smoothest prospective implementation.
This is especially so if paper records of claims from the interim period would have to be manually input into Medicare's automated payment systems in order to make retroactive payments for services furnished on or after January 1, 1999. Undertaking an effort, once PPS is implemented, to review hospital records of every outpatient service furnished between January 1, 1999 and July 1, 2000; translate those records into the data needed to process a Medicare claim for the service under PPS; and issue a retroactive payment reflecting the PPS rate for the service would cause a huge backlog of current bills to be processed (and of other carrier tasks), and thus would not be practicable. Therefore, there was no feasible way to have captured the information necessary to make PPS apply retroactively.
In addition to the practical problems described above, the statute does not require retroactive application of PPS. The statutory requirement to implement the PPS for services furnished on or after January 1, 1999 is ambiguous. While section 1833(t)(1)(A)'s reference to outpatient services “furnished during a year beginning with 1999” might be read as imposing such a requirement, it is also true that section 1833(t)(1)(B)(i) does not expressly set a time limit for HCFA to designate which services are “covered” outpatient services for purposes of payment under PPS. Nor does it set a deadline for HCFA to issue regulations implementing the outpatient PPS. As a result, the statute can also be read to require implementation of PPS for services furnished in a year beginning in 1999 if HCFA has designated in its implementing regulations those services as covered services for purposes of PPS. The better reading is that the system applies prospectively only.
We recognize that, under section 1833(a)(2)(B), Congress arguably made the old payment methodologies for outpatient services inapplicable to services furnished on or after January 1, 1999. Again, though, Congress imposed no corresponding limit on the time within which HCFA must designate the services that would be “covered” services for purposes of PPS. While it is therefore possible to read the statute in such a way that an outpatient service Start Printed Page 18490furnished after January 1, 1999 but not yet designated as a covered outpatient service by HCFA for purposes of PPS would have no payment methodology applicable to it, we do not believe that Congress intended such a result. We believe that where HCFA, because of significant Y2K concerns, has not yet designated a given outpatient service as a covered service for purposes of PPS, the most appropriate reading of section 1833(t)(1)(A) is that it authorizes the Secretary to continue to pay for the service under the existing methodology until PPS can be implemented. If the Congress had known about the Y2K problem at the time it enacted the PPS statute, this is the only rational approach it could have adopted.
We believe that a clear expression of Congressional intent not to require retroactive application of PPS can be found in the legislative history of amendments to section 1833(t) of the Act, enacted as sections 201, 202, and 204 of the BBRA 1999. In each instance, the legislation provides that the “amendments made by this section shall be effective as if included in the enactment of the BBA,” that is, the original enactment of PPS in section 1833(t) (sections 201(m), 202(b), and 204(c) of the BBRA 1999). This language was taken from the House version of the bill (H.R. Rep. No. 436 (Part I), 106th Cong., 1st Sess. 14, 16 (1999)). The House Report stated that the outpatient payment reforms contained in the BBRA 1999 (and hence in the BBA 1997) were intended to take effect “upon implementation of the hospital prospective payment system” by HCFA, id. at 52, 55, 56, not on January 1, 1999. The House Conference Committee Report reiterated the understanding that the payment and coinsurance provisions of the BBA and BBRA do not take effect until after implementation by HCFA. H. Conf. Rep. No. 479, 106th Cong., 1st Sess. 866 (1999) (”[c]urrently, beneficiaries pay 20% of charges for outpatient services,” but “[u]nder the outpatient PPS, beneficiary coinsurance will be limited to frozen dollar amounts based on 20% of national median charges for services in 1996, updated to the year of implementation of the PPS”); id. at 867 (“[t]he conferees fully expect that the beneficiary coinsurance phase-down will commence, as scheduled, on July 1, 2000”); 870 (“[h]ospital outpatient PPS is to be implemented simultaneously and in full for all services and hospitals (estimated for July 2000)”).
Both the House Report and the Conference Report expressly acknowledge, without disapproval, HCFA's decision to delay implementation of the outpatient PPS until after January 1, 2000. H.R. Rep. No. 436 (Part I) at 51 (stating that Secretary “delayed implementation of the new system until after the start of CY 2000 in order to ensure that ‘year 2000' data processing problems are fully resolved before the new system is implemented” and that “HCFA currently estimates that the outpatient department prospective payment system will be implemented in July 2000”); 145 Cong. Rec. at H12529 (daily ed. Nov. 17, 1999) (H. Conf. Rep. No. 479) (acknowledging “[t]here has already been a one-year delay in implementation of the BBA 97 provision” and stating that conferees “fully expect” that the outpatient prospective payment system “will commence, as scheduled, on July 1, 2000”). These statements indicate Congressional intent that payments and coinsurance for covered hospital outpatient services would be governed prospectively by PPS only after HCFA promulgated and made effective final implementing regulations.
Finally, there is a serious question as to whether retroactive implementation of PPS might constitute prohibited retroactive rulemaking. In Bowen v. Georgetown University Hospital, 488 U.S. 204, 208 (1988), the Supreme Court stated that a statutory grant of legislative rulemaking authority does not encompass the power to promulgate retroactive rules unless that power is conveyed by Congress in express terms, even where some substantial justification for retroactive rulemaking might exist. The Court then declined to find this express authorization for retroactive rulemaking in the Medicare statute's general grant of rulemaking authority.
We do not find this express authorization in section 1833(t) or any other statutory provision concerning the outpatient PPS. Section 1833(t)(1) requires that payment for outpatient services that are furnished during any calendar year beginning after January 1, 1999 and that are designated by HCFA as “covered” outpatient services shall be made under a prospective payment system. While Congress may have presumed, when it enacted section 1833(t) as part of the BBA, that HCFA would be able to designate covered outpatient services and implement the outpatient PPS by January 1, 1999, Congress did not foresee at that time that Y2K concerns would prevent the agency from doing so. As a result, the statute is silent as to what was to occur if HCFA was unable to designate covered outpatient services and implement PPS by January 1, 1999. We do not believe that this silence constitutes the express authorization of retroactive rulemaking required by the Supreme Court's Georgetown decision.
Comment: Several commenters contended that the proposed rules for beneficiary coinsurance are overly complex and that the phase-in period is too long. One commenter asked HCFA to consider a less involved method and a more aggressive time period for implementation. Another commenter suggested using a 5-year phase-in period. One commenter requested that we recommend a legislative change to the Congress to reduce beneficiary coinsurance to 20 percent by January 1, 2003. Still another commenter expressed concern that calculations of coinsurance amounts for each hospital will be particularly burdensome to Medicare fiscal intermediaries and, as a result of the increased workload, errors may occur. The commenter also recommended a more rapid reduction of coinsurance to 20 percent of the payment amount.
Response: We agree that the rules governing how coinsurance is to be calculated under the PPS are complex, and the phase-in to 20 percent coinsurance is a lengthy one. However, the methods for calculating coinsurance are dictated by the statute. The legislative changes were made in order to put some control on rapidly increasing beneficiary coinsurance payments, to begin to decrease the proportion of beneficiary liability for hospital outpatient services, and to continue to reduce beneficiary liability over time. As we have stated, the impetus to accelerate the reduction of beneficiary coinsurance has to be viewed within the context of other needs for increased Medicare expenditures and long-term protection of the trust funds. The delay in implementing the hospital outpatient PPS past the statutory effective date was unavoidable due to systems constraints imposed by Y2K compliance requirements.
Comment: One commenter noted that the proposed rule set beneficiary coinsurance at 20 percent of median charges, but the commenter believes that coinsurance amounts should be recalculated to equal 20 percent of the average charge for the applicable APC group. The commenter indicates that such a change would provide some financial relief to hospitals.
Response: Section 1833(t)(3)(B)(i) of the Act requires that unadjusted coinsurance amounts be calculated as 20 percent of the national median of the charges for services within the APC group. Start Printed Page 18491
Comment: One commenter stated that because coinsurance is based on the median charges of the APC, some beneficiaries would pay a higher coinsurance than they would under the current system. The commenter believes that beneficiaries who require less intensive services in an APC group will essentially subsidize other beneficiaries who receive more intensive services within the group. The commenter asserted that fairness would dictate beneficiaries be charged coinsurance amounts that more appropriately reflect the services received, not an amount based on a median of multiple services they did not receive.
Response: Section 1833(t)(3)(B)(ii) of the Act provides that the unadjusted coinsurance amounts are based on the national median of the charges for the “services within” an APC. Because an APC group consists of services that are both clinically similar and similar with respect to the resources required to perform the service, we would expect that charges for the services should also be fairly homogeneous. We believe that services within a group are homogeneous enough to warrant a single payment amount and a single coinsurance amount.
In the following sections, we describe how we determined the beneficiary coinsurance amount and the Medicare program payment amount for services paid for under the hospital outpatient PPS.
2. Determining the Unadjusted Coinsurance Amount and Program Payment Percentage
To calculate Medicare program payment amounts and beneficiary coinsurance amounts, we first determined for each APC group two base amounts, in accordance with statutory provisions:
- An unadjusted copayment amount, described in section 1833(t)(3)(B) of the Act; and
- The predeductible payment percentage, which we call the program payment percentage, described in section 1833(t)(3)(E) of the Act.
a. Calculating the Unadjusted Coinsurance Amount for Each APC Group
In the proposed rule, we described the specific steps used to calculate the unadjusted coinsurance amounts for each APC group as follows:
(i) We determined the national median of the charges billed in 1996 for the services that constitute an APC group after standardizing charges for geographic variations attributable to labor costs. (To determine the labor adjustment, we divided the portion of each charge that we estimated was attributable to labor costs (60 percent) by the hospital's inpatient wage index value and added the result to the nonlabor portion of the charge (40 percent)).
(ii) We updated charge values to projected 1999 levels by multiplying the 1996 median charge for the APC group by 13.0 percent (increased to 14.7 percent in this final rule), which the HCFA Office of the Actuary estimates to be the rate of growth of charges between 1996 and 1999.
(iii) To obtain the unadjusted coinsurance amount for the APC group, we multiplied the estimated 1999 national median charge for the APC group by 20 percent. The unadjusted coinsurance amount is frozen at the 1999 level until such time as the program payment percentage (as determined below) equals or exceeds 80 percent (section 1833(t)(3)(B)(ii) of the Act).
b. Calculating the Program Payment Percentage (Predeductible Payment Percentage)
In the proposed rule and in this final rule, we use the term “program payment percentage” to replace the term “pre-deductible payment percentage,” which is referred to in section 1833(t)(3)(E) of the Act. The program payment percentage is calculated annually for each APC group, until the value of the program payment percentage equals 80 percent. To determine the program payment percentage for each APC group, we—
(i) Subtract the APC group's unadjusted coinsurance amount from the payment rate set for the APC group; and
(ii) Divide the difference (APC payment rate minus unadjusted coinsurance amount) by the APC payment rate, and multiply by 100.
The program payment percentage will be recalculated each year because APC payment rates will change when APC rates are increased by annual market basket updates and whenever we revise an APC.
Comment: One commenter expressed concern about how the coinsurance amounts are determined. The commenter stated that the calculation is flawed and penalizes beneficiaries in those States where charges for services tend to be lower than in other States. The commenter alleged that if the hospitals in those States where charges for services tend to be lower accept a reduced coinsurance in order to hold beneficiaries harmless, the hospitals will be penalized. The commenter also asserted that Medigap policies and Medicaid programs will also be affected. The commenter further stated that coinsurance should be based on regional, not national, charges. The commenter contended that the provision does not achieve the intended outcome of equalizing payment across the nation.
Response: Sections 1833(t)(3) and (t)(8) of the Act prescribe how coinsurance amounts are to be calculated under the PPS. Our method of calculating unadjusted coinsurance amounts for each APC group based on 20 percent of national median charges follows the requirements of section 1833(t)(3)(B) of the Act.
Comment: A number of commenters believe that the payment system as proposed would create gross anomalies in coinsurance for particular chemotherapy drugs. For example, the proposed $36.61 coinsurance for fluorouracil is 10 times the hospital's cost to purchase that drug. The commenters asserted that this excessive coinsurance represents an abuse of patients and would undermine beneficiary confidence in the new system. They recommended that coinsurance be limited to 20 percent of the payment amount for each drug.
Several other commenters noted that classifying drugs with widely varying costs in the same APC will have a significant negative effect on beneficiary coinsurance, and in some cases beneficiaries could be required to pay a greater percentage of coinsurance for less effective therapies. For example, one commenter alleged that the coinsurance for the drug 5-FU, which the commenter believes has a current coinsurance of approximately $1, would increase to $40 under the proposed system.
Response: The coinsurance anomalies for chemotherapy drugs that appeared in the proposed rule are not an issue under this final rule. Unlike the proposed chemotherapy drug APCs, which grouped all chemotherapy drugs under four APCs, in this final rule, each chemotherapy drug is assigned to a separate APC. As discussed in section III.D.5 of this preamble, the unadjusted coinsurance amounts for these APCs is calculated as 20 percent of the APC payment rate.
Comment: One commenter noted that the proposed national unadjusted coinsurance amounts for cardiovascular stress testing and perfusion imaging result in beneficiaries bearing 85 percent of the total payment for stress testing and 60 percent for perfusion imaging, which many beneficiaries will be unable to afford. Another commenter Start Printed Page 18492requested that we either exclude cataract procedures and angioplasty from the hospital outpatient PPS or create an outlier policy that affords special treatment for these procedures in order to protect beneficiaries from excessive coinsurance amounts.
Response: Coinsurance amounts, by law, are based on 20 percent of the median of the charges actually billed in 1996 (updated to 1999) for the services within an APC. The fact that coinsurance is a larger proportion of the total payment for some APCs than for others reflects the differences in hospital charging practices for different services. For example, in examining departmental cost-to-charge ratios reflected on hospital cost reports, we have found that most hospitals have higher mark-ups in charges for radiology and diagnostic services than they do for clinic visits.
3. Calculating the Medicare Payment Amount and Beneficiary Coinsurance Amount
a. Calculating the Medicare Payment Amount
The national APC payment rate that we calculate for each APC group is the basis for determining the total payment (subject to wage-index adjustment) the hospital will receive from the beneficiary and the Medicare program. (A hospital that elects to reduce coinsurance, as described below in section III.F.4, may receive a total payment that is less than the APC payment rate.) The Medicare payment amount takes into account the wage index adjustment and the beneficiary deductible and coinsurance amounts. In addition, the amount calculated for an APC group applies to all the services that are classified within that APC group. The Medicare payment amount for a specific service classified within an APC group under the outpatient PPS is calculated as follows:
(i) Apply the appropriate wage index adjustment to the national payment rate that is set annually for each APC group.
(ii) Subtract from the adjusted APC payment rate the amount of any applicable deductible as provided under § 410.160.
(iii) Multiply the adjusted APC payment rate, from which the applicable deductible has been subtracted, by the program payment percentage determined for the APC group or 80 percent, whichever is lower. This amount is the preliminary Medicare payment amount.
(iv) If the wage-index adjusted coinsurance amount for the APC is reduced because it exceeds the inpatient deductible amount for the calendar year, add the amount of this reduction to the amount determined in (iii) above. The resulting amount is the final Medicare payment amount.
b. Calculating the Coinsurance Amount
A coinsurance amount is calculated annually for each APC group. The coinsurance amount calculated for an APC group applies to all the services that are classified within the APC group. The beneficiary coinsurance amount for an APC is calculated as follows:
Subtract the APC group's Medicare payment amount from the adjusted APC group payment rate less deductible; for example, coinsurance amount = (adjusted APC group payment rate less deductible)—APC group preliminary Medicare payment amount. If the resulting amount does not exceed the annual hospital inpatient deductible amount for the calendar year, the resulting amount is the beneficiary coinsurance amount. If the resulting amount exceeds the annual inpatient hospital deductible amount, the beneficiary coinsurance amount is limited to the inpatient hospital deductible. For example, assume that the wage-adjusted payment rate for an APC is $300; the program payment percentage for the APC group is 70 percent; the wage-adjusted coinsurance amount for the APC group is $90; and the beneficiary has not yet satisfied any portion of his or her $100 annual Part B deductible.
(A) Adjusted APC payment rate: $300.
(B) Subtract the applicable deductible:
$300-$100 = $200
(C) Multiply the remainder by the program payment percentage to determine the preliminary Medicare payment amount:
0.7 × $200 = $140
(D) Subtract the Medicare payment amount from the adjusted APC payment rate less deductible to determine the coinsurance amount, which cannot exceed the inpatient hospital deductible for the calendar year:
$200 − $140 = $60
(E) Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation.
$140 + $0 = $140
In this case, the beneficiary pays a deductible of $100 and a $60 coinsurance, and the program pays $140, for a total payment to the hospital of $300. Applying the program payment percentage ensures that the program and the beneficiary pay the same proportion of payment that they would have paid if no deductible were taken.
If the annual Part B deductible has already been satisfied, the calculation is:
(A) Adjusted APC payment rate: $300.
(B) Subtract the applicable deductible:
$300 − 0 = $300
(C) Multiply the remainder by the program payment percentage to determine the preliminary Medicare payment amount:
0.7 × $300 = $210
(D) Subtract the Medicare payment amount from the adjusted APC payment rate less deductible to determine the coinsurance amount. The coinsurance amount cannot exceed the amount of the inpatient hospital deductible for the calendar year:
$300 − $210= $90
(E) Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation.
$210 + $0 = $210
In this case, the beneficiary makes a $90 coinsurance payment, and the program pays $210, for a total payment to the hospital of $300.
The following example illustrates a case in which the inpatient hospital deductible limit on coinsurance amounts applies. Assume that the wage-adjusted payment rate for an APC is $2,000; the wage-adjusted coinsurance amount for the APC is $900; the program payment percentage is 55 percent; the inpatient hospital deductible amount for the calendar year is $776 and the beneficiary has not yet satisfied any portion of his or her $100 Part B deductible.
(A) Adjusted APC payment rate: $2,000.
(B) Subtract the applicable deductible:
$2000 − $100 = $1,900
(C) Multiply the remainder by the program payment percentage to determine the preliminary Medicare payment amount:
0.55 × $1,900 = $1,045
(D) Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less deductible to determine the coinsurance amount. The coinsurance amount cannot exceed the inpatient hospital deductible amount of $776:
$1,900 − $1,045 = $855, but coinsurance limited to $776
(E) Calculate the final Medicare payment amount by adding the Start Printed Page 18493preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation ($855 − $776 = $79).
$1,045 + $79 = $1,124
In this case, the beneficiary pays a deductible of $100 and coinsurance that is limited to $776. The program pays $1,124 (which includes the amount of the reduction in beneficiary coinsurance due to the inpatient hospital deductible limitation) for a total payment to the hospital of $2,000.
4. Hospital Election To Offer Reduced Coinsurance
For most APCs, the transition to the standard Medicare coinsurance rate (20 percent of the APC payment rate) will be gradual. For those APC groups for which coinsurance is currently a relatively high proportion of the total payment, the process will be correspondingly lengthy. The law offers hospitals, but not CMHCs, the option of electing to reduce coinsurance amounts and permits hospitals to disseminate information on their reduced rates. In this section, we discuss the procedure by which hospitals can elect to offer a reduced coinsurance amount, and the effect of the election on calculation of the program payment and beneficiary coinsurance.
Section 1833(t)(5)(B) of the Act, as added by section 4523 of the BBA 1997, requires the Secretary to establish a procedure under which a hospital, before the beginning of a year, may elect to reduce the coinsurance amount otherwise established for some or all hospital outpatient services to an amount that is not less than 20 percent of the hospital outpatient prospective payment amount. The statute further provides that the election of a reduced coinsurance amount will apply without change for the entire year, and that the hospital may disseminate information on its reduced copayments. Section 1833(t)(5)(C) of the Act, as added by the BBA 1997, provides that deductibles cannot be waived. Finally, section 1861(v)(1)(T) of the Act (as added by section 4451 of the BBA 1997) provides that no reduction in coinsurance elected by the hospital under section 1833(t)(5)(B) of the Act may be treated as a bad debt. We note that section 1833(t)(5) of the Act has been redesignated as section 1833(t)(8) of the Act by sections 201(a) and 202(a) of the BBRA 1999.
Elections to reduce coinsurance will not be taken into account in calculating transitional corridor payments to hospitals (discussed in section III.H.2 of this preamble). That is, a hospital's transitional corridor payment will be determined as if the hospital received unreduced coinsurance amounts from beneficiaries.
In the proposed rule, we stated that we would require that hospitals make the election to reduce coinsurance on a calendar year basis. The proposed rule required that the hospital must notify its fiscal intermediary of its election to reduce coinsurance no later than 90 days prior to the date the PPS is implemented or 90 days prior to the start of any subsequent calendar year and that the hospital's notification must be in writing. It must specifically identify the APC groups to which the hospital's election will apply and the coinsurance amount (within the limits identified below) that the hospital has elected for each group. The election of reduced coinsurance must remain in effect and unchanged during the year for which the election is made. Because the law states that hospitals may disseminate information on any reduced coinsurance amounts, we provided in the proposed rule that hospitals would be allowed to publicly advertise this information.
The proposed regulations provided that a hospital may elect to reduce the coinsurance amount for any or all APC groups. A hospital may not elect to reduce the coinsurance amount for some, but not all, services within the same APC group.
As proposed, a hospital may not elect a coinsurance amount for an APC group that is less than 20 percent of the adjusted APC payment rate for that hospital. In determining whether to make such an election, hospitals should note that the national coinsurance amount under this system, based on 20 percent of national median charges for each APC, may yield coinsurance amounts that are significantly higher or lower than the coinsurance that the hospital previously has collected. This is because the median of the national charges for an APC group, from which the coinsurance amount is ultimately derived, may be higher or lower than the hospital's historic charges. Therefore, in determining whether to elect lower coinsurance and the level at which to make the election, we advise that hospitals carefully study the wage-adjusted coinsurance amounts for each APC group in relation to the coinsurance amount that the hospital has previously collected.
As discussed in section III.F.1, under sections 1834(d)(2)(C)(ii) and 1834(d)(3)(C)(ii) of the Act the coinsurance for screening sigmoidoscopies furnished by hospitals and screening colonoscopies furnished by hospital outpatient departments and ASCs is 25 percent of the applicable payment rate. The payment rate for these colorectal cancer screening tests is the lower of the hospital outpatient rate or the ASC payment rate. The payment rate for screening barium enemas is the same as that for diagnostic barium enemas. However, the coinsurance amount for screening barium enemas is 20 percent of the APC payment rate. Hospitals may not elect to reduce coinsurance for screening sigmoidoscopies, screening colonoscopies, or screening barium enemas.
Calculation of coinsurance amounts on the basis of a hospital's election of reduced coinsurance is similar to the formula described in section III.F.3. For example, assume that the adjusted APC payment rate is $300; the program payment percentage for the APC group is 60 percent; the hospital has elected a $60 reduced coinsurance amount for the APC group; and the beneficiary has not satisfied the annual Part B deductible.
(A) Adjusted APC payment rate: $300.
(B) Subtract the applicable deductible:
$300 − $100 = $200
(C) Multiply the remainder by the program payment percentage to determine the Medicare payment amount:
0.6 × $200 = $120
(D) Beneficiary's coinsurance is the difference between the APC payment rate reduced by any deductible amount and the Medicare payment amount, but not to exceed the lesser of the reduced coinsurance amount or the inpatient hospital deductible amount:
$200 − $120 = $80 (limited to $60 because of the hospital-elected reduced coinsurance amount)
(E) Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation.
$120 + $0 = $120
In this case, Medicare makes its regular payment of $120, and the beneficiary pays a $100 deductible and a reduced coinsurance amount of $60. The hospital receives a total payment of $280 instead of the $300 that it would have received if it had not made its election to reduce coinsurance.
Comment: One commenter stated that it is currently illegal to accept lower coinsurance amounts from beneficiaries and asked for an explanation as to how Start Printed Page 18494we could propose to encourage hospitals to lower coinsurance.
Response: Although Medicare, in general, has prohibitions against reducing beneficiary coinsurance, redesignated section 1833(t)(8)(B) of the Act specifically provides the legal authority for hospitals to make elections to reduce coinsurance amounts for purposes of the outpatient PPS. However, those coinsurance amounts cannot be reduced below 20 percent of the adjusted APC payment rate for the hospital.
Comment: One commenter asked whether, in view of our proposal to allow hospitals to elect lower coinsurance, Medigap insurance plans will be permitted to offer a waiver of a participating hospital's coinsurance. That is, can a Medigap plan act as a preferred provider organization (PPO) with a financial incentive to select those hospitals that elect to reduce coinsurance?
Response: There are two kinds of Medigap policies—regular Medigap and Medicare SELECT. While regular Medigap policies must pay full supplemental benefits on all claims that are submitted by all Medicare providers and are approved by Medicare carriers and intermediaries, Medicare SELECT plans, which are a managed care form of Medigap, may restrict payment of supplemental benefits to network providers. Thus, by design, Medicare SELECT plans are permitted to negotiate selectively with hospitals. Ordinarily, Medicare SELECT plans contract with certain hospitals to waive the hospital deductible for inpatient services.
Since the Congress has expressly permitted hospitals to reduce outpatient coinsurance to no less than 20 percent of the PPS payment amount, a Medicare SELECT plan is free to contract selectively with these hospitals. We note that a hospital's election to reduce coinsurance under redesignated section 1833(t)(8)(B) of the Act requires that the reduction be across-the-board for some or all APC groups. Thus, an agreement between a Medicare SELECT plan and a hospital to reduce coinsurance would result in coinsurance reductions for all beneficiaries who receive those APC group services at the hospital, whether or not they are enrolled in the Medicare SELECT plan.
Comment: One commenter requested that we seek a legislative change to offer hospitals more flexibility under the coinsurance reduction provision by permitting them to review and revise coinsurance amounts every 3 months.
Response: We believe that there would be a significant impact on contractors if hospitals were allowed to revise their reduced coinsurance more often than annually. More frequent coinsurance changes may also be confusing to beneficiaries. Because we do not have a good estimate of how many hospitals will make the elections and we do not yet know whether those hospitals that do make elections will elect to reduce coinsurance for just a few or for a significant number of APCs, we do not support allowing hospitals to make or change elections more often than annually. However, we may reconsider our position after we gain more experience under the PPS and can better assess what the impact of more frequent elections would be on hospitals, beneficiaries, and HCFA and its contractors.
Comment: One commenter noted that if we intend to publish a final rule no more than 90 days before implementation of the PPS, hospitals would not have sufficient time to make coinsurance election decisions. The commenter recommended that hospitals be permitted to make the election 60 days before implementation of the system.
Response: This final rule will not be published more than 90 days before the date of implementation of the PPS. Therefore, the final regulations require that hospitals inform their fiscal intermediaries (FIs) of their elections to reduce coinsurance not later than June 1, 2000. Beginning with elections for calendar year 2001, elections are required to be made by December 1 preceding the calendar year. At this time, we do not know how many hospitals will choose to reduce coinsurance or for how many APCs these hospitals will elect reductions. While we want to provide hospitals sufficient time to make their elections, we also must provide fiscal intermediaries with enough time to incorporate the elections into their systems.
Comment: Several commenters disagreed with our proposal to allow hospitals to advertise reduced coinsurance amounts. They noted that, although the BBA 1997 provision with respect to hospitals' election to reduce coinsurance amounts provides that hospitals may “disseminate information” on their reductions, we have interpreted that to mean that hospitals may “advertise” their reductions. Two commenters stated that disseminating information is not synonymous with granting one category of hospitals the unique opportunity to advertise to attract customers. They believe that this interpretation is antithetical to the spirit underlying provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that prohibit beneficiary inducements and may conflict with State anti-kickback laws. Some commenters were also concerned that under our proposal to allow hospitals to advertise, hospitals may issue a general advertisement of reduced coinsurance when the reduction may apply only to certain services. Other commenters were concerned that hospital advertising may lead Medicare beneficiaries to believe that hospital outpatient care is more economical than other ambulatory settings, even when that is not the case, or beneficiaries may become confused and believe that all ambulatory providers have the ability to reduce coinsurance. These commenters asked us to reconsider our proposal to allow hospitals to advertise rather than to disseminate information. In addition, they asked us to establish additional requirements for hospitals' dissemination of information concerning coinsurance reductions so that beneficiaries are made aware that reduced coinsurance applies only to certain specified services, that it applies only to coinsurance billed by hospitals for those services, and that the law does not permit reduced coinsurance for other Part B services such as physician services.
Several other commenters stated that for the election to reduce coinsurance to be effective, hospitals must have the right to advertise and, therefore, the commenters supported our proposal to permit hospitals to advertise coinsurance reductions.
Response: We believe that hospitals must be able to advertise their coinsurance reductions in order to achieve what we believe to be the intent of the BBA provision, that is, to provide hospitals with some ability to compete with other ambulatory settings (where coinsurance is already 20 percent of the applicable Medicare payment rate) and to reduce beneficiary coinsurance liability.
Hospitals would have less incentive to reduce coinsurance if they could not advertise. In addition, beneficiaries need to be fully informed so that they can make informed decisions. We believe that advertising as a way of disseminating information has merit.
We were persuaded by some commenters' concerns that beneficiaries may not understand that reduced coinsurance applies to specific hospital outpatient services furnished by specific hospitals that choose to elect reductions and that similar reductions cannot be made by other providers of ambulatory services. We, therefore, are amending the regulations to require that all Start Printed Page 18495advertisements or other information furnished to beneficiaries must specify that the coinsurance reductions advertised apply only to the specified services of that hospital and that these coinsurance reductions are available only where a hospital elects to reduce coinsurance for hospital outpatient services and reductions are not allowed in other ambulatory settings or physician offices.
Comment: One commenter, noting the complexity of the PPS coinsurance requirements, requested that we provide a phase-in period in the final rule to allow hospitals sufficient time to implement the changes necessary to meet the requirements.
Response: The method required to be used in calculating coinsurance under the PPS results in an overall decrease in the total coinsurance amounts beneficiaries pay for hospital outpatient services. Total coinsurance is somewhat reduced in the first year of implementation and will be reduced even more in future years, until coinsurance for all PPS services equal 20 percent of the applicable APC payment rate. It is only by fully implementing the coinsurance provisions under section 1833(t)(3)(B) of the Act that beneficiaries will realize these reductions. We, therefore, do not support a phase-in period.
Comment: One commenter recommended that we include, as part of the public record, year by year estimates of the total economic burden placed on beneficiaries by the prolonged coinsurance phase-in period, assuming hospitals charge the maximum and minimum coinsurance amounts. The commenter believes these estimates would be useful as a basis for future discussions of how to remedy the coinsurance problem.
Response: As a rule, we develop estimates of impacts for legislative proposals that are under consideration by the Congress and for final legislation as we are developing regulations to implement the law. Although we do not have the resources available to model any number of other data analyses that may have merit, our data are made available to the public, so the commenter and any other interested party may perform the coinsurance analysis.
Comment: One commenter stated that the proposed PPS creates new complexities for Medicare beneficiaries in that they will have to wait for hospitals to do the calculations necessary to determine coinsurance. The beneficiaries will also receive multiple bills and explanations of benefits for multiple hospital visits occurring on the same day. The commenter stated that we will need to have an extensive process in place to explain why, in most cases, beneficiaries are paying 50 to 70 percent of their outpatient services and why they are receiving separate statements when they have multiple visits on the same day.
Response: In the proposed rule, we assigned medical visits, that is, clinic and emergency room visits, to APCs based on both the level of visit as defined by a HCPCS code and the diagnosis of the patient. In order to implement that type of APC assignment, we would have to require hospitals to submit a separate bill for each medical visit that occurred on the same day; however, under the final rule, medical visits are assigned to APCs based solely on the HCPCS code, and it will be possible for hospitals to bill for multiple medical visits on the same bill. We agree that the way coinsurance is determined under the PPS is a significant change. We are developing a brochure for beneficiaries that will explain the new system and the policies under the outpatient PPS that will affect them.
Comment: One commenter recommended that we make information available to beneficiaries that compares the average coinsurance for high volume procedures performed at hospitals in a particular geographic area so that beneficiaries can make informed health care decisions about their care.
Response: We believe that beneficiaries will be informed about the coinsurance reductions elected by hospitals in their area through advertisements and other information made available by hospitals.
Comment: One commenter asked whether the EOMB (Explanation of Medicare Benefits) notice to the beneficiary will clearly explain that a hospital's decision to reduce coinsurance applies to a specific service furnished at that specific hospital.
Response: We are reviewing the EOMB in light of the changes in Medicare payments and coinsurance amounts under the PPS, but we have not yet finalized our work. We will take the commenter's suggestion into consideration as we investigate changes we will make to the EOMB.
G. Adjustment for Area Wage Differences
1. Proposed Wage Index
Under section 1833(t)(2)(D) of the Act, the Secretary is required to determine a wage adjustment factor to adjust, in a budget-neutral manner, the portion of the payment rate and the coinsurance amount that is attributable to labor-related costs for relative differences in labor and labor-related costs across geographic regions. As stated in the proposed rule, we considered several options and we proposed using the hospital inpatient PPS wage index as the source of an adjustment factor for geographic wage differences for the hospital outpatient department PPS. We believe that using the hospital inpatient PPS wage index is both reasonable and logical, given the inseparable, subordinate status of the outpatient department within the hospital overall. Use of a hospital outpatient-specific wage index was not required by the Congress and we did not have either the time or resources necessary to construct one. We explained in our proposed rule that there are several possible versions of the hospital inpatient wage index that can be developed by extracting the basic wage and salary data from hospital cost reports, depending on the methodology that is applied to the data. For the hospital outpatient PPS, we proposed to adopt the same version that is used to determine payments to hospitals under the hospital inpatient PPS to adjust for relative differences in labor and labor-related costs across geographic areas. This version reflects the effect of hospital redesignation under 1886(d)(8)(B) of the Act and hospital reclassification under 1886(d)(10) of the Act.
By statute, we implement the annual updates of the hospital inpatient PPS on a fiscal year basis. However, we proposed to update the hospital outpatient department PPS on a calendar year basis. Therefore, the hospital inpatient PPS wage index values that are updated annually on October 1 would be implemented for the hospital outpatient department PPS on the January 1 immediately following. We proposed this schedule so that wage index changes will be implemented on a calendar year basis concurrently with other revisions and updates, such as the conversion factor update or changes in the APC groups resulting from new or deleted CPT codes. Subsequent to our proposal, section 201(h) of the BBRA 1999 amended section 1833(t)(8)(A) of the Act (as redesignated by section 201(a) of the BBRA 1999) to require the Secretary to review and revise the outpatient PPS wage index adjustment factor at least annually rather than on a periodic basis. (This section of the Act was further redesignated as section 1833(t)(9)(A) by section 202(a) of the BBRA 1999.) Start Printed Page 18496
2. Labor-Related Portion of Hospital Outpatient Department PPS Payment Rates
We proposed to recognize 60 percent of the hospital's outpatient department costs as labor-related costs that would be standardized for geographic wage differences. We initially estimated this percentage by comparing the percentage of costs attributed to labor by other systems (that is, hospital inpatient PPS and ASC) and by considering health care market factors such as the shift in more complex services from the inpatient to the outpatient setting, which could influence labor intensity and costs. We stated that 60 percent represented a reasonable estimate of outpatient costs attributable to labor, as it fell between the hospital inpatient PPS operating cost labor factor of 71.1 percent and the ASC labor factor of 34.45 percent, and is close to the labor-related costs under the hospital inpatient operating cost PPS attributed directly to wages, salaries, and employee benefits (61.4 percent) under the rebased 1992 hospital market basket that was used to develop the fiscal year 1997 update factor for inpatient PPS rates (published August 30, 1996 at 61 FR 46187).
We confirmed our estimate through regression analysis. Using this approach, we analyzed the percentage change in hospital costs attributable to a 1 percent increase in the wage index as expressed by the hospital wage index coefficient. The coefficient from a fully specified payment regression of the hospital cost per unit, standardized for the service mix on the wage index, disproportionate share patient percentage, modified teaching, rural, and urban variables, is approximately 0.60, suggesting a labor share of 60 percent. Even though we decided not to propose additional adjustments, we believed that the coefficient from this specification provided the best estimate of the labor share for the proposed PPS. This judgment was based on a policy to use a labor share that reflects the relationship between the wage index and costs, rather than the effects of correlated factors.
After calculating 60 percent of each hospital's total operating and capital costs, we divided that amount by the hospital's FY 1998 hospital inpatient PPS wage index value to standardize costs to remove the differences that are attributable to geographic wage differences. Therefore, as we explained in the proposed rule, the total cost of performing a procedure or visit would include standardized operating and capital costs, as well as related costs (for example, operating room time, medical/surgical supplies, anesthesia, recovery room, observation) and minor ancillary procedures such as venipuncture that we packaged.
Comment: Some commenters urged that we annually update the wage index applied to the outpatient PPS as we do under the hospital inpatient PPS.
Response: We proposed to update the wage index annually, on a calendar year basis. In addition, section 1833(t)(9)(A) of the Act, redesignated and amended by the BBRA 1999, requires us to review and revise the wage adjustment at least annually.
Comment: A professional society recommended eliminating the “regional variation for radiologic technologists working in small and rural practices” and applying the “same wage scale” used for their urban counterparts. The commenter asserted that our wage index methodology is biased against rural hospital radiology departments that must compete with the urban areas to attract and retain radiologic technologists. The commenter stated that hospitals are operating in a very competitive labor market in which rural facilities are forced to match or exceed wages paid in the urban areas for reduced workloads. The commenter further stated that the impact of higher hourly technologist wages does not result in a corresponding increase in a higher wage index for radiologic technologists in rural hospitals because these wages are averaged with those for all other hospital inpatient personnel working in the same area.
Response: The commenter is correct that the wage index is calculated based upon all of the wages paid and hours worked of hospital personnel within areas of the hospital that are paid under the inpatient PPS. The wages and hours are then totaled for a particular labor market area (defined as a Metropolitan Statistical Area [MSA] or all of the counties of a State that are not part of an MSA). We believe the inpatient wage index is an appropriate measure of the relative costs of labor across geographic areas for purposes of outpatient PPS.
Currently, we do not have data available that would allow us to calculate the wage index for the costs of employing staff in particular occupational categories. Collecting these data would require significant recordkeeping and reporting efforts for hospitals, and the impacts of adjusting the wage index using the data are uncertain. Although some analyses have indicated that the wage indices of rural areas could rise as a result of such an adjustment, these findings are limited by the lack of a national database through which to fully assess the impacts.
Comment: Several commenters viewed our proposal to establish a 60 percent labor share as an arbitrary decision for which we provided no rational support. One commenter stated that “Congress did not expect HCFA to invent a number.”
Response: As we explained in the proposed rule (63 FR 47581), we used a statistical tool, that is, regression analysis, to validate the percentage of costs that we had initially estimated could be attributed to labor and, therefore, subject to the wage adjustment. We adopted this approach because we did not have adequate and appropriate data readily available through a reputable source from which we could derive a hospital outpatient labor share within the time allotted to develop our new system. While hospital outpatient costs, including labor costs, are reported annually on the hospital cost report, they are not reported in a manner and format that allow us to capture the statistical and cost data necessary to calculate a precise hospital outpatient labor share. Therefore, we decided to use regression analysis to test our estimate of that labor share. Within the constraints imposed by a lack of accessible, reliable data and the compressed timeframe under which we were working to develop the outpatient PPS, we believe our approach was appropriate and the best available option.
Comment: Several commenters urged us to use more current hospital cost report data to determine the appropriate hospital outpatient labor share.
Response: As stated above, at this time the Medicare hospital cost report is not a feasible data source for determining a hospital outpatient labor share.
Comment: One commenter asserted that setting the labor-related share at 60 percent fails to recognize all labor costs associated with the delivery of hospital outpatient services. The commenter stated that the labor-related percentage for the outpatient PPS should be the same as that used for the hospital inpatient PPS, that is, 71.1 percent. Another commenter supported 60 percent as a “maximum” labor percentage on an interim basis and suggested that we reconsider our decision to use the inpatient PPS hospital wage index to adjust the outpatient PPS payments because of the commenter's concerns about flaws inherent in the system used to derive the inpatient PPS wage index values. A third commenter proposed that the Start Printed Page 18497labor-related portion should be closer to the 34.45 percent currently applied to adjust ASC payment for wage variation. The latter commenter contended that apportioning 60 percent of the outpatient PPS payment rate for wage adjustment would adversely affect rural hospitals because the wage index values for these areas are generally below 1.0.
Response: We note that commenters' opinions regarding an appropriate labor percentage are mixed. However, beyond expressing a preference for a percentage other than 60 percent, none of the commenters provided data to assist us in re-evaluating our proposal. We realize that rural hospitals would benefit from using a labor share that is less than 60 percent and that some other hospitals would derive advantages from a labor share greater than 60 percent. However, we believe the approach that we used to determine the labor share that will be applied to all hospitals paid under our new system is reasonable and the best option available at this time. We will re-evaluate our decision as we gain more experience with the new system and as new data become available.
3. Adjustment of Hospital Outpatient Department PPS Payment and Coinsurance Amounts for Geographic Wage Variations
In the proposed rule, we noted our intent to use fiscal year 1999 hospital inpatient PPS wage index values to compute the initial outpatient PPS rates. However, we have decided to use fiscal year 2000 inpatient PPS wage index values in determining the payment rates set forth in this final rule. The rationale for using the fiscal year 2000 wage index includes availability of the more recent wage index, that it is more current than the 1999 wage index would have been, and that it is being used to calculate FY 2000 payments under the hospital inpatient PPS.
We proposed to use the annually updated hospital inpatient PPS wage index values to adjust both program payment and coinsurance amounts under the outpatient PPS for area wage variations. Under our proposal, when intermediaries calculate actual payment amounts, they would multiply the prospectively determined APC payment rate and coinsurance amount by that labor-related percentage to determine the labor-related portion of the base payment rate and coinsurance amount that is to be adjusted using the applicable wage index factor. We proposed that the labor-related portion would then be multiplied by the hospital's inpatient PPS wage index factor, and the resulting wage-adjusted labor-related portion would be added to the nonlabor-related portion, resulting in wage-adjusted payment and coinsurance rates. The wage-adjusted coinsurance amount would then be subtracted from the wage-adjusted APC payment rate, and the remainder would be the Medicare payment amount for the service or procedure. Note that even if a hospital elects to reduce the coinsurance or if the coinsurance is capped at the inpatient deductible, the full coinsurance is assumed for purposes of determining the Medicare payment percentage. (See section III.F.3 for a discussion on how Medicare program payments are calculated when the Part B deductible applies.)
The following is an example of how an intermediary would calculate the Medicare payment for a surgical procedure with a hypothetical APC payment rate of $300 that is performed in the outpatient department of a hospital located in Heartland, USA. The coinsurance amount for the procedure is $120. The hospital inpatient PPS wage index value for hospitals located in Heartland, USA is 1.0234. The labor-related portion of the payment rate is $180 ($300 × 60 percent), and the nonlabor-related portion of the payment rate is $120 ($300 × 40 percent). The labor-related portion of the unadjusted coinsurance amount is $72 ($120 × 60 percent), and the nonlabor-related portion of the unadjusted coinsurance amount is $48 ($120 × 40 percent). It is assumed that the beneficiary deductible has been met.
Wage-Adjusted Payment Rate (rounded to nearest dollar):
= ($180 × 1.0234) + $120
= $184 + $120
= $304
Wage-Adjusted Coinsurance Amount (rounded to nearest dollar):
= ($72 × 1.0234) + $48
= $74 + $48
= $122
Calculate Medicare Program Payment Amount:
$304−$122 = $182
4. Special Rules Under the BBRA 1999
We issued the federal fiscal year (FY) 2000 hospital inpatient PPS wage index values in the Federal Register on July 30, 1999, in a final rule titled “Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2000 Rates” (64 FR 41490). Subsequent to that publication, section 152 of the BBRA 1999 reclassified certain counties and labor market areas for purposes of payment under the Medicare hospital inpatient PPS; section 153 of the BBRA 1999 enacted a “wage index correction”; and section 154 of the BBRA 1999 provided for the calculation and application of a wage index floor for a specified area. These changes are effective for FY 2000 and will be explained in detail in an interim final rule with comment that we expect to issue in the Federal Register shortly. The wage index values in Addendum H, Addendum I, and Addendum J reflect the changes made by the BBRA 1999.
H. Other Adjustments
1. Outlier Payments
Section 1833(t)(2)(E) of the Act, as enacted by the BBA 1997, authorized, but did not require, an outlier adjustment. In the proposed rule, we discussed our reasons for not implementing an outlier adjustment policy. We explained that we had reached that decision after carefully evaluating several factors. For the following reasons, we believed an outlier policy was not necessary: (a) in the proposed PPS, unlike the hospital inpatient PPS, we would use limited packaging of services and allow payment for multiple services delivered to a given patient on a given day; (b) payment for critical care services would reflect the intensity and higher costs associated with providing this type of medical care; and (c) we would make higher payment for serious medical cases even if critical care were not provided and additional payments would be made for any other laboratory work, x-rays, or surgical interventions resulting from medical visits to the emergency room.
Section 201(a) of the BBRA 1999 amended section 1833(t) of the Act by adding an outlier adjustment provision, section 1833(t)(5). Under this new provision, the statute now requires that we make an additional payment (that is, an outlier adjustment) for outpatient services for which a hospital's charges, adjusted to cost, exceed a fixed multiple of the outpatient PPS payment as adjusted by pass-through payments. The Secretary determines this fixed multiple and the percent of costs above the threshold that is to be paid under this outlier provision. The statute sets a limit on projected aggregate outlier payments. Under the statute, projected outlier payments may not exceed an “applicable percentage” of projected total payments. The applicable percentage means a percentage specified by the Secretary (projected percentage of outlier payments relative to total payments), subject to the following limits: for years before 2004, the projected percentage that we specify cannot exceed 2.5 percent; for 2004 and later, the projected percentage cannot Start Printed Page 18498exceed 3.0 percent. Section 201(c) of the BBRA 1999 amended section 1833(t)(2)(E) of the Act to require that these payments be budget neutral.
Section 1833(t)(5)(D) of the Act grants the Secretary authority until 2002 to identify outliers on a bill basis rather than on a specific service basis and to use an overall hospital cost-to-charge ratio (CCR) to calculate costs on the bill rather than using department-specific CCRs for each hospital.
To set the threshold or fixed multiple and the payment percent of costs above that multiple for which an outlier payment would be made, we first had to determine what specified percentage of total program payment, up to 2.5 percent, we should select. We decided to set the outlier target at 2.0 percent. In order to set the fixed multiple outlier threshold and payment percentage, we simulated PPS payments, as described below in section G of the preamble. As explained further below, we calibrated the threshold and the payment percentage applying an iterative process so that the simulated outlier payments were 2.5 percent of simulated total payments. For purposes of the simulation, we set a “target” of 2.5 percent (rather than 2.0 percent), because we believe that a given set of numerical criteria would result in a higher percentage of outlier payments under the simulation using 1996 data than under the PPS. This is because we believe that the 1996 data reflects undercoding of services, which means simulated total payments would likely be understated and it in turn means the percentage of outlier payments would be overstated. In addition, we are unable to fully estimate the amount and distribution of pass-through payments using the 1996 data. Our inability to make these estimates further understates the total payments under the simulation. We believe that a set of numerical criteria that results in simulated outlier payments of 2.5 percent using the 1996 data would result in outlier payments of 2.0 percent under PPS. The difference arises from the effect of undercoding in the historical data and the payment of pass-throughs under PPS. Under the budget neutrality requirement in section 1833(t)(2)(E) of the Act, as amended by section 201(c) of the BBRA 1999, we make a corresponding 2.0 percent reduction to the otherwise applicable conversion factor. We will monitor outlier payment and make any necessary refinements to the outlier methodology when we set outlier policies for CY 2002.
After setting the outlier target percentage and reducing the unadjusted conversion factor to reflect the 2 percent outlier reduction and the 2.5 percent pass-through adjustment (see discussion in section III.D), we identified those claims in our 1996 database with at least one payable service under the PPS system. For these bills, we first calculated the total PPS payment for the bill using the reduced conversion factor. Next, we calculated for each claim the total charges attributed to services being paid under the PPS system. These charges were then adjusted to cost, using a hospital-specific CCR. We used the sum of the hospital's total operating CCR and total capital CCR as the hospital specific CCR. These CCRs were calculated from the most current cost report data available and were adjusted to calendar year 1996.
We also identified all bills for the 1,800-plus hospitals that we had previously identified as having coded only the lowest level clinic visit code (CPT code 99201) for all visits. For these hospitals, we isolated those claims with at least one service with the CPT code 99201 and one or more additional PPS covered service. Due to the undercoding on these bills and the inherent problem in determining a possible outlier condition, we excluded these bills from the calculation process but set aside a proportional amount of outlier payments based on the proportional cost of these bills to the total cost of all bills used in the outlier calculation.
After determining the PPS payment and the cost for all 42 million claims for which there was at least one billable service under the PPS system, we experimented with several combinations of thresholds or fixed multiples and payment percent of costs over these multiples. We found that the combination of using a multiple of 2.5 for the threshold and the use of a payment percent of 75 percent of cost over this threshold achieved our target of a 2.5 percent outlier payment. Approximately 1.6 million claims in our 1996 claims database had calculated bill costs that exceeded the PPS payments on the claim by more than 2.5 times and thus qualified for an outlier payment in our model.
Comment: We received several comments that supported our proposal not to create outlier payments. However, most commenters opposed it and supported including an outlier policy. Several commenters disagreed that multiple payment for multiple services furnished during a given visit would absolve the need for outliers. One commenter stated that outlier payments are necessary because of the limited number of APC groups. Several commenters believe that outlier payments are necessary to recognize variability in APC groups stemming from treatment options and patient complexity. Some argued that our own data demonstrate that an outlier policy is necessary to ensure equitable payments. Several commenters stated that the data trimming algorithm that we used, excluding from our PPS database claims that were greater than three standard deviations from the geometric mean, probably eliminated claims that included high cost items and services that should have been reflected in our data and that may have been associated with the later technologies. A professional association noted that an examination of our PPS data indicated that “20 percent of outpatient services subject to the PPS (excluding clinic and emergency room visits) include maximum costs that are at least 10 times higher than the corresponding rate; 100 services have maximum costs that are at least 40 times higher than the corresponding payment rate.”
One commenter believes that an outlier policy is necessary for a payment system based on averaging to provide additional payments for potentially variable and expensive items such as pharmaceuticals and supplies. Several commenters suggested that outlier payments would be necessary if we did implement their option to carve out all pharmaceuticals and certain supplies from the hospital outpatient PPS and pay them separately based on reasonable costs or average wholesale price (AWP). Most commenters who urged establishing outlier payments advocated them for high cost drugs, supplies, and new technologies. Some commenters advised that a drug such as Activase administered to a cardiac patient in the emergency room prior to inpatient admission or transfer to another hospital for inpatient admission would be costly. One commenter estimated that the cost for two doses of the drug would exceed $4,000. One commenter urged an outlier policy that would adequately pay for iodine I 131 tositomomab. Another commenter recommended that we make an outlier payment for Hemophilia Factor Concentrate that could be packaged in APC 906 (Infusion Therapy, except Chemotherapy) or APC 907 (Intramuscular Injections) and Tissue Plasminogen Activator (TPA) and IV therapy drugs as outliers.
A professional association expressed the need for an outlier policy for tests whose costs exceed a reasonable range of costs for similar procedures. They identified CPT codes 95951 and 95956 as examples of those tests. Another association recommended adoption of Start Printed Page 18499an outlier policy to recognize higher costs associated with new technologies. The commenter suggested that the policy remain in effect a full year after the hospital outpatient PPS is implemented to allow us adequate time to collect the appropriate data for use in updating the payment rates. Several other commenters believe that we may need to adopt an outlier policy on an interim basis while data are collected to determine the appropriate assignment of certain services and items to an APC. One commenter advocated outlier payments for hospitals whose aggregate costs exceed total payments under the hospital outpatient PPS in a given year. A number of other commenters stated that the hospital outpatient PPS outlier policy should be similar to that currently used for the inpatient PPS.
Response: As we discussed above, section 201(a) of the BBRA 1999 amended the Act by adding a new section 1833(t)(5). This provision now requires the Secretary to make an additional outlier payment for outpatient services for which a hospital's or a CMHC's charges, adjusted to cost, exceed a fixed multiple of the new PPS payment as adjusted by pass-through payments. The Secretary is required to determine the fixed multiple and the percent of costs above the threshold that is to be paid under the outlier provision. As we explain above, to implement the outlier adjustment, we have determined that an outlier payment will be made when calculated bill costs exceed the PPS payments on a claim by more than 2.5 times. In addition, the provision of transitional pass-throughs under section 201(b) of the BBRA 1999, which requires the Secretary to make an additional payment for certain high cost medical devices, drugs, and biologicals, constitutes a kind of outlier adjustment (see section III.D of this preamble), and our decision to create special transitional payments for new technology items and services (see section III.C.8) will also provide additional payments to hospitals that incur higher costs under the outpatient PPS.
2. Transitional Corridors/Interim Payments
As we developed the proposed rule, we conducted extensive regression analysis of the relationship between outpatient hospital costs and several factors that affect costs, such as teaching intensity and disproportionate share percentage, as part of the analysis to determine whether payment adjustments should be proposed for the outpatient PPS. Ultimately, we did not propose any adjustments other than the wage index used to adjust for local variation in labor costs. One of the main reasons we did not propose any special adjustments was that the estimated effects of measured factors on costs were small and, in most cases, not statistically significant. In addition, we believe that the negative impacts estimated in the proposed rule for certain classes of hospitals were partially attributable to undercoding and coding variations in the data because coding did not affect the payment of many services under the current payment system, especially medical visits.
Since publication of our proposed policy, section 202(a)(3) of the BBRA 1999 added new paragraph (7) to section 1833(t) of the Act to require the Secretary to make payment adjustments during a transition period to limit the decline in payments under PPS for hospitals. These additional payments are to be implemented without regard to budget neutrality and are in effect through 2003.
Under paragraphs (A), (B), and (C) of section 1833(t)(7) of the Act, the amount of the payment adjustment for an individual hospital depends on the difference between the hospital's “PPS amount” and the hospital's “pre-BBA amount.” Section 1833(t)(7)(E) of the Act defines the “PPS amount” as the amount payable under PPS for the hospital's covered outpatient department services, excluding the effects of the transitional corridor and including coinsurance and deductibles. For purposes of calculating the PPS amount, we include the full copayment amounts; if a hospital chooses to reduce the copayment for some or all of the services that it furnishes, we will count the full copayment amounts rather than the reduced copayment amounts. Section 1833(t)(7)(F) of the Act defines the “pre-BBA amount” for a period as the amount equal to the product of (1) the hospital's reasonable cost for covered outpatient department services, and (2) the base outpatient department payment-to-cost ratio for the hospital. The statute defines “base payment-to-cost ratio” as the ratio of (1) the hospital's reimbursement for covered outpatient department services during the cost reporting period ending in 1996, to (2) the reasonable cost of the services for the period. The base payment-to-cost ratio will be calculated as if the amendments to sections 1833(i)(3)(B)(i)(II) and 1833(n)(1)(B)(i) of the Act made by section 4521 of the BBA 1997, to require that the full amount beneficiaries paid as coinsurance under section 1862(a)(2)(A) of the Act are taken into account in determining Medicare Part B Trust Fund payment to the hospital, were in effect in 1996.
For calendar years 2000 and 2001, payment to hospitals whose PPS payment is less than 100 percent, but is at least 90 percent, of the pre-BBA payment, is increased by 80 percent of the difference. Hospitals whose PPS payment is less than 90 percent, but is at least 80 percent, of the pre-BBA payment, will receive additional payment equal to the amount by which 71 percent of the estimated pre-BBA payment exceeds 70 percent of the PPS payment. Hospitals whose PPS payment is less than 80 percent, but is at least 70 percent, of the pre-BBA payment will receive additional payment equal to the amount by which 63 percent of the pre-BBA payment exceeds 60 percent of the PPS payment. Payments to hospitals whose PPS payment is less than 70 percent of the pre-BBA payment will be increased by 21 percent of the pre-BBA payment. For calendar years 2001 through 2003, the number of corridors and the associated percentage increases decline over time. As required by statute, interim payments will be made subject to retrospective adjustments. Section 1833(t)(7) of the Act provides special transition payments for cancer centers and small rural hospitals, which are discussed below in section III.H.3.
Comment: Hundreds of commenters, including associations, hospitals, and entities providing goods and services to hospitals, expressed grave concerns about the estimated impact of our proposed system on certain classes of hospitals. Many commenters noted that the case mix and service mix for specific classes of hospitals such as rehabilitation, cancer, children's, rural, and teaching hospitals are different than for other hospitals. They argued that a number of these hospitals deal with patients who typically require more resources. The commenters noted that we have authority under the statute to make adjustments for specific classes of hospitals. Some reasoned that given our estimates of substantial losses for certain classes of hospitals under the proposed hospital outpatient PPS, we should use our authority to exclude these classes of hospitals from the outpatient PPS for 2 years, require proper coding of bills from those hospitals, and have an opportunity to analyze the results of the improved coding. These commenters urged that we examine reasons other than coding that may contribute to the disparity. Many commenters recommended that a separate conversion factor be developed Start Printed Page 18500for the hospitals whose payments are adversely affected by the new system.
Response: As discussed above, section 1833(t)(7) of the Act, as added by section 202(a) of the BBRA 1999, provides that, for several years, additional payments be made to any facility for which the PPS payment is less than an estimate of the hospital's pre-PPS payment and that these payments are in addition to the total payments under the PPS. Our estimate of the impacts of this change in policy along with other payment-related provisions of the BBRA 1999 (discussed in further detail in section IX) show improved payments under PPS relative to pre-BBRA law for nearly all classes of hospitals. Our simulations show that hospitals overall receive an additional 4.6 percent in payments under PPS compared to pre-PPS law. Long-term care and children's hospitals show losses (1.7 percent and 3.2 percent, respectively). Moreover, urban hospitals with no indirect teaching or disproportionate share inpatient adjustments show a loss of 0.3 percent. In addition, we reexamined and reestimated the multivariate regression specifications described in the proposed rule to reflect the changes described in this rule. Based on the results of regression analysis, we believe further adjustments are not warranted at this time. We found, for example, the disproportionate share percentage did not have a statistically significant effect on unit costs standardized by service mix. In addition, positive and significant results did not occur for most teaching variables that we specified. For instance, positive and significant results did not occur for hospitals whose ratio of residents to inpatient and outpatient days was less than .28. Hospitals with a large number of residents to inpatient and outpatient days did demonstrate slightly higher standardized costs, but only when the regression model included independent variables for urban/rural location. Moreover, the parameter estimate was small and payment was not greatly improved when a corresponding adjustment was made to these teaching hospitals. Therefore, we are not making such adjustments for these hospital groups. We do not believe that this action will restrict beneficiary access to care because the projected losses are relatively small and could reflect undercoding on the part of these hospitals before PPS.
We will begin comprehensive analyses of cost and payment differentials between different classes of hospitals as soon as there is a sufficient amount of claims data submitted under the PPS. We will use data from the initial years of the PPS to conduct regression and simulation analyses. In addition, we will carefully track and analyze the additional payment made to hospitals under section 1833(t)(7) of the Act. These analyses will be used to consider and possibly propose adjustments in the system, particularly beginning in 2004 when the BBRA 1999 transition provisions expire.
Comment: Commenters from organizations representing teaching hospitals recommended that we include a budget-neutral payment adjustment for certain classes of hospitals such as teaching hospitals. For example, the concern is that PPS payments are not adequate for academic medical centers because they provide more resource-intensive outpatient services than other hospital types.
Response: As noted above, we are not making adjustments for specific classes of hospitals in this final rule. The primary reason for this decision is that section 1833(t)(7) of the Act requires additional payments through 2003 to all hospitals whose PPS payment falls below estimates of pre-PPS payment. We will conduct analyses and studies of cost and payment differential among different classes of hospitals, including teaching facilities, when sufficient data under the PPS have been submitted. We will carefully consider whether permanent adjustments should be made in the system once the BBRA 1999 transition provisions expire.
3. Cancer Centers and Small Rural Hospitals
Cancer Centers
In the BBA 1997, the Congress did not exclude from the hospital outpatient PPS the 10 cancer centers that are currently excluded from the inpatient PPS, but section 1833(t)(8) of the Act (as enacted in the BBA 1997) provides special consideration for these hospitals under the outpatient PPS. More specifically, that section provides that the outpatient PPS would not apply to the 10 cancer centers before January 1, 2000, and that the Secretary may establish a separate conversion factor for cancer centers to take into account the unique costs they incur due to their patient population and the intensity of their services.
In the proposed rule, we stated that, because we had no choice but to delay implementation of the PPS for all hospitals until sometime after January 1, 2000 due to Y2K concerns, we would begin paying cancer centers under hospital outpatient PPS at the same time. Also, we did not propose a separate conversion factor for cancer centers. Although our proposed impact analysis indicated that, under the PPS, the cancer centers could lose 32 percent of their current outpatient Medicare payments, we proposed to do additional work to try to explain the impact before we provided for a separate conversion factor or other payment adjustment.
Section 1833(t)(7)(D)(ii) of the Act, as added by the BBRA 1999, provides that the 10 cancer centers excluded from the inpatient PPS are permanently held harmless with respect to their pre-BBA 1997 amount.
Comment: The cancer centers commented that they are unlike other hospitals in that they treat the most difficult cases (patients often referred by community hospitals) and they are usually the first hospitals to use the latest technology related to cancer treatments. They also pointed out that their clinic visits often involve consultations with a number of physicians and therefore are longer and require more hospital resources than clinic visits in other hospitals. They believe that our proposed payments for clinic visits would seriously underpay them for their more comprehensive visits. The cancer centers also stated that any delay in recognizing and paying appropriately for new technology would affect them more adversely than it would other hospitals.
During the comment period for the proposed rule, the cancer centers submitted for our consideration an alternative payment methodology. Under their methodology, we would calculate a separate conversion factor for each of the 10 centers based on their individual base year Medicare payments and service mix. Subsequently, the conversion factors would be updated using the Congressionally determined update factor applicable to all hospitals. Hospitals would be paid interim payment amounts during the year, but payment would ultimately be based on the lesser of—
- The PPS payments they would receive using their individual conversion factor; or
- The payments they would receive based on their cost reports by applying the current (that is, pre-PPS) outpatient services payment methodology.
Capital costs would be excluded from this comparison and be paid on a reasonable cost pass-through basis. The proposal also envisioned some payment penalties and incentives similar to the penalties and incentives provided under the reasonable payment cost limit methodology applicable to hospitals excluded from the inpatient PPS. Start Printed Page 18501
Response: As noted above, new section 1833(t)(7)(D)(ii) of the Act holds cancer centers harmless on a permanent basis by providing that, in instances where Medicare payment to a cancer center under the hospital outpatient PPS would be lower than a specified pre-BBA Medicare payment for the same services, we are to pay the full pre-BBA amount. Therefore, an alternative approach to paying cancer centers under the hospital outpatient PPS is no longer needed.
Small Rural Hospitals
We noted in the proposed rule that rural hospitals generally receive a relatively high percentage of their Medicare income from outpatient services (greater than the national average), which compounds the impact of the reduction in Medicare payments to rural hospitals that we projected would result upon implementation of the hospital outpatient PPS. We attributed these reduced revenues to undercoding, lack of economies of scale, and reliance on the median instead of the geometric mean in the calculation of APC weights. Because our impact analysis revealed that low-volume rural hospitals that are sole community hospitals or Medicare-dependent hospitals could experience a considerable reduction in revenues under the outpatient PPS, we solicited comments in the proposed rule on two possible approaches to phasing in the outpatient PPS for these types of hospitals.
Section 1833(t)(7)(D)(i) of the Act provides that hospitals located in a rural area with 100 or fewer beds are held harmless with respect to their pre-BBA 1997 amount for outpatient services furnished before January 1, 2004. For purposes of implementing this provision, bed size will be determined in the same way it is for inpatient PPS for the indirect medical education adjustment as defined in § 412.105(b), Determination of number of beds. A hospital's location in a rural area will also be determined as it is in the inpatient PPS; see § 412.63(b), Geographic classifications.
Comment: Many commenters were concerned that the projected negative impact of the proposed outpatient PPS on rural hospitals would be magnified because outpatient revenues make up such a large part of rural hospitals' total revenues. Some commenters believe that our proposed PPS ratesetting method favors high volume, urban hospitals. Some commenters supported phasing in the outpatient PPS for rural disproportionate share hospitals because those facilities may not have the resources to improve their coding in the near future. One association opposed phasing in the PPS because doing so would postpone but not resolve the financial jeopardy imposed on rural hospitals by the hospital outpatient PPS. Some commenters recommended that we provide an “add-on” to the prospective rate for emergency services in low-volume sole community and rural disproportionate share hospitals. One commenter expressed concern about the numerous factors contributing to rural hospitals' negative margins that limit their ability to absorb losses, including a disproportionately high share of Medicare, Medicaid, and indigent patients, significant problems recruiting practitioners, low population density, and limited patient volume. Numerous commenters recommended that we establish a payment floor for low-volume rural hospitals. One association requested that we either revise the payment methodology or put in place a payment floor that guarantees health care services will continue to be available to Medicare beneficiaries served by rural hospitals.
Response: As we discuss above, in order to limit potential reductions in payment to hospitals under the outpatient PPS, section 1833(t)(7) of the Act, as added by section 202(a)(3) of the BBRA 1999, requires us to establish payment adjustments for hospitals whose PPS payments are less than our estimate of the hospital's pre-BBA payments. These additional payments are to be implemented in a non-budget neutral manner and are to be paid through 2003. Section 1833(t)(7)(D)(i) of the Act includes a special “hold harmless” provision, which is to be paid through 2003, for hospitals that are located in a rural area and that have no more than 100 beds. Under section 1833(t)(7)(D)(i) of the Act, as added by the BBRA 1999, small rural hospitals will be paid a predetermined pre-BBA amount for services covered under the outpatient PPS if payment under the PPS would be less than the pre-BBA amount. This hold harmless provision establishes a payment floor until January 1, 2004 for small rural hospitals. During this period, we will collect and analyze data under the PPS in order to assess whether any special adjustments will need to be made for rural hospitals once the hold harmless provision expires.
I. Annual Updates
1. Revisions to APC Groups, Weights and the Wage and Other Adjustments
Prior to enactment of the BBRA 1999, section 1833(t)(6)(A) of the Act required the Secretary to periodically review and revise the APC groups, the relative payment weights, and the wage and other adjustments to take into account changes in medical practice, changes in technology, the addition of new services, new cost data, and other relevant information and factors.
In the proposed rule, we described our plan to update the various components of the outpatient PPS. We proposed to keep the composition of all the APC groups essentially intact from one year to the next, with the exception of the few changes that may be necessary as a consequence of annual revisions to HCPCS and ICD-9-CM (International Classification of Diseases, Ninth Edition, Clinical Modification) codes. We stated that we did not plan to routinely reclassify services and procedures from one APC to another. We proposed to make these changes based on evidence that a reassignment would improve the group(s) either clinically or with respect to resource consumption. However, we specifically solicited comments on how frequently to recalibrate the APC weights and on the method and data that should be used. We defined recalibration as the updating of all the APC group weights based on more recent information.
We proposed to update the wage index values used to calculate program payment and coinsurance amounts on a calendar year basis, adopting, effective for services furnished each January 1, the wage index value established for a hospital under the inpatient PPS the previous October 1. The first update to the wage index values will be effective for calendar year 2001 beginning January 1, 2001.
Section 201(h)(1)(A) of the BBRA 1999 amended section 1833(t)(8)(A) of the Act (as redesignated by section 201(a) of the BBRA 1999) to require the Secretary to review the components of the outpatient PPS not less often than annually and revise the groups, the relative payment weights, and the wage and other adjustments to take into account changes in medical practice, changes in technology, and the addition of new services, new cost data, and other relevant information and factors. (Section 202(a) of the BBRA 1999 further redesignated section 1833(t)(8) as section 1833(t)(9).)
Section 201(h)(1)(B) of the BBRA 1999 further amended this section of the Act to require that the Secretary consult Start Printed Page 18502with an expert outside advisory panel composed of an appropriate selection of representatives of providers to review (and advise the Secretary concerning) the clinical integrity of the groups and weights. This provision allows these experts to use data other than those collected or developed by us during our review of the APC groups and weights. Section 201(h)(2) of the BBRA 1999 requires the Secretary to initiate the annual review process beginning in 2001 for the PPS payments that would take effect January 1, 2002.
Comment: A number of commenters urged that we adopt an annual update cycle for APC recalibration. Some commented that the APC update frequency should not be less often than the annual cycles that we have instituted for both the hospital inpatient PPS and physician fee schedule payment system. Many commenters maintained that annual updating is necessary to ensure that the APCs appropriately reflect changes in new technologies, standards of care, and other marketplace patterns. Several commenters stated that an annual update cycle is needed to take into account changes in drug prices and appropriately reflect advancements in nuclear medicine. Some commenters believe that updating the APCs less frequently than annually would adversely impact hospitals that would incur financial losses attributable to inappropriate payment for new technologies. Some commenters contended that infrequent updating would be a disincentive for manufacturers to develop new outpatient therapies.
Response: In accordance with the amendments enacted by the BBRA 1999, we will review and update annually, for implementation effective January 1 of each year, the APC groups, the relative payment weights, and the wage and other adjustments that are components of the outpatient PPS, beginning with the update to be effective January 1, 2002.
2. Annual Update to the Conversion Factor
We stated in the proposed rule that section 1833(t)(3)(C)(ii) of the Act requires us to update annually the conversion factor used to determine APC payment rates. Section 1833(t)(3)(C)(iii) of the Act provides that the update be equal to the hospital inpatient market basket percentage increase applicable to hospital discharges under section 1886(b)(3)(B)(iii) of the Act, reduced by one percentage point for the years 2000, 2001, and 2002. The Secretary also has the option (under section 1833(t)(3)(C)(iii) of the Act) of developing a market basket that is specific to hospital outpatient services. We advised in our proposed rule that we are considering this option, and specifically invited comments on possible sources of data that are suitable for constructing a market basket specific to hospital outpatient services. We did not receive any comments regarding potential data sources for constructing a hospital outpatient-specific market basket. Therefore, we will update the conversion factor annually by the hospital inpatient market basket increase (as specified in section 1886(b)(3)(B) of the Act), reduced by one percentage point for the years 2000, 2001, and 2002.
3. Advisory Panel for APC Updates
As stated above, section 1833(t)(9)(A) of the Act (as redesignated by section 201(a) of the BBRA 1999 and further redesignated by section 202(a) of the BBRA 1999) requires the Secretary, beginning in 2001, to consult with an expert outside advisory panel of appropriately selected provider representatives when annually reviewing and updating the APC groups and the relative group weights. The statute specifies that the expert panel will act in an advisory capacity on matters pertaining to the clinical integrity of the groups and weights and that it may use data other than those developed or collected by us in executing this function. We will initiate this review process in 2001 for the hospital outpatient PPS payments that will take effect for services furnished on or after January 1, 2002. We will adopt a process for identifying and appropriately selecting provider representatives to serve as members of an expert advisory panel. We anticipate informing the hospital community of the formation of an expert advisory panel through timely notice in the Federal Register.
J. Volume Control Measures
Section 1833(t)(2)(F) of the Act requires the Secretary to develop a method for controlling unnecessary increases in the volume of covered outpatient department services. Section 1833(t)(6)(C) of the Act, as added by the BBA 1997, authorizes the Secretary to adjust the update of the conversion factor if we determine that the volume of services paid for under the outpatient PPS increases beyond amounts we establish under section 1833(t)(2)(F) of the Act.
In the proposed rule, we proposed a volume control measure for services furnished in CY 2000 only. We discussed several long-term alternatives to control volume for services furnished in subsequent years, and we solicited comments on those options. We stated that we would propose an appropriate volume control mechanism for services furnished in CY 2001 and beyond after we completed further analysis. Given the complexities of developing an appropriate volume control mechanism for hospital outpatient services, we believed additional study was necessary.
For CY 2000, we proposed to use a modified version of the physician sustainable growth rate system (SGR), which is required under section 1848(d)(3) of the Act, for purposes of the hospital outpatient PPS. As we stated in the proposed rule, this appeared to be the most feasible initial approach. Using this approach, we proposed to update the target amount specified under section 1833(t)(3)(A) for CY 1999 as an expenditure target for services furnished in CY 2000. We stated that we would update the CY 1999 target for inflation (based on the projected change in the hospital market basket minus one percentage point), estimate changes in the volume and intensity of hospital outpatient services, and estimate Part B fee-for-service changes in enrollment. If volume exceeded the target for CY 2000, we proposed to adjust the update to the conversion factor for CY 2002. We further stated that we would compare the CY 2000 target to an estimate of CY 2000 actual payments to hospitals as determined by our Office of the Actuary using the best available data. We proposed that if unnecessary volume increases, as reflected by expenditure levels, caused payment to exceed the target, we would determine the percentage by which the target is exceeded, and adjust the CY 2002 update to the conversion factor by the same percentage.
We indicated that we would respond in the final rule to comments on our proposed volume control measure for services furnished in CY 2000, but not to comments about volume control options for services furnished after CY 2000, which will be addressed in a later proposed rule.
Comment: We received many comments opposing our proposed use of an SGR-like system to control unnecessary volume increases under the hospital outpatient PPS. Most commenters strongly urged us to exercise the discretionary authority allowed under section 1833(t)(9)(C) of the Act (as redesignated) not to adjust the update to the conversion factor. A few commenters endorsed the provision Start Printed Page 18503of the “President's Plan to Modernize and Strengthen Medicare for the 21st Century” (issued July 2, 1999) to delay adoption of a volume control measure in order to give hospitals additional time to adjust to the new system. Several commenters, including one national physicians' association, contended that we did not have the statutory authority to establish and use an expenditure target in the manner that we had proposed. The physicians' association stated that the law limits use of the SGR system to physician services. Some commenters believe that we lack the expertise needed to set an accurate target amount. Others argued that an expenditure target is not a reliable way to distinguish the growth of necessary versus unnecessary services and that our proposal would therefore have consequences not intended by the statute (that is, affecting all services rather than only those that would be considered unnecessary). Some commenters stated that expenditure caps only work when they directly affect those who control the volume. These commenters contended that a volume control measure is unfair to hospitals because it is physicians, not hospitals, who order services and therefore control volume. Some commenters were concerned that adopting a volume control measure would penalize hospitals for increases in outpatient volume attributable to technological changes that appropriately shift service delivery from the inpatient to outpatient setting. In addition, numerous organizations recommended that we not implement the volume expenditure targets and control measures because payments would be reduced to inadequate levels and affect beneficiary access to care.
Response: We are delaying implementation of a volume control mechanism as suggested by the “President's Plan to Modernize and Strengthen Medicare for the 21st Century” (the statute does not specify an implementation date). This delay gives hospitals time to adjust to the PPS, and it gives us additional time to study appropriate methods of controlling outpatient volume over the long term. We are currently working with a contractor to study options for volume control measures for outpatient services. In the future, before we make any final decision, we will publish a notice in which we will discuss our proposal and will provide a public comment period.
K. Claims Submission and Processing and Medical Review
Comment: Numerous commenters expressed a variety of concerns related to information exchange processes required by the new PPS. Several commenters stated that the remittance advice documents will need to reflect all of the components used in calculating payment for each claim, as well as possible coinsurance reductions. The commenters also were concerned that, with the complexity of the APC system, hospitals will need the ability to verify payment. One health system that had experience with 3M's APGs offered the experience of their member hospitals to assist us by providing input on the data needed by hospitals to manage APCs. This same commenter stated that hospitals must be given detailed instructions on claims submission, changes to the UB-92, and changes to the Correct Coding Initiative (CCI) in advance to ensure that systems and personnel can comply with Medicare requirements.
Response: We released specific hospital billing instructions that address line item reporting and reporting of service units on December 23, 1999 (Transmittals 1787 and 747). We will be issuing final instructions for implementation of this PPS in a program memorandum to fiscal intermediaries. The program memorandum addresses a range of issues such as appropriate use of revenue center/HCPCS codes for compliance with Medicare requirements and changes to Remittance Advice messages and Medicare Summary Notices/EOMBs.
All current correct coding initiative (CCI) edits with the exception of laboratory and anesthesiology edits have been incorporated in the outpatient code editor (OCE) that fiscal intermediaries use to process claims for hospital outpatient services for payment. We will address OCE changes in a program memorandum to fiscal intermediaries. The effective date of these edits is July 1, 2000.
We have decided not to pursue changes to the UB-92 claim form to allow line item diagnosis because, as we discuss in section III.C.3, we will not be using diagnosis to determine payments for clinic and emergency visits when the PPS is first implemented. Diagnosis codes, however, are still required to be reported on hospital outpatient bills.
Medical Review Under the Hospital Outpatient PPS
We have received inquiries regarding the anticipated medical review process for hospital outpatient PPS claims. The methodology of review for outpatient claims does not change under the PPS. The goal of medical review is to identify inappropriate billing and to ensure that payment is not made for noncovered services. Contractors may review any claim at any time, including requesting medical records, to ensure that payment is appropriate. In accordance with this final rule, Medicare will make payment under the PPS for hospital outpatient services including partial hospitalization services; certain Part B services furnished to inpatients who have no Part A coverage; partial hospitalization services furnished by CMHCs; vaccines, splints, casts and antigens provided by HHAs and CORFs that provide medical and other health services; and splints, casts and antigens provided to hospice patients for the treatment of a nonterminal illness. In addition, we expect focused reviews will include the adjustments we have made to the hospital outpatient PPS as a result of the enactment of the BBRA 1999, especially the transitional pass-through payments for innovative drugs, biologicals, and medical devices that are discussed in section III.D. Fiscal intermediaries will continue focused and random review of services such as ambulance, clinical diagnostic laboratory, orthotics, prosthetics, take home surgical dressings, chronic dialysis, screening mammographies, and outpatient rehabilitation (physical therapy including speech language pathology and occupational therapy) even though these services are excluded from the scope of services paid under the hospital outpatient PPS.
L. Prohibition Against Administrative or Judicial Review
Section 1833(t)(9) of the Act, as added by the BBA 1997, prohibits administrative or judicial review of the development of the PPS classification system, the groups, relative payment weights, wage adjustment factors, other adjustments, volume control methods, calculation of base amounts, periodic control methods, periodic adjustments, and the establishment of a separate conversion factor for cancer hospitals. Section 201(a) of the BBRA 1999 redesignates this section as section 1833(t)(11) of the Act, and section 201(d) of the BBRA 1999 amends the section by adding the following to the list of adjustments subject to the limitation on judicial review: the factors used to determine outlier payments, that is, the fixed multiple, or a fixed dollar cutoff amount; the marginal cost of care, or applicable total payment percentage; and the factors used to determine additional payments for certain medical devices, drugs, and biologicals such as the determination of insignificant cost, the duration of the additional payments, the portion of the outpatient PPS Start Printed Page 18504payment amount associated with particular devices, drugs, or biologicals, and any pro rata reduction. Section 202(a) of the BBRA 1999 further redesignates section 1833(t)(11) as section 1833(t)(12).
IV. Provider-Based Status
A. Background
The Medicare law (section 1861(u) of the Act) lists the types of facilities that are regarded as providers of services, but does not use or define the term “provider-based.” However, from the beginning of the Medicare program, some providers, which we refer to in this section as “main providers,” have owned and operated other facilities, such as SNFs or HHAs, that were administered financially and clinically by the main provider. The subordinate facilities may have been located on the main provider campus or may have been located away from the main provider. In order to accommodate the financial integration of the two facilities without creating an administrative burden, we have permitted the subordinate facility to be considered provider-based. The determination of provider-based status allowed the main provider to achieve certain economies of scale. To the extent that overhead costs of the main provider, such as administrative, general, housekeeping, etc., were shared by the subsidiary facility, these costs were allowed to flow to the subordinate facility through the cost allocation process in the cost report. This was considered appropriate because these facilities were also operationally integrated, and the provider-based facility was sharing the overhead costs and revenue producing services controlled by the main provider.
Before implementation of the hospital inpatient PPS in 1983, there was little incentive for providers to affiliate with one another merely to increase Medicare revenues or to misrepresent themselves as being provider-based, because at that time each provider was paid primarily on a retrospective, cost-based system. At that time, it was in the best interest of both the Medicare program and the providers to allow the subordinate facilities to claim provider-based status, because the main providers achieved certain economies, primarily on overhead costs, due to the low incremental nature of the additional costs incurred.
In the proposed rule, we pointed out the increase of provider-based facilities and the financial and organizational incentives for that increase since 1983. A variety of factors such as the emergence of integrated delivery systems and the pressure to enhance revenues have combined to create incentives for providers to affiliate with one another and to acquire control of nonprovider treatment settings, such as physician offices.
We noted in the proposed rule that it is essential that we make decisions regarding provider-based status appropriately, and that we have clear rules for identifying provider-based entities. By failing to distinguish properly between provider-based and free-standing facilities or organizations, we risk increasing program payments and beneficiary coinsurance with no commensurate benefit to the Medicare program or its beneficiaries and we jeopardize the delivery of safe and appropriate health care services to our beneficiaries.
Although there is no direct statutory requirement to maintain explicit criteria for determination of provider-based status, there are statutory references acknowledging the existence of this payment outcome. For example, section 1881(b) of the Act provides for separate payment rates for hospital-based ESRD facilities. There is currently no general definition of “provider-based facility” in the CFR. However, in the proposed rule, we cited issuances that do contain provisions for recognition of specific types of entities as provider-based, including Program Memorandum A-96-7, published on August 27, 1996, which pulled together instructions for specific entity types from previously published documents and consolidated them into a general instruction for the designation of provider-based status for all facilities or organizations. That Program Memorandum was subsequently reissued, without substantive change, as Program Memoranda A-98-15 and A-99-24 and, in October 1999, was manualized by the Provider Reimbursement Manual, Part I, Transmittal 411 (adding new section 2446), and the State Operations Manual, Transmittal 11 (replacing previous section 2003 and adding new section 2004). Our policy will continue to follow the principles we articulated in Program Memorandum A-96-7 and the Provider Reimbursement Manual and State Operations Manual sections cited above until October 10, 2000. After that date, we shall apply the policies set forth in these final regulations.
B. Provisions of the Proposed Rule
We announced our intention to implement §§ 413.24(d)(6)(i) and (ii), 413.65, 489.24(b), and 498.3, as revised based on our consideration of public comments, with respect to services furnished on or after 30 days following publication of a final rule. We describe these sections below and explain that we have now provided a 6-month delay in the effective date of the regulations on provider-based status.
We proposed to add a new § 413.65 on the determination of provider-based status. In paragraph (a), we proposed to define the following terms: department of a provider, free-standing facility, main provider, provider-based entity, and provider-based status. In paragraph (b), we proposed that a facility or organization would not be entitled to be treated as provider-based simply because it or the provider believe it to be provider-based. The facility or organization, or the provider, would have to contact HCFA and obtain an affirmative provider-based determination before billing of the facility's or organization's costs through the main provider, or inclusion of those costs on the main provider's cost report, is initiated. Further, we proposed to presume a facility not located on the campus of a hospital and used as a site of physician services of the kind ordinarily furnished in physician offices to be a free-standing facility unless we determined it to have provider-based status.
We proposed to require, in paragraph (c), that a main provider that acquires a facility or organization for which it wishes to claim provider-based status must report its acquisition of the facility or organization to us if the facility or organization is off the campus of the main provider, or is located on the campus of the main provider and, if acquired, would increase the main provider's costs by 5 percent or more. The main provider must also furnish all information needed for a determination as to whether the facility or organization meets the criteria in this section for provider-based status. A main provider that has had one or more facilities or organizations determined to have provider-based status also must report to us any material change in the relationship between it and any department or provider-based entity, such as a change in ownership of the entity or entry into a new or different management contract, that could affect the provider-based status of the department or entity.
In paragraph (d), we proposed the requirements for a determination of provider-based status. In paragraph (d)(1), we proposed to set forth licensure requirements for facilities or organizations seeking provider-based status.
In paragraph (d)(2), we proposed to require that a facility or organization be Start Printed Page 18505under the ownership and control of the main provider.
In paragraph (d)(3), with respect to administration and direct supervision of the main provider, we proposed to require that a facility or organization seeking provider-based status have a reporting relationship to the main provider that is characterized by the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and one of its departments.
In paragraph (d)(4), we proposed that a facility or organization seeking provider-based status and the main provider share integrated clinical services, as evidenced by privileging of the professional staff of the department or entity at the main provider, and the main provider's maintenance of the same monitoring and oversight of the department or entity as of other departments. Also, the medical director of the department or entity would be required to maintain a day-to-day reporting relationship with the chief medical officer (or equivalent) of the main provider, and be under the same supervision as any other director of the main provider.
In paragraph (d)(5), we proposed to require that the department or entity and the main provider be fully financially integrated within the main provider's financial system, as evidenced by the sharing of income and expenses. The department's or entity's costs should be reported in a cost center of the provider, and the department's or entity's financial status should be incorporated into, and readily identifiable in, the main provider's trial balance.
In paragraph (d)(6), we proposed to require that the main provider and the facility seeking status as a department of the provider be held out to the public as a single entity, so that when patients enter the department they are aware that they are entering the provider and will be billed accordingly. (This requirement would not apply to a provider-based entity that is itself a provider, such as a SNF.)
In paragraph (d)(7), we proposed to require that the department of a provider or provider-based entity and the main provider be located on the same campus, except where requirements relating to service to the same patient population are met.
Paragraph (e) would specifically prohibit the approval of provider-based status for any proposed department or entity that is owned by two or more providers engaged in a joint venture.
In proposed paragraph (f), we proposed to state that facilities or organizations operated under management contracts would be considered provider-based only if specific requirements are met related to: Staff employment, administrative functions, day-to-day control of operations, and holding of the management contract by the provider itself rather than by a parent organization.
In proposed paragraph (g), we proposed to specify nine obligations of hospital outpatient departments and hospital-based entities. We explained that these obligations ensure that facilities seeking recognition as hospital outpatient departments or hospital-based entities are in fact what they represent themselves to be, and are not simply the private offices of individual physicians or of physicians in group practices.
We also proposed to preclude any facility or organization that furnishes all services under arrangements from qualifying as provider-based. We believe the provision of services under arrangement was intended to be allowed only to a limited extent, in situations where cost-effectiveness or clinical considerations, or both, necessitate the provision of services by someone other than the provider's own staff. The “under arrangement” provision in section 1861(w)(1) of the Act and § 409.3 is not intended to allow a facility merely to act as a billing agent for another.
Proposed paragraph (h) states that, if we learn of a provider that has inappropriately treated a facility or organization as provider-based, before obtaining our determination of provider-based status, we would reconsider all payments to that main provider for those periods subject to reopening, and we would investigate to determine whether the designation was appropriate.
In proposed paragraph (i), we would apply the principles in paragraph (h) to situations involving inappropriate billing for services furnished in a physician's office or other facility or organization as if they had been furnished in a hospital outpatient or other department of a provider or in a provider-based entity.
We also proposed to add a new paragraph (j) that would allow us to review past determinations. If we find that a designation was in error, and the facility or organization in question does not meet the requirements of this section, we will notify the main provider that the provider-based status will cease as of the first day of the next cost report period following notification of the redetermination.
In addition, we proposed to add to § 413.24(d) new paragraphs (6)(i) and (6)(ii) to clarify that main providers, in completing their Medicare cost reports, may not allocate overhead costs to the provider-based or other cost centers that incur similar costs directly through management contracts or other arrangements. These changes are needed to prevent misallocation of management costs, which would result in excessive payment to those types of providers paid on a reasonable cost basis.
To provide an administrative appeals process for entities that have been denied provider-based status, we proposed to revise the regulations on provider appeals at § 498.3. As revised, these rules would specify that a provider seeking a determination that a facility or an organization is a department of the provider or a provider-based entity under proposed § 413.65 would be included in the definition of “prospective provider” for purposes of part 498, and would be afforded the same appeal rights as a prospective provider, such as a hospital or SNF, that we have found not to qualify for participation as a provider.
C. Comments and Responses
In response to our proposals, we received approximately 120 letters of comment, most of which raised a number of issues. Included among the commenters were hospitals and hospital and other provider associations, physicians, attorneys, and other individuals. Here we respond to comments submitted on the proposed rule.
General Comments
Many comments were not directed to a specific provision or criterion, but concerned the implementation of the regulations or the application of provider-based criteria to specific types of facilities. These are summarized below.
Effective Date
Comment: A commenter requested clarification as to when the parts of the final rule setting forth criteria for provider-based status would be effective, and a number of commenters requested an extended grace period or a delay in effective date of the final rules, with some commenters requesting delays as long as 12 to 18 months. Various reasons were cited, including the pressures on providers to prepare their systems and staff for the outpatient PPS, the need to bring operations into compliance with the provider-based criteria, and the anticipated workloads of HCFA regional offices that may Start Printed Page 18506receive a large number of requests for provider-based determinations. Commenters argued that it is unrealistic to expect that a hospital would engage in a full-blown analysis of its provider-based arrangements and modify each arrangement until it knows against which exact criteria it is measuring those arrangements. Any changes in status will require hospitals to implement billing and other operational changes. Thus, commenters argued that it is not reasonable to expect hospitals to complete such steps within a 30-day period.
Response: We agree, and are providing a delay in the effective date until October 10, 2000. Moreover, as stated in our response to comments on proposed § 413.65(j) below, any redetermination of provider-based status that finds the facility or organization not to be provider-based will not take effect for at least 6 months after the date the provider is notified of the redetermination.
Application to Specific Facilities
Comment: One commenter stated that under the Balanced Budget Act of 1997 (the BBA 1997) long-term hospitals established on or before September 30, 1995 are entitled to retain their long-term hospital classification notwithstanding their location in the same building or campus of another hospital. In the commenter's view, these hospitals should not now have this classification revoked by this proposed regulation.
Response: The provision referred to by the commenter, section 4417(a) of the BBA 1997, is codified in section 1886(d)(1)(B) of the Act and is implemented under regulations at § 412.22(f). That provision authorizes certain hospitals to continue being excluded from the Medicare hospital inpatient prospective payment system (PPS) based on their exclusion status and configuration on or before September 30, 1995, even though they would not otherwise qualify for this exclusion. The criteria for provider-based status do not conflict with or even directly relate to the section 4417(a) provision, and we have therefore not made any change in the regulations based on this comment.
Comment: The commenter believes that rural health clinics (RHCs) should be exempted from provider-based designation requirements if they meet the intent of the enabling regulation. The commenter requested that an RHC be granted provider-based status if it meets one of the following criteria: Is the sole source of primary care for the community; has traditionally served the community with an open door policy; or treats a disproportionate share of the community's Medicare and Medicaid population.
Response: We share the commenter's concern, but believe the criteria suggested are overly inclusive and could lead to a proliferation of RHCs in areas where there are no true shortages of care. While we do not believe a blanket exemption from the criteria is warranted, we have developed a special provision for RHCs affiliated with small rural hospitals, as described below in our responses to comments on § 415.65(d)(7), Location in immediate vicinity.
Comment: A commenter stated that there may be instances where the Medicare regulations related to provider-based definitions conflict with the Medicaid provider-based regulations, and asked whether Medicaid will be required to comply with the new Medicare provider-based regulations.
Response: Because hospitals under Medicaid are required to meet the same standards as Medicare facilities, these final rules would affect the Medicaid definition of these facilities as well as the Medicare definitions.
Comment: Commenters stated that the reasons cited for establishing provider-based requirements that are found in the preamble do not apply to clinical laboratories and thus these requirements should not apply. The commenters asked that we explicitly state in the final regulations that the provider-based requirements are not applicable to clinical laboratories. They believe the regulations have little bearing where, as with clinical laboratory services, reimbursement is under a fee schedule amount, and neither the Medicare program nor the beneficiary will pay anyone differently as a result of the treatment of the laboratory in the manner proposed.
Response: As explained more fully in the preamble to the proposed rule, our objective in issuing specific criteria for provider-based status is to ensure that higher levels of Medicare payment and increases in beneficiary liability for deductibles or coinsurance (which can all be associated with provider-based status) are limited to situations where the facility or organization is clearly and unequivocally an integral and subordinate part of a provider. Under this principle, we agree with the commenter's view that it would not be either necessary or appropriate to make provider-based determinations with respect to facilities or organizations if by law their status (that is, provider-based or free-standing) would not affect either Medicare payment levels or beneficiary liability. However, we believe that it is not necessary to specify in the regulations that specific facility types are excluded, since these facilities or organizations are unlikely to seek a provider-based determination. We will be careful to clarify this policy in program operating instructions.
Comment: A commenter stated that the proposed provider-based requirements seem to preclude the possibility of a Comprehensive Outpatient Rehabilitation Facility (CORF) meeting these new requirements. The commenter believes that in the past, CORFs have been permitted to be either provider-based or free-standing and asked whether the final rules will give CORFs the option of being either free-standing or provider-based.
Response: As explained more fully in the preamble to the proposed rule, our objective in issuing specific criteria for provider-based status is to ensure that higher levels of Medicare payment and increases in beneficiary liability for deductibles or coinsurance (which can all be associated with provider-based status) are limited to situations where the facility or organization is clearly and unequivocally an integral and subordinate part of a provider. We are aware that, under the cost-based payment system that applied to CORFs prior to January 1, 1999, approximately 17 percent of participating CORFs claimed provider-based status. However, effective January 1, 1999, in accordance with the BBA 1997, payment for all CORF services is made no longer on the basis of cost reimbursement but on the basis of the physician fee schedule. Beneficiary liability is also determined under the fee schedule, regardless of the organizational structure or affiliations of the CORF. The switch to fee schedule payment from a cost-based system eliminates or removes any payment incentives to be a provider-based rather than a free-standing CORF. Thus, as in the case of the preceding comment, we agree with the commenter's view that it would not be either necessary or appropriate to make provider-based determinations with respect to facilities or organizations if by law their status (that is, provider-based or free-standing) would not affect either Medicare payment levels or beneficiary liability. We also note that existing regulations at § 413.174 specify rules for determining whether ESRD facilities are independent or hospital-based, and we have revised § 413.65(a) to state that determinations with respect to ESRD facilities will continue to be made under § 413.174, Start Printed Page 18507not § 413.65. However, we believe that it is not necessary to specify in the regulations that most specific facility types are excluded, since these facilities or organizations are unlikely to seek a provider-based determination. We will be careful to clarify this policy in program operating instructions.
Application to Specific Facilities—Indian Health Service (IHS)
Comment: Several commenters requested an exception or exemption from the rules for IHS and tribal facilities. One commenter was concerned that the implementation of these proposed regulations will have the effect of denying Medicare participation as provider-based entities to a number of IHS facilities that are currently operated by Indian tribes under the auspices of Public Law 93-638. They will also cause a disruption of the coordinated health care delivery system(s) that exist between IHS and numerous tribes, and jeopardize statutorily authorized contracting and compacting relationships between the IHS and these tribes due to the conflict between these proposed regulations and the statutory opportunities for self-determination by the Indian tribes. The IHS strongly recommended that these proposed regulations not apply to IHS and tribal health systems as written. Recommendations were also made to deem satellite facilities within a discrete Indian reservation as meeting the definition of a provider-based entity as well as satellite facilities within a historical service unit. Finally, the IHS recommended that the current system be “grandfathered” to meet the definition of provider-based entity.
Response: We share many of these concerns and have provided special treatment for IHS and tribal facilities as described below.
Comment: A commenter was concerned that the proposed regulations would severely restrict a number of IHS satellite clinics from receiving reimbursement for the provision of Medicare Part B services. The commenter believes that a number of the requirements that must be met before an entity can be designated as provider-based for Medicare payment purposes are unrealistic for IHS satellite clinics, which are often the only Medicare providers on remote tribal lands. The commenter recommended that HCFA provide for an exemption for IHS satellite facilities that are generally located on a main hospital campus or within a short distance of a hospital. Also, the commenter recommended that the final rule clarify that IHS and tribal outpatient departments or satellite clinics are eligible to receive designation as a department of a provider or a provider-based entity and are eligible for Part B reimbursement.
Response: We share many of these concerns and have provided special treatment for IHS and tribal facilities as described below.
Comment: Many tribes have acquired operations of outpatient facilities and are in the process of acquiring the affiliated hospitals. The commenter stated that this trend, coupled with the complexities of the Indian Self-Determination Act (Pub. L. 93-638), the Indian Health Care Improvement Act (Pub. L. 94-437), and a moratorium on tribal compacting and contracting, requires special consideration by HCFA. The commenter requested that facilities be recognized as provider-based if—
(1) The outpatient facility is owned and operated by the tribe that owns the majority of the tribal shares utilized in funding the main hospital;
(2) The tribe has previously compacted programs that were historically administered by the hospital and are now administered through a committee or board comprised of medical staff of both facilities;
(3) The outpatient facility is in the same State as the hospital;
(4) There is coordination and integration of services, to the extent practicable, between the outpatient facility seeking provider-based status and the main provider.
Response: We recognize that the provision of health services to members of Federally recognized Tribes is based on a special and legally recognized relationship between Indian tribes and the United States Government. To address this relationship, the IHS has developed an integrated system to provide care that has its foundation in IHS hospitals. Because of these special circumstances, not present in the case of private, non-Federal facilities and organizations that serve patients generally, we agree that it would not be appropriate to apply the provider-based criteria to IHS facilities or organizations or to most tribal facilities or organizations. Therefore, we have revised the final rule to state that facilities and organizations operated by the IHS or Tribes will be considered to be departments of hospitals operated by the Indian Health Service or Tribes if, on or before April 7, 2000, they furnished only services that were billed as if they had been furnished by a department of a hospital operated by the Indian Health Service or a Tribe and they are: (1) owned and operated by the IHS; (2) owned by the Tribe but leased from the Tribe by the IHS under the Indian Self-Determination Act in accordance with applicable regulations and policies of the Indian Health Service in consultation with Tribes: or (3) owned by the IHS but leased and operated by the Tribe under the Indian Self-Determination Act in accordance with applicable regulations and policies of the Indian Health Service in consultation with Tribes. Facilities or organizations that are neither leased nor owned by the IHS would not be eligible for this special treatment, even if operated on Tribal land by members of the Tribe. These facilities would, of course, be eligible to participate in Medicare as FQHCs if applicable requirements in our regulations at 42 CFR part 405, subpart X are met. We did not adopt the conditions recommended by one commenter because we believe they may not apply to all Tribes.
Application to Specific Facilities—Federally Qualified Health Centers (FQHCs)
Comment: A commenter stated that despite specific acknowledgment of the eligibility of FQHCs to qualify as provider-based entities, certain proposed ownership, governance, and supervision criteria in connection with the determination of provider-based status would effectively prohibit entities from maintaining concurrent provider-based and FQHC designations. The commenter believe the criteria should be modified, or some other special provision created, to allow FQHCs to be departments of a provider.
Response: We understand the commenter's concerns and have provided special treatment for FQHCs as described below.
Comment: The commenter, a hospital that is affiliated with a number of off-site community health centers, believes the criteria in the proposed rule would deny provider-based status to community controlled, urban tax-exempt health centers operated under the license of a “main provider.” Several of the commenter's health centers are FQHCs that must fulfill certain criteria to maintain this status. In the commenter's view, it is not feasible to require the “main provider” to own and control these health centers or to require that the health centers and the “main provider” strictly meet all of the requirements set forth in the proposed rule. The commenter asked that the final rule be revised to take into account these historical relationships and “grandfather” the provider-based status of health centers that have been on the license of a disproportionate share hospital for at least 10 years. The recommended “grandfathering” Start Printed Page 18508provisions also could, in the commenter's view, require common Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation, integration of clinical care committees, main provider approval of clinical guidelines and protocols, and financial oversight and review by the main provider.
Response: We share many of these concerns and have provided special treatment for FQHCs as described below.
Comment: A commenter requested that we provide a transition period of at least five years for health centers that have been treated as provider-based entities for a significant period of time (for example, 10 years or more), so that the centers will have adequate time to achieve compliance with the provider-based criteria. In the commenter's view, an extended time period for compliance would permit continuity of care to the populations served by the health centers while granting the affected health centers an opportunity to find alternative funding streams.
Response: We recognize that FQHC qualification criteria effectively require these facilities to be governed by community-based boards independent of hospitals and other providers, while our provider-based criteria require facilities seeking provider-based status to be operated under the ownership and control of the main provider, and to be under the direct supervision of that provider. This does not preclude an FQHC from participating in Medicare as a free-standing entity; on the contrary, this participation is entirely appropriate. However, it does preclude the facility from qualifying as a department of a hospital or other provider under our criteria.
Despite the difference between HRSA and HCFA requirements, we are aware that some FQHCs may have been treated by hospitals as departments for purposes of Medicare and Medicaid billing, and we are concerned that an abrupt change in status for them could force some or all to close, leading to shortages of care in some areas. Therefore, we plan to establish special provisions for FQHCs and FQHC “look-alikes” (facilities that are structured like FQHCs and meet all requirements for grant funding, but have not actually received these grants). Specifically, we have revised the regulations to state that if a facility has since April 7, 1995 furnished only services that were billed as if they had been furnished by a department of a provider and either (1) received a grant before 1995 under section 330 of the Public Health Service Act or, before 1995, received funding from such a grant under a contract with the recipient of such a grant and meets the requirements to receive a grant under section 330 of the Public Health Service Act; or (2) based on the recommendation of the PHS, was determined by HCFA before 1995 to meet the requirements for receiving such a grant, the facility will continue to be treated, for purposes of this section, as a department of the provider without regard to whether it complies with the criteria for provider-based status in § 413.65. We note that both types of facilities would be obligated, for as long as they are treated as a department of a provider, to comply with the applicable requirements for departments of providers as stated in § 413.65(g).
Application of Standards
Comment: One commenter believes that the proposed rule did not make clear how it would apply to existing entities, because some language in the rule could be read to require that existing entities would not receive provider-based status until we have issued a determination letter. Another commenter requested that we clarify whether we expect to review all clinics prospectively or just new clinics. The commenter stated that requirements that only new clinics seek designation does not preclude us from auditing currently designated clinics. Another commenter asked if there will be a set time frame during which current providers with provider-based departments or entities under Program Memorandum A-96-7 must contact us and receive an official designation in order to continue billing as they currently do. More specifically, the commenter asked whether, if there is such a time frame, compliance with the criteria in the Program Memorandum would constitute a good faith effort as referred to in § 413.65(i)(2). Additional guidance was also requested as to what providers should do now to demonstrate that they have made a good faith effort.
Response: We plan to review all new requests for provider-based status. At present, we have no plans to systematically review all providers to determine whether they may be claiming provider-based status for some facilities or organizations inappropriately. However, we will review the status of specific facilities or organizations in response to complaints or any other credible information that indicates that provider-based status requirements are not being met. If the regional office determines that this is the case, it will take action in accordance with the rules in new § 413.65(h) and (i). In response to the comment about possible retroactive application of the new regulations, we note that they will apply only on or after their effective date of October 10, 2000. We will not apply the provider-based criteria in the new regulations to periods prior to that date; on the contrary, decisions for such periods will be reviewed only under the criteria in effect at the time, as stated in Program Memoranda and the Provider Reimbursement Manual and State Operations Manual.
Comment: Two commenters pointed out the proposed rules do not state whether the required approval status is retroactive to when the provider applied or to when we granted approval. These commenters believe it should be retroactive to the date of the provider's application for the determination.
Response: We plan to make provider-based status applicable as of the earliest date on which a request for provider-based status has been made and all requirements for provider-based status are shown to have been met, not on the date of our determination. Thus, if a provider requests provider-based status for a facility on May 1 and demonstrates that applicable criteria were met on that date, but the regional office did not make a formal determination until June 1, the determination would be effective on May 1.
Comment: The commenter stated that we should not have published important provider-based policies in a Federal Register document that some providers, such as skilled nursing facilities and home health agencies, may not have read. The commenter recommended that we re-issue these proposed rules separately from the proposed hospital outpatient prospective payment rules.
Response: We do not agree that the proposed rules were published in an obscure location. On the contrary, the number of written comments received, many of them from providers other than hospitals, indicates that our proposals were widely known among providers that could be affected. Therefore, we do not intend to republish the proposed rules.
Comment: A commenter expressed concern that these provider-based provisions are unnecessarily restrictive and will unreasonably limit practice arrangements. The commenter went on to state that in the current health care environment, physicians and hospitals need flexibility to adapt to local market conditions and participate in a variety of practice arrangements to provide cost effective, high quality care. An unnecessary strict definition of Start Printed Page 18509“provider-based entity” could have a chilling effect on the evolution of new care delivery structures that would expand access to care, especially in rural areas.
Response: We share the commenter's concern with preserving Medicare beneficiaries' access to care, but do not agree that the provider-based rules will limit access. We note that the rules do not prohibit hospitals from purchasing physician practices or taking other actions to enhance access to care in remote rural areas; they only set minimum standards for the type of affiliations that will be recognized for provider-based designation.
For example, an institutional provider such as a hospital or SNF may elect to use part of its institutional complex to house physician offices or other facilities that provide services complementing those of the provider. Those facilities'costs will have to be included in the trial balance of the institutional complex, in order to allow costs to be allocated accurately to all parts of the complex, and permit the costs of the provider to be determined. However, inclusion of such facilities' costs on the institutional complex trial balance does not make the facilities provider-based. On the contrary such facilities would have to meet the criteria in § 413.65 to qualify for provider-based status.
Comment: Different views were expressed on how much
discretion regional offices should have in applying the provider-based criteria. One commenter asked that we make the rules as clear and concise as possible. The commenter argued that rules allowing for great latitude in interpretation could be dangerous for the provider community. On the other hand, another commenter stated that we should allow Medicare regional offices greater latitude for determining when sufficient integration exists for a facility to qualify as provider-based, and should avoid adopting regulations that “micro-manage” a hospital's operations. Another commenter suggested that rather than requiring that all criteria must be met to achieve provider-based status, we change the test to substantially all. There may be circumstances where criteria are not fully met, but an overall assessment supports a provider-based determination. This same commenter recommended that a “pending” status be incorporated into the evaluation process, whereby hospitals not meeting the criteria for provider-based status would be afforded an opportunity to make the modifications necessary. Another commenter asked that instead of meeting all criteria, we permit the regional offices to evaluate a facility's status with respect to the main provider with input from local government and the fiscal intermediary. Another commenter also suggested that the standards only be enforced to the extent that they are applicable and relevant, consistent with state laws, and relate to practices that are subject to the control of the particular provider.
Response: We have tried to balance the need to apply standards that can be adapted to fit particular circumstances, and agree that the standards should not be overly prescriptive, but rely on regional judgment to ensure appropriate decision making. Because provider-based status is a matter of extreme importance to many facilities, published standards provide a basis for advance assessment and planning of particular organizational and financial arrangements. Therefore, we have decided that a facility or organization will be found to be provider-based only when it is in compliance with all standards set forth in these final rules.
With respect to the comment regarding situations in which all but a few criteria for provider-based status are met, we note that nothing prohibits the main provider from re-applying for approval of provider-based status for a facility or organization after having made the changes necessary to come into compliance. Regional offices would in such cases only need to verify compliance with whatever criteria had not been previously met, unless the amount of time that elapses between requests, or other factors, make a full re-evaluation necessary. Because facilities have this flexibility under the rules as proposed, we did not make any changes based on this comment.
Comment: One commenter believes that we had not fully addressed the impact of these rules on service delivery. The commenter suggested that changes would affect deemed status, survey and certification requirements, state licensure requirements, physician referral requirements, and a host of related issues. Another commenter stated that the new requirement regarding administration and supervision found in § 413.65(d)(3) could impact more than our estimated 105 providers. The commenter believes that if providers are required to convert management firm employees to hospital employees and then revert back when outpatient PPS becomes effective, this could impact 5,000 inpatient PPS hospitals.
Response: We again reviewed our requirements, but do not believe they will have the far-reaching effects envisioned by these commenters. In particular, to the extent a facility or organization that claims to be a department of a provider must be accredited, surveyed, or licensed as a part of that provider, or must adapt to the physician referral requirements of the main provider, that result does not flow from the existence of criteria for provider-based status, but instead is a direct result of the provider's decision to claim the facility or entity as a department. We also do not think it is reasonable to assume that any significant number of hospitals will restructure themselves repeatedly because of the final rules set forth below. As noted earlier, both the proposed and final rules closely parallel policies that have been stated explicitly on program instructions since 1996, and we are providing a 6-month delay in effective date for the final rule. Thus, hospitals and other providers have had ample time to assess the impact of any changes and to make necessary adjustments in an orderly way.
Comment: A commenter requested clarification as to how the proposed rules would apply to two hospitals seeking consolidation into a single provider. The commenter also asked whether two small PPS hospitals located approximately 15 to 25 miles apart in separate towns within a metropolitan statistical area (MSA) who wish to consolidate would be prohibited from doing so because of patient population or licensure requirements. Furthermore, if these two hospitals are already certified as a single provider, would the proposed rules require them to separate and create separate providers? Another commenter requested that the final regulatory text state that the provider-based requirements do not apply to any facility where there are inpatient beds since such a facility would be viewed as a “main provider.” The provider-based requirements should apply only to facilities or organizations other than main providers.
Response: Although the Program Memorandum and proposed rules were issued in response to situations primarily involving outpatient facilities, we believe the policies set forth in these documents are equally applicable to inpatient facilities, and should be applied in the many cases in which a determination about inpatient facilities must be made. The rules would not prohibit two previously separate hospitals from merging to become a single provider. However, for either facility to be considered provider-based with respect to the main provider, the facility would have to meet the criteria Start Printed Page 18510in this final rule. To clarify the scope of application of these regulations, we have added a definition of “remote location of a hospital” and a reference to hospital satellite facilities to § 413.65(a) Definitions, and have clarified the wording of several later sections by including references to remote locations and satellites. We have defined a “remote location of a hospital” as a facility or an organization that is either created by, or acquired by, a hospital that is a main provider for the purpose of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section. A remote location of a hospital may not be licensed to provide inpatient hospital services in its own right, and Medicare conditions of participation do not apply to a department as an independent entity. The term “remote location of a hospital” does not include a satellite facility as defined in § 412.22(h)(1) and § 412.25(e)(1). Hospitals may acquire remote locations by various means, but often do so by mergers or acquisitions, in which a single hospital purchases other, previously separate hospitals, and operates them as remote locations that are not separately organized as departments, but instead furnish the same types of services as the original hospital. For example, a long-term care or other specialty hospital might acquire one or more other hospitals, terminate their separate participation in Medicare, but continue to use them as sites of the same type of care as the original hospital. Satellite facilities are currently defined in our regulations at § 412.22(h)(1) (for hospitals) and § 412.25(e)(1) (for units). In general, a satellite facility is a part of a hospital (or of a hospital unit) that provides services in a building also used by another hospital, or in one or more buildings on the same campus as buildings also used by another hospital. Satellite status always involves co-location with another hospital, while remote locations are not co-located with other hospitals' facilities.
Comment: A commenter requested clarification that the provider-based requirements apply only to providers who are paid under the reasonable cost methodology. The preamble language in section VI implies that these requirements would also apply to providers under the outpatient PPS. The commenter believe that if this were the case, the requirements found in §§ 413.24(d)(6) and 413.65 would be appropriately placed in Subchapter E (for example, Part 482, Conditions of Participation for Hospitals).
Response: The rules set forth below are not limited in their scope to providers paid on a reasonable cost basis but, except where specifically stated in the text of the rules, apply to all providers and facilities seeking Medicare payment. While many of the problems associated with inappropriate accordance of provider-based status relate to cost reimbursement, the different payment systems used for various providers may produce some unintended incentives for one type of facility to gain an unfair payment advantage by misrepresenting itself. The specific requirements cited do not, like the Medicare conditions of participation, implement section 1861(e) of the Act, nor do they primarily concern patient health and safety. Therefore, we did not adopt the suggestion that the section be relocated to part 482.
Comment: A commenter would support a provision that prohibits hospitals from acquiring free-standing physician practices and converting them to hospital-based entities.
Response: We understand the commenter's concern, but do not have authority under the Medicare law to prohibit this practice. We do believe that the rules set forth below will keep hospitals from misrepresenting physicians' practices as hospital outpatient departments.
Section 413.24(d)(6) Adequate cost data and cost finding: Management contracts
Comment: The proposed cost reporting requirements state that if an overhead administrative cost center does not perform services for the off-site clinic or department, no costs should be allocated to that function. The commenter pointed out that this contradicts generally established Medicare cost reporting principles that have always required that the administrative costs be allocated to allowed and nonallowed cost centers.
Response: Our position, as expressed in the Provider Reimbursement Manual, Part II, Chapter 36 for hospitals, is to allow the provider to bypass the allocation of overhead through the cost report to avoid inappropriate allocations. An example of this would be lab services under arrangement, where there is obviously no administrative activity by the main provider. Our electronic cost report systems are set up to “skip” that particular cost center and to re-allocate the costs to the remaining cost centers. Likewise, where administrative costs such as billing are performed by the subordinate provider, no billing cost from the main provider should be allocated to that cost center from the main provider.
Comment: Several commenters suggested clarification of “like” costs by adding a definition or providing examples. Also, a commenter stated that since the main concern is costs, this provision should be applied when management costs exceed the hospital's operating costs of the department by 10 percent on a comparable basis. Another commenter stated that: (1) Management services benefit only the specific department to which they are expensed, and provide no direct services to other hospital departments; (2) A department under the management contract receives necessary services from other hospital overhead departments; (3) such overhead departments do not represent duplicate services provided under the management contract. Since management agreements can be drastically diverse, the commenter believes this clarification would assist in avoiding any confusion, as well as allow for consistency with generally accepted cost finding principles. Another commenter stated that most entities that contract to manage an area of a hospital manage just that area. Therefore, if they offer assistance with a particular function, it is only for that area and not for the whole hospital. The commenter believes the same principles of reimbursement should be applied whether the hospital provides the service directly or contracts for the service to be provided.
Response: Examples of similar costs when management contracts provide services also available through the main provider are the following: billing services, computer services, accounting services, and, possibly, general administrative staff. When the same services are included in the administrative and general costs of the main provider, and allocated down to subordinate cost centers or providers incurring and reporting these same costs in the trial balance, the result is a duplication of costs to the subordinate cost center or provider. As long as the main provider has the ability to identify these “like” service costs, these costs should be re-allocated to the remaining reimbursable and non-reimbursable cost centers in proportion to each cost center's total costs as prescribed in the Provider Reimbursement Manual, Part II, Chapter 36. However, if the main provider is not able to identify the costs of these same services to permit the exclusion of allocation to the subordinate providers or cost centers, Start Printed Page 18511the cost of the management contract of the subordinate provider or cost center must be reclassified to the main provider's administrative and general cost center, and allocated down to all reimbursable and non-reimbursable cost centers in proportion to each cost center's total cost.
Comment: With regard to the language in paragraph (d)(6)(ii), Medicare principles of reimbursement require that, when two entities are related, and one contracts from the other, reimbursement for these services is at cost due to the “related party principle.” The commenter stated that the cost of a service is both direct and indirect; Medicare reimbursement has a longstanding methodology concerning nonrevenue producing costs and their allocation on a provider's cost report. A separate work paper should not be required. The appropriate methodology for stepping down administrative costs should be based on the cost of the entity utilizing the service. The cost of the free-standing entity must be placed on the main provider's cost report to step down cost appropriately. Additional work papers would allow room for error and would delay any necessary adjustments.
Response: The intent of § 413.24(d)(6)(ii) was to require the main provider to report costs of related party entities that would not be reported through their accounting system on the main provider's books and records, for example, trial balance. Consequently, when there is a sharing of administrative services, for example, managerial staff, the related entity escapes any administrative overhead allocation when that same related entity is not reported on the main provider's trial balance of the cost report. While the commenter is correct regarding the proper reporting of related transactions at cost of the related entity, this regulation section goes further to require the main provider to develop the total cost of the related entity, utilizing and maintaining workpapers to justify the amount to be reported, and to report those costs by the main provider on the cost report trial balance.
Section 413.65(a) Definitions (retitled in this final rule as Section 413.65(a) Scope and definitions)
Comment: Two commenters requested that a definition be provided for “a provider's campus.” A definition would be important since the proposed regulation specifies additional requirements for off-campus locations.
Response: We agree that location on or off a hospital's campus is important. To provide a clear standard, we have revised the final rule to define “campus” as “the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by our regional office, to be part of the provider's campus.” This definition would encompass not only institutions that are located in self-contained, well-defined settings, but other locations, such as in central city areas, where there may be a group of buildings that function as a campus but are not strictly contiguous and may even be crossed by public streets. This would also allow the regional offices to determine, on a case-by-case basis, what comprises a hospital's campus. We believe allowing regional office discretion to make these determinations will allow us to take a flexible and realistic approach to the many physical configurations that hospitals and other providers can adopt.
Comment: The commenter expressed concern regarding the definition of provider-based facilities as many hospital-owned outpatient services are often provided with leased employees with ambulatory care experience. It is not clear that such an arrangement would satisfy the intent of the regulation.
Response: The regulations do not explicitly prohibit the use of leased employees, and each situation will be evaluated relative to the criteria in the regulations set forth below.
Comment: One commenter stated that the difference between “department of a provider” and “provider-based entity” is not clear from the definitions given of those terms. The commenter requested that we clarify in the regulations text whether a provider-based entity must be certified in its own right, and what type of certification this encompasses. The commenter also requested clarification in the regulations text concerning whether the term “provider” in the definition is intended to mean only entities that satisfy the Medicare definition of “provider” contained in § 400.202.
Response: We have clarified § 413.65(a) to state that a “department of a provider” is a facility or organization that could not by itself be qualified to participate in Medicare as a provider under § 489.2, while a “provider-based entity” could be so qualified. For example, a skilled nursing facility (SNF) could be a “provider-based entity,” whereas an entity that furnishes ambulatory surgical services could not be a provider-based entity, and could participate in Medicare (for example, receive Medicare payment for services furnished to beneficiaries), only as a department of a provider, as a physician office, or as an ambulatory surgical center approved by Medicare under part 416, if at all. We have further revised the final rule to clarify that a department of a provider furnishes services of the same type as the main provider (for example, a department of a hospital furnishes hospital services), while a provider-based entity furnishes services of a different type from those of the main provider (for example, a hospital-based RHC furnishes RHC services, not hospital services).
Comment: A commenter believes the proposed rule should be revised for medically underserved populations and health manpower shortage areas to allow the referral of beneficiaries back to their community for treatment of community-based therapy providers. Therapy services provided under such a referral would be included under the provider-based designation.
Response: We do not oppose use of such referrals where they are medically appropriate, but believe that referral arrangements should not be equated to provider-based status.
Comment: A commenter questioned the requirement that services be furnished “under the name” of the main provider entity. The commenter argued that the requirement is inconsistent with the commenter's view that health care in the late 1990s is, and in many markets must be, “marketed” in a highly competitive environment. The commenter's view is that having provider-based status turn on the names used will inevitably invite micro-management of the way the main provider's name is used by the department or other hospital-based entity.
Response: We disagree with any suggestion that health care is merely a generic commodity that can be repackaged under another name for marketing purposes. On the contrary, we believe that operating under the name of the main provider, and holding oneself forward to patients under that name, is an important indicator of status as an integral and subordinate part of that provider. Therefore, we did not make any changes in the regulation based on this comment.
Section 413.65(b) Responsibility for obtaining provider-based determinations
Comment: A commenter stated that the proposed rule does not state clearly enough whether our approval is required in order to permit billing each Start Printed Page 18512time a provider sets up a new service, regardless of whether the service is acquired, managed, new, located on the main campus, or off the main campus. Some commenters stated that if approval is required in all instances, it will cause a significant paperwork backlog and will be quite costly to administer.
Response: Section 413.65(b) states explicitly that a determination by us that a facility or organization is provider-based is required before the main provider may treat the facility or organization as provider-based for billing or cost reporting purposes. We recognize that this may generate some administrative cost, but believe the cost will be much less than the amounts that would be spent improperly if payment were made to a free-standing facility as if it were provider-based.
Comment: A commenter urged that the new determination process be applied to all current as well as new hospital-based services.
Response: We have no plans at present to review all hospitals and other providers with respect to provider-based criteria, but will look into any situations that come to our attention in which it appears that a facility does not meet the requirements of the new regulations but is being treated as provider-based. If the facility or organization does not qualify as provider-based, action will be taken as described later in this preamble and in § 413.65(i).
Comment: A commenter stated that there should be some mechanism in place for a long-term hospital (LTH) to seek an advance determination or advisory ruling that a proposed LTH satellite will be granted provider-based status. Because establishing an LTH requires a huge expenditure of time and human resources, an LTH main provider needs to know in advance whether or not its proposed satellite will receive a favorable provider-based determination. It is suggested that we institute a system by which advance rulings or determinations are available before the satellite is established.
Response: We understand the commenter's concern, but do not have the staff or facilities to provide advance approvals of restructuring proposals. We suggest that providers review the new criteria carefully and avoid forms of organization that are not clearly in compliance with them.
Comment: Two commenters suggested that we provide guidance on the application process providers must complete in order to receive a provider-based determination. In addition, time limits for approval of these determinations should be established. Furthermore, existing provider-based entities should not be required to change their billing and accounting procedures. A commenter also asked for clarification as to whether the intermediary and regional office is to be the contact, and who will make the actual determination of provider-based status.
Response: We are developing an application process and intend to have it in place and ready for use before the effective date of the regulation. We expect that determinations of provider-based status will be made by our regional offices. Involvement by other entities, such as fiscal intermediaries or State survey agencies, will be for information-gathering purposes and under the direction of the regional office.
Comment: A commenter suggested that if a determination goes against the provider, the provider should be given the option to come into compliance with the requirements or file an appeal.
Response: As noted earlier, the regulations do not prohibit a provider that meets most but not all criteria from taking action to fully meet the criteria, thus qualifying a facility or organization for provider-based status. In the case of a provider that believes that the determination of the regional office is incorrect, an appeals process is provided under part 498.
Comment: A commenter stated that the requirement in paragraph (b)(3) establishes an adverse presumption against provider status for “off-campus” physician practice sites, and that the focus on “campus” boundaries will prove elusive, and serve no real policy purpose.
Response: As explained later, we believe location in the immediate vicinity is an important indicator of provider-based status, and that location can be a good basis for identifying facilities for further scrutiny.
Section 413.65(c) Reporting
Comment: Several commenters pointed out that the regulatory language does not reflect the preamble language regarding off-campus entities and the five percent increase in a provider's costs.
Response: We have revised the final rule to correct this oversight.
Comment: One commenter asked whether this language applies only to entities that are applying for provider-based status, or also applies to entities that have already achieved provider-based status.
Response: The requirement applies to both types of providers, but providers that have entities with provider-based status are required to report only newly created or acquired facilities or organizations.
Comment: Two commenters stated that the five percent and off-campus criteria with regard to provider-based status do not take into account the characteristics of rural and frontier areas, and could lead to lower payments to some facilities, thus reducing the flow of Federal money into rural areas and possibly creating a shortage of care. In addition, considering the small budget of RHCs and other rural facilities, 5 percent is an inappropriately low and unreasonable growth limit.
Response: We understand the commenter's concern but do not agree that a 5 percent threshold for reporting is too low. Therefore, we made no change based on this comment.
Comment: A commenter asked whether this reporting requirement also applies to all newly developed services (that is, department on the campus of the hospital).
Response: The requirement applies to all newly developed on-campus services that could increase the costs of the provider by 5 percent or more.
Comment: A commenter requested clarification that a main provider that “creates” as well as “acquires” a facility or organization is responsible for reporting to us. The commenter also suggested specific items to be included in the reporting and approval process. These include specific data elements to be reported by the main provider, specifying our component with primary responsibility; specifying our approval process; adding a preliminary conditional approval process; adding a specific time period for our approval; and adding requirements for the effective date that the costs of the provider-based entity can be included on the main provider's cost report.
Response: We have revised the regulation to clarify that it applies to facilities or organizations created by the main provider, as well as those ongoing operations acquired by purchase or other means. We have not included the procedural detail requested by the commenter in regulations, but will consider including it in program instructions.
Comment: A commenter stated that the use of the phrase “any material change” in paragraph (c)(2) of this section is too vague and open to interpretation. It is suggested that the section be revised to clearly designate changes of ownership and new management agreements as the only two material changes that require reporting by provider-based entities. Start Printed Page 18513
Response: We do not agree that the range of reportable events should be limited in this way. On the contrary, we intend to require reporting of any change that could have a significant (“material”) effect on compliance with the provider-based criteria.
Comment: A commenter asked if the reporting requirements are coordinated with the notification of change of ownership requirements at § 489.18(b), where notice is to be given in advance, and whether there should be a cross reference or clarification with respect to the change in ownership regulation and this proposed regulation.
Response: We believe this suggestion has merit, and will consider revising our program instructions to specify that a report under § 489.18(b) should be reviewed for its applicability to provider-based determinations.
Section 413.65(d) Requirements
Comment: A commenter suggested that we clarify whether all requirements, or only a majority of the requirements, must be met to obtain provider-based status.
Response: We have revised the first sentence of paragraph (d) to state that all of the stated requirements must be met by a facility or organization that wishes to be classified as provider-based.
Section 413.65(d)(1) Licensure
Comment: Many commenters objected to the requirement that provider-based facilities share a common license with the main provider unless the State requires separate licensure for the subordinate facility. One commenter listed several reasons for this concern. First, in the commenter's opinion, licensure determinations may be made based on factors that are different from those that would be important for provider-based determinations. Another reason cited by the commenter is that State licensure laws may vary from State to State. Some State hospital licensure definitions are building specific, and do not include off-site outpatient facilities, thus giving what the commenter argues is undue weight to physical location in evaluating provider-based status. Finally, the commenter believes that requiring common licensure will create a situation where some States may have a large number of provider-based entities and others will have few or none, thus leading to inconsistent application of our rules. One commenter recommended that the same licensure requirement be waived for States with idiosyncratic licensure requirements. An alternative would be accreditation with the provider as a deemed status for meeting a common license requirement. The commenter suggested that the proposed language could be reworded to clarify that offsite clinics would not have to be licensed or operated under the same license as the provider in those States that do not license them.
Response: We recognize that licensure may not be an appropriate indicator of provider-based status in all States, and have therefore revised the regulations to require common licensure only in States with laws that permit common licensure of the provider and the prospective provider-based department under a single license. This means that in States that do not allow licensure of certain types of facilities, such as those providing ambulatory care or those located off the provider's main campus, the licensure criterion would not be applied. We do not agree that JCAHO or other accreditation should be accepted in lieu of licensure, since such accreditation may not necessarily reflect an on-site evaluation of the prospective provider-based department. In recognition of the fact that some hospitals are not licensed by the State because they are Indian Health Service (Federal) hospitals or are located on Tribal lands, we also will not apply the licensure requirement to departments of those hospitals.
Comment: Under paragraph (d)(1) as proposed, clinics in another State from the main provider could not be under the hospital's license. Several commenters argued that this requirement would arbitrarily affect rural and urban health care delivery, where the main provider is close to a State line. A commenter recommended that close proximity be used instead, where a hospital-based clinic is in another State from the main provider. For urban hospitals in large metropolitan statistical areas that cross State boundaries, the commenter believes that the market area of the main provider should be the primary determinant of the potential for integration with the main provider.
Response: Under the regulations as revised based on the comments summarized above, common licensure would not be required of facilities located across State lines if the law of the State in which the main provider is located does not allow such licensing. However, see the discussion, later in this preamble, of § 413.65(d)(7)(ii).
Comment: A commenter pointed out that the proposed rule appears to limit the licensure requirement to “departments” of the main provider. The commenter asked whether this requirement only applied to “provider-based entities.” The commenter also suggested that where a State has two licensure schemes for the same type of facility, we should not prefer one licensure scheme over the other for purposes of determining the provider-based status of the facility.
Response: The commenter is correct in noting that the common licensure requirement in the proposed rule would have applied only to provider-based departments. We did not propose to apply a common licensure requirement to provider-based entities such as SNFs and HHAs, because they are providers of services in their own right, and typically would be separately licensed without regard to their affiliation with the provider. We disagree with the commenter's view that licensure should not be viewed as an indicator of integration. On the contrary, our view is that if a facility could be licensed as part of a main provider but chooses not to be, the facility cannot reasonably be seen as an integral and subordinate part of that provider.
Comment: With regard to the proposed requirement that states that our determination regarding provider-based status will be based on a State health facilities' review commission, one commenter argued that relying on the commission's criteria for purposes of making provider-based determinations is arbitrary and inappropriate. The commenter believes imposing this criterion could disadvantage providers and discourage expansion to off-site locations, thus indirectly leading to shortages of care. Another commenter requested that there be a delay in implementation during which time changes can be made to the commission's definition of what rates it can regulate.
Response: We continue to believe it would be inappropriate for a facility to claim to be separate from the provider for State rate-setting purposes while also claiming to be an integral and subordinate part of the provider for Medicare purposes. To allow this practice would authorize providers to misrepresent their structures and affiliations in whatever way will yield the highest payment. Thus, we did not make changes to reflect the comment.
Section 413.65(d)(2) Operation under the ownership and control of the main provider
Comment: Regarding § 413.65(d)(2), the commenter suggested that the regulations provide a separate set of criteria that would allow a provider that is operated within one legal entity to be provider-based to a provider that is operated within another legal entity, as long as the two entities are under common control. Another commenter Start Printed Page 18514stated that this ownership and control requirement is unnecessarily rigid, since a hospital-based clinic, which was strictly an administrative division of the hospital, might qualify while another similar clinic, wholly owned by the hospital with slightly different governing bodies and documents, would not be eligible.
Response: We do not agree that common control of two separate entities by the same parent organization should be sufficient to meet a requirement for ownership and control by the main provider. While this arrangement may be an appropriate way to manage two separate entities, it does not establish provider-based status for either. With respect to the second comment, we agree that the form of administration of an entity can determine whether or not the entity is found to be provider-based. We believe this would be an appropriate result, since it would help ensure that only facilities that are organized as provider-based entities or departments of a provider are given this status.
Comment: One commenter believes it is unrealistic to require a potential provider-based facility or organization to be owned by the main provider and share bylaws and an identical governing body. The commenter stated that in the present business climate an entity can operate as a provider-based entity without meeting these criteria. It is recommended that we replace the proposed 100 percent ownership standard with a majority standard, require only overlapping governing bodies, and eliminate the requirement for organization under the same organizational documents. Another commenter believes that the key consideration should be whether the provider is in control of the day-to-day operations of that portion of the facility in which the provider seeks provider-based status, and not necessarily whether the building is 100 percent owned by the provider. The commenter believes we should rephrase this provision to require that the operations of that portion of the facility or organization in which the provider is seeking provider-based status be controlled by the provider.
Response: In response to the first comment, we recognize that many organizations enter into business relationships that involve overlapping of ownership, governance, and applicability of bylaws. However, this degree of collaboration does not mean that one facility is an integral and subordinate part of another. Therefore, we made no change based on this comment. Regarding the second comment, we wish to clarify that it is ownership of the business enterprise, not of the buildings or other physical assets of the enterprise, that is required under paragraph (b)(1). We have therefore revised the regulation text to refer to ownership of the business enterprise.
Comment: A commenter stated that the requirements contained in paragraph (d)(2) would preclude entities that are jointly owned through legitimate joint ventures or those separately organized subordinate facilities from qualifying for provider-based status. Additionally, to require the level of integration suggested by our proposed rule would prevent providers from establishing efficient systems of delegation and management, solely to qualify for provider-based status.
Response: We agree that this criterion would have the stated effect. As explained further in our discussion of comments on proposed § 413.65(e), facilities operated jointly by two or more providers cannot appropriately be considered integral and subordinate parts of either provider. With respect to the second comment, we do not oppose systems of operation that stress separate, decentralized operation where this leads to greater efficiency. However, we believe such facilities or organizations should be recognized as the separate enterprises that they are, not considered integral and subordinate parts of another institution.
Comment: A commenter suggested that the requirement under paragraph (d)(2) be modified for medically underserved populations and health manpower shortage areas.
Response: We are also concerned that our criteria not limit access to care for any vulnerable populations and have, to avoid this potential problem, created special provisions for FQHCs and IHS and tribal facilities. As described later in this preamble, we have also created an exception to the location requirements in paragraph (d)(7), which is designed to help avoid restricting access to primary care furnished by RHCs in remote, underserved areas. In view of these provisions, we do not believe it is necessary to also modify our requirement relating to ownership of the facility or organization.
Comment: A commenter stated that the proposed requirements in paragraph (d)(2) are inherently inconsistent with section 330 of the Public Health Service Act statutory and regulatory requirements and the Bureau of Primary Health Care expectations necessary to obtain and maintain section 330 funding (and FQHC status). The commenter believes HCFA should not require FQHCs to be 100 percent owned by the main provider or share a common governing body and common bylaws with the main provider. The commenter also suggested that we accept appropriate reporting relationships and satisfaction of other criteria (for example, licensure, quality assurance, integration of certain administrative and clinical functions, such as billing, purchasing, retention of medical records, quality assurance and utilization review procedures; and public awareness of the relationship between the health center and the main provider) as a sufficient basis for provider-based status.
Response: As described earlier, we have provided a special transition period for FQHCs. We believe this period will be adequate to avoid the problems envisioned in this comment.
Section 413.65(d)(3) Administration and supervision
Comment: A commenter recommended that the daily reporting relationship stated in § 413.65(d)(3) should be replaced with the standard of having the reporting relationships have the same intensity as on-site departments. The commenter stated that in practice at the hospital, there may be very little day-to-day contact between medical directors of various hospital services. Also, the commenter believes it is unlikely that departmental directors report directly to the chief executive officer, but rather to a chief operating officer or other designee. Finally, the commenter argued that under the common governance requirement, while all hospital employees are theoretically accountable to the governing body, the accountability may be directed through the CEO, and multiple executives may not have an independent reporting with the board. Another commenter also believes that the standards for the provider-based entity should mirror those of the main facility; personnel reporting structure needs to be respected within the regulations. Still another commenter found “intensity” to be a subjective standard and asked how it will be measured.
Response: We agree that reporting need not be daily in all cases, and have revised the final rule to state that the reporting relationship between the facility or organization seeking provider-based status and the main provider must have the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and one of its departments. We agree with the commenter that the intensity of supervision will have to be assessed on a case-by-case basis, but do not believe Start Printed Page 18515this will lead to imprecise or poorly reasoned decisions.
Comment: Several commenters believe that this requirement limits the flexibility of the entity to operate efficiently and effectively in the current environment, since hospitals frequently turn to many specialized management companies to operate more efficiently and effectively than with hospital resources. Another commenter stated that whether the administrative department utilizes employees at one location and contracts at another location should be irrelevant as long as the function is integrated with the main provider, follows the policies and procedures of the main provider, and is accountable to the governing body of the main provider as is any other department. Still another disagreed, and believes that it may be appropriate to require that the main provider manage such contracts.
Response: We do not agree that the provision unreasonably limits hospital flexibility. Paragraph (3)(iii)(B) explicitly allows different management contracts to be used for the facility or organization and the main provider, as long as the provider manages the contracts. Thus, we did not make any changes in the proposal based on these comments.
Comment: A commenter asked whether the administrative functions listed in paragraph (d)(3)(iii) are the only services that must be integrated between the main provider and the subordinate facility.
Response: The commenter was correct in understanding that the functions listed are the only administrative functions that must be integrated. There are also requirements for integration of certain financial functions, as described below.
Comment: One commenter posed several questions concerning this proposed requirement. First, in a certain situation, the facility fee is billed to the intermediary by the hospital billing department using the provider number, while the professional fee is billed to the Part B carrier by the faculty practice billing organization under its physician group number. The commenter asked if the different provider number and tax identification impact on the provider-based status, and if there is a more appropriate way to obtain billing numbers for hospital-based clinics. Also, the commenter asked if clinic space can be shared by two clinics, when one is provider-based and one is free-standing, without impacting the provider-based status of the first clinic.
Response: In the circumstances described, the use of separate billing and tax identification numbers for provider and physician services would not adversely affect a facility's request for provider-based status, since such billings are required under Medicare to be separate in the case of services in hospitals. The question regarding sharing of space, however, can be answered only in the context of a specific case, and we expect that such decisions will be made by our regional offices.
Comment: With respect to the oversight of contracts under paragraph (3)(B)(iii)(B), several commenters stated that it is common for hospitals to subcontract out the billing for different departments, especially the hospital outpatient department, due to the complexity and number of claims. These commenters stated that while it may be appropriate to require the main provider to manage such contracts, departments other than the billing department should be permitted to perform this management function. One commenter suggested revising the criterion on billing under the integration of administrative functions to state, “common billing or the contract for billing services is held by the provider where it is based.”
Response: We agree that departments other than the main provider's billing department may appropriately manage billing contracts, and have revised the criterion to state that the contract for a provider-based facility or organization must be managed by the main provider.
Section 413.65(d)(4) Clinical services
Comment: A commenter asked for clarification of paragraph (4)(iv) of this section, specifically concerning whether this language would require a Medicare certified HHA's improvement activities to be overseen by hospital medical staff, rather than the advisory committee as is now being done. The commenter believes that having the hospital medical staff overseeing the quality assurance activities of a HHA may not be appropriate or cost effective and may even slow the process of performance changes.
Response: The commenter is correct in understanding that compliance with this criterion would require oversight of a hospital-based HHA's quality improvement activities by the hospital's medical staff. We do not agree with the commenter that the outcome would be to substitute the judgment of the hospital for the HHA's own committee or that it would be inappropriate. The hospital conditions of participation contain a number of separate requirements that must be read together to make complete sense of this provision. Conditions spelled out at § 482.12 (Governing body), § 482.21 (Quality assurance), and § 482.22 (Medical staff) establish a chain of accountability in a hospital for the quality of care it provides. The requirements are clearly applicable to any activity (for example, provider-based entity) that is an integral part of the hospital. Thus, a quality improvement activity of the HHA is likely to be firmly grounded in the hospital's operating and governance fabric even when the group is “established” by the HHA, and staffed by employees and physicians who work primarily in home health. We would expect the linkages to be formal (that is, known to the governing bodies and medical staffs of both providers), and the quality assurance mechanisms interrelated to the extent that shared patients are the subject of the effort.
Comment: Regarding paragraph (d)(4)(v) of this provision, some commenters requested clarification of what is meant by a “unified retrieval system,” or for guidance as to what types of cross referencing are acceptable. Another commenter asked for an explanation of the practical expectations regarding the maintenance of medical records. Finally, a commenter expressed support for the requirement for a unified retrieval system (or cross references), saying the latter system would be used in States that mandate a unified system.
Response: We would like to clarify that what is intended is that a system be maintained under which both the potential provider-based entity or department of a provider and the main provider have access to the beneficiary's record, so that practitioners in either location can obtain relevant medical information about care in the other setting. We did not, however, make any changes in the requirement based on these comments.
Comment: A commenter believes that functions of operations should not be regulated to dissuade cost efficiency, and that laundry and housekeeping would be examples where shared services may not be the most effective manner of operation.
Response: We agree that in some cases it may be less expensive for a facility to obtain services independently, but continue to believe such separateness is an indicator that the facility is not an integral and subordinate part of a provider.
Comment: With regard to paragraph (d)(4)(vi) requiring integration of services of the main and provider-based entity, the commenter expressed concern about the potential impact of Start Printed Page 18516this section on a patient's freedom of choice. The commenter believes that the entity's efforts to meet this standard would limit a patient's freedom of choice. The commenter suggested that we clarify our position so that providers acting in good faith will not be sanctioned for attempting to comply with this requirement.
Response: Paragraph (d)(4)(vi) requires only that patients have access to the services of the main provider and that they be referred to it where the referral is appropriate. We wish to clarify that these criteria are not intended to restrict patient freedom of choice or the practitioner's freedom to refer patients to other locations, where doing so will result in better care for the patient.
Section 413.65(d)(5) Financial integration
Comment: A commenter believes that § 413.65(d)(5), which requires full integration of financial operations, is too rigid. An alternative approach is suggested that would allow managers of provider-based entities to retain some control over both the resources and information required to administer these units.
Response: Section 413.65(d)(5) requires that there be financial integration of the potential provider-based facility or organization and the main provider, but does not preclude normal management control of resources. Thus, we made no change in the regulation based on this comment.
Comment: A commenter stated that the criteria for common resource usage of building, equipment, and service personnel is not even relevant for multi-campus systems or even buildings that are across the street from each other, much less off-site hospital outpatient departments.
Response: Although the provider-based program memoranda required that there be significant common resource usage of buildings, equipment, and service personnel on a daily basis, this requirement does not appear in the proposed rule. Thus, we made no change in the regulation based on this comment.
Comment: One commenter stated that the requirement for financial integration seems unnecessary in light of the requirement for 100 percent ownership by the main provider. The commenter stated that some providers may wish to segregate the operations of certain departments in their financial systems, and expressed the view that as long as the costs of a department can be adequately identified on the cost report, the practice should be acceptable.
Response: We do not believe that these two requirements are duplicative. On the contrary, in some cases a provider may own 100 percent of another facility or organization, but not be financially integrated with it, either because the other facility or organization is engaged in a different, non-health care activity, or because it is organized and operated separately from the main provider. In these circumstances, we believe the criteria on financial integration apply appropriately to deny provider-based status to separate facilities or organizations.
Section 413.65(d)(6) Public awareness
Comment: Section 413.65(d)(6) requires that provider-based entities be identified as part of the main provider organization. The commenter did not understand the importance of this criterion, particularly when the provider-based organization is licensed and Medicare certified separately from the main provider.
Response: The proposed rule would not apply this criterion to provider-based entities (which may participate separately as providers), but only to provider-based departments. In the latter case, we think it is not unreasonable for such a department to be expected to identify itself with the provider of which it claims to be a part.
Section 413.65(d)(7) Location in immediate vicinity
Comment: A commenter stated that if off-site RHCs cannot be considered provider-based, it will be much harder to deliver care in rural areas. The commenter asked that RHCs be allowed to continue as provider-based RHCs even though they are off campus.
Response: We continue to believe close physical proximity is an important indicator of provider-based status. We note, however, that paragraph (d)(7) does allow off-campus facilities to be treated as provider-based if they meet the criterion relating to service to the same patient population.
Comment: Many commenters believe that more specific tests of service to the same patient population are needed. One commenter suggested that an appropriate criterion would be that the proposed provider-based facility or organization be located within the same geographic area that accounts for a high percentage of patients in the main provider. The commenter believes this test is consistent with Program Memorandum No. 96-7 and with the qualification requirements for sole community hospitals. Other commenters suggested that the main provider's geographical service area be considered the area from which the main provider drew 80 percent of its Medicare inpatients for the previous three years.
Response: We agree that more precise criteria are needed. Therefore, we have revised the regulations to provide that a prospective provider-based facility or organization will be considered to serve the same patient population as the main provider if, during the 12-month period immediately preceding the first day of the month in which the application for provider-based status is filed with us, at least 75 percent of the patients served by the facility or organization seeking provider-based status reside in the same zip code areas as at least 75 percent of the patients served by the main provider. As an alternative, we would consider a facility or organization to serve the same patient population if, during the same 12-month period described above, at least 75 percent of the patients served by the prospective provider-based facility or organization who required the type of care furnished by the main provider received that care from the main provider. We require this “same patient population” test to be met for the 12-month period used to support an initial determination of provider-based status, and it must continue to be met for each subsequent 12-month period to justify a continuation of provider-based status. Application of population/geographic standards to newly established facilities or organizations is discussed below.
Comment: Commenters suggested we show some flexibility with regard to the definition of patient population for teaching hospitals. The commenter stated that it will not always be the case that the patient populations for the teaching program will be the same as the overall mix or patient population for the main provider.
Response: We recognize that patient populations will not be identical in all cases, and thus have adopted a patient population criterion under which there may be a divergence of up to 25 percent between the main provider and the facility or organization seeking provider-based status. We believe this provides a reasonable allowance for differences in patient population. Moreover, we note that under section 1886 of the Act, Medicare provides much flexibility for teaching hospitals in other ways, for example, under section 1886(h)(4)(E), permitting the counting of residents for purposes of payment to teaching hospitals for the time the residents spend in nonhospital settings. Start Printed Page 18517
Comment: Two commenters suggested that the criterion on service to the same patient population be dropped. One commenter believes the criterion is overly vague, could limit access to care as facilities seek to control their service patterns, and, in general, represents a geographically based approach that is out of keeping with modern technology and communications. Another commenter stated that the criterion is unclear, and providers could find it burdensome to assemble the data to show compliance. Other commenters shared the second commenter's concern, but instead of recommending elimination of the criterion, they suggested that a more administrable solution would be to use regional or state standards to define “same geographic area,” such as, health systems area, a specified mileage amount, or our wage area.
Response: As described above, we have developed a more precisely stated test of service to the same patient population. We believe that test will be clear and understandable, not impose unrealistic burdens on providers, and allow provider-based designations that parallel service patterns.
Comment: With respect to paragraph (d)(7)(i), a commenter asserted that many currently operating facilities that are treated as provider-based by us provide types of service that are the same as those of the main provider, but serve patient populations from different geographic areas. The commenter believes these entities provide care under the direction of, and utilize substantial services from, the main provider. An example would be the geographically separate campuses of a single parent hospital that are located at various sites throughout a region. The commenter suggested that such campuses be presumed to be provider-based if they provide substantially the same services as the main provider, do not exceed the size of the main provider, and comply with all other provider-based requirements. Another commenter stated that the “same patient population” requirement should not apply to multi-campus long term care hospital locations. These locations are fundamentally different from other provider-based entities that the regulation addresses, since a long-term care hospital main provider and its remote campus furnish the same services, and offer the same programs of care, but operate in slightly different geographic areas. The commenter suggested that so long as all of the strict financial and administrative integration requirements of the proposed provider-based regulation are satisfied, the “same patient population” requirements should not apply to long-term care hospitals. The result of this criterion would be that satellites will not be established in many underserved areas where long term services are needed. Another commenter believes a specialty facility, such as a long-term care hospital, should be exempt from the geographic proximity requirement if it can demonstrate that it will improve the quality of patient care, and offer services that are not otherwise provided in that area.
Response: We recognize that there may be some cases in which a hospital and another facility seeking provider-based status as a remote location of that hospital may meet most or all other criteria in § 413.65, yet not qualify because the two facilities serve different patient populations. However, we do not agree that this result should lead us to abandon the “same patient population” test. On the contrary, we continue to believe that criterion is a valid indicator of provider-based status. Thus, we did not revise the regulation based on this comment. In this context, we note that there is no Medicare rule that would prohibit a hospital from setting up another hospital in another area. We do not agree with the commenter's assumption that because the program memorandum and proposed rule were issued in response to situations primarily involving outpatient facilities, they can apply only to such facilities. On the contrary, we believe the policies set forth in these documents are equally applicable to inpatient facilities, and should be applied in the many cases in which a determination about inpatient facilities must be made. In particular, the rules apply to remote locations of long-term care and other hospitals that are main providers, as well as to satellite facilities of hospitals and hospital units that are excluded from the hospital inpatient prospective payment system. Remote locations and satellite facilities are discussed more fully earlier in this preamble, and “satellite facilities” are specifically described in our regulations in §§ 412.22(h) and 412.25(e). (As explained in that document, we are concerned that establishment of satellites by hospitals and units excluded from the inpatient PPS could lead to payment abuses, such as circumvention of certain payment caps mandated by section 4414 of the Balanced Budget Act of 1997, and we have therefore established special payment rules for those facilities. Facilities seeking to qualify as “satellites” under the inpatient payment criteria in §§ 412.22(h) and 412.25(e) would first need to comply with the provider-based requirements before being eligible for satellite status.) We have revised the final rule to clarify its application to remote locations of hospitals and satellite facilities.
Comment: The commenter believes that flexibility in the definition of “located in the immediate vicinity” needs to be met with additional considerations when viewing rural and underserved areas; for example, it should not be our intention to eliminate the provider-based designation of a rural health clinic (RHC), when the purpose of the RHC is to be an outreach to geographically isolated areas.
Response: We share the commenter's concern and have developed a special provision for RHCs, as described below.
Comment: A commenter believes that the requirement that provider-based entities serve the same population as the main provider could cause significant problems for RHCs. The unique situations addressed by hospital-based RHCs attempting to satisfy the health care needs of medically underserved areas should be considered as exceptions to the proposed rule.
Response: We continue to believe close physical proximity is an important indicator of provider-based status; however, we recognize that small rural hospitals and their RHCs may not be able to demonstrate that a substantial number of clinic patients receive services from the main provider. Small rural hospitals typically provide limited inpatient care compared to their urban counterparts, which may cause the RHC patients to seek inpatient service from other providers. In light of this, we believe small rural hospitals (less than 50 beds) that own and operate RHCs should not be expected to demonstrate that they serve the same patient population as the main provider. Therefore, we are revising the regulation to allow off-campus RHCs affiliated with small rural hospitals (less than 50 beds) to retain their provider-based status without satisfying that requirement.
Comment: Several commenters opposed the inclusion of paragraph (d)(7)(ii), since they view a State border as an arbitrary boundary inhibiting a hospital's ability to serve patients, which seems counterproductive. They also argued that a regulation that fails to recognize the operation of health care systems that function across State lines is unrealistic. Another commenter suggested that we rely on the proposal concerning serving the same patient population. It was also stated that in one case a provider can be located in a city Start Printed Page 18518split by the State border with its related facility located one mile away, but in another state, while in another case, the provider and its subordinate facility can be a mile apart and in the same State. Another commenter believes that, since Medicare beneficiaries often cross borders for health care services, disallowing hospitals in these areas from establishing provider-based entities eliminates choices and prohibits the development of new services. The commenter recommended that we revise or eliminate this criterion. Another commenter suggested that LTHs and their satellites not be subject to this requirement if the main provider and its satellite are located in two contiguous States. Alternatively, the commenter suggested that we consider using the wage index areas as guidelines for the areas to be served by provider-based entities even if that area crosses State lines.
Response: After reviewing these comments, we have decided to revise the regulations to allow providers in one State to have provider-based facilities in an adjacent State, if doing so is not inconsistent with the law of either State, and other criteria are met, including those related to service to the same patient population.
Comment: With regard to paragraph (d)(7)(i), while the proposed rule permits a provider to show that a “high percentage” of patients of the main provider and the facility come from the same geographic region, new facilities would not have any historical data upon which to base this assertion, and therefore would fail to be able to demonstrate the criteria prior to operation. Another commenter believes the requirement may pose an impediment to new facilities being located in underserved or outlying areas. Thus, the commenters believe the same patient population requirement should not apply to new facilities, including new long-term care hospital satellites.
Response: We agree that it would be appropriate to establish a criterion that could be met by new facilities or organizations, and therefore have revised the final rule to include a special provision for new facilities or organizations. Under this revision, a new facility or organization, (one that has not been in operation for all of the 12-month period immediately preceding the first day of the month in which the application for provider-based status is filed with us), may be considered to meet the criterion on service to the same patient population, if it is located in a zip code area included among those that (during the 12-month period described above) accounted for at least 75 percent of the patients served by the main provider. We note that this provision would not be limited to long-term care hospitals' satellites or their remote locations, but would be available to all new facilities or organizations.
Section 413.65(e) Provider-based status not applicable to joint ventures
Comment: Several commenters expressed concern that this criterion would prohibit the use of joint ventures for entities that want to participate as provider-based entities, and argued that such a prohibition would unnecessarily restrict hospital flexibility. One believes this provision should be eliminated. Another commenter suggested modification of paragraph (d)(2) of the rule to establish majority ownership as the standard rather than 100 percent ownership. Still other commenters suggested that provider-based status for facilities or organizations run as joint ventures should be permitted, as long as the hospital at which the facility is located has the equipment or service under its control.
Response: We reviewed these comments carefully, but did not make any changes in the regulations based on them. When a facility or organization is run as a joint venture of two or more providers, it is by definition under their joint control, and therefore cannot be an integral and subordinate part of any individual provider. We have no interest in discouraging such ventures, but continue to believe they do not qualify as provider-based.
Section 413.65(f) Management contracts
Comment: Several commenters expressed the view that the criterion under which the staff of the facility or organization must be employed by the provider or another organization other than a management company is too restrictive, and should be deleted. One commenter argued that, if the written contract maintains the responsibility and control for services in the hands of the main provider, the employer of the staff working at the site is not relevant. Another believes the criterion will discourage economic efficiencies. If a provider is able to demonstrate integration and subordination of the off-site facility based upon other provider-based criteria, the fact that a hospital chooses to provide certain services either directly through its own employees or indirectly through an independent contractor/management arrangements is irrelevant. Another commenter argued that the proposed criterion is inconsistent with: the provision of the Medicare statute that expressly permits coverage of “services under arrangement”; with the hospital conditions of participation that recognize that contractors may be used to furnish patient care services; and with the Provider Reimbursement Manual, which recognizes that providers commonly contract for management services and the costs of the contract services may be allowed under Medicare principles of reimbursement. Still another commenter believes the proposed criterion would negatively impact the therapy profession, and could impact the health and safety of Medicare beneficiaries.
Response: We do not believe the criterion is overly restrictive, nor do we agree that employment of the staff of a facility or organization is irrelevant to the question of whether that facility or organization is an integral and subordinate part of a provider. On the contrary, employment of the staff of such a facility or organization will normally give the provider significant control over it, thus promoting integration. Conversely, if a facility or organization is staffed by personnel who are employed by another entity that has only a contractual relationship with the provider, the facility or organization may well be an integral and subordinate part of the management company, not of the provider.
We also do not agree that the criterion is inconsistent with section 1861(w)(1) of the Act, which permits providers to make arrangements for the provision of specific health services, nor do we believe adopting this criterion will undercut the ability of providers to have selective services provided under arrangements. In this regard, we point out that existing Medicare policy, stated in section 207 of the Medicare Hospital Manual (HCFA Publication 10), emphasizes the need for the hospital to exercise professional responsibility for the arranged-for services, not merely to serve as a billing mechanism for the other party. This is consistent with our view that section 1861(w)(1) was intended to allow specific health care services to be furnished under arrangements, but was never meant to be a vehicle by which a provider could nominally operate a facility or organization, but, in fact, contract out its operation to another entity. Finally, we note that while there are various sections of the hospital conditions of participation and the Provider Reimbursement Manual that recognize the possibility that specialized health care services or management services may be provided under contract, this does not indicate that providers may Start Printed Page 18519contract out entire departments or services while claiming them as provider-based. To clarify the scope of the requirement on contracted services, we have revised it to state that management staff of the facility or organization (rather than health care or support staff) need not be employed directly by the provider. We have also revised the rule to clarify that if staff of the facility or organization (other than management staff) are employed by an organization other than the management company or the provider, it must be the same organization that also employs the staff of the main provider.
Section 413.65(g) Obligations of hospital outpatient departments and hospital-based entities
Section 413.65(g)(1)
Because of the direct relationship between the proposed changes in this section and those in § 489.24(b), comments on both proposals are discussed later, under § 489.24(b), “Special responsibilities of Medicare hospitals in emergency cases.”
Comment: A commenter requested clarification as to the application of the anti-dumping requirement in the home health setting.
Response: Section 413.65(g)(1) states that the EMTALA requirements apply to hospital outpatient departments. EMTALA requirements would not apply to off-campus provider-based entities that are not hospital departments, such as home health agencies.
Section 413.65(g)(2)
Comment: While one commenter agreed with the requirement under § 413.65(g)(2) for billing of physician services with the appropriate site-of-service indicator, another commenter also believes there should be clarification that correct billing is the responsibility of the entity performing the billing function. Both commenters suggested that the hospital notify physicians who do their own billing that they must use the correct indicator; they agree that it should not be the responsibility of the hospital.
Response: We agree that physicians (or those to whom they assign their billing privileges) are responsible for appropriate billing, but note that physicians who practice in hospitals, including off-site hospital departments, do so under privileges granted by the hospital. Thus, we believe the hospital has a role in ensuring proper billing.
Section 413.65(g)(5)
Comment: Presently, provider-based clinics bill Medicare for the facility charge on a UB-92 form, and the physician fee is billed separately on a HCFA-1500 form, while other payers may accept a single bill for both charges. A commenter believes it is inappropriate to mandate that two bills be submitted for all patients, as long as charges for similar services are uniform regardless of payer.
Response: As explained further below, we have revised the final rule to eliminate the part of this criterion relating to billing of services to non-Medicare patients. We believe this responds to this commenter's concern.
Comment: Many commenters stated that Medicare should treat a facility that claims a facility fee as being provider-based even when other payers do not do so, reasoning that as long as the hospital claims that the patient is an outpatient for Medicare purposes, the practices of other payers, with respect to similar patients, are not significant, and should be ignored. Another commenter believes this requirement should be eliminated, because, in the commenter's view, it has no bearing on the outpatient services delivered to Medicare beneficiaries, and therefore does not affect Medicare reimbursement. To illustrate, a large commercial insurer does not have the capability to accept certain types of outpatient claims from hospitals; therefore, it requires claims for those services to be billed on a physician claim form, so hospitals will receive the proper reimbursement. If this criteria is retained as proposed, many hospital-based departments would not meet our criteria due to the nuances of other payers' policies, that are often contractual issues with providers. Still another commenter believes that we should reexamine the proposal made in paragraph (g)(5), and at a minimum, clarify what it means by its proposal mandating uniform “treatment of all patients, for billing purposes, as hospital outpatients.” If we are proposing to mandate that all outpatients be billed on the same basis, this would effectively extend Medicare direct billing or rebundling rules to all payers. In addition, this proposed requirement would not only be contrary to past policy and practice, but would affect departments that have differentiated billing practices. Another commenter stated that payers typically determine payments based upon how they define a particular service or their individual market power; Medicare certification of outpatient departments should not be influenced by how unrelated third parties pay for services to the patients they cover at these sites. Moreover, this criterion would be very difficult to implement, because hospitals can have hundreds of contracts with insurance companies and the providers that subcontract for part of the risk for plans.
Response: After review of the comments on this section, we have decided to revise it to restrict the requirement for uniform billing to Medicare patients only, thus allowing hospitals to bill other payers in whatever manner is appropriate under those payers' rules. As revised, § 413.65(g)(6) states that hospital outpatient departments (other than RHCs) must treat all Medicare patients, for billing purposes, as hospital outpatients. The department must not treat some Medicare patients as hospital outpatients and others as physician office patients.
Comment: A commenter stated that there appears to be some confusion as to whether this requirement applies to “departments” or all facilities and organizations seeking provider-based status. Also, the commenter asked if there is a provision of the proposed rule that mandates that a facility fee be charged to patients of facilities and organizations receiving provider-based status.
Response: As noted earlier, the proposed rule would not apply this criterion to provider-based entities (which may participate separately as providers) but only to provider-based departments. Regarding the second issue, we have, as described in response to the preceding comment, revised the final rule to eliminate the criterion regarding billing of payers other than Medicare.
Section 413.65(g)(7)
Comment: A commenter stated that requiring written notice for each patient (presumably signed by the patient), would be an overly burdensome requirement, and requested that the requirement allow for a clear, prominently displayed sign in lieu of individual notice. Another commenter believes that the proposed requirement would apply a standard to hospital outpatient departments that is not applied to any other site of service.
Response: First, we emphasize that notice is required only for Medicare beneficiaries, not for all patients. We recognize that providing notice will generate some burden for the provider, but believe that the protection it affords to patients warrants the requirement. We considered allowing the notice requirement to be satisfied through the posting of signs, as recommended by one commenter, but concluded that use of individual written notices would more effectively ensure that each Start Printed Page 18520beneficiary receives the necessary information. In response to the comment concerning settings other than hospital outpatient departments, we note that in other settings, a patient is unlikely to be misled as to what type of facility is the site of treatment, so provision of notice is not required. To avoid confusion as to when the requirement applies, we have revised the final rule to state that notice is required only if the hospital outpatient department or provider-based entity is not located on the campus of the hospital that is the main provider. We have revised this final rule to specify that the notice must be in writing, must be one the beneficiary can read and understand, and must be given to the beneficiary's authorized representative if the beneficiary is unconscious, under great duress, or for any other reason unable to read a written notice and understand and act on his or her own rights.
Section 413.65(g)(9) (redesignated in this final rule as Section 413.65(h), Furnishing all services under arrangement)
Comment: A commenter observed that § 413.65(g)(9) does not preclude an outpatient facility from obtaining a certain type of service from an off-site supplier. If this is correct, if the service is provided on-site in the hospital's outpatient facility, it is not clear how the proposed regulations are intended to be applied. It would appear that if the facility is looked at as a whole, all services are not provided “under arrangements”; therefore, paragraph (g)(9) of this section would not preclude the facility from being recognized as provider-based. However, in this case, the commenter stated that both licensure and ownership requirements would be difficult to satisfy. In most cases, that portion of the facility that is operated “under arrangements” with the hospital will not be on the hospital's license, nor will that portion necessarily be owned by the hospital. Thus, the commenter urged that the “under arrangements” portion of an outpatient facility be excluded from the licensure and ownership analyses.
Response: We agree that where a facility offers a variety of services, provision of a single type of service under arrangement would not prevent the facility from meeting this criterion. The criterion could not, of course, be met by a facility that furnished only a specific type of service (such as physical therapy), and provided that service only under arrangement. In the case envisioned by the second commenter, the facility would be out of compliance with licensure and ownership requirements, as well as the requirement involving services under arrangement, and we would agree that it could not be provider-based.
Comment: A commenter asked for clarification of “under arrangements”, in reference to our other regulations that contain these terms. Also, the commenter requested clarification on the types of services to which this standard applies, that is, direct patient care as opposed to facility related services.
Response: The term “arrangements” is defined in section 1861(w)(1) of the Act and the Medicare regulations § 409.3, in that “arrangements” refers to arrangements that provide that Medicare payment made to the provider that arranged for the services discharges the liability of the beneficiary or any other person to pay for the services. We wish to emphasize that the provision will apply to patient care services, not housekeeping, security, billing, or other services that are not patient care services but are needed to support their provision.
Section 413.65(h) Inappropriate treatment of a facility or organization as provider-based (redesignated in this final rule as paragraph (i))
Comment: This section establishes sanctions that may be used to address a main provider that has treated an entity as provider-based without our review and approval. A commenter believes that the investigation phase should precede the review of payments to the main provider. A commenter was also concerned that the individuals involved in these reviews and investigations are properly trained to make the required determinations.
Response: We believe review of payments will encompass two activities—investigation to determine whether applicable provider-based requirements were met, and a calculation of the amount of overpayment if they were not. Thus, investigation necessarily precedes recovery, but is a part of the overall effort, which is to reconsider payment amounts. To respond more effectively to concerns about how the review and recovery activities will occur, and to clarify the specific actions we will take in cases of inappropriate billing, we have reorganized paragraph (i) to deal separately with the processes of determination and review, recovery of overpayments, and the good faith effort exception. With respect to determination and review, we state that if we learn that a provider has treated a facility or organization as provider-based and the provider had not obtained a determination of provider-based status under this section, we will review current payments and, if necessary, take action in accordance with the rules on inappropriate billing in paragraph (j), investigate and determine whether the requirements for provider-based status in paragraph (d) of § 413.65 (or, for periods prior to October 10, 2000, the requirements in applicable program instructions) were met, and review all previous payments to that provider for all cost reporting periods subject to re-opening in accordance with § 405.1885 and § 405.1889 of this chapter. With respect to recovery of overpayments and the good faith exception, we have clarified that we will recover only the difference between the amount of payments that actually were made and the amount of payments that we estimate should have been made in the absence of a determination of provider-based status, and that recovery will not be made for any period prior to the effective date of these final rules if during all of that period the management of the entity made a good faith effort to operate it as a provider-based facility or organization, as described in paragraph (h)(3) of § 413.65. In response to the comment about the competence of individuals involved in these activities, we wish to emphasize that we will ensure that staff involved in these activities have the necessary expertise.
Comment: A commenter believes that it would be unfair to apply the proposed regulations retroactively, that is, to periods before the effective date of the final rule. Even though paragraphs (h) and (i) provide for a good faith exception, it is still unfair to provide that the conditions for this exception will apply prior to the effective date of the final regulation. The commenter requested that these sections be revised to provide that the period of recovery will not extend to any period prior to the effective date of the final regulations. Another commenter also believes that any payment changes be prospective (unless the hospital did not make a good faith effort to operate the site as provider-based).
Response: We agree that it would be inappropriate to apply the rules in paragraph (h) to any period prior to their effective date, and have revised the final rule to clarify that for such periods, we will make determinations based on the program memoranda or other instructions in effect at the time. However, the criteria in paragraph (i) that form the basis for a good faith exception were in effect prior to the issuance of these regulations. Regarding Start Printed Page 18521the last comment, we cannot agree to ignore possible overpayments resulting from noncompliance with published criteria in effect at that time.
Comment: A commenter believes that the term “good faith effort” should be defined to provide more direction and opportunity to comply. Also, entities making “good faith efforts” should be given an opportunity to correct those factors or criteria that render it out of compliance with the provider-based requirements.
Response: The conditions under which a provider will be found to have made a good faith effort were clarified in § 413.65(i)(2), and have been restated in the final rule.
Section 413.65(i) Inappropriate billing (redesignated in this final rule as paragraph (j))
Comment: A commenter believes that suspending all payments for outpatient services to facilities that have billed inappropriately as provider-based entities until the provider can demonstrate that payments are proper is too onerous. Instead, the commenter suggested that we consider suspending the reimbursement differential between a provider-based entity and a nonprovider-based entity until a determination is made or the facility has had a reasonable opportunity to comply.
Response: We understand the commenter's concern and have revised the final rule to authorize partial suspension of payment (that is, a reduction in payment) to the extent needed to prevent creation of an overpayment to the provider. This rule will allow payment to continue at a reduced rate, thus avoiding creation of financial hardship for the provider. To describe more clearly how we will deal with instances of inappropriate billing, we have reorganized paragraph (j) of § 413.65 to spell out more clearly the actions we will take, and the extent to which payment will be adjusted. Specifically, we state that if we find that a facility or organization is being treated as provider-based without having obtained a determination of provider-based status under this section, we will notify the provider, adjust future payments, review previous payments, determine whether the facility or organization qualifies for provider-based status under this paragraph, and continue payments only under specific conditions. The notice to the provider will explain that payments for past cost reporting periods may be reviewed and recovered, that future payments for services in or of the facility or organization will be adjusted, and that a determination of provider-based status will be made.
We further state that we will not stop all payment in such cases, but instead, will adjust future payments to approximate as closely as possible the amounts that would be paid in the absence of a provider-based determination, if all other requirements for billing were met. We also explain that we will review previous payments and, if necessary, take action in accordance with the rules on inappropriate treatment of a facility or organization described above. The regulation states that we will determine whether the facility or organization qualifies for provider-based status under the criteria in this section. If we determine that the facility or organization qualifies for provider-based status, future payment for services at or by the facility or organization will be adjusted to reflect that determination. Even if the facility or organization does not qualify for provider-based status, however, we will continue paying, at an appropriately adjusted level, for a limited time period in order to avoid disruption of services to program beneficiaries at that site and to allow an orderly transition to freestanding status.
The notice of denial of provider-based status sent to the provider will ask the provider to notify us in writing, within 30 days of the date the notice is issued, as to whether the facility or organization (or, where applicable, the practitioners who staff the facility or organization) will be seeking to enroll and meet other requirements to bill for services in a free-standing facility. If the provider indicates that the facility, organization, or practitioners will not be seeking to enroll, or if we do not receive a response within 30 days of the date the notice was issued, all payment will end as of the 30th day after the date of notice. If the provider indicates that the facility or organization, or its practitioners, will be seeking to enroll and meet other requirements for billing for services in a free-standing facility, payment for services of the facility or organization will continue, at the adjusted amounts described in paragraph (j)(2) of this section for as long as is required for all billing requirements to be met (but not longer than 6 months) if—
- The facility or organization, or its practitioners, submit a complete enrollment application and provide all other required information within 90 days after the date of notice, and
- The facility or organization, or its practitioners, furnish all other information we need to process the enrollment application and verify that other billing requirements are met.
If the necessary applications or information are not provided, we will terminate all payment to the provider, facility, or organization as of the date we issue notice that necessary applications or information have not been submitted. We have clarified the final rule to state that these reductions will occur where inappropriate billing is or has been taking place.
Comment: A commenter believes that there are already existing mechanisms for overpayment and recoupment that may be used in the situations described in this section. At the very least, administrative actions of this type should be subject to time frames in order to protect providers from the impact of extended investigations.
Response: We plan to conduct any recovery efforts in accordance with applicable law and regulations on overpayment recovery. However, investigations may be complex and require examination of many records, and we do not agree that they should be limited by additional, self-imposed restrictions.
Comment: A commenter stated that a facility or organization that requests a provider-based determination prior to the effective date of the final rule, and meets the good faith requirements, should not be subject to recovery of overpayment for periods either before or after the effective date of the final rule. This will prevent disruptions to existing arrangements that meet the good faith exception during the time that the request is being processed.
Response: If we were to adopt this proposal, we would be guaranteeing an overpayment to providers who, for a specific time period, knowingly billed for services as those of provider-based entities, even though they met only a few of the provider-based criteria. Thus, we did not adopt this comment.
Comment: A commenter requested that the requirement found at paragraph (i)(2)(iii) be clarified to state that management is only responsible for professional services billed by the hospital.
Response: As explained earlier, we believe hospitals' privileging mechanisms give them adequate leverage to prevent inappropriate billing by practitioners using their facilities. Therefore, we did not adopt this comment.
Comment: As to the good faith criteria found in paragraph (i)(2), a commenter questioned why requirements related to public awareness were chosen for inclusion. An organization can represent itself to the public in any number of inaccurate ways in order to mislead our officials and others. The Start Printed Page 18522commenter believes that we should focus our attention on more tangible expressions of good faith efforts to operate a provider based entity.
Response: We believe inclusion of this requirement is needed to help ensure that beneficiaries are protected from unexpected deductible and coinsurance liability. While we agree with the commenter that some providers may misrepresent the status of off-site facilities, we believe such providers cannot reasonably be said to have acted in good faith, and should not receive favorable treatment with respect to past overpayments.
Section 413.65(j) Correction of errors (redesignated in this final rule as paragraph (k))
Comment: A commenter disagreed with the language in this subsection that would allow us to review and rescind, if appropriate, any past determinations. The commenter believes that this subsection should be removed and any previous determinations should be grandfathered in under the new regulations. Other commenters recommended that we grandfather facilities or organizations that had previously been determined by the regional office to be provider-based, or that have not received such a determination but have been billing as provider-based without a determination for a period of at least ten years, so that those facilities or organizations could retain provider-based status even though they do not meet the criteria in the regulations.
Response: We do not agree that it would be appropriate to grandfather existing facilities or organizations, since this would in effect create an ongoing double standard, under which some facilities or organizations are held to higher standards than others. Moreover, the fact that improper billing may have continued undetected for a long period is not a reason to continue to permit such billing. As explained in the response to the following comment, however, any adverse determination regarding provider-based status of facilities or organizations which we previously determined were provider-based will not be effective until the start of the cost reporting period after the period in which the provider is notified of the redetermination, or for at least 6 months, whichever date is later.
Comment: A commenter believes that our proposal that we may review past provider-based determinations inserts needless uncertainty into the process for making provider-based designations. The commenter is concerned that providers may file before the final rule is published in order to avoid a crush of applications and subsequent disruption in payment, if they do not have a determination within 30 days of the rule becoming final. The commenter stated that providers need to be able to receive prompt determinations on which they can rely.
Response: We understand the concern about avoiding the need to process a large number of applications in a short time, and agree that it would not be appropriate to make abrupt changes in provider-based status. To avoid a possible crush of applications within a 30-day period, as envisioned by the commenter, we are providing the delayed effective date described earlier in this document. In addition, under § 413.65(j) of these regulations, when a facility or organization that previously was determined to be provider-based is found to no longer qualify for provider-based status, treatment of the facility or organization as provider-based will not cease until the first day of the first cost reporting period following notification of the redetermination, but not less than 6 months after the date the provider is notified of the redetermination. If there has been no prior determination of provider-based status, and a facility or organization is later found not to meet the criteria, that determination may be effective up to 6 months after the date the provider is notified of the determination, if within 30 days of the determination, the provider indicates that the facility or organization, or its practitioners, will enroll separately and, within 90 days, the facility or organization, or its practitioners, take other necessary action to enroll.
Section 489.24(b) Special responsibilities of Medicare hospitals in emergency cases
Comment: One commenter disagreed strongly with the proposed revisions to the regulation defining “comes to the emergency department,” and in particular expressed the view that patients arriving on the campus, sidewalk, driveway, or parking lot of hospital facilities should not be considered to have come to the emergency department. The commenter stated the view that an obligation under section 1867 of the Act (sometimes referred to as the Emergency Medical Treatment and Active Labor Act (EMTALA), after the original title of the legislation adding section 1867) and our regulations at §§ 489.20(l), (m), (q), and (r), and § 489.24 should be triggered only by a presentation to the emergency department, and that only in exceptional situations should EMTALA apply to someone not technically in the emergency department. The commenter recommended that the regulations be revised to state that in these cases, the hospital may rely on a variety of transport options, consistent with the individual's condition and established policies that are applied in a nondiscriminatory manner. The commenter also recommended that the statute be interpreted as requiring only that hospitals with emergency departments have policies and procedures to assure that a person who presents to the hospital requesting emergency services is provided a medical screening examination and, if needed, stabilization or an appropriate transfer.
Another commenter raised several arguments against the proposed change. The commenter stated that there is a legal and ethical conflict in requiring hospital personnel to leave an area of patient care and furnish assistance to another patient in a remote area of the hospital. The commenter also believes that ED personnel are not well-trained or practiced in immobilization or scene safety, and patients and staff may be put at risk if staff are asked to go into the field and render aid to a victim who needs the expert care and experience for which field emergency medical services (EMS) personnel are trained. Finally, the commenter expressed concern about possible increases in the liability insurance cost to hospitals as a result of the proposed change.
Response: We do not agree that the proposed language inappropriately extends the scope of hospitals' EMTALA responsibilities. On the contrary, existing regulations at § 489.24 make it clear that EMTALA applies to hospitals that offer services for emergency medical conditions, and we believe it would defeat the purpose of EMTALA if we were to allow hospitals to rely on narrow, legalistic definitions of “comes to the emergency department” or of “emergency department” to escape their EMTALA obligations. We would also note, as discussed further below, that there is no requirement that all areas of the hospital be equipped to provide emergency care or that treatment always be provided outside the emergency area or department. Similarly, there is no prohibition of appropriate transfers to other facilities where such a transfer is conducted in accordance with § 489.24. On the contrary, the intent of the revised regulation is to ensure that patients who come to the hospital and request examination or treatment for what may be an emergency medical condition are not denied EMTALA protection simply because they enter the Start Printed Page 18523wrong part of the hospital or fail to make their way to the emergency room.
Comment: Two commenters recommended clarification of the applicability of section 1867 of the Act regarding transfer requirements to scheduled patients at an “off-campus” hospital site, to ensure that the movement of scheduled patients unexpectedly requiring a higher level of care to another site of the same hospital is not construed as a “transfer” under the emergency access law, and that only those patients taken from one hospital's off-campus facility to another hospital's emergency department or inpatient unit be considered “transfers” that must be in accordance with the requirements of section 1867.
Response: We agree that movement of a patient from one part of a hospital to another, including movement from a remote location to a main hospital campus, does not constitute a “transfer” for EMTALA purposes, nor does it require compliance with the appropriate transfer requirements in § 489.24(d). The final regulations at § 489.24(i)(3)(i) clarify this policy.
Comment: A commenter expressed the view that the proposed revision to § 489.24 does not recognize the role that EMS personnel play in emergency situations and the true medical benefit provided by EMS personnel to patients in emergency situations. The commenter recommended that language be included in the regulation to authorize hospitals' use of EMS in responding to emergency situations on hospital grounds.
Response: We agree that EMS personnel can play a valuable role in transporting patients to appropriate sources of emergency care. A hospital may not, however, meet its EMTALA obligations merely by summoning EMS personnel. EMS may be used appropriately in conjunction with an appropriate hospital response to treat and move an individual who is already on hospital property. We therefore did not make any change to these regulations to authorize exclusive use of EMS to respond to emergency situations on hospital property.
Comment: A number of commenters stated that the anti-dumping rules implemented under section 1867 of the Act (EMTALA requirements) and our regulations at §§ 489.20(l), (m), (q), and (r), and § 489.24 should apply to the hospital's main campus and to all emergency departments. However, they argued that it is not reasonable to apply these rules to outpatient departments located off-campus that would not be set up to provide emergency services. In the commenters' view, it should suffice that patients in an emergency situation be directed to the hospital's emergency room. Another commenter stated that EMTALA obligations should be limited to those hospital entities that hold themselves out as providing emergency services, and should not be enforceable anywhere outside the emergency department or anywhere on hospital property, including an outpatient department or provider-based entity. Another commenter stated that the enforcement of this requirement would lead to the elimination of service-specific outpatient departments located off a main campus, and asked that we reconsider our policy. One commenter expressed concern that patients identifying a facility as a hospital-based department could mistakenly assume it is equipped to handle emergency cases. Another commenter believes that hospitals should be required to have policies and procedures in place to assure that all parts of the hospital are prepared to deal with getting an individual the appropriate medical screening.
Response: Existing regulations at § 489.24(b) define “hospital with an emergency department” to include all hospitals that offer services for emergency medical conditions, not just those that have organized emergency rooms or departments. To the extent a hospital acquires or creates an off-campus location, identifies it to us and to the public as a part of that hospital, and claims payment for services at that location as hospital services, we believe it is not unreasonable to expect that hospital also to assume the obligations, including compliance with EMTALA requirements, which flow from hospital status. This principle does not mean, of course, that a hospital must have a fully equipped and staffed emergency department at each location. It also does not mean that every appearance by an individual at an off-campus hospital department that does not offer services for emergency medical conditions will necessarily trigger an EMTALA obligation on the part of the hospital. Individuals come to these departments for many medical purposes which may not involve potential emergency medical conditions. Under these circumstances, the hospital would not have an EMTALA obligation with respect to that individual. This principle does mean, however, that if an individual comes to an off-campus department of a hospital and a request is made for examination or treatment for a potential emergency medical condition, the hospital incurs an obligation to provide, within its capability, an appropriate medical screening examination and necessary stabilizing treatment. In some cases, the patient may need to be taken back to the main hospital campus for a full screening and/or stabilizing treatment. Under these circumstances, the hospital is responsible for moving the patient or arranging his or her safe transport, but this movement would not be considered a “transfer” under § 489.24(b), since the patient is merely going from one part of the hospital to another. If it is necessary to transfer the patient to another medical facility, the hospital must provide an appropriate transfer in accordance with § 489.24(d).
After review of the comments on this issue, we have decided to revise the regulations to state more clearly the extent of a hospital's EMTALA obligations with respect to patients who come to a hospital department located off the hospital's main campus. Provider-based entities, such as SNFs or HHAs, located off the hospital campus would not, of course, be subject to EMTALA since a patient coming to such an entity would not have come to the hospital. We will require that each off-campus hospital department, during its regular hours of operation, have in effect procedures for: (1) assessing the possibility that an emergency medical condition exists, and providing such screening (as defined in § 489.24(a) and (b)) and necessary stabilization (as defined in § 489.24(c)) at the off-campus site); (2) transporting the patient to the hospital's emergency room or department for screening and necessary stabilization meeting the requirements of § 489.24; or (3) providing an appropriate transfer to another facility in accordance with the requirements in § 489.24(c). To meet these requirements, the hospital will need to develop procedures that permit staff of the off-campus department to contact emergency physicians or other qualified emergency practitioners at the main hospital campus, to obtain advice and direction regarding the handling of any potential emergencies, and to obtain prompt medical transport, by hospital-owned or other ambulance or other appropriate vehicle, either to the main hospital campus or, where an appropriate transfer is being provided, to another medical facility.
Specifically, we are adding new paragraph (i) to § 489.24 to describe a hospital's obligations. The paragraph states that, if an individual comes to a facility or organization that is located off the main hospital campus as defined in § 413.65(b), but has been determined under § 413.65 of this chapter to be a department of the hospital, and a Start Printed Page 18524request is made on the individual's behalf for examination or treatment of a potential emergency medical condition as otherwise described in paragraph (a) of § 489.24, the hospital is obligated to provide the individual with an appropriate medical screening examination and any necessary stabilizing treatment.
The capability of the hospital includes that of the hospital as a whole, not just the capability of the off-campus facility or organization. Except for cases described in paragraph (i)(3)(iii) (those in which the main hospital campus does not have the specialized capability or facilities needed to treat the individual, or the individual's condition is deteriorating so rapidly that transport to the main campus would significantly jeopardize the life or health of the individual), the obligation of a hospital under this section must be discharged within the hospital as a whole. However, the hospital is not required to locate additional personnel or staff to off-site locations to be on standby for possible emergencies.
In § 489.24(i)(2), Protocols for off-campus departments, we further state that the hospital must establish protocols for the handling of potential emergency cases at off-campus departments. These protocols must include provision for direct contact between personnel at the off-campus department and emergency personnel at the main hospital campus, and may provide for dispatch of practitioners, when appropriate, from the main hospital campus to the off-campus department to provide screening or stabilization services. The intent of these requirements is to ensure timely exchange of information between the two sites, and to allow the hospital the flexibility to bring emergency personnel to the patient, rather than the opposite, where doing so is the best medical approach to meeting the patient's needs.
Under the final rule, if the off-campus department is an urgent care center, primary care center, or other facility that is routinely staffed by physicians, RNs, or LPNs, these personnel must be trained, and given appropriate protocols, for the handling of emergency cases. At least one individual on duty at the off-campus department during its regular hours of operation must be designated as a qualified medical person as described in paragraph (d). The qualified medical person must initiate screening of individuals who come to the off-campus department with a potential emergency medical condition, and may be able to complete the screening and provide any necessary stabilizing treatment at the off-campus department, or to arrange an appropriate transfer.
The final rule further states that if the off-campus department is a physical therapy, radiology, or other facility not routinely staffed with physicians, RNs, or LPNs, the department's personnel must be given protocols that direct them to contact emergency personnel at the main hospital campus for direction. Under this direction, and in accordance with protocols established in advance by the hospital, the personnel at the off-campus department must describe patient appearance and reported symptoms and, if appropriate, arrange transportation of the individual to the main hospital campus (if the main hospital campus has the capability required by the individual, and movement to the main campus would not significantly jeopardize the individual's life or health), or assist in an appropriate transfer. Movement of the individual to the main campus of the hospital is not considered a transfer under this section, since the individual is simply being moved from one department of a hospital to another department or facility of the same hospital.
Finally, specific rules apply if the individual's condition warrants movement to a facility other than the main hospital campus, either because the main hospital campus does not have the specialized capability or facilities required by the individual, or because the individual's condition is deteriorating so quickly that taking the time required to move the individual to the main hospital campus could place the life or health of the individual in significant jeopardy. Under these circumstances, personnel at the off-campus department must, in accordance with protocols established in advance by the hospital, assist in arranging an appropriate transfer of the individual to a medical facility other than the main hospital. The hospital must have protocols to ensure that the movement is an appropriate transfer in accordance with paragraph (d)(2) of this section. The protocol must include procedures and agreements established in advance with other hospitals or medical facilities in the area of the off-campus department to facilitate these anticipated transfers. We note that the interpretive guidelines for enforcement of EMTALA requirements will be revised to conform to these new rules.
Section 498.3 Scope and applicability
Comment: A commenter asked for clarification as to whether appeal rights would be available in the event of revocation by us of provider-based status.
Response: We have revised § 489.3(b)(2) to specify that a determination that a facility or organization no longer qualifies for provider-based status is an initial determination, thus providing an administrative appeals mechanism for these decisions.
D. Requirements for Payment
We proposed to revise § 410.27, Outpatient Hospital Services and Supplies Incident to a Physician Service: Conditions, to require that services furnished at a location other than an RHC or an FQHC that we designate as having provider-based status under § 413.65 must be under the direct supervision of a physician as defined in § 410.32(b)(3)(ii).
Comment: Several commenters requested clarification of what we mean by “direct supervision.” One commenter asked that we further define the nature and extent of the supervision needed to comply with our proposal. One commenter asked whether the supervision requirement would be met if a physician is in the hospital or whether the physician must be in the department while the procedure is being performed. The same commenter asked whether the physician billing for the incident to services must be of the same specialty as the procedure being performed. A large trade association stated that we appear to be replacing our current policy in section 3112.4(A) of the Intermediary Manual, which states that we assume the physician supervision requirement to be met when incident to services are furnished on hospital premises, with a policy requiring direct physician supervision at all times, in all outpatient departments, regardless of whether or not they are located on the hospital campus. The commenter recommended that if we retain a direct supervision requirement, it should be limited to outpatient departments located off-site of the main provider. One commenter stated that facilities and organizations accorded provider-based status that are located on the main provider's campus should be subject to the same physician supervision requirements that apply to “incident to” services provided elsewhere on the campus.
Response: We regret that our proposal to define “direct supervision” by referring to the definition of “direct supervision of a physician” given at § 410.32(b)(3)(ii) may have been confusing to some commenters. Section 410.32(b)(3)(ii) defines “direct supervision” within (a physician) office Start Printed Page 18525setting as meaning that the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. The definition at § 410.32(b)(3)(ii) goes on to state that “direct supervision” does not mean that the physician must be present in the room when the procedure is performed.
Our intention in the proposed rule was to define “direct supervision” of hospital outpatient services incident to physician services when they are furnished at a department of a hospital to mean that a physician must be present on the premises of the entity accorded status as a department of the hospital and, therefore, immediately available to furnish assistance and direction for as long as patients are being treated at the site. By “direct supervision” we do not mean that the physician must physically be in the room where a procedure or service is furnished. Nor does the supervising physician necessarily have to be of the same specialty as the procedure or service that is being performed. We emphasize that our proposed amendment of § 410.27 to require direct supervision of hospital services furnished incident to a physician service to outpatients applies to services furnished at an entity that is located off the campus of a hospital that we designate as having provider-based status as a department of a hospital in accordance with the provisions of § 413.65. Our proposed amendment of § 410.27 to require direct supervision of hospital services furnished incident to a physician service to outpatients does not apply to services furnished in a department of a hospital that is located on the campus of that hospital. For hospital services furnished incident to a physician service to outpatients in a department of a hospital that is located on the campus of the hospital, we assume the direct supervision requirement to be met as we explain in section 3112.4(A) of the Intermediary Manual. The requirement at § 410.27 does not affect the definition of physician supervision in section 3112.4(A) of the Intermediary Manual. In response to these comments, we have revised our definition of “direct supervision by a physician” in the final regulation.
Comment: A major trade association asserted that requiring a physician to be on-site at a provider-based entity throughout the performance of all “incident to” services would be burdensome and costly for hospitals where there are a limited number of physicians available to provide coverage, particularly in rural settings. Another commenter believes that entities with provider-based status should not be subject to physician supervision requirements that are more stringent than those applicable to free-standing facilities. A third commenter believes that this requirement is unnecessary because the requirements for integration with the hospital and other requirements for provider-based status include adequate checks and balances to ensure quality care. The commenter recommended that this proposal be omitted from the final rule with the potential for a separate, better defined, proposal at a later date.
Response: We disagree with commenters who believe the proposed supervision requirement is not necessary or that it would be burdensome to the hospital. First, the supervision requirement is separate from and independent of the provider-based requirements, and hospitals and physicians already have to meet a direct supervision of “incident to” services requirement that is unrelated to provider-based issues. That is, we require that hospital services and supplies furnished to outpatients that are incident to physician services be furnished on a physician's order by hospital personnel and under a physician's supervision (Intermediary Manual, section 3112.4(A)). We assume the physician supervision requirement is met on hospital premises because staff physicians would always be nearby within the hospital. The effect of the regulations in this final rule is to extend this assumption to a department of a provider that is located on the campus of a hospital. However, the regulation does not extend the assumption of supervision to a department of a hospital that is located off the campus of the hospital. We would not extend this assumption to a provider-based entity, regardless of its location, because the “incident to” requirement in § 410.27(a)(1)(iii) applies only to hospitals. Also, as we state above, satisfying the requirements to be designated provider-based is unrelated to our requirement that hospital services furnished incident to a physician service to outpatients at an entity that has provider-based status be under the direct supervision of a physician. Finally, this supervision requirement is entirely consistent with the direct supervision requirements currently set forth in the Medicare Carriers Manual, Part 3, section 2050.1(B).
Comment: One commenter suggested that partial hospitalization services furnished by a hospital to its outpatients be exempt from the outpatient department “incident to” requirements, or that other requirements be drafted that would, in the commenter's opinion, be more appropriate to the nature of this care.
Response: Section 1861(s)(2)(B) restricts coverage of partial hospitalization services furnished by a hospital to its outpatients to services that meet “incident to” requirements. We do not have the discretion to ignore this statutory restriction.
Comment: One commenter asked that we provide an exception to the direct supervision requirement in the case of physical therapy services. The commenter questioned why therapists who furnish the same services in a provider-based entity that they would furnish in an independent practice should be subject to direct physician supervision in one setting and not the other.
Response: The provision on coverage for outpatient physical therapy and occupational therapy services does not require that they be “incident to” physician services (see section 1861(s)(2)(D) of the Act). Therefore, there is no need to exempt them from the supervision requirement for outpatient hospital services incident to a physician service that is furnished at a provider-based entity. We therefore made no change in the final regulation based on this comment.
Comment: One commenter suggested that we modify our proposed regulation to waive the direct supervision requirement in entities with provider-based status for certain procedures for which we already waive the direct supervision requirement when the procedures are performed on homebound patients, as set forth in section 2051 of the Medicare Carriers Manual. The commenter believes that general supervision is sufficient for these waived services, for example, the physician need not be present, but the services must be performed under a physician's overall supervision and control, and ordered by a physician.
Response: Under section 2050.2 of the Medicare Carriers Manual, subject to certain requirements, we waive the direct supervision requirement when the following services are furnished to homebound patients: injections; venipuncture; EKGs; therapeutic exercises; insertion and sterile irrigation of a catheter; changing of catheters and collection of catheterized specimen for urinalysis and culture; dressing changes, for example, the most common chronic conditions that may need dressing changes are decubitus care and gangrene; replacement and/or insertion of nasogastric tubes; removal of fecal Start Printed Page 18526impaction, including enemas; sputum collection for gram stain and culture, and possible acid-fast and/or fungal stain and culture; paraffin bath therapy for hands and/or feet in rheumatoid arthritis or osteoarthritis; and, teaching and training the patient for the care of colostomy and ileostomy, the care of permanent tracheostomy, testing urine and care of the feet (diabetic patients only), and blood pressure monitoring. While we believe the commenter's suggestion has merit, we do not believe it would be appropriate to adopt it before we have had time to analyze the issue further. Therefore, we did not revise the final rule based on this comment.
In our proposed rule, we proposed to require that the same supervision levels established for diagnostic x-ray and other diagnostic tests in accordance with § 410.32(b)(3) be required when these tests are furnished at an entity that has been accorded provider-based status by us.
Comment: A large industry federation generally favored our requiring that diagnostic tests be furnished at provider-based entities under levels of physician supervision that we specify, consistent with the definitions of general, direct, and personal supervision established at § 410.32(b)(3). The commenter suggested that we modify the definition of general supervision to make it clear that the training of nonphysician personnel and the maintenance of necessary equipment and supplies are the responsibility of the hospital, not the physicians.
Response: We agree and we will modify our regulation accordingly.
Comment: Numerous commenters, including radiology and imaging specialty groups, neurologists, vascular technologists, and sonographers, questioned the level of supervision required for various specific diagnostic tests and services.
Response: Our model for this proposed requirement was the requirement for physician supervision for diagnostic tests payable under the Medicare physician fee schedule that was issued in the October 31, 1997 physician fee schedule final rule (for CY 1998) (62 FR 59048). There have been issues raised about the appropriate level of supervision for some specific diagnostic services, similar to the comments we received about our proposed regulation. We have not yet resolved these issues, and this final rule is not the place to convey decisions about appropriate supervision levels for specific diagnostic tests and services by individual HCPCS code. In January 1998, we sent a memorandum to all Associate Regional Administrators advising them to instruct carriers to follow their existing policies on physician supervision of diagnostic tests until we provide further instruction. We intend to instruct hospitals and intermediaries to use the October 31, 1997 physician supervision requirements as a guide, pending issuance of updated requirements. In the meantime, fiscal intermediaries, in consultation with their medical directors, will define appropriate supervision levels for services not listed in the October 31, 1997 final rule when those services are furnished at an entity with provider-based status in order to determine whether claims for these services are reasonable and necessary.
V. Summary of and Response to MedPAC Recommendations
The following are additional recommendations contained in the report on Medicare payment policy that the Medicare Payment Advisory Commission submitted to the Congress in March 1999. (MedPAC, Report to the Congress: Medicare Payment Policy, March 1999.) We respond to recommendations that are specifically related to a particular component of the hospital outpatient PPS in the appropriate section of this preamble.
MedPAC Recommendation: MedPAC recommends that the Secretary evaluate payment amounts under the hospital outpatient PPS and the ambulatory surgical center (ASC) PPS along with the practice expense payments under the Medicare physician fee schedule for services furnished in physicians' offices to ensure that the differing payments made under the three payment systems do not create unwarranted financial incentives regarding site of care.
Response: We agree that the three payment systems should avoid creating unnecessary financial incentives to deliver care in particular settings. We will consider this matter further and evaluate differences in payments.
MedPAC Recommendation: MedPAC recommends that the Secretary study means of adjusting base prospective payment rates across ambulatory settings for patient characteristics such as age, frailty, comorbidities and coexisting conditions, and other measurable traits. Under this approach, payment would be less dependent on the type of facility and more dependent on the relative costliness of furnishing specific services to individual patients. MedPAC notes that no viable patient-level adjuster currently exists that could be used in this fashion.
As an interim measure, MedPAC recommends, with reservations, that HCFA evaluate facility-level adjustments in order to preserve access to care for particularly vulnerable segments of the Medicare population.
Response: The underlying premise in this recommendation, as MedPAC states, is that HCFA should move toward development of a more unified and rational payment system for ambulatory care. Many powerful arguments favor such a system, but the challenges of creating and implementing it are substantial. We will give further consideration to the recommendation to study possible adjustments that could be used in various settings.
We agree that we should evaluate the need for facility-level adjustments. We believe the best course is to evaluate the need for these adjustments during the next several years as we gain actual experience with the operation of the hospital outpatient PPS and are able to observe the effects on particular provider groups. In consideration of the transitional protections provided by the BBRA 1999, we have not adopted facility-level adjustments, other than an adjustment for local labor costs, at this time.
MedPAC Recommendation: MedPAC recommends that the Secretary seek legislation to develop and implement a single update mechanism that would link conversion factor updates to volume growth across all ambulatory care settings. These settings include hospital outpatient departments, physicians' offices, and ASCs, as well as other specific settings mentioned.
Response: We believe that this proposal requires further study to determine its feasibility and possible impact. Therefore, we are not prepared to seek legislation at this time.
MedPAC Recommendation: MedPAC recommends that we not use patient diagnosis to calculate relative weights or make payments for medical visits, “given the current state of the available data and the lack of definitive rules for reporting patients' diagnoses under the proposed system.”
Response: As discussed in section III.C.3, we have dropped diagnosis from our characterization of medical visit APCs. We hope to develop procedure codes for medical visits that are more descriptive of hospital outpatient resource use, rather than physician services. Once we revise procedure coding to better reflect hospital services, we will assess whether accurate diagnosis coding further improves recognition of resources.
MedPAC Recommendation: MedPAC recommends that the Secretary closely Start Printed Page 18527monitor the use of hospital outpatient services to ensure that beneficiary access to care is not compromised.
Response: We plan to evaluate the operation of the new PPS to address a variety of issues, including beneficiary access to care. We note that the provisions of the BBRA 1999 should mitigate substantially any payment reductions and hence the possibility of reduced access.
MedPAC Recommendation: MedPAC recommends that the Secretary consider making payment adjustments in addition to the proposed adjustment for local area wages under the new system. These adjustments should be tied to patient characteristics. The facility-level adjustments that are made until the time that a patient-level adjuster is available should reflect the population of Medicare patients treated by facilities identified to receive the adjustments.
MedPAC points out that HCFA, in setting Medicare payment rates for hospital inpatient services, adjusts payments based on the costs or provider characteristics of hospitals (for example, sole community hospitals). Rather than continuing this practice in the outpatient setting, MedPAC recommends that HCFA move toward making adjustments based on patient characteristics and the relative costliness of resources required in furnishing care to differing patients. Any differences in the payment of the same ambulatory care service should be based on patient characteristics, rather than on the setting. MedPAC recommends that HCFA evaluate any relationships between immutable patient characteristics and the cost of furnishing care.
Response: Other than those adjustments specified in sections 201 and 202 of the BBRA 1999, we have made no additional adjustments in this final rule. We will consider the possibility of adjustments in the future once we have actual experience with operation of the hospital outpatient PPS and can examine its effects. The extent to which adjustments at the level of patient characteristics will be feasible is unclear and would require further study.
VI. Provisions of the Final Rule
The provisions of this final rule reflect the provisions of the September 8, 1998 proposed rule, except as noted elsewhere in this preamble. Following is a synopsis of the major changes we have made, either in response to comments or in order to implement provisions of the BBRA 1999 that apply to the hospital outpatient prospective payment system.
For our proposal to adjust the CY 2002 update of the conversion factor by the percentage that actual CY 2000 payments exceed the estimated CY 2000 expenditure target, we are delaying implementation of the volume control mechanism for 2 years.
For our proposal to package costs that are directly related and integral to performing a procedure or furnishing a service on an outpatient basis, we are making the following changes:
- We are creating separate APC groups to pay for blood, blood products, and anti-hemophilic factors, for splints and casts, and for certain very costly drugs that are not included in the transitional pass-through payment provision.
- We are paying separately, at cost, for the acquisition of corneal tissue.
- As required by section 201(e) of the BBRA 1999, we are not paying for certain implantable items under the DMEPOS fee schedule, but are including them as covered outpatient services. We are packaging the costs of these items into the APC payment rate for the procedures or services with which they are associated. These include implantable items used in connection with diagnostic tests, implantable DME, and implantable prosthetic devices.
For our proposal to base payment for medical visits to clinics and emergency departments on diagnosis codes as well as HCPCS codes, we are not using diagnosis codes at this time.
For our proposal to classify a new technology procedure or service within the APC group that it most closely resembles in terms of clinical characteristics and resource utilization, pending collection of additional pricing data, we are creating separate APC groups to which we can temporarily classify new technology services while we gather additional data and gain pricing experience. We are also creating a process under which interested parties may submit requests for consideration of services that may be eligible for payment as new technology.
For our proposal to pay for drugs, pharmaceuticals, and biologicals (except for cancer therapy drugs and certain infrequently used but very expensive drugs) as part of the APC payment for the service or procedure with which they are used, we are establishing transitional pass-through payments, as directed by section 201(b) of the BBRA 1999. Under this provision, an additional payment will be made for current orphan drugs, current cancer therapy drugs, biologicals, and brachytherapy, and current radiopharmaceutical drugs and biological products.
For our proposal to classify a new or innovative medical device, drug or biological (for which we were not making payment as of December 31, 1996) within the APC group that it most closely resembles in terms of clinical characteristics and resource utilization, pending collection of additional pricing data, we are establishing transitional pass-through payments. Under this provision, as directed by section 201(b) of the BBRA 1999, an additional payment will be made for new or innovative devices, drugs, and biologicals whose cost is not insignificant in relation to the APC payment for the group of services with which they are used.
For our proposal not to establish an outlier adjustment, as directed by section 201(a) of the BBRA 1999, we will make an outlier payment when calculated bill costs exceed 2.5 times the PPS payment for a service.
For our proposal to determine comparability of resources and clinical characteristics among the codes within an APC group based on our claims data and the analyses and judgment of our medical advisors, supported by comments from medical specialty societies and trade associations, as provided in section 201(g) of the BBRA 1999, we are limiting the variation so that the highest median cost of an item or service in an APC group is no more than two times the lowest median cost of an item or service within that group. We will also consult with an expert outside advisory panel regarding the clinical integrity of the APC groups and weights as part of our update of the PPS.
For our proposal to periodically review and update payment weights, APC groups, and other elements of the hospital outpatient PPS, as required by section 201(h) of the BBRA 1999, we will annually review the groups, relative payment weights, and the wage and other adjustments that are a part of the PPS.
For our proposal to implement the hospital outpatient PPS fully and in its entirety for all hospitals beginning as early as possible in CY 2000, with no phase-in period, as required by section 202(a) of the BBRA 1999, we are establishing transitional corridors for services furnished before January 1, 2004 to limit losses facilities might otherwise face.
For our proposal not to make any adjustments for any specific classes of hospitals, we are holding small rural hospitals harmless through CY 2003 in accordance with the requirements set by section 202(a)(3) of the BBRA 1999, Start Printed Page 18528which added section 1833(t)(7)(D)(i) to the Act. Also, we are holding cancer centers permanently harmless in accordance with the requirements set by section 202(a)(3) of the BBRA 1999.
For our proposal on beneficiary coinsurance payment amounts, we are limiting the coinsurance amount for a procedure to be no more than the hospital inpatient deductible, as specified in section 204(a)(3) of the BBRA 1999.
The following is a synopsis of the principal changes that we are making in the provider-based requirements:
For our proposal to require main providers and provider-based entities to share a common license, we will require common licensure only where State law permits it. Where State law prohibits it or is silent, we will not apply the licensure requirement. We will also exempt IHS facilities and facilities located on Tribal lands from this requirement.
For our proposal requiring a main provider and a provider-based entity to serve a common service area indicated largely by overlapping patient populations, we have redefined “common service area” to mean a 75 percent threshold of patients who reside in a zip code area that is common to the main provider and the provider-based entity.
For our proposal to require provider-based entities to be in the same State as the main provider, we will allow providers in one State to have provider-based facilities in an adjacent State, if doing so is consistent both with the law of the affected States and with other criteria, including those related to a common service area.
For our proposal to require that a provider-based outpatient department bill all payers as an outpatient department, we have rescinded this requirement.
For our proposal to require FQHCs that have been billing Medicare as hospital outpatient departments to comply with the provider-based requirements, we are grandfathering both FQHCs and FQHC “look-alikes” (facilities that are organized as FQHCs but do not receive grants) so that these facilities will be considered departments of providers without having to meet § 413.65 requirements.
For our proposal to apply the provider-based requirements to Indian Health Service (including tribally operated) entities, we are creating a permanent exception for those entities that were billing as departments of IHS or Tribal hospitals on or before October 10, 2000.
For our proposal to consider provider-based entities to be part of the hospital for Emergency Medical Treatment and Active Labor Act (EMTALA) (“anti-dumping” purposes), we are maintaining the principle that off-site hospital facilities are subject to EMTALA. We have clarified the obligations of hospitals with respect to these locations to ensure they are consistent with staffing patterns and resources.
For our proposal to apply provider-based criteria to inpatient facilities such as multi-campus hospitals created by mergers and satellites of PPS-excluded hospitals that are created by hospitals leasing space in other hospitals, we have clarified the applicability of provider-based criteria to remote locations of hospitals and hospital satellite facilities.
VII. Collection of Information Requirements
Under the Paperwork Reduction Act (PRA) of 1995, we are required to provide 30-day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the PRA requires that we solicit comment on the following issues:
- The need for the information collection and its usefulness in carrying out the proper functions of our agency.
- The accuracy of our estimate of the information collection burden.
- The quality, utility, and clarity of the information to be collected.
- Recommendations to minimize the information collection burden on the affected public, including automated collection techniques.
We are soliciting public comment on each of these issues for the provisions summarized below that contain information collection requirements:
Section 413.24 Adequate cost data and cost finding
Section 413.24(d)(6)(ii) states that a provider must develop detailed work papers showing the exact cost of the services (including overhead) provided to or by the free-standing entity and show those carved out costs as nonreimbursable cost centers in the provider's trial balance. While these information collection requirements are subject to the PRA, the burden associated with these requirements is captured under §§ 413.65(c)(1) and (c)(2) below.
Section 413.65 Requirements for a determination that a facility or an organization is a department of a provider or a provider-based entity
Section 413.65(b)(2) states that a provider or a facility or organization must contact HCFA and the facility or organization must be determined by HCFA to be provider-based before the main provider begins billing for services of the facility or organization as if they were furnished by a department of the provider-based entity, or before it includes costs of those services on its cost report. While these information collection requirements are subject to the PRA, the burden associated with these requirements is captured under §§ 413.65(c)(1) and (c)(2) below.
Sections 413.65(c)(1) and (c)(2) state that a main provider that acquires a facility or organization for which it wishes to claim provider-based status, including any physician offices that a hospital wishes to operate as a hospital outpatient department or clinic, must report its acquisition of the facility or organization to HCFA and must furnish all information needed for a determination as to whether the facility or organization meets the requirements in paragraph (d) of this section for provider-based status, if the facility or organization is located off the campus of the provider or would increase the provider's total costs by at least 5 percent. Furthermore, a main provider that has had one or more entities considered provider-based also must report to HCFA any material change in the relationship between it and any provider-based facility or organization, such as a change in ownership of the facility or organization or entry into a new or different management contract that could affect the provider-based status of the facility or organization.
The burden associated with this requirement is the time for the main provider to report its acquisition to HCFA, furnish all information needed for a determination, report to HCFA any material change in the relationship between it and any provider-based facility or organization, such as a change in ownership of the facility or organization or entry into a new or different management contract that could affect the provider-based status of the facility or organization. It is estimated that 105 main providers will take 10 hours for a total of 1,050 hours.
Section 413.65(d)(4)(v) states that medical records for patients treated in a facility or organization must be integrated and maintained into a unified retrieval system (or cross reference) of the main provider. The burden Start Printed Page 18529associated with this requirement is the time required for the main provider to maintain medical records in a unified retrieval system. While this requirement is subject to the PRA, we believe this requirement is a usual and customary business activity and the burden associated with this requirement is exempt from the PRA, as stipulated under 5 CFR 1320.3(b)(2) and (b)(3).
Section 413.65(d)(7)(i) requires that for a facility or organization and the main provider that is not located on the same campus, the facility or organization must demonstrate a high level of integration with the main provider by showing that it meets all of the other provider-based criteria, and demonstrates that it serves the same patient population as the main provider, by submitting records showing that, during the 12-month period immediately preceding the first day of the month in which the application for provider-based status is filed with HCFA, and for each subsequent 12-month period meet the requirements of paragraphs (d)(7)(i)(A), (B), or (C) of this section. While the information collection requirements listed below are subject to the PRA, the burden associated with these requirements is captured under §§ 413.65(c)(1) and (c)(2).
Section 413.65(g)(7) states that when a Medicare beneficiary is treated in a hospital outpatient department or hospital-based entity, the hospital has a duty to notify the beneficiary, prior to the delivery of services, of the beneficiary's potential financial liability (that is, a coinsurance liability for a facility visit as well as for the physician service).
The burden associated with this requirement is the time for the provider to disseminate information to each beneficiary of the beneficiary's potential financial liability (that is, a coinsurance liability for a facility visit as well as for the physician service). It is estimated that 750 providers will make on average 667 disclosures on an annual basis, at 3 minutes per disclosure, for a total annual burden of 25,013 hours.
Section 413.65(j)(5) requires that upon notice of denial of provider-based status sent to the provider by HCFA, the notice will ask the provider to notify HCFA in writing, within 30 days of the date the notice is issued, of whether the facility or organization (or, where applicable, the practitioners who staff the facility or organization) will be seeking to enroll and meet other requirements to bill for services in a free-standing facility. This requirement is exempt from the PRA as stipulated under 5 CFR 1320.4(a)(2).
Further, if the provider indicates that the facility or organization, or its practitioners, will be seeking to meet enrollment and other requirements for billing for services in a free-standing facility, the facility or organization must submit a complete enrollment application and provide all other required information within 90 days after the date of notice; and the facility or organization, or its practitioners, furnish all other information needed by HCFA to process the enrollment application and verify that other billing requirements are met. The requirements and burden associated with the provider enrollment process are currently approved under OMB control number 0938-0685, with a current expiration date of September 30, 2001.
Section 424.24 Requirements for Medical and Other Health Services Furnished by Providers Under Medicare Part B
Section 424.24(e)(3)(i) requires that when a partial hospitalization service occurs the physician recertification must be signed by a physician who is treating the patient and has knowledge of the patient's response to treatment. While this signature requirement is subject to the PRA, the overall requirements associated with physician recertification, as currently referenced in HCFA regulation number HCFA-1006, published in the Federal Register on June 5, 1998, have not yet been approved by OMB under the PRA. Therefore, we continue to solicit comment on all of the requirements and associated burden referenced in § 424.24.
Section 419.42 Hospital Election To Reduce Copayment
Sections 419.42(b) and (c) state that a hospital must notify its fiscal intermediary of its election to reduce copayments no later than June 1, 2000 prior to the date the PPS is implemented or for subsequent calendar years, beginning with elections for calendar year 2001, no later than December 1 of the preceding calendar year. The hospital's election must be properly documented. It must specifically identify the ambulatory payment classification to which it applies and the coinsurance amounts (within the limits identified within this regulation) that the hospital has elected for each group.
The burden associated with these requirements is the time it takes a hospital to compile, review, and analyze data for both revenues and coinsurance; prepare and present the data to the hospital board; make a business decision as to whether the hospital would elect to reduce coinsurance; and then notify its fiscal intermediary of its election. A hospital would notify its fiscal intermediary of its election to reduce coinsurance only if there were other providers, in close proximity, that would attract a majority of the hospital's business if they did not reduce their coinsurance. Since hospitals do not want to lose money by absorbing coinsurance, we anticipate that this requirement will affect 750 hospitals and take them 10 hours each for a total of 7,500 hours.
Section 419.42(e) states that the hospital may advertise and otherwise disseminate information concerning the reduced level(s) of coinsurance that it has elected. All advertisements and information furnished to Medicare beneficiaries must specify that the coinsurance reductions advertised apply only to the specified services of that hospital and that these coinsurance reductions are available only for hospitals that choose to reduce coinsurance for hospital outpatient services and are not applicable in any other ambulatory settings or physician offices.
The burden associated with this requirement is the time for the hospital to disseminate information concerning its coinsurance election. It is estimated that 750 hospitals will each take 10 hours annually to disseminate this information via newsletters and information sessions at senior citizen centers for a total of 7,500 hours.
We have submitted a copy of this final rule to OMB for its review of the information collection requirements. These requirements are not effective until they have been approved by OMB. A notice will be published in the Federal Register when approval is obtained.
If you comment on any of these information collection and record keeping requirements, please mail copies directly to the following:
Health Care Financing Administration, Office of Information Services, Information Technology Investment Management Group, Division of HCFA Enterprise Standards, Room C2-26-17, 7500 Security Boulevard, Baltimore, MD 21244-1850, Attn: John Burke HCFA-1005-FC/R-240,
and
Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503, Attn.: Allison Herron Eydt, HCFA-1005-FC. Start Printed Page 18530
VIII. Response to Comments
Because of the large number of items of correspondence we normally receive on Federal Register documents published for comment, we are not able to acknowledge or respond to them individually. Comments on the provision of this final rule that implement provisions of the BBRA 1999 will be considered if we receive them by the date and time specified in the DATES section of this preamble. We will not consider comments concerning provisions that remain unchanged from the September 8, 1998 proposed rule or that were changed based on public comments.
IX. Regulatory Impact Analysis
A. Introduction
Section 804(2) of title 5, United States Code (as added by section 251 of Pub. L. 104-121), specifies that a “major rule” is any rule that the Office of Management and Budget finds is likely to result in—
- An annual effect on the economy of $100 million or more;
- A major increase in costs or prices for consumers, individual industries, Federal, State, or local government agencies, or geographic regions; or
- Significant adverse effects on competition, employment, investment productivity, innovation, or on the ability of United States based enterprises to compete with foreign-based enterprises in domestic and export markets.
We estimate, based on a simulation model, that the effect on hospitals participating in the Medicare program associated with this final rule would be to increase Medicare payments by $600 million in calendar year 2000. This figure includes beneficiary copayments. We estimate that the additional expenditures to hospitals from the Part B Trust Fund associated with this final rule will be $490 million in fiscal year 2000. Therefore, this rule is a major rule as defined in Title 5, United States Code, section 804(2).
We have examined the impacts of this final rule as required by Executive Order 12866, the Unfunded Mandates Reform Act of 1995, and the Regulatory Flexibility Act (RFA) (Public Law 96-354). Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, when 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 annually). Because the projected spending resulting from this final rule is expected to exceed $100 million, it is considered a major rule for purposes of the RFA.
The Unfunded Mandates Reform Act of 1995 also requires (in section 202) that agencies prepare an assessment of anticipated costs and benefits for any rule that may result in an expenditure in any 1 year by State, local, or tribal governments, in the aggregate, or by the private sector, of $100 million. This final rule does not mandate any requirements for State, local, or tribal governments.
We generally prepare a regulatory flexibility analysis that is consistent with the RFA (5 U.S.C. 601 through 612), unless we certify that a final rule will not have a significant economic impact on a substantial number of small entities. For purposes of the RFA, we consider all hospitals to be small entities.
Also, section 1102(b) of the Social Security Act requires us to prepare a regulatory impact analysis for any final rule that may have a significant impact on the operations of a substantial number of small rural hospitals. Such an analysis must conform to the provisions of section 604 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital with fewer than 100 beds that is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA). Section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21) designated hospitals in certain New England counties as belonging to the adjacent NECMA. Thus, for purposes of the proposed prospective payment system, we classify these hospitals as urban hospitals.
B. Estimated Impact on the Medicare Program
Our Office of the Actuary projects that the additional benefit expenditures from the Part B Trust Fund resulting from implementation of the hospital outpatient PPS for hospital outpatient services furnished on or after July 1, 2000, and the hospital outpatient provisions enacted by the BBRA 1999, are as follows:
Fiscal year Impact (In millions of dollars) 2000 490 2001 3,030 2002 3,520 2003 4,230 2004 4,670 C. Objectives
The primary objective of the hospital outpatient prospective payment system is to simplify the payment system and encourage hospital efficiency in providing outpatient services, while at the same time ensuring that payments are sufficient to compensate hospitals adequately for their legitimate costs. Another important goal of the new system is to reduce beneficiaries' share of outpatient payment to hospitals by freezing coinsurance amounts at an absolute level until they equal 20 percent of the total payment amounts.
We believe that implementation of the final PPS will ultimately further each of these goals while maintaining the financial viability of the hospital industry and ensuring access to high quality health care for Medicare beneficiaries. We expect that the provisions of this final rule with comment period will ensure that the outcomes of the PPS are reasonable and equitable while avoiding or minimizing unintended adverse consequences.
D. Limitations of Our Analysis
The following quantitative analysis presents the projected effects of our policy changes resulting from comments, as well as statutory changes enacted by the BBRA 1999, on various hospital groups. We use the best data available. In addition, we do not make adjustments for future changes in such variables as volume and intensity. For this final rule with comment period, we are soliciting comments and information about the anticipated effects of the changes on hospitals resulting from implementation of the hospital outpatient provisions of the BBRA 1999, and our methodology for estimating them.
E. Hospitals Included In and Excluded From the Prospective Payment System
The outpatient prospective payment system encompasses nearly all hospitals that participate in the Medicare program. However, Maryland hospitals that are paid under a cost containment waiver in accordance with section 1814(b)(3) of the Act are excluded from the PPS. Critical access hospitals (CAHs) are also excluded and are paid at cost under section 1834(g) of the Act. Start Printed Page 18531
F. Quantitative Analysis of the Impact of Policy Changes on Payment Under the Hospital Outpatient PPS: Basis and Methodology of Estimates
We have analyzed the impact on hospital payment under the outpatient PPS. Our analysis compares the payment impact of PPS compared to current law. The definition and calculation of current law used in the impact analysis is the same used in estimating the conversion factor. That is, current law reflects pre-PPS payment methodologies in effect on January 1, 2000, and prior to July 1, 2000, which include the elimination of the formula-driven overpayment and application of the capital and operating cost reductions. A detailed explanation of the current law calculation can be found in section III.E.2.a.
The data used in developing the quantitative analyses presented below are taken from the CY 1996 cost and charge data and the most current provider-specific file that is used for payment purposes. Our analysis has several qualifications. First, we draw upon various sources for the data used to categorize hospitals in Table 2, below. In some cases, there is a degree of variation in the data from the different sources. We have attempted to construct these variables with the best available source overall. For individual hospitals, however, some miscategorizations are possible.
Using CY 1996 cost and charge data, we simulated payments using the pre-PPS and PPS payment methodologies. Although we used only single-procedure/visit bills to determine APC relative payment weights, we used both single and multiple-procedure bills in the conversion factor and service mix calculations, regressions, and impact analyses. Both pre-PPS and PPS payment estimates include operating and capital costs, adjusted to the calendar year 1996 cost reporting period. We excluded Kaiser, New York Health and Hospital Corporation, and all-inclusive providers because reported charges on their cost reports are not actual charges. Cost-to-charge ratios for these hospitals are not comparable to all other hospitals. The excluded Maryland hospitals were not included in the calculation of the conversion factor and the simulations; however, we did include the 10 cancer hospitals that will be paid under the PPS.
We also trimmed outlier hospitals from the impact analysis because inclusion of hospitals with extremely high and low unit costs would not allow us to assess the impacts among the various classes of hospitals accurately. First, we identified all of the outlier hospitals by using an edit of 3 standard deviations from the mean of the logged unit costs. Trimming the data in this manner ensures that only the hospitals with aberrantly high and low costs are eliminated from the impact analysis. In doing this, we removed 97 hospitals of which 41 hospitals had extremely low unit costs and 56 hospitals had extremely high unit costs. We conducted a thorough analysis of these hospitals to ensure that we did not remove any particular type of hospital (for example, teaching hospitals) that would further harm the integrity of the data. We speculate that many of these hospitals are not coding accurately, and we will continue to perform further analysis in this area following implementation of the PPS.
After we removed the 58 excluded Maryland hospitals, the all-inclusive rate hospitals, the statistical outlier hospitals, and hospitals for which we could not identify payment variables, we used the remaining 5,362 hospitals as the basis for our analysis. Table 2, Annual Impact of Outpatient Prospective Payment System in CY2000-CY2001, below, demonstrates the results of our analysis. The table categorizes hospitals by various geographic and special payment consideration groups to illustrate the varying impacts on different types of hospitals. The first column represents the number of hospitals in each category. The second column shows the hospitals' Medicare outpatient payments under the current (non-PPS) payment system as a percentage of the hospitals' total Medicare payment. The third and fourth columns show the impact of the PPS excluding the transitional corridor payments enacted by the BBRA 1999. Column three shows the percentage change in total Medicare outpatient payments comparing pre-PPS payments with payments under the PPS. The fourth column shows the change in total (outpatient and inpatient) Medicare payments resulting from implementation of the PPS for outpatient services. The fifth and sixth columns show the impact of the PPS including the transitional corridor payments enacted by the BBRA 1999. Column five shows the percentage change in Medicare outpatient payments comparing pre-PPS payments with payments under the PPS. Column six shows the change in total (outpatient and inpatient) Medicare payments resulting from implementation of the PPS for outpatient services.
The first row of Table 2 shows the overall impact on the 5,362 hospitals included in the analysis. We included as much data as possible to the extent that we were able to capture all the provider information necessary to determine payment. Our estimates include the same set of services for both pre-PPS and PPS payments so that we could determine the impact of the PPS as accurately as possible. Because payment under the hospital outpatient PPS can only be determined if bills are accurately coded, the data upon which the impacts were developed do not reflect all CY 1996 hospital outpatient services, but only those that were coded using valid HCPCS codes.
The second row of Table 2 shows the overall impact of the PPS on the 4,828 hospitals that remain when we exclude psychiatric, long-term care, children's, and rehabilitation hospitals.
The next four rows of the table contain hospitals categorized according to their geographic location (all urban, which is subdivided into large urban and other urban, and rural). We include 2,665 hospitals located in urban areas (MSAs or NECMAs) in our analysis. Among these, 1,505 hospitals are located in large urban areas (populations over 1 million), and 1,160 hospitals are located in other urban areas (populations of 1 million or less). In addition, we include 2,160 hospitals located in rural areas in our analysis. The next two groupings are by bed-size categories, shown separately for urban and rural hospitals. The next category groups urban and rural hospitals by volume of outpatient services. We then show the distribution of urban and rural hospitals by regional census divisions.
The next three categories group hospitals according to whether or not they have residency programs (teaching hospitals that receive an indirect medical education (IME) adjustment), receive disproportionate share hospital (DSH) payments, or some combination of these two adjustments. In our analysis we show the impact of the PPS on the 3,738 nonteaching hospitals, the 821 teaching hospitals with fewer than 100 residents, and the 269 teaching hospitals with 100 or more residents.
In the DSH categories, hospitals are grouped according to their DSH payment status. The next category groups hospitals considered urban after geographic reclassification, in terms of whether they receive the IME adjustment, the DSH adjustment, both, or neither. The next five rows examine the impacts of the changes on rural hospitals by special payment groups (rural referral centers (RRCs), sole community hospitals/essential access community hospitals (SCHs/EACHs), Medicare dependent hospitals (MDHs), and hospitals that are both SCHs and Start Printed Page 18532RRCs), as well as rural hospitals not receiving a special payment designation. The RRCs (164), SCH/EACHs (634), MDHs (358), and SCH and RRCs (56) shown here were not reclassified for purposes of the standardized amount.
The next grouping is based on type of ownership. These data are taken primarily from the FY 1996 Medicare cost report files, if available; otherwise, earlier cost report data are used.
The final two groups are specialty hospitals. The first set includes eye and ear hospitals, trauma hospitals (hospitals having a level one trauma center), and cancer hospitals, which are TEFRA hospitals. The last group lists all other TEFRA hospitals, specifically, rehabilitation, psychiatric, long-term care, and children's hospitals.
G. Estimated Impact of the New APC System (Includes Table 2, Annual Impact of Hospital Outpatient Prospective Payment System in CY2000-CY2001)
Column 3 compares our estimate of PPS payments without application of the BBRA 1999 transitional corridors, but incorporating policy changes and all other BBRA 1999 provisions contained in this final rule, to our estimate of payments under the current system. The percent differences shown in columns 3 and 4 between current and PPS payment (without the BBRA 1999 transitional corridors) reflect the impact of the BBRA 1999 outlier and pass-through payment adjustments and nonbudget-neutral hold-harmless provisions for cancer hospitals, as well as distributional differences attributable to variation in cost and charge structures among hospitals.
The percent changes in columns 5 and 6 are the result of comparing our estimate of PPS payments with application of the BBRA 1999 transitional corridors, as well as the statutory and policy changes contained in this final rule, to our estimate of payments under the pre-PPS system. Percent differences between the pre-PPS and the PPS payment (with the BBRA 1999 transition) reflect the combined impact of the transitional corridor adjustments, outlier and pass-through payment adjustments and the hold-harmless provision for cancer hospitals, in addition to distributional differences attributable to variation in cost and charge structures among hospitals.
Basing the conversion factor on pre-PPS program and pre-PPS beneficiary payments and on budget-neutral outlier and pass-through adjustments results in no net change in payments to hospitals overall relative to pre-PPS payments. (As noted above, in section III.E.2 of this preamble, pursuant to section 201(l) of the BBRA 1999, we set the conversion factor by estimating pre-PPS rather than PPS copayments.) However, the BBRA hold-harmless provision for cancer hospitals results in a 0.2 percent increase in payments to hospitals overall because this provision is not budget neutral. Including the BBRA 1999 transitional corridor adjustments further increases payment to hospitals overall. We estimate that in calendar year 2000, payment will increase by an annual rate of 4.6 percent under the PPS compared to the pre-PPS payments.
Without the BBRA 1999 transitional corridor payments, the impact on short-term acute care hospitals is negative for a substantial number of hospital classifications. That is, for certain groups of hospitals, payments under the PPS without the transitional corridor payments would be several percentage points below pre-PPS payments. For nearly all of these hospital groups, the BBRA 1999 transitional corridor payments mitigate this negative impact. In addition, hospital groups that experience net gains without the BBRA 1999 transitional corridor payments experience even greater gains with them. The reason is that even though the average impact for hospitals in these groups is positive, some individual hospitals experience net losses in payments and, thus, benefit from the transitional corridor payments. The hospital groups that gain without the transitional corridor payments receive even greater increases in payments with the transitional corridor payments. The following discussion highlights some of the changes in payments among hospital classifications.
Comparing the pre-PPS and PPS payment estimates, payment to low-volume hospitals would decrease substantially without the BBRA 1999 transitional corridor payments (12.2 percent annually for rural and 7.7 percent annually for urban hospitals with fewer than 5,000 units of service). These hospitals experience a net gain with the BBRA 1999 transitional corridor payments (2.5 percent annually and 0.2 percent annually for low-volume rural and urban hospitals, respectively), although these payment increases are relatively small compared to the 4.6 percent annual increase for hospitals overall. We believe several factors contribute to this outcome, including undercoding, lack of economies of scale, and the reliance on the median instead of the geometric mean in the calculation of APC weights. The majority of these hospitals (about 75 percent) are rural. For these small hospitals, some of the higher standardized unit costs could be attributed to economies of scale. These low-volume rural hospitals also receive a greater percentage of their Medicare income (18.5 percent) from outpatient services than the national average (9.9 percent).
Major teaching hospitals, whose payments would decrease annually by 3.7 percentage points without the BBRA 1999 transitional corridor payments, gain 2.6 percent annually with the BBRA 1999 transitional corridor payments relative to pre-PPS payments. Major teaching hospitals receive less of their total Medicare income (9.1 percent) from outpatient services than the national average. This results in a 0.2 percent annual gain in their total Medicare payments. Minor teaching and nonteaching hospitals would experience marginal gains in outpatient payment without the BBRA 1999 transitional corridor payments. Payment to both hospital groups increases by 5.0 percent annually relative to the pre-PPS payment system.
Without the BBRA 1999 transitional corridor payments, hospitals with a high percentage of low-income patients (disproportionate share patient percentage greater than or equal to 0.35) would have a 2.5 percent annual decrease in payment relative to pre-PPS payments. But payments to these hospitals increase annually by 3.5 percent relative to pre-PPS payments with the BBRA 1999 transitional corridor payments. These hospitals have lower than average volume, and, like major teaching hospitals, receive a smaller than average percentage of their Medicare income from outpatient services. Thus, their total Medicare payments increase marginally, by 0.3 percent, with the BBRA 1999 transitional corridor payments.
Without the BBRA 1999 adjustments, payment to rural hospitals would decrease 1.8 percent annually and payment to large urban hospitals would decrease 0.3 percent annually, while payment to other urban hospitals would increase 1.8 percent annually relative to pre-PPS payments. These hospitals all experience net gains in PPS payment with the BBRA 1999 transitional corridor payments, at an annual rate of 4.4 percent, 4.3 percent, and 5.1 percent, respectively. Even though rural hospitals receive a greater percentage of their Medicare income (14.7 percent) from outpatient services compared to the national average, their total Medicare payments increase by only a fraction, 0.6 percent.
Negative impacts for urban hospitals in the Mid-Atlantic and the West North Central regions are also reversed under Start Printed Page 18533the BBRA 1999 transitional corridor payments, changing from −3.4 percent to 2.4 percent on an annual basis, and from −3.5 percent to 2.5 percent on an annual basis, respectively. Similarly, rural hospitals in nearly all census regions experience net increases in payment relative to pre-PPS payments with the BBRA 1999 transitional corridor payments.
The impact on TEFRA hospitals is shown separately at the end of the table. The TEFRA hospitals were not included in determining the impact on any of the other categories discussed above (for example, geographic location, bed size, volume, etc.). These hospitals demonstrated a very low service mix, but an average unit cost that approximates the national average. We believe that undercoding or billing an all-inclusive rate could account for their low-volume, low-service mix, and average cost per unit. We expect that once these hospitals begin to code services accurately under the PPS, payments will more closely approximate pre-PPS payments.
If the effect of the BBRA 1999 transition payments were removed, differences between pre-PPS payments and PPS payments among hospitals would still exist. These distributional differences are the result of many factors. First, cost variations among hospitals result in differences between pre-PPS payments and PPS payments, and charge structure variations result in differences between pre-PPS payments and PPS beneficiary copayment amounts. Hospitals whose costs are low relative to payment would gain under the PPS even without the BBRA 1999 transitional corridor payments. Because the transitional corridor payments are not budget neutral, these hospitals continue to gain relative to pre-PPS payments.
Redistributions may also occur as a result of current payment methods. Total Medicare outpatient payments are less than reported total costs because (in addition to the 5.8 and 10 percent reductions for operating and capital costs) the blended payment methods applicable to many surgical and diagnostic services often result in payments that are less than reported costs. Other services such as medical visits, chemotherapy services, and non-ASC approved surgeries are paid based on hospital costs. The new system redistributes the current total Medicare payments, based in part on cost-based payments and in part on blended payment amounts, across all services. Hospitals, in the aggregate, will receive proportionately less for services that are currently paid based on costs, and more for services that had been paid under blended payment methods.
Start Printed Page 18535Table 2. Annual Impact Of Hospital Outpatient Prospective Payment System In CY2000-CY2001
Number of hospitals Outpatient percent Excluding BBRA transitional corridors 1 Including BBRA transitional corridors Percent change in Medicare outpatient payments 3 Percent change in total Medicare payments Percent change in Medicare outpatient payments 3 Percent change in total Medicare payments (1) (2) (3) (4) (5) (6) ALL HOSPITALS 5,362 9.9 0.2 0.0 4.6 0.5 NON-TEFRA HOSPITALS 4,828 10 0.1 0.0 4.6 0.5 URBAN HOSPS 2 2,665 9.3 0.6 0.1 4.6 0.4 LARGE URBAN 2 (GT 1 MILL.) 1,505 9.1 −0.3 0.0 4.3 0.4 OTHER URBAN 2 (LE 1 MILL.) 1,160 9.7 1.8 0.2 5.1 0.5 RURAL HOSPS 2,160 14.7 −1.8 −0.3 4.4 0.6 BEDS (URBAN): 2 0—99 BEDS 672 14.9 0.6 0.1 4.6 0.7 100-199 BEDS 924 10.5 1.3 0.1 5.2 0.5 200-299 BEDS 533 9.2 0.8 0.1 4.4 0.4 300-499 BEDS 399 8.5 1.8 0.2 5.2 0.4 500 + BEDS 137 8.4 −2.9 −0.2 2.8 0.2 BEDS (RURAL): 0—49 BEDS 1,170 19.5 −8.5 −1.7 3.3 0.6 50-99 BEDS 615 15.5 −2.7 −0.4 4.4 0.7 100-149 BEDS 223 13.3 −0.2 0.0 3.8 0.5 150-199 BEDS 81 13 2.5 0.3 5.5 0.7 200 + BEDS 71 11.6 2.7 0.3 6.1 0.7 VOLUME (URBAN): LT 5,000 349 12 −7.7 −0.9 0.2 0.0 5,000-10,999 504 9.8 0.0 0.0 4.2 0.4 11,000-20,999 596 9.1 0.1 0.0 4.4 0.4 21,000-42,999 773 8.8 1.3 0.1 4.9 0.4 GT 42,999 443 9.7 0.4 0.0 4.6 0.4 VOLUME (RURAL): LT 5,000 1,049 18.5 −12.2 −2.3 2.5 0.5 5,000-10,999 595 15.2 −5.2 −0.8 2.9 0.4 11,000-20,999 322 13.8 0.1 0.0 4.7 0.6 21,000-42,999 173 13.6 2.4 0.3 5.7 0.8 GT 42,999 21 13.2 3.0 0.4 6.8 0.9 REGION (URBAN): 3 NEW ENGLAND 146 10.7 3.8 0.4 6.7 0.7 MIDDLE ATLANTIC 393 8.4 −3.4 −0.3 2.4 0.2 SOUTH ATLANTIC 401 8.6 0.3 0.0 4.2 0.4 EAST NORTH CENT. 465 10.7 1.0 0.1 4.5 0.5 Start Printed Page 18534 EAST SOUTH CENT. 161 7.9 1.8 0.1 4.6 0.4 WEST NORTH CENT. 183 9.5 0.9 0.1 4.9 0.5 WEST SOUTH CENT. 335 9.7 −2.7 −0.3 2.5 0.2 MOUNTAIN 123 10.2 3.1 0.3 6.1 0.6 PACIFIC 423 9.4 5.6 0.5 8.6 0.8 PUERTO RICO 35 6.6 10.8 0.7 13.2 0.9 REGION (RURAL): NEW ENGLAND 53 17.2 −3.2 −0.6 3.3 0.6 MIDDLE ATLANTIC 80 13.6 7.1 1.0 10.1 1.4 SOUTH ATLANTIC 285 11.8 −1.8 −0.2 3.6 0.4 EAST NORTH CENT. 282 15.7 −1.2 −0.2 4.3 0.7 EAST SOUTH CENT. 260 11.1 0.1 0.0 4.9 0.5 WEST NORTH CENT. 508 19.8 −5.2 −1.0 3.0 0.6 WEST SOUTH CENT. 337 14.2 −5.7 −0.8 3.0 0.4 MOUNTAIN 213 16.9 −3.4 −0.6 4.7 0.8 PACIFIC 140 15.9 0.7 0.1 6.3 1.0 PUERTO RICO 2 6.6 32.1 2.1 32.1 2.1 TEACHING STATUS: NON-TEACHING 3,738 11.3 0.5 0.1 5.0 0.6 MINOR 821 9.1 1.6 0.1 5.0 0.5 MAJOR 269 9.1 −3.7 −0.3 2.6 0.2 DSH PATIENT PERCENT: 0 101 10.9 −5.8 −0.6 0.7 0.1 GT 0—0.10 1,139 10.5 0.8 0.1 4.6 0.5 0.10-0.16 986 11 2.0 0.2 5.6 0.6 0.16-0.23 880 10.1 0.8 0.1 4.9 0.5 0.23-0.35 855 9.5 −1.5 −0.1 3.7 0.4 GE 0.35 867 9.2 −2.5 −0.2 3.5 0.3 URBAN IME/DSH: 2 IME & DSH 994 9 −0.4 0.0 4.1 0.4 IME/NO DSH 17 9.2 −3.6 −0.3 1.1 0.1 NO IME/DSH 1,611 9.9 1.9 0.2 5.4 0.5 NO IME/NO DSH 43 14.7 −8.2 −1.2 −0.3 0.0 RURAL HOSP. TYPES: NO SPECIAL STATUS 864 15 −2.2 −0.3 4.4 0.7 RRC 164 12.3 5.0 0.6 7.3 0.9 SCH/EACH 634 16.5 −7.7 −1.3 2.2 0.4 MDH 358 18.3 −5.4 −1.0 3.5 0.6 SCH AND RRC 56 13.9 −1.4 −0.2 3.1 0.4 TYPE OF OWNERSHIP: VOLUNTARY 2,816 9.9 0.6 0.1 4.7 0.5 PROPRIETARY 752 8.3 −0.1 0.0 4.7 0.4 GOVERNMENT 1,260 12.2 −2.3 −0.3 3.6 0.4 SPECIALTY HOSPITALS: EYE AND EAR 10 31.1 20.1 6.3 20.2 6.3 TRAUMA 159 9.1 −1.2 −0.1 4.0 0.4 CANCER 10 22 0.8 0.2 0.8 0.2 TEFRA HOSPITALS (NOT INCLUDED ON OTHER LINES): REHAB 147 3.7 −9.4 −0.3 1.7 0.1 PSYCH 281 9 21.3 1.9 27.9 2.5 LTC 65 3.7 −15.3 −0.6 −1.7 −0.1 CHILDREN 41 16.5 −11.9 −2.0 −3.2 −0.5 Notes: 1 Includes all BBRA provisions except the transitional corridor provisions that expire 01/01/04. 2 Does not include impact of reclassifications as allowed under section 401 of the BBRA 1999. 3 Estimate of change compared to pre-PPS payments, which reflect the payment methodologies in effect as of January 1, 2000, and prior to July 1, 2000. X. Federalism
We have examined this rule in accordance with Executive Order 13132, Federalism, and have determined that this final rule will not have any negative impact on the rights, roles, and responsibilities of State, local or Tribal governments.
XI. Waiver of Proposed Rulemaking
We ordinarily publish a notice of proposed rulemaking in the Federal Register and invite public comment on the proposed rule. The notice of proposed rulemaking includes a reference to the legal authority under which the rule is proposed, and the terms and substance 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. We find that the circumstances surrounding this rule make it impracticable to pursue a process of notice-and-comment rulemaking before the provisions of this rule take effect.
The BBRA 1999 was enacted on November 29, 1999. This final rule incorporates the following hospital outpatient PPS provisions in the BBRA 1999: outlier adjustment for high cost cases; transitional pass-through payment adjustments for additional costs (over the payments for APCs otherwise made) for new medical devices, drugs, and biologicals; definition of APCs so that the variation of costs of items within an APC is subject to certain limits; establishment of “transitional corridors” for the first 31/2 years of the new system that limit losses hospitals might otherwise face; payment for implantable devices under the hospital outpatient PPS, rather than under the Durable Medical Equipment Fee Schedule; limitation of the copayment on an outpatient procedure to the amount of the inpatient hospital deductible; requirement to review annually the APC groups, relative weights, and wage and other adjustments; and calculation of the conversion factor in a budget-neutral manner, eliminating the 5.7 percent reduction indicated in the proposed rule.
As discussed earlier in this rule, July 1, 2000 is the earliest date on which we can feasibly implement the PPS. The provisions of the BBRA 1999, enacted on November 29, 1999, made numerous refinements to the PPS. With respect to the BBRA 1999 provisions, it would have been impracticable to complete notice and comment procedures by July 1, 2000. Given the limited timeframe, given the nature and scope of the BBRA 1999 refinements, and given the time required to complete notice and comment rulemaking (to develop proposed policies, draft the proposed rule, provide a 60-day public comment period, consider public comments, develop final policies, draft a final rule), it would not have been possible to issue this document as a proposed rule and issue a final rule by July 1.
In addition, it would not be feasible to implement the hospital outpatient PPS without the BBRA 1999 provisions, not only because of the nature of the BBRA 1999 provisions, but also because section 201(m) of the BBRA 1999 states: “Except as provided in this section, the amendments made by this section shall be effective as if included in the enactment of BBA.” Therefore, if we undertook prior notice and comment procedures with respect to the BBRA 1999 provisions, then (because such procedures could not be completed by July 1, 2000) the PPS would not be implemented by July 1, 2000.
Accordingly, we find good cause to waive the procedures for prior notice and comment with respect to the provisions of this document that implement the BBRA 1999 refinements to hospital outpatient PPS. We are providing a 60-day period for public comment with respect to the provisions of this final rule with comment period that implement the BBRA refinements. We are not accepting comments with respect to the other aspects of this document (for which the public has already had an extensive opportunity to comment).
Start List of SubjectsList of Subjects
42 CFR Part 409
- Health facilities
- Medicare
42 CFR Part 410
- Health facilities
- Health professions
- Kidney diseases
- Laboratories
- Medicare
- Rural areas
- X-rays
42 CFR Part 411
- Kidney diseases
- Medicare
- Reporting and recordkeeping requirements
42 CFR Part 412
- Administrative practice and procedure
- Health facilities
- Medicare
- Puerto Rico
- Reporting and recordkeeping requirements
42 CFR Part 413
- Health facilities
- Kidney diseases
- Medicare
- Puerto Rico
- Reporting and recordkeeping requirements
42 CFR Part 419
- Health facilities
- Hospitals
- Medicare
42 CFR Part 424
- Emergency medical services
- Health facilities
- Health professions
- Medicare
42 CFR Part 489
- Health facilities
- Medicare
- Reporting and recordkeeping requirements
42 CFR Part 498
- Administrative practice and procedure
- Health facilities
- Health professions
- Medicare
- Reporting and recordkeeping requirements
42 CFR Part 1003
- Administrative practice and procedure
- Archives and records
- Grant program—social programs
- Maternal and Child Health
- Medicaid
- Medicare
- Penalties
For the reasons set forth in the preamble, 42 CFR chapter IV is amended as follows:
Start PartPART 409—HOSPITAL INSURANCE BENEFITS
End Part Start Amendment PartA. Part 409 is amended as set forth below:
End Amendment Part Start Amendment Part1. The authority citation for part 409 continues to read as follows:
End Amendment PartSubpart B—Inpatient Hospital Services and Inpatient Critical Access Hospital Services
Start Amendment Part2. In § 409.10, paragraph (b) is revised to read as follows:
End Amendment PartIncluded services.* * * * *(b) Inpatient hospital services does not include the following types of services:
(1) Posthospital SNF care, as described in § 409.20, furnished by a hospital or a critical access hospital that has a swing-bed approval.
(2) Nursing facility services, described in § 440.155 of this chapter, that may be furnished as a Medicaid service under title XIX of the Act in a swing-bed hospital that has an approval to furnish nursing facility services.
(3) Physician services that meet the requirements of § 415.102(a) of this chapter for payment on a fee schedule basis.
(4) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act.
(5) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act. Start Printed Page 18536
(6) Certified nurse mid-wife services, as defined in section 1861(gg) of the Act.
(7) Qualified psychologist services, as defined in section 1861(ii) of the Act.
(8) Services of an anesthetist, as defined in § 410.69 of this chapter.
PART 410—SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS
End Part Start Amendment PartB. Part 410 is amended as set forth below:
End Amendment Part Start Amendment Part1. The authority citation for part 410 continues to read as follows:
End Amendment PartSubpart A—General Provisions
Start Amendment Part2. In § 410.2, the introductory text is republished, the definition of “Community mental health center (CMHC)” is revised, and the definitions of “Encounter” and “Outpatient” are added in alphabetical order to read as follows:
End Amendment PartDefinitions.As used in this part—
Community mental health center (CMHC) means an entity that—
(1) Provides outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically mentally ill, and residents of its mental health service area who have been discharged from inpatient treatment at a mental health facility;
(2) Provides 24-hour-a-day emergency care services;
(3) Provides day treatment or other partial hospitalization services, or psychosocial rehabilitation services;
(4) Provides screening for patients being considered for admission to State mental health facilities to determine the appropriateness of this admission; and
(5) Meets applicable licensing or certification requirements for CMHCs in the State in which it is located.
Encounter means a direct personal contact between a patient and a physician, or other person who is authorized by State licensure law and, if applicable, by hospital or CAH staff bylaws, to order or furnish hospital services for diagnosis or treatment of the patient.
* * * * *Outpatient means a person who has not been admitted as an inpatient but who is registered on the hospital or CAH records as an outpatient and receives services (rather than supplies alone) directly from the hospital or CAH.
* * * * *Subpart B—Medical and Other Health Services
Start Amendment Part3. In § 410.27:
End Amendment Part Start Amendment PartA. The section heading is revised;
End Amendment Part Start Amendment PartB. The introductory text to paragraph (a) is revised;
End Amendment Part Start Amendment PartC. The introductory text to paragraph (a)(1) is republished;
End Amendment Part Start Amendment PartD. The word “and” at the end of paragraph (a)(1)(i) is removed; and
End Amendment Part Start Amendment PartE. New paragraphs (a)(1)(iii), (e), and (f) are added to read as follows:
End Amendment PartOutpatient hospital services and supplies incident to a physician service: Conditions.(a) Medicare Part B pays for hospital services and supplies furnished incident to a physician service to outpatients, including drugs and biologicals that cannot be self-administered, if—
(1) They are furnished—
* * * * *(iii) In the hospital or at a location (other than an RHC or an FQHC) that HCFA designates as a department of a provider under § 413.65 of this chapter; and
* * * * *(e) Services furnished by an entity other than the hospital are subject to the limitations specified in § 410.42(a).
(f) Services furnished at a location (other than an RHC or an FQHC) that HCFA designates as a department of a provider under § 413.65 of this chapter must be under the direct supervision of a physician. “Direct supervision” means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.
4. In § 410.28, paragraph (a)(4) is removed, paragraph (c) is redesignated as paragraph (d), and new paragraphs (c) and (e) are added to read as follows:
End Amendment PartHospital or CAH diagnostic services furnished to outpatients: Conditions.* * * * *(c) Diagnostic services furnished by an entity other than the hospital or CAH are subject to the limitations specified in § 410.42(a).
* * * * *(e) Medicare Part B makes payment under section 1833(t) of the Act for diagnostic services furnished at a facility (other than an RHC or an FQHC) that HCFA designates as having provider-based status only when the diagnostic services are furnished under the appropriate level of physician supervision specified by HCFA in accordance with the definitions in § 410.32(b)(3)(i), (b)(3)(ii), and (b)(3)(iii). Under general supervision at a facility accorded provider-based status, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the facility.
5. A new § 410.42 is added to read as follows:
End Amendment PartLimitations on coverage of certain services furnished to hospital outpatients.(a) General rule. Except as provided in paragraph (b) of this section, Medicare Part B does not pay for any item or service that is furnished to a hospital outpatient (as defined in § 410.2) during an encounter (as defined in § 410.2) by an entity other than the hospital unless the hospital has an arrangement (as defined in § 409.3 of this chapter) with that entity to furnish that particular service to its patients. As used in this paragraph, the term “hospital” includes a CAH.
(b) Exception. The limitations stated in paragraph (a) of this section do not apply to the following services:
(1) Physician services that meet the requirements of § 415.102(a) of this chapter for payment on a fee schedule basis.
(2) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act.
(3) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.
(4) Certified nurse mid-wife services, as defined in section 1861(gg) of the Act.
(5) Qualified psychologist services, as defined in section 1861(ii) of the Act.
(6) Services of an anesthetist, as defined in § 410.69.
(7) Services furnished to SNF residents as defined in § 411.15(p) of this chapter.
6. In § 410.43, paragraph (b) is revised to read as follows:
End Amendment PartPartial hospitalization services: Conditions and exclusions.* * * * *(b) The following services are separately covered and not paid as partial hospitalization services:
(1) Physician services that meet the requirements of § 415.102(a) of this chapter for payment on a fee schedule basis. Start Printed Page 18537
(2) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act.
(3) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.
(4) Qualified psychologist services, as defined in section 1861(ii) of the Act.
(5) Services furnished to SNF residents as defined in § 411.15(p) of this chapter.
PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT
End Part Start Amendment PartC. Part 411 is amended as set forth below:
End Amendment Part Start Amendment Part1. The authority citation for part 411 continues to read as follows:
End Amendment PartSubpart A—General Exclusions and Exclusion of Particular Services
Start Amendment Part2. In § 411.15:
End Amendment Part Start Amendment PartA. The introductory text is republished;
End Amendment Part Start Amendment PartB. The section heading to paragraph (m) is revised;
End Amendment Part Start Amendment PartC. Paragraph (m)(1) is revised;
End Amendment Part Start Amendment PartD. Paragraph (m)(2) is redesignated as paragraph (m)(3);
End Amendment Part Start Amendment PartE. The introductory text to newly redesignated paragraph (m)(3) is republished;
End Amendment Part Start Amendment PartF. Newly redesignated paragraphs (m)(3)(iii), (m)(3)(iv), and (m)(3)(v) are redesignated as paragraphs (m)(3)(iv), (m)(3)(v), and (m)(3)(vi), respectively; and
End Amendment Part Start Amendment PartG. New paragraphs (m)(2) and (m)(3)(iii) are added to read as follows:
End Amendment PartParticular services excluded from coverage.The following services are excluded from coverage:
* * * * *(m) Services to hospital patients— (1) Basic rule. Except as provided in paragraph (m)(3) of this section, any service furnished to an inpatient of a hospital or to a hospital outpatient (as defined in § 410.2 of this chapter) during an encounter (as defined in § 410.2 of this chapter) by an entity other than the hospital unless the hospital has an arrangement (as defined in § 409.3 of this chapter) with that entity to furnish that particular service to the hospital's patients. As used in this paragraph (m)(1), the term “hospital” includes a CAH.
(2) Scope of exclusion. Services subject to exclusion from coverage under the provisions of this paragraph (m) include, but are not limited to, clinical laboratory services; pacemakers and other prostheses and prosthetic devices (other than dental) that replace all or part of an internal body organ (for example, intraocular lenses); artificial limbs, knees, and hips; equipment and supplies covered under the prosthetic device benefits; and services incident to a physician service.
(3) Exceptions. The following services are not excluded from coverage:
* * * * *(iii) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.
* * * * *PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES
End Part Start Amendment PartD. Part 412 is amended as set forth below:
End Amendment Part Start Amendment Part1. The authority citation for part 412 continues to read as follows:
End Amendment PartSubpart C—Conditions for Payment Under the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs
Start Amendment Part2. In § 412.50, paragraphs (a) and (b) are revised to read as follows:
End Amendment PartFurnishing of inpatient hospital services directly or under arrangements.(a) The applicable payments made under the prospective payment systems, as described in subparts H and M of this part, are payment in full for all inpatient hospital services, as defined in § 409.10 of this chapter. Inpatient hospital services do not include the following types of services:
(1) Physician services that meet the requirements of § 415.102(a) of this chapter for payment on a fee schedule basis.
(2) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act.
(3) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.
(4) Certified nurse mid-wife services, as defined in section 1861(gg) of the Act.
(5) Qualified psychologist services, as defined in section 1861(ii) of the Act.
(6) Services of an anesthetist, as defined in § 410.69 of this chapter.
(b) HCFA does not pay any provider or supplier other than the hospital for services furnished to a beneficiary who is an inpatient, except for the services described in paragraphs (a)(1) through (a)(6) of this section.
* * * * *PART 413—PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES
End Part Start Amendment PartE. Part 413 is amended as set forth below:
End Amendment Part Start Amendment Part1. The authority citation for part 413 continues to read as follows:
End Amendment PartSubpart A—Introduction and General Rules
[Amended]2. In § 413.1, paragraph (a)(2)(viii) is removed.
End Amendment PartSubpart B—Accounting Records and Reports
Start Amendment Part3. In § 413.24, the heading to paragraph (d) is republished, and a new paragraph (d)(6) is added to read as follows:
End Amendment PartAdequate cost data and cost finding.* * * * *(d) Cost finding methods. * * *
(6) Management contracts. (i) If the main provider purchases services for a department of the provider or a provider-based entity through a management contract or otherwise directly assigns costs to the department or entity, the like costs of the main provider must be carved out to ensure that they are not allocated to the department of the provider or provider-based entity. However, if the like costs of the main provider cannot be separately identified, the costs of the services purchased through a management contract must be included in the main provider's administrative and general costs and allocated among the provider's overall statistics.
(ii) Costs of free-standing entities may not be shown in the provider's trial balance for purposes of stepping down overhead costs to these entities. The provider must develop detailed work papers showing the exact cost of the services (including overhead) provided to or by the free-standing entity and show those carved out costs as Start Printed Page 18538nonreimbursable cost centers in the provider's trial balance.
* * * * *Subpart E—Payments to Providers
Start Amendment Part4. A new § 413.65 is added to read as follows:
End Amendment PartRequirements for a determination that a facility or an organization has provider-based status.(a) Scope and definitions. (1) Scope. This section applies to all facilities or organizations for which provider-based status is sought, including remote locations of hospitals, as defined in paragraph (a)(2) of this section and satellite facilities as defined in § 412.22(h)(1) and § 412.25(e)(1) of this chapter, other than ESRD facilities. Determinations for ESRD facilities are made under § 413.174 of this chapter.
(2) Definitions. In this subpart E, unless the context indicates otherwise—
Campus means the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the HCFA regional office, to be part of the provider's campus.
Department of a provider means a facility or organization or a physician office that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of the same type as those furnished by the main provider under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section. A department of a provider may not be licensed to provide health care services in its own right, may not by itself be qualified to participate in Medicare as a provider under § 489.2 of this chapter, and Medicare conditions of participation do not apply to a department as an independent entity. For purposes of this part, the term “department of a provider” does not include an RHC or, except as specified in paragraph (m)(1) of this section, an FQHC.
Free-standing facility means an entity that furnishes health care services to Medicare beneficiaries and that is not integrated with any other entity as a main provider, a department of a provider, remote location of a hospital, satellite facility, or a provider-based entity.
Main provider means a provider that either creates, or acquires ownership of, another entity to deliver additional health care services under its name, ownership, and financial and administrative control.
Provider-based entity means a provider of health care services, or an RHC or an FQHC as defined in § 405.2401(b) of this chapter, that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the name, ownership, and administrative and financial control of the main provider, in accordance with the provisions of this section.
Provider-based status means the relationship between a main provider and a provider-based entity or a department of a provider, remote location of a hospital, or satellite facility, that complies with the provisions of this section.
Remote location of a hospital means a facility or an organization that is either created by, or acquired by, a hospital that is a main provider for the purpose of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section. A remote location of a hospital may not be licensed to provide inpatient hospital services in its own right, and Medicare conditions of participation do not apply to a remote location of a hospital as an independent entity. For purposes of this part, the term “remote location of a hospital” does not include a satellite facility as defined in § 412.22(h)(1) and § 412.25(e)(1) of this chapter.
(b) Responsibility for obtaining provider-based determinations. (1) A facility or organization is not entitled to be treated as provider-based simply because it or the main provider believe it is provider-based.
(2) A main provider or a facility or organization must contact HCFA and the facility or organization must be determined by HCFA to be provider-based before the main provider bills for services of the facility or organization as if the facility or organization were provider-based, or before it includes costs of those services on its cost report.
(3) A facility that is not located on the campus of a hospital and is used as a site of physician services of the kind ordinarily furnished in physician offices will be presumed to be a free-standing facility, unless it is determined by HCFA to have provider-based status.
(c) Reporting. (1) A main provider that creates or acquires a facility or organization for which it wishes to claim provider-based status, including any physician offices that a hospital wishes to operate as a hospital outpatient department or clinic, must report its acquisition of the facility or organization to HCFA if the facility or organization is located off the campus of the provider, or inclusion of the costs of the facility or organization in the provider's cost report would increase the total costs on the provider's cost report by at least 5 percent, and must furnish all information needed for a determination as to whether the facility or organization meets the requirements in paragraph (d) of this section for provider-based status.
(2) A main provider that has had one or more facilities or organizations considered provider-based also must report to HCFA any material change in the relationship between it and any provider-based facility or organization, such as a change in ownership of the facility or organization or entry into a new or different management contract that could affect the provider-based status of the facility or organization.
(d) Requirements. An entity must meet all of the following requirements to be determined by HCFA to have provider-based status.
(1) Licensure. The department of the provider, remote location of a hospital, or satellite facility and the main provider are operated under the same license, except in areas where the State requires a separate license for the department of the provider, remote location of a hospital, or satellite facility, or in States where State law does not permit licensure of the provider and the prospective department of the provider, remote location of a hospital, or satellite facility under a single license. If a State health facilities' cost review commission or other agency that has authority to regulate the rates charged by hospitals or other providers in a State finds that a particular facility or organization is not part of a provider, HCFA will determine that the facility or organization does not have provider-based status.
(2) Operation under the ownership and control of the main provider. The facility or organization seeking provider-based status is operated under the ownership and control of the main provider, as evidenced by the following:
(i) The business enterprise that constitutes the facility or organization is 100 percent owned by the provider.
(ii) The main provider and the facility or organization seeking status as a department of the provider, remote location of a hospital, or satellite facility have the same governing body.
(iii) The facility or organization is operated under the same organizational documents as the main provider. For Start Printed Page 18539example, the facility or organization seeking provider-based status must be subject to common bylaws and operating decisions of the governing body of the provider where it is based.
(iv) The main provider has final responsibility for administrative decisions, final approval for contracts with outside parties, final approval for personnel actions, final responsibility for personnel policies (such as fringe benefits/code of conduct), and final approval for medical staff appointments in the facility or organization.
(3) Administration and supervision. The reporting relationship between the facility or organization seeking provider-based status and the main provider must have the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and one of its departments, as evidenced by compliance with all of the following requirements:
(i) The facility or organization is under the direct supervision of the main provider.
(ii) The facility or organization is operated under the same monitoring and oversight by the provider as any other department of the provider, and is operated just as any other department of the provider with regard to supervision and accountability. The facility or organization director or individual responsible for daily operations at the entity—
(A) Maintains a reporting relationship with a manager at the main provider that has the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and its departments; and
(B) Is accountable to the governing body of the main provider, in the same manner as any department head of the provider.
(iii) The following administrative functions of the facility or organization are integrated with those of the provider where the facility or organization is based: billing services, records, human resources, payroll, employee benefit package, salary structure, and purchasing services. Either the same employees or group of employees handle these administrative functions for the facility or organization and the main provider, or the administrative functions for both the facility or organization and the entity are—
(A) Contracted out under the same contract agreement; or
(B) Handled under different contract agreements, with the contract of the facility or organization being managed by the main provider.
(4) Clinical services. The clinical services of the facility or organization seeking provider-based status and the main provider are integrated as evidenced by the following:
(i) Professional staff of the facility or organization have clinical privileges at the main provider.
(ii) The main provider maintains the same monitoring and oversight of the facility or organization as it does for any other department of the provider.
(iii) The medical director of the facility or organization seeking provider-based status maintains a reporting relationship with the Chief Medical Officer or other similar official of the main provider that has the same frequency, intensity, and level of accountability that exists in the relationship between the medical director of a department of the main provider and the Chief Medical Officer or other similar official of the main provider, and is under the same type of supervision and accountability as any other director, medical or otherwise, of the main provider.
(iv) Medical staff committees or other professional committees at the main provider are responsible for medical activities in the facility or organization including quality assurance, utilization review, and the coordination and integration of services, to the extent practicable, between the facility or organization seeking provider-based status and the main provider.
(v) Medical records for patients treated in the facility or organization are integrated into a unified retrieval system (or cross reference) of the main provider.
(vi) Inpatient and outpatient services of the facility or organization and the main provider are integrated, and patients treated at the facility or organization who require further care have full access to all services of the main provider and are referred where appropriate to the corresponding inpatient or outpatient department or service of the main provider.
(5) Financial integration. The financial operations of the facility or organization are fully integrated within the financial system of the main provider, as evidenced by shared income and expenses between the main provider and the facility or organization. The costs of the facility or organization are reported in a cost center of the provider, and the financial status of the facility or organization is incorporated and readily identified in the main provider's trial balance.
(6) Public awareness. The facility or organization seeking status as a department of a provider, remote location of a hospital, or satellite facility is held out to the public and other payers as part of the main provider. When patients enter the provider-based facility or organization, they are aware that they are entering the main provider and are billed accordingly.
(7) Location in immediate vicinity. The facility or organization and the main provider are located on the same campus, except where the following requirements are met:
(i) The facility or organization demonstrates a high level of integration with the main provider by showing that it meets all of the other provider-based criteria, and demonstrates that it serves the same patient population as the main provider, by submitting records showing that, during the 12-month period immediately preceding the first day of the month in which the application for provider-based status is filed with HCFA, and for each subsequent 12-month period—
(A) At least 75 percent of the patients served by the facility or organization reside in the same zip code areas as at least 75 percent of the patients served by the main provider;
(B) At least 75 percent of the patients served by the facility or organization who required the type of care furnished by the main provider received that care from that provider (for example, at least 75 percent of the patients of an RHC seeking provider-based status received inpatient hospital services from the hospital that is the main provider); or
(C) If the facility or organization is unable to meet the criteria in paragraph (d)(7)(i)(A) or (d)(7)(i)(B) of this section because it was not in operation during all of the 12-month period described in the previous sentence, the facility or organization is located in a zip code area included among those that, during all of the 12-month period described in the previous sentence, accounted for at least 75 percent of the patients served by the main provider.
(ii) A facility or organization is not considered to be in the “immediate vicinity” of the main provider unless the facility or organization and the main provider are located in the same State or, where consistent with the laws of both States, adjacent States.
(iii) A rural health clinic that is otherwise qualified as a provider-based entity of a hospital that is located in a rural area, as defined in § 412.62(f)(1)(iii) of this chapter, and has fewer than 50 beds, as determined under § 412.105(b) of this chapter, is not subject to the criterion in this paragraph (d)(7).
(e) Provider-based status not applicable to joint ventures. A facility or Start Printed Page 18540organization cannot be considered provider-based if the entity is owned by two or more providers engaged in a joint venture. For example, where a hospital has jointly purchased or jointly created free-standing facilities under joint venture arrangements, neither party to the joint venture arrangement can claim the free-standing facility as a provider-based entity.
(f) Management contracts. Facilities and organizations that otherwise meet the requirements of paragraph (d) of this section, but are operated under management contracts, must also meet all of the following criteria:
(1) The staff of the facility or organization, other than management staff, are employed by the provider or by another organization, other than the management company, which also employs the staff of the main provider.
(2) The administrative functions of the facility or organization are integrated with those of the main provider, as determined under criteria in paragraph (d)(3)(iii) of this section.
(3) The main provider has significant control over the operations of the facility or organization as determined under criteria in paragraph (b)(3)(ii) of this section.
(4) The management contract is held by the main provider itself, not by a parent organization that has control over both the main provider and the facility or organization.
(g) Obligations of hospital outpatient departments and hospital-based entities. (1) Hospital outpatient departments located either on or off the campus of the hospital that is the main provider must comply with the anti-dumping rules in §§ 489.20(l), (m), (q), and (r) and § 489.24 of this chapter. If any individual comes to any hospital-based entity (including an RHC) located on the main hospital campus, and a request is made on the individual's behalf for examination or treatment of a medical condition, as described in § 489.24 of this chapter, the hospital must comply with the anti-dumping rules in § 489.24 of this chapter.
(2) Physician services furnished in hospital outpatient departments or hospital-based entities (other than RHCs) must be billed with the correct site-of-service indicator, so that applicable site-of-service reductions to physician and practitioner payment amounts can be applied.
(3) Hospital outpatient departments must comply with all the terms of the hospital's provider agreement.
(4) Physicians who work in hospital outpatient departments or hospital-based entities are obligated to comply with the non-discrimination provisions in § 489.10(b) of this chapter.
(5) Hospital outpatient departments (other than RHCs) must treat all Medicare patients, for billing purposes, as hospital outpatients. The department must not treat some Medicare patients as hospital outpatients and others as physician office patients.
(6) In the case of a patient admitted to the hospital as an inpatient after receiving treatment in the hospital outpatient department or hospital-based entity, payments for services in the hospital outpatient department or hospital-based entity are subject to the payment window provisions applicable to PPS hospitals and to hospitals and units excluded from PPS set forth at § 412.2(c)(5) of this chapter and at § 413.40(c)(2), respectively.
(7) When a Medicare beneficiary is treated in a hospital outpatient department or hospital-based entity (other than an RHC) that is not located on the main provider's campus, the hospital has a duty to provide written notice to the beneficiary, prior to the delivery of services, of the amount of the beneficiary's potential financial liability (that is, of the fact that the beneficiary will incur a coinsurance liability for an outpatient visit to the hospital as well as for the physician service, and of the amount of that liability). The notice must be one that the beneficiary can read and understand. If the beneficiary is unconscious, under great duress, or for any other reason unable to read a written notice and understand and act on his or her own rights, the notice must be provided, prior to the delivery of services, to the beneficiary's authorized representative.
(8) Hospital outpatient departments must meet applicable hospital health and safety rules for Medicare-participating hospitals in part 482 of this chapter.
(h) Furnishing all services under arrangement. A facility or organization may not qualify for provider-based status if all patient care services furnished at the facility are furnished under arrangement.
(i) Inappropriate treatment of a facility or organization as provider-based. (1) Determination and review. If HCFA learns that a provider has treated a facility or organization as provider-based and the provider had not obtained a determination of provider-based status under this section, HCFA will—
(i) Review current payments and, if necessary, take action in accordance with the rules on inappropriate billing in paragraph (j) of this section;
(ii) Investigate and determine whether the requirements in paragraph (d) of this section (or, for periods prior to October 10, 2000, the requirements in applicable program instructions) were met; and
(iii) Review all previous payments to that provider for all cost reporting periods subject to re-opening in accordance with § 405.1885 and § 405.1889 of this chapter.
(2) Recovery of overpayments. If HCFA finds that payments for services at the facility or organization have been made as if the facility or organization were provider-based, even though HCFA had not previously determined that the facility or organization qualified for provider-based status, HCFA will recover the difference between the amount of payments that actually were made and the amount of payments that HCFA estimates should have been made in the absence of a determination of provider-based status, except that recovery will not be made for any period prior to October 10, 2000 if during all of that period the management of the entity made a good faith effort to operate it as a provider-based facility or organization, as described in paragraph (h)(3) of this section.
(3) Exception for good faith effort. HCFA determines that the management of a facility or organization has made a good faith effort to operate it as a provider-based entity if—
(i) The requirements regarding licensure and public awareness in paragraphs (d)(1) and (d)(6) of this section are met;
(ii) All facility services were billed as if they had been furnished by a department of a provider, remote location of a hospital, satellite facility, or a provider-based entity of the main provider; and
(iii) All professional services of physicians and other practitioners were billed with the correct site-of-service indicator, as described in paragraph (g)(2) of this section.
(j) Inappropriate billing. If HCFA finds that a facility or organization is being treated as provider-based without having obtained a determination of provider-based status under this section, HCFA will notify the provider, adjust future payments, review previous payments, determine whether the facility or organization qualifies for provider-based status under this paragraph, and continue payments only under specific conditions, as described in paragraphs (j)(1), (j)(2), (j)(3), and (j)(4) of this section.
(1) Notice to provider. If HCFA finds that inappropriate billing has occurred or is occurring since no provider-based Start Printed Page 18541determination has been made by HCFA, HCFA will issue written notice to the provider that payments for past cost reporting periods may be reviewed and recovered as described in paragraph (i) of this section, that future payments for services in or of the facility or organization will be adjusted as described in paragraph (j)(2) of this section, and that a determination of provider-based status will be made.
(2) Adjustment of payments. If HCFA finds that inappropriate billing has occurred or is occurring since no provider-based determination has been made by HCFA, HCFA will adjust future payments to the provider, the facility or organization, or both, to approximate as closely as possible the amounts that would be paid, in the absence of a provider-based determination, if all other requirements for billing were met.
(3) Review of previous payments. If HCFA finds that inappropriate billing has occurred or is occurring since no provider-based determination has been made by HCFA, HCFA will review previous payments and, if necessary, take action in accordance with the rules on inappropriate treatment of a facility or organization as provider-based in paragraph (h) of this section.
(4) Determination regarding provider-based status. If HCFA finds that inappropriate billing has occurred or is occurring since no provider-based determination has been made by HCFA, HCFA will determine whether the facility or organization qualifies for provider-based status under the criteria in this section. If HCFA determines that the facility or organization qualifies for provider-based status, future payment for services at or by the facility or organization will be adjusted to reflect that determination. If HCFA determines that the facility or organization does not qualify for provider-based status, future payment for services at or by the facility or organization will be made only in accordance with the rules in paragraph (i)(5) of this section.
(5) Continuation of payment. The notice of denial of provider-based status sent to the provider will ask the provider to notify HCFA in writing, within 30 days of the date the notice is issued, of whether the facility or organization (or, where applicable, the practitioners who staff the facility or organization) will be seeking to enroll and meet other requirements to bill for services in a free-standing facility. If the provider indicates that the facility, organization, or practitioners will not be seeking to enroll, or if HCFA does not receive a response within 30 days of the date the notice was issued, all payment under this paragraph (i)(5) will end as of the 30th day after the date of notice. If the provider indicates that the facility or organization, or its practitioners, will be seeking to meet enrollment and other requirements for billing for services in a free-standing facility, payment for services of the facility or organization will continue, at the adjusted amounts described in paragraph (j)(2) of this section for as long as is required for all billing requirements to be met (but not longer than 6 months) if the facility or organization, or its practitioners, submit a complete enrollment application and provide all other required information within 90 days after the date of notice; and the facility or organization, or its practitioners, furnish all other information needed by HCFA to process the enrollment application and verify that other billing requirements are met. If the necessary applications or information are not provided, HCFA will terminate all payment to the provider, facility, or organization as of the date HCFA issues notice that necessary applications or information have not been submitted.
(k) Correction of errors. HCFA may review a past determination of provider-based status for a facility or organization or may review the status of a facility or organization (that is, whether the facility or organization is provider-based) if no determination regarding provider-based status has previously been made, if HCFA believes that status may be inappropriate, based on the provisions of this section. If HCFA determines that a previous determination was in error, and the entity should not be considered provider-based, HCFA notifies the main provider. Treatment of the facility or organization as provider-based ceases with the first day of the next cost report period following notification of the redetermination, but not less than 6 months after the date of notification.
(l) Status of Indian Health Service and Tribal facilities and organizations. Facilities and organizations operated by the Indian Health Service or Tribes will be considered to be departments of hospitals operated by the Indian Health Service or Tribes if, on or before April 7, 2000, they furnished only services that were billed as if they had been furnished by a department of a hospital operated by the Indian Health Service or a Tribe and they are:
(1) Owned and operated by the Indian Health Service;
(2) Owned by the Tribe but leased from the Tribe by the IHS under the Indian Self-Determination Act (Pub. L. 93-638) in accordance with applicable regulations and policies of the Indian Health Service in consultation with Tribes: or
(3) Owned by the Indian Health Service but leased and operated by the Tribe under the Indian Self-Determination Act (Pub. L. 93-638) in accordance with applicable regulations and policies of the Indian Health Service in consultation with Tribes.
(m) FQHCs and “look-alikes”. A facility that has, since April 7, 1995, furnished only services that were billed as if they had been furnished by a department of a provider will continue to be treated, for purposes of this section, as a department of the provider without regard to whether it complies with the criteria for provider-based status in this section, if the facility—
(1) Received a grant before 1995 under section 330 of the Public Health Service Act, or is receiving funding from such a grant under a contract with the recipient of such a grant and meets the requirements to receive a grant under section 330 of the Public Health Service Act; or
(2) Based on the recommendation of the Public Health Service, was determined by HCFA before 1995 to meet the requirements for receiving such a grant.
(n) Effective date of provider-based status. Provider-based status for a facility or organization is effective on the earliest date on which a request for provider-based status has been made, and all requirements of this part have been met.
Subpart F—Specific Categories of Costs
Start Amendment Part5. In § 413.118, the heading to paragraph (d) is republished, and a new paragraph (d)(5) is added to read as follows:
End Amendment PartPayment for facility services related to covered ASC surgical procedures performed in hospitals on an outpatient basis.* * * * *(d) Blended payment amount. * * *
(5) For portions of cost reporting periods beginning on or after October 1, 1997, for purposes of calculating the blended payment amount under paragraph (d)(4) of this section, the ASC payment amount is the sum of the standard overhead amounts reduced by deductibles and coinsurance as defined in section 1866(a)(2)(ii) of the Act.
* * * * *6. In § 413.122:
End Amendment Part Start Amendment PartA. The heading to paragraph (b) is republished
End Amendment Part Start Amendment PartB. A new paragraph (b)(5) is added
End Amendment Part Start Amendment PartC. The heading to paragraph (c) is republished; and Start Printed Page 18542
End Amendment Part Start Amendment PartD. A new paragraph (c)(4) is added to read as follows:
End Amendment PartPayment for hospital outpatient radiology services and other diagnostic procedures.* * * * *(b) Payment for hospital outpatient radiology services. * * *
(5) For hospital outpatient radiology services furnished on or after October 1, 1997, the blended payment amount is equal to the sum of—
(i) 42 percent of the hospital-specific amount; and
(ii) 58 percent of the fee schedule amount calculated as 62 percent of the sum of the fee schedule amounts payable for the same services when furnished by participating physicians in their offices in the same locality, less deductible and coinsurance as defined in section 1866(a)(2)(A)(ii) of the Act.
(c) Payment for other diagnostic procedures. * * *
(4) For other diagnostic services furnished on or after October 1, 1997, the blended payment amount is equal to the sum of—
(i) 50 percent of the hospital-specific amount; and
(ii) 50 percent of the fee schedule amount calculated as 42 percent of the sum of the fee schedule amounts payable for the same services when furnished by participating physicians in their offices in the same locality less deductible and coinsurance as defined in section 1866(a)(2)(A)(ii) of the Act.
7. In § 413.124, paragraph (a) is revised to read as follows:
End Amendment PartReduction to hospital outpatient operating costs.(a) Except for sole community hospitals, as defined in § 412.92 of this chapter, and critical access hospitals, the reasonable costs of outpatient hospital services (other than capital-related costs of these services) are reduced by 5.8 percent for services furnished during portions of cost reporting periods occurring on or after October 1, 1990 and until the first date that the prospective payment system under part 419 of this chapter is implemented.
* * * * *Subpart G—Capital-Related Costs
Start Amendment Part8. In § 413.130, the heading to paragraph (j) and the introductory text to paragraph (j)(1) are republished, and paragraph (j)(1)(ii) is revised to read as follows:
End Amendment PartIntroduction to capital-related costs.* * * * *(j) Reduction to capital-related costs. (1) Except for sole community hospitals and critical access hospitals, the amount of capital-related costs of all hospital outpatient services is reduced by—
* * * * *(ii) 10 percent for portions of cost reporting periods occurring on or after October 1, 1991 and until the first date that the prospective payment system under part 419 of this chapter is implemented.
* * * * *F. A new part 419, consisting of §§ 419.1, 419.2, 419.20, 419.21, 419.22, 419.30, 419.31, 419.32, 419.40, 419.41, 419.42, 419.43, 419.44, 419.50, 419.60, and 419.70, is added to read as follows:
End Amendment Part Start PartPART 419—PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES
Subpart A—General Provisions
419.1 419.2Subpart B—Categories of Hospitals and Services Subject to and Excluded From the Hospital Outpatient Prospective Payment System
419.20 419.21 419.22Subpart C—Basic Methodology for Determining Prospective Payment Rates for Hospital Outpatient Services
419.30 419.31 419.32Subpart D—Payments to Hospitals
419.40 419.41 419.42 419.43 419.44Subpart E—Updates
419.50Subpart F—Limitations on Review
419.60Subpart G—Transitional Corridors
419.70 End Part Start PartPART 419—PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES
Subpart A—General Provisions
Basis and scope.(a) Basis. This part implements section 1833(t) of the Act by establishing a prospective payment system for services furnished on or after July 1, 2000 by hospital outpatient departments to Medicare beneficiaries who are registered on hospital records as outpatients.
(b) Scope. This subpart describes the basis of payment for outpatient hospital services under the prospective payment system. Subpart B sets forth the categories of hospitals and services that are subject to the outpatient hospital prospective payment system and those categories of hospitals and services that are excluded from the outpatient hospital prospective payment system. Subpart C sets forth the basic methodology by which prospective payment rates for hospital outpatient services are determined. Subpart D describes Medicare payment amounts, beneficiary copayment amounts, and methods of payment to hospitals under the hospital outpatient prospective payment system. Subpart E describes how the hospital outpatient prospective payment system may be updated. Subpart F describes limitations on administrative and judicial review. Subpart G describes the transitional payment adjustments that are made before 2004 to limit declines in payment for outpatient services.
Basis of payment.(a) Unit of payment. Under the hospital outpatient prospective payment system, predetermined amounts are paid for designated services furnished to Medicare beneficiaries. These services are identified by codes established under the Health Care Financing Administration Common Procedure Coding System (HCPCS). The prospective payment rate for each service or procedure for which payment is allowed under the hospital outpatient prospective payment system is Start Printed Page 18543determined according to the methodology described in subpart C of this part. The manner in which the Medicare payment amount and the beneficiary copayment amount for each service or procedure are determined is described in subpart D of this part.
(b) Determination of hospital outpatient prospective payment rates: Included costs. The prospective payment system establishes a national payment rate, standardized for geographic wage differences, that includes operating and capital-related costs that are directly related and integral to performing a procedure or furnishing a service on an outpatient basis. In general, these costs include, but are not limited to—
(1) Use of an operating suite, procedure room, or treatment room;
(2) Use of recovery room;
(3) Use of an observation bed;
(4) Anesthesia, certain drugs, biologicals, and other pharmaceuticals; medical and surgical supplies and equipment; surgical dressings; and devices used for external reduction of fractures and dislocations;
(5) Supplies and equipment for administering and monitoring anesthesia or sedation;
(6) Intraocular lenses (IOLs);
(7) Incidental services such as venipuncture;
(8) Capital-related costs;
(9) Implantable items used in connection with diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests;
(10) Durable medical equipment that is implantable;
(11) Implantable prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of these devices; and
(12) Costs incurred to procure donor tissue other than corneal tissue.
(c) Determination of hospital outpatient prospective payment rates: Excluded costs. The following costs are excluded from the hospital outpatient prospective payment rates:
(1) Medical education costs for approved nursing and allied health education programs.
(2) Corneal tissue acquisition costs incurred by hospitals that are paid for on a reasonable cost basis.
(3) Costs for services listed in § 419.22.
Subpart B—Categories of Hospitals and Services Subject to and Excluded From the Hospital Outpatient Prospective Payment System
Hospitals subject to the hospital outpatient prospective payment system.(a) Applicability. The hospital outpatient prospective payment system is applicable to any hospital participating in the Medicare program, except those specified in paragraph (b) of this section, for services furnished on or after July 1, 2000.
(b) Hospitals excluded from the outpatient prospective payment system. (1) Those services furnished by Maryland hospitals that are paid under a cost containment waiver in accordance with section 1814(b)(3) of the Act are excluded from the hospital outpatient prospective payment system.
(2) Critical access hospitals (CAHs) are excluded from the hospital outpatient prospective payment system.
Hospital outpatient services subject to the outpatient prospective payment system.Except for services described in § 419.22, effective for services furnished on or after July 1, 2000, payment is made under the hospital outpatient prospective payment system for the following:
(a) Medicare Part B services furnished to hospital outpatients designated by the Secretary under this part.
(b) Services designated by the Secretary that are covered under Medicare Part B when furnished to hospital inpatients who are either not entitled to benefits under Part A or who have exhausted their Part A benefits but are entitled to benefits under Part B of the program.
(c) Partial hospitalization services furnished by community mental health centers (CMHCs).
(d) The following medical and other health services furnished by a comprehensive outpatient rehabilitation facility (CORF) when they are provided outside the patient's plan (of care); or by a home health agency (HHA) to patients who are not under an HHA plan or treatment; or by a hospice program furnishing services to patients outside the hospice benefit:
(1) Antigens.
(2) Splints and casts.
(3) Pneumococcal vaccine, influenza vaccine, and hepatitis B vaccine.
Hospital outpatient services excluded from payment under the hospital outpatient prospective payment system.The following services are not paid for under the hospital outpatient prospective payment system:
(a) Physician services that meet the requirements of § 415.102(a) of this chapter for payment on a fee schedule basis.
(b) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.
(c) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act.
(d) Certified nurse-midwife services, as defined in section 1861(gg) of the Act.
(e) Services of qualified psychologists, as defined in section 1861(ii) of the Act.
(f) Services of an anesthetist as defined in § 410.69 of this chapter.
(g) Clinical social worker services as defined in section 1861(hh)(2) of the Act.
(h) Outpatient therapy services described in section 1833(a)(8) of the Act.
(i) Ambulance services, as described in section 1861(v)(1)(U) of the Act, or, if applicable, the fee schedule established under section 1834(l).
(j) Except as provided in § 419.22(b)(11), prosthetic devices, prosthetics, prosthetic supplies, and orthotic devices.
(k) Except as provided in § 419.2(b)(10), durable medical equipment supplied by the hospital for the patient to take home.
(l) Clinical diagnostic laboratory services.
(m) Services for patients with ESRD that are paid under the ESRD composite rate and drugs and supplies furnished during dialysis but not included in the composite rate.
(n) Services and procedures that the Secretary designates as requiring inpatient care.
(o) Hospital outpatient services furnished to SNF residents (as defined in § 411.15(p) of this chapter) as part of the patient's resident assessment or comprehensive care plan (and thus included under the SNF PPS) that are furnished by the hospital “under arrangements” but billable only by the SNF, regardless of whether or not the patient is in a Part A SNF stay.
(p) Services that are not covered by Medicare by statute.
(q) Services that are not reasonable or necessary for the diagnosis or treatment of an illness or disease.
Subpart C—Basic Methodology for Determining Prospective Payment Rates for Hospital Outpatient Services
Base expenditure target for calendar year 1999.(a) HCFA estimates the aggregate amount that would be payable for Start Printed Page 18544hospital outpatient services in calendar year 1999 by summing—
(1) The total amounts that would be payable from the Trust Fund for covered hospital outpatient services without regard to the outpatient prospective payment system described in this part; and
(2) The total amounts of coinsurance that would be payable by beneficiaries to hospitals for covered hospital outpatient services without regard to the outpatient prospective payment system described in this part.
(b) The estimated aggregate amount under paragraph (a) of this section is determined as though the deductible required under section 1833(b) of the Act did not apply.
Ambulatory payment classification (APC) system and payment weights.(a) APC groups. (1) HCFA classifies outpatient services and procedures that are comparable clinically and in terms of resource use into APC groups. Except as specified in paragraph (a)(2) of this section, items and services within a group are not comparable with respect to the use of resources if the highest median cost for an item or service within the group is more than 2 times greater than the lowest median cost for an item or service within the group.
(2) HCFA may make exceptions to the requirements set forth in paragraph (a)(1) in unusual cases, such as low volume items and services, but may not make such an exception in the case of a drug or biological that has been designated as an orphan drug under section 526 of the Federal Food, Drug and Cosmetic Act.
(3) The payment rate determined for an APC group in accordance with § 419.32, and the copayment amount and program payment amount determined for an APC group in accordance with subpart D of this part, apply to every HCPCS code classified within an APC group.
(b) APC weighting factors. (1) Using hospital outpatient claims data from calendar year 1996 and data from the most recent available hospital cost reports, HCFA determines the median costs for the services and procedures within each APC group.
(2) HCFA assigns to each APC group an appropriate weighting factor to reflect the relative median costs for the services within the APC group compared to the median costs for the services in all APC groups.
(c) Standardizing amounts. (1) HCFA determines the portion of costs determined in paragraph (b)(1) of this section that is labor-related. This is known as the “labor-related portion” of hospital outpatient costs.
(2) HCFA standardizes the median costs determined in paragraph (b)(1) of this section by adjusting for variations in hospital labor costs across geographic areas.
Calculation of prospective payment rates for hospital outpatient services.(a) Conversion factor for 1999. HCFA calculates a conversion factor in such a manner that payment for hospital outpatient services furnished in 1999 would have equaled the base expenditure target calculated in § 419.30, taking into account APC group weights and estimated service frequencies and reduced by the amounts that would be payable in 1999 as outlier payments under § 419.43(d) and transitional pass-through payments under § 419.43(e).
(b) Conversion factor for calendar year 2000 and subsequent years. (1) Subject to paragraph (b)(2) of this section, the conversion factor for a calendar year is equal to the conversion factor calculated for the previous year adjusted as follows:
(i) For calendar years 2000, 2001, and 2002, by the hospital inpatient market basket percentage increase applicable under section 1886(b)(3)(B)(iii) of the Act reduced by one percentage point.
(ii) For calendar years 2003 and subsequent years, by the hospital inpatient market basket percentage increase applicable under section 1886(b)(3)(B)(iii) of the Act.
(2) Beginning in calendar year 2000, HCFA may substitute for the hospital inpatient market basket percentage in paragraph (b) of this section a market basket percentage increase that is determined and applied to hospital outpatient services in the same manner that the hospital inpatient market basket percentage increase is determined and applied to inpatient hospital services.
(c) Payment rates. The payment rate for services and procedures for which payment is made under the hospital outpatient prospective payment system is the product of the conversion factor calculated under paragraph (a) or paragraph (b) of this section and the relative weight determined under § 419.31(b).
(d) Budget neutrality. HCFA adjusts the conversion factor as needed to ensure that updates and adjustments under § 419.50(a) are budget neutral.
Subpart D—Payments to Hospitals
Payment concepts.(a) In addition to the payment rate described in § 419.32, for each APC group there is a predetermined beneficiary coinsurance amount as described in § 419.41(a). The Medicare program payment amount for each APC group is calculated by applying the program payment percentage as described in § 419.41(b).
(b) For purposes of this section—
(1) Coinsurance percentage is calculated as the difference between the program payment percentage and 100 percent. The coinsurance percentage in any year is thus defined for each APC group as the greater of the following: the ratio of the APC group unadjusted copayment amount to the annual APC group payment rate, or 20 percent.
(2) Program payment percentage is calculated as the lower of the following: the ratio of the APC group payment rate minus the APC group unadjusted coinsurance amount, to the APC group payment rate, or 80 percent.
(3) Unadjusted coinsurance amount is calculated as 20 percent of the wage-adjusted national median of charges for services within an APC group furnished during 1996, updated to 1999 using an actuarial projection of charge increases for hospital outpatient department services during the period 1996 to 1999.
(c) Limitation of coinsurance amount to inpatient hospital deductible amount. The coinsurance amount for a procedure performed in a year cannot exceed the amount of the inpatient hospital deductible established under section 1813(b) of the Act for that year.
Calculation of national beneficiary coinsurance amounts and national Medicare program payment amounts.(a) To calculate the unadjusted coinsurance amount for each APC group, HCFA—
(1) Standardizes 1996 hospital charges for the services within each APC group to offset variations in hospital labor costs across geographic areas;
(2) Identifies the median of the wage-neutralized 1996 charges for each APC group; and
(3) Determines the value equal to 20 percent of the wage-neutralized 1996 median charge for each APC group and multiplies that value by an actuarial projection of increases in charges for hospital outpatient department services during the period 1996 to 1999. The result is the unadjusted beneficiary coinsurance amount for the APC group.
(b) HCFA calculates annually the program payment percentage for every APC group on the basis of each group's unadjusted coinsurance amount and its payment rate after the payment rate is adjusted in accordance with § 419.32.
(c) To determine payment amounts due for a service paid under the hospital Start Printed Page 18545outpatient prospective payment system, HCFA makes the following calculations:
(1) Makes the wage index adjustment in accordance with § 419.43.
(2) Subtracts the amount of the applicable Part B deductible provided under § 410.160 of this chapter.
(3) Multiplies the remainder by the program payment percentage for the group to determine the preliminary Medicare program payment amount.
(4) Subtracts the program payment amount from the amount determined in paragraph (c)(2) of this section to determine the coinsurance amount.
(i) The coinsurance amount for an APC cannot exceed the amount of the inpatient hospital deductible established under section 1813(b) of the Act for that year.
(ii) The coinsurance amount is computed as if the adjustments under § 419.43(d) and (e) (and any adjustment made under § 419.43(f) in relation to these adjustments) had not been paid.
(5) Adds the amount by which the coinsurance amount would have exceeded the inpatient hospital deductible for that year to the preliminary Medicare program payment amount determined in paragraph (c)(3) of this section to determine the final Medicare program payment amount.
Hospital election to reduce coinsurance.(a) A hospital may elect to reduce coinsurance for any or all APC groups on a calendar year basis. A hospital may not elect to reduce copayment for some, but not all, services within the same group.
(b) A hospital must notify its fiscal intermediary of its election to reduce coinsurance no later than—
(1) June 1, 2000, for coinsurance elections for the period July 1, 2000 through December 31, 2000; or
(2) December 1 preceding the beginning of each subsequent calendar year.
(c) The hospital's election must be properly documented. It must specifically identify the APCs to which it applies and the coinsurance amount (within the limits identified below) that the hospital has selected for each group.
(d) The election of reduced coinsurance remains in effect unchanged during the year for which the election was made.
(e) In electing reduced coinsurance, a hospital may elect a level that is less than that year's wage-adjusted coinsurance amount for the group but not less than 20 percent of the APC payment rate as determined in § 419.32.
(f) The hospital may advertise and otherwise disseminate information concerning the reduced level of coinsurance that it has elected. All advertisements and information furnished to Medicare beneficiaries must specify that the coinsurance reductions advertised apply only to the specified services of that hospital and that coinsurance reductions are available only for hospitals that choose to reduce coinsurance for hospital outpatient services and are not allowed in any other ambulatory settings or physician offices.
Adjustments to national program payment and beneficiary coinsurance amounts.(a) General rule. HCFA determines national prospective payment rates for hospital outpatient department services and determines a wage adjustment factor to adjust the portion of the APC payment and national beneficiary coinsurance amount attributable to labor-related costs for relative differences in labor and labor-related costs across geographic regions in a budget neutral manner.
(b) Labor-related portion of payment and copayment rates for hospital outpatient services. HCFA determines the portion of hospital outpatient costs attributable to labor and labor-related costs (known as the “labor-related portion” of hospital outpatient costs) in accordance with § 419.31(c)(1).
(c) Wage index factor. HCFA uses the hospital inpatient prospective payment system wage index established in accordance with part 412 of this chapter to make the adjustment referred to in paragraph (a) of this section.
(d) Outlier adjustment—(1) General rule. Subject to paragraph (d)(4) of this section, HCFA provides for an additional payment for each hospital outpatient service (or group of services) for which a hospital's charges, adjusted to cost, exceed the following:
(i) A fixed multiple of the sum of—
(A) The applicable Medicare hospital outpatient payment amount determined under § 419.32(c), as adjusted under § 419.43 (other than for adjustments under this paragraph (d) or paragraph (e) of this section); and
(B) Any transitional pass-through payment under paragraph (e) of this section.
(ii) At the option of HCFA, a fixed dollar amount.
(2) Amount of adjustment. The amount of the additional payment under paragraph (d)(1) of this section is determined by HCFA and approximates the marginal cost of care beyond the applicable cutoff point under paragraph (d)(1) of this section.
(3) Limit on aggregate outlier adjustments— (i) In general. The total of the additional payments made under this paragraph (d) for covered hospital outpatient department services furnished in a year (as estimated by HCFA before the beginning of the year) may not exceed the applicable percentage specified in paragraph (d)(3)(ii) of this section of the total program payments (sum of both the Medicare and beneficiary payments to the hospital) estimated to be made under this part for all hospital outpatient services furnished in that year. If this paragraph is first applied to less than a full year, the limit applies only to the portion of the year.
(ii) Applicable percentage. For purposes of paragraph (d)(3)(i) of this section, the term “applicable percentage” means a percentage specified by HCFA up to (but not to exceed)—
(A) For a year (or portion of a year) before 2004, 2.5 percent; and
(B) For 2004 and thereafter, 3.0 percent.
(4) Transitional authority. In applying paragraph (d)(1) of this section for hospital outpatient services furnished before January 1, 2002, HCFA may—
(i) Apply paragraph (d)(1) of this section to a bill for these services related to an outpatient encounter (rather than for a specific service or group of services) using hospital outpatient payment amounts and transitional pass-through payments covered under the bill; and
(ii) Use an appropriate cost-to-charge ratio for the hospital or CMHC (as determined by HCFA), rather than for specific departments within the hospital.
(e) Transitional pass-through for additional costs of innovative medical devices, drugs, and biologicals— (1) General rule. HCFA provides for an additional payment under this paragraph for any of the following that are provided as part of a hospital outpatient service (or group of services):
(i) Current orphan drugs. A drug or biological that is used for a rare disease or condition with respect to which the drug or biological has been designated as an orphan drug under section 526 of the Federal Food, Drug and Cosmetic Act if payment for the drug or biological as an outpatient hospital service under this part was being made on the first date that the system under this part is implemented.
(ii) Current cancer therapy drugs and biologicals and brachytherapy. A drug or biological that is used in cancer therapy, including, but not limited to, a chemotherapeutic agent, an antiemetic, Start Printed Page 18546a hematopoietic growth factor, a colony stimulating factor, a biological response modifier, a bisphosphonate, and a device of brachytherapy, if payment for the drug, biological, or device as an outpatient hospital service under this part was being made on the first date that the system under this part is implemented.
(iii) Current radiopharmaceutical drugs and biological products. A radiopharmaceutical drug or biological product used in diagnostic, monitoring, and therapeutic nuclear medicine procedures if payment for the drug or biological as an outpatient hospital service under this part was being made on the first date that the system under this part is implemented.
(iv) New medical devices, drugs, and biologicals. A medical device, drug, or biological not described in paragraph (e)(1)(i), (e)(1)(ii), or (e)(1)(iii) of this section if—
(A) Payment for the device, drug, or biological as an outpatient hospital service under this part was not being made as of December 31, 1996; and
(B) The cost of the device, drug, or biological is not insignificant (as defined in paragraph (e)(1)(iv)(C) of this section) in relation to the hospital outpatient fee schedule amount (as calculated under § 419.32(c)) payable for the service (or group of services) involved.
(C) The cost of the device, drug, or biological is considered not insignificant if it meets all of the following thresholds:
(1) Its expected reasonable cost exceeds 25 percent of the applicable fee schedule amount for the associated service.
(2) The expected reasonable cost of the new drug, biological, or device must exceed the current portion of the fee schedule amount determined to be associated with the drug, biological, or device by 25 percent.
(3) The difference between the expected reasonable cost of the item and the portion of the hospital outpatient fee schedule amount determined to be associated with the item exceeds 10 percent of the applicable hospital outpatient fee schedule amount.
(2) Limited period of payment. The payment under this paragraph (e) with respect to a medical device, drug, or biological applies during a period of at least 2 years, but not more than 3 years, that begins—
(i) On the first date this section is implemented in the case of a drug, biological, or device described in paragraphs (e)(2)(i), (e)(2)(ii), or (e)(2)(iii) of this section and in the case of a device, drug, or biological described in paragraph (e)(1)(iv) of this section and for which payment under this part is made as an outpatient hospital service before the first date; or
(ii) In the case of a device, drug, or biological described in paragraph (e)(1)(iv) of this section not described in paragraph (e)(2)(i) of this section, on the first date on which payment is made under this part for the device, drug, or biological as an outpatient hospital service.
(3) Amount of additional payment. Subject to paragraph (e)(4)(iii) of this section, the amount of the payment under this paragraph is—
(i) In the case of a drug or biological, the amount by which the amount determined under section 1842(o) of the Act for the drug or biological exceeds the portion of the otherwise applicable Medicare hospital outpatient fee schedule amount that HCFA determines is associated with the drug or biological; or
(ii) In the case of a medical device, the amount by which the hospital's charges for the device, adjusted to cost, exceeds the portion of the otherwise applicable Medicare hospital outpatient fee schedule amount that HCFA determines is associated with the device.
(4) Limit on aggregate annual adjustment—(i) General rule. The total of the additional payments made under this paragraph for hospital outpatient services furnished in a year, as estimated by HCFA before the beginning of the year, may not exceed the applicable percentage specified in paragraph (e)(4)(ii) of this section of the total program payments estimated to be made under this section for all hospital outpatient services furnished in that year. If this paragraph is first applied to less than a full year, the limit applies only to the portion of the year.
(ii) Applicable percentage. For purposes of paragraph (e)(4)(i) of this section, the term “applicable percentage” means—
(A) For a year (or portion of a year) before 2004, 2.5 percent; and
(B) For 2004 and thereafter, a percentage specified by HCFA up to (but not to exceed) 2.0 percent.
(iii) Uniform prospective reduction if aggregate limit projected to be exceeded. If HCFA estimates before the beginning of a year that the amount of the additional payments under this paragraph (e) for the year (or portion thereof) as determined under paragraph (e)(4)(i) of this section without regard to this paragraph (e)(4)(iii) would exceed the limit established under this paragraph (e)(4)(iii), HCFA reduces pro rata the amount of each of the additional payments under this paragraph for that year (or portion thereof) in order to ensure that the aggregate additional payments under this paragraph (as so estimated) do not exceed the limit.
(f) Budget neutrality. Outlier adjustments under paragraph (d) of this section and transitional pass-through payments under paragraph (e) of this section are established in a budget-neutral manner.
Payment reductions for surgical procedures.(a) Multiple surgical procedures. When more than one surgical procedure for which payment is made under the hospital outpatient prospective payment system is performed during a single surgical encounter, the Medicare program payment amount and the beneficiary copayment amount are based on—
(1) The full amounts for the procedure with the highest APC payment rate; and
(2) One-half of the full program and the beneficiary payment amounts for all other covered procedures.
(b) Terminated procedures. When a surgical procedure is terminated prior to completion due to extenuating circumstances or circumstances that threaten the well-being of the patient, the Medicare program payment amount and the beneficiary copayment amount are based on—
(1) The full amounts if the procedure is discontinued after the induction of anesthesia or after the procedure is started; or
(2) One-half of the full program and the beneficiary coinsurance amounts if the procedure is discontinued after the patient is prepared for surgery and taken to the room where the procedure is to be performed but before anesthesia is induced.
Subpart E—Updates
Annual review.(a) General rule. Not less often than annually, HCFA reviews and updates groups, relative payment weights, and the wage and other adjustments to take into account changes in medical practice, changes in technology, the addition of new services, new cost data, and other relevant information and factors.
(b) Consultation requirement. HCFA will consult with an expert outside advisory panel composed of an appropriate selection of representatives of providers to review (and advise HCFA concerning) the clinical integrity of the groups and weights. The panel may use data collected or developed by entities and organizations (other than the Department of Health and Human Services) in conducting the review. Start Printed Page 18547
(c) Effective dates. HCFA conducts the first annual review under paragraph (a) of this section in 2001 for payments made in 2002.
Subpart F—Limitations on Review
Limitations on administrative and judicial review.There can be no administrative or judicial review under sections 1869 and 1878 of the Act or otherwise of the following:
(a) The development of the APC system, including—
(1) Establishment of the groups and relative payment weights;
(2) Wage adjustment factors;
(3) Other adjustments; and
(4) Methods for controlling unnecessary increases in volume.
(b) The calculation of base amounts described in section 1833(t)(3) of the Act.
(c) Periodic adjustments described in section 1833(t)(9) of the Act.
(d) The establishment of a separate conversion factor for hospitals described in section 1886(d)(1)(B)(v) of the Act.
(e) The determination of the fixed multiple, or a fixed dollar cutoff amount, the marginal cost of care, or applicable percentage under § 419.43(d) or the determination of insignificance of cost, the duration of the additional payments (consistent with § 419.43(e)), the portion of the Medicare hospital outpatient fee schedule amount associated with particular devices, drugs, or biologicals, and the application of any pro rata reduction under § 419.43(e).
Subpart G—Transitional Corridors
Transitional adjustment to limit decline in payment.(a) Before 2002. Except as provided in paragraph (d) of this section, for covered hospital outpatient services furnished before January 1, 2002, for which the prospective payment system amount (as defined in paragraph (e) of this section) is—
(1) At least 90 percent, but less than 100 percent, of the pre-BBA amount (as defined in paragraph (f) of this section), the amount of payment under this part is increased by 80 percent of the amount of this difference;
(2) At least 80 percent, but less than 90 percent, of the pre-BBA amount, the amount of payment under this part is increased by the amount by which the product of 0.71 and the pre-BBA amount exceeds the product of 0.70 and the prospective payment system amount;
(3) At least 70 percent, but less than 80 percent, of the pre-BBA amount, the amount of payment under this part is increased by the amount by which the product of 0.63 and the pre-BBA amount, exceeds the product of 0.60 and the PPS amount; or
(4) Less than 70 percent of the pre-BBA amount, the amount of payment under this part shall be increased by 21 percent of the pre-BBA amount.
(b) For 2002. Except as provided in paragraph (d) of this section, for covered hospital outpatient services furnished during 2002, for which the prospective payment system amount is—
(1) At least 90 percent, but less than 100 percent, of the pre-BBA amount, the amount of payment under this part is increased by 70 percent of the amount of this difference;
(2) At least 80 percent, but less than 90 percent, of the pre-BBA amount, the amount of payment under this part is increased by the amount by which the product of 0.61 and the pre-BBA amount exceeds the product of 0.60 and the prospective payment system amount; or
(3) Less than 80 percent of the pre-BBA amount, the amount of payment under this part is increased by 13 percent of the pre-BBA amount.
(c) For 2003. Except as provided in paragraph (d) of this section, for covered hospital outpatient services furnished during 2003, for which the prospective payment system amount is—
(1) At least 90 percent, but less than 100 percent, of the pre-BBA amount, the amount of payment under this part is increased by 60 percent of the amount of this difference; or
(2) Less than 90 percent of the pre-BBA amount, the amount of payment under this part is increased by 6 percent of the pre-BBA amount.
(d) Hold harmless provisions— (1) Temporary treatment for small rural hospitals. For covered hospital outpatient services furnished in a calendar year before January 1, 2004 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 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; and
(ii) Has 100 or fewer beds as defined in § 412.105(b) of this chapter.
(2) Permanent treatment for cancer hospitals. In the case of a hospital described in § 412.23(f) of this chapter for which the prospective payment system amount is less than the pre-BBA amount for covered hospital outpatient services, the amount of payment under this part is increased by the amount of this difference.
(e) Prospective payment system amount defined. In this paragraph, the term “prospective payment system amount” means, with respect to covered hospital outpatient services, the amount payable under this part for these services (determined without regard to this paragraph or any reduction in coinsurance elected under § 419.42), including amounts payable as copayment under § 419.41, coinsurance under section 1866(a)(2)(A)(ii) of the Act, and the deductible under section 1833(b) of the Act.
(f) Pre-BBA amount defined— (1) General rule. In this paragraph, the “pre-BBA amount” means, with respect to covered hospital outpatient services furnished by a hospital or a community mental health center (CMHC) in a year, an amount equal to the product of the reasonable cost of the provider for these services for the portions of the provider's cost reporting period (or periods) occurring in the year and the base provider outpatient payment-to-cost ratio for the provider (as defined in paragraph (f)(2) of this section).
(2) Base payment-to-cost-ratio defined. For purposes of this paragraph, HCFA shall determine these ratios as if the amendments to sections 1833(i)(3)(B)(i)(II) and 1833(n)(1)(B)(i) of the Act made by section 4521 of the BBA, to require that the full amount beneficiaries paid as coinsurance under section 1862(a)(2)(A) of the Act are taken into account in determining Medicare Part B Trust Fund payment to the hospital, were in effect in 1996. The “base payment-to-cost ratio” for a hospital or CMHC means the ratio of—
(i) The provider's payment under this part for covered outpatient services furnished during the cost reporting period ending in 1996, including any payment for these services through cost-sharing described in paragraph (e) of this section; and
(ii) The reasonable cost of these services for this period, without applying the cost reductions under section 1861(v)(1)(S) of the Act.
(g) Interim payments. HCFA makes payments under this paragraph to hospitals and CMHCs on an interim basis, subject to retrospective adjustments based on settled cost reports.
(h) No effect on coinsurance. No payment made under this section affects the unadjusted coinsurance amount or the coinsurance amount described in § 419.41.
(i) Application without regard to budget neutrality. The additional payments made under this paragraph— Start Printed Page 18548
(1) Are not considered an adjustment under § 419.43(f); and
(2) Are not implemented in a budget neutral manner.
PART 424—CONDITIONS FOR MEDICARE PAYMENT
End Part Start Amendment PartG. Part 424 is amended as set forth below:
End Amendment Part Start Amendment Part1. The authority citation for part 424 continues to read as follows:
End Amendment Part Start Amendment Part2. In § 424.24, the heading to paragraph (e) is republished, and a new paragraph (e)(3) is added to read as follows:
End Amendment PartRequirements for medical and other health services furnished by providers under Medicare Part B.* * * * *(e) Partial hospitalization services: Content of certification and plan of treatment requirements—
* * * * *(3) Recertification requirements.
(i) Signature. The physician recertification must be signed by a physician who is treating the patient and has knowledge of the patient's response to treatment.
(ii) Timing. The first recertification is required as of the 18th day of partial hospitalization services. Subsequent recertifications are required at intervals established by the provider, but no less frequently than every 30 days.
(iii) Content. The recertification must specify that the patient would otherwise require inpatient psychiatric care in the absence of continued stay in the partial hospitalization program and describe the following:
(A) The patient's response to the therapeutic interventions provided by the partial hospitalization program.
(B) The patient's psychiatric symptoms that continue to place the patient at risk of hospitalization.
(C) Treatment goals for coordination of services to facilitate discharge from the partial hospitalization program.
* * * * *PART 489—PROVIDER AGREEMENTS AND SUPPLIER APPROVAL
End Part Start Amendment PartH. Part 489 is amended as set forth below:
End Amendment Part Start Amendment Part1. The authority citation to part 489 continues to read as follows:
End Amendment PartSubpart B—Essentials of Provider Agreements
Start Amendment Part2. In § 489.20, the introductory text to the section is republished; the introductory text to paragraph (d) is revised; paragraphs (d)(3), (d)(4), and (d)(5) are redesignated as paragraphs (d)(4), (d)(5), and (d)(6), respectively; and a new paragraph (d)(3) is added to read as follows:
End Amendment PartBasic commitments.The provider agrees to the following:
* * * * *(d) In the case of a hospital or a CAH that furnishes services to Medicare beneficiaries, either to furnish directly or to make arrangements (as defined in § 409.3 of this chapter) for all Medicare-covered services to inpatients and outpatients of a hospital or a CAH except the following:
* * * * *(3) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.
* * * * *3. In § 489.24, the definition for “Comes to the emergency department” in paragraph (b) is revised, and a new paragraph (i) is added to read as follows:
End Amendment PartSpecial responsibilities of Medicare hospitals in emergency cases.* * * * *(b) * * *
Comes to the emergency department means, with respect to an individual requesting examination or treatment, that the individual is on the hospital property. For purposes of this section, “property” means the entire main hospital campus as defined in § 413.65(b) of this chapter, including the parking lot, sidewalk, and driveway, as well as any facility or organization that is located off the main hospital campus but has been determined under § 413.65 of this chapter to be a department of the hospital. The responsibilities of hospitals with respect to these off-campus facilities or organizations are described in paragraph (i) of this section. Property also includes ambulances owned and operated by the hospital even if the ambulance is not on hospital grounds. An individual in a nonhospital-owned ambulance on hospital property is considered to have come to the hospital's emergency department. An individual in a nonhospital-owned ambulance off hospital property is not considered to have come to the hospital's emergency department even if a member of the ambulance staff contacts the hospital by telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment. In these situations, the hospital may deny access if it is in “diversionary status,” that is, it does not have the staff or facilities to accept any additional emergency patients. If, however, the ambulance staff disregards the hospital's instructions and transports the individual on to hospital property, the individual is considered to have come to the emergency department.
* * * * *(i) Off-campus departments. If an individual comes to a facility or organization that is located off the main hospital campus but has been determined under § 416.35 of this chapter to be a department of the hospital and a request is made on the individual's behalf for examination or treatment of a potential emergency medical condition as otherwise described in paragraph (a) of this section, the hospital is obligated in accordance with the rules in this paragraph to provide the individual with an appropriate medical screening examination and any necessary stabilizing treatment or an appropriate transfer.
(1) Capability of the hospital. The capability of the hospital includes that of the hospital as a whole, not just the capability of the off-campus department. Except for cases described in paragraph (i)(3)(ii) of this section, the obligation of a hospital under this section must be discharged within the hospital as a whole. However, the hospital is not required to locate additional personnel or staff to off-campus departments to be on standby for possible emergencies.
(2) Protocols for off-campus departments. The hospital must establish protocols for the handling of individuals with potential emergency conditions at off-campus departments. These protocols must provide for direct contact between personnel at the off-campus department and emergency personnel at the main hospital campus and may provide for dispatch of practitioners, when appropriate, from the main hospital campus to the off-campus department to provide screening or stabilization services.
(i) If the off-campus department is an urgent care center, primary care center, or other facility that is routinely staffed by physicians, RNs, or LPNs, these department personnel must be trained, and given appropriate protocols, for the handling of emergency cases. At least one individual on duty at the off-campus department during its regular hours of operation must be designated Start Printed Page 18549as a qualified medical person as described in paragraph (d) of this section. The qualified medical person must initiate screening of individuals who come to the off-campus department with a potential emergency medical condition, and may be able to complete the screening and provide any necessary stabilizing treatment at the off-campus department, or to arrange an appropriate transfer.
(ii) If the off-campus department is a physical therapy, radiology, or other facility not routinely staffed with physicians, RNs, or LPNs, the department's personnel must be given protocols that direct them to contact emergency personnel at the main hospital campus for direction. Under this direction, and in accordance with protocols established in advance by the hospital, the personnel at the off-campus department must describe patient appearance and report symptoms and, if appropriate, either arrange transportation of the individual to the main hospital campus in accordance with paragraph (i)(3)(i) of this section or assist in an appropriate transfer as described in paragraphs (i)(3)(ii) and (d)(2) of this section.
(3) Movement or appropriate transfer from off-campus departments—(i) If the main hospital campus has the capability required by the individual and movement of the individual to the main campus would not significantly jeopardize the life or health of the individual, the personnel at the off-campus department must assist in arranging this movement. Movement of the individual to the main campus of the hospital is not considered a transfer under this section, since the individual is simply being moved from one department of a hospital to another department or facility of the same hospital.
(ii) If transfer of an individual with a potential emergency condition to a medical facility other than the main hospital campus is warranted, either because the main hospital campus does not have the specialized capability or facilities required by the individual, or because the individual's condition is deteriorating so rapidly that taking the time needed to move the individual to the main hospital campus would significantly jeopardize the life or health of the individual, personnel at the off-campus department must, in accordance with protocols established in advance by the hospital, assist in arranging an appropriate transfer of the individual to a medical facility other than the main hospital. The protocols must include procedures and agreements established in advance with other hospitals or medical facilities in the area of the off-campus department to facilitate these appropriate transfers. Such a transfer would require—
(A) That there be either a request by or on behalf of the individual as described in paragraph (d)(1)(ii)(A) of this section or a certification by a physician or a qualified medical person as described in paragraph (d)(1)(ii)(B) or (d)(1)(ii)(C) of this section; and
(B) That the transfer comply with the requirements described in paragraph (d)(2) of this section.
(iii) If the individual is being appropriately transferred to another medical facility from the off-campus department, the requirement for the provision of medical treatment in paragraph (d)(2)(i) of this section would be met by provision of medical treatment within the capability of the transferring off-campus department.
PART 498—APPEALS PROCEDURES FOR DETERMINATIONS THAT AFFECT PARTICIPATION IN THE MEDICARE PROGRAM AND FOR DETERMINATIONS THAT AFFECT THE PARTICIPATION OF ICFs/MR AND CERTAIN NFs IN THE MEDICAID PROGRAM
End Part Start Amendment PartI. Part 498 is amended as set forth below:
End Amendment Part Start Amendment Part1. The authority citation for part 498 continues to read as follows:
End Amendment Part Start Amendment Part2. In § 498.2, the introductory text is republished, and the definition of “Provider” is revised to read as follows:
End Amendment PartDefinitions.As used in this part—
* * * * *Provider means a hospital, critical access hospital (CAH), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), or hospice, that has in effect an agreement to participate in Medicare, that has in effect an agreement to participate in Medicaid, or a clinic, rehabilitation agency, or public health agency that has a similar agreement but only to furnish outpatient physical therapy or outpatient speech pathology services, and prospective provider means any of the listed entities that seeks to participate in Medicare as a provider or to have any facility or organization determined to be a department of the provider or provider-based entity under § 413.65 of this chapter.
* * * * *3. In § 498.3, the introductory text to paragraph (b) is republished; paragraphs (b)(2) through (b)(15) are redesignated as paragraphs (b)(3) through (b)(16), respectively; and a new paragraph (b)(2) is added to read as follows:
End Amendment PartScope and applicability.* * * * *(b) Initial determinations by HCFA. HCFA makes initial determinations with respect to the following matters:
* * * * *(2) Whether a prospective department of a provider, remote location of a hospital, satellite facility, or provider-based entity qualifies for provider-based status under § 413.65 of this chapter, or whether such a facility or entity currently treated as a department of a provider, remote location of a hospital, satellite facility, or a provider-based entity no longer qualifies for that status under § 413.65 of this chapter.
* * * * *PART 1003—CIVIL MONEY PENALTIES, ASSESSMENTS AND EXCLUSIONS
End Part Start Amendment PartJ. Part 1003 is amended as set forth below:
End Amendment Part Start Amendment Part1. The authority citation for part 1003 is revised to read as follows:
End Amendment Part Start Amendment Part2. Section 1003.100 is amended by revising paragraph (a), by republishing the introductory text to paragraphs (b) and (b)(1), by revising paragraphs (b)(1)(xi) and (b)(1)(xii), and by adding paragraph (b)(1)(xiii) to read as follows:
End Amendment PartBasis and purpose.(a) Basis. This part implements sections 1128(c), 1128A, 1128E, 1140, 1866(g), 1876(i), 1877(g), 1882(d) and 1903(m)(5) of the Social Security Act, and sections 421(c) and 427(b)(2) of Pub. L. 99-660 (42 U.S.C. 1320a-7, 1320a-7a, 1320a-7e, 1320a-7c, 1320b-10, 1395cc(g), 1395mm, 1395ss(d), 1396(m), 11131(c), and 11137(b)(2)).
(b) Purpose. This part—
(1) Provides for the imposition of civil money penalties and, as applicable, assessments against persons who—
* * * * *(xi) Are physicians or entities that enter into an arrangement or scheme that they know or should know has as a principal purpose the assuring of referrals by the physician to a particular entity that, if made directly, would violate the provisions of § 411.353 of this title; Start Printed Page 18550
(xii) Violate the Federal health care programs' anti-kickback statute as set forth in section 1128B of the Act; or
(xiii) Knowingly and willfully present, or cause to be presented, a bill or request for payment for nonphysician services furnished to hospital patients (unless the services are furnished by the hospital, either directly or under an arrangement) in violation of sections 1862(a)(14) and 1866(a)(1)(H) of the Act.
* * * * *3. Section 1003.102 is amended by republishing the introductory text to paragraph (b), by adding and reserving paragraphs (b)(12) through (b)(14), and by adding a new paragraph (b)(15) to read as follows:
End Amendment PartBasis for civil money penalties and assessments.* * * * *(b) The OIG may impose a penalty, and where authorized, an assessment against any person (including an insurance company in the case of paragraphs (b)(5) and (b)(6) of this section) whom it determines in accordance with this part—
* * * * *(15) Has knowingly and willfully presented, or caused to be presented, a bill or request for payment for items and services furnished to a hospital patient for which payment may be made under the Medicare or another Federal health care program, if that bill or request is inconsistent with an arrangement under section 1866(a)(1)(H) of the Act, or violates the requirements for such an arrangement.
* * * * *4. Section 1003.103 is amended by revising paragraph (a), by adding and reserving paragraphs (i) and (j), and by adding a new paragraph (k) to read as follows:
End Amendment PartAmount of penalty.(a) Except as provided in paragraphs (b) and (d) through (k) of this section, the OIG may impose a penalty of not more than $10,000 for each item or service that is subject to a determination under § 1003.102.
* * * * *(k) For violations of section 1862(a)(14) of the Act and § 1003.102(b)(15), the OIG may impose a penalty of not more than $2,000 for each bill or request for payment for items and services furnished to a hospital patient.
5. Section 1003.105 is amended by republishing the introductory text to paragraph (a)(1) and by revising paragraph (a)(1)(i) to read as follows:
End Amendment PartExclusion from participation in Medicare, Medicaid and other Federal health care programs.(a)(1) Except as set forth in paragraph (b) of this section, in lieu of or in addition to any penalty or assessment, the OIG may exclude from participation in Medicare, Medicaid and other Federal health care programs the following persons for a period of time determined under § 1003.107—
(i) Any person who is subject to a penalty or assessment under § 1003.102(a), (b)(1) through (b)(4), or (b)(15).
* * * * *(Catalog of Federal Domestic Assistance 93.774, Medicare—Supplementary Medical Insurance Program)
Dated: March 3, 2000.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.
Dated: March 28, 2000.
June G. Brown,
Inspector General, Department of Health and Human Services.
Approved: March 29, 2000.Donna E. Shalala,
Secretary.
Note:
The following addenda will not appear in the Code of Federal Regulations.
Note to Addenda A, B, C, E and F:
Addenda A, B, and C have a number of errors in the following columns: APC, status indicator, payment rate, and national unadjusted coinsurance and minimum unadjusted coinsurance. We identified these errors too late in preparing this rule for publication to correct them. Some of the errors are related to the status codes assigned to the HCPCS codes and APCs.
Some errors affect addenda B, C, and E. Several of these errors involve procedures incorrectly identified as inpatient procedures, and one inpatient procedure incorrectly identified as an outpatient procedure. Certain PET scan codes and other codes are shown in incorrect APCs. Screening sigmoidoscopy and colonoscopy APCs have the wrong HCPCS codes and incorrect payment rates and coinsurance amounts. Certain dental codes were inadvertently identified as errors, so their correct APC assignments, payment rate and coinsurance amounts were not shown in the addenda. Two breath tests are subject to the clinical diagnostic lab fee schedule. We have listed below the corrections that have payment implications.
Addendum F does not include status indicators G and H which identify items that are eligible for pass-through payments. (See section III.B.3 of the preamble for a complete description of all status indications used in conjunction with this final rule.)
We also note that the word “proposed” should not appear on any Addenda contained in this final rule such as on Addendum A or C.
The fiscal intermediaries will receive the necessary changes to process outpatient PPS claims correctly. We will post the corrected Addendum B on our Website and publish a correction document in the Federal Register.
Our Website address is http://www.hcfa.gov/medicare/hopsmain.htm.
—————————— 1 Not subject to national coinsurance. Minimum unadjusted coinsurance is 25% of the payment rate. The Payment rate is the lower of the HOPD payment rate or the Ambulatory Surgical Center payment. 2 Not subject to national coinsurance. 3 Eligible for pass-through payments. See Preamble for payment rate determination. See Addendum K for complete list of pass-through codes. Start Printed Page 18551List Accompanying Note To Addenda A, B, C, E and F
CPT/ HCPCS HOPD Status Indicator Description APC Relative Weight Proposed Payment Rate National Unadjusted Coinsurance Minimum Unadjusted Coinsurance 20979 E US bone stimulation 31375 C Partial removal of larynx 35481 T Atherectomy, open 0081 19.36 $938.71 $434.25 $187.74 61795 S Brain surgery using computer 0302 8.21 $398.08 $216.55 $79.62 61886 T Implant neurostim arrays 0222 25.48 $1,235.45 $780.07 $247.09 75945 S Intravascular us 0267 2.72 $131.88 $80.06 $26.38 75946 S Intravascular us add-on 0267 2.72 $131.88 $80.06 $26.38 78267 A Breath test attain/anal, c-14 78268 A Breath test analysis, c-14 92978 S Intravasc us, heart add-on 0267 2.72 $131.88 $80.06 $26.38 92979 S Intravasc us, heart add-on 0267 2.72 $131.88 $80.06 $26.38 96570 T Photodynamic Tx, 30 min 0973 5.16 $250.19 $50.04 96571 T Photodynamic Tx, addl 15 min 0973 5.16 $250.19 $50.04 D0277 S Vert bitewings-sev to eight 0330 1.51 $73.22 $14.64 $14.64 D0472 S Gross exam, prep & report 0330 1.51 $73.22 $14.64 $14.64 Start Printed Page 18551 D0473 S Micro exam, prep & report 0330 1.51 $73.22 $14.64 $14.64 D0474 S Micro w exam of surg margins 0330 1.51 $73.22 $14.64 $14.64 D0480 S Cytopath smear prep & report 0330 1.51 $73.22 $14.64 $14.64 D4268 S Surgical revision procedure 0330 1.51 $73.22 $14.64 $14.64 G0104 S CA screen; flexible sigmoidscope 0159 2.83 $137.22 $34.31 G0105 S Colorectal screen; high risk ind 0158 7.98 $386.93 $96.73 G0122 S Colon ca scrn; barium enema 0157 1.79 $86.79 $17.36 G0125 S Lung Image (PET) 0981 46.40 $2,249.80 $449.96 G0126 S Lung Image (PET) staging 0981 46.40 $2,249.80 $449.96 G0163 S PET for rec of colorectal cancer 0981 46.40 $2,249.80 $449.96 G0164 S PET for lymphoma staging 0981 46.40 $2,249.80 $449.96 G0165 S PET, rec of melanoma/met cancer 0981 46.40 $2,249.80 $449.96 G0168 T Wound closure by adhesive 0970 0.52 $25.21 $5.04 G0169 T Removal tissue; no anesthesia 0013 0.91 $44.12 $17.66 $8.82 G0170 T Skin biograft 0025 3.74 $181.34 $70.66 $36.27 G0171 T Skin biograft add-on 0025 3.74 $181.34 $70.66 $36.27 —————————— CPT codes and descriptions only are copyright American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Copyright American Dental Association. All rights reserved. 1 Not subject to national coinsurance. Minimum unadjusted coinsurance is 25% of the payment rate. The payment rate is the lower of the HOPD payment rate or the Ambulatory Surgical Center payment. ÿ09ÿ09ÿ09ÿ09 ÿ09 2 Not subject to national coinsurance.ÿ09ÿ09ÿ09ÿ09ÿ09ÿ09 3 Eligible for pass-through payments. See Preamble for payment rate determination. See Addendum K for complete list of pass-through codes.Addendum A.—List of Hospital Outpatient Ambulatory Payment Classes With Status Indicators, Relative Weights, Payment Rates, and Coinsurance Amounts
APC Group Title Status Indicator Relative Weight Payment Rate National Unadjusted Coinsurance Minimum Unadjusted Coinsurance 0001 Photochemotherapy S 0.47 $22.79 $8.49 $4.56 0002 Fine needle Biopsy/Aspiration T 0.62 $30.06 $17.66 $6.01 0003 Bone Marrow Biopsy/Aspiration T 0.98 $47.52 $27.99 $9.50 0004 Level I Needle Biopsy/Aspiration Except Bone Marrow T 1.84 $89.22 $32.57 $17.84 0005 Level II Needle Biopsy/Aspiration Except Bone Marrow T 5.41 $262.32 $119.75 $52.46 0006 Level I Incision & Drainage T 2.00 $96.97 $33.95 $19.39 0007 Level II Incision & Drainage T 3.68 $178.43 $72.03 $35.69 0008 Level III Incision & Drainage T 6.15 $298.20 $113.67 $59.64 0009 Nail Procedures T 0.74 $35.88 $9.63 $7.18 0010 Level I Destruction of Lesion T 0.55 $26.67 $9.86 $5.33 0011 Level II Destruction of Lesion T 2.72 $131.88 $50.01 $26.38 0012 Level I Debridement & Destruction T 0.53 $25.70 $9.18 $5.14 0013 Level II Debridement & Destruction T 0.91 $44.12 $17.66 $8.82 0014 Level III Debridement & Destruction T 1.50 $72.73 $24.55 $14.55 0015 Level IV Debridement & Destruction T 1.77 $85.82 $31.20 $17.16 0016 Level V Debridement & Destruction T 3.53 $171.16 $74.67 $34.23 0017 Level VI Debridement & Destruction T 12.45 $603.66 $289.16 $120.73 0018 Biopsy Skin, Subcutaneous Tissue or Mucous Membrane T 0.94 $45.58 $17.66 $9.12 0019 Level I Excision/Biopsy T 4.00 $193.95 $78.91 $38.79 0020 Level II Excision/Biopsy T 6.51 $315.65 $130.53 $63.13 0021 Level III Excision/Biopsy T 10.49 $508.63 $236.51 $101.73 0022 Level IV Excision/Biopsy T 12.49 $605.60 $292.94 $121.12 0023 Exploration Penetrating Wound T 1.98 $96.00 $40.37 $19.20 0024 Level I Skin Repair T 2.43 $117.82 $44.50 $23.56 0025 Level II Skin Repair T 3.74 $181.34 $70.66 $36.27 0026 Level III Skin Repair T 12.11 $587.18 $277.92 $117.44 0027 Level IV Skin Repair T 15.80 $766.10 $383.10 $153.22 0029 Incision/Excision Breast T 12.85 $623.06 $303.50 $124.61 0030 Breast Reconstruction/Mastectomy T 20.19 $978.95 $523.95 $195.79 0031 Hyperbaric Oxygen S 3.00 $145.46 $140.85 $29.09 0032 Placement Transvenous Catheters/Arterial Cutdown T 5.40 $261.83 $119.52 $52.37 0033 Partial Hospitalization P 4.17 $202.19 $48.17 $40.44 0040 Arthrocentesis & Ligament/Tendon Injection T 2.11 $102.31 $40.60 $20.46 0041 Arthroscopy T 24.57 $1,191.33 $592.08 $238.27 0042 Arthroscopically-Aided Procedures T 29.22 $1,416.79 $804.74 $283.36 0043 Closed Treatment Fracture Finger/Toe/Trunk T 1.64 $79.52 $25.46 $15.90 0044 Closed Treatment Fracture/Dislocation Except Finger/Toe/Trunk T 2.17 $105.22 $38.08 $21.04 0045 Bone/Joint Manipulation Under Anesthesia T 11.02 $534.33 $277.12 $106.87 0046 Open/Percutaneous Treatment Fracture or Dislocation T 22.29 $1,080.78 $535.76 $216.16 0047 Arthroplasty without Prosthesis T 22.09 $1,071.08 $537.03 $214.22 0048 Arthroplasty with Prosthesis T 29.06 $1,409.03 $725.94 $281.81 0049 Level I Musculoskeletal Procedures Except Hand and Foot T 15.04 $729.25 $356.95 $145.85 0050 Level II Musculoskeletal Procedures Except Hand and Foot T 21.13 $1,024.53 $513.86 $204.91 0051 Level III Musculoskeletal Procedures Except Hand and Foot T 27.76 $1,346.00 $675.24 $269.20 0052 Level IV Musculoskeletal Procedures Except Hand and Foot T 36.16 $1,753.29 $930.91 $350.66 0053 Level I Hand Musculoskeletal Procedures T 11.32 $548.87 $253.49 $109.77 0054 Level II Hand Musculoskeletal Procedures T 19.66 $953.26 $472.33 $190.65 0055 Level I Foot Musculoskeletal Procedures T 15.47 $750.10 $355.34 $150.02 0056 Level II Foot Musculoskeletal Procedures T 17.30 $838.83 $405.81 $167.77 Start Printed Page 18552 0057 Bunion Procedures T 21.00 $1,018.23 $496.65 $203.65 0058 Level I Strapping and Cast Application S 1.09 $52.85 $19.27 $10.57 0059 Level II Strapping and Cast Application S 1.74 $84.37 $29.59 $16.87 0060 Manipulation Therapy S 0.77 $37.34 $7.80 $7.47 0070 Thoracentesis/Lavage Procedures T 3.64 $176.49 $79.60 $35.30 0071 Level I Endoscopy Upper Airway T 0.55 $26.67 $14.22 $5.33 0072 Level II Endoscopy Upper Airway T 1.26 $61.09 $41.52 $12.22 0073 Level III Endoscopy Upper Airway T 4.11 $199.28 $91.07 $39.86 0074 Level IV Endoscopy Upper Airway T 13.61 $659.91 $347.54 $131.98 0075 Level V Endoscopy Upper Airway T 18.55 $899.44 $467.29 $179.89 0076 Endoscopy Lower Airway T 8.06 $390.81 $197.05 $78.16 0077 Level I Pulmonary Treatment S 0.43 $20.85 $12.62 $4.17 0078 Level II Pulmonary Treatment S 1.34 $64.97 $29.13 $12.99 0079 Ventilation Initiation and Management S 3.18 $154.19 $107.70 $30.84 0080 Diagnostic Cardiac Catheterization T 25.77 $1,249.51 $713.89 $249.90 0081 Non-Coronary Angioplasty or Atherectomy T 19.36 $938.71 $434.25 $187.74 0082 Coronary Atherectomy T 40.34 $1,955.97 $859.56 $391.19 0083 Coronary Angiosplasty T 45.79 $2,220.22 $1,322.95 $444.04 0084 Level I Electrophysiologic Evaluation S 10.70 $518.81 $177.79 $103.76 0085 Level II Electrophysiologic Evaluation S 27.06 $1,312.06 $654.48 $262.41 0086 Ablate Heart Dysrhythm Focus S 47.62 $2,308.95 $1,265.37 $461.79 0087 Cardiac Electrophysiologic Recording/Mapping S 9.53 $462.08 $214.72 $92.42 0088 Thrombectomy T 26.49 $1,284.42 $678.68 $256.88 0089 Level I Implantation/Removal/Revision of Pacemaker, AICD or Vascular Device T 6.49 $314.68 $130.07 $62.94 0090 Level II Implantation/Removal/Revision of Pacemaker, AICD or Vascular Device T 20.96 $1,016.29 $573.04 $203.26 0091 Level I Vascular Ligation T 14.79 $717.12 $348.23 $143.42 0092 Level II Vascular Ligation T 20.21 $979.92 $505.37 $195.98 0093 Vascular Repair/Fistula Construction T 17.95 $870.34 $422.33 $174.07 0094 Resuscitation and Cardioversion S 4.51 $218.68 $105.29 $43.74 0095 Cardiac Rehabilitation S 0.64 $31.03 $16.98 $6.21 0096 Non-Invasive Vascular Studies S 2.06 $99.88 $61.48 $19.98 0097 Cardiovascular Stress Test S 1.62 $78.55 $62.40 $15.71 0098 Injection of Sclerosing Solution T 1.19 $57.70 $20.88 $11.54 0099 Continuous Cardiac Monitoring S 0.38 $18.43 $14.68 $3.69 0100 Continuous ECG S 1.70 $82.43 $71.57 $16.49 0101 Tilt Table Evaluation S 4.47 $216.74 $128.84 $43.35 0102 Electronic Analysis of Pacemakers/other Devices S 0.45 $21.82 $12.62 $4.36 0109 Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant S 4.13 $200.25 $40.05 $40.05 0110 Transfusion S 5.83 $282.68 $122.73 $56.54 0111 Blood Product Exchange S 14.17 $687.06 $300.74 $137.41 0112 Extracorporeal Photopheresis S 39.60 $1,920.09 $663.65 $384.02 0113 Excision Lymphatic System T 13.89 $673.49 $326.55 $134.70 0114 Thyroid/Lymphadenectomy Procedures T 19.56 $948.41 $493.78 $189.68 0116 Chemotherapy Administration by Other Technique Except Infusion S 2.34 $113.46 $22.69 $22.69 0117 Chemotherapy Administration by Infusion Only S 1.84 $89.22 $71.80 $17.84 0118 Chemotherapy Administration by Both Infusion and Other Technique S 2.90 $140.61 $72.03 $28.12 0120 Infusion Therapy Except Chemotherapy S 1.66 $80.49 $42.67 $16.10 0121 Level I Tube changes and Repositioning T 2.36 $114.43 $52.53 $22.89 0122 Level II Tube changes and Repositioning T 5.04 $244.37 $114.93 $48.88 0123 Level III Tube changes and Repositioning T 13.89 $673.49 $350.75 $134.70 0130 Level I Laparoscopy T 25.36 $1,229.63 $659.53 $245.93 0131 Level II Laparoscopy T 41.81 $2,027.24 $1,089.88 $405.45 0132 Level III Laparoscopy T 48.91 $2,371.50 $1,239.22 $474.30 0140 Esophageal Dilation without Endoscopy T 4.74 $229.83 $107.24 $45.97 0141 Upper GI Procedures T 7.15 $346.68 $184.67 $69.34 0142 Small Intestine Endoscopy T 7.45 $361.23 $162.42 $72.25 0143 Lower GI Endoscopy T 7.98 $386.93 $199.12 $77.39 0144 Diagnostic Anoscopy T 2.23 $108.13 $49.32 $21.63 0145 Therapeutic Anoscopy T 7.46 $361.71 $179.39 $72.34 0146 Level I Sigmoidoscopy T 2.83 $137.22 $65.15 $27.44 0147 Level II Sigmoidoscopy T 6.26 $303.53 $149.11 $60.71 0148 Level I Anal/Rectal Procedure T 2.34 $113.46 $43.59 $22.69 0149 Level II Anal/Rectal Procedure T 12.86 $623.54 $293.06 $124.71 0150 Level III Anal/Rectal Procedure T 17.68 $857.25 $437.12 $171.45 0151 Endoscopic Retrograde Cholangio-Pancreatography (ERCP) T 10.53 $510.57 $245.46 $102.11 0152 Percutaneous Biliary Endoscopic Procedures T 8.22 $398.56 $207.38 $79.71 0153 Peritoneal and Abdominal Procedures T 19.62 $951.32 $496.31 $190.26 0154 Hernia/Hydrocele Procedures T 22.43 $1,087.57 $556.98 $217.51 2 0157 Colorectal Cancer Screening: Barium Enema S 1.79 $86.79 $17.36 1 0158 Colorectal Cancer Screening: Colonoscopy S 7.98 $386.93 $96.73 1 0159 Colorectal Cancer Screening: Flexible Sigmoidoscopy S 7.98 $137.22 $34.31 Start Printed Page 18553 0160 Level I Cystourethroscopy and other Genitourinary Procedures T 5.43 $263.28 $110.11 $52.66 0161 Level II Cystourethroscopy and other Genitourinary Procedures T 10.94 $530.45 $249.36 $106.09 0162 Level III Cystourethroscopy and other Genitourinary Procedures T 17.49 $848.04 $427.49 $169.61 0163 Level IV Cystourethroscopy and other Genitourinary Procedures T 28.98 $1,405.16 $792.58 $281.03 0164 Level I Urinary and Anal Procedures T 2.17 $105.23 $33.03 $21.05 0165 Level II Urinary and Anal Procedures T 3.89 $188.61 $91.76 $37.72 0166 Level I Urethral Procedures T 10.17 $493.11 $218.73 $98.62 0167 Level II Urethral Procedures T 21.06 $1,021.14 $555.84 $204.23 0168 Level III Urethral Procedures T 24.94 $1,209.27 $536.11 $241.85 0169 Lithotripsy T 46.72 $2,265.32 $1,384.20 $453.06 0170 Dialysis for Other Than ESRD Patients S 6.68 $323.89 $72.26 $64.78 0180 Circumcision T 13.62 $660.39 $304.87 $132.08 0181 Penile Procedures T 32.37 $1,569.53 $906.36 $313.91 0182 Insertion of Penile Prosthesis T 52.11 $2,526.66 $1,525.05 $505.33 0183 Testes/Epididymis Procedures T 18.26 $885.37 $448.94 $177.07 0184 Prostate Biopsy T 4.94 $239.53 $122.96 $47.91 0190 Surgical Hysteroscopy T 17.85 $865.49 $443.89 $173.10 0191 Level I Female Reproductive Procedures T 1.19 $57.70 $17.43 $11.54 0192 Level II Female Reproductive Procedures T 2.38 $115.40 $35.33 $23.08 0193 Level III Female Reproductive Procedures T 8.93 $432.99 $171.13 $86.60 0194 Level IV Female Reproductive Procedures T 16.21 $785.98 $395.94 $157.20 0195 Level V Female Reproductive Procedures T 18.68 $905.74 $483.80 $181.15 0196 Dilatation & Curettage T 14.47 $701.61 $357.98 $140.32 0197 Infertility Procedures T 2.40 $116.37 $49.55 $23.27 0198 Pregnancy and Neonatal Care Procedures T 1.34 $64.97 $33.03 $12.99 0199 Vaginal Delivery T 11.20 $543.06 $157.83 $108.61 0200 Therapeutic Abortion T 13.89 $673.49 $373.23 $134.70 0201 Spontaneous Abortion T 13.00 $630.33 $329.65 $126.07 0210 Spinal Tap T 3.00 $145.46 $62.40 $29.09 0211 Level I Nervous System Injections T 3.32 $160.98 $74.78 $32.20 0212 Level II Nervous System Injections T 3.64 $176.49 $88.78 $35.30 0213 Extended EEG Studies and Sleep Studies S 11.15 $540.63 $290.42 $108.13 0214 Electroencephalogram S 2.32 $112.49 $58.50 $22.50 0215 Level I Nerve and Muscle Tests S 1.15 $55.76 $30.05 $11.15 0216 Level II Nerve and Muscle Tests S 2.87 $139.16 $64.69 $27.83 0217 Level III Nerve and Muscle Tests S 5.87 $284.62 $156.68 $56.92 0220 Level I Nerve Procedures T 13.96 $676.88 $326.21 $135.38 0221 Level II Nerve Procedures T 18.36 $890.22 $463.62 $178.04 0222 Implantation of Neurological Device T 25.48 $1,235.45 $780.07 $247.09 0223 Level I Revision/Removal Neurological Device T 6.34 $307.41 $153.24 $61.48 0224 Level II Revision/Removal Neurological Device T 15.94 $772.88 $374.61 $154.58 0225 Implantation of Neurostimulator Electrodes T 3.43 $166.31 $64.46 $33.26 0230 Level I Eye Tests S 0.98 $47.52 $22.48 $9.50 0231 Level II Eye Tests S 2.64 $128.01 $59.87 $25.60 0232 Level I Anterior Segment Eye T 6.04 $292.86 $134.66 $58.57 0233 Level II Anterior Segment Eye T 13.79 $668.64 $331.60 $133.73 0234 Level III Anterior Segment Eye Procedures T 20.64 $1,000.77 $502.16 $200.15 0235 Level I Posterior Segment Eye Procedures T 2.94 $142.55 $78.91 $28.51 0236 Level II Posterior Segment Eye Procedures T 6.70 $324.86 $147.96 $64.97 0237 Level III Posterior Segment Eye Procedures T 33.96 $1,646.62 $852.68 $329.32 0238 Level I Repair and Plastic Eye Procedures T 2.80 $135.76 $58.96 $27.15 0239 Level II Repair and Plastic Eye Procedures T 6.26 $303.53 $123.42 $60.71 0240 Level III Repair and Plastic Eye Procedures T 13.47 $653.12 $315.31 $130.62 0241 Level IV Repair and Plastic Eye Procedures T 16.60 $804.89 $384.47 $160.98 0242 Level V Repair and Plastic Eye Procedures T 23.70 $1,149.14 $597.36 $229.83 0243 Strabismus/Muscle Procedures T 17.99 $872.28 $431.39 $174.46 0244 Corneal Transplant T 32.88 $1,594.26 $851.42 $318.85 0245 Cataract Procedures without IOL Insert T 26.55 $1,287.33 $623.85 $257.47 0246 Cataract Procedures with IOL Insert T 26.55 $1,287.33 $623.85 $257.47 0247 Laser Eye Procedures Except Retinal T 4.89 $237.10 $112.86 $47.42 0248 Laser Retinal Procedures T 4.19 $203.16 $94.05 $40.63 0250 Nasal Cauterization/Packing T 2.21 $107.16 $38.54 $21.43 0251 Level I ENT Procedures T 1.68 $81.46 $27.99 $16.29 0252 Level II ENT Procedures T 5.18 $251.16 $114.24 $50.23 0253 Level III ENT Procedures T 12.02 $582.81 $284.00 $116.56 0254 Level IV ENT Procedures T 12.45 $603.66 $272.41 $120.73 0256 Level V ENT Procedures T 25.40 $1,231.57 $623.05 $246.31 0257 Implantation of Cochlear Device T 115.31 $5,591.04 $3,498.58 $1,118.21 0258 Tonsil and Adenoid Procedures T 18.62 $902.83 $462.81 $180.57 0260 Level I Plain Film Except Teeth X 0.79 $38.30 $22.02 $7.66 0261 Level II Plain Film Except Teeth Including Bone Density Measurement X 1.38 $66.91 $38.77 $13.38 0262 Plain Film of Teeth X 0.40 $19.39 $10.90 $3.88 Start Printed Page 18554 0263 Level I Miscellaneous Radiology Procedures X 1.68 $81.46 $45.88 $16.29 0264 Level II Miscellaneous Radiology Procedures X 3.83 $185.71 $108.97 $37.14 0265 Level I Diagnostic Ultrasound Except Vascular S 1.17 $56.73 $38.08 $11.35 0266 Level II Diagnostic Ultrasound Except Vascular S 1.79 $86.79 $57.35 $17.36 0267 Vascular Ultrasound S 2.72 $131.88 $80.06 $26.38 0268 Guidance Under Ultrasound X 2.23 $108.13 $69.51 $21.63 0269 Echocardiogram Except Transesophageal S 4.40 $213.34 $114.01 $42.67 0270 Transesophageal Echocardiogram S 5.55 $269.10 $150.26 $53.82 0271 Mammography S 0.70 $33.94 $19.50 $6.79 0272 Level I Fluoroscopy X 1.40 $67.88 $39.00 $13.58 0273 Level II Fluoroscopy X 2.49 $120.73 $61.02 $24.15 0274 Myelography S 4.83 $234.19 $128.12 $46.84 0275 Arthrography S 2.74 $132.85 $72.26 $26.57 0276 Level I Digestive Radiology S 1.79 $86.79 $49.78 $17.36 0277 Level II Digestive Radiology S 2.47 $119.76 $69.28 $23.95 0278 Diagnostic Urography S 2.85 $138.19 $81.67 $27.64 0279 Level I Diagnostic Angiography and Venography Except Extremity S 6.30 $305.47 $174.57 $61.09 0280 Level II Diagnostic Angiography and Venography Except Extremity S 14.98 $726.34 $380.12 $145.27 0281 Venography of Extremity S 4.40 $213.34 $115.16 $42.67 0282 Level I Computerized Axial Tomography S 2.38 $115.40 $94.51 $23.08 0283 Level II Computerized Axial Tomography S 4.89 $237.10 $179.39 $47.42 0284 Magnetic Resonance Imaging S 8.02 $388.87 $257.39 $77.77 0285 Positron Emission Tomography (PET) S 15.06 $730.22 $415.21 $146.04 0286 Myocardial Scans S 7.28 $352.99 $200.04 $70.60 0290 Standard Non-Imaging Nuclear Medicine S 1.94 $94.06 $55.51 $18.81 0291 Level I Diagnostic Nuclear Medicine Excluding Myocardial Scans S 3.15 $152.73 $93.14 $30.55 0292 Level II Diagnostic Nuclear Medicine Excluding Myocardial Scans S 4.36 $211.40 $126.63 $42.28 0294 Level I Therapeutic Nuclear Medicine S 5.13 $248.74 $144.06 $49.75 0295 Level II Therapeutic Nuclear Medicine S 19.85 $962.47 $609.17 $192.49 0296 Level I Therapeutic Radiologic Procedures S 3.57 $173.10 $100.25 $34.62 0297 Level II Therapeutic Radiologic Procedures S 6.13 $297.23 $172.51 $59.45 0300 Level I Radiation Therapy S 1.98 $96.00 $47.72 $19.20 0301 Level II Radiation Therapy S 2.21 $107.16 $52.53 $21.43 0302 Level III Radiation Therapy S 8.21 $398.08 $216.55 $79.62 0303 Treatment Device Construction X 2.83 $137.22 $69.28 $27.44 0304 Level I Therapeutic Radiation Treatment Preparation X 1.49 $72.25 $41.52 $14.45 0305 Level II Therapeutic Radiation Treatment Preparation X 4.06 $196.86 $97.50 $39.37 0310 Level III Therapeutic Radiation Treatment Preparation X 13.98 $677.85 $339.05 $135.57 0311 Radiation Physics Services X 1.32 $64.00 $31.66 $12.80 0312 Radioelement Applications S 4.09 $198.31 $109.65 $39.66 0313 Brachytherapy S 7.89 $382.56 $164.02 $76.51 0314 Hyperthermic Therapies S 5.88 $285.10 $150.95 $57.02 0320 Electroconvulsive Therapy S 3.68 $178.43 $80.06 $35.69 0321 Biofeedback and Other Training S 1.26 $61.09 $29.25 $12.22 0322 Brief Individual Psychotherapy S 1.32 $64.00 $14.22 $12.80 0323 Extended Individual Psychotherapy S 1.85 $89.70 $22.48 $17.94 0324 Family Psychotherapy S 1.87 $90.67 $20.19 $18.13 0325 Group Psychotherapy S 1.55 $75.16 $19.96 $15.03 0330 Dental Procedures S 1.51 $73.22 $14.64 $14.64 0340 Minor Ancillary Procedures X 1.04 $50.43 $12.85 $10.09 0341 Immunology Tests X 0.13 $6.30 $3.67 $1.26 0342 Level I Pathology X 0.26 $12.61 $8.03 $2.52 0343 Level II Pathology X 0.45 $21.82 $12.16 $4.36 0344 Level III Pathology X 0.79 $38.30 $23.63 $7.66 2 0354 Administration of Influenza Vaccine X 0.13 $6.19 0355 Level I Immunizations X 0.19 $9.21 $5.05 $1.84 0356 Level II Immunizations X 0.36 $17.46 $4.82 $3.49 0357 Level III Immunizations X 1.85 $89.70 $38.31 $17.94 0358 Level IV Immunizations X 6.98 $338.44 $126.74 $67.69 0359 Injections X 0.96 $46.55 $9.31 $9.31 0360 Level I Alimentary Tests X 1.38 $66.91 $34.75 $13.38 0361 Level II Alimentary Tests X 3.53 $171.16 $88.09 $34.23 0362 Fitting of Vision Aids X 0.51 $24.73 $9.63 $4.95 0363 Otorhinolaryngologic Function Tests X 2.83 $137.22 $53.22 $27.44 0364 Level I Audiometry X 0.68 $32.97 $13.31 $6.59 0365 Level II Audiometry X 1.47 $71.28 $22.48 $14.26 0366 Electrocardiogram (ECG) X 0.38 $18.43 $15.60 $3.69 0367 Level I Pulmonary Test X 0.83 $40.24 $20.65 $8.05 0368 Level II Pulmonary Tests X 1.66 $80.49 $42.44 $16.10 0369 Level III Pulmonary Tests X 2.34 $113.46 $58.50 $22.69 0370 Allergy Tests X 0.57 $27.64 $11.81 $5.53 0371 Allergy Injections X 0.32 $15.52 $3.67 $3.10 0372 Therapeutic Phlebotomy X 0.43 $20.85 $10.09 $4.17 Start Printed Page 18555 0373 Neuropsychological Testing X 3.21 $155.64 $44.96 $31.13 0374 Monitoring Psychiatric Drugs X 1.17 $56.73 $13.08 $11.35 0600 Low Level Clinic Visits V 0.98 $47.52 $9.50 $9.50 0601 Mid Level Clinic Visits V 1.00 $48.49 $9.70 $9.70 0602 High Level Clinic Visits V 1.66 $80.49 $16.29 $16.10 0603 Interdisciplinary Team Conference V 1.66 $80.49 $16.29 $16.10 0610 Low Level Emergency Visits V 1.34 $64.97 $20.65 $12.99 0611 Mid Level Emergency Visits V 2.11 $102.31 $36.47 $20.46 0612 High Level Emergency Visits V 3.19 $154.67 $54.14 $30.93 0620 Critical Care S 8.60 $416.99 $152.78 $83.40 3 0701 Strontium X $84.76 3 0702 Samariam X $139.06 3 0704 Satumomab Pendetide X $63.13 3 0705 Tc99 Tetrofosmin X $71.08 3 0725 Leucovorin Calcium X $1.07 3 0726 Dexrazoxane Hydrochloride X $18.81 3 0727 Injection, Etidronate Disodium X $9.31 3 0728 Filgrastim (G-CSF) X $25.21 3 0730 Pamidronate Disodium X $30.93 3 0731 Sargramostim (GM-CSF) X $16.97 3 0732 Mesna X $2.42 3 0733 Epoetin Alpha X $1.75 3 0750 Dolasetron Mesylate 10 mg X $1.94 3 0754 Metoclopramide HCL X $.19 3 0755 Thiethylperazine Maleate X $.68 3 0761 Oral Substitute for IV Antiemtic X $.10 3 0762 Dronabinol X $.48 3 0763 Dolasetron Mesylate 100 mg Oral X $8.53 3 0764 Granisetron HCL, 100 mcg X $2.33 3 0765 Granisetron HCL, 1mg Oral X $3.20 3 0768 Ondansetron Hydrochloride per 1 mg Injection X $.87 3 0769 Ondansetron Hydrochloride 8 mg oral X $2.62 3 0800 Leuprolide Acetate per 3.75 mg X $68.56 3 0801 Cyclophosphamide X $.19 3 0802 Etoposide X $3.10 3 0803 Melphalan X $.19 3 0807 Aldesleukin single use vial X $65.07 3 0809 BCG (Intravesical) one vial X $19.78 3 0810 Goserelin Acetate Implant, per 3.6 mg X $59.74 3 0811 Carboplatin 50 mg X $13.96 3 0812 Carmustine 100 mg X $10.57 3 0813 Cisplatin 10 mg X $4.56 3 0814 Asparaginase, 10,000 units X $8.34 3 0815 Cyclophosphamide 100 mg X $.48 3 0816 Cyclophosphamide, Lyophilized 100 mg X $1.16 3 0817 Cytrabine 100 mg X $.68 3 0818 Dactinomycin 0.5 mg X $1.75 3 0819 Dacarbazine 100 mg X $1.26 3 0820 Daunorubicin HCI 10 mg X $11.64 3 0821 Daunorubicin Citrate, Liposomal Formulation, 10 mg X $7.76 3 0822 Diethylstibestrol Diphosphate 250 mg X $2.13 3 0823 Docetaxel 20 mg X $34.72 3 0824 Etoposide 10 mg X $.58 3 0826 Methotrexate Oral 2.5 mg X $.29 3 0827 Floxuridine 500 mg X $18.81 3 0828 Gemcitabine HCL 200 mg X $9.31 3 0830 Irinotecan 20 mg X $14.16 3 0831 Ifosfamide per 1 gram X $13.58 3 0832 Idarubicin Hydrochloride 5 mg X $46.45 3 0833 Interferon Alfacon-1, Recombinant, 1 mcg X $.19 3 0834 Interferon, Alfa-2A, Recombinant 3 million units X $3.20 3 0836 Interferon, Alfa-2B, Recombinant, 1 million units X $1.36 3 0838 Interferon, Gamma 1-B, 3 million units X $22.79 3 0839 Mechlorethamine HCI 10 mg X $1.65 3 0840 Melphalan HCI 50 mg X $44.71 3 0841 Methotrexate Sodium 5 mg X $.10 3 0842 Fludarabine Phosphate 50 mg X $30.84 3 0843 Pegaspargase per single dose vial X $178.72 3 0844 Pentostatin 10 mg X $133.73 3 0847 Doxorubicin HCL 10 mg X $2.81 3 0849 Rituximab, 100 mg X $51.40 3 0850 Streptozocin 1 gm X $14.64 3 0851 Thiotepa 15 mg X $9.50 Start Printed Page 18556 3 0852 Topotecan 4 mg X $73.22 3 0853 Vinblastine Sulfate 1 mg X $.39 3 0854 Vincristine Sulfate 1 mg X $2.23 3 0855 Vinorelbine Tartrate per 10 mg X $9.60 3 0856 Porfimer Sodium 75 mg X $34.62 3 0857 Bleomycin Sulfate 15 units X $48.29 3 0858 Cladribine, 1mg X $8.24 3 0859 Fluorouracil X $.19 3 0860 Plicamycin 2.5 mg X $1.36 3 0861 Leuprolide Acetate 1 mg X $19.39 3 0862 Mitomycin, 5mg X $19.88 3 0863 Paclitaxel, 30mg X $30.16 3 0864 Mitoxantrone HCl, per 5mg X $25.80 3 0865 Interferon alfa-N3, 250,000 IU X $1.07 3 0884 Rho (D) Immune Globulin, Human one dose pack X $3.78 2 0886 Azathioprine, 50 mg oral X 0.02 $.97 $.19 2 0887 Azathioprine, Parenteral 100 mg, 20 ml each injection X 1.40 $67.88 $13.58 2 0888 Cyclosporine, Oral 100 mg X 0.08 $3.88 $.78 2 0889 Cyclosporine, Parenteral X 0.36 $17.46 $3.49 2 0890 Lymphocyte Immune Globulin 50 mg/ml, 5 ml each X 3.79 $183.77 $36.75 2 0891 Tacrolimus per 1 mg oral X 3.15 $152.73 $30.55 3 0892 Daclizumab, Parenteral, 25 mg X $54.11 3 0900 Injection, Alglucerase per 10 units X $5.14 3 0901 Alpha I, Proteinase Inhibitor, Human per 10mg X $15.22 3 0902 Botulinum Toxin, Type A per unit X $56.05 3 0903 CMV Immune Globulin X $54.11 3 0905 Immune Globulin per 500 mg X $6.40 3 0906 RSV Immune Globulin X $85.53 2 0907 Ganciclovir Sodium 500 mg injection X 0.51 $24.73 $4.95 2 0908 Tetanus Immune Globulin, Human, up to 250 units X 0.90 $43.64 $8.73 3 0909 Interferon Beta—1a 33 mcg X $28.70 3 0910 Interferon Beta—1b 0.25 mg X $8.44 2 0911 Streptokinase per 250,000 iu X 1.64 $79.69 $15.94 3 0913 Ganciclovir 4.5 mg, Implant X $701.51 2 0914 Reteplase, 37.6 mg (Two Single Use Vials) X 38.20 $1,852.21 $370.44 2 0915 Alteplase recombinant, 10mg X 5.85 $283.70 $56.74 3 0916 Imiglucerase per unit X $.58 2 0917 Dipyridamole, 10mg Adenosine 6MG X 0.36 $17.46 $3.49 3 0918 Brachytherapy Seeds, Any type, Each S $9.99 3 0925 Factor VIII (Antihemophilic Factor, Human) per iu X $.19 3 0926 Factor VIII (Antihemophilic Factor, Porcine) per iu X $.19 3 0927 Factor VIII (Antihemophilic Factor, Recombinant) per iu X $.19 3 0928 Factor IX, Complex X $.08 3 0929 Other Hemophilia Clotting Factors per iu X $.27 3 0930 Antithrombin III (Human) per iu X $.19 3 0931 Factor IX (Antihemophilic Factor, Purified, Non-Recombinant) X $.04 3 0932 Factor IX (Antihemophilic Factor, Recombinant) X $.10 2 0949 Plasma, Pooled Multiple Donor, Solvent/Detergent Treated, Frozen S 3.49 $169.22 $33.84 2 0950 Blood (Whole) For Transfusion S 2.08 $101.02 $20.20 2 0952 Cryoprecipitate S 0.70 $33.92 $6.78 2 0953 Fibrinogen Unit S 0.48 $23.27 $4.65 2 0954 Leukocyte Poor Blood S 2.83 $137.21 $27.44 2 0955 Plasma, Fresh Frozen S 2.26 $109.35 $21.87 2 0956 Plasma Protein Fraction S 1.26 $61.09 $12.22 2 0957 Platelet Concentrate S 0.98 $47.46 $9.49 2 0958 Platelet Rich Plasma S 1.16 $56.25 $11.25 2 0959 Red Blood Cells S 2.04 $99.04 $19.81 2 0960 Washed Red Blood Cells S 3.81 $184.53 $36.91 2 0961 Infusion, Albumin (Human) 5%, 500 ml X 2.77 $134.31 $26.86 2 0962 Infusion, Albumin (Human) 25%, 50 ml X 1.38 $66.91 $13.38 2 0970 New Technology—Level I ($0-$50) T 0.52 $25.21 $5.04 2 0971 New Technology—Level II ($50-$100) S 1.55 $75.16 $15.03 2 0972 New Technology—Level III ($100-$200) T 3.09 $149.83 $29.97 2 0973 New Technology—Level IV ($200-$300) T 5.16 $250.19 $50.04 2 0974 New Technology—Level V ($300-$500) T 8.25 $400.02 $80.00 2 0975 New Technology—Level VI ($500-$750) T 12.90 $625.48 $125.10 2 0976 New Technology—Level VII ($750-$1000) T 18.05 $875.19 $175.04 2 0977 New Technology—Level VIII ($1000-$1250) T 23.20 $1,124.90 $224.98 2 0978 New Technology—Level IX ($1250-$1500) T 28.36 $1,375.09 $275.02 2 0979 New Technology—Level X ($1500-$1750) T 33.51 $1,624.80 $324.96 2 0980 New Technology—Level XI ($1750-$2000) S 38.67 $1,875.00 $375.00 2 0981 New Technology—Level XII ($2000-$2500) T 46.40 $2,249.80 $449.96 2 0982 New Technology—Level XIII ($2500-$3500) T 61.87 $2,999.90 $599.98 Start Printed Page 18557 2 0983 New Technology—Level XIV ($3500-$5000) T 87.65 $4,249.89 $849.98 2 0984 New Technology—Level XV ($5000-$6000) T 113.43 $5,499.89 $1,099.98 3 7000 Amifostine, 500 mg X $41.99 3 7001 Amphotericin B lipid complex, 50 mg, Inj X $12.12 3 7002 Clonidine, HCl, 1 MG X $4.17 3 7003 Epoprostenol, 0.5 MG, inj X $2.23 3 7004 Immune globulin intravenous human 5g, inj X $45.48 3 7005 Gonadorelin hcI, 100 mcg X $9.12 2 7007 Milrinone lacetate, per 5 ml, inj X 0.47 $22.79 $4.56 3 7010 Morphine sulfate concentrate (preservative free) per 10 mg X $.68 3 7011 Oprelevekin, inj, 5 mg X $30.35 3 7012 Pentamidine isethionate, 300 mg X $8.73 3 7014 Fentanyl citrate, inj, up to 2 ml X $.19 3 7015 Busulfan, oral 2 mg X $.19 3 7019 Aprotinin, 10,000 kiu X $2.42 3 7021 Baclofen, intrathecal, 50 mcg X $.10 3 7022 Elliotts B Solution, per ml X $19.20 3 7023 Treatment for bladder calculi, I.e. Renacidin per 500 ml X $4.46 3 7024 Corticorelin ovine triflutate, 0.1 mg X $45.77 3 7025 Digoxin immune FAB (Ovine), 10 mg X $14.06 3 7026 Ethanolamine oleate, 1000 ml X $2.13 3 7027 Fomepizole, 1.5 G X $141.29 3 7028 Fosphenytoin, 50 mg X $.78 3 7029 Glatiramer acetate, 25 mg X $3.59 3 7030 Hemin, 1 mg X $.10 3 7031 Octreotide Acetate, 500 mcg X $5.43 3 7032 Sermorelin acetate, 0.5 mg X $53.34 3 7033 Somatrem, 5 mg X $28.03 3 7034 Somatropin, 1 mg X $5.04 3 7035 Teniposide, 50 mg X $20.85 2 7036 Urokinase, inj, IV, 250,000 I.U. X 0.73 $35.40 $7.08 3 7037 Urofollitropin, 75 I.U. X $8.24 3 7038 Muromonab-CD3, 5 mg X $89.60 3 7039 Pegademase bovine inj 25 I.U. X $1.16 3 7040 Pentastarch 10% inj, 100 ml X $2.04 2 7041 Tirofiban HCL, 0.5 mg X 0.02 $.97 $.19 3 7042 Capecitabine, oral 150 mg X $.19 3 7043 Infliximab, 10 MG X $6.89 3 7045 Trimetrexate Glucoronate X $8.15 3 7046 Doxorubicin Hcl Liposome X $39.18 —————————— CPT codes and descriptions only are copyright American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Copyright American Dental Association. All rights reserved. 1 Not subject to national coinsurance. Minimum unadjusted coinsurance is 25% of the payment rate. The payment rate is the lower of the HOPD payment rate or the Ambulatory Surgical Center payment. ÿ09ÿ09ÿ09ÿ09 2 Not subject to national coinsurance.ÿ09ÿ09ÿ09ÿ09ÿ09ÿ09 3 Eligible for pass-through payments. See Preamble for payment rate determination. See Addendum K for complete list of pass-through codes.Addendum B.—Hospital Outpatient Department (HOPD) Payment Status by HCPCS Code and Related Information
CPT/ HCPCS HOPD Status Indicator Description APC Relative Weight Payment Rate National Unadjusted Coinsurance Minimum Unadjusted Coinsurance 00100 N Anesth, salivary gland 00102 N Anesth, repair of cleft lip 00103 N Anesth, blepharoplasty 00104 N Anesth, electroshock 00120 N Anesth, ear surgery 00124 N Anesth, ear exam 00126 N Anesth, tympanotomy 00140 N Anesth, procedures on eye 00142 N Anesth, lens surgery 00144 N Anesth, corneal transplant 00145 N Anesth, vitrectomy 00147 N Anesth, iridectomy 00148 N Anesth, eye exam 00160 N Anesth, nose/sinus surgery 00162 N Anesth, nose/sinus surgery 00164 N Anesth, biopsy of nose 00170 N Anesth, procedure on mouth 00172 N Anesth, cleft palate repair 00174 C Anesth, pharyngeal surgery 00176 C Anesth, pharyngeal surgery 00190 N Anesth, facial bone surgery 00192 C Anesth, facial bone surgery 00210 N Anesth, open head surgery 00212 N Anesth, skull drainage Start Printed Page 18558 00214 C Anesth, skull drainage 00215 C Anesth, skull fracture 00216 N Anesth, head vessel surgery 00218 N Anesth, special head surgery 00220 N Anesth, spinal fluid shunt 00222 N Anesth, head nerve surgery 00300 N Anesth, head/neck/ptrunk 00320 N Anesth, neck organ surgery 00322 N Anesth, biopsy of thyroid 00350 N Anesth, neck vessel surgery 00352 N Anesth, neck vessel surgery 00400 N Anesth, skin, ext/per/atrunk 00402 N Anesth, surgery of breast 00404 C Anesth, surgery of breast 00406 C Anesth, surgery of breast 00410 N Anesth, correct heart rhythm 00450 N Anesth, surgery of shoulder 00452 C Anesth, surgery of shoulder 00454 N Anesth, collar bone biopsy 00470 N Anesth, removal of rib 00472 N Anesth, chest wall repair 00474 C Anesth, surgery of rib(s) 00500 N Anesth, esophageal surgery 00520 N Anesth, chest procedure 00522 N Anesth, chest lining biopsy 00524 C Anesth, chest drainage 00528 N Anesth, chest partition view 00530 C Anesth, pacemaker insertion 00532 N Anesth, vascular access 00534 N Anesth, cardioverter/defib 00540 C Anesth, chest surgery 00542 C Anesth, release of lung 00544 C Anesth, chest lining removal 00546 C Anesth, lung, chest wall surg 00548 N Anesth, trachea, bronchi surg 00560 C Anesth, open heart surgery 00562 C Anesth, open heart surgery 00580 C Anesth heart/lung transplant 00600 N Anesth, spine, cord surgery 00604 C Anesth, surgery of vertebra 00620 N Anesth, spine, cord surgery 00622 C Anesth, removal of nerves 00630 N Anesth, spine, cord surgery 00632 C Anesth, removal of nerves 00634 C Anesth for chemonucleolysis 00670 C Anesth, spine, cord surgery 00700 N Anesth, abdominal wall surg 00702 N Anesth, for liver biopsy 00730 N Anesth, abdominal wall surg 00740 N Anesth, upper gi visualize 00750 N Anesth, repair of hernia 00752 N Anesth, repair of hernia 00754 N Anesth, repair of hernia 00756 N Anesth, repair of hernia 00770 N Anesth, blood vessel repair 00790 N Anesth, surg upper abdomen 00792 C Anesth, part liver removal 00794 C Anesth, pancreas removal 00796 C Anesth, for liver transplant 00800 N Anesth, abdominal wall surg 00802 C Anesth, fat layer removal 00810 N Anesth, low intestine scope 00820 N Anesth, abdominal wall surg 00830 N Anesth, repair of hernia 00832 N Anesth, repair of hernia 00840 N Anesth, surg lower abdomen 00842 N Anesth, amniocentesis 00844 C Anesth, pelvis surgery 00846 C Anesth, hysterectomy 00848 C Anesth, pelvic organ surg 00850 C Anesth, cesarean section 00855 C Anesth, hysterectomy 00857 C Analgesia, labor & c-section Start Printed Page 18559 00860 N Anesth, surgery of abdomen 00862 N Anesth, kidney/ureter surg 00864 C Anesth, removal of bladder 00865 C Anesth, removal of prostate 00866 C Anesth, removal of adrenal 00868 C Anesth, kidney transplant 00870 N Anesth, bladder stone surg 00872 N Anesth kidney stone destruct 00873 N Anesth kidney stone destruct 00880 N Anesth, abdomen vessel surg 00882 C Anesth, major vein ligation 00884 C Anesth, major vein revision 00900 N Anesth, perineal procedure 00902 N Anesth, anorectal surgery 00904 C Anesth, perineal surgery 00906 N Anesth, removal of vulva 00908 C Anesth, removal of prostate 00910 N Anesth, bladder surgery 00912 N Anesth, bladder tumor surg 00914 N Anesth, removal of prostate 00916 N Anesth, bleeding control 00918 N Anesth, stone removal 00920 N Anesth, genitalia surgery 00922 N Anesth, sperm duct surgery 00924 N Anesth, testis exploration 00926 N Anesth, removal of testis 00928 C Anesth, removal of testis 00930 N Anesth, testis suspension 00932 C Anesth, amputation of penis 00934 C Anesth, penis, nodes removal 00936 C Anesth, penis, nodes removal 00938 N Anesth, insert penis device 00940 N Anesth, vaginal procedures 00942 N Anesth, surgery on vagina 00944 C Anesth, vaginal hysterectomy 00946 N Anesth, vaginal delivery 00948 N Anesth, repair of cervix 00950 N Anesth, vaginal endoscopy 00952 N Anesth, hysteroscope/graph 00955 C Analgesia, vaginal delivery 01120 N Anesth, pelvis surgery 01130 N Anesth, body cast procedure 01140 C Anesth, amputation at pelvis 01150 C Anesth, pelvic tumor surgery 01160 N Anesth, pelvis procedure 01170 N Anesth, pelvis surgery 01180 N Anesth, pelvis nerve removal 01190 C Anesth, pelvis nerve removal 01200 N Anesth, hip joint procedure 01202 N Anesth, arthroscopy of hip 01210 N Anesth, hip joint surgery 01212 C Anesth, hip disarticulation 01214 C Anesth, replacement of hip 01220 N Anesth, procedure on femur 01230 N Anesth, surgery of femur 01232 C Anesth, amputation of femur 01234 C Anesth, radical femur surg 01250 N Anesth, upper leg surgery 01260 N Anesth, upper leg veins surg 01270 N Anesth, thigh arteries surg 01272 C Anesth, femoral artery surg 01274 C Anesth, femoral embolectomy 01320 N Anesth, knee area surgery 01340 N Anesth, knee area procedure 01360 N Anesth, knee area surgery 01380 N Anesth, knee joint procedure 01382 N Anesth, knee arthroscopy 01390 N Anesth, knee area procedure 01392 N Anesth, knee area surgery 01400 N Anesth, knee joint surgery 01402 C Anesth, replacement of knee 01404 C Anesth, amputation at knee 01420 N Anesth, knee joint casting Start Printed Page 18560 01430 N Anesth, knee veins surgery 01432 N Anesth, knee vessel surg 01440 N Anesth, knee arteries surg 01442 C Anesth, knee artery surg 01444 C Anesth, knee artery repair 01462 N Anesth, lower leg procedure 01464 N Anesth, ankle arthroscopy 01470 N Anesth, lower leg surgery 01472 N Anesth, achilles tendon surg 01474 N Anesth, lower leg surgery 01480 N Anesth, lower leg bone surg 01482 N Anesth, radical leg surgery 01484 N Anesth, lower leg revision 01486 C Anesth, ankle replacement 01490 N Anesth, lower leg casting 01500 N Anesth, leg arteries surg 01502 C Anesth, lwr leg embolectomy 01520 N Anesth, lower leg vein surg 01522 N Anesth, lower leg vein surg 01610 N Anesth, surgery of shoulder 01620 N Anesth, shoulder procedure 01622 N Anesth, shoulder arthroscopy 01630 N Anesth, surgery of shoulder 01632 C Anesth, surgery of shoulder 01634 C Anesth, shoulder joint amput 01636 C Anesth, forequarter amput 01638 C Anesth, shoulder replacement 01650 N Anesth, shoulder artery surg 01652 C Anesth, shoulder vessel surg 01654 C Anesth, shoulder vessel surg 01656 C Anesth, arm-leg vessel surg 01670 N Anesth, shoulder vein surg 01680 N Anesth, shoulder casting 01682 N Anesth, airplane cast 01710 N Anesth, elbow area surgery 01712 N Anesth, uppr arm tendon surg 01714 N Anesth, uppr arm tendon surg 01716 N Anesth, biceps tendon repair 01730 N Anesth, uppr arm procedure 01732 N Anesth, elbow arthroscopy 01740 N Anesth, upper arm surgery 01742 N Anesth, humerus surgery 01744 N Anesth, humerus repair 01756 C Anesth, radical humerus surg 01758 N Anesth, humeral lesion surg 01760 N Anesth, elbow replacement 01770 N Anesth, uppr arm artery surg 01772 C Anesth, uppr arm embolectomy 01780 N Anesth, upper arm vein surg 01782 C Anesth, uppr arm vein repair 01784 N Anesth, av fistula repair 01810 N Anesth, lower arm surgery 01820 N Anesth, lower arm procedure 01830 N Anesth, lower arm surgery 01832 N Anesth, wrist replacement 01840 N Anesth, lwr arm artery surg 01842 C Anesth, lwr arm embolectomy 01844 N Anesth, vascular shunt surg 01850 N Anesth, lower arm vein surg 01852 C Anesth, lwr arm vein repair 01860 N Anesth, lower arm casting 01904 C Anesth, skull x-ray inject 01906 N Anesth, lumbar myelography 01908 N Anesth, cervical myelography 01910 N Anesth, skull myelography 01912 N Anesth, lumbar diskography 01914 N Anesth, cervical diskography 01916 N Anesth, head arteriogram 01918 N Anesth, limb arteriogram 01920 N Anesth, catheterize heart 01921 N Anesth, vessel surgery 01922 N Anesth, cat or MRI scan 01990 C Support for organ donor Start Printed Page 18561 01995 N Regional anesthesia, limb 01996 N Manage daily drug therapy 01999 N Unlisted anesth procedure 10040 T Acne surgery of skin abscess 0006 2.00 $96.97 $33.95 $19.39 10060 T Drainage of skin abscess 0006 2.00 $96.97 $33.95 $19.39 10061 T Drainage of skin abscess 0006 2.00 $96.97 $33.95 $19.39 10080 T Drainage of pilonidal cyst 0006 2.00 $96.97 $33.95 $19.39 10081 T Drainage of pilonidal cyst 0007 3.68 $178.43 $72.03 $35.69 10120 T Remove foreign body 0006 2.00 $96.97 $33.95 $19.39 10121 T Remove foreign body 0020 6.51 $315.65 $130.53 $63.13 10140 T Drainage of hematoma/fluid 0007 3.68 $178.43 $72.03 $35.69 10160 T Puncture drainage of lesion 0006 2.00 $96.97 $33.95 $19.39 10180 T Complex drainage, wound 0007 3.68 $178.43 $72.03 $35.69 11000 T Debride infected skin 0015 1.77 $85.82 $31.20 $17.16 11001 T Debride infected skin add-on 0015 1.77 $85.82 $31.20 $17.16 11010 T Debride skin, fx 0022 12.49 $605.60 $292.94 $121.12 11011 T Debride skin/muscle, fx 0022 12.49 $605.60 $292.94 $121.12 11012 T Debride skin/muscle/bone, fx 0022 12.49 $605.60 $292.94 $121.12 11040 T Debride skin, partial 0015 1.77 $85.82 $31.20 $17.16 11041 T Debride skin, full 0015 1.77 $85.82 $31.20 $17.16 11042 T Debride skin/tissue 0016 3.53 $171.16 $74.67 $34.23 11043 T Debride tissue/muscle 0016 3.53 $171.16 $74.67 $34.23 11044 T Debride tissue/muscle/bone 0017 12.45 $603.66 $289.16 $120.73 11055 T Trim skin lesion 0015 1.77 $85.82 $31.20 $17.16 11056 T Trim skin lesions, 2 to 4 0015 1.77 $85.82 $31.20 $17.16 11057 T Trim skin lesions, over 4 0015 1.77 $85.82 $31.20 $17.16 11100 T Biopsy of skin lesion 0018 0.94 $45.58 $17.66 $9.12 11101 T Biopsy, skin add-on 0018 0.94 $45.58 $17.66 $9.12 11200 T Removal of skin tags 0015 1.77 $85.82 $31.20 $17.16 11201 T Remove skin tags add-on 0015 1.77 $85.82 $31.20 $17.16 11300 T Shave skin lesion 0013 0.91 $44.12 $17.66 $8.82 11301 T Shave skin lesion 0013 0.91 $44.12 $17.66 $8.82 11302 T Shave skin lesion 0014 1.50 $72.73 $24.55 $14.55 11303 T Shave skin lesion 0015 1.77 $85.82 $31.20 $17.16 11305 T Shave skin lesion 0013 0.91 $44.12 $17.66 $8.82 11306 T Shave skin lesion 0013 0.91 $44.12 $17.66 $8.82 11307 T Shave skin lesion 0014 1.50 $72.73 $24.55 $14.55 11308 T Shave skin lesion 0015 1.77 $85.82 $31.20 $17.16 11310 T Shave skin lesion 0013 0.91 $44.12 $17.66 $8.82 11311 T Shave skin lesion 0013 0.91 $44.12 $17.66 $8.82 11312 T Shave skin lesion 0015 1.77 $85.82 $31.20 $17.16 11313 T Shave skin lesion 0016 3.53 $171.16 $74.67 $34.23 11400 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11401 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11402 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11403 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11404 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11406 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11420 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11421 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11422 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11423 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11424 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11426 T Removal of skin lesion 0022 12.49 $605.60 $292.94 $121.12 11440 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11441 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11442 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11443 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11444 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11446 T Removal of skin lesion 0022 12.49 $605.60 $292.94 $121.12 11450 T Removal, sweat gland lesion 0022 12.49 $605.60 $292.94 $121.12 11451 T Removal, sweat gland lesion 0022 12.49 $605.60 $292.94 $121.12 11462 T Removal, sweat gland lesion 0022 12.49 $605.60 $292.94 $121.12 11463 T Removal, sweat gland lesion 0022 12.49 $605.60 $292.94 $121.12 11470 T Removal, sweat gland lesion 0022 12.49 $605.60 $292.94 $121.12 11471 T Removal, sweat gland lesion 0022 12.49 $605.60 $292.94 $121.12 11600 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11601 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11602 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11603 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11604 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11606 T Removal of skin lesion 0021 10.49 $508.63 $236.51 $101.73 11620 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 Start Printed Page 18562 11621 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11622 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11623 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11624 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11626 T Removal of skin lesion 0022 12.49 $605.60 $292.94 $121.12 11640 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11641 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11642 T Removal of skin lesion 0019 4.00 $193.95 $78.91 $38.79 11643 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11644 T Removal of skin lesion 0020 6.51 $315.65 $130.53 $63.13 11646 T Removal of skin lesion 0022 12.49 $605.60 $292.94 $121.12 11719 T Trim nail(s) 0009 0.74 $35.88 $9.63 $7.18 11720 T Debride nail, 1-5 0009 0.74 $35.88 $9.63 $7.18 11721 T Debride nail, 6 or more 0009 0.74 $35.88 $9.63 $7.18 11730 T Removal of nail plate 0013 0.91 $44.12 $17.66 $8.82 11732 T Remove nail plate, add-on 0012 0.53 $25.70 $9.18 $5.14 11740 T Drain blood from under nail 0009 0.74 $35.88 $9.63 $7.18 11750 T Removal of nail bed 0019 4.00 $193.95 $78.91 $38.79 11752 T Remove nail bed/finger tip 0022 12.49 $605.60 $292.94 $121.12 11755 T Biopsy, nail unit 0019 4.00 $193.95 $78.91 $38.79 11760 T Repair of nail bed 0024 2.43 $117.82 $44.50 $23.56 11762 T Reconstruction of nail bed 0024 2.43 $117.82 $44.50 $23.56 11765 T Excision of nail fold, toe 0015 1.77 $85.82 $31.20 $17.16 11770 T Removal of pilonidal lesion 0021 10.49 $508.63 $236.51 $101.73 11771 T Removal of pilonidal lesion 0022 12.49 $605.60 $292.94 $121.12 11772 T Removal of pilonidal lesion 0022 12.49 $605.60 $292.94 $121.12 11900 T Injection into skin lesions 0012 0.53 $25.70 $9.18 $5.14 11901 T Added skin lesions injection 0013 0.91 $44.12 $17.66 $8.82 11920 T Correct skin color defects 0024 2.43 $117.82 $44.50 $23.56 11921 T Correct skin color defects 0024 2.43 $117.82 $44.50 $23.56 11922 T Correct skin color defects 0024 2.43 $117.82 $44.50 $23.56 11950 T Therapy for contour defects 0024 2.43 $117.82 $44.50 $23.56 11951 T Therapy for contour defects 0024 2.43 $117.82 $44.50 $23.56 11952 T Therapy for contour defects 0024 2.43 $117.82 $44.50 $23.56 11954 T Therapy for contour defects 0024 2.43 $117.82 $44.50 $23.56 11960 T Insert tissue expander(s) 0026 12.11 $587.18 $277.92 $117.44 11970 T Replace tissue expander 0026 12.11 $587.18 $277.92 $117.44 11971 T Remove tissue expander(s) 0022 12.49 $605.60 $292.94 $121.12 11975 E Insert contraceptive cap 11976 T Removal of contraceptive cap 0019 4.00 $193.95 $78.91 $38.79 11977 E Removal/reinsert contra cap 11980 E Implant hormone pellet(s) 12001 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12002 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12004 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12005 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12006 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12007 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12011 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12013 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12014 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12015 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12016 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12017 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12018 T Repair superficial wound(s) 0024 2.43 $117.82 $44.50 $23.56 12020 T Closure of split wound 0024 2.43 $117.82 $44.50 $23.56 12021 T Closure of split wound 0024 2.43 $117.82 $44.50 $23.56 12031 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12032 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12034 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12035 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12036 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12037 T Layer closure of wound(s) 0026 12.11 $587.18 $277.92 $117.44 12041 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12042 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12044 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12045 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12046 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12047 T Layer closure of wound(s) 0026 12.11 $587.18 $277.92 $117.44 12051 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12052 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12053 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12054 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 Start Printed Page 18563 12055 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12056 T Layer closure of wound(s) 0024 2.43 $117.82 $44.50 $23.56 12057 T Layer closure of wound(s) 0026 12.11 $587.18 $277.92 $117.44 13100 T Repair of wound or lesion 0025 3.74 $181.34 $70.66 $36.27 13101 T Repair of wound or lesion 0025 3.74 $181.34 $70.66 $36.27 13102 T Repair wound/lesion add-on 0025 3.74 $181.34 $70.66 $36.27 13120 T Repair of wound or lesion 0025 3.74 $181.34 $70.66 $36.27 13121 T Repair of wound or lesion 0025 3.74 $181.34 $70.66 $36.27 13122 T Repair wound/lesion add-on 0025 3.74 $181.34 $70.66 $36.27 13131 T Repair of wound or lesion 0025 3.74 $181.34 $70.66 $36.27 13132 T Repair of wound or lesion 0025 3.74 $181.34 $70.66 $36.27 13133 T Repair wound/lesion add-on 0025 3.74 $181.34 $70.66 $36.27 13150 T Repair of wound or lesion 0026 12.11 $587.18 $277.92 $117.44 13151 T Repair of wound or lesion 0025 3.74 $181.34 $70.66 $36.27 13152 T Repair of wound or lesion 0025 3.74 $181.34 $70.66 $36.27 13153 T Repair wound/lesion add-on 0025 3.74 $181.34 $70.66 $36.27 13160 T Late closure of wound 0026 12.11 $587.18 $277.92 $117.44 14000 T Skin tissue rearrangement 0026 12.11 $587.18 $277.92 $117.44 14001 T Skin tissue rearrangement 0026 12.11 $587.18 $277.92 $117.44 14020 T Skin tissue rearrangement 0026 12.11 $587.18 $277.92 $117.44 14021 T Skin tissue rearrangement 0026 12.11 $587.18 $277.92 $117.44 14040 T Skin tissue rearrangement 0026 12.11 $587.18 $277.92 $117.44 14041 T Skin tissue rearrangement 0026 12.11 $587.18 $277.92 $117.44 14060 T Skin tissue rearrangement 0026 12.11 $587.18 $277.92 $117.44 14061 T Skin tissue rearrangement 0026 12.11 $587.18 $277.92 $117.44 14300 T Skin tissue rearrangement 0026 12.11 $587.18 $277.92 $117.44 14350 T Skin tissue rearrangement 0026 12.11 $587.18 $277.92 $117.44 15000 T Skin graft 0026 12.11 $587.18 $277.92 $117.44 15001 T Skin graft add-on 0026 12.11 $587.18 $277.92 $117.44 15050 T Skin pinch graft 0026 12.11 $587.18 $277.92 $117.44 15100 T Skin split graft 0026 12.11 $587.18 $277.92 $117.44 15101 T Skin split graft add-on 0026 12.11 $587.18 $277.92 $117.44 15120 T Skin split graft 0026 12.11 $587.18 $277.92 $117.44 15121 T Skin split graft add-on 0026 12.11 $587.18 $277.92 $117.44 15200 T Skin full graft 0026 12.11 $587.18 $277.92 $117.44 15201 T Skin full graft add-on 0026 12.11 $587.18 $277.92 $117.44 15220 T Skin full graft 0026 12.11 $587.18 $277.92 $117.44 15221 T Skin full graft add-on 0026 12.11 $587.18 $277.92 $117.44 15240 T Skin full graft 0026 12.11 $587.18 $277.92 $117.44 15241 T Skin full graft add-on 0026 12.11 $587.18 $277.92 $117.44 15260 T Skin full graft 0026 12.11 $587.18 $277.92 $117.44 15261 T Skin full graft add-on 0026 12.11 $587.18 $277.92 $117.44 15350 T Skin homograft 0026 12.11 $587.18 $277.92 $117.44 15351 T Skin homograft add-on 0026 12.11 $587.18 $277.92 $117.44 15400 T Skin heterograft 0026 12.11 $587.18 $277.92 $117.44 15401 T Skin heterograft add-on 0026 12.11 $587.18 $277.92 $117.44 15570 T Form skin pedicle flap 0026 12.11 $587.18 $277.92 $117.44 15572 T Form skin pedicle flap 0026 12.11 $587.18 $277.92 $117.44 15574 T Form skin pedicle flap 0026 12.11 $587.18 $277.92 $117.44 15576 T Form skin pedicle flap 0026 12.11 $587.18 $277.92 $117.44 15600 T Skin graft 0026 12.11 $587.18 $277.92 $117.44 15610 T Skin graft 0026 12.11 $587.18 $277.92 $117.44 15620 T Skin graft 0026 12.11 $587.18 $277.92 $117.44 15630 T Skin graft 0026 12.11 $587.18 $277.92 $117.44 15650 T Transfer skin pedicle flap 0026 12.11 $587.18 $277.92 $117.44 15732 T Muscle-skin graft, head/neck 0027 15.80 $766.10 $383.10 $153.22 15734 T Muscle-skin graft, trunk 0027 15.80 $766.10 $383.10 $153.22 15736 T Muscle-skin graft, arm 0027 15.80 $766.10 $383.10 $153.22 15738 T Muscle-skin graft, leg 0027 15.80 $766.10 $383.10 $153.22 15740 T Island pedicle flap graft 0027 15.80 $766.10 $383.10 $153.22 15750 T Neurovascular pedicle graft 0027 15.80 $766.10 $383.10 $153.22 15756 C Free muscle flap, microvasc 15757 C Free skin flap, microvasc 15758 C Free fascial flap, microvasc 15760 T Composite skin graft 0027 15.80 $766.10 $383.10 $153.22 15770 T Derma-fat-fascia graft 0027 15.80 $766.10 $383.10 $153.22 15775 T Hair transplant punch grafts 0026 12.11 $587.18 $277.92 $117.44 15776 T Hair transplant punch grafts 0026 12.11 $587.18 $277.92 $117.44 15780 T Abrasion treatment of skin 0022 12.49 $605.60 $292.94 $121.12 15781 T Abrasion treatment of skin 0022 12.49 $605.60 $292.94 $121.12 15782 T Abrasion treatment of skin 0022 12.49 $605.60 $292.94 $121.12 15783 T Abrasion treatment of skin 0015 1.77 $85.82 $31.20 $17.16 15786 T Abrasion, lesion, single 0013 0.91 $44.12 $17.66 $8.82 Start Printed Page 18564 15787 T Abrasion, lesions, add-on 0016 3.53 $171.16 $74.67 $34.23 15788 T Chemical peel, face, epiderm 0013 0.91 $44.12 $17.66 $8.82 15789 T Chemical peel, face, dermal 0015 1.77 $85.82 $31.20 $17.16 15792 T Chemical peel, nonfacial 0016 3.53 $171.16 $74.67 $34.23 15793 T Chemical peel, nonfacial 0016 3.53 $171.16 $74.67 $34.23 15810 T Salabrasion 0016 3.53 $171.16 $74.67 $34.23 15811 T Salabrasion 0022 12.49 $605.60 $292.94 $121.12 15819 T Plastic surgery, neck 0026 12.11 $587.18 $277.92 $117.44 15820 T Revision of lower eyelid 0026 12.11 $587.18 $277.92 $117.44 15821 T Revision of lower eyelid 0026 12.11 $587.18 $277.92 $117.44 15822 T Revision of upper eyelid 0026 12.11 $587.18 $277.92 $117.44 15823 T Revision of upper eyelid 0026 12.11 $587.18 $277.92 $117.44 15824 T Removal of forehead wrinkles 0027 15.80 $766.10 $383.10 $153.22 15825 T Removal of neck wrinkles 0026 12.11 $587.18 $277.92 $117.44 15826 T Removal of brow wrinkles 0027 15.80 $766.10 $383.10 $153.22 15828 T Removal of face wrinkles 0027 15.80 $766.10 $383.10 $153.22 15829 T Removal of skin wrinkles 0026 12.11 $587.18 $277.92 $117.44 15831 T Excise excessive skin tissue 0027 15.80 $766.10 $383.10 $153.22 15832 T Excise excessive skin tissue 0027 15.80 $766.10 $383.10 $153.22 15833 T Excise excessive skin tissue 0027 15.80 $766.10 $383.10 $153.22 15834 T Excise excessive skin tissue 0027 15.80 $766.10 $383.10 $153.22 15835 T Excise excessive skin tissue 0026 12.11 $587.18 $277.92 $117.44 15836 T Excise excessive skin tissue 0027 15.80 $766.10 $383.10 $153.22 15837 T Excise excessive skin tissue 0027 15.80 $766.10 $383.10 $153.22 15838 T Excise excessive skin tissue 0022 12.49 $605.60 $292.94 $121.12 15839 T Excise excessive skin tissue 0027 15.80 $766.10 $383.10 $153.22 15840 T Graft for face nerve palsy 0027 15.80 $766.10 $383.10 $153.22 15841 T Graft for face nerve palsy 0027 15.80 $766.10 $383.10 $153.22 15842 T Graft for face nerve palsy 0027 15.80 $766.10 $383.10 $153.22 15845 T Skin and muscle repair, face 0027 15.80 $766.10 $383.10 $153.22 15850 T Removal of sutures 0013 0.91 $44.12 $17.66 $8.82 15851 T Removal of sutures 0013 0.91 $44.12 $17.66 $8.82 15852 T Dressing change, not for burn 0012 0.53 $25.70 $9.18 $5.14 15860 N Test for blood flow in graft 15876 T Suction assisted lipectomy 0027 15.80 $766.10 $383.10 $153.22 15877 T Suction assisted lipectomy 0027 15.80 $766.10 $383.10 $153.22 15878 T Suction assisted lipectomy 0027 15.80 $766.10 $383.10 $153.22 15879 T Suction assisted lipectomy 0027 15.80 $766.10 $383.10 $153.22 15920 T Removal of tail bone ulcer 0022 12.49 $605.60 $292.94 $121.12 15922 T Removal of tail bone ulcer 0027 15.80 $766.10 $383.10 $153.22 15931 T Remove sacrum pressure sore 0022 12.49 $605.60 $292.94 $121.12 15933 T Remove sacrum pressure sore 0022 12.49 $605.60 $292.94 $121.12 15934 T Remove sacrum pressure sore 0027 15.80 $766.10 $383.10 $153.22 15935 T Remove sacrum pressure sore 0027 15.80 $766.10 $383.10 $153.22 15936 T Remove sacrum pressure sore 0027 15.80 $766.10 $383.10 $153.22 15937 T Remove sacrum pressure sore 0027 15.80 $766.10 $383.10 $153.22 15940 T Remove hip pressure sore 0022 12.49 $605.60 $292.94 $121.12 15941 T Remove hip pressure sore 0022 12.49 $605.60 $292.94 $121.12 15944 T Remove hip pressure sore 0027 15.80 $766.10 $383.10 $153.22 15945 T Remove hip pressure sore 0027 15.80 $766.10 $383.10 $153.22 15946 T Remove hip pressure sore 0027 15.80 $766.10 $383.10 $153.22 15950 T Remove thigh pressure sore 0022 12.49 $605.60 $292.94 $121.12 15951 T Remove thigh pressure sore 0022 12.49 $605.60 $292.94 $121.12 15952 T Remove thigh pressure sore 0027 15.80 $766.10 $383.10 $153.22 15953 T Remove thigh pressure sore 0027 15.80 $766.10 $383.10 $153.22 15956 T Remove thigh pressure sore 0027 15.80 $766.10 $383.10 $153.22 15958 T Remove thigh pressure sore 0027 15.80 $766.10 $383.10 $153.22 15999 T Removal of pressure sore 0022 12.49 $605.60 $292.94 $121.12 16000 T Initial treatment of burn(s) 0015 1.77 $85.82 $31.20 $17.16 16010 T Treatment of burn(s) 0015 1.77 $85.82 $31.20 $17.16 16015 T Treatment of burn(s) 0017 12.45 $603.66 $289.16 $120.73 16020 T Treatment of burn(s) 0015 1.77 $85.82 $31.20 $17.16 16025 T Treatment of burn(s) 0014 1.50 $72.73 $24.55 $14.55 16030 T Treatment of burn(s) 0015 1.77 $85.82 $31.20 $17.16 16035 T Incision of burn scab 0020 6.51 $315.65 $130.53 $63.13 17000 T Destroy benign/premal lesion 0010 0.55 $26.67 $9.86 $5.33 17003 T Destroy lesions, 2-14 0010 0.55 $26.67 $9.86 $5.33 17004 T Destroy lesions, 15 or more 0011 2.72 $131.88 $50.01 $26.38 17106 T Destruction of skin lesions 0011 2.72 $131.88 $50.01 $26.38 17107 T Destruction of skin lesions 0011 2.72 $131.88 $50.01 $26.38 17108 T Destruction of skin lesions 0011 2.72 $131.88 $50.01 $26.38 17110 T Destruct lesion, 1-14 0010 0.55 $26.67 $9.86 $5.33 17111 T Destruct lesion, 15 or more 0011 2.72 $131.88 $50.01 $26.38 Start Printed Page 18565 17250 T Chemical cautery, tissue 0014 1.50 $72.73 $24.55 $14.55 17260 T Destruction of skin lesions 0013 0.91 $44.12 $17.66 $8.82 17261 T Destruction of skin lesions 0013 0.91 $44.12 $17.66 $8.82 17262 T Destruction of skin lesions 0013 0.91 $44.12 $17.66 $8.82 17263 T Destruction of skin lesions 0013 0.91 $44.12 $17.66 $8.82 17264 T Destruction of skin lesions 0015 1.77 $85.82 $31.20 $17.16 17266 T Destruction of skin lesions 0016 3.53 $171.16 $74.67 $34.23 17270 T Destruction of skin lesions 0015 1.77 $85.82 $31.20 $17.16 17271 T Destruction of skin lesions 0013 0.91 $44.12 $17.66 $8.82 17272 T Destruction of skin lesions 0013 0.91 $44.12 $17.66 $8.82 17273 T Destruction of skin lesions 0015 1.77 $85.82 $31.20 $17.16 17274 T Destruction of skin lesions 0015 1.77 $85.82 $31.20 $17.16 17276 T Destruction of skin lesions 0015 1.77 $85.82 $31.20 $17.16 17280 T Destruction of skin lesions 0015 1.77 $85.82 $31.20 $17.16 17281 T Destruction of skin lesions 0015 1.77 $85.82 $31.20 $17.16 17282 T Destruction of skin lesions 0015 1.77 $85.82 $31.20 $17.16 17283 T Destruction of skin lesions 0015 1.77 $85.82 $31.20 $17.16 17284 T Destruction of skin lesions 0016 3.53 $171.16 $74.67 $34.23 17286 T Destruction of skin lesions 0016 3.53 $171.16 $74.67 $34.23 17304 T Chemosurgery of skin lesion 0020 6.51 $315.65 $130.53 $63.13 17305 T 2nd stage chemosurgery 0020 6.51 $315.65 $130.53 $63.13 17306 T 3rd stage chemosurgery 0020 6.51 $315.65 $130.53 $63.13 17307 T Followup skin lesion therapy 0020 6.51 $315.65 $130.53 $63.13 17310 T Extensive skin chemosurgery 0020 6.51 $315.65 $130.53 $63.13 17340 T Cryotherapy of skin 0012 0.53 $25.70 $9.18 $5.14 17360 T Skin peel therapy 0016 3.53 $171.16 $74.67 $34.23 17380 T Hair removal by electrolysis 0016 3.53 $171.16 $74.67 $34.23 17999 T Skin tissue procedure 0004 1.84 $89.22 $32.57 $17.84 19000 T Drainage of breast lesion 0004 1.84 $89.22 $32.57 $17.84 19001 T Drain breast lesion add-on 0004 1.84 $89.22 $32.57 $17.84 19020 T Incision of breast lesion 0008 6.15 $298.20 $113.67 $59.64 19030 N Injection for breast x-ray 19100 T Biopsy of breast 0005 5.41 $262.32 $119.75 $52.46 19101 T Biopsy of breast 0029 12.85 $623.06 $303.50 $124.61 19110 T Nipple exploration 0029 12.85 $623.06 $303.50 $124.61 19112 T Excise breast duct fistula 0029 12.85 $623.06 $303.50 $124.61 19120 T Removal of breast lesion 0029 12.85 $623.06 $303.50 $124.61 19125 T Excision, breast lesion 0029 12.85 $623.06 $303.50 $124.61 19126 T Excision, addl breast lesion 0029 12.85 $623.06 $303.50 $124.61 19140 T Removal of breast tissue 0029 12.85 $623.06 $303.50 $124.61 19160 T Removal of breast tissue 0030 20.19 $978.95 $523.95 $195.79 19162 T Remove breast tissue, nodes 0030 20.19 $978.95 $523.95 $195.79 19180 T Removal of breast 0030 20.19 $978.95 $523.95 $195.79 19182 T Removal of breast 0030 20.19 $978.95 $523.95 $195.79 19200 C Removal of breast 19220 C Removal of breast 19240 C Removal of breast 19260 C Removal of chest wall lesion 19271 C Revision of chest wall 19272 C Extensive chest wall surgery 19290 T Place needle wire, breast 0029 12.85 $623.06 $303.50 $124.61 19291 T Place needle wire, breast 0029 12.85 $623.06 $303.50 $124.61 19316 T Suspension of breast 0030 20.19 $978.95 $523.95 $195.79 19318 T Reduction of large breast 0030 20.19 $978.95 $523.95 $195.79 19324 T Enlarge breast 0030 20.19 $978.95 $523.95 $195.79 19325 T Enlarge breast with implant 0030 20.19 $978.95 $523.95 $195.79 19328 T Removal of breast implant 0030 20.19 $978.95 $523.95 $195.79 19330 T Removal of implant material 0030 20.19 $978.95 $523.95 $195.79 19340 T Immediate breast prosthesis 0030 20.19 $978.95 $523.95 $195.79 19342 T Delayed breast prosthesis 0030 20.19 $978.95 $523.95 $195.79 19350 T Breast reconstruction 0030 20.19 $978.95 $523.95 $195.79 19355 T Correct inverted nipple(s) 0030 20.19 $978.95 $523.95 $195.79 19357 T Breast reconstruction 0030 20.19 $978.95 $523.95 $195.79 19361 C Breast reconstruction 19364 C Breast reconstruction 19366 T Breast reconstruction 0030 20.19 $978.95 $523.95 $195.79 19367 C Breast reconstruction 19368 C Breast reconstruction 19369 C Breast reconstruction 19370 T Surgery of breast capsule 0030 20.19 $978.95 $523.95 $195.79 19371 T Removal of breast capsule 0030 20.19 $978.95 $523.95 $195.79 19380 T Revise breast reconstruction 0030 20.19 $978.95 $523.95 $195.79 19396 T Design custom breast implant 0029 12.85 $623.06 $303.50 $124.61 Start Printed Page 18566 19499 T Breast surgery procedure 0029 12.85 $623.06 $303.50 $124.61 20000 T Incision of abscess 0006 2.00 $96.97 $33.95 $19.39 20005 T Incision of deep abscess 0049 15.04 $729.25 $356.95 $145.85 20100 T Explore wound, neck 0023 1.98 $96.00 $40.37 $19.20 20101 T Explore wound, chest 0026 12.11 $587.18 $277.92 $117.44 20102 T Explore wound, abdomen 0026 12.11 $587.18 $277.92 $117.44 20103 T Explore wound, extremity 0023 1.98 $96.00 $40.37 $19.20 20150 T Excise epiphyseal bar 0051 27.76 $1,346.00 $675.24 $269.20 20200 T Muscle biopsy 0020 6.51 $315.65 $130.53 $63.13 20205 T Deep muscle biopsy 0021 10.49 $508.63 $236.51 $101.73 20206 T Needle biopsy, muscle 0005 5.41 $262.32 $119.75 $52.46 20220 T Bone biopsy, trocar/needle 0019 4.00 $193.95 $78.91 $38.79 20225 T Bone biopsy, trocar/needle 0020 6.51 $315.65 $130.53 $63.13 20240 T Bone biopsy, excisional 0022 12.49 $605.60 $292.94 $121.12 20245 T Bone biopsy, excisional 0022 12.49 $605.60 $292.94 $121.12 20250 T Open bone biopsy 0049 15.04 $729.25 $356.95 $145.85 20251 T Open bone biopsy 0049 15.04 $729.25 $356.95 $145.85 20500 T Injection of sinus tract 0252 5.18 $251.16 $114.24 $50.23 20501 N Inject sinus tract for x-ray 20520 T Removal of foreign body 0019 4.00 $193.95 $78.91 $38.79 20525 T Removal of foreign body 0022 12.49 $605.60 $292.94 $121.12 20550 T Inject tendon/ligament/cyst 0040 2.11 $102.31 $40.60 $20.46 20600 T Drain/inject, joint/bursa 0040 2.11 $102.31 $40.60 $20.46 20605 T Drain/inject, joint/bursa 0040 2.11 $102.31 $40.60 $20.46 20610 T Drain/inject, joint/bursa 0040 2.11 $102.31 $40.60 $20.46 20615 T Treatment of bone cyst 0004 1.84 $89.22 $32.57 $17.84 20650 T Insert and remove bone pin 0049 15.04 $729.25 $356.95 $145.85 20660 C Apply, remove fixation device 20661 C Application of head brace 20662 C Application of pelvis brace 20663 C Application of thigh brace 20664 C Halo brace application 20665 N Removal of fixation device 20670 T Removal of support implant 0021 10.49 $508.63 $236.51 $101.73 20680 T Removal of support implant 0022 12.49 $605.60 $292.94 $121.12 20690 T Apply bone fixation device 0050 21.13 $1,024.53 $513.86 $204.91 20692 T Apply bone fixation device 0050 21.13 $1,024.53 $513.86 $204.91 20693 T Adjust bone fixation device 0049 15.04 $729.25 $356.95 $145.85 20694 T Remove bone fixation device 0049 15.04 $729.25 $356.95 $145.85 20802 C Replantation, arm, complete 20805 C Replant, forearm, complete 20808 C Replantation hand, complete 20816 C Replantation digit, complete 20822 C Replantation digit, complete 20824 C Replantation thumb, complete 20827 C Replantation thumb, complete 20838 C Replantation foot, complete 20900 T Removal of bone for graft 0050 21.13 $1,024.53 $513.86 $204.91 20902 T Removal of bone for graft 0050 21.13 $1,024.53 $513.86 $204.91 20910 T Remove cartilage for graft 0026 12.11 $587.18 $277.92 $117.44 20912 T Remove cartilage for graft 0026 12.11 $587.18 $277.92 $117.44 20920 T Removal of fascia for graft 0026 12.11 $587.18 $277.92 $117.44 20922 T Removal of fascia for graft 0026 12.11 $587.18 $277.92 $117.44 20924 T Removal of tendon for graft 0050 21.13 $1,024.53 $513.86 $204.91 20926 T Removal of tissue for graft 0026 12.11 $587.18 $277.92 $117.44 20930 C Spinal bone allograft 20931 C Spinal bone allograft 20936 C Spinal bone autograft 20937 C Spinal bone autograft 20938 C Spinal bone autograft 20950 T Fluid pressure, muscle 0008 6.15 $298.20 $113.67 $59.64 20955 C Fibula bone graft, microvasc 20956 C Iliac bone graft, microvasc 20957 C Mt bone graft, microvasc 20962 C Other bone graft, microvasc 20969 C Bone/skin graft, microvasc 20970 C Bone/skin graft, iliac crest 20972 C Bone/skin graft, metatarsal 20973 C Bone/skin graft, great toe 20974 A Electrical bone stimulation 20975 T Electrical bone stimulation 0049 15.04 $729.25 $356.95 $145.85 20979 T Us bone stimulation 0049 15.04 $729.25 $356.95 $145.85 20999 N Musculoskeletal surgery Start Printed Page 18567 21010 T Incision of jaw joint 0254 12.45 $603.66 $272.41 $120.73 21015 T Resection of facial tumor 0254 12.45 $603.66 $272.41 $120.73 21025 T Excision of bone, lower jaw 0256 25.40 $1,231.57 $623.05 $246.31 21026 T Excision of facial bone(s) 0256 25.40 $1,231.57 $623.05 $246.31 21029 T Contour of face bone lesion 0256 25.40 $1,231.57 $623.05 $246.31 21030 T Removal of face bone lesion 0254 12.45 $603.66 $272.41 $120.73 21031 T Remove exostosis, mandible 0253 12.02 $582.81 $284.00 $116.56 21032 T Remove exostosis, maxilla 0253 12.02 $582.81 $284.00 $116.56 21034 T Removal of face bone lesion 0256 25.40 $1,231.57 $623.05 $246.31 21040 T Removal of jaw bone lesion 0253 12.02 $582.81 $284.00 $116.56 21041 T Removal of jaw bone lesion 0256 25.40 $1,231.57 $623.05 $246.31 21044 T Removal of jaw bone lesion 0256 25.40 $1,231.57 $623.05 $246.31 21045 C Extensive jaw surgery 21050 T Removal of jaw joint 0256 25.40 $1,231.57 $623.05 $246.31 21060 T Remove jaw joint cartilage 0256 25.40 $1,231.57 $623.05 $246.31 21070 T Remove coronoid process 0256 25.40 $1,231.57 $623.05 $246.31 21076 T Prepare face/oral prosthesis 0254 12.45 $603.66 $272.41 $120.73 21077 T Prepare face/oral prosthesis 0256 25.40 $1,231.57 $623.05 $246.31 21079 T Prepare face/oral prosthesis 0256 25.40 $1,231.57 $623.05 $246.31 21080 T Prepare face/oral prosthesis 0256 25.40 $1,231.57 $623.05 $246.31 21081 T Prepare face/oral prosthesis 0256 25.40 $1,231.57 $623.05 $246.31 21082 T Prepare face/oral prosthesis 0256 25.40 $1,231.57 $623.05 $246.31 21083 T Prepare face/oral prosthesis 0256 25.40 $1,231.57 $623.05 $246.31 21084 T Prepare face/oral prosthesis 0256 25.40 $1,231.57 $623.05 $246.31 21085 T Prepare face/oral prosthesis 0253 12.02 $582.81 $284.00 $116.56 21086 T Prepare face/oral prosthesis 0256 25.40 $1,231.57 $623.05 $246.31 21087 T Prepare face/oral prosthesis 0256 25.40 $1,231.57 $623.05 $246.31 21088 T Prepare face/oral prosthesis 0256 25.40 $1,231.57 $623.05 $246.31 21089 T Prepare face/oral prosthesis 0253 12.02 $582.81 $284.00 $116.56 21100 T Maxillofacial fixation 0256 25.40 $1,231.57 $623.05 $246.31 21110 T Interdental fixation 0254 12.45 $603.66 $272.41 $120.73 21116 N Injection, jaw joint x-ray 21120 T Reconstruction of chin 0254 12.45 $603.66 $272.41 $120.73 21121 T Reconstruction of chin 0254 12.45 $603.66 $272.41 $120.73 21122 T Reconstruction of chin 0254 12.45 $603.66 $272.41 $120.73 21123 T Reconstruction of chin 0254 12.45 $603.66 $272.41 $120.73 21125 T Augmentation, lower jaw bone 0254 12.45 $603.66 $272.41 $120.73 21127 T Augmentation, lower jaw bone 0256 25.40 $1,231.57 $623.05 $246.31 21137 T Reduction of forehead 0254 12.45 $603.66 $272.41 $120.73 21138 T Reduction of forehead 0256 25.40 $1,231.57 $623.05 $246.31 21139 T Reduction of forehead 0256 25.40 $1,231.57 $623.05 $246.31 21141 C Reconstruct midface, lefort 21142 C Reconstruct midface, lefort 21143 C Reconstruct midface, lefort 21145 C Reconstruct midface, lefort 21146 C Reconstruct midface, lefort 21147 C Reconstruct midface, lefort 21150 C Reconstruct midface, lefort 21151 C Reconstruct midface, lefort 21154 C Reconstruct midface, lefort 21155 C Reconstruct midface, lefort 21159 C Reconstruct midface, lefort 21160 C Reconstruct midface, lefort 21172 C Reconstruct orbit/forehead 21175 C Reconstruct orbit/forehead 21179 C Reconstruct entire forehead 21180 C Reconstruct entire forehead 21181 T Contour cranial bone lesion 0254 12.45 $603.66 $272.41 $120.73 21182 C Reconstruct cranial bone 21183 C Reconstruct cranial bone 21184 C Reconstruct cranial bone 21188 C Reconstruction of midface 21193 C Reconstruct lower jaw bone 21194 C Reconstruct lower jaw bone 21195 C Reconstruct lower jaw bone 21196 C Reconstruct lower jaw bone 21198 T Reconstruct lower jaw bone 0256 25.40 $1,231.57 $623.05 $246.31 21206 T Reconstruct upper jaw bone 0256 25.40 $1,231.57 $623.05 $246.31 21208 T Augmentation of facial bones 0256 25.40 $1,231.57 $623.05 $246.31 21209 T Reduction of facial bones 0256 25.40 $1,231.57 $623.05 $246.31 21210 T Face bone graft 0256 25.40 $1,231.57 $623.05 $246.31 21215 T Lower jaw bone graft 0256 25.40 $1,231.57 $623.05 $246.31 21230 T Rib cartilage graft 0256 25.40 $1,231.57 $623.05 $246.31 Start Printed Page 18568 21235 T Ear cartilage graft 0254 12.45 $603.66 $272.41 $120.73 21240 T Reconstruction of jaw joint 0256 25.40 $1,231.57 $623.05 $246.31 21242 T Reconstruction of jaw joint 0256 25.40 $1,231.57 $623.05 $246.31 21243 T Reconstruction of jaw joint 0256 25.40 $1,231.57 $623.05 $246.31 21244 T Reconstruction of lower jaw 0256 25.40 $1,231.57 $623.05 $246.31 21245 T Reconstruction of jaw 0256 25.40 $1,231.57 $623.05 $246.31 21246 T Reconstruction of jaw 0256 25.40 $1,231.57 $623.05 $246.31 21247 C Reconstruct lower jaw bone 21248 T Reconstruction of jaw 0256 25.40 $1,231.57 $623.05 $246.31 21249 T Reconstruction of jaw 0256 25.40 $1,231.57 $623.05 $246.31 21255 C Reconstruct lower jaw bone 21256 C Reconstruction of orbit 21260 T Revise eye sockets 0256 25.40 $1,231.57 $623.05 $246.31 21261 T Revise eye sockets 0256 25.40 $1,231.57 $623.05 $246.31 21263 T Revise eye sockets 0256 25.40 $1,231.57 $623.05 $246.31 21267 T Revise eye sockets 0256 25.40 $1,231.57 $623.05 $246.31 21268 C Revise eye sockets 21270 T Augmentation, cheek bone 0256 25.40 $1,231.57 $623.05 $246.31 21275 T Revision, orbitofacial bones 0256 25.40 $1,231.57 $623.05 $246.31 21280 T Revision of eyelid 0256 25.40 $1,231.57 $623.05 $246.31 21282 T Revision of eyelid 0253 12.02 $582.81 $284.00 $116.56 21295 T Revision of jaw muscle/bone 0253 12.02 $582.81 $284.00 $116.56 21296 T Revision of jaw muscle/bone 0254 12.45 $603.66 $272.41 $120.73 21299 T Cranio/maxillofacial surgery 0253 12.02 $582.81 $284.00 $116.56 21300 T Treatment of skull fracture 0253 12.02 $582.81 $284.00 $116.56 21310 T Treatment of nose fracture 0253 12.02 $582.81 $284.00 $116.56 21315 T Treatment of nose fracture 0253 12.02 $582.81 $284.00 $116.56 21320 T Treatment of nose fracture 0253 12.02 $582.81 $284.00 $116.56 21325 T Treatment of nose fracture 0253 12.02 $582.81 $284.00 $116.56 21330 T Treatment of nose fracture 0254 12.45 $603.66 $272.41 $120.73 21335 T Treatment of nose fracture 0254 12.45 $603.66 $272.41 $120.73 21336 T Treat nasal septal fracture 0046 22.29 $1,080.78 $535.76 $216.16 21337 T Treat nasal septal fracture 0253 12.02 $582.81 $284.00 $116.56 21338 T Treat nasoethmoid fracture 0254 12.45 $603.66 $272.41 $120.73 21339 T Treat nasoethmoid fracture 0254 12.45 $603.66 $272.41 $120.73 21340 T Treatment of nose fracture 0256 25.40 $1,231.57 $623.05 $246.31 21343 C Treatment of sinus fracture 21344 C Treatment of sinus fracture 21345 T Treat nose/jaw fracture 0254 12.45 $603.66 $272.41 $120.73 21346 C Treat nose/jaw fracture 21347 C Treat nose/jaw fracture 21348 C Treat nose/jaw fracture 21355 T Treat cheek bone fracture 0256 25.40 $1,231.57 $623.05 $246.31 21356 C Treat cheek bone fracture 21360 C Treat cheek bone fracture 21365 C Treat cheek bone fracture 21366 C Treat cheek bone fracture 21385 C Treat eye socket fracture 21386 C Treat eye socket fracture 21387 C Treat eye socket fracture 21390 C Treat eye socket fracture 21395 C Treat eye socket fracture 21400 T Treat eye socket fracture 0252 5.18 $251.16 $114.24 $50.23 21401 T Treat eye socket fracture 0253 12.02 $582.81 $284.00 $116.56 21406 T Treat eye socket fracture 0256 25.40 $1,231.57 $623.05 $246.31 21407 T Treat eye socket fracture 0256 25.40 $1,231.57 $623.05 $246.31 21408 C Treat eye socket fracture 21421 T Treat mouth roof fracture 0254 12.45 $603.66 $272.41 $120.73 21422 C Treat mouth roof fracture 21423 C Treat mouth roof fracture 21431 C Treat craniofacial fracture 21432 C Treat craniofacial fracture 21433 C Treat craniofacial fracture 21435 C Treat craniofacial fracture 21436 C Treat craniofacial fracture 21440 T Treat dental ridge fracture 0253 12.02 $582.81 $284.00 $116.56 21445 T Treat dental ridge fracture 0254 12.45 $603.66 $272.41 $120.73 21450 T Treat lower jaw fracture 0251 1.68 $81.46 $27.99 $16.29 21451 T Treat lower jaw fracture 0254 12.45 $603.66 $272.41 $120.73 21452 T Treat lower jaw fracture 0253 12.02 $582.81 $284.00 $116.56 21453 T Treat lower jaw fracture 0256 25.40 $1,231.57 $623.05 $246.31 21454 T Treat lower jaw fracture 0254 12.45 $603.66 $272.41 $120.73 21461 T Treat lower jaw fracture 0256 25.40 $1,231.57 $623.05 $246.31 Start Printed Page 18569 21462 T Treat lower jaw fracture 0256 25.40 $1,231.57 $623.05 $246.31 21465 T Treat lower jaw fracture 0256 25.40 $1,231.57 $623.05 $246.31 21470 T Treat lower jaw fracture 0256 25.40 $1,231.57 $623.05 $246.31 21480 T Reset dislocated jaw 0251 1.68 $81.46 $27.99 $16.29 21485 T Reset dislocated jaw 0253 12.02 $582.81 $284.00 $116.56 21490 T Repair dislocated jaw 0256 25.40 $1,231.57 $623.05 $246.31 21493 T Treat hyoid bone fracture 0252 5.18 $251.16 $114.24 $50.23 21494 T Treat hyoid bone fracture 0252 5.18 $251.16 $114.24 $50.23 21495 C Treat hyoid bone fracture 21497 T Interdental wiring 0253 12.02 $582.81 $284.00 $116.56 21499 T Head surgery procedure 0253 12.02 $582.81 $284.00 $116.56 21501 T Drain neck/chest lesion 0008 6.15 $298.20 $113.67 $59.64 21502 T Drain chest lesion 0050 21.13 $1,024.53 $513.86 $204.91 21510 C Drainage of bone lesion 21550 T Biopsy of neck/chest 0019 4.00 $193.95 $78.91 $38.79 21555 T Remove lesion, neck/chest 0022 12.49 $605.60 $292.94 $121.12 21556 T Remove lesion, neck/chest 0022 12.49 $605.60 $292.94 $121.12 21557 C Remove tumor, neck/chest 21600 T Partial removal of rib 0050 21.13 $1,024.53 $513.86 $204.91 21610 T Partial removal of rib 0050 21.13 $1,024.53 $513.86 $204.91 21615 C Removal of rib 21616 C Removal of rib and nerves 21620 C Partial removal of sternum 21627 C Sternal debridement 21630 C Extensive sternum surgery 21632 C Extensive sternum surgery 21700 T Revision of neck muscle 0008 6.15 $298.20 $113.67 $59.64 21705 C Revision of neck muscle/rib 21720 T Revision of neck muscle 0008 6.15 $298.20 $113.67 $59.64 21725 T Revision of neck muscle 0008 6.15 $298.20 $113.67 $59.64 21740 C Reconstruction of sternum 21750 C Repair of sternum separation 21800 T Treatment of rib fracture 0043 1.64 $79.52 $25.46 $15.90 21805 T Treatment of rib fracture 0046 22.29 $1,080.78 $535.76 $216.16 21810 C Treatment of rib fracture(s) 21820 T Treat sternum fracture 0043 1.64 $79.52 $25.46 $15.90 21825 C Treat sternum fracture 21899 T Neck/chest surgery procedure 0252 5.18 $251.16 $114.24 $50.23 21920 T Biopsy soft tissue of back 0020 6.51 $315.65 $130.53 $63.13 21925 T Biopsy soft tissue of back 0022 12.49 $605.60 $292.94 $121.12 21930 T Remove lesion, back or flank 0022 12.49 $605.60 $292.94 $121.12 1935 T Remove tumor, back 0022 12.49 $605.60 $292.94 $121.12 22100 C Remove part of neck vertebra 22101 C Remove part, thorax vertebra 22102 C Remove part, lumbar vertebra 22103 C Remove extra spine segment 22110 C Remove part of neck vertebra 22112 C Remove part, thorax vertebra 22114 C Remove part, lumbar vertebra 22116 C Remove extra spine segment 22210 C Revision of neck spine 22212 C Revision of thorax spine 22214 C Revision of lumbar spine 22216 C Revise, extra spine segment 22220 C Revision of neck spine 22222 C Revision of thorax spine 22224 C Revision of lumbar spine 22226 C Revise, extra spine segment 22305 T Treat spine process fracture 0043 1.64 $79.52 $25.46 $15.90 22310 T Treat spine fracture 0043 1.64 $79.52 $25.46 $15.90 22315 T Treat spine fracture 0043 1.64 $79.52 $25.46 $15.90 22318 C Treat odontoid fx w/o graft 22319 C Treat odontoid fx w/graft 22325 C Treat spine fracture 22326 C Treat neck spine fracture 22327 C Treat thorax spine fracture 22328 C Treat each add spine fx 22505 T Manipulation of spine 0045 11.02 $534.33 $277.12 $106.87 22548 C Neck spine fusion 22554 C Neck spine fusion 22556 C Thorax spine fusion 22558 C Lumbar spine fusion 22585 C Additional spinal fusion Start Printed Page 18570 22590 C Spine & skull spinal fusion 22595 C Neck spinal fusion 22600 C Neck spine fusion 22610 C Thorax spine fusion 22612 C Lumbar spine fusion 22614 C Spine fusion, extra segment 22630 C Lumbar spine fusion 22632 C Spine fusion, extra segment 22800 C Fusion of spine 22802 C Fusion of spine 22804 C Fusion of spine 22808 C Fusion of spine 22810 C Fusion of spine 22812 C Fusion of spine 22818 C Kyphectomy, 1-2 segments 22819 C Kyphectomy, 3 or more 22830 C Exploration of spinal fusion 22840 C Insert spine fixation device 22841 C Insert spine fixation device 22842 C Insert spine fixation device 22843 C Insert spine fixation device 22844 C Insert spine fixation device 22845 C Insert spine fixation device 22846 C Insert spine fixation device 22847 C Insert spine fixation device 22848 C Insert pelv fixation device 22849 C Reinsert spinal fixation 22850 C Remove spine fixation device 22851 C Apply spine prosth device 22852 C Remove spine fixation device 22855 C Remove spine fixation device 22899 T Spine surgery procedure 0043 1.64 $79.52 $25.46 $15.90 22900 T Remove abdominal wall lesion 0022 12.49 $605.60 $292.94 $121.12 22999 T Abdomen surgery procedure 0022 12.49 $605.60 $292.94 $121.12 23000 T Removal of calcium deposits 0021 10.49 $508.63 $236.51 $101.73 23020 T Release shoulder joint 0051 27.76 $1,346.00 $675.24 $269.20 23030 T Drain shoulder lesion 0008 6.15 $298.20 $113.67 $59.64 23031 T Drain shoulder bursa 0008 6.15 $298.20 $113.67 $59.64 23035 C Drain shoulder bone lesion 23040 T Exploratory shoulder surgery 0050 21.13 $1,024.53 $513.86 $204.91 23044 T Exploratory shoulder surgery 0050 21.13 $1,024.53 $513.86 $204.91 23065 T Biopsy shoulder tissues 0021 10.49 $508.63 $236.51 $101.73 23066 T Biopsy shoulder tissues 0022 12.49 $605.60 $292.94 $121.12 23075 T Removal of shoulder lesion 0021 10.49 $508.63 $236.51 $101.73 23076 T Removal of shoulder lesion 0022 12.49 $605.60 $292.94 $121.12 23077 T Remove tumor of shoulder 0022 12.49 $605.60 $292.94 $121.12 23100 T Biopsy of shoulder joint 0049 15.04 $729.25 $356.95 $145.85 23101 T Shoulder joint surgery 0050 21.13 $1,024.53 $513.86 $204.91 23105 T Remove shoulder joint lining 0050 21.13 $1,024.53 $513.86 $204.91 23106 T Incision of collarbone joint 0050 21.13 $1,024.53 $513.86 $204.91 23107 T Explore treat shoulder joint 0050 21.13 $1,024.53 $513.86 $204.91 23120 T Partial removal, collar bone 0051 27.76 $1,346.00 $675.24 $269.20 23125 C Removal of collar bone 23130 T Remove shoulder bone, part 0051 27.76 $1,346.00 $675.24 $269.20 23140 T Removal of bone lesion 0049 15.04 $729.25 $356.95 $145.85 23145 T Removal of bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 23146 T Removal of bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 23150 T Removal of humerus lesion 0050 21.13 $1,024.53 $513.86 $204.91 23155 T Removal of humerus lesion 0050 21.13 $1,024.53 $513.86 $204.91 23156 T Removal of humerus lesion 0050 21.13 $1,024.53 $513.86 $204.91 23170 T Remove collar bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 23172 T Remove shoulder blade lesion 0050 21.13 $1,024.53 $513.86 $204.91 23174 T Remove humerus lesion 0050 21.13 $1,024.53 $513.86 $204.91 23180 T Remove collar bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 23182 T Remove shoulder blade lesion 0050 21.13 $1,024.53 $513.86 $204.91 23184 T Remove humerus lesion 0050 21.13 $1,024.53 $513.86 $204.91 23190 T Partial removal of scapula 0050 21.13 $1,024.53 $513.86 $204.91 23195 C Removal of head of humerus 23200 C Removal of collar bone 23210 C Removal of shoulder blade 23220 C Partial removal of humerus 23221 C Partial removal of humerus 23222 C Partial removal of humerus Start Printed Page 18571 23330 T Remove shoulder foreign body 0019 4.00 $193.95 $78.91 $38.79 23331 T Remove shoulder foreign body 0022 12.49 $605.60 $292.94 $121.12 23332 C Remove shoulder foreign body 23350 N Injection for shoulder x-ray 23395 C Muscle transfer, shoulder/arm 23397 C Muscle transfers 23400 C Fixation of shoulder blade 23405 T Incision of tendon & muscle 0050 21.13 $1,024.53 $513.86 $204.91 23406 T Incise tendon(s) & muscle(s) 0050 21.13 $1,024.53 $513.86 $204.91 23410 T Repair of tendon(s) 0052 36.16 $1,753.29 $930.91 $350.66 23412 T Repair of tendon(s) 0052 36.16 $1,753.29 $930.91 $350.66 23415 T Release of shoulder ligament 0051 27.76 $1,346.00 $675.24 $269.20 23420 T Repair of shoulder 0052 36.16 $1,753.29 $930.91 $350.66 23430 T Repair biceps tendon 0052 36.16 $1,753.29 $930.91 $350.66 23440 C Remove/transplant tendon 23450 T Repair shoulder capsule 0052 36.16 $1,753.29 $930.91 $350.66 23455 T Repair shoulder capsule 0052 36.16 $1,753.29 $930.91 $350.66 23460 T Repair shoulder capsule 0052 36.16 $1,753.29 $930.91 $350.66 23462 T Repair shoulder capsule 0052 36.16 $1,753.29 $930.91 $350.66 23465 T Repair shoulder capsule 0052 36.16 $1,753.29 $930.91 $350.66 23466 T Repair shoulder capsule 0052 36.16 $1,753.29 $930.91 $350.66 23470 C Reconstruct shoulder joint 23472 C Reconstruct shoulder joint 23480 T Revision of collar bone 0051 27.76 $1,346.00 $675.24 $269.20 23485 T Revision of collar bone 0051 27.76 $1,346.00 $675.24 $269.20 23490 T Reinforce clavicle 0051 27.76 $1,346.00 $675.24 $269.20 23491 T Reinforce shoulder bones 0051 27.76 $1,346.00 $675.24 $269.20 23500 T Treat clavicle fracture 0043 1.64 $79.52 $25.46 $15.90 23505 T Treat clavicle fracture 0043 1.64 $79.52 $25.46 $15.90 23515 T Treat clavicle fracture 0046 22.29 $1,080.78 $535.76 $216.16 23520 T Treat clavicle dislocation 0043 1.64 $79.52 $25.46 $15.90 23525 T Treat clavicle dislocation 0043 1.64 $79.52 $25.46 $15.90 23530 T Treat clavicle dislocation 0046 22.29 $1,080.78 $535.76 $216.16 23532 T Treat clavicle dislocation 0046 22.29 $1,080.78 $535.76 $216.16 23540 T Treat clavicle dislocation 0043 1.64 $79.52 $25.46 $15.90 23545 T Treat clavicle dislocation 0043 1.64 $79.52 $25.46 $15.90 23550 T Treat clavicle dislocation 0046 22.29 $1,080.78 $535.76 $216.16 23552 T Treat clavicle dislocation 0046 22.29 $1,080.78 $535.76 $216.16 23570 T Treat shoulder blade fx 0043 1.64 $79.52 $25.46 $15.90 23575 T Treat shoulder blade fx 0043 1.64 $79.52 $25.46 $15.90 23585 T Treat scapula fracture 0046 22.29 $1,080.78 $535.76 $216.16 23600 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 23605 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 23615 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 23616 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 23620 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 23625 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 23630 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 23650 T Treat shoulder dislocation 0043 1.64 $79.52 $25.46 $15.90 23655 T Treat shoulder dislocation 0045 11.02 $534.33 $277.12 $106.87 23660 T Treat shoulder dislocation 0046 22.29 $1,080.78 $535.76 $216.16 23665 T Treat dislocation/fracture 0044 2.17 $105.22 $38.08 $21.04 23670 T Treat dislocation/fracture 0046 22.29 $1,080.78 $535.76 $216.16 23675 T Treat dislocation/fracture 0044 2.17 $105.22 $38.08 $21.04 23680 T Treat dislocation/fracture 0046 22.29 $1,080.78 $535.76 $216.16 23700 T Fixation of shoulder 0045 11.02 $534.33 $277.12 $106.87 23800 T Fusion of shoulder joint 0051 27.76 $1,346.00 $675.24 $269.20 23802 T Fusion of shoulder joint 0051 27.76 $1,346.00 $675.24 $269.20 23900 C Amputation of arm & girdle 23920 C Amputation at shoulder joint 23921 T Amputation follow-up surgery 0026 12.11 $587.18 $277.92 $117.44 23929 T Shoulder surgery procedure 0043 1.64 $79.52 $25.46 $15.90 23930 T Drainage of arm lesion 0008 6.15 $298.20 $113.67 $59.64 23931 T Drainage of arm bursa 0008 6.15 $298.20 $113.67 $59.64 23935 T Drain arm/elbow bone lesion 0049 15.04 $729.25 $356.95 $145.85 24000 T Exploratory elbow surgery 0050 21.13 $1,024.53 $513.86 $204.91 24006 T Release elbow joint 0050 21.13 $1,024.53 $513.86 $204.91 24065 T Biopsy arm/elbow soft tissue 0020 6.51 $315.65 $130.53 $63.13 24066 T Biopsy arm/elbow soft tissue 0020 6.51 $315.65 $130.53 $63.13 24075 T Remove arm/elbow lesion 0021 10.49 $508.63 $236.51 $101.73 24076 T Remove arm/elbow lesion 0022 12.49 $605.60 $292.94 $121.12 24077 T Remove tumor of arm/elbow 0022 12.49 $605.60 $292.94 $121.12 24100 T Biopsy elbow joint lining 0049 15.04 $729.25 $356.95 $145.85 Start Printed Page 18572 24101 T Explore/treat elbow joint 0050 21.13 $1,024.53 $513.86 $204.91 24102 T Remove elbow joint lining 0050 21.13 $1,024.53 $513.86 $204.91 24105 T Removal of elbow bursa 0049 15.04 $729.25 $356.95 $145.85 24110 T Remove humerus lesion 0049 15.04 $729.25 $356.95 $145.85 24115 T Remove/graft bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 24116 T Remove/graft bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 24120 T Remove elbow lesion 0049 15.04 $729.25 $356.95 $145.85 24125 T Remove/graft bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 24126 T Remove/graft bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 24130 T Removal of head of radius 0050 21.13 $1,024.53 $513.86 $204.91 24134 T Removal of arm bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 24136 T Remove radius bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 24138 T Remove elbow bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 24140 T Partial removal of arm bone 0050 21.13 $1,024.53 $513.86 $204.91 24145 T Partial removal of radius 0050 21.13 $1,024.53 $513.86 $204.91 24147 T Partial removal of elbow 0050 21.13 $1,024.53 $513.86 $204.91 24149 C Radical resection of elbow 24150 C Extensive humerus surgery 24151 C Extensive humerus surgery 24152 C Extensive radius surgery 24153 C Extensive radius surgery 24155 T Removal of elbow joint 0051 27.76 $1,346.00 $675.24 $269.20 24160 T Remove elbow joint implant 0050 21.13 $1,024.53 $513.86 $204.91 24164 T Remove radius head implant 0050 21.13 $1,024.53 $513.86 $204.91 24200 T Removal of arm foreign body 0019 4.00 $193.95 $78.91 $38.79 24201 T Removal of arm foreign body 0021 10.49 $508.63 $236.51 $101.73 24220 N Injection for elbow x-ray 24301 T Muscle/tendon transfer 0050 21.13 $1,024.53 $513.86 $204.91 24305 T Arm tendon lengthening 0050 21.13 $1,024.53 $513.86 $204.91 24310 T Revision of arm tendon 0049 15.04 $729.25 $356.95 $145.85 24320 T Repair of arm tendon 0051 27.76 $1,346.00 $675.24 $269.20 24330 T Revision of arm muscles 0051 27.76 $1,346.00 $675.24 $269.20 24331 T Revision of arm muscles 0051 27.76 $1,346.00 $675.24 $269.20 24340 T Repair of biceps tendon 0051 27.76 $1,346.00 $675.24 $269.20 24341 T Repair arm tendon/muscle 0051 27.76 $1,346.00 $675.24 $269.20 24342 T Repair of ruptured tendon 0051 27.76 $1,346.00 $675.24 $269.20 24350 T Repair of tennis elbow 0050 21.13 $1,024.53 $513.86 $204.91 24351 T Repair of tennis elbow 0050 21.13 $1,024.53 $513.86 $204.91 24352 T Repair of tennis elbow 0050 21.13 $1,024.53 $513.86 $204.91 24354 T Repair of tennis elbow 0050 21.13 $1,024.53 $513.86 $204.91 24356 T Revision of tennis elbow 0050 21.13 $1,024.53 $513.86 $204.91 24360 T Reconstruct elbow joint 0047 22.09 $1,071.08 $537.03 $214.22 24361 T Reconstruct elbow joint 0048 29.06 $1,409.03 $725.94 $281.81 24362 T Reconstruct elbow joint 0048 29.06 $1,409.03 $725.94 $281.81 24363 T Replace elbow joint 0048 29.06 $1,409.03 $725.94 $281.81 24365 T Reconstruct head of radius 0047 22.09 $1,071.08 $537.03 $214.22 24366 T Reconstruct head of radius 0048 29.06 $1,409.03 $725.94 $281.81 24400 T Revision of humerus 0050 21.13 $1,024.53 $513.86 $204.91 24410 T Revision of humerus 0050 21.13 $1,024.53 $513.86 $204.91 24420 T Revision of humerus 0051 27.76 $1,346.00 $675.24 $269.20 24430 T Repair of humerus 0051 27.76 $1,346.00 $675.24 $269.20 24435 T Repair humerus with graft 0051 27.76 $1,346.00 $675.24 $269.20 24470 T Revision of elbow joint 0051 27.76 $1,346.00 $675.24 $269.20 24495 T Decompression of forearm 0050 21.13 $1,024.53 $513.86 $204.91 24498 T Reinforce humerus 0051 27.76 $1,346.00 $675.24 $269.20 24500 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 24505 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 24515 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 24516 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 24530 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 24535 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 24538 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 24545 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 24546 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 24560 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 24565 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 24566 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 24575 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 24576 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 24577 T Treat humerus fracture 0044 2.17 $105.22 $38.08 $21.04 24579 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 24582 T Treat humerus fracture 0046 22.29 $1,080.78 $535.76 $216.16 24586 T Treat elbow fracture 0046 22.29 $1,080.78 $535.76 $216.16 Start Printed Page 18573 24587 T Treat elbow fracture 0046 22.29 $1,080.78 $535.76 $216.16 24600 T Treat elbow dislocation 0044 2.17 $105.22 $38.08 $21.04 24605 T Treat elbow dislocation 0045 11.02 $534.33 $277.12 $106.87 24615 T Treat elbow dislocation 0046 22.29 $1,080.78 $535.76 $216.16 24620 T Treat elbow fracture 0044 2.17 $105.22 $38.08 $21.04 24635 T Treat elbow fracture 0046 22.29 $1,080.78 $535.76 $216.16 24640 T Treat elbow dislocation 0044 2.17 $105.22 $38.08 $21.04 24650 T Treat radius fracture 0044 2.17 $105.22 $38.08 $21.04 24655 T Treat radius fracture 0044 2.17 $105.22 $38.08 $21.04 24665 T Treat radius fracture 0046 22.29 $1,080.78 $535.76 $216.16 24666 T Treat radius fracture 0046 22.29 $1,080.78 $535.76 $216.16 24670 T Treat ulnar fracture 0044 2.17 $105.22 $38.08 $21.04 24675 T Treat ulnar fracture 0044 2.17 $105.22 $38.08 $21.04 24685 T Treat ulnar fracture 0046 22.29 $1,080.78 $535.76 $216.16 24800 T Fusion of elbow joint 0051 27.76 $1,346.00 $675.24 $269.20 24802 T Fusion/graft of elbow joint 0051 27.76 $1,346.00 $675.24 $269.20 24900 C Amputation of upper arm 24920 C Amputation of upper arm 24925 T Amputation follow-up surgery 0049 15.04 $729.25 $356.95 $145.85 24930 C Amputation follow-up surgery 24931 C Amputate upper arm & implant 24935 T Revision of amputation 0052 36.16 $1,753.29 $930.91 $350.66 24940 C Revision of upper arm 24999 T Upper arm/elbow surgery 0044 2.17 $105.22 $38.08 $21.04 25000 T Incision of tendon sheath 0049 15.04 $729.25 $356.95 $145.85 25020 T Decompression of forearm 0049 15.04 $729.25 $356.95 $145.85 25023 T Decompression of forearm 0050 21.13 $1,024.53 $513.86 $204.91 25028 T Drainage of forearm lesion 0049 15.04 $729.25 $356.95 $145.85 25031 T Drainage of forearm bursa 0049 15.04 $729.25 $356.95 $145.85 25035 T Treat forearm bone lesion 0049 15.04 $729.25 $356.95 $145.85 25040 T Explore/treat wrist joint 0050 21.13 $1,024.53 $513.86 $204.91 25065 T Biopsy forearm soft tissues 0020 6.51 $315.65 $130.53 $63.13 25066 T Biopsy forearm soft tissues 0022 12.49 $605.60 $292.94 $121.12 25075 T Removal of forearm lesion 0020 6.51 $315.65 $130.53 $63.13 25076 T Removal of forearm lesion 0022 12.49 $605.60 $292.94 $121.12 25077 T Remove tumor, forearm/wrist 0022 12.49 $605.60 $292.94 $121.12 25085 T Incision of wrist capsule 0049 15.04 $729.25 $356.95 $145.85 25100 T Biopsy of wrist joint 0049 15.04 $729.25 $356.95 $145.85 25101 T Explore/treat wrist joint 0050 21.13 $1,024.53 $513.86 $204.91 25105 T Remove wrist joint lining 0050 21.13 $1,024.53 $513.86 $204.91 25107 T Remove wrist joint cartilage 0050 21.13 $1,024.53 $513.86 $204.91 25110 T Remove wrist tendon lesion 0049 15.04 $729.25 $356.95 $145.85 25111 T Remove wrist tendon lesion 0053 11.32 $548.87 $253.49 $109.77 25112 T Reremove wrist tendon lesion 0053 11.32 $548.87 $253.49 $109.77 25115 T Remove wrist/forearm lesion 0049 15.04 $729.25 $356.95 $145.85 25116 T Remove wrist/forearm lesion 0049 15.04 $729.25 $356.95 $145.85 25118 T Excise wrist tendon sheath 0050 21.13 $1,024.53 $513.86 $204.91 25119 T Partial removal of ulna 0050 21.13 $1,024.53 $513.86 $204.91 25120 T Removal of forearm lesion 0050 21.13 $1,024.53 $513.86 $204.91 25125 T Remove/graft forearm lesion 0050 21.13 $1,024.53 $513.86 $204.91 25126 T Remove/graft forearm lesion 0050 21.13 $1,024.53 $513.86 $204.91 25130 T Removal of wrist lesion 0050 21.13 $1,024.53 $513.86 $204.91 25135 T Remove & graft wrist lesion 0050 21.13 $1,024.53 $513.86 $204.91 25136 T Remove & graft wrist lesion 0050 21.13 $1,024.53 $513.86 $204.91 25145 T Remove forearm bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 25150 T Partial removal of ulna 0050 21.13 $1,024.53 $513.86 $204.91 25151 T Partial removal of radius 0050 21.13 $1,024.53 $513.86 $204.91 25170 C Extensive forearm surgery 25210 T Removal of wrist bone 0054 19.66 $953.26 $472.33 $190.65 25215 T Removal of wrist bones 0054 19.66 $953.26 $472.33 $190.65 25230 T Partial removal of radius 0050 21.13 $1,024.53 $513.86 $204.91 25240 T Partial removal of ulna 0050 21.13 $1,024.53 $513.86 $204.91 25246 N Injection for wrist x-ray 25248 T Remove forearm foreign body 0049 15.04 $729.25 $356.95 $145.85 25250 T Removal of wrist prosthesis 0050 21.13 $1,024.53 $513.86 $204.91 25251 T Removal of wrist prosthesis 0050 21.13 $1,024.53 $513.86 $204.91 25260 T Repair forearm tendon/muscle 0050 21.13 $1,024.53 $513.86 $204.91 25263 T Repair forearm tendon/muscle 0050 21.13 $1,024.53 $513.86 $204.91 25265 T Repair forearm tendon/muscle 0050 21.13 $1,024.53 $513.86 $204.91 25270 T Repair forearm tendon/muscle 0050 21.13 $1,024.53 $513.86 $204.91 25272 T Repair forearm tendon/muscle 0050 21.13 $1,024.53 $513.86 $204.91 25274 T Repair forearm tendon/muscle 0050 21.13 $1,024.53 $513.86 $204.91 25280 T Revise wrist/forearm tendon 0050 21.13 $1,024.53 $513.86 $204.91 Start Printed Page 18574 25290 T Incise wrist/forearm tendon 0050 21.13 $1,024.53 $513.86 $204.91 25295 T Release wrist/forearm tendon 0049 15.04 $729.25 $356.95 $145.85 25300 T Fusion of tendons at wrist 0050 21.13 $1,024.53 $513.86 $204.91 25301 T Fusion of tendons at wrist 0050 21.13 $1,024.53 $513.86 $204.91 25310 T Transplant forearm tendon 0051 27.76 $1,346.00 $675.24 $269.20 25312 T Transplant forearm tendon 0051 27.76 $1,346.00 $675.24 $269.20 25315 T Revise palsy hand tendon(s) 0051 27.76 $1,346.00 $675.24 $269.20 25316 T Revise palsy hand tendon(s) 0051 27.76 $1,346.00 $675.24 $269.20 25320 T Repair/revise wrist joint 0051 27.76 $1,346.00 $675.24 $269.20 25332 T Revise wrist joint 0047 22.09 $1,071.08 $537.03 $214.22 25335 T Realignment of hand 0051 27.76 $1,346.00 $675.24 $269.20 25337 T Reconstruct ulna/radioulnar 0051 27.76 $1,346.00 $675.24 $269.20 25350 T Revision of radius 0051 27.76 $1,346.00 $675.24 $269.20 25355 T Revision of radius 0051 27.76 $1,346.00 $675.24 $269.20 25360 T Revision of ulna 0050 21.13 $1,024.53 $513.86 $204.91 25365 T Revise radius & ulna 0050 21.13 $1,024.53 $513.86 $204.91 25370 T Revise radius or ulna 0051 27.76 $1,346.00 $675.24 $269.20 25375 T Revise radius & ulna 0051 27.76 $1,346.00 $675.24 $269.20 25390 C Shorten radius or ulna 25391 C Lengthen radius or ulna 25392 C Shorten radius & ulna 25393 C Lengthen radius & ulna 25400 T Repair radius or ulna 0050 21.13 $1,024.53 $513.86 $204.91 25405 C Repair/graft radius or ulna 25415 T Repair radius & ulna 0050 21.13 $1,024.53 $513.86 $204.91 25420 C Repair/graft radius & ulna 25425 T Repair/graft radius or ulna 0051 27.76 $1,346.00 $675.24 $269.20 25426 T Repair/graft radius & ulna 0051 27.76 $1,346.00 $675.24 $269.20 25440 T Repair/graft wrist bone 0051 27.76 $1,346.00 $675.24 $269.20 25441 T Reconstruct wrist joint 0048 29.06 $1,409.03 $725.94 $281.81 25442 T Reconstruct wrist joint 0048 29.06 $1,409.03 $725.94 $281.81 25443 T Reconstruct wrist joint 0048 29.06 $1,409.03 $725.94 $281.81 25444 T Reconstruct wrist joint 0048 29.06 $1,409.03 $725.94 $281.81 25445 T Reconstruct wrist joint 0048 29.06 $1,409.03 $725.94 $281.81 25446 T Wrist replacement 0048 29.06 $1,409.03 $725.94 $281.81 25447 T Repair wrist joint(s) 0047 22.09 $1,071.08 $537.03 $214.22 25449 T Remove wrist joint implant 0047 22.09 $1,071.08 $537.03 $214.22 25450 T Revision of wrist joint 0051 27.76 $1,346.00 $675.24 $269.20 25455 T Revision of wrist joint 0051 27.76 $1,346.00 $675.24 $269.20 25490 T Reinforce radius 0051 27.76 $1,346.00 $675.24 $269.20 25491 T Reinforce ulna 0051 27.76 $1,346.00 $675.24 $269.20 25492 T Reinforce radius and ulna 0051 27.76 $1,346.00 $675.24 $269.20 25500 T Treat fracture of radius 0044 2.17 $105.22 $38.08 $21.04 25505 T Treat fracture of radius 0044 2.17 $105.22 $38.08 $21.04 25515 T Treat fracture of radius 0046 22.29 $1,080.78 $535.76 $216.16 25520 T Treat fracture of radius 0044 2.17 $105.22 $38.08 $21.04 25525 T Treat fracture of radius 0046 22.29 $1,080.78 $535.76 $216.16 25526 T Treat fracture of radius 0046 22.29 $1,080.78 $535.76 $216.16 25530 T Treat fracture of ulna 0044 2.17 $105.22 $38.08 $21.04 25535 T Treat fracture of ulna 0044 2.17 $105.22 $38.08 $21.04 25545 T Treat fracture of ulna 0046 22.29 $1,080.78 $535.76 $216.16 25560 T Treat fracture radius & ulna 0044 2.17 $105.22 $38.08 $21.04 25565 T Treat fracture radius & ulna 0044 2.17 $105.22 $38.08 $21.04 25574 T Treat fracture radius & ulna 0046 22.29 $1,080.78 $535.76 $216.16 25575 T Treat fracture radius/ulna 0046 22.29 $1,080.78 $535.76 $216.16 25600 T Treat fracture radius/ulna 0044 2.17 $105.22 $38.08 $21.04 25605 T Treat fracture radius/ulna 0044 2.17 $105.22 $38.08 $21.04 25611 T Treat fracture radius/ulna 0046 22.29 $1,080.78 $535.76 $216.16 25620 T Treat fracture radius/ulna 0046 22.29 $1,080.78 $535.76 $216.16 25622 T Treat wrist bone fracture 0044 2.17 $105.22 $38.08 $21.04 25624 T Treat wrist bone fracture 0044 2.17 $105.22 $38.08 $21.04 25628 T Treat wrist bone fracture 0046 22.29 $1,080.78 $535.76 $216.16 25630 T Treat wrist bone fracture 0044 2.17 $105.22 $38.08 $21.04 25635 T Treat wrist bone fracture 0044 2.17 $105.22 $38.08 $21.04 25645 T Treat wrist bone fracture 0046 22.29 $1,080.78 $535.76 $216.16 25650 T Treat wrist bone fracture 0044 2.17 $105.22 $38.08 $21.04 25660 T Treat wrist dislocation 0044 2.17 $105.22 $38.08 $21.04 25670 T Treat wrist dislocation 0046 22.29 $1,080.78 $535.76 $216.16 25675 T Treat wrist dislocation 0044 2.17 $105.22 $38.08 $21.04 25676 T Treat wrist dislocation 0046 22.29 $1,080.78 $535.76 $216.16 25680 T Treat wrist fracture 0044 2.17 $105.22 $38.08 $21.04 25685 T Treat wrist fracture 0046 22.29 $1,080.78 $535.76 $216.16 25690 T Treat wrist dislocation 0044 2.17 $105.22 $38.08 $21.04 Start Printed Page 18575 25695 T Treat wrist dislocation 0046 22.29 $1,080.78 $535.76 $216.16 25800 T Fusion of wrist joint 0051 27.76 $1,346.00 $675.24 $269.20 25805 T Fusion/graft of wrist joint 0051 27.76 $1,346.00 $675.24 $269.20 25810 T Fusion/graft of wrist joint 0051 27.76 $1,346.00 $675.24 $269.20 25820 T Fusion of hand bones 0053 11.32 $548.87 $253.49 $109.77 25825 T Fuse hand bones with graft 0054 19.66 $953.26 $472.33 $190.65 25830 T Fusion, radioulnar jnt/ulna 0051 27.76 $1,346.00 $675.24 $269.20 25900 C Amputation of forearm 25905 C Amputation of forearm 25907 T Amputation follow-up surgery 0049 15.04 $729.25 $356.95 $145.85 25909 C Amputation follow-up surgery 25915 C Amputation of forearm 25920 C Amputate hand at wrist 25922 T Amputate hand at wrist 0049 15.04 $729.25 $356.95 $145.85 25924 C Amputation follow-up surgery 25927 C Amputation of hand 25929 T Amputation follow-up surgery 0026 12.11 $587.18 $277.92 $117.44 25931 C Amputation follow-up surgery 25999 T Forearm or wrist surgery 0044 2.17 $105.22 $38.08 $21.04 26010 T Drainage of finger abscess 0006 2.00 $96.97 $33.95 $19.39 26011 T Drainage of finger abscess 0007 3.68 $178.43 $72.03 $35.69 26020 T Drain hand tendon sheath 0053 11.32 $548.87 $253.49 $109.77 26025 T Drainage of palm bursa 0053 11.32 $548.87 $253.49 $109.77 26030 T Drainage of palm bursa(s) 0053 11.32 $548.87 $253.49 $109.77 26034 T Treat hand bone lesion 0053 11.32 $548.87 $253.49 $109.77 26035 T Decompress fingers/hand 0053 11.32 $548.87 $253.49 $109.77 26037 T Decompress fingers/hand 0053 11.32 $548.87 $253.49 $109.77 26040 T Release palm contracture 0054 19.66 $953.26 $472.33 $190.65 26045 T Release palm contracture 0054 19.66 $953.26 $472.33 $190.65 26055 T Incise finger tendon sheath 0053 11.32 $548.87 $253.49 $109.77 26060 T Incision of finger tendon 0053 11.32 $548.87 $253.49 $109.77 26070 T Explore/treat hand joint 0053 11.32 $548.87 $253.49 $109.77 26075 T Explore/treat finger joint 0053 11.32 $548.87 $253.49 $109.77 26080 T Explore/treat finger joint 0053 11.32 $548.87 $253.49 $109.77 26100 T Biopsy hand joint lining 0053 11.32 $548.87 $253.49 $109.77 26105 T Biopsy finger joint lining 0053 11.32 $548.87 $253.49 $109.77 26110 T Biopsy finger joint lining 0053 11.32 $548.87 $253.49 $109.77 26115 T Removal of hand lesion 0022 12.49 $605.60 $292.94 $121.12 26116 T Removal of hand lesion 0022 12.49 $605.60 $292.94 $121.12 26117 T Remove tumor, hand/finger 0022 12.49 $605.60 $292.94 $121.12 26121 T Release palm contracture 0054 19.66 $953.26 $472.33 $190.65 26123 T Release palm contracture 0054 19.66 $953.26 $472.33 $190.65 26125 T Release palm contracture 0054 19.66 $953.26 $472.33 $190.65 26130 T Remove wrist joint lining 0053 11.32 $548.87 $253.49 $109.77 26135 T Revise finger joint, each 0054 19.66 $953.26 $472.33 $190.65 26140 T Revise finger joint, each 0053 11.32 $548.87 $253.49 $109.77 26145 T Tendon excision, palm/finger 0053 11.32 $548.87 $253.49 $109.77 26160 T Remove tendon sheath lesion 0053 11.32 $548.87 $253.49 $109.77 26170 T Removal of palm tendon, each 0053 11.32 $548.87 $253.49 $109.77 26180 T Removal of finger tendon 0053 11.32 $548.87 $253.49 $109.77 26185 T Remove finger bone 0053 11.32 $548.87 $253.49 $109.77 26200 T Remove hand bone lesion 0053 11.32 $548.87 $253.49 $109.77 26205 T Remove/graft bone lesion 0054 19.66 $953.26 $472.33 $190.65 26210 T Removal of finger lesion 0053 11.32 $548.87 $253.49 $109.77 26215 T Remove/graft finger lesion 0053 11.32 $548.87 $253.49 $109.77 26230 T Partial removal of hand bone 0053 11.32 $548.87 $253.49 $109.77 26235 T Partial removal, finger bone 0053 11.32 $548.87 $253.49 $109.77 26236 T Partial removal, finger bone 0053 11.32 $548.87 $253.49 $109.77 26250 T Extensive hand surgery 0053 11.32 $548.87 $253.49 $109.77 26255 T Extensive hand surgery 0054 19.66 $953.26 $472.33 $190.65 26260 T Extensive finger surgery 0053 11.32 $548.87 $253.49 $109.77 26261 T Extensive finger surgery 0053 11.32 $548.87 $253.49 $109.77 26262 T Partial removal of finger 0053 11.32 $548.87 $253.49 $109.77 26320 T Removal of implant from hand 0020 6.51 $315.65 $130.53 $63.13 26350 T Repair finger/hand tendon 0054 19.66 $953.26 $472.33 $190.65 26352 T Repair/graft hand tendon 0054 19.66 $953.26 $472.33 $190.65 26356 T Repair finger/hand tendon 0054 19.66 $953.26 $472.33 $190.65 26357 T Repair finger/hand tendon 0054 19.66 $953.26 $472.33 $190.65 26358 T Repair/graft hand tendon 0054 19.66 $953.26 $472.33 $190.65 26370 T Repair finger/hand tendon 0054 19.66 $953.26 $472.33 $190.65 26372 T Repair/graft hand tendon 0054 19.66 $953.26 $472.33 $190.65 26373 T Repair finger/hand tendon 0054 19.66 $953.26 $472.33 $190.65 26390 T Revise hand/finger tendon 0054 19.66 $953.26 $472.33 $190.65 Start Printed Page 18576 26392 T Repair/graft hand tendon 0054 19.66 $953.26 $472.33 $190.65 26410 T Repair hand tendon 0053 11.32 $548.87 $253.49 $109.77 26412 T Repair/graft hand tendon 0054 19.66 $953.26 $472.33 $190.65 26415 T Excision, hand/finger tendon 0054 19.66 $953.26 $472.33 $190.65 26416 T Graft hand or finger tendon 0054 19.66 $953.26 $472.33 $190.65 26418 T Repair finger tendon 0053 11.32 $548.87 $253.49 $109.77 26420 T Repair/graft finger tendon 0054 19.66 $953.26 $472.33 $190.65 26426 T Repair finger/hand tendon 0054 19.66 $953.26 $472.33 $190.65 26428 T Repair/graft finger tendon 0054 19.66 $953.26 $472.33 $190.65 26432 T Repair finger tendon 0053 11.32 $548.87 $253.49 $109.77 26433 T Repair finger tendon 0053 11.32 $548.87 $253.49 $109.77 26434 T Repair/graft finger tendon 0054 19.66 $953.26 $472.33 $190.65 26437 T Realignment of tendons 0053 11.32 $548.87 $253.49 $109.77 26440 T Release palm/finger tendon 0053 11.32 $548.87 $253.49 $109.77 26442 T Release palm & finger tendon 0054 19.66 $953.26 $472.33 $190.65 26445 T Release hand/finger tendon 0053 11.32 $548.87 $253.49 $109.77 26449 T Release forearm/hand tendon 0054 19.66 $953.26 $472.33 $190.65 26450 T Incision of palm tendon 0053 11.32 $548.87 $253.49 $109.77 26455 T Incision of finger tendon 0053 11.32 $548.87 $253.49 $109.77 26460 T Incise hand/finger tendon 0053 11.32 $548.87 $253.49 $109.77 26471 T Fusion of finger tendons 0053 11.32 $548.87 $253.49 $109.77 26474 T Fusion of finger tendons 0053 11.32 $548.87 $253.49 $109.77 26476 T Tendon lengthening 0053 11.32 $548.87 $253.49 $109.77 26477 T Tendon shortening 0053 11.32 $548.87 $253.49 $109.77 26478 T Lengthening of hand tendon 0053 11.32 $548.87 $253.49 $109.77 26479 T Shortening of hand tendon 0053 11.32 $548.87 $253.49 $109.77 26480 T Transplant hand tendon 0054 19.66 $953.26 $472.33 $190.65 26483 T Transplant/graft hand tendon 0054 19.66 $953.26 $472.33 $190.65 26485 T Transplant palm tendon 0054 19.66 $953.26 $472.33 $190.65 26489 T Transplant/graft palm tendon 0054 19.66 $953.26 $472.33 $190.65 26490 T Revise thumb tendon 0054 19.66 $953.26 $472.33 $190.65 26492 T Tendon transfer with graft 0054 19.66 $953.26 $472.33 $190.65 26494 T Hand tendon/muscle transfer 0054 19.66 $953.26 $472.33 $190.65 26496 T Revise thumb tendon 0054 19.66 $953.26 $472.33 $190.65 26497 T Finger tendon transfer 0054 19.66 $953.26 $472.33 $190.65 26498 T Finger tendon transfer 0054 19.66 $953.26 $472.33 $190.65 26499 T Revision of finger 0054 19.66 $953.26 $472.33 $190.65 26500 T Hand tendon reconstruction 0053 11.32 $548.87 $253.49 $109.77 26502 T Hand tendon reconstruction 0054 19.66 $953.26 $472.33 $190.65 26504 T Hand tendon reconstruction 0054 19.66 $953.26 $472.33 $190.65 26508 T Release thumb contracture 0053 11.32 $548.87 $253.49 $109.77 26510 T Thumb tendon transfer 0054 19.66 $953.26 $472.33 $190.65 26516 T Fusion of knuckle joint 0054 19.66 $953.26 $472.33 $190.65 26517 T Fusion of knuckle joints 0054 19.66 $953.26 $472.33 $190.65 26518 T Fusion of knuckle joints 0054 19.66 $953.26 $472.33 $190.65 26520 T Release knuckle contracture 0053 11.32 $548.87 $253.49 $109.77 26525 T Release finger contracture 0053 11.32 $548.87 $253.49 $109.77 26530 T Revise knuckle joint 0047 22.09 $1,071.08 $537.03 $214.22 26531 T Revise knuckle with implant 0048 29.06 $1,409.03 $725.94 $281.81 26535 T Revise finger joint 0047 22.09 $1,071.08 $537.03 $214.22 26536 T Revise/implant finger joint 0048 29.06 $1,409.03 $725.94 $281.81 26540 T Repair hand joint 0053 11.32 $548.87 $253.49 $109.77 26541 T Repair hand joint with graft 0054 19.66 $953.26 $472.33 $190.65 26542 T Repair hand joint with graft 0053 11.32 $548.87 $253.49 $109.77 26545 T Reconstruct finger joint 0054 19.66 $953.26 $472.33 $190.65 26546 T Repair nonunion hand 0054 19.66 $953.26 $472.33 $190.65 26548 T Reconstruct finger joint 0054 19.66 $953.26 $472.33 $190.65 26550 T Construct thumb replacement 0054 19.66 $953.26 $472.33 $190.65 26551 C Great toe-hand transfer 26553 C Single transfer, toe-hand 26554 C Double transfer, toe-hand 26555 T Positional change of finger 0054 19.66 $953.26 $472.33 $190.65 26556 C Toe joint transfer 26560 T Repair of web finger 0053 11.32 $548.87 $253.49 $109.77 26561 T Repair of web finger 0054 19.66 $953.26 $472.33 $190.65 26562 T Repair of web finger 0054 19.66 $953.26 $472.33 $190.65 26565 T Correct metacarpal flaw 0054 19.66 $953.26 $472.33 $190.65 26567 T Correct finger deformity 0054 19.66 $953.26 $472.33 $190.65 26568 T Lengthen metacarpal/finger 0054 19.66 $953.26 $472.33 $190.65 26580 T Repair hand deformity 0054 19.66 $953.26 $472.33 $190.65 26585 T Repair finger deformity 0054 19.66 $953.26 $472.33 $190.65 26587 T Reconstruct extra finger 0053 11.32 $548.87 $253.49 $109.77 26590 T Repair finger deformity 0054 19.66 $953.26 $472.33 $190.65 Start Printed Page 18577 26591 T Repair muscles of hand 0054 19.66 $953.26 $472.33 $190.65 26593 T Release muscles of hand 0053 11.32 $548.87 $253.49 $109.77 26596 T Excision constricting tissue 0054 19.66 $953.26 $472.33 $190.65 26597 T Release of scar contracture 0054 19.66 $953.26 $472.33 $190.65 26600 T Treat metacarpal fracture 0044 2.17 $105.22 $38.08 $21.04 26605 T Treat metacarpal fracture 0044 2.17 $105.22 $38.08 $21.04 26607 T Treat metacarpal fracture 0044 2.17 $105.22 $38.08 $21.04 26608 T Treat metacarpal fracture 0046 22.29 $1,080.78 $535.76 $216.16 26615 T Treat metacarpal fracture 0046 22.29 $1,080.78 $535.76 $216.16 26641 T Treat thumb dislocation 0044 2.17 $105.22 $38.08 $21.04 26645 T Treat thumb fracture 0044 2.17 $105.22 $38.08 $21.04 26650 T Treat thumb fracture 0046 22.29 $1,080.78 $535.76 $216.16 26665 T Treat thumb fracture 0046 22.29 $1,080.78 $535.76 $216.16 26670 T Treat hand dislocation 0044 2.17 $105.22 $38.08 $21.04 26675 T Treat hand dislocation 0045 11.02 $534.33 $277.12 $106.87 26676 T Pin hand dislocation 0046 22.29 $1,080.78 $535.76 $216.16 26685 T Treat hand dislocation 0046 22.29 $1,080.78 $535.76 $216.16 26686 T Treat hand dislocation 0046 22.29 $1,080.78 $535.76 $216.16 26700 T Treat knuckle dislocation 0043 1.64 $79.52 $25.46 $15.90 26705 T Treat knuckle dislocation 0045 11.02 $534.33 $277.12 $106.87 26706 T Pin knuckle dislocation 0044 2.17 $105.22 $38.08 $21.04 26715 T Treat knuckle dislocation 0046 22.29 $1,080.78 $535.76 $216.16 26720 T Treat finger fracture, each 0043 1.64 $79.52 $25.46 $15.90 26725 T Treat finger fracture, each 0043 1.64 $79.52 $25.46 $15.90 26727 T Treat finger fracture, each 0046 22.29 $1,080.78 $535.76 $216.16 26735 T Treat finger fracture, each 0046 22.29 $1,080.78 $535.76 $216.16 26740 T Treat finger fracture, each 0043 1.64 $79.52 $25.46 $15.90 26742 T Treat finger fracture, each 0044 2.17 $105.22 $38.08 $21.04 26746 T Treat finger fracture, each 0046 22.29 $1,080.78 $535.76 $216.16 26750 T Treat finger fracture, each 0043 1.64 $79.52 $25.46 $15.90 26755 T Treat finger fracture, each 0043 1.64 $79.52 $25.46 $15.90 26756 T Pin finger fracture, each 0046 22.29 $1,080.78 $535.76 $216.16 26765 T Treat finger fracture, each 0046 22.29 $1,080.78 $535.76 $216.16 26770 T Treat finger dislocation 0043 1.64 $79.52 $25.46 $15.90 26775 T Treat finger dislocation 0045 11.02 $534.33 $277.12 $106.87 26776 T Pin finger dislocation 0046 22.29 $1,080.78 $535.76 $216.16 26785 T Treat finger dislocation 0046 22.29 $1,080.78 $535.76 $216.16 26820 T Thumb fusion with graft 0054 19.66 $953.26 $472.33 $190.65 26841 T Fusion of thumb 0054 19.66 $953.26 $472.33 $190.65 26842 T Thumb fusion with graft 0054 19.66 $953.26 $472.33 $190.65 26843 T Fusion of hand joint 0054 19.66 $953.26 $472.33 $190.65 26844 T Fusion/graft of hand joint 0054 19.66 $953.26 $472.33 $190.65 26850 T Fusion of knuckle 0054 19.66 $953.26 $472.33 $190.65 26852 T Fusion of knuckle with graft 0054 19.66 $953.26 $472.33 $190.65 26860 T Fusion of finger joint 0054 19.66 $953.26 $472.33 $190.65 26861 T Fusion of finger jnt, add-on 0054 19.66 $953.26 $472.33 $190.65 26862 T Fusion/graft of finger joint 0054 19.66 $953.26 $472.33 $190.65 26863 T Fuse/graft added joint 0054 19.66 $953.26 $472.33 $190.65 26910 T Amputate metacarpal bone 0054 19.66 $953.26 $472.33 $190.65 26951 T Amputation of finger/thumb 0053 11.32 $548.87 $253.49 $109.77 26952 T Amputation of finger/thumb 0053 11.32 $548.87 $253.49 $109.77 26989 T Hand/finger surgery 0043 1.64 $79.52 $25.46 $15.90 26990 T Drainage of pelvis lesion 0049 15.04 $729.25 $356.95 $145.85 26991 T Drainage of pelvis bursa 0049 15.04 $729.25 $356.95 $145.85 26992 C Drainage of bone lesion 27000 T Incision of hip tendon 0049 15.04 $729.25 $356.95 $145.85 27001 T Incision of hip tendon 0050 21.13 $1,024.53 $513.86 $204.91 27003 T Incision of hip tendon 0050 21.13 $1,024.53 $513.86 $204.91 27005 C Incision of hip tendon 27006 C Incision of hip tendons 27025 C Incision of hip/thigh fascia 27030 C Drainage of hip joint 27033 T Exploration of hip joint 0051 27.76 $1,346.00 $675.24 $269.20 27035 C Denervation of hip joint 27036 C Excision of hip joint/muscle 27040 T Biopsy of soft tissues 0021 10.49 $508.63 $236.51 $101.73 27041 T Biopsy of soft tissues 0022 12.49 $605.60 $292.94 $121.12 27047 T Remove hip/pelvis lesion 0022 12.49 $605.60 $292.94 $121.12 27048 T Remove hip/pelvis lesion 0022 12.49 $605.60 $292.94 $121.12 27049 T Remove tumor, hip/pelvis 0022 12.49 $605.60 $292.94 $121.12 27050 T Biopsy of sacroiliac joint 0049 15.04 $729.25 $356.95 $145.85 27052 T Biopsy of hip joint 0049 15.04 $729.25 $356.95 $145.85 27054 C Removal of hip joint lining Start Printed Page 18578 27060 T Removal of ischial bursa 0049 15.04 $729.25 $356.95 $145.85 27062 T Remove femur lesion/bursa 0049 15.04 $729.25 $356.95 $145.85 27065 T Removal of hip bone lesion 0049 15.04 $729.25 $356.95 $145.85 27066 T Removal of hip bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 27067 T Remove/graft hip bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 27070 C Partial removal of hip bone 27071 C Partial removal of hip bone 27075 C Extensive hip surgery 27076 C Extensive hip surgery 27077 C Extensive hip surgery 27078 C Extensive hip surgery 27079 C Extensive hip surgery 27080 T Removal of tail bone 0050 21.13 $1,024.53 $513.86 $204.91 27086 T Remove hip foreign body 0019 4.00 $193.95 $78.91 $38.79 27087 T Remove hip foreign body 0049 15.04 $729.25 $356.95 $145.85 27090 C Removal of hip prosthesis 27091 C Removal of hip prosthesis 27093 N Injection for hip x-ray 27095 N Injection for hip x-ray 27096 N Inject sacroiliac joint 27097 T Revision of hip tendon 0050 21.13 $1,024.53 $513.86 $204.91 27098 T Transfer tendon to pelvis 0050 21.13 $1,024.53 $513.86 $204.91 27100 T Transfer of abdominal muscle 0051 27.76 $1,346.00 $675.24 $269.20 27105 T Transfer of spinal muscle 0051 27.76 $1,346.00 $675.24 $269.20 27110 T Transfer of iliopsoas muscle 0051 27.76 $1,346.00 $675.24 $269.20 27111 T Transfer of iliopsoas muscle 0051 27.76 $1,346.00 $675.24 $269.20 27120 C Reconstruction of hip socket 27122 C Reconstruction of hip socket 27125 C Partial hip replacement 27130 C Total hip replacement 27132 C Total hip replacement 27134 C Revise hip joint replacement 27137 C Revise hip joint replacement 27138 C Revise hip joint replacement 27140 C Transplant femur ridge 27146 C Incision of hip bone 27147 C Revision of hip bone 27151 C Incision of hip bones 27156 C Revision of hip bones 27158 C Revision of pelvis 27161 C Incision of neck of femur 27165 C Incision/fixation of femur 27170 C Repair/graft femur head/neck 27175 C Treat slipped epiphysis 27176 C Treat slipped epiphysis 27177 C Treat slipped epiphysis 27178 C Treat slipped epiphysis 27179 C Revise head/neck of femur 27181 C Treat slipped epiphysis 27185 C Revision of femur epiphysis 27187 C Reinforce hip bones 27193 T Treat pelvic ring fracture 0044 2.17 $105.22 $38.08 $21.04 27194 T Treat pelvic ring fracture 0045 11.02 $534.33 $277.12 $106.87 27200 T Treat tail bone fracture 0043 1.64 $79.52 $25.46 $15.90 27202 T Treat tail bone fracture 0046 22.29 $1,080.78 $535.76 $216.16 27215 C Treat pelvic fracture(s) 27216 C Treat pelvic ring fracture 27217 C Treat pelvic ring fracture 27218 C Treat pelvic ring fracture 27220 T Treat hip socket fracture 0044 2.17 $105.22 $38.08 $21.04 27222 C Treat hip socket fracture 27226 C Treat hip wall fracture 27227 C Treat hip fracture(s) 27228 C Treat hip fracture(s) 27230 T Treat thigh fracture 0044 2.17 $105.22 $38.08 $21.04 27232 C Treat thigh fracture 27235 C Treat thigh fracture 27236 C Treat thigh fracture 27238 T Treat thigh fracture 0044 2.17 $105.22 $38.08 $21.04 27240 C Treat thigh fracture 27244 C Treat thigh fracture 27245 C Treat thigh fracture 27246 T Treat thigh fracture 0044 2.17 $105.22 $38.08 $21.04 Start Printed Page 18579 27248 C Treat thigh fracture 27250 T Treat hip dislocation 0044 2.17 $105.22 $38.08 $21.04 27252 T Treat hip dislocation 0045 11.02 $534.33 $277.12 $106.87 27253 C Treat hip dislocation 27254 C Treat hip dislocation 27256 T Treat hip dislocation 0044 2.17 $105.22 $38.08 $21.04 27257 T Treat hip dislocation 0045 11.02 $534.33 $277.12 $106.87 27258 C Treat hip dislocation 27259 C Treat hip dislocation 27265 T Treat hip dislocation 0044 2.17 $105.22 $38.08 $21.04 27266 T Treat hip dislocation 0047 22.09 $1,071.08 $537.03 $214.22 27275 T Manipulation of hip joint 0045 11.02 $534.33 $277.12 $106.87 27280 C Fusion of sacroiliac joint 27282 C Fusion of pubic bones 27284 C Fusion of hip joint 27286 C Fusion of hip joint 27290 C Amputation of leg at hip 27295 C Amputation of leg at hip 27299 T Pelvis/hip joint surgery 0043 1.64 $79.52 $25.46 $15.90 27301 T Drain thigh/knee lesion 0008 6.15 $298.20 $113.67 $59.64 27303 C Drainage of bone lesion 27305 T Incise thigh tendon & fascia 0049 15.04 $729.25 $356.95 $145.85 27306 T Incision of thigh tendon 0049 15.04 $729.25 $356.95 $145.85 27307 T Incision of thigh tendons 0049 15.04 $729.25 $356.95 $145.85 27310 T Exploration of knee joint 0050 21.13 $1,024.53 $513.86 $204.91 27315 T Partial removal, thigh nerve 0220 13.96 $676.88 $326.21 $135.38 27320 T Partial removal, thigh nerve 0220 13.96 $676.88 $326.21 $135.38 27323 T Biopsy, thigh soft tissues 0021 10.49 $508.63 $236.51 $101.73 27324 T Biopsy, thigh soft tissues 0022 12.49 $605.60 $292.94 $121.12 27327 T Removal of thigh lesion 0022 12.49 $605.60 $292.94 $121.12 27328 T Removal of thigh lesion 0022 12.49 $605.60 $292.94 $121.12 27329 T Remove tumor, thigh/knee 0022 12.49 $605.60 $292.94 $121.12 27330 T Biopsy, knee joint lining 0050 21.13 $1,024.53 $513.86 $204.91 27331 T Explore/treat knee joint 0050 21.13 $1,024.53 $513.86 $204.91 27332 T Removal of knee cartilage 0050 21.13 $1,024.53 $513.86 $204.91 27333 T Removal of knee cartilage 0050 21.13 $1,024.53 $513.86 $204.91 27334 T Remove knee joint lining 0050 21.13 $1,024.53 $513.86 $204.91 27335 T Remove knee joint lining 0050 21.13 $1,024.53 $513.86 $204.91 27340 T Removal of kneecap bursa 0049 15.04 $729.25 $356.95 $145.85 27345 T Removal of knee cyst 0049 15.04 $729.25 $356.95 $145.85 27347 T Remove knee cyst 0049 15.04 $729.25 $356.95 $145.85 27350 T Removal of kneecap 0050 21.13 $1,024.53 $513.86 $204.91 27355 T Remove femur lesion 0050 21.13 $1,024.53 $513.86 $204.91 27356 T Remove femur lesion/graft 0050 21.13 $1,024.53 $513.86 $204.91 27357 T Remove femur lesion/graft 0050 21.13 $1,024.53 $513.86 $204.91 27358 T Remove femur lesion/fixation 0050 21.13 $1,024.53 $513.86 $204.91 27360 T Partial removal, leg bone(s) 0050 21.13 $1,024.53 $513.86 $204.91 27365 C Extensive leg surgery 27370 N Injection for knee x-ray 27372 T Removal of foreign body 0022 12.49 $605.60 $292.94 $121.12 27380 T Repair of kneecap tendon 0049 15.04 $729.25 $356.95 $145.85 27381 T Repair/graft kneecap tendon 0049 15.04 $729.25 $356.95 $145.85 27385 T Repair of thigh muscle 0049 15.04 $729.25 $356.95 $145.85 27386 T Repair/graft of thigh muscle 0049 15.04 $729.25 $356.95 $145.85 27390 T Incision of thigh tendon 0049 15.04 $729.25 $356.95 $145.85 27391 T Incision of thigh tendons 0049 15.04 $729.25 $356.95 $145.85 27392 T Incision of thigh tendons 0049 15.04 $729.25 $356.95 $145.85 27393 T Lengthening of thigh tendon 0050 21.13 $1,024.53 $513.86 $204.91 27394 T Lengthening of thigh tendons 0050 21.13 $1,024.53 $513.86 $204.91 27395 T Lengthening of thigh tendons 0051 27.76 $1,346.00 $675.24 $269.20 27396 T Transplant of thigh tendon 0050 21.13 $1,024.53 $513.86 $204.91 27397 T Transplants of thigh tendons 0051 27.76 $1,346.00 $675.24 $269.20 27400 T Revise thigh muscles/tendons 0051 27.76 $1,346.00 $675.24 $269.20 27403 T Repair of knee cartilage 0050 21.13 $1,024.53 $513.86 $204.91 27405 T Repair of knee ligament 0051 27.76 $1,346.00 $675.24 $269.20 27407 T Repair of knee ligament 0051 27.76 $1,346.00 $675.24 $269.20 27409 T Repair of knee ligaments 0051 27.76 $1,346.00 $675.24 $269.20 27418 T Repair degenerated kneecap 0051 27.76 $1,346.00 $675.24 $269.20 27420 T Revision of unstable kneecap 0051 27.76 $1,346.00 $675.24 $269.20 27422 T Revision of unstable kneecap 0051 27.76 $1,346.00 $675.24 $269.20 27424 T Revision/removal of kneecap 0051 27.76 $1,346.00 $675.24 $269.20 27425 T Lateral retinacular release 0050 21.13 $1,024.53 $513.86 $204.91 27427 T Reconstruction, knee 0052 36.16 $1,753.29 $930.91 $350.66 Start Printed Page 18580 27428 T Reconstruction, knee 0052 36.16 $1,753.29 $930.91 $350.66 27429 T Reconstruction, knee 0052 36.16 $1,753.29 $930.91 $350.66 27430 T Revision of thigh muscles 0051 27.76 $1,346.00 $675.24 $269.20 27435 T Incision of knee joint 0051 27.76 $1,346.00 $675.24 $269.20 27437 T Revise kneecap 0047 22.09 $1,071.08 $537.03 $214.22 27438 T Revise kneecap with implant 0048 29.06 $1,409.03 $725.94 $281.81 27440 T Revision of knee joint 0047 22.09 $1,071.08 $537.03 $214.22 27441 T Revision of knee joint 0047 22.09 $1,071.08 $537.03 $214.22 27442 T Revision of knee joint 0047 22.09 $1,071.08 $537.03 $214.22 27443 T Revision of knee joint 0047 22.09 $1,071.08 $537.03 $214.22 27445 C Revision of knee joint 27446 C Revision of knee joint 27447 C Total knee replacement 27448 C Incision of thigh 27450 C Incision of thigh 27454 C Realignment of thigh bone 27455 C Realignment of knee 27457 C Realignment of knee 27465 C Shortening of thigh bone 27466 C Lengthening of thigh bone 27468 C Shorten/lengthen thighs 27470 C Repair of thigh 27472 C Repair/graft of thigh 27475 C Surgery to stop leg growth 27477 C Surgery to stop leg growth 27479 C Surgery to stop leg growth 27485 C Surgery to stop leg growth 27486 C Revise/replace knee joint 27487 C Revise/replace knee joint 27488 C Removal of knee prosthesis 27495 C Reinforce thigh 27496 T Decompression of thigh/knee 0049 15.04 $729.25 $356.95 $145.85 27497 T Decompression of thigh/knee 0049 15.04 $729.25 $356.95 $145.85 27498 T Decompression of thigh/knee 0049 15.04 $729.25 $356.95 $145.85 27499 T Decompression of thigh/knee 0049 15.04 $729.25 $356.95 $145.85 27500 T Treatment of thigh fracture 0044 2.17 $105.22 $38.08 $21.04 27501 T Treatment of thigh fracture 0044 2.17 $105.22 $38.08 $21.04 27502 T Treatment of thigh fracture 0044 2.17 $105.22 $38.08 $21.04 27503 T Treatment of thigh fracture 0044 2.17 $105.22 $38.08 $21.04 27506 C Treatment of thigh fracture 27507 C Treatment of thigh fracture 27508 T Treatment of thigh fracture 0044 2.17 $105.22 $38.08 $21.04 27509 T Treatment of thigh fracture 0046 22.29 $1,080.78 $535.76 $216.16 27510 T Treatment of thigh fracture 0044 2.17 $105.22 $38.08 $21.04 27511 C Treatment of thigh fracture 27513 C Treatment of thigh fracture 27514 C Treatment of thigh fracture 27516 T Treat thigh fx growth plate 0044 2.17 $105.22 $38.08 $21.04 27517 T Treat thigh fx growth plate 0044 2.17 $105.22 $38.08 $21.04 27519 C Treat thigh fx growth plate 27520 T Treat kneecap fracture 0044 2.17 $105.22 $38.08 $21.04 27524 C Treat kneecap fracture 27530 T Treat knee fracture 0044 2.17 $105.22 $38.08 $21.04 27532 T Treat knee fracture 0044 2.17 $105.22 $38.08 $21.04 27535 C Treat knee fracture 27536 C Treat knee fracture 27538 T Treat knee fracture(s) 0044 2.17 $105.22 $38.08 $21.04 27540 C Treat knee fracture 27550 T Treat knee dislocation 0044 2.17 $105.22 $38.08 $21.04 27552 T Treat knee dislocation 0045 11.02 $534.33 $277.12 $106.87 27556 T Treat knee dislocation 0046 22.29 $1,080.78 $535.76 $216.16 27557 C Treat knee dislocation 27558 C Treat knee dislocation 27560 T Treat kneecap dislocation 0044 2.17 $105.22 $38.08 $21.04 27562 T Treat kneecap dislocation 0045 11.02 $534.33 $277.12 $106.87 27566 T Treat kneecap dislocation 0046 22.29 $1,080.78 $535.76 $216.16 27570 T Fixation of knee joint 0045 11.02 $534.33 $277.12 $106.87 27580 C Fusion of knee 27590 C Amputate leg at thigh 27591 C Amputate leg at thigh 27592 C Amputate leg at thigh 27594 T Amputation follow-up surgery 0049 15.04 $729.25 $356.95 $145.85 27596 C Amputation follow-up surgery Start Printed Page 18581 27598 C Amputate lower leg at knee 27599 T Leg surgery procedure 0044 2.17 $105.22 $38.08 $21.04 27600 T Decompression of lower leg 0049 15.04 $729.25 $356.95 $145.85 27601 T Decompression of lower leg 0049 15.04 $729.25 $356.95 $145.85 27602 T Decompression of lower leg 0049 15.04 $729.25 $356.95 $145.85 27603 T Drain lower leg lesion 0008 6.15 $298.20 $113.67 $59.64 27604 T Drain lower leg bursa 0049 15.04 $729.25 $356.95 $145.85 27605 T Incision of achilles tendon 0055 15.47 $750.10 $355.34 $150.02 27606 T Incision of achilles tendon 0049 15.04 $729.25 $356.95 $145.85 27607 T Treat lower leg bone lesion 0049 15.04 $729.25 $356.95 $145.85 27610 T Explore/treat ankle joint 0050 21.13 $1,024.53 $513.86 $204.91 27612 T Exploration of ankle joint 0050 21.13 $1,024.53 $513.86 $204.91 27613 T Biopsy lower leg soft tissue 0020 6.51 $315.65 $130.53 $63.13 27614 T Biopsy lower leg soft tissue 0022 12.49 $605.60 $292.94 $121.12 27615 T Remove tumor, lower leg 0046 22.29 $1,080.78 $535.76 $216.16 27618 T Remove lower leg lesion 0021 10.49 $508.63 $236.51 $101.73 27619 T Remove lower leg lesion 0022 12.49 $605.60 $292.94 $121.12 27620 T Explore/treat ankle joint 0050 21.13 $1,024.53 $513.86 $204.91 27625 T Remove ankle joint lining 0050 21.13 $1,024.53 $513.86 $204.91 27626 T Remove ankle joint lining 0050 21.13 $1,024.53 $513.86 $204.91 27630 T Removal of tendon lesion 0049 15.04 $729.25 $356.95 $145.85 27635 T Remove lower leg bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 27637 T Remove/graft leg bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 27638 T Remove/graft leg bone lesion 0050 21.13 $1,024.53 $513.86 $204.91 27640 T Partial removal of tibia 0051 27.76 $1,346.00 $675.24 $269.20 27641 T Partial removal of fibula 0050 21.13 $1,024.53 $513.86 $204.91 27645 C Extensive lower leg surgery 27646 C Extensive lower leg surgery 27647 T Extensive ankle/heel surgery 0051 27.76 $1,346.00 $675.24 $269.20 27648 N Injection for ankle x-ray 27650 T Repair achilles tendon 0051 27.76 $1,346.00 $675.24 $269.20 27652 T Repair/graft achilles tendon 0051 27.76 $1,346.00 $675.24 $269.20 27654 T Repair of achilles tendon 0051 27.76 $1,346.00 $675.24 $269.20 27656 T Repair leg fascia defect 0049 15.04 $729.25 $356.95 $145.85 27658 T Repair of leg tendon, each 0049 15.04 $729.25 $356.95 $145.85 27659 T Repair of leg tendon, each 0049 15.04 $729.25 $356.95 $145.85 27664 T Repair of leg tendon, each 0049 15.04 $729.25 $356.95 $145.85 27665 T Repair of leg tendon, each 0050 21.13 $1,024.53 $513.86 $204.91 27675 T Repair lower leg tendons 0049 15.04 $729.25 $356.95 $145.85 27676 T Repair lower leg tendons 0050 21.13 $1,024.53 $513.86 $204.91 27680 T Release of lower leg tendon 0050 21.13 $1,024.53 $513.86 $204.91 27681 T Release of lower leg tendons 0050 21.13 $1,024.53 $513.86 $204.91 27685 T Revision of lower leg tendon 0050 21.13 $1,024.53 $513.86 $204.91 27686 T Revise lower leg tendons 0050 21.13 $1,024.53 $513.86 $204.91 27687 T Revision of calf tendon 0050 21.13 $1,024.53 $513.86 $204.91 27690 T Revise lower leg tendon 0051 27.76 $1,346.00 $675.24 $269.20 27691 T Revise lower leg tendon 0051 27.76 $1,346.00 $675.24 $269.20 27692 T Revise additional leg tendon 0051 27.76 $1,346.00 $675.24 $269.20 27695 T Repair of ankle ligament 0050 21.13 $1,024.53 $513.86 $204.91 27696 T Repair of ankle ligaments 0050 21.13 $1,024.53 $513.86 $204.91 27698 T Repair of ankle ligament 0050 21.13 $1,024.53 $513.86 $204.91 27700 T Revision of ankle joint 0047 22.09 $1,071.08 $537.03 $214.22 27702 C Reconstruct ankle joint 27703 C Reconstruction, ankle joint 27704 T Removal of ankle implant 0049 15.04 $729.25 $356.95 $145.85 27705 T Incision of tibia 0051 27.76 $1,346.00 $675.24 $269.20 27707 T Incision of fibula 0049 15.04 $729.25 $356.95 $145.85 27709 T Incision of tibia & fibula 0050 21.13 $1,024.53 $513.86 $204.91 27712 C Realignment of lower leg 27715 C Revision of lower leg 27720 C Repair of tibia 27722 C Repair/graft of tibia 27724 C Repair/graft of tibia 27725 C Repair of lower leg 27727 C Repair of lower leg 27730 T Repair of tibia epiphysis 0050 21.13 $1,024.53 $513.86 $204.91 27732 T Repair of fibula epiphysis 0050 21.13 $1,024.53 $513.86 $204.91 27734 T Repair lower leg epiphyses 0050 21.13 $1,024.53 $513.86 $204.91 27740 T Repair of leg epiphyses 0050 21.13 $1,024.53 $513.86 $204.91 27742 T Repair of leg epiphyses 0051 27.76 $1,346.00 $675.24 $269.20 27745 T Reinforce tibia 0051 27.76 $1,346.00 $675.24 $269.20 27750 T Treatment of tibia fracture 0044 2.17 $105.22 $38.08 $21.04 27752 T Treatment of tibia fracture 0044 2.17 $105.22 $38.08 $21.04 Start Printed Page 18582 27756 T Treatment of tibia fracture 0046 22.29 $1,080.78 $535.76 $216.16 27758 T Treatment of tibia fracture 0046 22.29 $1,080.78 $535.76 $216.16 27759 T Treatment of tibia fracture 0046 22.29 $1,080.78 $535.76 $216.16 27760 T Treatment of ankle fracture 0044 2.17 $105.22 $38.08 $21.04 27762 T Treatment of ankle fracture 0044 2.17 $105.22 $38.08 $21.04 27766 T Treatment of ankle fracture 0046 22.29 $1,080.78 $535.76 $216.16 27780 T Treatment of fibula fracture 0044 2.17 $105.22 $38.08 $21.04 27781 T Treatment of fibula fracture 0044 2.17 $105.22 $38.08 $21.04 27784 T Treatment of fibula fracture 0046 22.29 $1,080.78 $535.76 $216.16 27786 T Treatment of ankle fracture 0044 2.17 $105.22 $38.08 $21.04 27788 T Treatment of ankle fracture 0044 2.17 $105.22 $38.08 $21.04 27792 T Treatment of ankle fracture 0046 22.29 $1,080.78 $535.76 $216.16 27808 T Treatment of ankle fracture 0044 2.17 $105.22 $38.08 $21.04 27810 T Treatment of ankle fracture 0044 2.17 $105.22 $38.08 $21.04 27814 T Treatment of ankle fracture 0046 22.29 $1,080.78 $535.76 $216.16 27816 T Treatment of ankle fracture 0044 2.17 $105.22 $38.08 $21.04 27818 T Treatment of ankle fracture 0044 2.17 $105.22 $38.08 $21.04 27822 T Treatment of ankle fracture 0046 22.29 $1,080.78 $535.76 $216.16 27823 T Treatment of ankle fracture 0046 22.29 $1,080.78 $535.76 $216.16 27824 T Treat lower leg fracture 0044 2.17 $105.22 $38.08 $21.04 27825 T Treat lower leg fracture 0044 2.17 $105.22 $38.08 $21.04 27826 T Treat lower leg fracture 0046 22.29 $1,080.78 $535.76 $216.16 27827 T Treat lower leg fracture 0046 22.29 $1,080.78 $535.76 $216.16 27828 T Treat lower leg fracture 0046 22.29 $1,080.78 $535.76 $216.16 27829 T Treat lower leg joint 0046 22.29 $1,080.78 $535.76 $216.16 27830 T Treat lower leg dislocation 0044 2.17 $105.22 $38.08 $21.04 27831 T Treat lower leg dislocation 0045 11.02 $534.33 $277.12 $106.87 27832 T Treat lower leg dislocation 0046 22.29 $1,080.78 $535.76 $216.16 27840 T Treat ankle dislocation 0044 2.17 $105.22 $38.08 $21.04 27842 T Treat ankle dislocation 0045 11.02 $534.33 $277.12 $106.87 27846 T Treat ankle dislocation 0046 22.29 $1,080.78 $535.76 $216.16 27848 T Treat ankle dislocation 0046 22.29 $1,080.78 $535.76 $216.16 27860 T Fixation of ankle joint 0045 11.02 $534.33 $277.12 $106.87 27870 T Fusion of ankle joint 0051 27.76 $1,346.00 $675.24 $269.20 27871 T Fusion of tibiofibular joint 0051 27.76 $1,346.00 $675.24 $269.20 27880 C Amputation of lower leg 27881 C Amputation of lower leg 27882 C Amputation of lower leg 27884 T Amputation follow-up surgery 0049 15.04 $729.25 $356.95 $145.85 27886 C Amputation follow-up surgery 27888 C Amputation of foot at ankle 27889 T Amputation of foot at ankle 0050 21.13 $1,024.53 $513.86 $204.91 27892 T Decompression of leg 0049 15.04 $729.25 $356.95 $145.85 27893 T Decompression of leg 0049 15.04 $729.25 $356.95 $145.85 27894 T Decompression of leg 0049 15.04 $729.25 $356.95 $145.85 27899 T Leg/ankle surgery procedure 0044 2.17 $105.22 $38.08 $21.04 28001 T Drainage of bursa of foot 0008 6.15 $298.20 $113.67 $59.64 28002 T Treatment of foot infection 0049 15.04 $729.25 $356.95 $145.85 28003 T Treatment of foot infection 0049 15.04 $729.25 $356.95 $145.85 28005 T Treat foot bone lesion 0055 15.47 $750.10 $355.34 $150.02 28008 T Incision of foot fascia 0055 15.47 $750.10 $355.34 $150.02 28010 T Incision of toe tendon 0055 15.47 $750.10 $355.34 $150.02 28011 T Incision of toe tendons 0055 15.47 $750.10 $355.34 $150.02 28020 T Exploration of foot joint 0055 15.47 $750.10 $355.34 $150.02 28022 T Exploration of foot joint 0055 15.47 $750.10 $355.34 $150.02 28024 T Exploration of toe joint 0055 15.47 $750.10 $355.34 $150.02 28030 T Removal of foot nerve 0220 13.96 $676.88 $326.21 $135.38 28035 T Decompression of tibia nerve 0220 13.96 $676.88 $326.21 $135.38 28043 T Excision of foot lesion 0021 10.49 $508.63 $236.51 $101.73 28045 T Excision of foot lesion 0055 15.47 $750.10 $355.34 $150.02 28046 T Resection of tumor, foot 0055 15.47 $750.10 $355.34 $150.02 28050 T Biopsy of foot joint lining 0055 15.47 $750.10 $355.34 $150.02 28052 T Biopsy of foot joint lining 0055 15.47 $750.10 $355.34 $150.02 28054 T Biopsy of toe joint lining 0055 15.47 $750.10 $355.34 $150.02 28060 T Partial removal, foot fascia 0056 17.30 $838.83 $405.81 $167.77 28062 T Removal of foot fascia 0056 17.30 $838.83 $405.81 $167.77 28070 T Removal of foot joint lining 0056 17.30 $838.83 $405.81 $167.77 28072 T Removal of foot joint lining 0056 17.30 $838.83 $405.81 $167.77 28080 T Removal of foot lesion 0055 15.47 $750.10 $355.34 $150.02 28086 T Excise foot tendon sheath 0055 15.47 $750.10 $355.34 $150.02 28088 T Excise foot tendon sheath 0055 15.47 $750.10 $355.34 $150.02 28090 T Removal of foot lesion 0055 15.47 $750.10 $355.34 $150.02 28092 T Removal of toe lesions 0055 15.47 $750.10 $355.34 $150.02 Start Printed Page 18583 28100 T Removal of ankle/heel lesion 0055 15.47 $750.10 $355.34 $150.02 28102 T Remove/graft foot lesion 0056 17.30 $838.83 $405.81 $167.77 28103 T Remove/graft foot lesion 0056 17.30 $838.83 $405.81 $167.77 28104 T Removal of foot lesion 0055 15.47 $750.10 $355.34 $150.02 28106 T Remove/graft foot lesion 0056 17.30 $838.83 $405.81 $167.77 28107 T Remove/graft foot lesion 0056 17.30 $838.83 $405.81 $167.77 28108 T Removal of toe lesions 0055 15.47 $750.10 $355.34 $150.02 28110 T Part removal of metatarsal 0057 21.00 $1,018.23 $496.65 $203.65 28111 T Part removal of metatarsal 0055 15.47 $750.10 $355.34 $150.02 28112 T Part removal of metatarsal 0055 15.47 $750.10 $355.34 $150.02 28113 T Part removal of metatarsal 0055 15.47 $750.10 $355.34 $150.02 28114 T Removal of metatarsal heads 0055 15.47 $750.10 $355.34 $150.02 28116 T Revision of foot 0055 15.47 $750.10 $355.34 $150.02 28118 T Removal of heel bone 0055 15.47 $750.10 $355.34 $150.02 28119 T Removal of heel spur 0055 15.47 $750.10 $355.34 $150.02 28120 T Part removal of ankle/heel 0055 15.47 $750.10 $355.34 $150.02 28122 T Partial removal of foot bone 0055 15.47 $750.10 $355.34 $150.02 28124 T Partial removal of toe 0055 15.47 $750.10 $355.34 $150.02 28126 T Partial removal of toe 0055 15.47 $750.10 $355.34 $150.02 28130 T Removal of ankle bone 0055 15.47 $750.10 $355.34 $150.02 28140 T Removal of metatarsal 0055 15.47 $750.10 $355.34 $150.02 28150 T Removal of toe 0055 15.47 $750.10 $355.34 $150.02 28153 T Partial removal of toe 0055 15.47 $750.10 $355.34 $150.02 28160 T Partial removal of toe 0055 15.47 $750.10 $355.34 $150.02 28171 T Extensive foot surgery 0055 15.47 $750.10 $355.34 $150.02 28173 T Extensive foot surgery 0055 15.47 $750.10 $355.34 $150.02 28175 T Extensive foot surgery 0055 15.47 $750.10 $355.34 $150.02 28190 T Removal of foot foreign body 0019 4.00 $193.95 $78.91 $38.79 28192 T Removal of foot foreign body 0021 10.49 $508.63 $236.51 $101.73 28193 T Removal of foot foreign body 0020 6.51 $315.65 $130.53 $63.13 28200 T Repair of foot tendon 0055 15.47 $750.10 $355.34 $150.02 28202 T Repair/graft of foot tendon 0056 17.30 $838.83 $405.81 $167.77 28208 T Repair of foot tendon 0055 15.47 $750.10 $355.34 $150.02 28210 T Repair/graft of foot tendon 0055 15.47 $750.10 $355.34 $150.02 28220 T Release of foot tendon 0055 15.47 $750.10 $355.34 $150.02 28222 T Release of foot tendons 0055 15.47 $750.10 $355.34 $150.02 28225 T Release of foot tendon 0055 15.47 $750.10 $355.34 $150.02 28226 T Release of foot tendons 0055 15.47 $750.10 $355.34 $150.02 28230 T Incision of foot tendon(s) 0055 15.47 $750.10 $355.34 $150.02 28232 T Incision of toe tendon 0055 15.47 $750.10 $355.34 $150.02 28234 T Incision of foot tendon 0055 15.47 $750.10 $355.34 $150.02 28238 T Revision of foot tendon 0056 17.30 $838.83 $405.81 $167.77 28240 T Release of big toe 0055 15.47 $750.10 $355.34 $150.02 28250 T Revision of foot fascia 0056 17.30 $838.83 $405.81 $167.77 28260 T Release of midfoot joint 0056 17.30 $838.83 $405.81 $167.77 28261 T Revision of foot tendon 0056 17.30 $838.83 $405.81 $167.77 28262 T Revision of foot and ankle 0056 17.30 $838.83 $405.81 $167.77 28264 T Release of midfoot joint 0056 17.30 $838.83 $405.81 $167.77 28270 T Release of foot contracture 0055 15.47 $750.10 $355.34 $150.02 28272 T Release of toe joint, each 0055 15.47 $750.10 $355.34 $150.02 28280 T Fusion of toes 0055 15.47 $750.10 $355.34 $150.02 28285 T Repair of hammertoe 0055 15.47 $750.10 $355.34 $150.02 28286 T Repair of hammertoe 0055 15.47 $750.10 $355.34 $150.02 28288 T Partial removal of foot bone 0056 17.30 $838.83 $405.81 $167.77 28289 T Repair hallux rigidus 0056 17.30 $838.83 $405.81 $167.77 28290 T Correction of bunion 0057 21.00 $1,018.23 $496.65 $203.65 28292 T Correction of bunion 0057 21.00 $1,018.23 $496.65 $203.65 28293 T Correction of bunion 0057 21.00 $1,018.23 $496.65 $203.65 28294 T Correction of bunion 0057 21.00 $1,018.23 $496.65 $203.65 28296 T Correction of bunion 0057 21.00 $1,018.23 $496.65 $203.65 28297 T Correction of bunion 0057 21.00 $1,018.23 $496.65 $203.65 28298 T Correction of bunion 0057 21.00 $1,018.23 $496.65 $203.65 28299 T Correction of bunion 0057 21.00 $1,018.23 $496.65 $203.65 28300 T Incision of heel bone 0056 17.30 $838.83 $405.81 $167.77 28302 T Incision of ankle bone 0056 17.30 $838.83 $405.81 $167.77 28304 T Incision of midfoot bones 0056 17.30 $838.83 $405.81 $167.77 28305 T Incise/graft midfoot bones 0056 17.30 $838.83 $405.81 $167.77 28306 T Incision of metatarsal 0056 17.30 $838.83 $405.81 $167.77 28307 T Incision of metatarsal 0056 17.30 $838.83 $405.81 $167.77 28308 T Incision of metatarsal 0056 17.30 $838.83 $405.81 $167.77 28309 T Incision of metatarsals 0056 17.30 $838.83 $405.81 $167.77 28310 T Revision of big toe 0055 15.47 $750.10 $355.34 $150.02 28312 T Revision of toe 0055 15.47 $750.10 $355.34 $150.02 Start Printed Page 18584 28313 T Repair deformity of toe 0055 15.47 $750.10 $355.34 $150.02 28315 T Removal of sesamoid bone 0055 15.47 $750.10 $355.34 $150.02 28320 T Repair of foot bones 0056 17.30 $838.83 $405.81 $167.77 28322 T Repair of metatarsals 0056 17.30 $838.83 $405.81 $167.77 28340 T Resect enlarged toe tissue 0055 15.47 $750.10 $355.34 $150.02 28341 T Resect enlarged toe 0055 15.47 $750.10 $355.34 $150.02 28344 T Repair extra toe(s) 0056 17.30 $838.83 $405.81 $167.77 28345 T Repair webbed toe(s) 0056 17.30 $838.83 $405.81 $167.77 28360 T Reconstruct cleft foot 0056 17.30 $838.83 $405.81 $167.77 28400 T Treatment of heel fracture 0044 2.17 $105.22 $38.08 $21.04 28405 T Treatment of heel fracture 0044 2.17 $105.22 $38.08 $21.04 28406 T Treatment of heel fracture 0046 22.29 $1,080.78 $535.76 $216.16 28415 T Treat heel fracture 0046 22.29 $1,080.78 $535.76 $216.16 28420 T Treat/graft heel fracture 0046 22.29 $1,080.78 $535.76 $216.16 28430 T Treatment of ankle fracture 0044 2.17 $105.22 $38.08 $21.04 28435 T Treatment of ankle fracture 0044 2.17 $105.22 $38.08 $21.04 28436 T Treatment of ankle fracture 0046 22.29 $1,080.78 $535.76 $216.16 28445 T Treat ankle fracture 0046 22.29 $1,080.78 $535.76 $216.16 28450 T Treat midfoot fracture, each 0044 2.17 $105.22 $38.08 $21.04 28455 T Treat midfoot fracture, each 0044 2.17 $105.22 $38.08 $21.04 28456 T Treat midfoot fracture 0046 22.29 $1,080.78 $535.76 $216.16 28465 T Treat midfoot fracture, each 0046 22.29 $1,080.78 $535.76 $216.16 28470 T Treat metatarsal fracture 0044 2.17 $105.22 $38.08 $21.04 28475 T Treat metatarsal fracture 0044 2.17 $105.22 $38.08 $21.04 28476 T Treat metatarsal fracture 0046 22.29 $1,080.78 $535.76 $216.16 28485 T Treat metatarsal fracture 0046 22.29 $1,080.78 $535.76 $216.16 28490 T Treat big toe fracture 0043 1.64 $79.52 $25.46 $15.90 28495 T Treat big toe fracture 0043 1.64 $79.52 $25.46 $15.90 28496 T Treat big toe fracture 0046 22.29 $1,080.78 $535.76 $216.16 28505 T Treat big toe fracture 0046 22.29 $1,080.78 $535.76 $216.16 28510 T Treatment of toe fracture 0043 1.64 $79.52 $25.46 $15.90 28515 T Treatment of toe fracture 0043 1.64 $79.52 $25.46 $15.90 28525 T Treat toe fracture 0046 22.29 $1,080.78 $535.76 $216.16 28530 T Treat sesamoid bone fracture 0044 2.17 $105.22 $38.08 $21.04 28531 T Treat sesamoid bone fracture 0046 22.29 $1,080.78 $535.76 $216.16 28540 T Treat foot dislocation 0044 2.17 $105.22 $38.08 $21.04 28545 T Treat foot dislocation 0045 11.02 $534.33 $277.12 $106.87 28546 T Treat foot dislocation 0046 22.29 $1,080.78 $535.76 $216.16 28555 T Repair foot dislocation 0046 22.29 $1,080.78 $535.76 $216.16 28570 T Treat foot dislocation 0044 2.17 $105.22 $38.08 $21.04 28575 T Treat foot dislocation 0045 11.02 $534.33 $277.12 $106.87 28576 T Treat foot dislocation 0046 22.29 $1,080.78 $535.76 $216.16 28585 T Repair foot dislocation 0046 22.29 $1,080.78 $535.76 $216.16 28600 T Treat foot dislocation 0044 2.17 $105.22 $38.08 $21.04 28605 T Treat foot dislocation 0045 11.02 $534.33 $277.12 $106.87 28606 T Treat foot dislocation 0046 22.29 $1,080.78 $535.76 $216.16 28615 T Repair foot dislocation 0046 22.29 $1,080.78 $535.76 $216.16 28630 T Treat toe dislocation 0043 1.64 $79.52 $25.46 $15.90 28635 T Treat toe dislocation 0045 11.02 $534.33 $277.12 $106.87 28636 T Treat toe dislocation 0046 22.29 $1,080.78 $535.76 $216.16 28645 T Repair toe dislocation 0046 22.29 $1,080.78 $535.76 $216.16 28660 T Treat toe dislocation 0043 1.64 $79.52 $25.46 $15.90 28665 T Treat toe dislocation 0045 11.02 $534.33 $277.12 $106.87 28666 T Treat toe dislocation 0046 22.29 $1,080.78 $535.76 $216.16 28675 T Repair of toe dislocation 0046 22.29 $1,080.78 $535.76 $216.16 28705 T Fusion of foot bones 0056 17.30 $838.83 $405.81 $167.77 28715 T Fusion of foot bones 0056 17.30 $838.83 $405.81 $167.77 28725 T Fusion of foot bones 0056 17.30 $838.83 $405.81 $167.77 28730 T Fusion of foot bones 0056 17.30 $838.83 $405.81 $167.77 28735 T Fusion of foot bones 0056 17.30 $838.83 $405.81 $167.77 28737 T Revision of foot bones 0055 15.47 $750.10 $355.34 $150.02 28740 T Fusion of foot bones 0056 17.30 $838.83 $405.81 $167.77 28750 T Fusion of big toe joint 0055 15.47 $750.10 $355.34 $150.02 28755 T Fusion of big toe joint 0055 15.47 $750.10 $355.34 $150.02 28760 T Fusion of big toe joint 0056 17.30 $838.83 $405.81 $167.77 28800 C Amputation of midfoot 28805 C Amputation thru metatarsal 28810 T Amputation toe & metatarsal 0055 15.47 $750.10 $355.34 $150.02 28820 T Amputation of toe 0055 15.47 $750.10 $355.34 $150.02 28825 T Partial amputation of toe 0055 15.47 $750.10 $355.34 $150.02 28899 T Foot/toes surgery procedure 0043 1.64 $79.52 $25.46 $15.90 29000 S Application of body cast 0059 1.74 $84.37 $29.59 $16.87 29010 S Application of body cast 0059 1.74 $84.37 $29.59 $16.87 Start Printed Page 18585 29015 S Application of body cast 0059 1.74 $84.37 $29.59 $16.87 29020 S Application of body cast 0059 1.74 $84.37 $29.59 $16.87 29025 S Application of body cast 0059 1.74 $84.37 $29.59 $16.87 29035 S Application of body cast 0059 1.74 $84.37 $29.59 $16.87 29040 S Application of body cast 0059 1.74 $84.37 $29.59 $16.87 29044 S Application of body cast 0059 1.74 $84.37 $29.59 $16.87 29046 S Application of body cast 0059 1.74 $84.37 $29.59 $16.87 29049 S Application of figure eight 0059 1.74 $84.37 $29.59 $16.87 29055 S Application of shoulder cast 0059 1.74 $84.37 $29.59 $16.87 29058 S Application of shoulder cast 0059 1.74 $84.37 $29.59 $16.87 29065 S Application of long arm cast 0059 1.74 $84.37 $29.59 $16.87 29075 S Application of forearm cast 0059 1.74 $84.37 $29.59 $16.87 29085 S Apply hand/wrist cast 0059 1.74 $84.37 $29.59 $16.87 29105 S Apply long arm splint 0059 1.74 $84.37 $29.59 $16.87 29125 S Apply forearm splint 0059 1.74 $84.37 $29.59 $16.87 29126 S Apply forearm splint 0059 1.74 $84.37 $29.59 $16.87 29130 S Application of finger splint 0059 1.74 $84.37 $29.59 $16.87 29131 S Application of finger splint 0059 1.74 $84.37 $29.59 $16.87 29200 S Strapping of chest 0059 1.74 $84.37 $29.59 $16.87 29220 S Strapping of low back 0059 1.74 $84.37 $29.59 $16.87 29240 S Strapping of shoulder 0059 1.74 $84.37 $29.59 $16.87 29260 S Strapping of elbow or wrist 0059 1.74 $84.37 $29.59 $16.87 29280 S Strapping of hand or finger 0059 1.74 $84.37 $29.59 $16.87 29305 S Application of hip cast 0059 1.74 $84.37 $29.59 $16.87 29325 S Application of hip casts 0059 1.74 $84.37 $29.59 $16.87 29345 S Application of long leg cast 0059 1.74 $84.37 $29.59 $16.87 29355 S Application of long leg cast 0059 1.74 $84.37 $29.59 $16.87 29358 S Apply long leg cast brace 0059 1.74 $84.37 $29.59 $16.87 29365 S Application of long leg cast 0059 1.74 $84.37 $29.59 $16.87 29405 S Apply short leg cast 0059 1.74 $84.37 $29.59 $16.87 29425 S Apply short leg cast 0059 1.74 $84.37 $29.59 $16.87 29435 S Apply short leg cast 0059 1.74 $84.37 $29.59 $16.87 29440 S Addition of walker to cast 0059 1.74 $84.37 $29.59 $16.87 29445 S Apply rigid leg cast 0059 1.74 $84.37 $29.59 $16.87 29450 S Application of leg cast 0059 1.74 $84.37 $29.59 $16.87 29505 S Application, long leg splint 0058 1.09 $52.85 $19.27 $10.57 29515 S Application lower leg splint 0058 1.09 $52.85 $19.27 $10.57 29520 S Strapping of hip 0058 1.09 $52.85 $19.27 $10.57 29530 S Strapping of knee 0058 1.09 $52.85 $19.27 $10.57 29540 S Strapping of ankle 0058 1.09 $52.85 $19.27 $10.57 29550 S Strapping of toes 0058 1.09 $52.85 $19.27 $10.57 29580 S Application of paste boot 0058 1.09 $52.85 $19.27 $10.57 29590 S Application of foot splint 0058 1.09 $52.85 $19.27 $10.57 29700 S Removal/revision of cast 0058 1.09 $52.85 $19.27 $10.57 29705 S Removal/revision of cast 0058 1.09 $52.85 $19.27 $10.57 29710 S Removal/revision of cast 0058 1.09 $52.85 $19.27 $10.57 29715 S Removal/revision of cast 0058 1.09 $52.85 $19.27 $10.57 29720 S Repair of body cast 0058 1.09 $52.85 $19.27 $10.57 29730 S Windowing of cast 0058 1.09 $52.85 $19.27 $10.57 29740 S Wedging of cast 0058 1.09 $52.85 $19.27 $10.57 29750 S Wedging of clubfoot cast 0058 1.09 $52.85 $19.27 $10.57 29799 S Casting/strapping procedure 0058 1.09 $52.85 $19.27 $10.57 29800 T Jaw arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29804 T Jaw arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29815 T Shoulder arthroscopy 0041 24.57 $1,191.33 $592.08 $238.27 29819 T Shoulder arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29820 T Shoulder arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29821 T Shoulder arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29822 T Shoulder arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29823 T Shoulder arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29825 T Shoulder arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29826 T Shoulder arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29830 T Elbow arthroscopy 0041 24.57 $1,191.33 $592.08 $238.27 29834 T Elbow arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29835 T Elbow arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29836 T Elbow arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29837 T Elbow arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29838 T Elbow arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29840 T Wrist arthroscopy 0041 24.57 $1,191.33 $592.08 $238.27 29843 T Wrist arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29844 T Wrist arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29845 T Wrist arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29846 T Wrist arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 Start Printed Page 18586 29847 T Wrist arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29848 T Wrist endoscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29850 T Knee arthroscopy/surgery 0042 29.22 $1,416.79 $804.74 $283.36 29851 T Knee arthroscopy/surgery 0042 29.22 $1,416.79 $804.74 $283.36 29855 T Tibial arthroscopy/surgery 0042 29.22 $1,416.79 $804.74 $283.36 29856 T Tibial arthroscopy/surgery 0042 29.22 $1,416.79 $804.74 $283.36 29860 T Hip arthroscopy, dx 0041 24.57 $1,191.33 $592.08 $238.27 29861 T Hip arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29862 T Hip arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29863 T Hip arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29870 T Knee arthroscopy, dx 0041 24.57 $1,191.33 $592.08 $238.27 29871 T Knee arthroscopy/drainage 0041 24.57 $1,191.33 $592.08 $238.27 29874 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29875 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29876 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29877 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29879 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29880 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29881 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29882 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29883 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29884 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29885 T Knee arthroscopy/surgery 0042 29.22 $1,416.79 $804.74 $283.36 29886 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29887 T Knee arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29888 T Knee arthroscopy/surgery 0042 29.22 $1,416.79 $804.74 $283.36 29889 T Knee arthroscopy/surgery 0042 29.22 $1,416.79 $804.74 $283.36 29891 T Ankle arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29892 T Ankle arthroscopy/surgery 0042 29.22 $1,416.79 $804.74 $283.36 29893 T Scope, plantar fasciotomy 0055 15.47 $750.10 $355.34 $150.02 29894 T Ankle arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29895 T Ankle arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29897 T Ankle arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29898 T Ankle arthroscopy/surgery 0041 24.57 $1,191.33 $592.08 $238.27 29909 T Arthroscopy of joint 0041 24.57 $1,191.33 $592.08 $238.27 30000 T Drainage of nose lesion 0251 1.68 $81.46 $27.99 $16.29 30020 T Drainage of nose lesion 0251 1.68 $81.46 $27.99 $16.29 30100 T Intranasal biopsy 0252 5.18 $251.16 $114.24 $50.23 30110 T Removal of nose polyp(s) 0253 12.02 $582.81 $284.00 $116.56 30115 T Removal of nose polyp(s) 0253 12.02 $582.81 $284.00 $116.56 30117 T Removal of intranasal lesion 0253 12.02 $582.81 $284.00 $116.56 30118 T Removal of intranasal lesion 0254 12.45 $603.66 $272.41 $120.73 30120 T Revision of nose 0253 12.02 $582.81 $284.00 $116.56 30124 T Removal of nose lesion 0252 5.18 $251.16 $114.24 $50.23 30125 T Removal of nose lesion 0256 25.40 $1,231.57 $623.05 $246.31 30130 T Removal of turbinate bones 0253 12.02 $582.81 $284.00 $116.56 30140 T Removal of turbinate bones 0253 12.02 $582.81 $284.00 $116.56 30150 T Partial removal of nose 0256 25.40 $1,231.57 $623.05 $246.31 30160 T Removal of nose 0256 25.40 $1,231.57 $623.05 $246.31 30200 T Injection treatment of nose 0253 12.02 $582.81 $284.00 $116.56 30210 T Nasal sinus therapy 0252 5.18 $251.16 $114.24 $50.23 30220 T Insert nasal septal button 0252 5.18 $251.16 $114.24 $50.23 30300 T Remove nasal foreign body 0251 1.68 $81.46 $27.99 $16.29 30310 T Remove nasal foreign body 0253 12.02 $582.81 $284.00 $116.56 30320 T Remove nasal foreign body 0253 12.02 $582.81 $284.00 $116.56 30400 T Reconstruction of nose 0256 25.40 $1,231.57 $623.05 $246.31 30410 T Reconstruction of nose 0256 25.40 $1,231.57 $623.05 $246.31 30420 T Reconstruction of nose 0256 25.40 $1,231.57 $623.05 $246.31 30430 T Revision of nose 0254 12.45 $603.66 $272.41 $120.73 30435 T Revision of nose 0256 25.40 $1,231.57 $623.05 $246.31 30450 T Revision of nose 0256 25.40 $1,231.57 $623.05 $246.31 30460 T Revision of nose 0256 25.40 $1,231.57 $623.05 $246.31 30462 T Revision of nose 0256 25.40 $1,231.57 $623.05 $246.31 30520 T Repair of nasal septum 0256 25.40 $1,231.57 $623.05 $246.31 30540 T Repair nasal defect 0256 25.40 $1,231.57 $623.05 $246.31 30545 T Repair nasal defect 0256 25.40 $1,231.57 $623.05 $246.31 30560 T Release of nasal adhesions 0251 1.68 $81.46 $27.99 $16.29 30580 T Repair upper jaw fistula 0256 25.40 $1,231.57 $623.05 $246.31 30600 T Repair mouth/nose fistula 0256 25.40 $1,231.57 $623.05 $246.31 30620 T Intranasal reconstruction 0256 25.40 $1,231.57 $623.05 $246.31 30630 T Repair nasal septum defect 0254 12.45 $603.66 $272.41 $120.73 30801 T Cauterization, inner nose 0252 5.18 $251.16 $114.24 $50.23 30802 T Cauterization, inner nose 0253 12.02 $582.81 $284.00 $116.56 Start Printed Page 18587 30901 T Control of nosebleed 0250 2.21 $107.16 $38.54 $21.43 30903 T Control of nosebleed 0250 2.21 $107.16 $38.54 $21.43 30905 T Control of nosebleed 0250 2.21 $107.16 $38.54 $21.43 30906 T Repeat control of nosebleed 0250 2.21 $107.16 $38.54 $21.43 30915 T Ligation, nasal sinus artery 0091 14.79 $717.12 $348.23 $143.42 30920 T Ligation, upper jaw artery 0092 20.21 $979.92 $505.37 $195.98 30930 T Therapy, fracture of nose 0253 12.02 $582.81 $284.00 $116.56 30999 T Nasal surgery procedure 0251 1.68 $81.46 $27.99 $16.29 31000 T Irrigation, maxillary sinus 0251 1.68 $81.46 $27.99 $16.29 31002 T Irrigation, sphenoid sinus 0252 5.18 $251.16 $114.24 $50.23 31020 T Exploration, maxillary sinus 0253 12.02 $582.81 $284.00 $116.56 31030 T Exploration, maxillary sinus 0256 25.40 $1,231.57 $623.05 $246.31 31032 T Explore sinus, remove polyps 0256 25.40 $1,231.57 $623.05 $246.31 31040 T Exploration behind upper jaw 0254 12.45 $603.66 $272.41 $120.73 31050 T Exploration, sphenoid sinus 0256 25.40 $1,231.57 $623.05 $246.31 31051 T Sphenoid sinus surgery 0256 25.40 $1,231.57 $623.05 $246.31 31070 T Exploration of frontal sinus 0254 12.45 $603.66 $272.41 $120.73 31075 T Exploration of frontal sinus 0256 25.40 $1,231.57 $623.05 $246.31 31080 T Removal of frontal sinus 0256 25.40 $1,231.57 $623.05 $246.31 31081 T Removal of frontal sinus 0256 25.40 $1,231.57 $623.05 $246.31 31084 T Removal of frontal sinus 0256 25.40 $1,231.57 $623.05 $246.31 31085 T Removal of frontal sinus 0256 25.40 $1,231.57 $623.05 $246.31 31086 T Removal of frontal sinus 0256 25.40 $1,231.57 $623.05 $246.31 31087 T Removal of frontal sinus 0256 25.40 $1,231.57 $623.05 $246.31 31090 T Exploration of sinuses 0256 25.40 $1,231.57 $623.05 $246.31 31200 T Removal of ethmoid sinus 0256 25.40 $1,231.57 $623.05 $246.31 31201 T Removal of ethmoid sinus 0256 25.40 $1,231.57 $623.05 $246.31 31205 T Removal of ethmoid sinus 0256 25.40 $1,231.57 $623.05 $246.31 31225 C Removal of upper jaw 31230 C Removal of upper jaw 31231 T Nasal endoscopy, dx 0071 0.55 $26.67 $14.22 $5.33 31233 T Nasal/sinus endoscopy, dx 0072 1.26 $61.09 $41.52 $12.22 31235 T Nasal/sinus endoscopy, dx 0074 13.61 $659.91 $347.54 $131.98 31237 T Nasal/sinus endoscopy, surg 0074 13.61 $659.91 $347.54 $131.98 31238 T Nasal/sinus endoscopy, surg 0074 13.61 $659.91 $347.54 $131.98 31239 T Nasal/sinus endoscopy, surg 0075 18.55 $899.44 $467.29 $179.89 31240 T Nasal/sinus endoscopy, surg 0074 13.61 $659.91 $347.54 $131.98 31254 T Revision of ethmoid sinus 0075 18.55 $899.44 $467.29 $179.89 31255 T Removal of ethmoid sinus 0075 18.55 $899.44 $467.29 $179.89 31256 T Exploration maxillary sinus 0075 18.55 $899.44 $467.29 $179.89 31267 T Endoscopy, maxillary sinus 0075 18.55 $899.44 $467.29 $179.89 31276 T Sinus endoscopy, surgical 0075 18.55 $899.44 $467.29 $179.89 31287 T Nasal/sinus endoscopy, surg 0075 18.55 $899.44 $467.29 $179.89 31288 T Nasal/sinus endoscopy, surg 0075 18.55 $899.44 $467.29 $179.89 31290 C Nasal/sinus endoscopy, surg 31291 C Nasal/sinus endoscopy, surg 31292 C Nasal/sinus endoscopy, surg 31293 C Nasal/sinus endoscopy, surg 31294 C Nasal/sinus endoscopy, surg 31299 T Sinus surgery procedure 0252 5.18 $251.16 $114.24 $50.23 31300 T Removal of larynx lesion 0256 25.40 $1,231.57 $623.05 $246.31 31320 T Diagnostic incision, larynx 0256 25.40 $1,231.57 $623.05 $246.31 31360 C Removal of larynx 31365 C Removal of larynx 31367 C Partial removal of larynx 31368 C Partial removal of larynx 31370 C Partial removal of larynx 31375 T Partial removal of larynx 0256 25.40 $1,231.57 $623.05 $246.31 31380 C Partial removal of larynx 31382 C Partial removal of larynx 31390 C Removal of larynx & pharynx 31395 C Reconstruct larynx & pharynx 31400 T Revision of larynx 0256 25.40 $1,231.57 $623.05 $246.31 31420 T Removal of epiglottis 0256 25.40 $1,231.57 $623.05 $246.31 31500 S Insert emergency airway 0094 4.51 $218.68 $105.29 $43.74 31502 T Change of windpipe airway 0121 2.36 $114.43 $52.53 $22.89 31505 T Diagnostic laryngoscopy 0072 1.26 $61.09 $41.52 $12.22 31510 T Laryngoscopy with biopsy 0074 13.61 $659.91 $347.54 $131.98 31511 T Remove foreign body, larynx 0072 1.26 $61.09 $41.52 $12.22 31512 T Removal of larynx lesion 0074 13.61 $659.91 $347.54 $131.98 31513 T Injection into vocal cord 0073 4.11 $199.28 $91.07 $39.86 31515 T Laryngoscopy for aspiration 0074 13.61 $659.91 $347.54 $131.98 31520 T Diagnostic laryngoscopy 0072 1.26 $61.09 $41.52 $12.22 Start Printed Page 18588 31525 T Diagnostic laryngoscopy 0074 13.61 $659.91 $347.54 $131.98 31526 T Diagnostic laryngoscopy 0074 13.61 $659.91 $347.54 $131.98 31527 T Laryngoscopy for treatment 0075 18.55 $899.44 $467.29 $179.89 31528 T Laryngoscopy and dilatation 0074 13.61 $659.91 $347.54 $131.98 31529 T Laryngoscopy and dilatation 0074 13.61 $659.91 $347.54 $131.98 31530 T Operative laryngoscopy 0075 18.55 $899.44 $467.29 $179.89 31531 T Operative laryngoscopy 0075 18.55 $899.44 $467.29 $179.89 31535 T Operative laryngoscopy 0075 18.55 $899.44 $467.29 $179.89 31536 T Operative laryngoscopy 0075 18.55 $899.44 $467.29 $179.89 31540 T Operative laryngoscopy 0075 18.55 $899.44 $467.29 $179.89 31541 T Operative laryngoscopy 0075 18.55 $899.44 $467.29 $179.89 31560 T Operative laryngoscopy 0075 18.55 $899.44 $467.29 $179.89 31561 T Operative laryngoscopy 0075 18.55 $899.44 $467.29 $179.89 31570 T Laryngoscopy with injection 0075 18.55 $899.44 $467.29 $179.89 31571 T Laryngoscopy with injection 0075 18.55 $899.44 $467.29 $179.89 31575 T Diagnostic laryngoscopy 0071 0.55 $26.67 $14.22 $5.33 31576 T Laryngoscopy with biopsy 0074 13.61 $659.91 $347.54 $131.98 31577 T Remove foreign body, larynx 0073 4.11 $199.28 $91.07 $39.86 31578 T Removal of larynx lesion 0074 13.61 $659.91 $347.54 $131.98 31579 T Diagnostic laryngoscopy 0073 4.11 $199.28 $91.07 $39.86 31580 T Revision of larynx 0256 25.40 $1,231.57 $623.05 $246.31 31582 C Revision of larynx 31584 C Treat larynx fracture 31585 T Treat larynx fracture 0253 12.02 $582.81 $284.00 $116.56 31586 T Treat larynx fracture 0256 25.40 $1,231.57 $623.05 $246.31 31587 C Revision of larynx 31588 T Revision of larynx 0256 25.40 $1,231.57 $623.05 $246.31 31590 T Reinnervate larynx 0256 25.40 $1,231.57 $623.05 $246.31 31595 T Larynx nerve surgery 0256 25.40 $1,231.57 $623.05 $246.31 31599 T Larynx surgery procedure 0253 12.02 $582.81 $284.00 $116.56 31600 T Incision of windpipe 0254 12.45 $603.66 $272.41 $120.73 31601 T Incision of windpipe 0254 12.45 $603.66 $272.41 $120.73 31603 T Incision of windpipe 0254 12.45 $603.66 $272.41 $120.73 31605 T Incision of windpipe 0254 12.45 $603.66 $272.41 $120.73 31610 T Incision of windpipe 0254 12.45 $603.66 $272.41 $120.73 31611 T Surgery/speech prosthesis 0254 12.45 $603.66 $272.41 $120.73 31612 T Puncture/clear windpipe 0253 12.02 $582.81 $284.00 $116.56 31613 T Repair windpipe opening 0254 12.45 $603.66 $272.41 $120.73 31614 T Repair windpipe opening 0256 25.40 $1,231.57 $623.05 $246.31 31615 T Visualization of windpipe 0076 8.06 $390.81 $197.05 $78.16 31622 T Dx bronchoscope/wash 0076 8.06 $390.81 $197.05 $78.16 31623 T Dx bronchoscope/brush 0076 8.06 $390.81 $197.05 $78.16 31624 T Dx bronchoscope/lavage 0076 8.06 $390.81 $197.05 $78.16 31625 T Bronchoscopy with biopsy 0076 8.06 $390.81 $197.05 $78.16 31628 T Bronchoscopy with biopsy 0076 8.06 $390.81 $197.05 $78.16 31629 T Bronchoscopy with biopsy 0076 8.06 $390.81 $197.05 $78.16 31630 T Bronchoscopy with repair 0076 8.06 $390.81 $197.05 $78.16 31631 T Bronchoscopy with dilation 0076 8.06 $390.81 $197.05 $78.16 31635 T Remove foreign body, airway 0076 8.06 $390.81 $197.05 $78.16 31640 T Bronchoscopy & remove lesion 0076 8.06 $390.81 $197.05 $78.16 31641 T Bronchoscopy, treat blockage 0076 8.06 $390.81 $197.05 $78.16 31643 T Diag bronchoscope/catheter 0076 8.06 $390.81 $197.05 $78.16 31645 T Bronchoscopy, clear airways 0076 8.06 $390.81 $197.05 $78.16 31646 T Bronchoscopy, reclear airway 0076 8.06 $390.81 $197.05 $78.16 31656 T Bronchoscopy, inj for x-ray 0076 8.06 $390.81 $197.05 $78.16 31700 T Insertion of airway catheter 0072 1.26 $61.09 $41.52 $12.22 31708 N Instill airway contrast dye 31710 N Insertion of airway catheter 31715 N Injection for bronchus x-ray 31717 T Bronchial brush biopsy 0073 4.11 $199.28 $91.07 $39.86 31720 T Clearance of airways 0072 1.26 $61.09 $41.52 $12.22 31725 C Clearance of airways 31730 T Intro, windpipe wire/tube 0073 4.11 $199.28 $91.07 $39.86 31750 T Repair of windpipe 0256 25.40 $1,231.57 $623.05 $246.31 31755 T Repair of windpipe 0256 25.40 $1,231.57 $623.05 $246.31 31760 C Repair of windpipe 31766 C Reconstruction of windpipe 31770 C Repair/graft of bronchus 31775 C Reconstruct bronchus 31780 C Reconstruct windpipe 31781 C Reconstruct windpipe 31785 C Remove windpipe lesion 31786 C Remove windpipe lesion Start Printed Page 18589 31800 C Repair of windpipe injury 31805 C Repair of windpipe injury 31820 T Closure of windpipe lesion 0253 12.02 $582.81 $284.00 $116.56 31825 T Repair of windpipe defect 0254 12.45 $603.66 $272.41 $120.73 31830 T Revise windpipe scar 0254 12.45 $603.66 $272.41 $120.73 31899 T Airways surgical procedure 0076 8.06 $390.81 $197.05 $78.16 32000 T Drainage of chest 0070 3.64 $176.49 $79.60 $35.30 32002 T Treatment of collapsed lung 0070 3.64 $176.49 $79.60 $35.30 32005 T Treat lung lining chemically 0070 3.64 $176.49 $79.60 $35.30 32020 T Insertion of chest tube 0070 3.64 $176.49 $79.60 $35.30 32035 C Exploration of chest 32036 C Exploration of chest 32095 C Biopsy through chest wall 32100 C Exploration/biopsy of chest 32110 C Explore/repair chest 32120 C Re-exploration of chest 32124 C Explore chest free adhesions 32140 C Removal of lung lesion(s) 32141 C Remove/treat lung lesions 32150 C Removal of lung lesion(s) 32151 C Remove lung foreign body 32160 C Open chest heart massage 32200 C Drain, open, lung lesion 32201 C Drain, percut, lung lesion 32215 C Treat chest lining 32220 C Release of lung 32225 C Partial release of lung 32310 C Removal of chest lining 32320 C Free/remove chest lining 32400 T Needle biopsy chest lining 0005 5.41 $262.32 $119.75 $52.46 32402 C Open biopsy chest lining 32405 T Biopsy, lung or mediastinum 0005 5.41 $262.32 $119.75 $52.46 32420 T Puncture/clear lung 0070 3.64 $176.49 $79.60 $35.30 32440 C Removal of lung 32442 C Sleeve pneumonectomy 32445 C Removal of lung 32480 C Partial removal of lung 32482 C Bilobectomy 32484 C Segmentectomy 32486 C Sleeve lobectomy 32488 C Completion pneumonectomy 32491 C Lung volume reduction 32500 C Partial removal of lung 32501 C Repair bronchus add-on 32520 C Remove lung & revise chest 32522 C Remove lung & revise chest 32525 C Remove lung & revise chest 32540 C Removal of lung lesion 32601 T Thoracoscopy, diagnostic 0076 8.06 $390.81 $197.05 $78.16 32602 T Thoracoscopy, diagnostic 0076 8.06 $390.81 $197.05 $78.16 32603 T Thoracoscopy, diagnostic 0076 8.06 $390.81 $197.05 $78.16 32604 T Thoracoscopy, diagnostic 0076 8.06 $390.81 $197.05 $78.16 32605 T Thoracoscopy, diagnostic 0076 8.06 $390.81 $197.05 $78.16 32606 T Thoracoscopy, diagnostic 0076 8.06 $390.81 $197.05 $78.16 32650 C Thoracoscopy, surgical 32651 C Thoracoscopy, surgical 32652 C Thoracoscopy, surgical 32653 C Thoracoscopy, surgical 32654 C Thoracoscopy, surgical 32655 C Thoracoscopy, surgical 32656 C Thoracoscopy, surgical 32657 C Thoracoscopy, surgical 32658 C Thoracoscopy, surgical 32659 C Thoracoscopy, surgical 32660 C Thoracoscopy, surgical 32661 C Thoracoscopy, surgical 32662 C Thoracoscopy, surgical 32663 C Thoracoscopy, surgical 32664 C Thoracoscopy, surgical 32665 C Thoracoscopy, surgical 32800 C Repair lung hernia 32810 C Close chest after drainage 32815 C Close bronchial fistula Start Printed Page 18590 32820 C Reconstruct injured chest 32850 C Donor pneumonectomy 32851 C Lung transplant, single 32852 C Lung transplant with bypass 32853 C Lung transplant, double 32854 C Lung transplant with bypass 32900 C Removal of rib(s) 32905 C Revise & repair chest wall 32906 C Revise & repair chest wall 32940 C Revision of lung 32960 T Therapeutic pneumothorax 0070 3.64 $176.49 $79.60 $35.30 32997 C Total lung lavage 32999 T Chest surgery procedure 0070 3.64 $176.49 $79.60 $35.30 33010 T Drainage of heart sac 0070 3.64 $176.49 $79.60 $35.30 33011 T Repeat drainage of heart sac 0070 3.64 $176.49 $79.60 $35.30 33015 C Incision of heart sac 33020 C Incision of heart sac 33025 C Incision of heart sac 33030 C Partial removal of heart sac 33031 C Partial removal of heart sac 33050 C Removal of heart sac lesion 33120 C Removal of heart lesion 33130 C Removal of heart lesion 33140 C Heart revascularize (tmr) 33200 C Insertion of heart pacemaker 33201 C Insertion of heart pacemaker 33206 T Insertion of heart pacemaker 0090 20.96 $1,016.29 $573.04 $203.26 33207 T Insertion of heart pacemaker 0090 20.96 $1,016.29 $573.04 $203.26 33208 T Insertion of heart pacemaker 0090 20.96 $1,016.29 $573.04 $203.26 33210 T Insertion of heart electrode 0089 6.49 $314.68 $130.07 $62.94 33211 T Insertion of heart electrode 0089 6.49 $314.68 $130.07 $62.94 33212 T Insertion of pulse generator 0090 20.96 $1,016.29 $573.04 $203.26 33213 T Insertion of pulse generator 0090 20.96 $1,016.29 $573.04 $203.26 33214 T Upgrade of pacemaker system 0090 20.96 $1,016.29 $573.04 $203.26 33216 T Revise eltrd pacing-defib 0090 20.96 $1,016.29 $573.04 $203.26 33217 T Revise eltrd pacing-defib 0090 20.96 $1,016.29 $573.04 $203.26 33218 T Revise eltrd pacing-defib 0090 20.96 $1,016.29 $573.04 $203.26 33220 T Revise eltrd pacing-defib 0089 6.49 $314.68 $130.07 $62.94 33222 T Revise pocket, pacemaker 0026 12.11 $587.18 $277.92 $117.44 33223 T Revise pocket, pacing-defib 0026 12.11 $587.18 $277.92 $117.44 33233 T Removal of pacemaker system 0090 20.96 $1,016.29 $573.04 $203.26 33234 T Removal of pacemaker system 0090 20.96 $1,016.29 $573.04 $203.26 33235 T Removal pacemaker electrode 0090 20.96 $1,016.29 $573.04 $203.26 33236 C Remove electrode/thoracotomy 33237 C Remove electrode/thoracotomy 33238 C Remove electrode/thoracotomy 33240 T Insert pulse generator 0090 20.96 $1,016.29 $573.04 $203.26 33241 T Remove pulse generator 0089 6.49 $314.68 $130.07 $62.94 33243 C Remove eltrd/thoracotomy 33244 T Remove eltrd, transven 0090 20.96 $1,016.29 $573.04 $203.26 33245 C Insert epic eltrd pace-defib 33246 C Insert epic eltrd/generator 33249 T Eltrd/insert pace-defib 0090 20.96 $1,016.29 $573.04 $203.26 33250 C Ablate heart dysrhythm focus 33251 C Ablate heart dysrhythm focus 33253 C Reconstruct atria 33261 C Ablate heart dysrhythm focus 33282 C Implant pat-active ht record 33284 C Remove pat-active ht record 33300 C Repair of heart wound 33305 C Repair of heart wound 33310 C Exploratory heart surgery 33315 C Exploratory heart surgery 33320 C Repair major blood vessel(s) 33321 C Repair major vessel 33322 C Repair major blood vessel(s) 33330 C Insert major vessel graft 33332 C Insert major vessel graft 33335 C Insert major vessel graft 33400 C Repair of aortic valve 33401 C Valvuloplasty, open 33403 C Valvuloplasty, w/cp bypass 33404 C Prepare heart-aorta conduit Start Printed Page 18591 33405 C Replacement of aortic valve 33406 C Replacement of aortic valve 33410 C Replacement of aortic valve 33411 C Replacement of aortic valve 33412 C Replacement of aortic valve 33413 C Replacement of aortic valve 33414 C Repair of aortic valve 33415 C Revision, subvalvular tissue 33416 C Revise ventricle muscle 33417 C Repair of aortic valve 33420 C Revision of mitral valve 33422 C Revision of mitral valve 33425 C Repair of mitral valve 33426 C Repair of mitral valve 33427 C Repair of mitral valve 33430 C Replacement of mitral valve 33460 C Revision of tricuspid valve 33463 C Valvuloplasty, tricuspid 33464 C Valvuloplasty, tricuspid 33465 C Replace tricuspid valve 33468 C Revision of tricuspid valve 33470 C Revision of pulmonary valve 33471 C Valvotomy, pulmonary valve 33472 C Revision of pulmonary valve 33474 C Revision of pulmonary valve 33475 C Replacement, pulmonary valve 33476 C Revision of heart chamber 33478 C Revision of heart chamber 33496 C Repair, prosth valve clot 33500 C Repair heart vessel fistula 33501 C Repair heart vessel fistula 33502 C Coronary artery correction 33503 C Coronary artery graft 33504 C Coronary artery graft 33505 C Repair artery w/tunnel 33506 C Repair artery, translocation 33510 C CABG, vein, single 33511 C CABG, vein, two 33512 C CABG, vein, three 33513 C CABG, vein, four 33514 C CABG, vein, five 33516 C Cabg, vein, six or more 33517 C CABG, artery-vein, single 33518 C CABG, artery-vein, two 33519 C CABG, artery-vein, three 33521 C CABG, artery-vein, four 33522 C CABG, artery-vein, five 33523 C Cabg, art-vein, six or more 33530 C Coronary artery, bypass/reop 33533 C CABG, arterial, single 33534 C CABG, arterial, two 33535 C CABG, arterial, three 33536 C Cabg, arterial, four or more 33542 C Removal of heart lesion 33545 C Repair of heart damage 33572 C Open coronary endarterectomy 33600 C Closure of valve 33602 C Closure of valve 33606 C Anastomosis/artery-aorta 33608 C Repair anomaly w/conduit 33610 C Repair by enlargement 33611 C Repair double ventricle 33612 C Repair double ventricle 33615 C Repair, simple fontan 33617 C Repair, modified fontan 33619 C Repair single ventricle 33641 C Repair heart septum defect 33645 C Revision of heart veins 33647 C Repair heart septum defects 33660 C Repair of heart defects 33665 C Repair of heart defects 33670 C Repair of heart chambers 33681 C Repair heart septum defect Start Printed Page 18592 33684 C Repair heart septum defect 33688 C Repair heart septum defect 33690 C Reinforce pulmonary artery 33692 C Repair of heart defects 33694 C Repair of heart defects 33697 C Repair of heart defects 33702 C Repair of heart defects 33710 C Repair of heart defects 33720 C Repair of heart defect 33722 C Repair of heart defect 33730 C Repair heart-vein defect(s) 33732 C Repair heart-vein defect 33735 C Revision of heart chamber 33736 C Revision of heart chamber 33737 C Revision of heart chamber 33750 C Major vessel shunt 33755 C Major vessel shunt 33762 C Major vessel shunt 33764 C Major vessel shunt & graft 33766 C Major vessel shunt 33767 C Major vessel shunt 33770 C Repair great vessels defect 33771 C Repair great vessels defect 33774 C Repair great vessels defect 33775 C Repair great vessels defect 33776 C Repair great vessels defect 33777 C Repair great vessels defect 33778 C Repair great vessels defect 33779 C Repair great vessels defect 33780 C Repair great vessels defect 33781 C Repair great vessels defect 33786 C Repair arterial trunk 33788 C Revision of pulmonary artery 33800 C Aortic suspension 33802 C Repair vessel defect 33803 C Repair vessel defect 33813 C Repair septal defect 33814 C Repair septal defect 33820 C Revise major vessel 33822 C Revise major vessel 33824 C Revise major vessel 33840 C Remove aorta constriction 33845 C Remove aorta constriction 33851 C Remove aorta constriction 33852 C Repair septal defect 33853 C Repair septal defect 33860 C Ascending aortic graft 33861 C Ascending aortic graft 33863 C Ascending aortic graft 33870 C Transverse aortic arch graft 33875 C Thoracic aortic graft 33877 C Thoracoabdominal graft 33910 C Remove lung artery emboli 33915 C Remove lung artery emboli 33916 C Surgery of great vessel 33917 C Repair pulmonary artery 33918 C Repair pulmonary atresia 33919 C Repair pulmonary atresia 33920 C Repair pulmonary atresia 33922 C Transect pulmonary artery 33924 C Remove pulmonary shunt 33930 C Removal of donor heart/lung 33935 C Transplantation, heart/lung 33940 C Removal of donor heart 33945 C Transplantation of heart 33960 C External circulation assist 33961 C External circulation assist 33968 C Remove aortic assist device 33970 C Aortic circulation assist 33971 C Aortic circulation assist 33973 C Insert balloon device 33974 C Remove intra-aortic balloon 33975 C Implant ventricular device Start Printed Page 18593 33976 C Implant ventricular device 33977 C Remove ventricular device 33978 C Remove ventricular device 33999 T Cardiac surgery procedure 0070 3.64 $176.49 $79.60 $35.30 34001 C Removal of artery clot 34051 C Removal of artery clot 34101 T Removal of artery clot 0088 26.49 $1,284.42 $678.68 $256.88 34111 T Removal of arm artery clot 0088 26.49 $1,284.42 $678.68 $256.88 34151 C Removal of artery clot 34201 T Removal of artery clot 0088 26.49 $1,284.42 $678.68 $256.88 34203 T Removal of leg artery clot 0088 26.49 $1,284.42 $678.68 $256.88 34401 C Removal of vein clot 34421 C Removal of vein clot 34451 C Removal of vein clot 34471 T Removal of vein clot 0088 26.49 $1,284.42 $678.68 $256.88 34490 T Removal of vein clot 0088 26.49 $1,284.42 $678.68 $256.88 34501 T Repair valve, femoral vein 0088 26.49 $1,284.42 $678.68 $256.88 34502 C Reconstruct vena cava 34510 T Transposition of vein valve 0088 26.49 $1,284.42 $678.68 $256.88 34520 T Cross-over vein graft 0088 26.49 $1,284.42 $678.68 $256.88 34530 T Leg vein fusion 0088 26.49 $1,284.42 $678.68 $256.88 35001 C Repair defect of artery 35002 C Repair artery rupture, neck 35005 C Repair defect of artery 35011 C Repair defect of artery 35013 C Repair artery rupture, arm 35021 C Repair defect of artery 35022 C Repair artery rupture, chest 35045 C Repair defect of arm artery 35081 C Repair defect of artery 35082 C Repair artery rupture, aorta 35091 C Repair defect of artery 35092 C Repair artery rupture, aorta 35102 C Repair defect of artery 35103 C Repair artery rupture, groin 35111 C Repair defect of artery 35112 C Repair artery rupture, spleen 35121 C Repair defect of artery 35122 C Repair artery rupture, belly 35131 C Repair defect of artery 35132 C Repair artery rupture, groin 35141 C Repair defect of artery 35142 C Repair artery rupture, thigh 35151 C Repair defect of artery 35152 C Repair artery rupture, knee 35161 C Repair defect of artery 35162 C Repair artery rupture 35180 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35182 C Repair blood vessel lesion 35184 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35188 T Repair blood vessel lesion 0088 26.49 $1,284.42 $678.68 $256.88 35189 C Repair blood vessel lesion 35190 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35201 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35206 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35207 T Repair blood vessel lesion 0088 26.49 $1,284.42 $678.68 $256.88 35211 C Repair blood vessel lesion 35216 C Repair blood vessel lesion 35221 C Repair blood vessel lesion 35226 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35231 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35236 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35241 C Repair blood vessel lesion 35246 C Repair blood vessel lesion 35251 C Repair blood vessel lesion 35256 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35261 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35266 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35271 C Repair blood vessel lesion 35276 C Repair blood vessel lesion 35281 C Repair blood vessel lesion 35286 T Repair blood vessel lesion 0081 19.36 $938.71 $434.25 $187.74 35301 C Rechanneling of artery Start Printed Page 18594 35311 C Rechanneling of artery 35321 T Rechanneling of artery 0081 19.36 $938.71 $434.25 $187.74 35331 C Rechanneling of artery 35341 C Rechanneling of artery 35351 C Rechanneling of artery 35355 C Rechanneling of artery 35361 C Rechanneling of artery 35363 C Rechanneling of artery 35371 C Rechanneling of artery 35372 C Rechanneling of artery 35381 C Rechanneling of artery 35390 C Reoperation, carotid add-on 35400 C Angioscopy 35450 C Repair arterial blockage 35452 C Repair arterial blockage 35454 C Repair arterial blockage 35456 C Repair arterial blockage 35458 C Repair arterial blockage 35459 T Repair arterial blockage 0081 19.36 $938.71 $434.25 $187.74 35460 T Repair venous blockage 0081 19.36 $938.71 $434.25 $187.74 35470 T Repair arterial blockage 0081 19.36 $938.71 $434.25 $187.74 35471 T Repair arterial blockage 0081 19.36 $938.71 $434.25 $187.74 35472 T Repair arterial blockage 0081 19.36 $938.71 $434.25 $187.74 35473 T Repair arterial blockage 0081 19.36 $938.71 $434.25 $187.74 35474 T Repair arterial blockage 0081 19.36 $938.71 $434.25 $187.74 35475 T Repair arterial blockage 0081 19.36 $938.71 $434.25 $187.74 35476 T Repair venous blockage 0081 19.36 $938.71 $434.25 $187.74 35480 C Atherectomy, open 35481 C Atherectomy, open 35482 C Atherectomy, open 35483 C Atherectomy, open 35484 T Atherectomy, open 0081 19.36 $938.71 $434.25 $187.74 35485 T Atherectomy, open 0081 19.36 $938.71 $434.25 $187.74 35490 T Atherectomy, percutaneous 0081 19.36 $938.71 $434.25 $187.74 35491 T Atherectomy, percutaneous 0081 19.36 $938.71 $434.25 $187.74 35492 T Atherectomy, percutaneous 0081 19.36 $938.71 $434.25 $187.74 35493 T Atherectomy, percutaneous 0081 19.36 $938.71 $434.25 $187.74 35494 T Atherectomy, percutaneous 0081 19.36 $938.71 $434.25 $187.74 35495 T Atherectomy, percutaneous 0081 19.36 $938.71 $434.25 $187.74 35500 T Harvest vein for bypass 0081 19.36 $938.71 $434.25 $187.74 35501 C Artery bypass graft 35506 C Artery bypass graft 35507 C Artery bypass graft 35508 C Artery bypass graft 35509 C Artery bypass graft 35511 C Artery bypass graft 35515 C Artery bypass graft 35516 C Artery bypass graft 35518 C Artery bypass graft 35521 C Artery bypass graft 35526 C Artery bypass graft 35531 C Artery bypass graft 35533 C Artery bypass graft 35536 C Artery bypass graft 35541 C Artery bypass graft 35546 C Artery bypass graft 35548 C Artery bypass graft 35549 C Artery bypass graft 35551 C Artery bypass graft 35556 C Artery bypass graft 35558 C Artery bypass graft 35560 C Artery bypass graft 35563 C Artery bypass graft 35565 C Artery bypass graft 35566 C Artery bypass graft 35571 C Artery bypass graft 35582 C Vein bypass graft 35583 C Vein bypass graft 35585 C Vein bypass graft 35587 C Vein bypass graft 35601 C Artery bypass graft 35606 C Artery bypass graft 35612 C Artery bypass graft Start Printed Page 18595 35616 C Artery bypass graft 35621 C Artery bypass graft 35623 C Bypass graft, not vein 35626 C Artery bypass graft 35631 C Artery bypass graft 35636 C Artery bypass graft 35641 C Artery bypass graft 35642 C Artery bypass graft 35645 C Artery bypass graft 35646 C Artery bypass graft 35650 C Artery bypass graft 35651 C Artery bypass graft 35654 C Artery bypass graft 35656 C Artery bypass graft 35661 C Artery bypass graft 35663 C Artery bypass graft 35665 C Artery bypass graft 35666 C Artery bypass graft 35671 C Artery bypass graft 35681 C Composite bypass graft 35682 C Composite bypass graft 35683 C Composite bypass graft 35691 C Arterial transposition 35693 C Arterial transposition 35694 C Arterial transposition 35695 C Arterial transposition 35700 C Reoperation, bypass graft 35701 C Exploration, carotid artery 35721 C Exploration, femoral artery 35741 C Exploration popliteal artery 35761 C Exploration of artery/vein 35800 C Explore neck vessels 35820 C Explore chest vessels 35840 C Explore abdominal vessels 35860 C Explore limb vessels 35870 C Repair vessel graft defect 35875 T Removal of clot in graft 0088 26.49 $1,284.42 $678.68 $256.88 35876 T Removal of clot in graft 0088 26.49 $1,284.42 $678.68 $256.88 35879 T Revise graft w/vein 0088 26.49 $1,284.42 $678.68 $256.88 35881 T Revise graft w/vein 0088 26.49 $1,284.42 $678.68 $256.88 35901 C Excision, graft, neck 35903 C Excision, graft, extremity 35905 C Excision, graft, thorax 35907 C Excision, graft, abdomen 36000 N Place needle in vein 36005 N Injection, venography 36010 N Place catheter in vein 36011 N Place catheter in vein 36012 N Place catheter in vein 36013 N Place catheter in artery 36014 N Place catheter in artery 36015 N Place catheter in artery 36100 N Establish access to artery 36120 N Establish access to artery 36140 N Establish access to artery 36145 N Artery to vein shunt 36160 N Establish access to aorta 36200 N Place catheter in aorta 36215 N Place catheter in artery 36216 N Place catheter in artery 36217 N Place catheter in artery 36218 N Place catheter in artery 36245 N Place catheter in artery 36246 N Place catheter in artery 36247 N Place catheter in artery 36248 N Place catheter in artery 36260 T Insertion of infusion pump 0093 17.95 $870.34 $422.33 $174.07 36261 T Revision of infusion pump 0089 6.49 $314.68 $130.07 $62.94 36262 T Removal of infusion pump 0089 6.49 $314.68 $130.07 $62.94 36299 T Vessel injection procedure 0089 6.49 $314.68 $130.07 $62.94 36400 N Drawing blood 36405 N Drawing blood 36406 N Drawing blood Start Printed Page 18596 36410 N Drawing blood 36415 E Drawing blood 36420 T Establish access to vein 0032 5.40 $261.83 $119.52 $52.37 36425 T Establish access to vein 0032 5.40 $261.83 $119.52 $52.37 36430 S Blood transfusion service 0110 5.83 $282.68 $122.73 $56.54 36440 S Blood transfusion service 0110 5.83 $282.68 $122.73 $56.54 36450 S Exchange transfusion service 0110 5.83 $282.68 $122.73 $56.54 36455 S Exchange transfusion service 0110 5.83 $282.68 $122.73 $56.54 36460 S Transfusion service, fetal 0110 5.83 $282.68 $122.73 $56.54 36468 T Injection(s), spider veins 0098 1.19 $57.70 $20.88 $11.54 36469 T Injection(s), spider veins 0098 1.19 $57.70 $20.88 $11.54 36470 T Injection therapy of vein 0098 1.19 $57.70 $20.88 $11.54 36471 T Injection therapy of veins 0098 1.19 $57.70 $20.88 $11.54 36481 N Insertion of catheter, vein 36488 T Insertion of catheter, vein 0032 5.40 $261.83 $119.52 $52.37 36489 T Insertion of catheter, vein 0032 5.40 $261.83 $119.52 $52.37 36490 T Insertion of catheter, vein 0032 5.40 $261.83 $119.52 $52.37 36491 T Insertion of catheter, vein 0032 5.40 $261.83 $119.52 $52.37 36493 T Repositioning of cvc 0032 5.40 $261.83 $119.52 $52.37 36500 N Insertion of catheter, vein 36510 C Insertion of catheter, vein 36520 S Plasma and/or cell exchange 0111 14.17 $687.06 $300.74 $137.41 36521 S Apheresis w/adsorp/reinfuse 0111 14.17 $687.06 $300.74 $137.41 36522 S Photopheresis 0112 39.60 $1,920.09 $663.65 $384.02 36530 T Insertion of infusion pump 0093 17.95 $870.34 $422.33 $174.07 36531 T Revision of infusion pump 0089 6.49 $314.68 $130.07 $62.94 36532 T Removal of infusion pump 0089 6.49 $314.68 $130.07 $62.94 36533 T Insertion of access device 0093 17.95 $870.34 $422.33 $174.07 36534 T Revision of access device 0089 6.49 $314.68 $130.07 $62.94 36535 T Removal of access device 0089 6.49 $314.68 $130.07 $62.94 36550 C Declot vascular device 36600 N Withdrawal of arterial blood 36620 N Insertion catheter, artery 36625 N Insertion catheter, artery 36640 T Insertion catheter, artery 0032 5.40 $261.83 $119.52 $52.37 36660 C Insertion catheter, artery 36680 S Insert needle, bone cavity 0120 1.66 $80.49 $42.67 $16.10 36800 T Insertion of cannula 0093 17.95 $870.34 $422.33 $174.07 36810 T Insertion of cannula 0093 17.95 $870.34 $422.33 $174.07 36815 T Insertion of cannula 0093 17.95 $870.34 $422.33 $174.07 36819 T Av fusion by basilic vein 0093 17.95 $870.34 $422.33 $174.07 36821 T Av fusion direct any site 0088 26.49 $1,284.42 $678.68 $256.88 36822 C Insertion of cannula(s) 36823 C Insertion of cannula(s) 36825 T Artery-vein graft 0088 26.49 $1,284.42 $678.68 $256.88 36830 T Artery-vein graft 0088 26.49 $1,284.42 $678.68 $256.88 36831 T Av fistula excision 0088 26.49 $1,284.42 $678.68 $256.88 36832 T Av fistula revision 0088 26.49 $1,284.42 $678.68 $256.88 36833 T Av fistula revision 0088 26.49 $1,284.42 $678.68 $256.88 36834 C Repair A-V aneurysm 36835 T Artery to vein shunt 0093 17.95 $870.34 $422.33 $174.07 36860 T External cannula declotting 0090 20.96 $1,016.29 $573.04 $203.26 36861 T Cannula declotting 0090 20.96 $1,016.29 $573.04 $203.26 37140 C Revision of circulation 37145 C Revision of circulation 37160 C Revision of circulation 37180 C Revision of circulation 37181 C Splice spleen/kidney veins 37195 C Thrombolytic therapy, stroke 37200 C Transcatheter biopsy 37201 C Transcatheter therapy infuse 37202 C Transcatheter therapy infuse 37203 T Transcatheter retrieval 0089 6.49 $314.68 $130.07 $62.94 37204 T Transcatheter occlusion 0081 19.36 $938.71 $434.25 $187.74 37205 T Transcatheter stent 0081 19.36 $938.71 $434.25 $187.74 37206 T Transcatheter stent add-on 0081 19.36 $938.71 $434.25 $187.74 37207 T Transcatheter stent 0081 19.36 $938.71 $434.25 $187.74 37208 T Transcatheter stent add-on 0081 19.36 $938.71 $434.25 $187.74 37209 T Exchange arterial catheter 0081 19.36 $938.71 $434.25 $187.74 37250 T Iv us first vessel add-on 0081 19.36 $938.71 $434.25 $187.74 37251 T Iv us each add vessel add-on 0081 19.36 $938.71 $434.25 $187.74 37565 T Ligation of neck vein 0081 19.36 $938.71 $434.25 $187.74 37600 T Ligation of neck artery 0081 19.36 $938.71 $434.25 $187.74 Start Printed Page 18597 37605 T Ligation of neck artery 0091 14.79 $717.12 $348.23 $143.42 37606 T Ligation of neck artery 0091 14.79 $717.12 $348.23 $143.42 37607 T Ligation of a-v fistula 0092 20.21 $979.92 $505.37 $195.98 37609 T Temporal artery procedure 0020 6.51 $315.65 $130.53 $63.13 37615 T Ligation of neck artery 0091 14.79 $717.12 $348.23 $143.42 37616 C Ligation of chest artery 37617 C Ligation of abdomen artery 37618 E Ligation of extremity artery 37620 C Revision of major vein 37650 T Revision of major vein 0091 14.79 $717.12 $348.23 $143.42 37660 C Revision of major vein 37700 T Revise leg vein 0091 14.79 $717.12 $348.23 $143.42 37720 T Removal of leg vein 0092 20.21 $979.92 $505.37 $195.98 37730 T Removal of leg veins 0092 20.21 $979.92 $505.37 $195.98 37735 T Removal of leg veins/lesion 0092 20.21 $979.92 $505.37 $195.98 37760 T Revision of leg veins 0091 14.79 $717.12 $348.23 $143.42 37780 T Revision of leg vein 0091 14.79 $717.12 $348.23 $143.42 37785 T Revise secondary varicosity 0091 14.79 $717.12 $348.23 $143.42 37788 C Revascularization, penis 37790 T Penile venous occlusion 0181 32.37 $1,569.53 $906.36 $313.91 37799 T Vascular surgery procedure 0020 6.51 $315.65 $130.53 $63.13 38100 C Removal of spleen, total 38101 C Removal of spleen, partial 38102 C Removal of spleen, total 38115 C Repair of ruptured spleen 38120 T Laparoscopy, splenectomy 0131 41.81 $2,027.24 $1,089.88 $405.45 38129 T Laparoscope proc, spleen 0130 25.36 $1,229.63 $659.53 $245.93 38200 N Injection for spleen x-ray 38230 S Bone marrow collection 0109 4.13 $200.25 $40.05 $40.05 38231 S Stem cell collection 0111 14.17 $687.06 $300.74 $137.41 38240 S Bone marrow/stem transplant 0109 4.13 $200.25 $40.05 $40.05 38241 S Bone marrow/stem transplant 0109 4.13 $200.25 $40.05 $40.05 38300 T Drainage, lymph node lesion 0008 6.15 $298.20 $113.67 $59.64 38305 T Drainage, lymph node lesion 0008 6.15 $298.20 $113.67 $59.64 38308 T Incision of lymph channels 0113 13.89 $673.49 $326.55 $134.70 38380 C Thoracic duct procedure 38381 C Thoracic duct procedure 38382 C Thoracic duct procedure 38500 T Biopsy/removal, lymph nodes 0113 13.89 $673.49 $326.55 $134.70 38505 T Needle biopsy, lymph nodes 0005 5.41 $262.32 $119.75 $52.46 38510 T Biopsy/removal, lymph nodes 0113 13.89 $673.49 $326.55 $134.70 38520 T Biopsy/removal, lymph nodes 0113 13.89 $673.49 $326.55 $134.70 38525 T Biopsy/removal, lymph nodes 0113 13.89 $673.49 $326.55 $134.70 38530 T Biopsy/removal, lymph nodes 0113 13.89 $673.49 $326.55 $134.70 38542 T Explore deep node(s), neck 0114 19.56 $948.41 $493.78 $189.68 38550 T Removal, neck/armpit lesion 0113 13.89 $673.49 $326.55 $134.70 38555 T Removal, neck/armpit lesion 0114 19.56 $948.41 $493.78 $189.68 38562 C Removal, pelvic lymph nodes 38564 C Removal, abdomen lymph nodes 38570 T Laparoscopy, lymph node biop 0131 41.81 $2,027.24 $1,089.88 $405.45 38571 T Laparoscopy, lymphadenectomy 0132 48.91 $2,371.50 $1,239.22 $474.30 38572 T Laparoscopy, lymphadenectomy 0131 41.81 $2,027.24 $1,089.88 $405.45 38589 T Laparoscope proc, lymphatic 0130 25.36 $1,229.63 $659.53 $245.93 38700 C Removal of lymph nodes, neck 38720 T Removal of lymph nodes, neck 0114 19.56 $948.41 $493.78 $189.68 38724 C Removal of lymph nodes, neck 38740 T Remove armpit lymph nodes 0114 19.56 $948.41 $493.78 $189.68 38745 T Remove armpit lymph nodes 0114 19.56 $948.41 $493.78 $189.68 38746 C Remove thoracic lymph nodes 38747 C Remove abdominal lymph nodes 38760 T Remove groin lymph nodes 0114 19.56 $948.41 $493.78 $189.68 38765 C Remove groin lymph nodes 38770 C Remove pelvis lymph nodes 38780 C Remove abdomen lymph nodes 38790 N Inject for lymphatic x-ray 38792 N Identify sentinel node 38794 N Access thoracic lymph duct 38999 T Blood/lymph system procedure 0008 6.15 $298.20 $113.67 $59.64 39000 C Exploration of chest 39010 C Exploration of chest 39200 C Removal chest lesion 39220 C Removal chest lesion 39400 T Visualization of chest 0076 8.06 $390.81 $197.05 $78.16 Start Printed Page 18598 39499 C Chest procedure 39501 C Repair diaphragm laceration 39502 C Repair paraesophageal hernia 39503 C Repair of diaphragm hernia 39520 C Repair of diaphragm hernia 39530 C Repair of diaphragm hernia 39531 C Repair of diaphragm hernia 39540 C Repair of diaphragm hernia 39541 C Repair of diaphragm hernia 39545 C Revision of diaphragm 39560 C Resect diaphragm, simple 39561 C Resect diaphragm, complex 39599 C Diaphragm surgery procedure 40490 T Biopsy of lip 0252 5.18 $251.16 $114.24 $50.23 40500 T Partial excision of lip 0253 12.02 $582.81 $284.00 $116.56 40510 T Partial excision of lip 0254 12.45 $603.66 $272.41 $120.73 40520 T Partial excision of lip 0253 12.02 $582.81 $284.00 $116.56 40525 T Reconstruct lip with flap 0254 12.45 $603.66 $272.41 $120.73 40527 T Reconstruct lip with flap 0254 12.45 $603.66 $272.41 $120.73 40530 T Partial removal of lip 0254 12.45 $603.66 $272.41 $120.73 40650 T Repair lip 0253 12.02 $582.81 $284.00 $116.56 40652 T Repair lip 0253 12.02 $582.81 $284.00 $116.56 40654 T Repair lip 0254 12.45 $603.66 $272.41 $120.73 40700 T Repair cleft lip/nasal 0256 25.40 $1,231.57 $623.05 $246.31 40701 T Repair cleft lip/nasal 0256 25.40 $1,231.57 $623.05 $246.31 40702 T Repair cleft lip/nasal 0256 25.40 $1,231.57 $623.05 $246.31 40720 T Repair cleft lip/nasal 0256 25.40 $1,231.57 $623.05 $246.31 40761 T Repair cleft lip/nasal 0256 25.40 $1,231.57 $623.05 $246.31 40799 T Lip surgery procedure 0253 12.02 $582.81 $284.00 $116.56 40800 T Drainage of mouth lesion 0251 1.68 $81.46 $27.99 $16.29 40801 T Drainage of mouth lesion 0252 5.18 $251.16 $114.24 $50.23 40804 T Removal, foreign body, mouth 0251 1.68 $81.46 $27.99 $16.29 40805 T Removal, foreign body, mouth 0252 5.18 $251.16 $114.24 $50.23 40806 T Incision of lip fold 0251 1.68 $81.46 $27.99 $16.29 40808 T Biopsy of mouth lesion 0251 1.68 $81.46 $27.99 $16.29 40810 T Excision of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 40812 T Excise/repair mouth lesion 0252 5.18 $251.16 $114.24 $50.23 40814 T Excise/repair mouth lesion 0253 12.02 $582.81 $284.00 $116.56 40816 T Excision of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 40818 T Excise oral mucosa for graft 0251 1.68 $81.46 $27.99 $16.29 40819 T Excise lip or cheek fold 0252 5.18 $251.16 $114.24 $50.23 40820 T Treatment of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 40830 T Repair mouth laceration 0251 1.68 $81.46 $27.99 $16.29 40831 T Repair mouth laceration 0253 12.02 $582.81 $284.00 $116.56 40840 T Reconstruction of mouth 0254 12.45 $603.66 $272.41 $120.73 40842 T Reconstruction of mouth 0254 12.45 $603.66 $272.41 $120.73 40843 T Reconstruction of mouth 0254 12.45 $603.66 $272.41 $120.73 40844 T Reconstruction of mouth 0256 25.40 $1,231.57 $623.05 $246.31 40845 T Reconstruction of mouth 0256 25.40 $1,231.57 $623.05 $246.31 40899 T Mouth surgery procedure 0252 5.18 $251.16 $114.24 $50.23 41000 T Drainage of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 41005 T Drainage of mouth lesion 0251 1.68 $81.46 $27.99 $16.29 41006 T Drainage of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 41007 T Drainage of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 41008 T Drainage of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 41009 T Drainage of mouth lesion 0251 1.68 $81.46 $27.99 $16.29 41010 T Incision of tongue fold 0253 12.02 $582.81 $284.00 $116.56 41015 T Drainage of mouth lesion 0252 5.18 $251.16 $114.24 $50.23 41016 T Drainage of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 41017 T Drainage of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 41018 T Drainage of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 41100 T Biopsy of tongue 0252 5.18 $251.16 $114.24 $50.23 41105 T Biopsy of tongue 0253 12.02 $582.81 $284.00 $116.56 41108 T Biopsy of floor of mouth 0252 5.18 $251.16 $114.24 $50.23 41110 T Excision of tongue lesion 0253 12.02 $582.81 $284.00 $116.56 41112 T Excision of tongue lesion 0253 12.02 $582.81 $284.00 $116.56 41113 T Excision of tongue lesion 0253 12.02 $582.81 $284.00 $116.56 41114 T Excision of tongue lesion 0254 12.45 $603.66 $272.41 $120.73 41115 T Excision of tongue fold 0253 12.02 $582.81 $284.00 $116.56 41116 T Excision of mouth lesion 0253 12.02 $582.81 $284.00 $116.56 41120 T Partial removal of tongue 0256 25.40 $1,231.57 $623.05 $246.31 41130 C Partial removal of tongue 41135 C Tongue and neck surgery Start Printed Page 18599 41140 C Removal of tongue 41145 C Tongue removal, neck surgery 41150 C Tongue, mouth, jaw surgery 41153 C Tongue, mouth, neck surgery 41155 C Tongue, jaw, & neck surgery 41250 T Repair tongue laceration 0251 1.68 $81.46 $27.99 $16.29 41251 T Repair tongue laceration 0253 12.02 $582.81 $284.00 $116.56 41252 T Repair tongue laceration 0253 12.02 $582.81 $284.00 $116.56 41500 T Fixation of tongue 0253 12.02 $582.81 $284.00 $116.56 41510 T Tongue to lip surgery 0253 12.02 $582.81 $284.00 $116.56 41520 T Reconstruction, tongue fold 0253 12.02 $582.81 $284.00 $116.56 41599 T Tongue and mouth surgery 0251 1.68 $81.46 $27.99 $16.29 41800 T Drainage of gum lesion 0251 1.68 $81.46 $27.99 $16.29 41805 T Removal foreign body, gum 0253 12.02 $582.81 $284.00 $116.56 41806 T Removal foreign body, jawbone 0253 12.02 $582.81 $284.00 $116.56 41820 T Excision, gum, each quadrant 0252 5.18 $251.16 $114.24 $50.23 41821 T Excision of gum flap 0252 5.18 $251.16 $114.24 $50.23 41822 T Excision of gum lesion 0253 12.02 $582.81 $284.00 $116.56 41823 T Excision of gum lesion 0253 12.02 $582.81 $284.00 $116.56 41825 T Excision of gum lesion 0253 12.02 $582.81 $284.00 $116.56 41826 T Excision of gum lesion 0253 12.02 $582.81 $284.00 $116.56 41827 T Excision of gum lesion 0253 12.02 $582.81 $284.00 $116.56 41828 T Excision of gum lesion 0253 12.02 $582.81 $284.00 $116.56 41830 T Removal of gum tissue 0253 12.02 $582.81 $284.00 $116.56 41850 T Treatment of gum lesion 0253 12.02 $582.81 $284.00 $116.56 41870 T Gum graft 0253 12.02 $582.81 $284.00 $116.56 41872 T Repair gum 0253 12.02 $582.81 $284.00 $116.56 41874 T Repair tooth socket 0253 12.02 $582.81 $284.00 $116.56 41899 T Dental surgery procedure 0253 12.02 $582.81 $284.00 $116.56 42000 T Drainage mouth roof lesion 0251 1.68 $81.46 $27.99 $16.29 42100 T Biopsy roof of mouth 0252 5.18 $251.16 $114.24 $50.23 42104 T Excision lesion, mouth roof 0253 12.02 $582.81 $284.00 $116.56 42106 T Excision lesion, mouth roof 0253 12.02 $582.81 $284.00 $116.56 42107 T Excision lesion, mouth roof 0254 12.45 $603.66 $272.41 $120.73 42120 T Remove palate/lesion 0256 25.40 $1,231.57 $623.05 $246.31 42140 T Excision of uvula 0252 5.18 $251.16 $114.24 $50.23 42145 T Repair palate, pharynx/uvula 0254 12.45 $603.66 $272.41 $120.73 42160 T Treatment mouth roof lesion 0253 12.02 $582.81 $284.00 $116.56 42180 T Repair palate 0251 1.68 $81.46 $27.99 $16.29 42182 T Repair palate 0256 25.40 $1,231.57 $623.05 $246.31 42200 T Reconstruct cleft palate 0256 25.40 $1,231.57 $623.05 $246.31 42205 T Reconstruct cleft palate 0256 25.40 $1,231.57 $623.05 $246.31 42210 T Reconstruct cleft palate 0256 25.40 $1,231.57 $623.05 $246.31 42215 T Reconstruct cleft palate 0256 25.40 $1,231.57 $623.05 $246.31 42220 T Reconstruct cleft palate 0256 25.40 $1,231.57 $623.05 $246.31 42225 T Reconstruct cleft palate 0256 25.40 $1,231.57 $623.05 $246.31 42226 T Lengthening of palate 0256 25.40 $1,231.57 $623.05 $246.31 42227 T Lengthening of palate 0256 25.40 $1,231.57 $623.05 $246.31 42235 T Repair palate 0254 12.45 $603.66 $272.41 $120.73 42260 T Repair nose to lip fistula 0253 12.02 $582.81 $284.00 $116.56 42280 T Preparation, palate mold 0251 1.68 $81.46 $27.99 $16.29 42281 T Insertion, palate prosthesis 0253 12.02 $582.81 $284.00 $116.56 42299 T Palate/uvula surgery 0251 1.68 $81.46 $27.99 $16.29 42300 T Drainage of salivary gland 0253 12.02 $582.81 $284.00 $116.56 42305 T Drainage of salivary gland 0253 12.02 $582.81 $284.00 $116.56 42310 T Drainage of salivary gland 0251 1.68 $81.46 $27.99 $16.29 42320 T Drainage of salivary gland 0251 1.68 $81.46 $27.99 $16.29 42325 T Create salivary cyst drain 0252 5.18 $251.16 $114.24 $50.23 42326 T Create salivary cyst drain 0252 5.18 $251.16 $114.24 $50.23 42330 T Removal of salivary stone 0252 5.18 $251.16 $114.24 $50.23 42335 T Removal of salivary stone 0253 12.02 $582.81 $284.00 $116.56 42340 T Removal of salivary stone 0253 12.02 $582.81 $284.00 $116.56 42400 T Biopsy of salivary gland 0004 1.84 $89.22 $32.57 $17.84 42405 T Biopsy of salivary gland 0253 12.02 $582.81 $284.00 $116.56 42408 T Excision of salivary cyst 0253 12.02 $582.81 $284.00 $116.56 42409 T Drainage of salivary cyst 0253 12.02 $582.81 $284.00 $116.56 42410 T Excise parotid gland/lesion 0256 25.40 $1,231.57 $623.05 $246.31 42415 T Excise parotid gland/lesion 0256 25.40 $1,231.57 $623.05 $246.31 42420 T Excise parotid gland/lesion 0256 25.40 $1,231.57 $623.05 $246.31 42425 T Excise parotid gland/lesion 0256 25.40 $1,231.57 $623.05 $246.31 42426 C Excise parotid gland/lesion 42440 T Excise submaxillary gland 0256 25.40 $1,231.57 $623.05 $246.31 42450 T Excise sublingual gland 0253 12.02 $582.81 $284.00 $116.56 Start Printed Page 18600 42500 T Repair salivary duct 0254 12.45 $603.66 $272.41 $120.73 42505 T Repair salivary duct 0256 25.40 $1,231.57 $623.05 $246.31 42507 T Parotid duct diversion 0256 25.40 $1,231.57 $623.05 $246.31 42508 T Parotid duct diversion 0256 25.40 $1,231.57 $623.05 $246.31 42509 T Parotid duct diversion 0256 25.40 $1,231.57 $623.05 $246.31 42510 T Parotid duct diversion 0256 25.40 $1,231.57 $623.05 $246.31 42550 N Injection for salivary x-ray 42600 T Closure of salivary fistula 0253 12.02 $582.81 $284.00 $116.56 42650 T Dilation of salivary duct 0252 5.18 $251.16 $114.24 $50.23 42660 T Dilation of salivary duct 0252 5.18 $251.16 $114.24 $50.23 42665 T Ligation of salivary duct 0253 12.02 $582.81 $284.00 $116.56 42699 T Salivary surgery procedure 0253 12.02 $582.81 $284.00 $116.56 42700 T Drainage of tonsil abscess 0251 1.68 $81.46 $27.99 $16.29 42720 T Drainage of throat abscess 0253 12.02 $582.81 $284.00 $116.56 42725 T Drainage of throat abscess 0256 25.40 $1,231.57 $623.05 $246.31 42800 T Biopsy of throat 0252 5.18 $251.16 $114.24 $50.23 42802 T Biopsy of throat 0253 12.02 $582.81 $284.00 $116.56 42804 T Biopsy of upper nose/throat 0253 12.02 $582.81 $284.00 $116.56 42806 T Biopsy of upper nose/throat 0253 12.02 $582.81 $284.00 $116.56 42808 T Excise pharynx lesion 0253 12.02 $582.81 $284.00 $116.56 42809 T Remove pharynx foreign body 0251 1.68 $81.46 $27.99 $16.29 42810 T Excision of neck cyst 0253 12.02 $582.81 $284.00 $116.56 42815 T Excision of neck cyst 0256 25.40 $1,231.57 $623.05 $246.31 42820 T Remove tonsils and adenoids 0258 18.62 $902.83 $462.81 $180.57 42821 T Remove tonsils and adenoids 0258 18.62 $902.83 $462.81 $180.57 42825 T Removal of tonsils 0258 18.62 $902.83 $462.81 $180.57 42826 T Removal of tonsils 0258 18.62 $902.83 $462.81 $180.57 42830 T Removal of adenoids 0258 18.62 $902.83 $462.81 $180.57 42831 T Removal of adenoids 0258 18.62 $902.83 $462.81 $180.57 42835 T Removal of adenoids 0258 18.62 $902.83 $462.81 $180.57 42836 T Removal of adenoids 0258 18.62 $902.83 $462.81 $180.57 42842 C Extensive surgery of throat 42844 T Extensive surgery of throat 0256 25.40 $1,231.57 $623.05 $246.31 42845 C Extensive surgery of throat 42860 T Excision of tonsil tags 0258 18.62 $902.83 $462.81 $180.57 42870 T Excision of lingual tonsil 0258 18.62 $902.83 $462.81 $180.57 42890 T Partial removal of pharynx 0256 25.40 $1,231.57 $623.05 $246.31 42892 T Revision of pharyngeal walls 0256 25.40 $1,231.57 $623.05 $246.31 42894 C Revision of pharyngeal walls 42900 T Repair throat wound 0253 12.02 $582.81 $284.00 $116.56 42950 T Reconstruction of throat 0254 12.45 $603.66 $272.41 $120.73 42953 C Repair throat, esophagus 42955 T Surgical opening of throat 0254 12.45 $603.66 $272.41 $120.73 42960 T Control throat bleeding 0250 2.21 $107.16 $38.54 $21.43 42961 C Control throat bleeding 42962 T Control throat bleeding 0256 25.40 $1,231.57 $623.05 $246.31 42970 T Control nose/throat bleeding 0250 2.21 $107.16 $38.54 $21.43 42971 C Control nose/throat bleeding 42972 T Control nose/throat bleeding 0253 12.02 $582.81 $284.00 $116.56 42999 T Throat surgery procedure 0252 5.18 $251.16 $114.24 $50.23 43020 T Incision of esophagus 0254 12.45 $603.66 $272.41 $120.73 43030 C Throat muscle surgery 43045 C Incision of esophagus 43100 C Excision of esophagus lesion 43101 C Excision of esophagus lesion 43107 C Removal of esophagus 43108 C Removal of esophagus 43112 C Removal of esophagus 43113 C Removal of esophagus 43116 C Partial removal of esophagus 43117 C Partial removal of esophagus 43118 C Partial removal of esophagus 43121 C Partial removal of esophagus 43122 C Parital removal of esophagus 43123 C Partial removal of esophagus 43124 C Removal of esophagus 43130 C Removal of esophagus pouch 43135 C Removal of esophagus pouch 43200 T Esophagus endoscopy 0141 7.15 $346.68 $184.67 $69.34 43202 T Esophagus endoscopy, biopsy 0141 7.15 $346.68 $184.67 $69.34 43204 T Esophagus endoscopy & inject 0141 7.15 $346.68 $184.67 $69.34 43205 T Esophagus endoscopy/ligation 0141 7.15 $346.68 $184.67 $69.34 43215 T Esophagus endoscopy 0141 7.15 $346.68 $184.67 $69.34 Start Printed Page 18601 43216 T Esophagus endoscopy/lesion 0141 7.15 $346.68 $184.67 $69.34 43217 T Esophagus endoscopy 0141 7.15 $346.68 $184.67 $69.34 43219 T Esophagus endoscopy 0141 7.15 $346.68 $184.67 $69.34 43220 T Esoph endoscopy, dilation 0141 7.15 $346.68 $184.67 $69.34 43226 T Esoph endoscopy, dilation 0141 7.15 $346.68 $184.67 $69.34 43227 T Esoph endoscopy, repair 0141 7.15 $346.68 $184.67 $69.34 43228 T Esoph endoscopy, ablation 0141 7.15 $346.68 $184.67 $69.34 43234 T Upper GI endoscopy, exam 0141 7.15 $346.68 $184.67 $69.34 43235 T Uppr gi endoscopy, diagnosis 0141 7.15 $346.68 $184.67 $69.34 43239 T Upper GI endoscopy, biopsy 0141 7.15 $346.68 $184.67 $69.34 43241 T Upper GI endoscopy with tube 0141 7.15 $346.68 $184.67 $69.34 43243 T Upper gi endoscopy & inject 0141 7.15 $346.68 $184.67 $69.34 43244 T Upper GI endoscopy/ligation 0141 7.15 $346.68 $184.67 $69.34 43245 T Operative upper GI endoscopy 0141 7.15 $346.68 $184.67 $69.34 43246 T Place gastrostomy tube 0141 7.15 $346.68 $184.67 $69.34 43247 T Operative upper GI endoscopy 0141 7.15 $346.68 $184.67 $69.34 43248 T Uppr gi endoscopy/guide wire 0141 7.15 $346.68 $184.67 $69.34 43249 T Esoph endoscopy, dilation 0141 7.15 $346.68 $184.67 $69.34 43250 T Upper GI endoscopy/tumor 0141 7.15 $346.68 $184.67 $69.34 43251 T Operative upper GI endoscopy 0141 7.15 $346.68 $184.67 $69.34 43255 T Operative upper GI endoscopy 0141 7.15 $346.68 $184.67 $69.34 43258 T Operative upper GI endoscopy 0141 7.15 $346.68 $184.67 $69.34 43259 T Endoscopic ultrasound exam 0141 7.15 $346.68 $184.67 $69.34 43260 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43261 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43262 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43263 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43264 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43265 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43267 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43268 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43269 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43271 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43272 T Endo cholangiopancreatograph 0151 10.53 $510.57 $245.46 $102.11 43280 T Laparoscopy, fundoplasty 0132 48.91 $2,371.50 $1,239.22 $474.30 43289 T Laparoscope proc, esoph 0130 25.36 $1,229.63 $659.53 $245.93 43300 C Repair of esophagus 43305 C Repair esophagus and fistula 43310 C Repair of esophagus 43312 C Repair esophagus and fistula 43320 C Fuse esophagus & stomach 43324 C Revise esophagus & stomach 43325 C Revise esophagus & stomach 43326 C Revise esophagus & stomach 43330 C Repair of esophagus 43331 C Repair of esophagus 43340 C Fuse esophagus & intestine 43341 C Fuse esophagus & intestine 43350 C Surgical opening, esophagus 43351 C Surgical opening, esophagus 43352 C Surgical opening, esophagus 43360 C Gastrointestinal repair 43361 C Gastrointestinal repair 43400 C Ligate esophagus veins 43401 C Esophagus surgery for veins 43405 C Ligate/staple esophagus 43410 C Repair esophagus wound 43415 C Repair esophagus wound 43420 C Repair esophagus opening 43425 C Repair esophagus opening 43450 T Dilate esophagus 0140 4.74 $229.83 $107.24 $45.97 43453 T Dilate esophagus 0140 4.74 $229.83 $107.24 $45.97 43456 T Dilate esophagus 0140 4.74 $229.83 $107.24 $45.97 43458 T Dilate esophagus 0140 4.74 $229.83 $107.24 $45.97 43460 C Pressure treatment esophagus 43496 C Free jejunum flap, microvasc 43499 T Esophagus surgery procedure 0140 4.74 $229.83 $107.24 $45.97 43500 C Surgical opening of stomach 43501 C Surgical repair of stomach 43502 C Surgical repair of stomach 43510 C Surgical opening of stomach 43520 C Incision of pyloric muscle 43600 T Biopsy of stomach 0141 7.15 $346.68 $184.67 $69.34 Start Printed Page 18602 43605 C Biopsy of stomach 43610 C Excision of stomach lesion 43611 C Excision of stomach lesion 43620 C Removal of stomach 43621 C Removal of stomach 43622 C Removal of stomach 43631 C Removal of stomach, partial 43632 C Removal of stomach, partial 43633 C Removal of stomach, partial 43634 C Removal of stomach, partial 43635 C Removal of stomach, partial 43638 C Removal of stomach, partial 43639 C Removal of stomach, partial 43640 C Vagotomy & pylorus repair 43641 C Vagotomy & pylorus repair 43651 T Laparoscopy, vagus nerve 0132 48.91 $2,371.50 $1,239.22 $474.30 43652 T Laparoscopy, vagus nerve 0132 48.91 $2,371.50 $1,239.22 $474.30 43653 T Laparoscopy, gastrostomy 0131 41.81 $2,027.24 $1,089.88 $405.45 43659 T Laparoscope proc, stom 0130 25.36 $1,229.63 $659.53 $245.93 43750 T Place gastrostomy tube 0141 7.15 $346.68 $184.67 $69.34 43760 T Change gastrostomy tube 0121 2.36 $114.43 $52.53 $22.89 43761 T Reposition gastrostomy tube 0121 2.36 $114.43 $52.53 $22.89 43800 C Reconstruction of pylorus 43810 C Fusion of stomach and bowel 43820 C Fusion of stomach and bowel 43825 C Fusion of stomach and bowel 43830 T Place gastrostomy tube 0141 7.15 $346.68 $184.67 $69.34 43831 T Place gastrostomy tube 0141 7.15 $346.68 $184.67 $69.34 43832 C Place gastrostomy tube 43840 C Repair of stomach lesion 43842 C Gastroplasty for obesity 43843 C Gastroplasty for obesity 43846 C Gastric bypass for obesity 43847 C Gastric bypass for obesity 43848 C Revision gastroplasty 43850 C Revise stomach-bowel fusion 43855 C Revise stomach-bowel fusion 43860 C Revise stomach-bowel fusion 43865 C Revise stomach-bowel fusion 43870 T Repair stomach opening 0025 3.74 $181.34 $70.66 $36.27 43880 C Repair stomach-bowel fistula 43999 T Stomach surgery procedure 0121 2.36 $114.43 $52.53 $22.89 44005 C Freeing of bowel adhesion 44010 C Incision of small bowel 44015 C Insert needle cath bowel 44020 C Exploration of small bowel 44021 C Decompress small bowel 44025 C Incision of large bowel 44050 C Reduce bowel obstruction 44055 C Correct malrotation of bowel 44100 T Biopsy of bowel 0141 7.15 $346.68 $184.67 $69.34 44110 C Excision of bowel lesion(s) 44111 C Excision of bowel lesion(s) 44120 C Removal of small intestine 44121 C Removal of small intestine 44125 C Removal of small intestine 44130 C Bowel to bowel fusion 44139 C Mobilization of colon 44140 C Partial removal of colon 44141 C Partial removal of colon 44143 C Partial removal of colon 44144 C Partial removal of colon 44145 C Partial removal of colon 44146 C Partial removal of colon 44147 C Partial removal of colon 44150 C Removal of colon 44151 C Removal of colon/ileostomy 44152 C Removal of colon/ileostomy 44153 C Removal of colon/ileostomy 44155 C Removal of colon/ileostomy 44156 C Removal of colon/ileostomy 44160 C Removal of colon 44200 T Laparoscopy, enterolysis 0131 41.81 $2,027.24 $1,089.88 $405.45 Start Printed Page 18603 44201 T Laparoscopy, jejunostomy 0131 41.81 $2,027.24 $1,089.88 $405.45 44202 C Laparo, resect intestine 44209 T Laparoscope proc, intestine 0130 25.36 $1,229.63 $659.53 $245.93 44300 C Open bowel to skin 44310 C Ileostomy/jejunostomy 44312 T Revision of ileostomy 0026 12.11 $587.18 $277.92 $117.44 44314 C Revision of ileostomy 44316 C Devise bowel pouch 44320 C Colostomy 44322 C Colostomy with biopsies 44340 T Revision of colostomy 0026 12.11 $587.18 $277.92 $117.44 44345 C Revision of colostomy 44346 C Revision of colostomy 44360 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44361 T Small bowel endoscopy/biopsy 0142 7.45 $361.23 $162.42 $72.25 44363 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44364 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44365 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44366 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44369 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44372 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44373 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44376 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44377 T Small bowel endoscopy/biopsy 0142 7.45 $361.23 $162.42 $72.25 44378 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44380 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44382 T Small bowel endoscopy 0142 7.45 $361.23 $162.42 $72.25 44385 T Endoscopy of bowel pouch 0143 7.98 $386.93 $199.12 $77.39 44386 T Endoscopy, bowel pouch/biop 0143 7.98 $386.93 $199.12 $77.39 44388 T Colon endoscopy 0143 7.98 $386.93 $199.12 $77.39 44389 T Colonoscopy with biopsy 0143 7.98 $386.93 $199.12 $77.39 44390 T Colonoscopy for foreign body 0143 7.98 $386.93 $199.12 $77.39 44391 T Colonoscopy for bleeding 0143 7.98 $386.93 $199.12 $77.39 44392 T Colonoscopy & polypectomy 0143 7.98 $386.93 $199.12 $77.39 44393 T Colonoscopy, lesion removal 0143 7.98 $386.93 $199.12 $77.39 44394 T Colonoscopy w/snare 0143 7.98 $386.93 $199.12 $77.39 44500 C Intro, gastrointestinal tube 44602 C Suture, small intestine 44603 C Suture, small intestine 44604 C Suture, large intestine 44605 C Repair of bowel lesion 44615 C Intestinal stricturoplasty 44620 C Repair bowel opening 44625 C Repair bowel opening 44626 C Repair bowel opening 44640 C Repair bowel-skin fistula 44650 C Repair bowel fistula 44660 C Repair bowel-bladder fistula 44661 C Repair bowel-bladder fistula 44680 C Surgical revision, intestine 44700 C Suspend bowel w/prosthesis 44799 T Intestine surgery procedure 0142 7.45 $361.23 $162.42 $72.25 44800 C Excision of bowel pouch 44820 C Excision of mesentery lesion 44850 C Repair of mesentery 44899 C Bowel surgery procedure 44900 C Drain app abscess, open 44901 C Drain app abscess, percut 44950 C Appendectomy 44955 C Appendectomy add-on 44960 C Appendectomy 44970 T Laparoscopy, appendectomy 0130 25.36 $1,229.63 $659.53 $245.93 44979 T Laparoscope proc, app 0130 25.36 $1,229.63 $659.53 $245.93 45000 T Drainage of pelvic abscess 0149 12.86 $623.54 $293.06 $124.71 45005 T Drainage of rectal abscess 0148 2.34 $113.46 $43.59 $22.69 45020 T Drainage of rectal abscess 0149 12.86 $623.54 $293.06 $124.71 45100 T Biopsy of rectum 0149 12.86 $623.54 $293.06 $124.71 45108 T Removal of anorectal lesion 0150 17.68 $857.25 $437.12 $171.45 45110 C Removal of rectum 45111 C Partial removal of rectum 45112 C Removal of rectum 45113 C Partial proctectomy 45114 C Partial removal of rectum Start Printed Page 18604 45116 C Partial removal of rectum 45119 C Remove rectum w/reservoir 45120 C Removal of rectum 45121 C Removal of rectum and colon 45123 C Partial proctectomy 45126 C Pelvic exenteration 45130 C Excision of rectal prolapse 45135 C Excision of rectal prolapse 45150 T Excision of rectal stricture 0150 17.68 $857.25 $437.12 $171.45 45160 T Excision of rectal lesion 0150 17.68 $857.25 $437.12 $171.45 45170 T Excision of rectal lesion 0150 17.68 $857.25 $437.12 $171.45 45190 T Destruction, rectal tumor 0150 17.68 $857.25 $437.12 $171.45 45300 T Proctosigmoidoscopy 0146 2.83 $137.22 $65.15 $27.44 45303 T Proctosigmoidoscopy 0146 2.83 $137.22 $65.15 $27.44 45305 T Proctosigmoidoscopy & biopsy 0146 2.83 $137.22 $65.15 $27.44 45307 T Proctosigmoidoscopy 0146 2.83 $137.22 $65.15 $27.44 45308 T Proctosigmoidoscopy 0147 6.26 $303.53 $149.11 $60.71 45309 T Proctosigmoidoscopy 0147 6.26 $303.53 $149.11 $60.71 45315 T Proctosigmoidoscopy 0147 6.26 $303.53 $149.11 $60.71 45317 T Proctosigmoidoscopy 0146 2.83 $137.22 $65.15 $27.44 45320 T Proctosigmoidoscopy 0147 6.26 $303.53 $149.11 $60.71 45321 T Proctosigmoidoscopy 0147 6.26 $303.53 $149.11 $60.71 45330 T Diagnostic sigmoidoscopy 0146 2.83 $137.22 $65.15 $27.44 45331 T Sigmoidoscopy and biopsy 0146 2.83 $137.22 $65.15 $27.44 45332 T Sigmoidoscopy 0146 2.83 $137.22 $65.15 $27.44 45333 T Sigmoidoscopy & polypectomy 0147 6.26 $303.53 $149.11 $60.71 45334 T Sigmoidoscopy for bleeding 0147 6.26 $303.53 $149.11 $60.71 45337 T Sigmoidoscopy & decompress 0147 6.26 $303.53 $149.11 $60.71 45338 T Sigmoidoscopy 0147 6.26 $303.53 $149.11 $60.71 45339 T Sigmoidoscopy 0147 6.26 $303.53 $149.11 $60.71 45355 T Surgical colonoscopy 0143 7.98 $386.93 $199.12 $77.39 45378 T Diagnostic colonoscopy 0143 7.98 $386.93 $199.12 $77.39 45379 T Colonoscopy 0143 7.98 $386.93 $199.12 $77.39 45380 T Colonoscopy and biopsy 0143 7.98 $386.93 $199.12 $77.39 45382 T Colonoscopy/control bleeding 0143 7.98 $386.93 $199.12 $77.39 45383 T Lesion removal colonoscopy 0143 7.98 $386.93 $199.12 $77.39 45384 T Colonoscopy 0143 7.98 $386.93 $199.12 $77.39 45385 T Lesion removal colonoscopy 0143 7.98 $386.93 $199.12 $77.39 45500 T Repair of rectum 0150 17.68 $857.25 $437.12 $171.45 45505 T Repair of rectum 0150 17.68 $857.25 $437.12 $171.45 45520 T Treatment of rectal prolapse 0098 1.19 $57.70 $20.88 $11.54 45540 C Correct rectal prolapse 45541 C Correct rectal prolapse 45550 C Repair rectum/remove sigmoid 45560 T Repair of rectocele 0150 17.68 $857.25 $437.12 $171.45 45562 C Exploration/repair of rectum 45563 C Exploration/repair of rectum 45800 C Repair rect/bladder fistula 45805 C Repair fistula w/colostomy 45820 C Repair rectourethral fistula 45825 C Repair fistula w/colostomy 45900 T Reduction of rectal prolapse 0148 2.34 $113.46 $43.59 $22.69 45905 T Dilation of anal sphincter 0149 12.86 $623.54 $293.06 $124.71 45910 T Dilation of rectal narrowing 0149 12.86 $623.54 $293.06 $124.71 45915 T Remove rectal obstruction 0148 2.34 $113.46 $43.59 $22.69 45999 T Rectum surgery procedure 0148 2.34 $113.46 $43.59 $22.69 46030 T Removal of rectal marker 0149 12.86 $623.54 $293.06 $124.71 46040 T Incision of rectal abscess 0148 2.34 $113.46 $43.59 $22.69 46045 T Incision of rectal abscess 0150 17.68 $857.25 $437.12 $171.45 46050 T Incision of anal abscess 0148 2.34 $113.46 $43.59 $22.69 46060 T Incision of rectal abscess 0150 17.68 $857.25 $437.12 $171.45 46070 T Incision of anal septum 0148 2.34 $113.46 $43.59 $22.69 46080 T Incision of anal sphincter 0149 12.86 $623.54 $293.06 $124.71 46083 T Incise external hemorrhoid 0148 2.34 $113.46 $43.59 $22.69 46200 T Removal of anal fissure 0150 17.68 $857.25 $437.12 $171.45 46210 T Removal of anal crypt 0149 12.86 $623.54 $293.06 $124.71 46211 T Removal of anal crypts 0150 17.68 $857.25 $437.12 $171.45 46220 T Removal of anal tab 0149 12.86 $623.54 $293.06 $124.71 46221 T Ligation of hemorrhoid(s) 0148 2.34 $113.46 $43.59 $22.69 46230 T Removal of anal tabs 0149 12.86 $623.54 $293.06 $124.71 46250 T Hemorrhoidectomy 0150 17.68 $857.25 $437.12 $171.45 46255 T Hemorrhoidectomy 0150 17.68 $857.25 $437.12 $171.45 46257 T Remove hemorrhoids & fissure 0150 17.68 $857.25 $437.12 $171.45 Start Printed Page 18605 46258 T Remove hemorrhoids & fistula 0150 17.68 $857.25 $437.12 $171.45 46260 T Hemorrhoidectomy 0150 17.68 $857.25 $437.12 $171.45 46261 T Remove hemorrhoids & fissure 0150 17.68 $857.25 $437.12 $171.45 46262 T Remove hemorrhoids & fistula 0150 17.68 $857.25 $437.12 $171.45 46270 T Removal of anal fistula 0150 17.68 $857.25 $437.12 $171.45 46275 T Removal of anal fistula 0150 17.68 $857.25 $437.12 $171.45 46280 T Removal of anal fistula 0150 17.68 $857.25 $437.12 $171.45 46285 T Removal of anal fistula 0150 17.68 $857.25 $437.12 $171.45 46288 T Repair anal fistula 0150 17.68 $857.25 $437.12 $171.45 46320 T Removal of hemorrhoid clot 0148 2.34 $113.46 $43.59 $22.69 46500 T Injection into hemorrhoids 0148 2.34 $113.46 $43.59 $22.69 46600 N Diagnostic anoscopy 46604 T Anoscopy and dilation 0144 2.23 $108.13 $49.32 $21.63 46606 T Anoscopy and biopsy 0145 7.46 $361.71 $179.39 $72.34 46608 T Anoscopy/remove for body 0144 2.23 $108.13 $49.32 $21.63 46610 T Anoscopy/remove lesion 0145 7.46 $361.71 $179.39 $72.34 46611 T Anoscopy 0145 7.46 $361.71 $179.39 $72.34 46612 T Anoscopy/remove lesions 0145 7.46 $361.71 $179.39 $72.34 46614 T Anoscopy/control bleeding 0145 7.46 $361.71 $179.39 $72.34 46615 T Anoscopy 0145 7.46 $361.71 $179.39 $72.34 46700 T Repair of anal stricture 0150 17.68 $857.25 $437.12 $171.45 46705 C Repair of anal stricture 46715 C Repair of anovaginal fistula 46716 C Repair of anovaginal fistula 46730 C Construction of absent anus 46735 C Construction of absent anus 46740 C Construction of absent anus 46742 C Repair of imperforated anus 46744 C Repair of cloacal anomaly 46746 C Repair of cloacal anomaly 46748 C Repair of cloacal anomaly 46750 T Repair of anal sphincter 0150 17.68 $857.25 $437.12 $171.45 46751 C Repair of anal sphincter 46753 T Reconstruction of anus 0150 17.68 $857.25 $437.12 $171.45 46754 T Removal of suture from anus 0149 12.86 $623.54 $293.06 $124.71 46760 T Repair of anal sphincter 0150 17.68 $857.25 $437.12 $171.45 46761 T Repair of anal sphincter 0150 17.68 $857.25 $437.12 $171.45 46762 T Implant artificial sphincter 0150 17.68 $857.25 $437.12 $171.45 46900 T Destruction, anal lesion(s) 0016 3.53 $171.16 $74.67 $34.23 46910 T Destruction, anal lesion(s) 0016 3.53 $171.16 $74.67 $34.23 46916 T Cryosurgery, anal lesion(s) 0016 3.53 $171.16 $74.67 $34.23 46917 T Laser surgery, anal lesions 0014 1.50 $72.73 $24.55 $14.55 46922 T Excision of anal lesion(s) 0017 12.45 $603.66 $289.16 $120.73 46924 T Destruction, anal lesion(s) 0017 12.45 $603.66 $289.16 $120.73 46934 T Destruction of hemorrhoids 0148 2.34 $113.46 $43.59 $22.69 46935 T Destruction of hemorrhoids 0148 2.34 $113.46 $43.59 $22.69 46936 T Destruction of hemorrhoids 0149 12.86 $623.54 $293.06 $124.71 46937 T Cryotherapy of rectal lesion 0150 17.68 $857.25 $437.12 $171.45 46938 T Cryotherapy of rectal lesion 0150 17.68 $857.25 $437.12 $171.45 46940 T Treatment of anal fissure 0149 12.86 $623.54 $293.06 $124.71 46942 T Treatment of anal fissure 0149 12.86 $623.54 $293.06 $124.71 46945 T Ligation of hemorrhoids 0148 2.34 $113.46 $43.59 $22.69 46946 T Ligation of hemorrhoids 0148 2.34 $113.46 $43.59 $22.69 46999 T Anus surgery procedure 0149 12.86 $623.54 $293.06 $124.71 47000 T Needle biopsy of liver 0005 5.41 $262.32 $119.75 $52.46 47001 C Needle biopsy, liver add-on 47010 C Open drainage, liver lesion 47011 C Percut drain, liver lesion 47015 C Inject/aspirate liver cyst 47100 C Wedge biopsy of liver 47120 C Partial removal of liver 47122 C Extensive removal of liver 47125 C Partial removal of liver 47130 C Partial removal of liver 47133 C Removal of donor liver 47134 C Partial removal, donor liver 47135 C Transplantation of liver 47136 C Transplantation of liver 47300 C Surgery for liver lesion 47350 C Repair liver wound 47360 C Repair liver wound 47361 C Repair liver wound 47362 C Repair liver wound Start Printed Page 18606 47399 T Liver surgery procedure 0005 5.41 $262.32 $119.75 $52.46 47400 C Incision of liver duct 47420 C Incision of bile duct 47425 C Incision of bile duct 47460 C Incise bile duct sphincter 47480 C Incision of gallbladder 47490 C Incision of gallbladder 47500 N Injection for liver x-rays 47505 N Injection for liver x-rays 47510 T Insert catheter, bile duct 0152 8.22 $398.56 $207.38 $79.71 47511 T Insert bile duct drain 0152 8.22 $398.56 $207.38 $79.71 47525 T Change bile duct catheter 0122 5.04 $244.37 $114.93 $48.88 47530 T Revise/reinsert bile tube 0121 2.36 $114.43 $52.53 $22.89 47550 C Bile duct endoscopy add-on 47552 T Biliary endoscopy thru skin 0152 8.22 $398.56 $207.38 $79.71 47553 T Biliary endoscopy thru skin 0152 8.22 $398.56 $207.38 $79.71 47554 T Biliary endoscopy thru skin 0152 8.22 $398.56 $207.38 $79.71 47555 T Biliary endoscopy thru skin 0152 8.22 $398.56 $207.38 $79.71 47556 T Biliary endoscopy thru skin 0152 8.22 $398.56 $207.38 $79.71 47560 T Laparoscopy w/cholangio 0130 25.36 $1,229.63 $659.53 $245.93 47561 T Laparo w/cholangio/biopsy 0130 25.36 $1,229.63 $659.53 $245.93 47562 T Laparoscopic cholecystectomy 0131 41.81 $2,027.24 $1,089.88 $405.45 47563 T Laparo cholecystectomy/graph 0131 41.81 $2,027.24 $1,089.88 $405.45 47564 T Laparo cholecystectomy/explr 0131 41.81 $2,027.24 $1,089.88 $405.45 47570 T Laparo cholecystoenterostomy 0131 41.81 $2,027.24 $1,089.88 $405.45 47579 T Laparoscope proc, biliary 0130 25.36 $1,229.63 $659.53 $245.93 47600 C Removal of gallbladder 47605 C Removal of gallbladder 47610 C Removal of gallbladder 47612 C Removal of gallbladder 47620 C Removal of gallbladder 47630 T Remove bile duct stone 0152 8.22 $398.56 $207.38 $79.71 47700 C Exploration of bile ducts 47701 C Bile duct revision 47711 C Excision of bile duct tumor 47712 C Excision of bile duct tumor 47715 C Excision of bile duct cyst 47716 C Fusion of bile duct cyst 47720 C Fuse gallbladder & bowel 47721 C Fuse upper gi structures 47740 C Fuse gallbladder & bowel 47741 C Fuse gallbladder & bowel 47760 C Fuse bile ducts and bowel 47765 C Fuse liver ducts & bowel 47780 C Fuse bile ducts and bowel 47785 C Fuse bile ducts and bowel 47800 C Reconstruction of bile ducts 47801 C Placement, bile duct support 47802 C Fuse liver duct & intestine 47900 C Suture bile duct injury 47999 T Bile tract surgery procedure 0121 2.36 $114.43 $52.53 $22.89 48000 C Drainage of abdomen 48001 C Placement of drain, pancreas 48005 C Resect/debride pancreas 48020 C Removal of pancreatic stone 48100 C Biopsy of pancreas 48102 T Needle biopsy, pancreas 0005 5.41 $262.32 $119.75 $52.46 48120 C Removal of pancreas lesion 48140 C Partial removal of pancreas 48145 C Partial removal of pancreas 48146 C Pancreatectomy 48148 C Removal of pancreatic duct 48150 C Partial removal of pancreas 48152 C Pancreatectomy 48153 C Pancreatectomy 48154 C Pancreatectomy 48155 C Removal of pancreas 48160 E Pancreas removal/transplant 48180 C Fuse pancreas and bowel 48400 C Injection, intraop add-on 48500 C Surgery of pancreas cyst 48510 C Drain pancreatic pseudocyst 48511 C Drain pancreatic pseudocyst Start Printed Page 18607 48520 C Fuse pancreas cyst and bowel 48540 C Fuse pancreas cyst and bowel 48545 C Pancreatorrhaphy 48547 C Duodenal exclusion 48550 E Donor pancreatectomy 48554 E Transpl allograft pancreas 48556 C Removal, allograft pancreas 48999 T Pancreas surgery procedure 0005 5.41 $262.32 $119.75 $52.46 49000 C Exploration of abdomen 49002 C Reopening of abdomen 49010 C Exploration behind abdomen 49020 C Drain abdominal abscess 49021 C Drain abdominal abscess 49040 C Drain, open, abdom abscess 49041 C Drain, percut, abdom abscess 49060 C Drain, open, retrop abscess 49061 C Drain, percut, retroper absc 49062 C Drain to peritoneal cavity 49080 T Puncture, peritoneal cavity 0070 3.64 $176.49 $79.60 $35.30 49081 T Removal of abdominal fluid 0070 3.64 $176.49 $79.60 $35.30 49085 T Remove abdomen foreign body 0153 19.62 $951.32 $496.31 $190.26 49180 T Biopsy, abdominal mass 0005 5.41 $262.32 $119.75 $52.46 49200 C Removal of abdominal lesion 49201 C Removal of abdominal lesion 49215 C Excise sacral spine tumor 49220 C Multiple surgery, abdomen 49250 T Excision of umbilicus 0153 19.62 $951.32 $496.31 $190.26 49255 C Removal of omentum 49320 T Diag laparo separate proc 0130 25.36 $1,229.63 $659.53 $245.93 49321 T Laparoscopy, biopsy 0130 25.36 $1,229.63 $659.53 $245.93 49322 T Laparoscopy, aspiration 0130 25.36 $1,229.63 $659.53 $245.93 49323 T Laparo drain lymphocele 0130 25.36 $1,229.63 $659.53 $245.93 49329 T Laparo proc, abdm/per/oment 0130 25.36 $1,229.63 $659.53 $245.93 49400 N Air injection into abdomen 49420 T Insert abdominal drain 0153 19.62 $951.32 $496.31 $190.26 49421 T Insert abdominal drain 0153 19.62 $951.32 $496.31 $190.26 49422 T Remove perm cannula/catheter 0123 13.89 $673.49 $350.75 $134.70 49423 T Exchange drainage catheter 0153 19.62 $951.32 $496.31 $190.26 49424 N Assess cyst, contrast inject 49425 C Insert abdomen-venous drain 49426 T Revise abdomen-venous shunt 0153 19.62 $951.32 $496.31 $190.26 49427 N Injection, abdominal shunt 49428 C Ligation of shunt 49429 T Removal of shunt 0123 13.89 $673.49 $350.75 $134.70 49495 T Repair inguinal hernia, init 0154 22.43 $1,087.57 $556.98 $217.51 49496 T Repair inguinal hernia, init 0154 22.43 $1,087.57 $556.98 $217.51 49500 T Repair inguinal hernia 0154 22.43 $1,087.57 $556.98 $217.51 49501 T Repair inguinal hernia, init 0154 22.43 $1,087.57 $556.98 $217.51 49505 T Repair inguinal hernia 0154 22.43 $1,087.57 $556.98 $217.51 49507 T Repair inguinal hernia 0154 22.43 $1,087.57 $556.98 $217.51 49520 T Rerepair inguinal hernia 0154 22.43 $1,087.57 $556.98 $217.51 49521 T Repair inguinal hernia, rec 0154 22.43 $1,087.57 $556.98 $217.51 49525 T Repair inguinal hernia 0154 22.43 $1,087.57 $556.98 $217.51 49540 T Repair lumbar hernia 0154 22.43 $1,087.57 $556.98 $217.51 49550 T Repair femoral hernia 0154 22.43 $1,087.57 $556.98 $217.51 49553 T Repair femoral hernia, init 0154 22.43 $1,087.57 $556.98 $217.51 49555 T Repair femoral hernia 0154 22.43 $1,087.57 $556.98 $217.51 49557 T Repair femoral hernia, recur 0154 22.43 $1,087.57 $556.98 $217.51 49560 T Repair abdominal hernia 0154 22.43 $1,087.57 $556.98 $217.51 49561 T Repair incisional hernia 0154 22.43 $1,087.57 $556.98 $217.51 49565 T Rerepair abdominal hernia 0154 22.43 $1,087.57 $556.98 $217.51 49566 T Repair incisional hernia 0154 22.43 $1,087.57 $556.98 $217.51 49568 T Hernia repair w/mesh 0154 22.43 $1,087.57 $556.98 $217.51 49570 T Repair epigastric hernia 0154 22.43 $1,087.57 $556.98 $217.51 49572 T Repair epigastric hernia 0154 22.43 $1,087.57 $556.98 $217.51 49580 T Repair umbilical hernia 0154 22.43 $1,087.57 $556.98 $217.51 49582 T Repair umbilical hernia 0154 22.43 $1,087.57 $556.98 $217.51 49585 T Repair umbilical hernia 0154 22.43 $1,087.57 $556.98 $217.51 49587 T Repair umbilical hernia 0154 22.43 $1,087.57 $556.98 $217.51 49590 T Repair abdominal hernia 0154 22.43 $1,087.57 $556.98 $217.51 49600 T Repair umbilical lesion 0154 22.43 $1,087.57 $556.98 $217.51 49605 C Repair umbilical lesion 49606 C Repair umbilical lesion Start Printed Page 18608 49610 C Repair umbilical lesion 49611 C Repair umbilical lesion 49650 T Laparo hernia repair initial 0131 41.81 $2,027.24 $1,089.88 $405.45 49651 T Laparo hernia repair recur 0131 41.81 $2,027.24 $1,089.88 $405.45 49659 T Laparo proc, hernia repair 0131 41.81 $2,027.24 $1,089.88 $405.45 49900 C Repair of abdominal wall 49905 C Omental flap 49906 C Free omental flap, microvasc 49999 T Abdomen surgery procedure 0121 2.36 $114.43 $52.53 $22.89 50010 C Exploration of kidney 50020 C Renal abscess, open drain 50021 C Renal abscess, percut drain 50040 C Drainage of kidney 50045 C Exploration of kidney 50060 C Removal of kidney stone 50065 C Incision of kidney 50070 C Incision of kidney 50075 C Removal of kidney stone 50080 T Removal of kidney stone 0163 28.98 $1,405.16 $792.58 $281.03 50081 T Removal of kidney stone 0163 28.98 $1,405.16 $792.58 $281.03 50100 C Revise kidney blood vessels 50120 C Exploration of kidney 50125 C Explore and drain kidney 50130 C Removal of kidney stone 50135 C Exploration of kidney 50200 T Biopsy of kidney 0005 5.41 $262.32 $119.75 $52.46 50205 C Biopsy of kidney 50220 C Removal of kidney 50225 C Removal of kidney 50230 C Removal of kidney 50234 C Removal of kidney & ureter 50236 C Removal of kidney & ureter 50240 C Partial removal of kidney 50280 C Removal of kidney lesion 50290 C Removal of kidney lesion 50300 C Removal of donor kidney 50320 C Removal of donor kidney 50340 C Removal of kidney 50360 C Transplantation of kidney 50365 C Transplantation of kidney 50370 C Remove transplanted kidney 50380 C Reimplantation of kidney 50390 T Drainage of kidney lesion 0005 5.41 $262.32 $119.75 $52.46 50392 T Insert kidney drain 0160 5.43 $263.28 $110.11 $52.66 50393 T Insert ureteral tube 0160 5.43 $263.28 $110.11 $52.66 50394 N Injection for kidney x-ray 50395 T Create passage to kidney 0160 5.43 $263.28 $110.11 $52.66 50396 T Measure kidney pressure 0165 3.89 $188.61 $91.76 $37.72 50398 T Change kidney tube 0122 5.04 $244.37 $114.93 $48.88 50400 C Revision of kidney/ureter 50405 C Revision of kidney/ureter 50500 C Repair of kidney wound 50520 C Close kidney-skin fistula 50525 C Repair renal-abdomen fistula 50526 C Repair renal-abdomen fistula 50540 C Revision of horseshoe kidney 50541 T Laparo ablate renal cyst 0131 41.81 $2,027.24 $1,089.88 $405.45 50544 T Laparoscopy, pyeloplasty 0131 41.81 $2,027.24 $1,089.88 $405.45 50546 C Laparoscopic nephrectomy 50547 C Laparo removal donor kidney 50548 T Laparo-asst remove k/ureter 0132 48.91 $2,371.50 $1,239.22 $474.30 50549 T Laparoscope proc, renal 0130 25.36 $1,229.63 $659.53 $245.93 50551 T Kidney endoscopy 0161 10.94 $530.45 $249.36 $106.09 50553 T Kidney endoscopy 0161 10.94 $530.45 $249.36 $106.09 50555 T Kidney endoscopy & biopsy 0161 10.94 $530.45 $249.36 $106.09 50557 T Kidney endoscopy & treatment 0161 10.94 $530.45 $249.36 $106.09 50559 T Renal endoscopy/radiotracer 0161 10.94 $530.45 $249.36 $106.09 50561 T Kidney endoscopy & treatment 0161 10.94 $530.45 $249.36 $106.09 50570 C Kidney endoscopy 50572 C Kidney endoscopy 50574 C Kidney endoscopy & biopsy 50575 C Kidney endoscopy 50576 C Kidney endoscopy & treatment Start Printed Page 18609 50578 C Renal endoscopy/radiotracer 50580 C Kidney endoscopy & treatment 50590 T Fragmenting of kidney stone 0169 46.72 $2,265.32 $1,384.20 $453.06 50600 C Exploration of ureter 50605 C Insert ureteral support 50610 C Removal of ureter stone 50620 C Removal of ureter stone 50630 C Removal of ureter stone 50650 C Removal of ureter 50660 C Removal of ureter 50684 N Injection for ureter x-ray 50686 T Measure ureter pressure 0165 3.89 $188.61 $91.76 $37.72 50688 T Change of ureter tube 0121 2.36 $114.43 $52.53 $22.89 50690 N Injection for ureter x-ray 50700 C Revision of ureter 50715 C Release of ureter 50722 C Release of ureter 50725 C Release/revise ureter 50727 C Revise ureter 50728 C Revise ureter 50740 C Fusion of ureter & kidney 50750 C Fusion of ureter & kidney 50760 C Fusion of ureters 50770 C Splicing of ureters 50780 C Reimplant ureter in bladder 50782 C Reimplant ureter in bladder 50783 C Reimplant ureter in bladder 50785 C Reimplant ureter in bladder 50800 C Implant ureter in bowel 50810 C Fusion of ureter & bowel 50815 C Urine shunt to bowel 50820 C Construct bowel bladder 50825 C Construct bowel bladder 50830 C Revise urine flow 50840 C Replace ureter by bowel 50845 C Appendico-vesicostomy 50860 C Transplant ureter to skin 50900 C Repair of ureter 50920 C Closure ureter/skin fistula 50930 C Closure ureter/bowel fistula 50940 C Release of ureter 50945 T Laparoscopy ureterolithotomy 0131 41.81 $2,027.24 $1,089.88 $405.45 50951 T Endoscopy of ureter 0162 17.49 $848.04 $427.49 $169.61 50953 T Endoscopy of ureter 0162 17.49 $848.04 $427.49 $169.61 50955 T Ureter endoscopy & biopsy 0162 17.49 $848.04 $427.49 $169.61 50957 T Ureter endoscopy & treatment 0162 17.49 $848.04 $427.49 $169.61 50959 T Ureter endoscopy & tracer 0162 17.49 $848.04 $427.49 $169.61 50961 T Ureter endoscopy & treatment 0162 17.49 $848.04 $427.49 $169.61 50970 C Ureter endoscopy 50972 C Ureter endoscopy & catheter 50974 C Ureter endoscopy & biopsy 50976 C Ureter endoscopy & treatment 50978 C Ureter endoscopy & tracer 50980 C Ureter endoscopy & treatment 51000 T Drainage of bladder 0165 3.89 $188.61 $91.76 $37.72 51005 T Drainage of bladder 0164 2.17 $105.23 $33.03 $21.05 51010 T Drainage of bladder 0165 3.89 $188.61 $91.76 $37.72 51020 T Incise & treat bladder 0162 17.49 $848.04 $427.49 $169.61 51030 T Incise & treat bladder 0162 17.49 $848.04 $427.49 $169.61 51040 T Incise & drain bladder 0162 17.49 $848.04 $427.49 $169.61 51045 T Incise bladder/drain ureter 0162 17.49 $848.04 $427.49 $169.61 51050 T Removal of bladder stone 0162 17.49 $848.04 $427.49 $169.61 51060 C Removal of ureter stone 51065 T Removal of ureter stone 0162 17.49 $848.04 $427.49 $169.61 51080 T Drainage of bladder abscess 0008 6.15 $298.20 $113.67 $59.64 51500 T Removal of bladder cyst 0154 22.43 $1,087.57 $556.98 $217.51 51520 T Removal of bladder lesion 0162 17.49 $848.04 $427.49 $169.61 51525 C Removal of bladder lesion 51530 C Removal of bladder lesion 51535 C Repair of ureter lesion 51550 C Partial removal of bladder 51555 C Partial removal of bladder 51565 C Revise bladder & ureter(s) Start Printed Page 18610 51570 C Removal of bladder 51575 C Removal of bladder & nodes 51580 C Remove bladder/revise tract 51585 C Removal of bladder & nodes 51590 C Remove bladder/revise tract 51595 C Remove bladder/revise tract 51596 C Remove bladder/create pouch 51597 C Removal of pelvic structures 51600 N Injection for bladder x-ray 51605 N Preparation for bladder x-ray 51610 N Injection for bladder x-ray 51700 T Irrigation of bladder 0164 2.17 $105.23 $33.03 $21.05 51705 T Change of bladder tube 0121 2.36 $114.43 $52.53 $22.89 51710 T Change of bladder tube 0121 2.36 $114.43 $52.53 $22.89 51715 T Endoscopic injection/implant 0167 21.06 $1,021.14 $555.84 $204.23 51720 T Treatment of bladder lesion 0165 3.89 $188.61 $91.76 $37.72 51725 T Simple cystometrogram 0165 3.89 $188.61 $91.76 $37.72 51726 T Complex cystometrogram 0165 3.89 $188.61 $91.76 $37.72 51736 T Urine flow measurement 0164 2.17 $105.23 $33.03 $21.05 51741 T Electro-uroflowmetry, first 0164 2.17 $105.23 $33.03 $21.05 51772 T Urethra pressure profile 0165 3.89 $188.61 $91.76 $37.72 51784 T Anal/urinary muscle study 0164 2.17 $105.23 $33.03 $21.05 51785 T Anal/urinary muscle study 0164 2.17 $105.23 $33.03 $21.05 51792 T Urinary reflex study 0165 3.89 $188.61 $91.76 $37.72 51795 T Urine voiding pressure study 0164 2.17 $105.23 $33.03 $21.05 51797 T Intraabdominal pressure test 0164 2.17 $105.23 $33.03 $21.05 51800 C Revision of bladder/urethra 51820 C Revision of urinary tract 51840 C Attach bladder/urethra 51841 C Attach bladder/urethra 51845 C Repair bladder neck 51860 C Repair of bladder wound 51865 C Repair of bladder wound 51880 T Repair of bladder opening 0162 17.49 $848.04 $427.49 $169.61 51900 C Repair bladder/vagina lesion 51920 C Close bladder-uterus fistula 51925 C Hysterectomy/bladder repair 51940 C Correction of bladder defect 51960 C Revision of bladder & bowel 51980 C Construct bladder opening 51990 T Laparo urethral suspension 0131 41.81 $2,027.24 $1,089.88 $405.45 51992 T Laparo sling operation 0132 48.91 $2,371.50 $1,239.22 $474.30 52000 T Cystoscopy 0160 5.43 $263.28 $110.11 $52.66 52005 T Cystoscopy & ureter catheter 0161 10.94 $530.45 $249.36 $106.09 52007 T Cystoscopy and biopsy 0161 10.94 $530.45 $249.36 $106.09 52010 T Cystoscopy & duct catheter 0161 10.94 $530.45 $249.36 $106.09 52204 T Cystoscopy 0161 10.94 $530.45 $249.36 $106.09 52214 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52224 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52234 T Cystoscopy and treatment 0162 17.49 $848.04 $427.49 $169.61 52235 T Cystoscopy and treatment 0162 17.49 $848.04 $427.49 $169.61 52240 T Cystoscopy and treatment 0163 28.98 $1,405.16 $792.58 $281.03 52250 T Cystoscopy and radiotracer 0162 17.49 $848.04 $427.49 $169.61 52260 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52265 T Cystoscopy and treatment 0160 5.43 $263.28 $110.11 $52.66 52270 T Cystoscopy & revise urethra 0161 10.94 $530.45 $249.36 $106.09 52275 T Cystoscopy & revise urethra 0161 10.94 $530.45 $249.36 $106.09 52276 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52277 T Cystoscopy and treatment 0162 17.49 $848.04 $427.49 $169.61 52281 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52282 T Cystoscopy, implant stent 0162 17.49 $848.04 $427.49 $169.61 52283 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52285 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52290 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52300 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52301 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52305 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52310 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52315 T Cystoscopy and treatment 0161 10.94 $530.45 $249.36 $106.09 52317 T Remove bladder stone 0162 17.49 $848.04 $427.49 $169.61 52318 T Remove bladder stone 0162 17.49 $848.04 $427.49 $169.61 52320 T Cystoscopy and treatment 0162 17.49 $848.04 $427.49 $169.61 52325 T Cystoscopy, stone removal 0162 17.49 $848.04 $427.49 $169.61 Start Printed Page 18611 52327 T Cystoscopy, inject material 0161 10.94 $530.45 $249.36 $106.09 52330 T Cystoscopy and treatment 0162 17.49 $848.04 $427.49 $169.61 52332 T Cystoscopy and treatment 0162 17.49 $848.04 $427.49 $169.61 52334 T Create passage to kidney 0162 17.49 $848.04 $427.49 $169.61 52335 T Endoscopy of urinary tract 0162 17.49 $848.04 $427.49 $169.61 52336 T Cystoscopy, stone removal 0162 17.49 $848.04 $427.49 $169.61 52337 T Cystoscopy, stone removal 0162 17.49 $848.04 $427.49 $169.61 52338 T Cystoscopy and treatment 0162 17.49 $848.04 $427.49 $169.61 52339 T Cystoscopy and treatment 0162 17.49 $848.04 $427.49 $169.61 52340 T Cystoscopy and treatment 0162 17.49 $848.04 $427.49 $169.61 52450 T Incision of prostate 0162 17.49 $848.04 $427.49 $169.61 52500 T Revision of bladder neck 0162 17.49 $848.04 $427.49 $169.61 52510 T Dilation prostatic urethra 0161 10.94 $530.45 $249.36 $106.09 52601 T Prostatectomy (TURP) 0163 28.98 $1,405.16 $792.58 $281.03 52606 T Control postop bleeding 0162 17.49 $848.04 $427.49 $169.61 52612 T Prostatectomy, first stage 0163 28.98 $1,405.16 $792.58 $281.03 52614 T Prostatectomy, second stage 0163 28.98 $1,405.16 $792.58 $281.03 52620 T Remove residual prostate 0163 28.98 $1,405.16 $792.58 $281.03 52630 T Remove prostate regrowth 0163 28.98 $1,405.16 $792.58 $281.03 52640 T Relieve bladder contracture 0162 17.49 $848.04 $427.49 $169.61 52647 T Laser surgery of prostate 0163 28.98 $1,405.16 $792.58 $281.03 52648 T Laser surgery of prostate 0163 28.98 $1,405.16 $792.58 $281.03 52700 T Drainage of prostate abscess 0162 17.49 $848.04 $427.49 $169.61 53000 T Incision of urethra 0166 10.17 $493.11 $218.73 $98.62 53010 T Incision of urethra 0166 10.17 $493.11 $218.73 $98.62 53020 T Incision of urethra 0166 10.17 $493.11 $218.73 $98.62 53025 T Incision of urethra 0166 10.17 $493.11 $218.73 $98.62 53040 T Drainage of urethra abscess 0166 10.17 $493.11 $218.73 $98.62 53060 T Drainage of urethra abscess 0166 10.17 $493.11 $218.73 $98.62 53080 T Drainage of urinary leakage 0166 10.17 $493.11 $218.73 $98.62 53085 C Drainage of urinary leakage 53200 T Biopsy of urethra 0166 10.17 $493.11 $218.73 $98.62 53210 T Removal of urethra 0168 24.94 $1,209.27 $536.11 $241.85 53215 T Removal of urethra 0168 24.94 $1,209.27 $536.11 $241.85 53220 T Treatment of urethra lesion 0168 24.94 $1,209.27 $536.11 $241.85 53230 T Removal of urethra lesion 0168 24.94 $1,209.27 $536.11 $241.85 53235 T Removal of urethra lesion 0168 24.94 $1,209.27 $536.11 $241.85 53240 T Surgery for urethra pouch 0168 24.94 $1,209.27 $536.11 $241.85 53250 T Removal of urethra gland 0166 10.17 $493.11 $218.73 $98.62 53260 T Treatment of urethra lesion 0166 10.17 $493.11 $218.73 $98.62 53265 T Treatment of urethra lesion 0166 10.17 $493.11 $218.73 $98.62 53270 T Removal of urethra gland 0167 21.06 $1,021.14 $555.84 $204.23 53275 T Repair of urethra defect 0166 10.17 $493.11 $218.73 $98.62 53400 T Revise urethra, stage 1 0168 24.94 $1,209.27 $536.11 $241.85 53405 T Revise urethra, stage 2 0168 24.94 $1,209.27 $536.11 $241.85 53410 T Reconstruction of urethra 0168 24.94 $1,209.27 $536.11 $241.85 53415 C Reconstruction of urethra 53420 T Reconstruct urethra, stage 1 0168 24.94 $1,209.27 $536.11 $241.85 53425 T Reconstruct urethra, stage 2 0168 24.94 $1,209.27 $536.11 $241.85 53430 T Reconstruction of urethra 0168 24.94 $1,209.27 $536.11 $241.85 53440 T Correct bladder function 0182 52.11 $2,526.66 $1,525.05 $505.33 53442 T Remove perineal prosthesis 0166 10.17 $493.11 $218.73 $98.62 53443 C Reconstruction of urethra 53445 T Correct urine flow control 0182 52.11 $2,526.66 $1,525.05 $505.33 53447 T Remove artificial sphincter 0168 24.94 $1,209.27 $536.11 $241.85 53449 T Correct artificial sphincter 0168 24.94 $1,209.27 $536.11 $241.85 53450 T Revision of urethra 0168 24.94 $1,209.27 $536.11 $241.85 53460 T Revision of urethra 0168 24.94 $1,209.27 $536.11 $241.85 53502 T Repair of urethra injury 0166 10.17 $493.11 $218.73 $98.62 53505 T Repair of urethra injury 0167 21.06 $1,021.14 $555.84 $204.23 53510 T Repair of urethra injury 0166 10.17 $493.11 $218.73 $98.62 53515 T Repair of urethra injury 0168 24.94 $1,209.27 $536.11 $241.85 53520 T Repair of urethra defect 0168 24.94 $1,209.27 $536.11 $241.85 53600 T Dilate urethra stricture 0164 2.17 $105.23 $33.03 $21.05 53601 T Dilate urethra stricture 0164 2.17 $105.23 $33.03 $21.05 53605 T Dilate urethra stricture 0161 10.94 $530.45 $249.36 $106.09 53620 T Dilate urethra stricture 0165 3.89 $188.61 $91.76 $37.72 53621 T Dilate urethra stricture 0164 2.17 $105.23 $33.03 $21.05 53660 T Dilation of urethra 0164 2.17 $105.23 $33.03 $21.05 53661 T Dilation of urethra 0164 2.17 $105.23 $33.03 $21.05 53665 T Dilation of urethra 0166 10.17 $493.11 $218.73 $98.62 53670 N Insert urinary catheter 53675 T Insert urinary catheter 0164 2.17 $105.23 $33.03 $21.05 Start Printed Page 18612 2 53850 T Prostatic microwave thermotx 0980 38.67 $1,875.00 $375.00 2 53852 T Prostatic rf thermotx 0980 38.67 $1,875.00 $375.00 53899 T Urology surgery procedure 0165 3.89 $188.61 $91.76 $37.72 54000 T Slitting of prepuce 0166 10.17 $493.11 $218.73 $98.62 54001 T Slitting of prepuce 0166 10.17 $493.11 $218.73 $98.62 54015 T Drain penis lesion 0008 6.15 $298.20 $113.67 $59.64 54050 T Destruction, penis lesion(s) 0013 0.91 $44.12 $17.66 $8.82 54055 T Destruction, penis lesion(s) 0016 3.53 $171.16 $74.67 $34.23 54056 T Cryosurgery, penis lesion(s) 0013 0.91 $44.12 $17.66 $8.82 54057 T Laser surg, penis lesion(s) 0017 12.45 $603.66 $289.16 $120.73 54060 T Excision of penis lesion(s) 0017 12.45 $603.66 $289.16 $120.73 54065 T Destruction, penis lesion(s) 0017 12.45 $603.66 $289.16 $120.73 54100 T Biopsy of penis 0020 6.51 $315.65 $130.53 $63.13 54105 T Biopsy of penis 0021 10.49 $508.63 $236.51 $101.73 54110 T Treatment of penis lesion 0181 32.37 $1,569.53 $906.36 $313.91 54111 T Treat penis lesion, graft 0181 32.37 $1,569.53 $906.36 $313.91 54112 T Treat penis lesion, graft 0181 32.37 $1,569.53 $906.36 $313.91 54115 T Treatment of penis lesion 0008 6.15 $298.20 $113.67 $59.64 54120 T Partial removal of penis 0181 32.37 $1,569.53 $906.36 $313.91 54125 C Removal of penis 54130 C Remove penis & nodes 54135 C Remove penis & nodes 54150 T Circumcision 0180 13.62 $660.39 $304.87 $132.08 54152 T Circumcision 0180 13.62 $660.39 $304.87 $132.08 54160 T Circumcision 0180 13.62 $660.39 $304.87 $132.08 54161 T Circumcision 0180 13.62 $660.39 $304.87 $132.08 54200 T Treatment of penis lesion 0165 3.89 $188.61 $91.76 $37.72 54205 T Treatment of penis lesion 0181 32.37 $1,569.53 $906.36 $313.91 54220 T Treatment of penis lesion 0165 3.89 $188.61 $91.76 $37.72 54230 N Prepare penis study 54231 T Dynamic cavernosometry 0165 3.89 $188.61 $91.76 $37.72 54235 T Penile injection 0164 2.17 $105.23 $33.03 $21.05 54240 T Penis study 0164 2.17 $105.23 $33.03 $21.05 54250 T Penis study 0165 3.89 $188.61 $91.76 $37.72 54300 T Revision of penis 0181 32.37 $1,569.53 $906.36 $313.91 54304 T Revision of penis 0181 32.37 $1,569.53 $906.36 $313.91 54308 T Reconstruction of urethra 0181 32.37 $1,569.53 $906.36 $313.91 54312 T Reconstruction of urethra 0181 32.37 $1,569.53 $906.36 $313.91 54316 T Reconstruction of urethra 0181 32.37 $1,569.53 $906.36 $313.91 54318 T Reconstruction of urethra 0181 32.37 $1,569.53 $906.36 $313.91 54322 T Reconstruction of urethra 0181 32.37 $1,569.53 $906.36 $313.91 54324 T Reconstruction of urethra 0181 32.37 $1,569.53 $906.36 $313.91 54326 T Reconstruction of urethra 0181 32.37 $1,569.53 $906.36 $313.91 54328 T Revise penis/urethra 0181 32.37 $1,569.53 $906.36 $313.91 54332 C Revise penis/urethra 54336 C Revise penis/urethra 54340 T Secondary urethral surgery 0181 32.37 $1,569.53 $906.36 $313.91 54344 T Secondary urethral surgery 0181 32.37 $1,569.53 $906.36 $313.91 54348 T Secondary urethral surgery 0181 32.37 $1,569.53 $906.36 $313.91 54352 T Reconstruct urethra/penis 0181 32.37 $1,569.53 $906.36 $313.91 54360 T Penis plastic surgery 0181 32.37 $1,569.53 $906.36 $313.91 54380 T Repair penis 0181 32.37 $1,569.53 $906.36 $313.91 54385 T Repair penis 0181 32.37 $1,569.53 $906.36 $313.91 54390 C Repair penis and bladder 54400 T Insert semi-rigid prosthesis 0182 52.11 $2,526.66 $1,525.05 $505.33 54401 T Insert self-contd prosthesis 0182 52.11 $2,526.66 $1,525.05 $505.33 54402 T Remove penis prosthesis 0181 32.37 $1,569.53 $906.36 $313.91 54405 T Insert multi-comp prosthesis 0182 52.11 $2,526.66 $1,525.05 $505.33 54407 T Remove multi-comp prosthesis 0181 32.37 $1,569.53 $906.36 $313.91 54409 T Revise penis prosthesis 0181 32.37 $1,569.53 $906.36 $313.91 54420 T Revision of penis 0181 32.37 $1,569.53 $906.36 $313.91 54430 C Revision of penis 54435 T Revision of penis 0181 32.37 $1,569.53 $906.36 $313.91 54440 T Repair of penis 0181 32.37 $1,569.53 $906.36 $313.91 54450 T Preputial stretching 0165 3.89 $188.61 $91.76 $37.72 54500 T Biopsy of testis 0005 5.41 $262.32 $119.75 $52.46 54505 T Biopsy of testis 0183 18.26 $885.37 $448.94 $177.07 54510 T Removal of testis lesion 0183 18.26 $885.37 $448.94 $177.07 54520 T Removal of testis 0183 18.26 $885.37 $448.94 $177.07 54530 T Removal of testis 0154 22.43 $1,087.57 $556.98 $217.51 54535 C Extensive testis surgery 54550 T Exploration for testis 0154 22.43 $1,087.57 $556.98 $217.51 54560 C Exploration for testis Start Printed Page 18613 54600 T Reduce testis torsion 0183 18.26 $885.37 $448.94 $177.07 54620 T Suspension of testis 0183 18.26 $885.37 $448.94 $177.07 54640 T Suspension of testis 0154 22.43 $1,087.57 $556.98 $217.51 54650 C Orchiopexy (Fowler-Stephens) 54660 T Revision of testis 0183 18.26 $885.37 $448.94 $177.07 54670 T Repair testis injury 0183 18.26 $885.37 $448.94 $177.07 54680 T Relocation of testis(es) 0183 18.26 $885.37 $448.94 $177.07 54690 T Laparoscopy, orchiectomy 0131 41.81 $2,027.24 $1,089.88 $405.45 54692 T Laparoscopy, orchiopexy 0132 48.91 $2,371.50 $1,239.22 $474.30 54699 T Laparoscope proc, testis 0130 25.36 $1,229.63 $659.53 $245.93 54700 T Drainage of scrotum 0183 18.26 $885.37 $448.94 $177.07 54800 T Biopsy of epididymis 0004 1.84 $89.22 $32.57 $17.84 54820 T Exploration of epididymis 0183 18.26 $885.37 $448.94 $177.07 54830 T Remove epididymis lesion 0183 18.26 $885.37 $448.94 $177.07 54840 T Remove epididymis lesion 0183 18.26 $885.37 $448.94 $177.07 54860 T Removal of epididymis 0183 18.26 $885.37 $448.94 $177.07 54861 T Removal of epididymis 0183 18.26 $885.37 $448.94 $177.07 54900 T Fusion of spermatic ducts 0183 18.26 $885.37 $448.94 $177.07 54901 T Fusion of spermatic ducts 0183 18.26 $885.37 $448.94 $177.07 55000 T Drainage of hydrocele 0004 1.84 $89.22 $32.57 $17.84 55040 T Removal of hydrocele 0154 22.43 $1,087.57 $556.98 $217.51 55041 T Removal of hydroceles 0154 22.43 $1,087.57 $556.98 $217.51 55060 T Repair of hydrocele 0183 18.26 $885.37 $448.94 $177.07 55100 T Drainage of scrotum abscess 0008 6.15 $298.20 $113.67 $59.64 55110 T Explore scrotum 0183 18.26 $885.37 $448.94 $177.07 55120 T Removal of scrotum lesion 0183 18.26 $885.37 $448.94 $177.07 55150 T Removal of scrotum 0183 18.26 $885.37 $448.94 $177.07 55175 T Revision of scrotum 0183 18.26 $885.37 $448.94 $177.07 55180 T Revision of scrotum 0183 18.26 $885.37 $448.94 $177.07 55200 T Incision of sperm duct 0183 18.26 $885.37 $448.94 $177.07 55250 T Removal of sperm duct(s) 0183 18.26 $885.37 $448.94 $177.07 55300 N Prepare, sperm duct x-ray 55400 T Repair of sperm duct 0183 18.26 $885.37 $448.94 $177.07 55450 T Ligation of sperm duct 0183 18.26 $885.37 $448.94 $177.07 55500 T Removal of hydrocele 0183 18.26 $885.37 $448.94 $177.07 55520 T Removal of sperm cord lesion 0183 18.26 $885.37 $448.94 $177.07 55530 T Revise spermatic cord veins 0183 18.26 $885.37 $448.94 $177.07 55535 T Revise spermatic cord veins 0154 22.43 $1,087.57 $556.98 $217.51 55540 T Revise hernia & sperm veins 0154 22.43 $1,087.57 $556.98 $217.51 55550 T Laparo ligate spermatic vein 0131 41.81 $2,027.24 $1,089.88 $405.45 55559 T Laparo proc, spermatic cord 0130 25.36 $1,229.63 $659.53 $245.93 55600 C Incise sperm duct pouch 55605 C Incise sperm duct pouch 55650 C Remove sperm duct pouch 55680 T Remove sperm pouch lesion 0183 18.26 $885.37 $448.94 $177.07 55700 T Biopsy of prostate 0184 4.94 $239.53 $122.96 $47.91 55705 T Biopsy of prostate 0184 4.94 $239.53 $122.96 $47.91 55720 T Drainage of prostate abscess 0162 17.49 $848.04 $427.49 $169.61 55725 T Drainage of prostate abscess 0162 17.49 $848.04 $427.49 $169.61 55801 C Removal of prostate 55810 C Extensive prostate surgery 55812 C Extensive prostate surgery 55815 C Extensive prostate surgery 55821 C Removal of prostate 55831 C Removal of prostate 55840 C Extensive prostate surgery 55842 C Extensive prostate surgery 55845 C Extensive prostate surgery 55859 T Percut/needle insert, pros 0162 17.49 $848.04 $427.49 $169.61 55860 C Surgical exposure, prostate 55862 C Extensive prostate surgery 55865 C Extensive prostate surgery 55870 T Electroejaculation 0197 2.40 $116.37 $49.55 $23.27 55899 T Genital surgery procedure 0164 2.17 $105.23 $33.03 $21.05 55970 E Sex transformation, M to F 55980 E Sex transformation, F to M 56405 T I & D of vulva/perineum 0192 2.38 $115.40 $35.33 $23.08 56420 T Drainage of gland abscess 0192 2.38 $115.40 $35.33 $23.08 56440 T Surgery for vulva lesion 0194 16.21 $785.98 $395.94 $157.20 56441 T Lysis of labial lesion(s) 0193 8.93 $432.99 $171.13 $86.60 56501 T Destruction, vulva lesion(s) 0016 3.53 $171.16 $74.67 $34.23 56515 T Destruction, vulva lesion(s) 0017 12.45 $603.66 $289.16 $120.73 56605 T Biopsy of vulva/perineum 0019 4.00 $193.95 $78.91 $38.79 Start Printed Page 18614 56606 T Biopsy of vulva/perineum 0019 4.00 $193.95 $78.91 $38.79 56620 T Partial removal of vulva 0195 18.68 $905.74 $483.80 $181.15 56625 T Complete removal of vulva 0195 18.68 $905.74 $483.80 $181.15 56630 C Extensive vulva surgery 56631 C Extensive vulva surgery 56632 C Extensive vulva surgery 56633 C Extensive vulva surgery 56634 C Extensive vulva surgery 56637 C Extensive vulva surgery 56640 C Extensive vulva surgery 56700 T Partial removal of hymen 0194 16.21 $785.98 $395.94 $157.20 56720 T Incision of hymen 0193 8.93 $432.99 $171.13 $86.60 56740 T Remove vagina gland lesion 0194 16.21 $785.98 $395.94 $157.20 56800 T Repair of vagina 0194 16.21 $785.98 $395.94 $157.20 56805 C Repair clitoris 56810 T Repair of perineum 0194 16.21 $785.98 $395.94 $157.20 57000 T Exploration of vagina 0194 16.21 $785.98 $395.94 $157.20 57010 T Drainage of pelvic abscess 0194 16.21 $785.98 $395.94 $157.20 57020 T Drainage of pelvic fluid 0193 8.93 $432.99 $171.13 $86.60 57061 T Destruction vagina lesion(s) 0194 16.21 $785.98 $395.94 $157.20 57065 T Destruction vagina lesion(s) 0194 16.21 $785.98 $395.94 $157.20 57100 T Biopsy of vagina 0192 2.38 $115.40 $35.33 $23.08 57105 T Biopsy of vagina 0194 16.21 $785.98 $395.94 $157.20 57106 T Remove vagina wall, partial 0194 16.21 $785.98 $395.94 $157.20 57107 T Remove vagina tissue, part 0194 16.21 $785.98 $395.94 $157.20 57109 T Vaginectomy partial w/nodes 0194 16.21 $785.98 $395.94 $157.20 57110 C Remove vagina wall, complete 57111 C Remove vagina tissue, compl 57112 C Vaginectomy w/nodes, compl 57120 C Closure of vagina 57130 T Remove vagina lesion 0194 16.21 $785.98 $395.94 $157.20 57135 T Remove vagina lesion 0194 16.21 $785.98 $395.94 $157.20 57150 T Treat vagina infection 0192 2.38 $115.40 $35.33 $23.08 57160 T Insert pessary/other device 0191 1.19 $57.70 $17.43 $11.54 57170 T Fitting of diaphragm/cap 0191 1.19 $57.70 $17.43 $11.54 57180 T Treat vaginal bleeding 0192 2.38 $115.40 $35.33 $23.08 57200 T Repair of vagina 0194 16.21 $785.98 $395.94 $157.20 57210 T Repair vagina/perineum 0194 16.21 $785.98 $395.94 $157.20 57220 T Revision of urethra 0195 18.68 $905.74 $483.80 $181.15 57230 T Repair of urethral lesion 0194 16.21 $785.98 $395.94 $157.20 57240 T Repair bladder & vagina 0195 18.68 $905.74 $483.80 $181.15 57250 T Repair rectum & vagina 0195 18.68 $905.74 $483.80 $181.15 57260 T Repair of vagina 0195 18.68 $905.74 $483.80 $181.15 57265 T Extensive repair of vagina 0195 18.68 $905.74 $483.80 $181.15 57268 T Repair of bowel bulge 0195 18.68 $905.74 $483.80 $181.15 57270 C Repair of bowel pouch 57280 C Suspension of vagina 57282 C Repair of vaginal prolapse 57284 T Repair paravaginal defect 0195 18.68 $905.74 $483.80 $181.15 57288 T Repair bladder defect 0195 18.68 $905.74 $483.80 $181.15 57289 T Repair bladder & vagina 0195 18.68 $905.74 $483.80 $181.15 57291 T Construction of vagina 0195 18.68 $905.74 $483.80 $181.15 57292 C Construct vagina with graft 57300 T Repair rectum-vagina fistula 0195 18.68 $905.74 $483.80 $181.15 57305 C Repair rectum-vagina fistula 57307 C Fistula repair & colostomy 57308 C Fistula repair, transperine 57310 C Repair urethrovaginal lesion 57311 C Repair urethrovaginal lesion 57320 C Repair bladder-vagina lesion 57330 C Repair bladder-vagina lesion 57335 C Repair vagina 57400 T Dilation of vagina 0194 16.21 $785.98 $395.94 $157.20 57410 T Pelvic examination 0194 16.21 $785.98 $395.94 $157.20 57415 T Remove vaginal foreign body 0194 16.21 $785.98 $395.94 $157.20 57452 T Examination of vagina 0191 1.19 $57.70 $17.43 $11.54 57454 T Vagina examination & biopsy 0192 2.38 $115.40 $35.33 $23.08 57460 T Cervix excision 0193 8.93 $432.99 $171.13 $86.60 57500 T Biopsy of cervix 0193 8.93 $432.99 $171.13 $86.60 57505 T Endocervical curettage 0192 2.38 $115.40 $35.33 $23.08 57510 T Cauterization of cervix 0193 8.93 $432.99 $171.13 $86.60 57511 T Cryocautery of cervix 0192 2.38 $115.40 $35.33 $23.08 57513 T Laser surgery of cervix 0193 8.93 $432.99 $171.13 $86.60 Start Printed Page 18615 57520 T Conization of cervix 0194 16.21 $785.98 $395.94 $157.20 57522 T Conization of cervix 0195 18.68 $905.74 $483.80 $181.15 57530 T Removal of cervix 0195 18.68 $905.74 $483.80 $181.15 57531 C Removal of cervix, radical 57540 C Removal of residual cervix 57545 C Remove cervix/repair pelvis 57550 T Removal of residual cervix 0195 18.68 $905.74 $483.80 $181.15 57555 T Remove cervix/repair vagina 0195 18.68 $905.74 $483.80 $181.15 57556 T Remove cervix, repair bowel 0195 18.68 $905.74 $483.80 $181.15 57700 T Revision of cervix 0194 16.21 $785.98 $395.94 $157.20 57720 T Revision of cervix 0194 16.21 $785.98 $395.94 $157.20 57800 T Dilation of cervical canal 0193 8.93 $432.99 $171.13 $86.60 57820 T D & c of residual cervix 0196 14.47 $701.61 $357.98 $140.32 58100 T Biopsy of uterus lining 0191 1.19 $57.70 $17.43 $11.54 58120 T Dilation and curettage 0196 14.47 $701.61 $357.98 $140.32 58140 C Removal of uterus lesion 58145 T Removal of uterus lesion 0195 18.68 $905.74 $483.80 $181.15 58150 C Total hysterectomy 58152 C Total hysterectomy 58180 C Partial hysterectomy 58200 C Extensive hysterectomy 58210 C Extensive hysterectomy 58240 C Removal of pelvis contents 58260 C Vaginal hysterectomy 58262 C Vaginal hysterectomy 58263 C Vaginal hysterectomy 58267 C Hysterectomy & vagina repair 58270 C Hysterectomy & vagina repair 58275 C Hysterectomy/revise vagina 58280 C Hysterectomy/revise vagina 58285 C Extensive hysterectomy 58300 E Insert intrauterine device 58301 T Remove intrauterine device 0191 1.19 $57.70 $17.43 $11.54 58321 T Artificial insemination 0197 2.40 $116.37 $49.55 $23.27 58322 T Artificial insemination 0197 2.40 $116.37 $49.55 $23.27 58323 T Sperm washing 0197 2.40 $116.37 $49.55 $23.27 58340 N Catheter for hysterography 58345 T Reopen fallopian tube 0194 16.21 $785.98 $395.94 $157.20 58350 T Reopen fallopian tube 0194 16.21 $785.98 $395.94 $157.20 58400 C Suspension of uterus 58410 C Suspension of uterus 58520 C Repair of ruptured uterus 58540 C Revision of uterus 58550 T Laparo-asst vag hysterectomy 0132 48.91 $2,371.50 $1,239.22 $474.30 58551 T Laparoscopy, remove myoma 0131 41.81 $2,027.24 $1,089.88 $405.45 58555 T Hysteroscopy, dx, sep proc 0191 1.19 $57.70 $17.43 $11.54 58558 T Hysteroscopy, biopsy 0190 17.85 $865.49 $443.89 $173.10 58559 T Hysteroscopy, lysis 0190 17.85 $865.49 $443.89 $173.10 58560 T Hysteroscopy, resect septum 0190 17.85 $865.49 $443.89 $173.10 58561 T Hysteroscopy, remove myoma 0190 17.85 $865.49 $443.89 $173.10 58562 T Hysteroscopy, remove fb 0190 17.85 $865.49 $443.89 $173.10 58563 T Hysteroscopy, ablation 0190 17.85 $865.49 $443.89 $173.10 58578 T Laparo proc, uterus 0190 17.85 $865.49 $443.89 $173.10 58579 T Hysteroscope procedure 0190 17.85 $865.49 $443.89 $173.10 58600 C Division of fallopian tube 58605 C Division of fallopian tube 58611 C Ligate oviduct(s) add-on 58615 C Occlude fallopian tube(s) 58660 T Laparoscopy, lysis 0131 41.81 $2,027.24 $1,089.88 $405.45 58661 T Laparoscopy, remove adnexa 0131 41.81 $2,027.24 $1,089.88 $405.45 58662 T Laparoscopy, excise lesions 0131 41.81 $2,027.24 $1,089.88 $405.45 58670 T Laparoscopy, tubal cautery 0131 41.81 $2,027.24 $1,089.88 $405.45 58671 T Laparoscopy, tubal block 0131 41.81 $2,027.24 $1,089.88 $405.45 58672 T Laparoscopy, fimbrioplasty 0131 41.81 $2,027.24 $1,089.88 $405.45 58673 T Laparoscopy, salpingostomy 0131 41.81 $2,027.24 $1,089.88 $405.45 58679 T Laparo proc, oviduct-ovary 0130 25.36 $1,229.63 $659.53 $245.93 58700 C Removal of fallopian tube 58720 C Removal of ovary/tube(s) 58740 C Revise fallopian tube(s) 58750 C Repair oviduct 58752 C Revise ovarian tube(s) 58760 C Remove tubal obstruction 58770 C Create new tubal opening Start Printed Page 18616 58800 T Drainage of ovarian cyst(s) 0195 18.68 $905.74 $483.80 $181.15 58805 C Drainage of ovarian cyst(s) 58820 T Drain ovary abscess, open 0195 18.68 $905.74 $483.80 $181.15 58822 C Drain ovary abscess, percut 58823 C Drain pelvic abscess, percut 58825 C Transposition, ovary(s) 58900 T Biopsy of ovary(s) 0195 18.68 $905.74 $483.80 $181.15 58920 T Partial removal of ovary(s) 0195 18.68 $905.74 $483.80 $181.15 58925 T Removal of ovarian cyst(s) 0195 18.68 $905.74 $483.80 $181.15 58940 C Removal of ovary(s) 58943 C Removal of ovary(s) 58950 C Resect ovarian malignancy 58951 C Resect ovarian malignancy 58952 C Resect ovarian malignancy 58960 C Exploration of abdomen 58970 T Retrieval of oocyte 0194 16.21 $785.98 $395.94 $157.20 58974 T Transfer of embryo 0197 2.40 $116.37 $49.55 $23.27 58976 T Transfer of embryo 0197 2.40 $116.37 $49.55 $23.27 58999 T Genital surgery procedure 0019 4.00 $193.95 $78.91 $38.79 59000 T Amniocentesis 0198 1.34 $64.97 $33.03 $12.99 59012 T Fetal cord puncture, prenatal 0198 1.34 $64.97 $33.03 $12.99 59015 T Chorion biopsy 0198 1.34 $64.97 $33.03 $12.99 59020 T Fetal contract stress test 0198 1.34 $64.97 $33.03 $12.99 59025 T Fetal non-stress test 0198 1.34 $64.97 $33.03 $12.99 59030 T Fetal scalp blood sample 0198 1.34 $64.97 $33.03 $12.99 59050 T Fetal monitor w/report 0198 1.34 $64.97 $33.03 $12.99 59051 E Fetal monitor/interpret only 59100 C Remove uterus lesion 59120 C Treat ectopic pregnancy 59121 C Treat ectopic pregnancy 59130 C Treat ectopic pregnancy 59135 C Treat ectopic pregnancy 59136 C Treat ectopic pregnancy 59140 C Treat ectopic pregnancy 59150 T Treat ectopic pregnancy 0131 41.81 $2,027.24 $1,089.88 $405.45 59151 T Treat ectopic pregnancy 0131 41.81 $2,027.24 $1,089.88 $405.45 59160 T D & c after delivery 0196 14.47 $701.61 $357.98 $140.32 59200 T Insert cervical dilator 0191 1.19 $57.70 $17.43 $11.54 59300 T Episiotomy or vaginal repair 0194 16.21 $785.98 $395.94 $157.20 59320 T Revision of cervix 0194 16.21 $785.98 $395.94 $157.20 59325 C Revision of cervix 59350 C Repair of uterus 59400 E Obstetrical care 59409 T Obstetrical care 0199 11.20 $543.06 $157.83 $108.61 59410 E Obstetrical care 59412 T Antepartum manipulation 0199 11.20 $543.06 $157.83 $108.61 59414 T Deliver placenta 0199 11.20 $543.06 $157.83 $108.61 59425 E Antepartum care only 59426 E Antepartum care only 59430 E Care after delivery 59510 E Cesarean delivery 59514 C Cesarean delivery only 59515 E Cesarean delivery 59525 C Remove uterus after cesarean 59610 E Vbac delivery 59612 T Vbac delivery only 0199 11.20 $543.06 $157.83 $108.61 59614 E Vbac care after delivery 59618 E Attempted vbac delivery 59620 C Attempted vbac delivery only 59622 E Attempted vbac after care 59812 T Treatment of miscarriage 0201 13.00 $630.33 $329.65 $126.07 59820 T Care of miscarriage 0201 13.00 $630.33 $329.65 $126.07 59821 T Treatment of miscarriage 0201 13.00 $630.33 $329.65 $126.07 59830 C Treat uterus infection 59840 T Abortion 0200 13.89 $673.49 $373.23 $134.70 59841 T Abortion 0200 13.89 $673.49 $373.23 $134.70 59850 C Abortion 59851 C Abortion 59852 C Abortion 59855 C Abortion 59856 C Abortion 59857 C Abortion 59866 C Abortion (mpr) Start Printed Page 18617 59870 T Evacuate mole of uterus 0201 13.00 $630.33 $329.65 $126.07 59871 T Remove cerclage suture 0194 16.21 $785.98 $395.94 $157.20 59898 T Laparo proc, ob care/deliver 0130 25.36 $1,229.63 $659.53 $245.93 59899 T Maternity care procedure 0198 1.34 $64.97 $33.03 $12.99 60000 T Drain thyroid/tongue cyst 0253 12.02 $582.81 $284.00 $116.56 60001 T Aspirate/inject thyriod cyst 0002 0.62 $30.06 $17.66 $6.01 60100 T Biopsy of thyroid 0004 1.84 $89.22 $32.57 $17.84 60200 T Remove thyroid lesion 0114 19.56 $948.41 $493.78 $189.68 60210 T Partial thyroid excision 0114 19.56 $948.41 $493.78 $189.68 60212 C Parital thyroid excision 60220 T Partial removal of thyroid 0114 19.56 $948.41 $493.78 $189.68 60225 T Partial removal of thyroid 0114 19.56 $948.41 $493.78 $189.68 60240 T Removal of thyroid 0114 19.56 $948.41 $493.78 $189.68 60252 C Removal of thyroid 60254 C Extensive thyroid surgery 60260 C Repeat thyroid surgery 60270 C Removal of thyroid 60271 C Removal of thyroid 60280 T Remove thyroid duct lesion 0114 19.56 $948.41 $493.78 $189.68 60281 T Remove thyroid duct lesion 0114 19.56 $948.41 $493.78 $189.68 60500 T Explore parathyroid glands 0256 25.40 $1,231.57 $623.05 $246.31 60502 C Re-explore parathyroids 60505 C Explore parathyroid glands 60512 C Autotransplant parathyroid 60520 C Removal of thymus gland 60521 C Removal of thymus gland 60522 C Removal of thymus gland 60540 C Explore adrenal gland 60545 C Explore adrenal gland 60600 C Remove carotid body lesion 60605 C Remove carotid body lesion 60650 C Laparoscopy adrenalectomy 60659 T Laparo proc, endocrine 0130 25.36 $1,229.63 $659.53 $245.93 60699 T Endocrine surgery procedure 0004 1.84 $89.22 $32.57 $17.84 61000 T Remove cranial cavity fluid 0212 3.64 $176.49 $88.78 $35.30 61001 T Remove cranial cavity fluid 0212 3.64 $176.49 $88.78 $35.30 61020 T Remove brain cavity fluid 0212 3.64 $176.49 $88.78 $35.30 61026 T Injection into brain canal 0212 3.64 $176.49 $88.78 $35.30 61050 T Remove brain canal fluid 0212 3.64 $176.49 $88.78 $35.30 61055 T Injection into brain canal 0212 3.64 $176.49 $88.78 $35.30 61070 T Brain canal shunt procedure 0212 3.64 $176.49 $88.78 $35.30 61105 C Twist drill hole 61107 C Drill skull for implantation 61108 C Drill skull for drainage 61120 C Burr hole for puncture 61140 C Pierce skull for biopsy 61150 C Pierce skull for drainage 61151 C Pierce skull for drainage 61154 C Pierce skull & remove clot 61156 C Pierce skull for drainage 61210 C Pierce skull, implant device 61215 T Insert brain-fluid device 0222 25.48 $1,235.45 $780.07 $247.09 61250 C Pierce skull & explore 61253 C Pierce skull & explore 61304 C Open skull for exploration 61305 C Open skull for exploration 61312 C Open skull for drainage 61313 C Open skull for drainage 61314 C Open skull for drainage 61315 C Open skull for drainage 61320 C Open skull for drainage 61321 C Open skull for drainage 61330 T Decompress eye socket 0256 25.40 $1,231.57 $623.05 $246.31 61332 C Explore/biopsy eye socket 61333 C Explore orbit/remove lesion 61334 C Explore orbit/remove object 61340 C Relieve cranial pressure 61343 C Incise skull (press relief) 61345 C Relieve cranial pressure 61440 C Incise skull for surgery 61450 C Incise skull for surgery 61458 C Incise skull for brain wound 61460 C Incise skull for surgery Start Printed Page 18618 61470 C Incise skull for surgery 61480 C Incise skull for surgery 61490 C Incise skull for surgery 61500 C Removal of skull lesion 61501 C Remove infected skull bone 61510 C Removal of brain lesion 61512 C Remove brain lining lesion 61514 C Removal of brain abscess 61516 C Removal of brain lesion 61518 C Removal of brain lesion 61519 C Remove brain lining lesion 61520 C Removal of brain lesion 61521 C Removal of brain lesion 61522 C Removal of brain abscess 61524 C Removal of brain lesion 61526 C Removal of brain lesion 61530 C Removal of brain lesion 61531 C Implant brain electrodes 61533 C Implant brain electrodes 61534 C Removal of brain lesion 61535 C Remove brain electrodes 61536 C Removal of brain lesion 61538 C Removal of brain tissue 61539 C Removal of brain tissue 61541 C Incision of brain tissue 61542 C Removal of brain tissue 61543 C Removal of brain tissue 61544 C Remove & treat brain lesion 61545 C Excision of brain tumor 61546 C Removal of pituitary gland 61548 C Removal of pituitary gland 61550 C Release of skull seams 61552 C Release of skull seams 61556 C Incise skull/sutures 61557 C Incise skull/sutures 61558 C Excision of skull/sutures 61559 C Excision of skull/sutures 61563 C Excision of skull tumor 61564 C Excision of skull tumor 61570 C Remove foreign body, brain 61571 C Incise skull for brain wound 61575 C Skull base/brainstem surgery 61576 C Skull base/brainstem surgery 61580 C Craniofacial approach, skull 61581 C Craniofacial approach, skull 61582 C Craniofacial approach, skull 61583 C Craniofacial approach, skull 61584 C Orbitocranial approach/skull 61585 C Orbitocranial approach/skull 61586 C Resect nasopharynx, skull 61590 C Infratemporal approach/skull 61591 C Infratemporal approach/skull 61592 C Orbitocranial approach/skull 61595 C Transtemporal approach/skull 61596 C Transcochlear approach/skull 61597 C Transcondylar approach/skull 61598 C Transpetrosal approach/skull 61600 C Resect/excise cranial lesion 61601 C Resect/excise cranial lesion 61605 C Resect/excise cranial lesion 61606 C Resect/excise cranial lesion 61607 C Resect/excise cranial lesion 61608 C Resect/excise cranial lesion 61609 C Transect artery, sinus 61610 C Transect artery, sinus 61611 C Transect artery, sinus 61612 C Transect artery, sinus 61613 C Remove aneurysm, sinus 61615 C Resect/excise lesion, skull 61616 C Resect/excise lesion, skull 61618 C Repair dura 61619 C Repair dura 61624 C Occlusion/embolization cath Start Printed Page 18619 61626 C Occlusion/embolization cath 61680 C Intracranial vessel surgery 61682 C Intracranial vessel surgery 61684 C Intracranial vessel surgery 61686 C Intracranial vessel surgery 61690 C Intracranial vessel surgery 61692 C Intracranial vessel surgery 61700 C Inner skull vessel surgery 61702 C Inner skull vessel surgery 61703 C Clamp neck artery 61705 C Revise circulation to head 61708 C Revise circulation to head 61710 C Revise circulation to head 61711 C Fusion of skull arteries 61720 C Incise skull/brain surgery 61735 C Incise skull/brain surgery 61750 C Incise skull/brain biopsy 61751 C Brain biopsy w/ct/mr guide 61760 C Implant brain electrodes 61770 C Incise skull for treatment 61790 T Treat trigeminal nerve 0220 13.96 $676.88 $326.21 $135.38 61791 C Treat trigeminal tract 61793 E Focus radiation beam 61795 C Brain surgery using computer 61850 C Implant neuroelectrodes 61860 C Implant neuroelectrodes 61862 C Implant neurostimul, subcort 61870 C Implant neuroelectrodes 61875 C Implant neuroelectrodes 61880 C Revise/remove neuroelectrode 61885 T Implant neurostim one array 0222 25.48 $1,235.45 $780.07 $247.09 61886 C Implant neurostim arrays 61888 C Revise/remove neuroreceiver 62000 C Treat skull fracture 62005 C Treat skull fracture 62010 C Treatment of head injury 62100 C Repair brain fluid leakage 62115 C Reduction of skull defect 62116 C Reduction of skull defect 62117 C Reduction of skull defect 62120 C Repair skull cavity lesion 62121 C Incise skull repair 62140 C Repair of skull defect 62141 C Repair of skull defect 62142 C Remove skull plate/flap 62143 C Replace skull plate/flap 62145 C Repair of skull & brain 62146 C Repair of skull with graft 62147 C Repair of skull with graft 62180 C Establish brain cavity shunt 62190 C Establish brain cavity shunt 62192 C Establish brain cavity shunt 62194 T Replace/irrigate catheter 0121 2.36 $114.43 $52.53 $22.89 62200 C Establish brain cavity shunt 62201 C Establish brain cavity shunt 62220 C Establish brain cavity shunt 62223 C Establish brain cavity shunt 62225 T Replace/irrigate catheter 0121 2.36 $114.43 $52.53 $22.89 62230 T Replace/revise brain shunt 0224 15.94 $772.88 $374.61 $154.58 62256 C Remove brain cavity shunt 62258 C Replace brain cavity shunt 62263 T Lysis epidural adhesions 0212 3.64 $176.49 $88.78 $35.30 62268 T Drain spinal cord cyst 0212 3.64 $176.49 $88.78 $35.30 62269 T Needle biopsy, spinal cord 0005 5.41 $262.32 $119.75 $52.46 62270 T Spinal fluid tap, diagnostic 0210 3.00 $145.46 $62.40 $29.09 62272 T Drain spinal fluid 0210 3.00 $145.46 $62.40 $29.09 62273 T Treat epidural spine lesion 0212 3.64 $176.49 $88.78 $35.30 62280 T Treat spinal cord lesion 0212 3.64 $176.49 $88.78 $35.30 62281 T Treat spinal cord lesion 0212 3.64 $176.49 $88.78 $35.30 62282 T Treat spinal canal lesion 0212 3.64 $176.49 $88.78 $35.30 62284 N Injection for myelogram 62287 T Percutaneous diskectomy 0220 13.96 $676.88 $326.21 $135.38 62290 N Inject for spine disk x-ray Start Printed Page 18620 62291 N Inject for spine disk x-ray 62292 T Injection into disk lesion 0212 3.64 $176.49 $88.78 $35.30 62294 T Injection into spinal artery 0212 3.64 $176.49 $88.78 $35.30 62310 T Inject spine c/t 0212 3.64 $176.49 $88.78 $35.30 62311 T Inject spine l/s (cd) 0212 3.64 $176.49 $88.78 $35.30 62318 T Inject spine w/cath, c/t 0212 3.64 $176.49 $88.78 $35.30 62319 T Inject spine w/cath l/s (cd) 0212 3.64 $176.49 $88.78 $35.30 62350 T Implant spinal canal cath 0223 6.34 $307.41 $153.24 $61.48 62351 C Implant spinal canal cath 62355 T Remove spinal canal catheter 0223 6.34 $307.41 $153.24 $61.48 62360 T Insert spine infusion device 0222 25.48 $1,235.45 $780.07 $247.09 62361 T Implant spine infusion pump 0222 25.48 $1,235.45 $780.07 $247.09 62362 T Implant spine infusion pump 0222 25.48 $1,235.45 $780.07 $247.09 62365 T Remove spine infusion device 0224 15.94 $772.88 $374.61 $154.58 62367 S Analyze spine infusion pump 0102 0.45 $21.82 $12.62 $4.36 62368 S Analyze spine infusion pump 0102 0.45 $21.82 $12.62 $4.36 63001 C Removal of spinal lamina 63003 C Removal of spinal lamina 63005 C Removal of spinal lamina 63011 C Removal of spinal lamina 63012 C Removal of spinal lamina 63015 C Removal of spinal lamina 63016 C Removal of spinal lamina 63017 C Removal of spinal lamina 63020 C Neck spine disk surgery 63030 C Low back disk surgery 63035 C Spinal disk surgery add-on 63040 C Neck spine disk surgery 63042 C Low back disk surgery 63045 C Removal of spinal lamina 63046 C Removal of spinal lamina 63047 C Removal of spinal lamina 63048 C Remove spinal lamina add-on 63055 C Decompress spinal cord 63056 C Decompress spinal cord 63057 C Decompress spine cord add-on 63064 C Decompress spinal cord 63066 C Decompress spine cord add-on 63075 C Neck spine disk surgery 63076 C Neck spine disk surgery 63077 C Spine disk surgery, thorax 63078 C Spine disk surgery, thorax 63081 C Removal of vertebral body 63082 C Remove vertebral body add-on 63085 C Removal of vertebral body 63086 C Remove vertebral body add-on 63087 C Removal of vertebral body 63088 C Remove vertebral body add-on 63090 C Removal of vertebral body 63091 C Remove vertebral body add-on 63170 C Incise spinal cord tract(s) 63172 C Drainage of spinal cyst 63173 C Drainage of spinal cyst 63180 C Revise spinal cord ligaments 63182 C Revise spinal cord ligaments 63185 C Incise spinal column/nerves 63190 C Incise spinal column/nerves 63191 C Incise spinal column/nerves 63194 C Incise spinal column & cord 63195 C Incise spinal column & cord 63196 C Incise spinal column & cord 63197 C Incise spinal column & cord 63198 C Incise spinal column & cord 63199 C Incise spinal column & cord 63200 C Release of spinal cord 63250 C Revise spinal cord vessels 63251 C Revise spinal cord vessels 63252 C Revise spinal cord vessels 63265 C Excise intraspinal lesion 63266 C Excise intraspinal lesion 63267 C Excise intraspinal lesion 63268 C Excise intraspinal lesion 63270 C Excise intraspinal lesion Start Printed Page 18621 63271 C Excise intraspinal lesion 63272 C Excise intraspinal lesion 63273 C Excise intraspinal lesion 63275 C Biopsy/excise spinal tumor 63276 C Biopsy/excise spinal tumor 63277 C Biopsy/excise spinal tumor 63278 C Biopsy/excise spinal tumor 63280 C Biopsy/excise spinal tumor 63281 C Biopsy/excise spinal tumor 63282 C Biopsy/excise spinal tumor 63283 C Biopsy/excise spinal tumor 63285 C Biopsy/excise spinal tumor 63286 C Biopsy/excise spinal tumor 63287 C Biopsy/excise spinal tumor 63290 C Biopsy/excise spinal tumor 63300 C Removal of vertebral body 63301 C Removal of vertebral body 63302 C Removal of vertebral body 63303 C Removal of vertebral body 63304 C Removal of vertebral body 63305 C Removal of vertebral body 63306 C Removal of vertebral body 63307 C Removal of vertebral body 63308 C Remove vertebral body add-on 63600 T Remove spinal cord lesion 0220 13.96 $676.88 $326.21 $135.38 63610 T Stimulation of spinal cord 0220 13.96 $676.88 $326.21 $135.38 63615 T Remove lesion of spinal cord 0220 13.96 $676.88 $326.21 $135.38 63650 T Implant neuroelectrodes 0224 15.94 $772.88 $374.61 $154.58 63655 C Implant neuroelectrodes 63660 T Revise/remove neuroelectrode 0224 15.94 $772.88 $374.61 $154.58 63685 T Implant neuroreceiver 0222 25.48 $1,235.45 $780.07 $247.09 63688 T Revise/remove neuroreceiver 0224 15.94 $772.88 $374.61 $154.58 63700 C Repair of spinal herniation 63702 C Repair of spinal herniation 63704 C Repair of spinal herniation 63706 C Repair of spinal herniation 63707 C Repair spinal fluid leakage 63709 C Repair spinal fluid leakage 63710 C Graft repair of spine defect 63740 C Install spinal shunt 63741 C Install spinal shunt 63744 T Revision of spinal shunt 0224 15.94 $772.88 $374.61 $154.58 63746 T Removal of spinal shunt 0223 6.34 $307.41 $153.24 $61.48 64400 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64402 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64405 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64408 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64410 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64412 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64413 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64415 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64417 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64418 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64420 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64421 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64425 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64430 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64435 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64445 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64450 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64470 T Inj paravertebral c/t 0211 3.32 $160.98 $74.78 $32.20 64472 T Inj paravertebral c/t add-on 0211 3.32 $160.98 $74.78 $32.20 64475 T Inj paravertebral l/s 0211 3.32 $160.98 $74.78 $32.20 64476 T Inj paravertebral l/s add-on 0211 3.32 $160.98 $74.78 $32.20 64479 T Inj foramen epidural c/t 0211 3.32 $160.98 $74.78 $32.20 64480 T Inj foramen epidural add-on 0211 3.32 $160.98 $74.78 $32.20 64483 T Inj foramen epidural l/s 0211 3.32 $160.98 $74.78 $32.20 64484 T Inj foramen epidural add-on 0211 3.32 $160.98 $74.78 $32.20 64505 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64508 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64510 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64520 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 64530 T Injection for nerve block 0211 3.32 $160.98 $74.78 $32.20 Start Printed Page 18622 64550 A Apply neurostimulator 64553 T Implant neuroelectrodes 0225 3.43 $166.31 $64.46 $33.26 64555 T Implant neuroelectrodes 0225 3.43 $166.31 $64.46 $33.26 64560 T Implant neuroelectrodes 0225 3.43 $166.31 $64.46 $33.26 64565 T Implant neuroelectrodes 0225 3.43 $166.31 $64.46 $33.26 64573 T Implant neuroelectrodes 0225 3.43 $166.31 $64.46 $33.26 64575 T Implant neuroelectrodes 0225 3.43 $166.31 $64.46 $33.26 64577 T Implant neuroelectrodes 0225 3.43 $166.31 $64.46 $33.26 64580 T Implant neuroelectrodes 0225 3.43 $166.31 $64.46 $33.26 64585 T Revise/remove neuroelectrode 0225 3.43 $166.31 $64.46 $33.26 64590 T Implant neuroreceiver 0222 25.48 $1,235.45 $780.07 $247.09 64595 T Revise/remove neuroreceiver 0225 3.43 $166.31 $64.46 $33.26 64600 T Injection treatment of nerve 0211 3.32 $160.98 $74.78 $32.20 64605 T Injection treatment of nerve 0211 3.32 $160.98 $74.78 $32.20 64610 T Injection treatment of nerve 0211 3.32 $160.98 $74.78 $32.20 64612 T Destroy nerve, face muscle 0211 3.32 $160.98 $74.78 $32.20 64613 T Destroy nerve, spine muscle 0211 3.32 $160.98 $74.78 $32.20 64620 T Injection treatment of nerve 0211 3.32 $160.98 $74.78 $32.20 64622 T Destr paravertebrl nerve l/s 0211 3.32 $160.98 $74.78 $32.20 64623 T Destr paravertebral n add-on 0211 3.32 $160.98 $74.78 $32.20 64626 T Destr paravertebrl nerve c/t 0211 3.32 $160.98 $74.78 $32.20 64627 T Destr paravertebral n add-on 0211 3.32 $160.98 $74.78 $32.20 64630 T Injection treatment of nerve 0211 3.32 $160.98 $74.78 $32.20 64640 T Injection treatment of nerve 0211 3.32 $160.98 $74.78 $32.20 64680 T Injection treatment of nerve 0211 3.32 $160.98 $74.78 $32.20 64702 T Revise finger/toe nerve 0220 13.96 $676.88 $326.21 $135.38 64704 T Revise hand/foot nerve 0220 13.96 $676.88 $326.21 $135.38 64708 T Revise arm/leg nerve 0220 13.96 $676.88 $326.21 $135.38 64712 T Revision of sciatic nerve 0220 13.96 $676.88 $326.21 $135.38 64713 T Revision of arm nerve(s) 0220 13.96 $676.88 $326.21 $135.38 64714 T Revise low back nerve(s) 0220 13.96 $676.88 $326.21 $135.38 64716 T Revision of cranial nerve 0220 13.96 $676.88 $326.21 $135.38 64718 T Revise ulnar nerve at elbow 0220 13.96 $676.88 $326.21 $135.38 64719 T Revise ulnar nerve at wrist 0220 13.96 $676.88 $326.21 $135.38 64721 T Carpal tunnel surgery 0220 13.96 $676.88 $326.21 $135.38 64722 T Relieve pressure on nerve(s) 0220 13.96 $676.88 $326.21 $135.38 64726 T Release foot/toe nerve 0220 13.96 $676.88 $326.21 $135.38 64727 T Internal nerve revision 0220 13.96 $676.88 $326.21 $135.38 64732 T Incision of brow nerve 0220 13.96 $676.88 $326.21 $135.38 64734 T Incision of cheek nerve 0220 13.96 $676.88 $326.21 $135.38 64736 T Incision of chin nerve 0220 13.96 $676.88 $326.21 $135.38 64738 T Incision of jaw nerve 0220 13.96 $676.88 $326.21 $135.38 64740 T Incision of tongue nerve 0220 13.96 $676.88 $326.21 $135.38 64742 T Incision of facial nerve 0220 13.96 $676.88 $326.21 $135.38 64744 T Incise nerve, back of head 0220 13.96 $676.88 $326.21 $135.38 64746 T Incise diaphragm nerve 0220 13.96 $676.88 $326.21 $135.38 64752 C Incision of vagus nerve 64755 C Incision of stomach nerves 64760 C Incision of vagus nerve 64761 T Incision of pelvis nerve 0220 13.96 $676.88 $326.21 $135.38 64763 C Incise hip/thigh nerve 64766 C Incise hip/thigh nerve 64771 T Sever cranial nerve 0220 13.96 $676.88 $326.21 $135.38 64772 T Incision of spinal nerve 0220 13.96 $676.88 $326.21 $135.38 64774 T Remove skin nerve lesion 0220 13.96 $676.88 $326.21 $135.38 64776 T Remove digit nerve lesion 0220 13.96 $676.88 $326.21 $135.38 64778 T Digit nerve surgery add-on 0220 13.96 $676.88 $326.21 $135.38 64782 T Remove limb nerve lesion 0220 13.96 $676.88 $326.21 $135.38 64783 T Limb nerve surgery add-on 0220 13.96 $676.88 $326.21 $135.38 64784 T Remove nerve lesion 0220 13.96 $676.88 $326.21 $135.38 64786 T Remove sciatic nerve lesion 0221 18.36 $890.22 $463.62 $178.04 64787 T Implant nerve end 0220 13.96 $676.88 $326.21 $135.38 64788 T Remove skin nerve lesion 0220 13.96 $676.88 $326.21 $135.38 64790 T Removal of nerve lesion 0220 13.96 $676.88 $326.21 $135.38 64792 T Removal of nerve lesion 0221 18.36 $890.22 $463.62 $178.04 64795 T Biopsy of nerve 0220 13.96 $676.88 $326.21 $135.38 64802 C Remove sympathetic nerves 64804 C Remove sympathetic nerves 64809 C Remove sympathetic nerves 64818 C Remove sympathetic nerves 64820 C Remove sympathetic nerves 64831 T Repair of digit nerve 0221 18.36 $890.22 $463.62 $178.04 64832 T Repair nerve add-on 0221 18.36 $890.22 $463.62 $178.04 Start Printed Page 18623 64834 T Repair of hand or foot nerve 0221 18.36 $890.22 $463.62 $178.04 64835 T Repair of hand or foot nerve 0221 18.36 $890.22 $463.62 $178.04 64836 T Repair of hand or foot nerve 0221 18.36 $890.22 $463.62 $178.04 64837 T Repair nerve add-on 0221 18.36 $890.22 $463.62 $178.04 64840 T Repair of leg nerve 0221 18.36 $890.22 $463.62 $178.04 64856 T Repair/transpose nerve 0221 18.36 $890.22 $463.62 $178.04 64857 T Repair arm/leg nerve 0221 18.36 $890.22 $463.62 $178.04 64858 T Repair sciatic nerve 0221 18.36 $890.22 $463.62 $178.04 64859 T Nerve surgery 0221 18.36 $890.22 $463.62 $178.04 64861 T Repair of arm nerves 0221 18.36 $890.22 $463.62 $178.04 64862 T Repair of low back nerves 0221 18.36 $890.22 $463.62 $178.04 64864 T Repair of facial nerve 0221 18.36 $890.22 $463.62 $178.04 64865 T Repair of facial nerve 0221 18.36 $890.22 $463.62 $178.04 64866 C Fusion of facial/other nerve 64868 C Fusion of facial/other nerve 64870 T Fusion of facial/other nerve 0221 18.36 $890.22 $463.62 $178.04 64872 T Subsequent repair of nerve 0221 18.36 $890.22 $463.62 $178.04 64874 T Repair & revise nerve add-on 0221 18.36 $890.22 $463.62 $178.04 64876 T Repair nerve/shorten bone 0221 18.36 $890.22 $463.62 $178.04 64885 T Nerve graft, head or neck 0221 18.36 $890.22 $463.62 $178.04 64886 T Nerve graft, head or neck 0221 18.36 $890.22 $463.62 $178.04 64890 T Nerve graft, hand or foot 0221 18.36 $890.22 $463.62 $178.04 64891 T Nerve graft, hand or foot 0221 18.36 $890.22 $463.62 $178.04 64892 T Nerve graft, arm or leg 0221 18.36 $890.22 $463.62 $178.04 64893 T Nerve graft, arm or leg 0221 18.36 $890.22 $463.62 $178.04 64895 T Nerve graft, hand or foot 0221 18.36 $890.22 $463.62 $178.04 64896 T Nerve graft, hand or foot 0221 18.36 $890.22 $463.62 $178.04 64897 T Nerve graft, arm or leg 0221 18.36 $890.22 $463.62 $178.04 64898 T Nerve graft, arm or leg 0221 18.36 $890.22 $463.62 $178.04 64901 T Nerve graft add-on 0221 18.36 $890.22 $463.62 $178.04 64902 T Nerve graft add-on 0221 18.36 $890.22 $463.62 $178.04 64905 T Nerve pedicle transfer 0221 18.36 $890.22 $463.62 $178.04 64907 T Nerve pedicle transfer 0221 18.36 $890.22 $463.62 $178.04 64999 T Nervous system surgery 0211 3.32 $160.98 $74.78 $32.20 65091 T Revise eye 0242 23.70 $1,149.14 $597.36 $229.83 65093 T Revise eye with implant 0241 16.60 $804.89 $384.47 $160.98 65101 T Removal of eye 0242 23.70 $1,149.14 $597.36 $229.83 65103 T Remove eye/insert implant 0242 23.70 $1,149.14 $597.36 $229.83 65105 T Remove eye/attach implant 0242 23.70 $1,149.14 $597.36 $229.83 65110 T Removal of eye 0242 23.70 $1,149.14 $597.36 $229.83 65112 T Remove eye/revise socket 0242 23.70 $1,149.14 $597.36 $229.83 65114 T Remove eye/revise socket 0242 23.70 $1,149.14 $597.36 $229.83 65125 T Revise ocular implant 0240 13.47 $653.12 $315.31 $130.62 65130 T Insert ocular implant 0241 16.60 $804.89 $384.47 $160.98 65135 T Insert ocular implant 0241 16.60 $804.89 $384.47 $160.98 65140 T Attach ocular implant 0242 23.70 $1,149.14 $597.36 $229.83 65150 T Revise ocular implant 0241 16.60 $804.89 $384.47 $160.98 65155 T Reinsert ocular implant 0242 23.70 $1,149.14 $597.36 $229.83 65175 T Removal of ocular implant 0240 13.47 $653.12 $315.31 $130.62 65205 S Remove foreign body from eye 0231 2.64 $128.01 $59.87 $25.60 65210 S Remove foreign body from eye 0231 2.64 $128.01 $59.87 $25.60 65220 S Remove foreign body from eye 0231 2.64 $128.01 $59.87 $25.60 65222 S Remove foreign body from eye 0231 2.64 $128.01 $59.87 $25.60 65235 T Remove foreign body from eye 0232 6.04 $292.86 $134.66 $58.57 65260 T Remove foreign body from eye 0237 33.96 $1,646.62 $852.68 $329.32 65265 T Remove foreign body from eye 0237 33.96 $1,646.62 $852.68 $329.32 65270 T Repair of eye wound 0240 13.47 $653.12 $315.31 $130.62 65272 T Repair of eye wound 0232 6.04 $292.86 $134.66 $58.57 65273 C Repair of eye wound 65275 T Repair of eye wound 0233 13.79 $668.64 $331.60 $133.73 65280 T Repair of eye wound 0233 13.79 $668.64 $331.60 $133.73 65285 T Repair of eye wound 0234 20.64 $1,000.77 $502.16 $200.15 65286 T Repair of eye wound 0232 6.04 $292.86 $134.66 $58.57 65290 T Repair of eye socket wound 0243 17.99 $872.28 $431.39 $174.46 65400 T Removal of eye lesion 0232 6.04 $292.86 $134.66 $58.57 65410 T Biopsy of cornea 0233 13.79 $668.64 $331.60 $133.73 65420 T Removal of eye lesion 0233 13.79 $668.64 $331.60 $133.73 65426 T Removal of eye lesion 0233 13.79 $668.64 $331.60 $133.73 65430 S Corneal smear 0231 2.64 $128.01 $59.87 $25.60 65435 T Curette/treat cornea 0239 6.26 $303.53 $123.42 $60.71 65436 T Curette/treat cornea 0232 6.04 $292.86 $134.66 $58.57 65450 T Treatment of corneal lesion 0232 6.04 $292.86 $134.66 $58.57 65600 T Revision of cornea 0240 13.47 $653.12 $315.31 $130.62 Start Printed Page 18624 65710 T Corneal transplant 0244 32.88 $1,594.26 $851.42 $318.85 65730 T Corneal transplant 0244 32.88 $1,594.26 $851.42 $318.85 65750 T Corneal transplant 0244 32.88 $1,594.26 $851.42 $318.85 65755 T Corneal transplant 0244 32.88 $1,594.26 $851.42 $318.85 65760 E Revision of cornea 65765 E Revision of cornea 65767 E Corneal tissue transplant 65770 T Revise cornea with implant 0244 32.88 $1,594.26 $851.42 $318.85 65771 E Radial keratotomy 65772 T Correction of astigmatism 0232 6.04 $292.86 $134.66 $58.57 65775 T Correction of astigmatism 0233 13.79 $668.64 $331.60 $133.73 65800 T Drainage of eye 0232 6.04 $292.86 $134.66 $58.57 65805 T Drainage of eye 0233 13.79 $668.64 $331.60 $133.73 65810 T Drainage of eye 0233 13.79 $668.64 $331.60 $133.73 65815 T Drainage of eye 0233 13.79 $668.64 $331.60 $133.73 65820 T Relieve inner eye pressure 0232 6.04 $292.86 $134.66 $58.57 65850 T Incision of eye 0234 20.64 $1,000.77 $502.16 $200.15 65855 T Laser surgery of eye 0247 4.89 $237.10 $112.86 $47.42 65860 T Incise inner eye adhesions 0247 4.89 $237.10 $112.86 $47.42 65865 T Incise inner eye adhesions 0233 13.79 $668.64 $331.60 $133.73 65870 T Incise inner eye adhesions 0233 13.79 $668.64 $331.60 $133.73 65875 T Incise inner eye adhesions 0233 13.79 $668.64 $331.60 $133.73 65880 T Incise inner eye adhesions 0232 6.04 $292.86 $134.66 $58.57 65900 T Remove eye lesion 0232 6.04 $292.86 $134.66 $58.57 65920 T Remove implant from eye 0233 13.79 $668.64 $331.60 $133.73 65930 T Remove blood clot from eye 0233 13.79 $668.64 $331.60 $133.73 66020 T Injection treatment of eye 0232 6.04 $292.86 $134.66 $58.57 66030 T Injection treatment of eye 0232 6.04 $292.86 $134.66 $58.57 66130 T Remove eye lesion 0233 13.79 $668.64 $331.60 $133.73 66150 T Glaucoma surgery 0233 13.79 $668.64 $331.60 $133.73 66155 T Glaucoma surgery 0234 20.64 $1,000.77 $502.16 $200.15 66160 T Glaucoma surgery 0234 20.64 $1,000.77 $502.16 $200.15 66165 T Glaucoma surgery 0234 20.64 $1,000.77 $502.16 $200.15 66170 T Glaucoma surgery 0234 20.64 $1,000.77 $502.16 $200.15 66172 T Incision of eye 0234 20.64 $1,000.77 $502.16 $200.15 66180 T Implant eye shunt 0234 20.64 $1,000.77 $502.16 $200.15 66185 T Revise eye shunt 0234 20.64 $1,000.77 $502.16 $200.15 66220 T Repair eye lesion 0236 6.70 $324.86 $147.96 $64.97 66225 T Repair/graft eye lesion 0234 20.64 $1,000.77 $502.16 $200.15 66250 T Follow-up surgery of eye 0233 13.79 $668.64 $331.60 $133.73 66500 T Incision of iris 0232 6.04 $292.86 $134.66 $58.57 66505 T Incision of iris 0232 6.04 $292.86 $134.66 $58.57 66600 T Remove iris and lesion 0233 13.79 $668.64 $331.60 $133.73 66605 T Removal of iris 0233 13.79 $668.64 $331.60 $133.73 66625 T Removal of iris 0232 6.04 $292.86 $134.66 $58.57 66630 T Removal of iris 0233 13.79 $668.64 $331.60 $133.73 66635 T Removal of iris 0233 13.79 $668.64 $331.60 $133.73 66680 T Repair iris & ciliary body 0233 13.79 $668.64 $331.60 $133.73 66682 T Repair iris & ciliary body 0233 13.79 $668.64 $331.60 $133.73 66700 T Destruction, ciliary body 0232 6.04 $292.86 $134.66 $58.57 66710 T Destruction, ciliary body 0232 6.04 $292.86 $134.66 $58.57 66720 T Destruction, ciliary body 0232 6.04 $292.86 $134.66 $58.57 66740 T Destruction, ciliary body 0233 13.79 $668.64 $331.60 $133.73 66761 T Revision of iris 0247 4.89 $237.10 $112.86 $47.42 66762 T Revision of iris 0247 4.89 $237.10 $112.86 $47.42 66770 T Removal of inner eye lesion 0247 4.89 $237.10 $112.86 $47.42 66820 T Incision, secondary cataract 0232 6.04 $292.86 $134.66 $58.57 66821 T After cataract laser surgery 0247 4.89 $237.10 $112.86 $47.42 66825 T Reposition intraocular lens 0233 13.79 $668.64 $331.60 $133.73 66830 T Removal of lens lesion 0232 6.04 $292.86 $134.66 $58.57 66840 T Removal of lens material 0245 26.55 $1,287.33 $623.85 $257.47 66850 T Removal of lens material 0245 26.55 $1,287.33 $623.85 $257.47 66852 T Removal of lens material 0245 26.55 $1,287.33 $623.85 $257.47 66920 T Extraction of lens 0245 26.55 $1,287.33 $623.85 $257.47 66930 T Extraction of lens 0245 26.55 $1,287.33 $623.85 $257.47 66940 T Extraction of lens 0245 26.55 $1,287.33 $623.85 $257.47 66983 T Remove cataract/insert lens 0246 26.55 $1,287.33 $623.85 $257.47 66984 T Remove cataract/insert lens 0246 26.55 $1,287.33 $623.85 $257.47 66985 T Insert lens prosthesis 0246 26.55 $1,287.33 $623.85 $257.47 66986 T Exchange lens prosthesis 0246 26.55 $1,287.33 $623.85 $257.47 66999 T Eye surgery procedure 0247 4.89 $237.10 $112.86 $47.42 67005 T Partial removal of eye fluid 0237 33.96 $1,646.62 $852.68 $329.32 67010 T Partial removal of eye fluid 0237 33.96 $1,646.62 $852.68 $329.32 Start Printed Page 18625 67015 T Release of eye fluid 0237 33.96 $1,646.62 $852.68 $329.32 67025 T Replace eye fluid 0237 33.96 $1,646.62 $852.68 $329.32 67027 T Implant eye drug system 0237 33.96 $1,646.62 $852.68 $329.32 67028 T Injection eye drug 0236 6.70 $324.86 $147.96 $64.97 67030 T Incise inner eye strands 0236 6.70 $324.86 $147.96 $64.97 67031 T Laser surgery, eye strands 0247 4.89 $237.10 $112.86 $47.42 67036 T Removal of inner eye fluid 0237 33.96 $1,646.62 $852.68 $329.32 67038 T Strip retinal membrane 0237 33.96 $1,646.62 $852.68 $329.32 67039 T Laser treatment of retina 0237 33.96 $1,646.62 $852.68 $329.32 67040 T Laser treatment of retina 0237 33.96 $1,646.62 $852.68 $329.32 67101 T Repair detached retina 0236 6.70 $324.86 $147.96 $64.97 67105 T Repair detached retina 0248 4.19 $203.16 $94.05 $40.63 67107 T Repair detached retina 0237 33.96 $1,646.62 $852.68 $329.32 67108 T Repair detached retina 0237 33.96 $1,646.62 $852.68 $329.32 67110 T Repair detached retina 0236 6.70 $324.86 $147.96 $64.97 67112 T Rerepair detached retina 0237 33.96 $1,646.62 $852.68 $329.32 67115 T Release encircling material 0236 6.70 $324.86 $147.96 $64.97 67120 T Remove eye implant material 0236 6.70 $324.86 $147.96 $64.97 67121 T Remove eye implant material 0237 33.96 $1,646.62 $852.68 $329.32 67141 T Treatment of retina 0235 2.94 $142.55 $78.91 $28.51 67145 T Treatment of retina 0248 4.19 $203.16 $94.05 $40.63 67208 T Treatment of retinal lesion 0235 2.94 $142.55 $78.91 $28.51 67210 T Treatment of retinal lesion 0248 4.19 $203.16 $94.05 $40.63 67218 T Treatment of retinal lesion 0237 33.96 $1,646.62 $852.68 $329.32 67220 T Treatment of choroid lesion 0237 33.96 $1,646.62 $852.68 $329.32 67227 T Treatment of retinal lesion 0235 2.94 $142.55 $78.91 $28.51 67228 T Treatment of retinal lesion 0248 4.19 $203.16 $94.05 $40.63 67250 T Reinforce eye wall 0240 13.47 $653.12 $315.31 $130.62 67255 T Reinforce/graft eye wall 0237 33.96 $1,646.62 $852.68 $329.32 67299 T Eye surgery procedure 0248 4.19 $203.16 $94.05 $40.63 67311 T Revise eye muscle 0243 17.99 $872.28 $431.39 $174.46 67312 T Revise two eye muscles 0243 17.99 $872.28 $431.39 $174.46 67314 T Revise eye muscle 0243 17.99 $872.28 $431.39 $174.46 67316 T Revise two eye muscles 0243 17.99 $872.28 $431.39 $174.46 67318 T Revise eye muscle(s) 0243 17.99 $872.28 $431.39 $174.46 67320 T Revise eye muscle(s) add-on 0243 17.99 $872.28 $431.39 $174.46 67331 T Eye surgery follow-up add-on 0243 17.99 $872.28 $431.39 $174.46 67332 T Rerevise eye muscles add-on 0243 17.99 $872.28 $431.39 $174.46 67334 T Revise eye muscle w/suture 0243 17.99 $872.28 $431.39 $174.46 67335 T Eye suture during surgery 0243 17.99 $872.28 $431.39 $174.46 67340 T Revise eye muscle add-on 0243 17.99 $872.28 $431.39 $174.46 67343 T Release eye tissue 0243 17.99 $872.28 $431.39 $174.46 67345 T Destroy nerve of eye muscle 0238 2.80 $135.76 $58.96 $27.15 67350 S Biopsy eye muscle 0231 2.64 $128.01 $59.87 $25.60 67399 T Eye muscle surgery procedure 0243 17.99 $872.28 $431.39 $174.46 67400 T Explore/biopsy eye socket 0241 16.60 $804.89 $384.47 $160.98 67405 T Explore/drain eye socket 0241 16.60 $804.89 $384.47 $160.98 67412 T Explore/treat eye socket 0241 16.60 $804.89 $384.47 $160.98 67413 T Explore/treat eye socket 0241 16.60 $804.89 $384.47 $160.98 67414 T Explr/decompress eye socket 0242 23.70 $1,149.14 $597.36 $229.83 67415 T Aspiration, orbital contents 0239 6.26 $303.53 $123.42 $60.71 67420 T Explore/treat eye socket 0242 23.70 $1,149.14 $597.36 $229.83 67430 T Explore/treat eye socket 0242 23.70 $1,149.14 $597.36 $229.83 67440 T Explore/drain eye socket 0242 23.70 $1,149.14 $597.36 $229.83 67445 T Explr/decompress eye socket 0242 23.70 $1,149.14 $597.36 $229.83 67450 T Explore/biopsy eye socket 0242 23.70 $1,149.14 $597.36 $229.83 67500 S Inject/treat eye socket 0231 2.64 $128.01 $59.87 $25.60 67505 T Inject/treat eye socket 0238 2.80 $135.76 $58.96 $27.15 67515 T Inject/treat eye socket 0239 6.26 $303.53 $123.42 $60.71 67550 T Insert eye socket implant 0242 23.70 $1,149.14 $597.36 $229.83 67560 T Revise eye socket implant 0241 16.60 $804.89 $384.47 $160.98 67570 T Decompress optic nerve 0242 23.70 $1,149.14 $597.36 $229.83 67599 T Orbit surgery procedure 0239 6.26 $303.53 $123.42 $60.71 67700 T Drainage of eyelid abscess 0238 2.80 $135.76 $58.96 $27.15 67710 T Incision of eyelid 0239 6.26 $303.53 $123.42 $60.71 67715 T Incision of eyelid fold 0240 13.47 $653.12 $315.31 $130.62 67800 T Remove eyelid lesion 0238 2.80 $135.76 $58.96 $27.15 67801 T Remove eyelid lesions 0239 6.26 $303.53 $123.42 $60.71 67805 T Remove eyelid lesions 0238 2.80 $135.76 $58.96 $27.15 67808 T Remove eyelid lesion(s) 0240 13.47 $653.12 $315.31 $130.62 67810 T Biopsy of eyelid 0238 2.80 $135.76 $58.96 $27.15 67820 T Revise eyelashes 0238 2.80 $135.76 $58.96 $27.15 67825 T Revise eyelashes 0238 2.80 $135.76 $58.96 $27.15 Start Printed Page 18626 67830 T Revise eyelashes 0239 6.26 $303.53 $123.42 $60.71 67835 T Revise eyelashes 0240 13.47 $653.12 $315.31 $130.62 67840 T Remove eyelid lesion 0239 6.26 $303.53 $123.42 $60.71 67850 T Treat eyelid lesion 0239 6.26 $303.53 $123.42 $60.71 67875 T Closure of eyelid by suture 0239 6.26 $303.53 $123.42 $60.71 67880 T Revision of eyelid 0232 6.04 $292.86 $134.66 $58.57 67882 T Revision of eyelid 0240 13.47 $653.12 $315.31 $130.62 67900 T Repair brow defect 0240 13.47 $653.12 $315.31 $130.62 67901 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67902 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67903 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67904 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67906 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67908 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67909 T Revise eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67911 T Revise eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67914 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67915 T Repair eyelid defect 0239 6.26 $303.53 $123.42 $60.71 67916 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67917 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67921 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67922 T Repair eyelid defect 0239 6.26 $303.53 $123.42 $60.71 67923 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67924 T Repair eyelid defect 0240 13.47 $653.12 $315.31 $130.62 67930 T Repair eyelid wound 0240 13.47 $653.12 $315.31 $130.62 67935 T Repair eyelid wound 0240 13.47 $653.12 $315.31 $130.62 67938 T Remove eyelid foreign body 0238 2.80 $135.76 $58.96 $27.15 67950 T Revision of eyelid 0240 13.47 $653.12 $315.31 $130.62 67961 T Revision of eyelid 0240 13.47 $653.12 $315.31 $130.62 67966 T Revision of eyelid 0240 13.47 $653.12 $315.31 $130.62 67971 T Reconstruction of eyelid 0241 16.60 $804.89 $384.47 $160.98 67973 T Reconstruction of eyelid 0241 16.60 $804.89 $384.47 $160.98 67974 T Reconstruction of eyelid 0241 16.60 $804.89 $384.47 $160.98 67975 T Reconstruction of eyelid 0240 13.47 $653.12 $315.31 $130.62 67999 T Revision of eyelid 0240 13.47 $653.12 $315.31 $130.62 68020 T Incise/drain eyelid lining 0240 13.47 $653.12 $315.31 $130.62 68040 T Treatment of eyelid lesions 0239 6.26 $303.53 $123.42 $60.71 68100 T Biopsy of eyelid lining 0232 6.04 $292.86 $134.66 $58.57 68110 S Remove eyelid lining lesion 0231 2.64 $128.01 $59.87 $25.60 68115 T Remove eyelid lining lesion 0239 6.26 $303.53 $123.42 $60.71 68130 T Remove eyelid lining lesion 0233 13.79 $668.64 $331.60 $133.73 68135 T Remove eyelid lining lesion 0239 6.26 $303.53 $123.42 $60.71 68200 S Treat eyelid by injection 0230 0.98 $47.52 $22.48 $9.50 68320 T Revise/graft eyelid lining 0240 13.47 $653.12 $315.31 $130.62 68325 T Revise/graft eyelid lining 0242 23.70 $1,149.14 $597.36 $229.83 68326 T Revise/graft eyelid lining 0241 16.60 $804.89 $384.47 $160.98 68328 T Revise/graft eyelid lining 0241 16.60 $804.89 $384.47 $160.98 68330 T Revise eyelid lining 0233 13.79 $668.64 $331.60 $133.73 68335 T Revise/graft eyelid lining 0241 16.60 $804.89 $384.47 $160.98 68340 T Separate eyelid adhesions 0240 13.47 $653.12 $315.31 $130.62 68360 T Revise eyelid lining 0234 20.64 $1,000.77 $502.16 $200.15 68362 T Revise eyelid lining 0234 20.64 $1,000.77 $502.16 $200.15 68399 T Eyelid lining surgery 0239 6.26 $303.53 $123.42 $60.71 68400 T Incise/drain tear gland 0238 2.80 $135.76 $58.96 $27.15 68420 T Incise/drain tear sac 0240 13.47 $653.12 $315.31 $130.62 68440 T Incise tear duct opening 0238 2.80 $135.76 $58.96 $27.15 68500 T Removal of tear gland 0241 16.60 $804.89 $384.47 $160.98 68505 T Partial removal, tear gland 0241 16.60 $804.89 $384.47 $160.98 68510 T Biopsy of tear gland 0240 13.47 $653.12 $315.31 $130.62 68520 T Removal of tear sac 0241 16.60 $804.89 $384.47 $160.98 68525 T Biopsy of tear sac 0240 13.47 $653.12 $315.31 $130.62 68530 T Clearance of tear duct 0240 13.47 $653.12 $315.31 $130.62 68540 T Remove tear gland lesion 0241 16.60 $804.89 $384.47 $160.98 68550 T Remove tear gland lesion 0242 23.70 $1,149.14 $597.36 $229.83 68700 T Repair tear ducts 0241 16.60 $804.89 $384.47 $160.98 68705 T Revise tear duct opening 0238 2.80 $135.76 $58.96 $27.15 68720 T Create tear sac drain 0242 23.70 $1,149.14 $597.36 $229.83 68745 T Create tear duct drain 0241 16.60 $804.89 $384.47 $160.98 68750 T Create tear duct drain 0242 23.70 $1,149.14 $597.36 $229.83 68760 T Close tear duct opening 0238 2.80 $135.76 $58.96 $27.15 68761 S Close tear duct opening 0231 2.64 $128.01 $59.87 $25.60 68770 T Close tear system fistula 0240 13.47 $653.12 $315.31 $130.62 68801 S Dilate tear duct opening 0231 2.64 $128.01 $59.87 $25.60 Start Printed Page 18627 68810 S Probe nasolacrimal duct 0231 2.64 $128.01 $59.87 $25.60 68811 T Probe nasolacrimal duct 0240 13.47 $653.12 $315.31 $130.62 68815 T Probe nasolacrimal duct 0240 13.47 $653.12 $315.31 $130.62 68840 S Explore/irrigate tear ducts 0231 2.64 $128.01 $59.87 $25.60 68850 N Injection for tear sac x-ray 68899 S Tear duct system surgery 0231 2.64 $128.01 $59.87 $25.60 69000 T Drain external ear lesion 0006 2.00 $96.97 $33.95 $19.39 69005 T Drain external ear lesion 0007 3.68 $178.43 $72.03 $35.69 69020 T Drain outer ear canal lesion 0006 2.00 $96.97 $33.95 $19.39 69090 E Pierce earlobes 69100 T Biopsy of external ear 0019 4.00 $193.95 $78.91 $38.79 69105 T Biopsy of external ear canal 0253 12.02 $582.81 $284.00 $116.56 69110 T Remove external ear, partial 0020 6.51 $315.65 $130.53 $63.13 69120 T Removal of external ear 0253 12.02 $582.81 $284.00 $116.56 69140 T Remove ear canal lesion(s) 0254 12.45 $603.66 $272.41 $120.73 69145 T Remove ear canal lesion(s) 0020 6.51 $315.65 $130.53 $63.13 69150 C Extensive ear canal surgery 69155 C Extensive ear/neck surgery 69200 X Clear outer ear canal 0340 1.04 $50.43 $12.85 $10.09 69205 T Clear outer ear canal 0022 12.49 $605.60 $292.94 $121.12 69210 X Remove impacted ear wax 0340 1.04 $50.43 $12.85 $10.09 69220 T Clean out mastoid cavity 0012 0.53 $25.70 $9.18 $5.14 69222 T Clean out mastoid cavity 0253 12.02 $582.81 $284.00 $116.56 69300 T Revise external ear 0254 12.45 $603.66 $272.41 $120.73 69310 T Rebuild outer ear canal 0256 25.40 $1,231.57 $623.05 $246.31 69320 T Rebuild outer ear canal 0256 25.40 $1,231.57 $623.05 $246.31 69399 T Outer ear surgery procedure 0252 5.18 $251.16 $114.24 $50.23 69400 T Inflate middle ear canal 0251 1.68 $81.46 $27.99 $16.29 69401 N Inflate middle ear canal 69405 T Catheterize middle ear canal 0252 5.18 $251.16 $114.24 $50.23 69410 T Inset middle ear (baffle) 0252 5.18 $251.16 $114.24 $50.23 69420 T Incision of eardrum 0252 5.18 $251.16 $114.24 $50.23 69421 T Incision of eardrum 0253 12.02 $582.81 $284.00 $116.56 69424 T Remove ventilating tube 0252 5.18 $251.16 $114.24 $50.23 69433 T Create eardrum opening 0252 5.18 $251.16 $114.24 $50.23 69436 T Create eardrum opening 0253 12.02 $582.81 $284.00 $116.56 69440 T Exploration of middle ear 0253 12.02 $582.81 $284.00 $116.56 69450 T Eardrum revision 0256 25.40 $1,231.57 $623.05 $246.31 69501 T Mastoidectomy 0256 25.40 $1,231.57 $623.05 $246.31 69502 C Mastoidectomy 69505 T Remove mastoid structures 0256 25.40 $1,231.57 $623.05 $246.31 69511 T Extensive mastoid surgery 0256 25.40 $1,231.57 $623.05 $246.31 69530 T Extensive mastoid surgery 0256 25.40 $1,231.57 $623.05 $246.31 69535 C Remove part of temporal bone 69540 T Remove ear lesion 0253 12.02 $582.81 $284.00 $116.56 69550 T Remove ear lesion 0256 25.40 $1,231.57 $623.05 $246.31 69552 T Remove ear lesion 0256 25.40 $1,231.57 $623.05 $246.31 69554 C Remove ear lesion 69601 T Mastoid surgery revision 0256 25.40 $1,231.57 $623.05 $246.31 69602 T Mastoid surgery revision 0256 25.40 $1,231.57 $623.05 $246.31 69603 T Mastoid surgery revision 0256 25.40 $1,231.57 $623.05 $246.31 69604 T Mastoid surgery revision 0256 25.40 $1,231.57 $623.05 $246.31 69605 T Mastoid surgery revision 0256 25.40 $1,231.57 $623.05 $246.31 69610 T Repair of eardrum 0253 12.02 $582.81 $284.00 $116.56 69620 T Repair of eardrum 0253 12.02 $582.81 $284.00 $116.56 69631 T Repair eardrum structures 0256 25.40 $1,231.57 $623.05 $246.31 69632 T Rebuild eardrum structures 0256 25.40 $1,231.57 $623.05 $246.31 69633 T Rebuild eardrum structures 0256 25.40 $1,231.57 $623.05 $246.31 69635 T Repair eardrum structures 0256 25.40 $1,231.57 $623.05 $246.31 69636 T Rebuild eardrum structures 0256 25.40 $1,231.57 $623.05 $246.31 69637 T Rebuild eardrum structures 0256 25.40 $1,231.57 $623.05 $246.31 69641 T Revise middle ear & mastoid 0256 25.40 $1,231.57 $623.05 $246.31 69642 T Revise middle ear & mastoid 0256 25.40 $1,231.57 $623.05 $246.31 69643 T Revise middle ear & mastoid 0256 25.40 $1,231.57 $623.05 $246.31 69644 T Revise middle ear & mastoid 0256 25.40 $1,231.57 $623.05 $246.31 69645 T Revise middle ear & mastoid 0256 25.40 $1,231.57 $623.05 $246.31 69646 T Revise middle ear & mastoid 0256 25.40 $1,231.57 $623.05 $246.31 69650 T Release middle ear bone 0254 12.45 $603.66 $272.41 $120.73 69660 T Revise middle ear bone 0256 25.40 $1,231.57 $623.05 $246.31 69661 T Revise middle ear bone 0256 25.40 $1,231.57 $623.05 $246.31 69662 T Revise middle ear bone 0256 25.40 $1,231.57 $623.05 $246.31 69666 T Repair middle ear structures 0256 25.40 $1,231.57 $623.05 $246.31 69667 T Repair middle ear structures 0256 25.40 $1,231.57 $623.05 $246.31 Start Printed Page 18628 69670 T Remove mastoid air cells 0256 25.40 $1,231.57 $623.05 $246.31 69676 T Remove middle ear nerve 0256 25.40 $1,231.57 $623.05 $246.31 69700 T Close mastoid fistula 0256 25.40 $1,231.57 $623.05 $246.31 69710 E Implant/replace hearing aid 69711 T Remove/repair hearing aid 0256 25.40 $1,231.57 $623.05 $246.31 69720 T Release facial nerve 0256 25.40 $1,231.57 $623.05 $246.31 69725 T Release facial nerve 0256 25.40 $1,231.57 $623.05 $246.31 69740 T Repair facial nerve 0256 25.40 $1,231.57 $623.05 $246.31 69745 T Repair facial nerve 0256 25.40 $1,231.57 $623.05 $246.31 69799 T Middle ear surgery procedure 0253 12.02 $582.81 $284.00 $116.56 69801 T Incise inner ear 0256 25.40 $1,231.57 $623.05 $246.31 69802 T Incise inner ear 0256 25.40 $1,231.57 $623.05 $246.31 69805 T Explore inner ear 0256 25.40 $1,231.57 $623.05 $246.31 69806 T Explore inner ear 0256 25.40 $1,231.57 $623.05 $246.31 69820 T Establish inner ear window 0256 25.40 $1,231.57 $623.05 $246.31 69840 T Revise inner ear window 0256 25.40 $1,231.57 $623.05 $246.31 69905 T Remove inner ear 0256 25.40 $1,231.57 $623.05 $246.31 69910 T Remove inner ear & mastoid 0256 25.40 $1,231.57 $623.05 $246.31 69915 T Incise inner ear nerve 0256 25.40 $1,231.57 $623.05 $246.31 69930 T Implant cochlear device 0257 115.31 $5,591.04 $3,498.58 $1,118.21 69949 T Inner ear surgery procedure 0253 12.02 $582.81 $284.00 $116.56 69950 C Incise inner ear nerve 69955 T Release facial nerve 0256 25.40 $1,231.57 $623.05 $246.31 69960 T Release inner ear canal 0256 25.40 $1,231.57 $623.05 $246.31 69970 C Remove inner ear lesion 69979 T Temporal bone surgery 0252 5.18 $251.16 $114.24 $50.23 69990 N Microsurgery add-on 70010 S Contrast x-ray of brain 0274 4.83 $234.19 $128.12 $46.84 70015 S Contrast x-ray of brain 0274 4.83 $234.19 $128.12 $46.84 70030 X X-ray eye for foreign body 0260 0.79 $38.30 $22.02 $7.66 70100 X X-ray exam of jaw 0260 0.79 $38.30 $22.02 $7.66 70110 X X-ray exam of jaw 0260 0.79 $38.30 $22.02 $7.66 70120 X X-ray exam of mastoids 0260 0.79 $38.30 $22.02 $7.66 70130 X X-ray exam of mastoids 0260 0.79 $38.30 $22.02 $7.66 70134 X X-ray exam of middle ear 0261 1.38 $66.91 $38.77 $13.38 70140 X X-ray exam of facial bones 0260 0.79 $38.30 $22.02 $7.66 70150 X X-ray exam of facial bones 0260 0.79 $38.30 $22.02 $7.66 70160 X X-ray exam of nasal bones 0260 0.79 $38.30 $22.02 $7.66 70170 X X-ray exam of tear duct 0263 1.68 $81.46 $45.88 $16.29 70190 X X-ray exam of eye sockets 0260 0.79 $38.30 $22.02 $7.66 70200 X X-ray exam of eye sockets 0260 0.79 $38.30 $22.02 $7.66 70210 X X-ray exam of sinuses 0260 0.79 $38.30 $22.02 $7.66 70220 X X-ray exam of sinuses 0260 0.79 $38.30 $22.02 $7.66 70240 X X-ray exam, pituitary saddle 0260 0.79 $38.30 $22.02 $7.66 70250 X X-ray exam of skull 0260 0.79 $38.30 $22.02 $7.66 70260 X X-ray exam of skull 0261 1.38 $66.91 $38.77 $13.38 70300 X X-ray exam of teeth 0262 0.40 $19.39 $10.90 $3.88 70310 X X-ray exam of teeth 0262 0.40 $19.39 $10.90 $3.88 70320 X Full mouth x-ray of teeth 0262 0.40 $19.39 $10.90 $3.88 70328 X X-ray exam of jaw joint 0260 0.79 $38.30 $22.02 $7.66 70330 X X-ray exam of jaw joints 0260 0.79 $38.30 $22.02 $7.66 70332 S X-ray exam of jaw joint 0275 2.74 $132.85 $72.26 $26.57 70336 S Magnetic image, jaw joint 0284 8.02 $388.87 $257.39 $77.77 70350 X X-ray head for orthodontia 0260 0.79 $38.30 $22.02 $7.66 70355 X Panoramic x-ray of jaws 0260 0.79 $38.30 $22.02 $7.66 70360 X X-ray exam of neck 0260 0.79 $38.30 $22.02 $7.66 70370 X Throat x-ray & fluoroscopy 0273 2.49 $120.73 $61.02 $24.15 70371 X Speech evaluation, complex 0272 1.40 $67.88 $39.00 $13.58 70373 X Contrast x-ray of larynx 0263 1.68 $81.46 $45.88 $16.29 70380 X X-ray exam of salivary gland 0260 0.79 $38.30 $22.02 $7.66 70390 X X-ray exam of salivary duct 0263 1.68 $81.46 $45.88 $16.29 70450 S CAT scan of head or brain 0283 4.89 $237.10 $179.39 $47.42 70460 S Contrast CAT scan of head 0283 4.89 $237.10 $179.39 $47.42 70470 S Contrast CAT scans of head 0283 4.89 $237.10 $179.39 $47.42 70480 S CAT scan of skull 0283 4.89 $237.10 $179.39 $47.42 70481 S Contrast CAT scan of skull 0283 4.89 $237.10 $179.39 $47.42 70482 S Contrast CAT scans of skull 0283 4.89 $237.10 $179.39 $47.42 70486 S Cat scan of face/jaw 0282 2.38 $115.40 $94.51 $23.08 70487 S Contrast CAT scan, face/jaw 0283 4.89 $237.10 $179.39 $47.42 70488 S Contrast cat scans, face/jaw 0283 4.89 $237.10 $179.39 $47.42 70490 S CAT scan of neck tissue 0283 4.89 $237.10 $179.39 $47.42 70491 S Contrast CAT of neck tissue 0283 4.89 $237.10 $179.39 $47.42 70492 S Contrast CAT of neck tissue 0283 4.89 $237.10 $179.39 $47.42 Start Printed Page 18629 70540 S Magnetic image, face/neck 0284 8.02 $388.87 $257.39 $77.77 70541 S Magnetic image, head (MRA) 0284 8.02 $388.87 $257.39 $77.77 70551 S Magnetic image, brain (MRI) 0284 8.02 $388.87 $257.39 $77.77 70552 S Magnetic image, brain (MRI) 0284 8.02 $388.87 $257.39 $77.77 70553 S Magnetic image, brain (mri) 0284 8.02 $388.87 $257.39 $77.77 71010 X Chest x-ray 0260 0.79 $38.30 $22.02 $7.66 71015 X Chest x-ray 0260 0.79 $38.30 $22.02 $7.66 71020 X Chest x-ray 0260 0.79 $38.30 $22.02 $7.66 71021 X Chest x-ray 0260 0.79 $38.30 $22.02 $7.66 71022 X Chest x-ray 0260 0.79 $38.30 $22.02 $7.66 71023 X Chest x-ray and fluoroscopy 0272 1.40 $67.88 $39.00 $13.58 71030 X Chest x-ray 0260 0.79 $38.30 $22.02 $7.66 71034 X Chest x-ray and fluoroscopy 0272 1.40 $67.88 $39.00 $13.58 71035 X Chest x-ray 0260 0.79 $38.30 $22.02 $7.66 71036 X X-ray guidance for biopsy 0273 2.49 $120.73 $61.02 $24.15 71040 X Contrast x-ray of bronchi 0263 1.68 $81.46 $45.88 $16.29 71060 X Contrast x-ray of bronchi 0263 1.68 $81.46 $45.88 $16.29 71090 X X-ray & pacemaker insertion 0273 2.49 $120.73 $61.02 $24.15 71100 X X-ray exam of ribs 0260 0.79 $38.30 $22.02 $7.66 71101 X X-ray exam of ribs/chest 0260 0.79 $38.30 $22.02 $7.66 71110 X X-ray exam of ribs 0260 0.79 $38.30 $22.02 $7.66 71111 X X-ray exam of ribs/chest 0261 1.38 $66.91 $38.77 $13.38 71120 X X-ray exam of breastbone 0260 0.79 $38.30 $22.02 $7.66 71130 X X-ray exam of breastbone 0260 0.79 $38.30 $22.02 $7.66 71250 S Cat scan of chest 0283 4.89 $237.10 $179.39 $47.42 71260 S Contrast CAT scan of chest 0283 4.89 $237.10 $179.39 $47.42 71270 S Contrast CAT scans of chest 0283 4.89 $237.10 $179.39 $47.42 71550 S Magnetic image, chest (mri) 0284 8.02 $388.87 $257.39 $77.77 71555 E Magnetic image, chest (mra) 72010 X X-ray exam of spine 0261 1.38 $66.91 $38.77 $13.38 72020 X X-ray exam of spine 0260 0.79 $38.30 $22.02 $7.66 72040 X X-ray exam of neck spine 0260 0.79 $38.30 $22.02 $7.66 72050 X X-ray exam of neck spine 0261 1.38 $66.91 $38.77 $13.38 72052 X X-ray exam of neck spine 0261 1.38 $66.91 $38.77 $13.38 72069 X X-ray exam of trunk spine 0260 0.79 $38.30 $22.02 $7.66 72070 X X-ray exam of thoracic spine 0260 0.79 $38.30 $22.02 $7.66 72072 X X-ray exam of thoracic spine 0260 0.79 $38.30 $22.02 $7.66 72074 X X-ray exam of thoracic spine 0260 0.79 $38.30 $22.02 $7.66 72080 X X-ray exam of trunk spine 0260 0.79 $38.30 $22.02 $7.66 72090 X X-ray exam of trunk spine 0260 0.79 $38.30 $22.02 $7.66 72100 X X-ray exam of lower spine 0260 0.79 $38.30 $22.02 $7.66 72110 X X-ray exam of lower spine 0261 1.38 $66.91 $38.77 $13.38 72114 X X-ray exam of lower spine 0261 1.38 $66.91 $38.77 $13.38 72120 X X-ray exam of lower spine 0260 0.79 $38.30 $22.02 $7.66 72125 S CAT scan of neck spine 0283 4.89 $237.10 $179.39 $47.42 72126 S Contrast CAT scan of neck 0283 4.89 $237.10 $179.39 $47.42 72127 S Contrast CAT scans of neck 0283 4.89 $237.10 $179.39 $47.42 72128 S CAT scan of thorax spine 0283 4.89 $237.10 $179.39 $47.42 72129 S Contrast CAT scan of thorax 0283 4.89 $237.10 $179.39 $47.42 72130 S Contrast CAT scans of thorax 0283 4.89 $237.10 $179.39 $47.42 72131 S CAT scan of lower spine 0283 4.89 $237.10 $179.39 $47.42 72132 S Contrast CAT of lower spine 0283 4.89 $237.10 $179.39 $47.42 72133 S Contrast cat scans, low spine 0283 4.89 $237.10 $179.39 $47.42 72141 S Magnetic image, neck spine 0284 8.02 $388.87 $257.39 $77.77 72142 S Magnetic image, neck spine 0284 8.02 $388.87 $257.39 $77.77 72146 S Magnetic image, chest spine 0284 8.02 $388.87 $257.39 $77.77 72147 S Magnetic image, chest spine 0284 8.02 $388.87 $257.39 $77.77 72148 S Magnetic image, lumbar spine 0284 8.02 $388.87 $257.39 $77.77 72149 S Magnetic image, lumbar spine 0284 8.02 $388.87 $257.39 $77.77 72156 S Magnetic image, neck spine 0284 8.02 $388.87 $257.39 $77.77 72157 S Magnetic image, chest spine 0284 8.02 $388.87 $257.39 $77.77 72158 S Magnetic image, lumbar spine 0284 8.02 $388.87 $257.39 $77.77 72159 E Magnetic image, spine (mra) 72170 X X-ray exam of pelvis 0260 0.79 $38.30 $22.02 $7.66 72190 X X-ray exam of pelvis 0260 0.79 $38.30 $22.02 $7.66 72192 S CAT scan of pelvis 0283 4.89 $237.10 $179.39 $47.42 72193 S Contrast CAT scan of pelvis 0283 4.89 $237.10 $179.39 $47.42 72194 S Contrast CAT scans of pelvis 0283 4.89 $237.10 $179.39 $47.42 72196 S Magnetic image, pelvis 0284 8.02 $388.87 $257.39 $77.77 72198 E Magnetic image, pelvis (mra) 72200 X X-ray exam sacroiliac joints 0260 0.79 $38.30 $22.02 $7.66 72202 X X-ray exam sacroiliac joints 0260 0.79 $38.30 $22.02 $7.66 72220 X X-ray exam of tailbone 0260 0.79 $38.30 $22.02 $7.66 Start Printed Page 18630 72240 S Contrast x-ray of neck spine 0274 4.83 $234.19 $128.12 $46.84 72255 S Contrast x-ray, thorax spine 0274 4.83 $234.19 $128.12 $46.84 72265 S Contrast x-ray, lower spine 0274 4.83 $234.19 $128.12 $46.84 72270 S Contrast x-ray of spine 0274 4.83 $234.19 $128.12 $46.84 72275 S Epidurography 0274 4.83 $234.19 $128.12 $46.84 72285 S X-ray c/t spine disk 0274 4.83 $234.19 $128.12 $46.84 72295 S X-ray of lower spine disk 0274 4.83 $234.19 $128.12 $46.84 73000 X X-ray exam of collar bone 0260 0.79 $38.30 $22.02 $7.66 73010 X X-ray exam of shoulder blade 0260 0.79 $38.30 $22.02 $7.66 73020 X X-ray exam of shoulder 0260 0.79 $38.30 $22.02 $7.66 73030 X X-ray exam of shoulder 0260 0.79 $38.30 $22.02 $7.66 73040 S Contrast x-ray of shoulder 0275 2.74 $132.85 $72.26 $26.57 73050 X X-ray exam of shoulders 0260 0.79 $38.30 $22.02 $7.66 73060 X X-ray exam of humerus 0260 0.79 $38.30 $22.02 $7.66 73070 X X-ray exam of elbow 0260 0.79 $38.30 $22.02 $7.66 73080 X X-ray exam of elbow 0260 0.79 $38.30 $22.02 $7.66 73085 S Contrast x-ray of elbow 0275 2.74 $132.85 $72.26 $26.57 73090 X X-ray exam of forearm 0260 0.79 $38.30 $22.02 $7.66 73092 X X-ray exam of arm, infant 0260 0.79 $38.30 $22.02 $7.66 73100 X X-ray exam of wrist 0260 0.79 $38.30 $22.02 $7.66 73110 X X-ray exam of wrist 0260 0.79 $38.30 $22.02 $7.66 73115 S Contrast x-ray of wrist 0275 2.74 $132.85 $72.26 $26.57 73120 X X-ray exam of hand 0260 0.79 $38.30 $22.02 $7.66 73130 X X-ray exam of hand 0260 0.79 $38.30 $22.02 $7.66 73140 X X-ray exam of finger(s) 0260 0.79 $38.30 $22.02 $7.66 73200 S CAT scan of arm 0283 4.89 $237.10 $179.39 $47.42 73201 S Contrast CAT scan of arm 0283 4.89 $237.10 $179.39 $47.42 73202 S Contrast CAT scans of arm 0283 4.89 $237.10 $179.39 $47.42 73220 S Magnetic image, arm/hand 0284 8.02 $388.87 $257.39 $77.77 73221 S Magnetic image, joint of arm 0284 8.02 $388.87 $257.39 $77.77 73225 E Magnetic image, upper (mra) 73500 X X-ray exam of hip 0260 0.79 $38.30 $22.02 $7.66 73510 X X-ray exam of hip 0260 0.79 $38.30 $22.02 $7.66 73520 X X-ray exam of hips 0260 0.79 $38.30 $22.02 $7.66 73525 S Contrast x-ray of hip 0275 2.74 $132.85 $72.26 $26.57 73530 X X-ray exam of hip 0261 1.38 $66.91 $38.77 $13.38 73540 X X-ray exam of pelvis & hips 0260 0.79 $38.30 $22.02 $7.66 73542 S X-ray exam, sacroiliac joint 0275 2.74 $132.85 $72.26 $26.57 73550 X X-ray exam of thigh 0260 0.79 $38.30 $22.02 $7.66 73560 X X-ray exam of knee, 1 or 2 0260 0.79 $38.30 $22.02 $7.66 73562 X X-ray exam of knee, 3 0260 0.79 $38.30 $22.02 $7.66 73564 X X-ray exam, knee, 4 or more 0260 0.79 $38.30 $22.02 $7.66 73565 X X-ray exam of knees 0260 0.79 $38.30 $22.02 $7.66 73580 S Contrast x-ray of knee joint 0275 2.74 $132.85 $72.26 $26.57 73590 X X-ray exam of lower leg 0260 0.79 $38.30 $22.02 $7.66 73592 X X-ray exam of leg, infant 0261 1.38 $66.91 $38.77 $13.38 73600 X X-ray exam of ankle 0260 0.79 $38.30 $22.02 $7.66 73610 X X-ray exam of ankle 0260 0.79 $38.30 $22.02 $7.66 73615 S Contrast x-ray of ankle 0275 2.74 $132.85 $72.26 $26.57 73620 X X-ray exam of foot 0260 0.79 $38.30 $22.02 $7.66 73630 X X-ray exam of foot 0260 0.79 $38.30 $22.02 $7.66 73650 X X-ray exam of heel 0260 0.79 $38.30 $22.02 $7.66 73660 X X-ray exam of toe(s) 0260 0.79 $38.30 $22.02 $7.66 73700 S CAT scan of leg 0283 4.89 $237.10 $179.39 $47.42 73701 S Contrast CAT scan of leg 0283 4.89 $237.10 $179.39 $47.42 73702 S Contrast CAT scans of leg 0283 4.89 $237.10 $179.39 $47.42 73720 S Magnetic image, leg/foot 0284 8.02 $388.87 $257.39 $77.77 73721 S Magnetic image, joint of leg 0284 8.02 $388.87 $257.39 $77.77 73725 E Magnetic image/lower (mra) 74000 X X-ray exam of abdomen 0260 0.79 $38.30 $22.02 $7.66 74010 X X-ray exam of abdomen 0260 0.79 $38.30 $22.02 $7.66 74020 X X-ray exam of abdomen 0260 0.79 $38.30 $22.02 $7.66 74022 X X-ray exam series, abdomen 0261 1.38 $66.91 $38.77 $13.38 74150 S CAT scan of abdomen 0283 4.89 $237.10 $179.39 $47.42 74160 S Contrast CAT scan of abdomen 0283 4.89 $237.10 $179.39 $47.42 74170 S Contrast CAT scans, abdomen 0283 4.89 $237.10 $179.39 $47.42 74181 S Magnetic image/abdomen (mri) 0284 8.02 $388.87 $257.39 $77.77 74185 E Magnetic image/abdomen (MRA) 74190 X X-ray exam of peritoneum 0263 1.68 $81.46 $45.88 $16.29 74210 S Contrast x-ray exam of throat 0276 1.79 $86.79 $49.78 $17.36 74220 S Contrast x-ray, esophagus 0276 1.79 $86.79 $49.78 $17.36 74230 S Cinema x-ray, throat/esoph 0276 1.79 $86.79 $49.78 $17.36 74235 S Remove esophagus obstruction 0296 3.57 $173.10 $100.25 $34.62 Start Printed Page 18631 74240 S X-ray exam, upper gi tract 0276 1.79 $86.79 $49.78 $17.36 74241 S X-ray exam, upper gi tract 0276 1.79 $86.79 $49.78 $17.36 74245 S X-ray exam, upper gi tract 0277 2.47 $119.76 $69.28 $23.95 74246 S Contrast x-ray uppr gi tract 0276 1.79 $86.79 $49.78 $17.36 74247 S Contrast x-ray uppr gi tract 0276 1.79 $86.79 $49.78 $17.36 74249 S Contrast x-ray uppr gi tract 0277 2.47 $119.76 $69.28 $23.95 74250 S X-ray exam of small bowel 0276 1.79 $86.79 $49.78 $17.36 74251 S X-ray exam of small bowel 0277 2.47 $119.76 $69.28 $23.95 74260 S X-ray exam of small bowel 0277 2.47 $119.76 $69.28 $23.95 74270 S Contrast x-ray exam of colon 0276 1.79 $86.79 $49.78 $17.36 74280 S Contrast x-ray exam of colon 0277 2.47 $119.76 $69.28 $23.95 74283 S Contrast x-ray exam of colon 0276 1.79 $86.79 $49.78 $17.36 74290 S Contrast x-ray, gallbladder 0276 1.79 $86.79 $49.78 $17.36 74291 S Contrast x-rays, gallbladder 0276 1.79 $86.79 $49.78 $17.36 74300 C X-ray bile ducts/pancreas 74301 C X-rays at surgery add-on 74305 X X-ray bile ducts/pancreas 0263 1.68 $81.46 $45.88 $16.29 74320 X Contrast x-ray of bile ducts 0264 3.83 $185.71 $108.97 $37.14 74327 S X-ray bile stone removal 0296 3.57 $173.10 $100.25 $34.62 74328 X X-ray bile duct endoscopy 0264 3.83 $185.71 $108.97 $37.14 74329 X X-ray for pancreas endoscopy 0264 3.83 $185.71 $108.97 $37.14 74330 X X-ray bile/panc endoscopy 0264 3.83 $185.71 $108.97 $37.14 74340 X X-ray guide for GI tube 0272 1.40 $67.88 $39.00 $13.58 74350 X X-ray guide, stomach tube 0264 3.83 $185.71 $108.97 $37.14 74355 X X-ray guide, intestinal tube 0264 3.83 $185.71 $108.97 $37.14 74360 S X-ray guide, GI dilation 0296 3.57 $173.10 $100.25 $34.62 74363 S X-ray, bile duct dilation 0297 6.13 $297.23 $172.51 $59.45 74400 S Contrast x-ray, urinary tract 0278 2.85 $138.19 $81.67 $27.64 74410 S Contrast x-ray, urinary tract 0278 2.85 $138.19 $81.67 $27.64 74415 S Contrast x-ray, urinary tract 0278 2.85 $138.19 $81.67 $27.64 74420 S Contrast x-ray, urinary tract 0278 2.85 $138.19 $81.67 $27.64 74425 S Contrast x-ray, urinary tract 0278 2.85 $138.19 $81.67 $27.64 74430 S Contrast x-ray, bladder 0278 2.85 $138.19 $81.67 $27.64 74440 S X-ray, male genital tract 0278 2.85 $138.19 $81.67 $27.64 74445 S X-ray exam of penis 0278 2.85 $138.19 $81.67 $27.64 74450 S X-ray, urethra/bladder 0278 2.85 $138.19 $81.67 $27.64 74455 S X-ray, urethra/bladder 0278 2.85 $138.19 $81.67 $27.64 74470 X X-ray exam of kidney lesion 0264 3.83 $185.71 $108.97 $37.14 74475 S X-ray control, cath insert 0297 6.13 $297.23 $172.51 $59.45 74480 S X-ray control, cath insert 0297 6.13 $297.23 $172.51 $59.45 74485 S X-ray guide, GU dilation 0296 3.57 $173.10 $100.25 $34.62 74710 X X-ray measurement of pelvis 0260 0.79 $38.30 $22.02 $7.66 74740 X X-ray, female genital tract 0264 3.83 $185.71 $108.97 $37.14 74742 X X-ray, fallopian tube 0264 3.83 $185.71 $108.97 $37.14 74775 S X-ray exam of perineum 0278 2.85 $138.19 $81.67 $27.64 75552 S Magnetic image, myocardium 0284 8.02 $388.87 $257.39 $77.77 75553 S Magnetic image, myocardium 0284 8.02 $388.87 $257.39 $77.77 75554 S Cardiac MRI/function 0284 8.02 $388.87 $257.39 $77.77 75555 S Cardiac MRI/limited study 0284 8.02 $388.87 $257.39 $77.77 75556 E Cardiac MRI/flow mapping 75600 S Contrast x-ray exam of aorta 0280 14.98 $726.34 $380.12 $145.27 75605 S Contrast x-ray exam of aorta 0280 14.98 $726.34 $380.12 $145.27 75625 S Contrast x-ray exam of aorta 0280 14.98 $726.34 $380.12 $145.27 75630 S X-ray aorta, leg arteries 0280 14.98 $726.34 $380.12 $145.27 75650 S Artery x-rays, head & neck 0280 14.98 $726.34 $380.12 $145.27 75658 S Artery x-rays, arm 0280 14.98 $726.34 $380.12 $145.27 75660 S Artery x-rays, head & neck 0279 6.30 $305.47 $174.57 $61.09 75662 S Artery x-rays, head & neck 0279 6.30 $305.47 $174.57 $61.09 75665 S Artery x-rays, head & neck 0280 14.98 $726.34 $380.12 $145.27 75671 S Artery x-rays, head & neck 0280 14.98 $726.34 $380.12 $145.27 75676 S Artery x-rays, neck 0280 14.98 $726.34 $380.12 $145.27 75680 S Artery x-rays, neck 0280 14.98 $726.34 $380.12 $145.27 75685 S Artery x-rays, spine 0279 6.30 $305.47 $174.57 $61.09 75705 S Artery x-rays, spine 0279 6.30 $305.47 $174.57 $61.09 75710 S Artery x-rays, arm/leg 0280 14.98 $726.34 $380.12 $145.27 75716 S Artery x-rays, arms/legs 0280 14.98 $726.34 $380.12 $145.27 75722 S Artery x-rays, kidney 0280 14.98 $726.34 $380.12 $145.27 75724 S Artery x-rays, kidneys 0280 14.98 $726.34 $380.12 $145.27 75726 S Artery x-rays, abdomen 0280 14.98 $726.34 $380.12 $145.27 75731 S Artery x-rays, adrenal gland 0280 14.98 $726.34 $380.12 $145.27 75733 S Artery x-rays, adrenals 0280 14.98 $726.34 $380.12 $145.27 75736 S Artery x-rays, pelvis 0280 14.98 $726.34 $380.12 $145.27 75741 S Artery x-rays, lung 0279 6.30 $305.47 $174.57 $61.09 Start Printed Page 18632 75743 S Artery x-rays, lungs 0280 14.98 $726.34 $380.12 $145.27 75746 S Artery x-rays, lung 0279 6.30 $305.47 $174.57 $61.09 75756 S Artery x-rays, chest 0279 6.30 $305.47 $174.57 $61.09 75774 S Artery x-ray, each vessel 0280 14.98 $726.34 $380.12 $145.27 75790 S Visualize A-V shunt 0281 4.40 $213.34 $115.16 $42.67 75801 X Lymph vessel x-ray, arm/leg 0264 3.83 $185.71 $108.97 $37.14 75803 X Lymph vessel x-ray, arms/legs 0264 3.83 $185.71 $108.97 $37.14 75805 X Lymph vessel x-ray, trunk 0264 3.83 $185.71 $108.97 $37.14 75807 X Lymph vessel x-ray, trunk 0264 3.83 $185.71 $108.97 $37.14 75809 X Nonvascular shunt, x-ray 0264 3.83 $185.71 $108.97 $37.14 75810 S Vein x-ray, spleen/liver 0279 6.30 $305.47 $174.57 $61.09 75820 S Vein x-ray, arm/leg 0281 4.40 $213.34 $115.16 $42.67 75822 S Vein x-ray, arms/legs 0281 4.40 $213.34 $115.16 $42.67 75825 S Vein x-ray, trunk 0279 6.30 $305.47 $174.57 $61.09 75827 S Vein x-ray, chest 0279 6.30 $305.47 $174.57 $61.09 75831 S Vein x-ray, kidney 0279 6.30 $305.47 $174.57 $61.09 75833 S Vein x-ray, kidneys 0279 6.30 $305.47 $174.57 $61.09 75840 S Vein x-ray, adrenal gland 0279 6.30 $305.47 $174.57 $61.09 75842 S Vein x-ray, adrenal glands 0279 6.30 $305.47 $174.57 $61.09 75860 S Vein x-ray, neck 0279 6.30 $305.47 $174.57 $61.09 75870 S Vein x-ray, skull 0279 6.30 $305.47 $174.57 $61.09 75872 S Vein x-ray, skull 0279 6.30 $305.47 $174.57 $61.09 75880 S Vein x-ray, eye socket 0279 6.30 $305.47 $174.57 $61.09 75885 S Vein x-ray, liver 0279 6.30 $305.47 $174.57 $61.09 75887 S Vein x-ray, liver 0280 14.98 $726.34 $380.12 $145.27 75889 S Vein x-ray, liver 0279 6.30 $305.47 $174.57 $61.09 75891 S Vein x-ray, liver 0279 6.30 $305.47 $174.57 $61.09 75893 N Venous sampling by catheter 75894 S X-rays, transcath therapy 0297 6.13 $297.23 $172.51 $59.45 75896 S X-rays, transcath therapy 0297 6.13 $297.23 $172.51 $59.45 75898 X Follow-up angiogram 0264 3.83 $185.71 $108.97 $37.14 75900 C Arterial catheter exchange 75940 C X-ray placement, vein filter 75945 C Intravascular us 75946 C Intravascular us add-on 75960 C Transcatheter intro, stent 75961 C Retrieval, broken catheter 75962 C Repair arterial blockage 75964 C Repair artery blockage, each 75966 C Repair arterial blockage 75968 C Repair artery blockage, each 75970 C Vascular biopsy 75978 C Repair venous blockage 75980 S Contrast x-ray exam bile duct 0297 6.13 $297.23 $172.51 $59.45 75982 S Contrast x-ray exam bile duct 0297 6.13 $297.23 $172.51 $59.45 75984 S X-ray control catheter change 0296 3.57 $173.10 $100.25 $34.62 75989 X Abscess drainage under x-ray 0273 2.49 $120.73 $61.02 $24.15 75992 C Atherectomy, x-ray exam 75993 C Atherectomy, x-ray exam 75994 C Atherectomy, x-ray exam 75995 C Atherectomy, x-ray exam 75996 C Atherectomy, x-ray exam 76000 X Fluoroscope examination 0272 1.40 $67.88 $39.00 $13.58 76001 X Fluoroscope exam, extensive 0273 2.49 $120.73 $61.02 $24.15 76003 X Needle localization by x-ray 0272 1.40 $67.88 $39.00 $13.58 76005 X Fluoroguide for spine inject 0273 2.49 $120.73 $61.02 $24.15 76006 X X-ray stress view 0261 1.38 $66.91 $38.77 $13.38 76010 X X-ray, nose to rectum 0260 0.79 $38.30 $22.02 $7.66 76020 X X-rays for bone age 0261 1.38 $66.91 $38.77 $13.38 76040 X X-rays, bone evaluation 0260 0.79 $38.30 $22.02 $7.66 76061 X X-rays, bone survey 0261 1.38 $66.91 $38.77 $13.38 76062 X X-rays, bone survey 0261 1.38 $66.91 $38.77 $13.38 76065 X X-rays, bone evaluation 0261 1.38 $66.91 $38.77 $13.38 76066 X Joint(s) survey, single film 0260 0.79 $38.30 $22.02 $7.66 76070 E CT scan, bone density study 76075 X Dual energy x-ray study 0261 1.38 $66.91 $38.77 $13.38 76076 X Dual energy x-ray study 0261 1.38 $66.91 $38.77 $13.38 76078 X Photodensitometry 0261 1.38 $66.91 $38.77 $13.38 76080 X X-ray exam of fistula 0263 1.68 $81.46 $45.88 $16.29 76086 X X-ray of mammary duct 0263 1.68 $81.46 $45.88 $16.29 76088 X X-ray of mammary ducts 0263 1.68 $81.46 $45.88 $16.29 76090 S Mammogram, one breast 0271 0.70 $33.94 $19.50 $6.79 76091 S Mammogram, both breasts 0271 0.70 $33.94 $19.50 $6.79 Start Printed Page 18633 76092 A Mammogram, screening 76093 S Magnetic image, breast 0284 8.02 $388.87 $257.39 $77.77 76094 S Magnetic image, both breasts 0284 8.02 $388.87 $257.39 $77.77 76095 X Stereotactic breast biopsy 0264 3.83 $185.71 $108.97 $37.14 76096 X X-ray of needle wire, breast 0263 1.68 $81.46 $45.88 $16.29 76098 X X-ray exam, breast specimen 0260 0.79 $38.30 $22.02 $7.66 76100 X X-ray exam of body section 0261 1.38 $66.91 $38.77 $13.38 76101 X Complex body section x-ray 0263 1.68 $81.46 $45.88 $16.29 76102 X Complex body section x-rays 0264 3.83 $185.71 $108.97 $37.14 76120 X Cinematic x-rays 0261 1.38 $66.91 $38.77 $13.38 76125 X Cinematic x-rays add-on 0261 1.38 $66.91 $38.77 $13.38 76140 E X-ray consultation 76150 X X-ray exam, dry process 0260 0.79 $38.30 $22.02 $7.66 76350 N Special x-ray contrast study 76355 S CAT scan for localization 0283 4.89 $237.10 $179.39 $47.42 76360 S CAT scan for needle biopsy 0283 4.89 $237.10 $179.39 $47.42 76365 S CAT scan for cyst aspiration 0283 4.89 $237.10 $179.39 $47.42 76370 S CAT scan for therapy guide 0282 2.38 $115.40 $94.51 $23.08 76375 S 3D/holograph reconstr add-on 0282 2.38 $115.40 $94.51 $23.08 76380 S CAT scan follow-up study 0282 2.38 $115.40 $94.51 $23.08 76390 S Mr spectroscopy 0284 8.02 $388.87 $257.39 $77.77 76400 S Magnetic image, bone marrow 0284 8.02 $388.87 $257.39 $77.77 76499 X Radiographic procedure 0260 0.79 $38.30 $22.02 $7.66 76506 S Echo exam of head 0266 1.79 $86.79 $57.35 $17.36 76511 S Echo exam of eye 0266 1.79 $86.79 $57.35 $17.36 76512 S Echo exam of eye 0266 1.79 $86.79 $57.35 $17.36 76513 S Echo exam of eye, water bath 0265 1.17 $56.73 $38.08 $11.35 76516 S Echo exam of eye 0266 1.79 $86.79 $57.35 $17.36 76519 S Echo exam of eye 0266 1.79 $86.79 $57.35 $17.36 76529 S Echo exam of eye 0265 1.17 $56.73 $38.08 $11.35 76536 S Echo exam of head and neck 0265 1.17 $56.73 $38.08 $11.35 76604 S Echo exam of chest 0266 1.79 $86.79 $57.35 $17.36 76645 S Echo exam of breast(s) 0265 1.17 $56.73 $38.08 $11.35 76700 S Echo exam of abdomen 0266 1.79 $86.79 $57.35 $17.36 76705 S Echo exam of abdomen 0266 1.79 $86.79 $57.35 $17.36 76770 S Echo exam abdomen back wall 0266 1.79 $86.79 $57.35 $17.36 76775 S Echo exam abdomen back wall 0266 1.79 $86.79 $57.35 $17.36 76778 S Echo exam kidney transplant 0266 1.79 $86.79 $57.35 $17.36 76800 S Echo exam spinal canal 0266 1.79 $86.79 $57.35 $17.36 76805 S Echo exam of pregnant uterus 0266 1.79 $86.79 $57.35 $17.36 76810 S Echo exam of pregnant uterus 0265 1.17 $56.73 $38.08 $11.35 76815 S Echo exam of pregnant uterus 0265 1.17 $56.73 $38.08 $11.35 76816 S Echo exam follow-up/repeat 0265 1.17 $56.73 $38.08 $11.35 76818 S Fetal biophysical profile 0266 1.79 $86.79 $57.35 $17.36 76825 S Echo exam of fetal heart 0269 4.40 $213.34 $114.01 $42.67 76826 S Echo exam of fetal heart 0269 4.40 $213.34 $114.01 $42.67 76827 S Echo exam of fetal heart 0269 4.40 $213.34 $114.01 $42.67 76828 S Echo exam of fetal heart 0269 4.40 $213.34 $114.01 $42.67 76830 S Echo exam, transvaginal 0266 1.79 $86.79 $57.35 $17.36 76831 S Echo exam, uterus 0266 1.79 $86.79 $57.35 $17.36 76856 S Echo exam of pelvis 0266 1.79 $86.79 $57.35 $17.36 76857 S Echo exam of pelvis 0265 1.17 $56.73 $38.08 $11.35 76870 S Echo exam of scrotum 0266 1.79 $86.79 $57.35 $17.36 76872 S Echo exam, transrectal 0266 1.79 $86.79 $57.35 $17.36 76873 S Echograp trans r, pros study 0266 1.79 $86.79 $57.35 $17.36 76880 S Echo exam of extremity 0266 1.79 $86.79 $57.35 $17.36 76885 S Echo exam, infant hips 0266 1.79 $86.79 $57.35 $17.36 76886 S Echo exam, infant hips 0266 1.79 $86.79 $57.35 $17.36 76930 X Echo guide for heart sac tap 0268 2.23 $108.13 $69.51 $21.63 76932 X Echo guide for heart biopsy 0268 2.23 $108.13 $69.51 $21.63 76934 X Echo guide for chest tap 0268 2.23 $108.13 $69.51 $21.63 76936 X Echo guide for artery repair 0268 2.23 $108.13 $69.51 $21.63 76938 X Echo exam for drainage 0268 2.23 $108.13 $69.51 $21.63 76941 X Echo guide for transfusion 0268 2.23 $108.13 $69.51 $21.63 76942 X Echo guide for biopsy 0268 2.23 $108.13 $69.51 $21.63 76945 X Echo guide, villus sampling 0268 2.23 $108.13 $69.51 $21.63 76946 X Echo guide for amniocentesis 0268 2.23 $108.13 $69.51 $21.63 76948 X Echo guide, ova aspiration 0268 2.23 $108.13 $69.51 $21.63 76950 X Echo guidance radiotherapy 0268 2.23 $108.13 $69.51 $21.63 76960 X Echo guidance radiotherapy 0268 2.23 $108.13 $69.51 $21.63 76965 X Echo guidance radiotherapy 0268 2.23 $108.13 $69.51 $21.63 76970 S Ultrasound exam follow-up 0265 1.17 $56.73 $38.08 $11.35 76975 S GI endoscopic ultrasound 0266 1.79 $86.79 $57.35 $17.36 Start Printed Page 18634 76977 S Us bone density measure 0265 1.17 $56.73 $38.08 $11.35 76986 S Echo exam at surgery 0266 1.79 $86.79 $57.35 $17.36 76999 S Echo examination procedure 0266 1.79 $86.79 $57.35 $17.36 77261 E Radiation therapy planning 77262 E Radiation therapy planning 77263 E Radiation therapy planning 77280 X Set radiation therapy field 0304 1.49 $72.25 $41.52 $14.45 77285 X Set radiation therapy field 0305 4.06 $196.86 $97.50 $39.37 77290 X Set radiation therapy field 0305 4.06 $196.86 $97.50 $39.37 77295 X Set radiation therapy field 0310 13.98 $677.85 $339.05 $135.57 77299 E Radiation therapy planning 77300 X Radiation therapy dose plan 0304 1.49 $72.25 $41.52 $14.45 77305 X Radiation therapy dose plan 0304 1.49 $72.25 $41.52 $14.45 77310 X Radiation therapy dose plan 0304 1.49 $72.25 $41.52 $14.45 77315 X Radiation therapy dose plan 0305 4.06 $196.86 $97.50 $39.37 77321 X Radiation therapy port plan 0305 4.06 $196.86 $97.50 $39.37 77326 X Radiation therapy dose plan 0305 4.06 $196.86 $97.50 $39.37 77327 X Radiation therapy dose plan 0305 4.06 $196.86 $97.50 $39.37 77328 X Radiation therapy dose plan 0305 4.06 $196.86 $97.50 $39.37 77331 X Special radiation dosimetry 0304 1.49 $72.25 $41.52 $14.45 77332 X Radiation treatment aid(s) 0303 2.83 $137.22 $69.28 $27.44 77333 X Radiation treatment aid(s) 0303 2.83 $137.22 $69.28 $27.44 77334 X Radiation treatment aid(s) 0303 2.83 $137.22 $69.28 $27.44 77336 X Radiation physics consult 0311 1.32 $64.00 $31.66 $12.80 77370 X Radiation physics consult 0311 1.32 $64.00 $31.66 $12.80 77399 X External radiation dosimetry 0311 1.32 $64.00 $31.66 $12.80 77401 S Radiation treatment delivery 0300 1.98 $96.00 $47.72 $19.20 77402 S Radiation treatment delivery 0300 1.98 $96.00 $47.72 $19.20 77403 S Radiation treatment delivery 0300 1.98 $96.00 $47.72 $19.20 77404 S Radiation treatment delivery 0300 1.98 $96.00 $47.72 $19.20 77406 S Radiation treatment delivery 0300 1.98 $96.00 $47.72 $19.20 77407 S Radiation treatment delivery 0300 1.98 $96.00 $47.72 $19.20 77408 S Radiation treatment delivery 0300 1.98 $96.00 $47.72 $19.20 77409 S Radiation treatment delivery 0300 1.98 $96.00 $47.72 $19.20 77411 S Radiation treatment delivery 0301 2.21 $107.16 $52.53 $21.43 77412 S Radiation treatment delivery 0301 2.21 $107.16 $52.53 $21.43 77413 S Radiation treatment delivery 0301 2.21 $107.16 $52.53 $21.43 77414 S Radiation treatment delivery 0300 1.98 $96.00 $47.72 $19.20 77416 S Radiation treatment delivery 0301 2.21 $107.16 $52.53 $21.43 77417 X Radiology port film(s) 0260 0.79 $38.30 $22.02 $7.66 77427 E Radiation tx management, x5 77431 E Radiation therapy management 77432 E Stereotactic radiation trmt 77470 S Special radiation treatment 0302 8.21 $398.08 $216.55 $79.62 77499 E Radiation therapy management 77520 S Proton beam delivery 0301 2.21 $107.16 $52.53 $21.43 77523 S Proton beam delivery 0301 2.21 $107.16 $52.53 $21.43 77600 S Hyperthermia treatment 0314 5.88 $285.10 $150.95 $57.02 77605 S Hyperthermia treatment 0314 5.88 $285.10 $150.95 $57.02 77610 S Hyperthermia treatment 0314 5.88 $285.10 $150.95 $57.02 77615 S Hyperthermia treatment 0314 5.88 $285.10 $150.95 $57.02 77620 S Hyperthermia treatment 0314 5.88 $285.10 $150.95 $57.02 77750 S Infuse radioactive materials 0301 2.21 $107.16 $52.53 $21.43 77761 S Radioelement application 0312 4.09 $198.31 $109.65 $39.66 77762 S Radioelement application 0312 4.09 $198.31 $109.65 $39.66 77763 S Radioelement application 0312 4.09 $198.31 $109.65 $39.66 77776 S Radioelement application 0312 4.09 $198.31 $109.65 $39.66 77777 S Radioelement application 0312 4.09 $198.31 $109.65 $39.66 77778 S Radioelement application 0312 4.09 $198.31 $109.65 $39.66 77781 S High intensity brachytherapy 0313 7.89 $382.56 $164.02 $76.51 77782 S High intensity brachytherapy 0313 7.89 $382.56 $164.02 $76.51 77783 S High intensity brachytherapy 0313 7.89 $382.56 $164.02 $76.51 77784 S High intensity brachytherapy 0313 7.89 $382.56 $164.02 $76.51 77789 S Radioelement application 0300 1.98 $96.00 $47.72 $19.20 77790 N Radioelement handling 77799 S Radium/radioisotope therapy 0313 7.89 $382.56 $164.02 $76.51 78000 S Thyroid, single uptake 0290 1.94 $94.06 $55.51 $18.81 78001 S Thyroid, multiple uptakes 0290 1.94 $94.06 $55.51 $18.81 78003 S Thyroid suppress/stimul 0290 1.94 $94.06 $55.51 $18.81 78006 S Thyroid imaging with uptake 0291 3.15 $152.73 $93.14 $30.55 78007 S Thyroid image, mult uptakes 0291 3.15 $152.73 $93.14 $30.55 78010 S Thyroid imaging 0290 1.94 $94.06 $55.51 $18.81 78011 S Thyroid imaging with flow 0290 1.94 $94.06 $55.51 $18.81 Start Printed Page 18635 78015 S Thyroid met imaging 0291 3.15 $152.73 $93.14 $30.55 78016 S Thyroid met imaging/studies 0292 4.36 $211.40 $126.63 $42.28 78018 S Thyroid met imaging, body 0292 4.36 $211.40 $126.63 $42.28 78020 S Thyroid met uptake 0292 4.36 $211.40 $126.63 $42.28 78070 S Parathyroid nuclear imaging 0292 4.36 $211.40 $126.63 $42.28 78075 S Adrenal nuclear imaging 0292 4.36 $211.40 $126.63 $42.28 78099 S Endocrine nuclear procedure 0290 1.94 $94.06 $55.51 $18.81 78102 S Bone marrow imaging, ltd 0291 3.15 $152.73 $93.14 $30.55 78103 S Bone marrow imaging, mult 0292 4.36 $211.40 $126.63 $42.28 78104 S Bone marrow imaging, body 0292 4.36 $211.40 $126.63 $42.28 78110 S Plasma volume, single 0291 3.15 $152.73 $93.14 $30.55 78111 S Plasma volume, multiple 0291 3.15 $152.73 $93.14 $30.55 78120 S Red cell mass, single 0291 3.15 $152.73 $93.14 $30.55 78121 S Red cell mass, multiple 0291 3.15 $152.73 $93.14 $30.55 78122 S Blood volume 0292 4.36 $211.40 $126.63 $42.28 78130 S Red cell survival study 0292 4.36 $211.40 $126.63 $42.28 78135 S Red cell survival kinetics 0292 4.36 $211.40 $126.63 $42.28 78140 S Red cell sequestration 0292 4.36 $211.40 $126.63 $42.28 78160 S Plasma iron turnover 0292 4.36 $211.40 $126.63 $42.28 78162 S Iron absorption exam 0292 4.36 $211.40 $126.63 $42.28 78170 S Red cell iron utilization 0292 4.36 $211.40 $126.63 $42.28 78172 S Total body iron estimation 0292 4.36 $211.40 $126.63 $42.28 78185 S Spleen imaging 0291 3.15 $152.73 $93.14 $30.55 78190 S Platelet survival, kinetics 0291 3.15 $152.73 $93.14 $30.55 78191 S Platelet survival 0291 3.15 $152.73 $93.14 $30.55 78195 S Lymph system imaging 0292 4.36 $211.40 $126.63 $42.28 78199 S Blood/lymph nuclear exam 0290 1.94 $94.06 $55.51 $18.81 78201 S Liver imaging 0291 3.15 $152.73 $93.14 $30.55 78202 S Liver imaging with flow 0291 3.15 $152.73 $93.14 $30.55 78205 S Liver imaging (3D) 0292 4.36 $211.40 $126.63 $42.28 78206 S Liver image (3D) w/flow 0292 4.36 $211.40 $126.63 $42.28 78215 S Liver and spleen imaging 0291 3.15 $152.73 $93.14 $30.55 78216 S Liver & spleen image/flow 0291 3.15 $152.73 $93.14 $30.55 78220 S Liver function study 0292 4.36 $211.40 $126.63 $42.28 78223 S Hepatobiliary imaging 0292 4.36 $211.40 $126.63 $42.28 78230 S Salivary gland imaging 0291 3.15 $152.73 $93.14 $30.55 78231 S Serial salivary imaging 0291 3.15 $152.73 $93.14 $30.55 78232 S Salivary gland function exam 0291 3.15 $152.73 $93.14 $30.55 78258 S Esophageal motility study 0291 3.15 $152.73 $93.14 $30.55 78261 S Gastric mucosa imaging 0291 3.15 $152.73 $93.14 $30.55 78262 S Gastroesophageal reflux exam 0291 3.15 $152.73 $93.14 $30.55 78264 S Gastric emptying study 0292 4.36 $211.40 $126.63 $42.28 2 78267 T Breath tst attain/anal c-14 0971 1.55 $75.16 $15.03 2 78268 T Breath test analysis, c-14 0970 0.52 $25.21 $5.04 78270 S Vit B-12 absorption exam 0290 1.94 $94.06 $55.51 $18.81 78271 S Vit B-12 absorp exam, IF 0290 1.94 $94.06 $55.51 $18.81 78272 S Vit B-12 absorp, combined 0291 3.15 $152.73 $93.14 $30.55 78278 S Acute GI blood loss imaging 0292 4.36 $211.40 $126.63 $42.28 78282 S GI protein loss exam 0290 1.94 $94.06 $55.51 $18.81 78290 S Meckel's divert exam 0291 3.15 $152.73 $93.14 $30.55 78291 S Leveen/shunt patency exam 0292 4.36 $211.40 $126.63 $42.28 78299 S GI nuclear procedure 0290 1.94 $94.06 $55.51 $18.81 78300 S Bone imaging, limited area 0291 3.15 $152.73 $93.14 $30.55 78305 S Bone imaging, multiple areas 0292 4.36 $211.40 $126.63 $42.28 78306 S Bone imaging, whole body 0292 4.36 $211.40 $126.63 $42.28 78315 S Bone imaging, 3 phase 0292 4.36 $211.40 $126.63 $42.28 78320 S Bone imaging (3D) 0292 4.36 $211.40 $126.63 $42.28 78350 X Bone mineral, single photon 0261 1.38 $66.91 $38.77 $13.38 78351 E Bone mineral, dual photon 78399 S Musculoskeletal nuclear exam 0290 1.94 $94.06 $55.51 $18.81 78414 S Non-imaging heart function 0292 4.36 $211.40 $126.63 $42.28 78428 S Cardiac shunt imaging 0292 4.36 $211.40 $126.63 $42.28 78445 S Vascular flow imaging 0291 3.15 $152.73 $93.14 $30.55 78455 S Venous thrombosis study 0291 3.15 $152.73 $93.14 $30.55 78456 S Acute venous thrombus image 0291 3.15 $152.73 $93.14 $30.55 78457 S Venous thrombosis imaging 0291 3.15 $152.73 $93.14 $30.55 78458 S Ven thrombosis images, bilat 0291 3.15 $152.73 $93.14 $30.55 78459 E Heart muscle imaging (PET) 78460 S Heart muscle blood, single 0286 7.28 $352.99 $200.04 $70.60 78461 S Heart muscle blood, multiple 0286 7.28 $352.99 $200.04 $70.60 78464 S Heart image (3D), single 0286 7.28 $352.99 $200.04 $70.60 78465 S Heart image (3D), multiple 0286 7.28 $352.99 $200.04 $70.60 78466 S Heart infarct image 0292 4.36 $211.40 $126.63 $42.28 Start Printed Page 18636 78468 S Heart infarct image (ef) 0292 4.36 $211.40 $126.63 $42.28 78469 S Heart infarct image (3D) 0292 4.36 $211.40 $126.63 $42.28 78472 S Gated heart, planar, single 0286 7.28 $352.99 $200.04 $70.60 78473 S Gated heart, multiple 0286 7.28 $352.99 $200.04 $70.60 78478 S Heart wall motion add-on 0286 7.28 $352.99 $200.04 $70.60 78480 S Heart function add-on 0286 7.28 $352.99 $200.04 $70.60 78481 S Heart first pass, single 0286 7.28 $352.99 $200.04 $70.60 78483 S Heart first pass, multiple 0286 7.28 $352.99 $200.04 $70.60 78491 E Heart image (pet), single 78492 E Heart image (pet), multiple 78494 S Heart image, spect 0296 3.57 $173.10 $100.25 $34.62 78496 S Heart first pass add-on 0296 3.57 $173.10 $100.25 $34.62 78499 S Cardiovascular nuclear exam 0292 4.36 $211.40 $126.63 $42.28 78580 S Lung perfusion imaging 0291 3.15 $152.73 $93.14 $30.55 78584 S Lung V/Q image single breath 0292 4.36 $211.40 $126.63 $42.28 78585 S Lung V/Q imaging 0292 4.36 $211.40 $126.63 $42.28 78586 S Aerosol lung image, single 0292 4.36 $211.40 $126.63 $42.28 78587 S Aerosol lung image, multiple 0292 4.36 $211.40 $126.63 $42.28 78588 S Perfusion lung image 0292 4.36 $211.40 $126.63 $42.28 78591 S Vent image, 1 breath, 1 proj 0291 3.15 $152.73 $93.14 $30.55 78593 S Vent image, 1 proj, gas 0292 4.36 $211.40 $126.63 $42.28 78594 S Vent image, mult proj, gas 0292 4.36 $211.40 $126.63 $42.28 78596 S Lung differential function 0292 4.36 $211.40 $126.63 $42.28 78599 S Respiratory nuclear exam 0291 3.15 $152.73 $93.14 $30.55 78600 S Brain imaging, ltd static 0292 4.36 $211.40 $126.63 $42.28 78601 S Brain imaging, ltd w/flow 0292 4.36 $211.40 $126.63 $42.28 78605 S Brain imaging, complete 0291 3.15 $152.73 $93.14 $30.55 78606 S Brain imaging, compl w/flow 0292 4.36 $211.40 $126.63 $42.28 78607 S Brain imaging (3D) 0292 4.36 $211.40 $126.63 $42.28 78608 E Brain imaging (PET) 78609 E Brain imaging (PET) 78610 S Brain flow imaging only 0291 3.15 $152.73 $93.14 $30.55 78615 S Cerebral blood flow imaging 0292 4.36 $211.40 $126.63 $42.28 78630 S Cerebrospinal fluid scan 0292 4.36 $211.40 $126.63 $42.28 78635 S CSF ventriculography 0292 4.36 $211.40 $126.63 $42.28 78645 S CSF shunt evaluation 0292 4.36 $211.40 $126.63 $42.28 78647 S Cerebrospinal fluid scan 0292 4.36 $211.40 $126.63 $42.28 78650 S CSF leakage imaging 0292 4.36 $211.40 $126.63 $42.28 78655 S 0292 4.36 $211.40 $126.63 $42.28 78660 S Nuclear exam of tear flow 0291 3.15 $152.73 $93.14 $30.55 78699 S Nervous system nuclear exam 0292 4.36 $211.40 $126.63 $42.28 78700 S Kidney imaging, static 0291 3.15 $152.73 $93.14 $30.55 78701 S Kidney imaging with flow 0291 3.15 $152.73 $93.14 $30.55 78704 S Imaging renogram 0292 4.36 $211.40 $126.63 $42.28 78707 S Kidney flow/function image 0292 4.36 $211.40 $126.63 $42.28 78708 S Kidney flow/function image 0292 4.36 $211.40 $126.63 $42.28 78709 S Kidney flow/function image 0292 4.36 $211.40 $126.63 $42.28 78710 S Kidney imaging (3D) 0292 4.36 $211.40 $126.63 $42.28 78715 S Renal vascular flow exam 0291 3.15 $152.73 $93.14 $30.55 78725 S Kidney function study 0291 3.15 $152.73 $93.14 $30.55 78730 S Urinary bladder retention 0291 3.15 $152.73 $93.14 $30.55 78740 S Ureteral reflux study 0291 3.15 $152.73 $93.14 $30.55 78760 S Testicular imaging 0291 3.15 $152.73 $93.14 $30.55 78761 S Testicular imaging/flow 0291 3.15 $152.73 $93.14 $30.55 78799 S Genitourinary nuclear exam 0292 4.36 $211.40 $126.63 $42.28 78800 S Tumor imaging, limited area 0292 4.36 $211.40 $126.63 $42.28 78801 S Tumor imaging, mult areas 0292 4.36 $211.40 $126.63 $42.28 78802 S Tumor imaging, whole body 0292 4.36 $211.40 $126.63 $42.28 78803 S Tumor imaging (3D) 0292 4.36 $211.40 $126.63 $42.28 78805 S Abscess imaging, ltd area 0292 4.36 $211.40 $126.63 $42.28 78806 S Abscess imaging, whole body 0292 4.36 $211.40 $126.63 $42.28 78807 S Nuclear localization/abscess 0292 4.36 $211.40 $126.63 $42.28 78810 E Tumor imaging (PET) 78890 N Nuclear medicine data proc 78891 N Nuclear med data proc 78990 N Provide diag radionuclide(s) 78999 S Nuclear diagnostic exam 0291 3.15 $152.73 $93.14 $30.55 79000 S Init hyperthyroid therapy 0294 5.13 $248.74 $144.06 $49.75 79001 S Repeat hyperthyroid therapy 0294 5.13 $248.74 $144.06 $49.75 79020 S Thyroid ablation 0294 5.13 $248.74 $144.06 $49.75 79030 S Thyroid ablation, carcinoma 0294 5.13 $248.74 $144.06 $49.75 79035 S Thyroid metastatic therapy 0294 5.13 $248.74 $144.06 $49.75 79100 S Hematopoetic nuclear therapy 0294 5.13 $248.74 $144.06 $49.75 Start Printed Page 18637 79200 S Intracavitary nuclear trmt 0295 19.85 $962.47 $609.17 $192.49 79300 S Interstitial nuclear therapy 0294 5.13 $248.74 $144.06 $49.75 79400 S Nonhemato nuclear therapy 0295 19.85 $962.47 $609.17 $192.49 79420 S Intravascular nuclear ther 0295 19.85 $962.47 $609.17 $192.49 79440 S Nuclear joint therapy 0294 5.13 $248.74 $144.06 $49.75 79900 N Provide ther radiopharm(s) 79999 S Nuclear medicine therapy 0294 5.13 $248.74 $144.06 $49.75 80048 A Basic metabolic panel 80050 A General health panel 80051 A Electrolyte panel 80053 A Comprehen metabolic panel 80055 A Obstetric panel 80061 A Lipid panel 80069 A Renal function panel 80072 A Arthritis panel 80074 A Acute hepatitis panel 80076 A Hepatic function panel 80090 A Torch antibody panel 80100 A Drug screen 80101 A Drug screen 80102 A Drug confirmation 80103 N Drug analysis, tissue prep 80150 A Assay of amikacin 80152 A Assay of amitriptyline 80154 A Assay of benzodiazepines 80156 A Assay of carbamazepine 80158 A Assay of cyclosporine 80160 A Assay of desipramine 80162 A Assay of digoxin 80164 A Assay, dipropylacetic acid 80166 A Assay of doxepin 80168 A Assay of ethosuximide 80170 A Assay of gentamicin 80172 A Assay of gold 80174 A Assay of imipramine 80176 A Assay of lidocaine 80178 A Assay of lithium 80182 A Assay of nortriptyline 80184 A Assay of phenobarbital 80185 A Assay of phenytoin, total 80186 A Assay of phenytoin, free 80188 A Assay of primidone 80190 A Assay of procainamide 80192 A Assay of procainamide 80194 A Assay of quinidine 80196 A Assay of salicylate 80197 A Assay of tacrolimus 80198 A Assay of theophylline 80200 A Assay of tobramycin 80201 A Assay of topiramate 80202 A Assay of vancomycin 80299 A Quantitative assay, drug 80400 A Acth stimulation panel 80402 A Acth stimulation panel 80406 A Acth stimulation panel 80408 A Aldosterone suppression eval 80410 A Calcitonin stimul panel 80412 A CRH stimulation panel 80414 A Testosterone response 80415 A Estradiol response panel 80416 A Renin stimulation panel 80417 A Renin stimulation panel 80418 A Pituitary evaluation panel 80420 A Dexamethasone panel 80422 A Glucagon tolerance panel 80424 A Glucagon tolerance panel 80426 A Gonadotropin hormone panel 80428 A Growth hormone panel 80430 A Growth hormone panel 80432 A Insulin suppression panel 80434 A Insulin tolerance panel 80435 A Insulin tolerance panel 80436 A Metyrapone panel Start Printed Page 18638 80438 A TRH stimulation panel 80439 A TRH stimulation panel 80440 A TRH stimulation panel 80500 X Lab pathology consultation 0343 0.45 $21.82 $12.16 $4.36 80502 X Lab pathology consultation 0343 0.45 $21.82 $12.16 $4.36 81000 A Urinalysis, nonauto w/scope 81001 A Urinalysis, auto w/scope 81002 A Urinalysis nonauto w/o scope 81003 A Urinalysis, auto, w/o scope 81005 A Urinalysis 81007 A Urine screen for bacteria 81015 A Microscopic exam of urine 81020 A Urinalysis, glass test 81025 A Urine pregnancy test 81050 A Urinalysis, volume measure 81099 A Urinalysis test procedure 82000 A Assay of blood acetaldehyde 82003 A Assay of acetaminophen 82009 A Test for acetone/ketones 82010 A Acetone assay 82013 A Acetylcholinesterase assay 82016 A Acylcarnitines, qual 82017 A Acylcarnitines, quant 82024 A Assay of acth 82030 A Assay of adp & amp 82040 A Assay of serum albumin 82042 A Assay of urine albumin 82043 A Microalbumin, quantitative 82044 A Microalbumin, semiquant 82055 A Assay of ethanol 82075 A Assay of breath ethanol 82085 A Assay of aldolase 82088 A Assay of aldosterone 82101 A Assay of urine alkaloids 82103 A Alpha-1-antitrypsin, total 82104 A Alpha-1-antitrypsin, pheno 82105 A Alpha-fetoprotein, serum 82106 A Alpha-fetoprotein, amniotic 82108 A Assay of aluminum 82120 A Amines, vaginal fluid qual 82127 A Amino acid, single qual 82128 A Amino acids, mult qual 82131 A Amino acids, single quant 82135 A Assay, aminolevulinic acid 82136 A Amino acids, quant, 2-5 82139 A Amino acids, quan, 6 or more 82140 A Assay of ammonia 82143 A Amniotic fluid scan 82145 A Assay of amphetamines 82150 A Assay of amylase 82154 A Androstanediol glucuronide 82157 A Assay of androstenedione 82160 A Assay of androsterone 82163 A Assay of angiotensin II 82164 A Angiotensin I enzyme test 82172 A Assay of apolipoprotein 82175 A Assay of arsenic 82180 A Assay of ascorbic acid 82190 A Atomic absorption 82205 A Assay of barbiturates 82232 A Assay of beta-2 protein 82239 A Bile acids, total 82240 A Bile acids, cholylglycine 82247 A Bilirubin, total 82248 A Bilirubin, direct 82251 A Assay of bilirubin 82252 A Fecal bilirubin test 82261 A Assay of biotinidase 82270 A Test for blood, feces 82273 A Test for blood, other source 82286 A Assay of bradykinin 82300 A Assay of cadmium 82306 A Assay of vitamin D Start Printed Page 18639 82307 A Assay of vitamin D 82308 A Assay of calcitonin 82310 A Assay of calcium 82330 A Assay of calcium 82331 A Calcium infusion test 82340 A Assay of calcium in urine 82355 A Calculus (stone) analysis 82360 A Calculus (stone) assay 82365 A Calculus (stone) assay 82370 A X-ray assay, calculus 82374 A Assay, blood carbon dioxide 82375 A Assay, blood carbon monoxide 82376 A Test for carbon monoxide 82378 A Carcinoembryonic antigen 82379 A Assay of carnitine 82380 A Assay of carotene 82382 A Assay, urine catecholamines 82383 A Assay, blood catecholamines 82384 A Assay, three catecholamines 82387 A Assay of cathepsin-d 82390 A Assay of ceruloplasmin 82397 A Chemiluminescent assay 82415 A Assay of chloramphenicol 82435 A Assay of blood chloride 82436 A Assay of urine chloride 82438 A Assay, other fluid chlorides 82441 A Test for chlorohydrocarbons 82465 A Assay of serum cholesterol 82480 A Assay, serum cholinesterase 82482 A Assay, rbc cholinesterase 82485 A Assay, chondroitin sulfate 82486 A Gas/liquid chromatography 82487 A Paper chromatography 82488 A Paper chromatography 82489 A Thin layer chromatography 82491 A Chromotography, quant, sing 82492 A Chromotography, quant, mult 82495 A Assay of chromium 82507 A Assay of citrate 82520 A Assay of cocaine 82523 A Collagen crosslinks 82525 A Assay of copper 82528 A Assay of corticosterone 82530 A Cortisol, free 82533 A Total cortisol 82540 A Assay of creatine 82541 A Column chromotography, qual 82542 A Column chromotography, quant 82543 A Column chromotograph/isotope 82544 A Column chromotograph/isotope 82550 A Assay of ck (cpk) 82552 A Assay of cpk in blood 82553 A Creatine, MB fraction 82554 A Creatine, isoforms 82565 A Assay of creatinine 82570 A Assay of urine creatinine 82575 A Creatinine clearance test 82585 A Assay of cryofibrinogen 82595 A Assay of cryoglobulin 82600 A Assay of cyanide 82607 A Vitamin B-12 82608 A B-12 binding capacity 82615 A Test for urine cystines 82626 A Dehydroepiandrosterone 82627 A Dehydroepiandrosterone 82633 A Desoxycorticosterone 82634 A Deoxycortisol 82638 A Assay of dibucaine number 82646 A Assay of dihydrocodeinone 82649 A Assay of dihydromorphinone 82651 A Assay of dihydrotestosterone 82652 A Assay of dihydroxyvitamin d 82654 A Assay of dimethadione Start Printed Page 18640 82657 A Enzyme cell activity 82658 A Enzyme cell activity, ra 82664 A Electrophoretic test 82666 A Assay of epiandrosterone 82668 A Assay of erythropoietin 82670 A Assay of estradiol 82671 A Assay of estrogens 82672 A Assay of estrogen 82677 A Assay of estriol 82679 A Assay of estrone 82690 A Assay of ethchlorvynol 82693 A Assay of ethylene glycol 82696 A Assay of etiocholanolone 82705 A Fats/lipids, feces, qual 82710 A Fats/lipids, feces, quant 82715 A Assay of fecal fat 82725 A Assay of blood fatty acids 82726 A Long chain fatty acids 82728 A Assay of ferritin 82731 A Assay of fetal fibronectin 82735 A Assay of fluoride 82742 A Assay of flurazepam 82746 A Blood folic acid serum 82747 A Assay of folic acid, rbc 82757 A Assay of semen fructose 82759 A Assay of rbc galactokinase 82760 A Assay of galactose 82775 A Assay galactose transferase 82776 A Galactose transferase test 82784 A Assay of gammaglobulin igm 82785 A Assay of gammaglobulin ige 82787 A Igg 1, 2, 3 and 4 82800 A Blood pH 82803 A Blood gases: pH, pO2 & pCO2 82805 A Blood gases W/02 saturation 82810 A Blood gases, O2 sat only 82820 A Hemoglobin-oxygen affinity 82926 A Assay of gastric acid 82928 A Assay of gastric acid 82938 A Gastrin test 82941 A Assay of gastrin 82943 A Assay of glucagon 82946 A Glucagon tolerance test 82947 A Assay of glucose, quant 82948 A Reagent strip/blood glucose 82950 A Glucose test 82951 A Glucose tolerance test (GTT) 82952 A GTT-added samples 82953 A Glucose-tolbutamide test 82955 A Assay of g6pd enzyme 82960 A Test for G6PD enzyme 82962 A Glucose blood test 82963 A Assay of glucosidase 82965 A Assay of gdh enzyme 82975 A Assay of glutamine 82977 A Assay of GGT 82978 A Assay of glutathione 82979 A Assay, rbc glutathione 82980 A Assay of glutethimide 82985 A Glycated protein 83001 A Gonadotropin (FSH) 83002 A Gonadotropin (LH) 83003 A Assay, growth hormone (hgh) 83008 A Assay of guanosine 83010 A Assay of haptoglobin, quant 83012 A Assay of haptoglobins 83013 A H pylori breath tst analysis 83014 A H pylori drug admin/collect 83015 A Heavy metal screen 83018 A Quantitative screen, metals 83020 A Hemoglobin electrophoresis 83021 A Hemoglobin chromotography 83026 A Hemoglobin, copper sulfate Start Printed Page 18641 83030 A Fetal hemoglobin assay 83033 A Fetal fecal hemoglobin assay 83036 A Glycated hemoglobin test 83045 A Blood methemoglobin test 83050 A Blood methemoglobin assay 83051 A Assay of plasma hemoglobin 83055 A Blood sulfhemoglobin test 83060 A Blood sulfhemoglobin assay 83065 A Assay of hemoglobin heat 83068 A Hemoglobin stability screen 83069 A Assay of urine hemoglobin 83070 A Assay of hemosiderin, qual 83071 A Assay of hemosiderin, quant 83080 A Assay of b hexosaminidase 83088 A Assay of histamine 83150 A Assay of for hva 83491 A Assay of corticosteroids 83497 A Assay of 5-hiaa 83498 A Assay of progesterone 83499 A Assay of progesterone 83500 A Assay, free hydroxyproline 83505 A Assay, total hydroxyproline 83516 A Immunoassay, nonantibody 83518 A Immunoassay, dipstick 83519 A Immunoassay, nonantibody 83520 A Immunoassay, RIA 83525 A Assay of insulin 83527 A Assay of insulin 83528 A Assay of intrinsic factor 83540 A Assay of iron 83550 A Iron binding test 83570 A Assay of idh enzyme 83582 A Assay of ketogenic steroids 83586 A Assay 17-ketosteroids 83593 A Fractionation, ketosteroids 83605 A Assay of lactic acid 83615 A Lactate (LD) (LDH) enzyme 83625 A Assay of ldh enzymes 83632 A Placental lactogen 83633 A Test urine for lactose 83634 A Assay of urine for lactose 83655 A Assay of lead 83661 A Assay of l/s ratio 83662 A L/S ratio, foam stability 83670 A Assay of lap enzyme 83690 A Assay of lipase 83715 A Assay of blood lipoproteins 83716 A Assay of blood lipoproteins 83718 A Assay of lipoprotein 83719 A Assay of blood lipoprotein 83721 A Assay of blood lipoprotein 83727 A Assay of lrh hormone 83735 A Assay of magnesium 83775 A Assay of md enzyme 83785 A Assay of manganese 83788 A Mass spectrometry qual 83789 A Mass spectrometry quant 83805 A Assay of meprobamate 83825 A Assay of mercury 83835 A Assay of metanephrines 83840 A Assay of methadone 83857 A Assay of methemalbumin 83858 A Assay of methsuximide 83864 A Mucopolysaccharides 83866 A Mucopolysaccharides screen 83872 A Assay synovial fluid mucin 83873 A Assay of csf protein 83874 A Assay of myoglobin 83883 A Assay, nephelometry not spec 83885 A Assay of nickel 83887 A Assay of nicotine 83890 A Molecule isolate 83891 A Molecule isolate nucleic Start Printed Page 18642 83892 A Molecular diagnostics 83893 A Molecule dot/slot/blot 83894 A Molecule gel electrophor 83896 A Molecular diagnostics 83897 A Molecule nucleic transfer 83898 A Molecule nucleic ampli 83901 A Molecule nucleic ampli 83902 A Molecular diagnostics 83903 A Molecule mutation scan 83904 A Molecule mutation identify 83905 A Molecule mutation identify 83906 A Molecule mutation identify 83912 A Genetic examination 83915 A Assay of nucleotidase 83916 A Oligoclonal bands 83918 A Assay, organic acids quant 83919 A Assay, organic acids qual 83925 A Assay of opiates 83930 A Assay of blood osmolality 83935 A Assay of urine osmolality 83937 A Assay of osteocalcin 83945 A Assay of oxalate 83970 A Assay of parathormone 83986 A Assay of body fluid acidity 83992 A Assay for phencyclidine 84022 A Assay of phenothiazine 84030 A Assay of blood pku 84035 A Assay of phenylketones 84060 A Assay acid phosphatase 84061 A Phosphatase, forensic exam 84066 A Assay prostate phosphatase 84075 A Assay alkaline phosphatase 84078 A Assay alkaline phosphatase 84080 A Assay alkaline phosphatases 84081 A Amniotic fluid enzyme test 84085 A Assay of rbc pg6d enzyme 84087 A Assay phosphohexose enzymes 84100 A Assay of phosphorus 84105 A Assay of urine phosphorus 84106 A Test for porphobilinogen 84110 A Assay of porphobilinogen 84119 A Test urine for porphyrins 84120 A Assay of urine porphyrins 84126 A Assay of feces porphyrins 84127 A Assay of feces porphyrins 84132 A Assay of serum potassium 84133 A Assay of urine potassium 84134 A Assay of prealbumin 84135 A Assay of pregnanediol 84138 A Assay of pregnanetriol 84140 A Assay of pregnenolone 84143 A Assay of 17-hydroxypregneno 84144 A Assay of progesterone 84146 A Assay of prolactin 84150 A Assay of prostaglandin 84153 A Assay of psa, total 84154 A Assay of psa, free 84155 A Assay of protein 84160 A Assay of serum protein 84165 A Assay of serum proteins 84181 A Western blot test 84182 A Protein, western blot test 84202 A Assay RBC protoporphyrin 84203 A Test RBC protoporphyrin 84206 A Assay of proinsulin 84207 A Assay of vitamin b-6 84210 A Assay of pyruvate 84220 A Assay of pyruvate kinase 84228 A Assay of quinine 84233 A Assay of estrogen 84234 A Assay of progesterone 84235 A Assay of endocrine hormone 84238 A Assay, nonendocrine receptor Start Printed Page 18643 84244 A Assay of renin 84252 A Assay of vitamin b-2 84255 A Assay of selenium 84260 A Assay of serotonin 84270 A Assay of sex hormone globul 84275 A Assay of sialic acid 84285 A Assay of silica 84295 A Assay of serum sodium 84300 A Assay of urine sodium 84305 A Assay of somatomedin 84307 A Assay of somatostatin 84311 A Spectrophotometry 84315 A Body fluid specific gravity 84375 A Chromatogram assay, sugars 84376 A Sugars, single, qual 84377 A Sugars, multiple, qual 84378 A Sugars single quant 84379 A Sugars multiple quant 84392 A Assay of urine sulfate 84402 A Assay of testosterone 84403 A Assay of total testosterone 84425 A Assay of vitamin b-1 84430 A Assay of thiocyanate 84432 A Assay of thyroglobulin 84436 A Assay of total thyroxine 84437 A Assay of neonatal thyroxine 84439 A Assay of free thyroxine 84442 A Assay of thyroid activity 84443 A Assay thyroid stim hormone 84445 A Assay of tsi 84446 A Assay of vitamin e 84449 A Assay of transcortin 84450 A Transferase (AST) (SGOT) 84460 A Alanine amino (ALT) (SGPT) 84466 A Assay of transferrin 84478 A Assay of triglycerides 84479 A Assay of thyroid (t3 or t4) 84480 A Assay, triiodothyronine (t3) 84481 A Free assay (FT-3) 84482 A T3 reverse 84484 A Assay of troponin, quant 84485 A Assay duodenal fluid trypsin 84488 A Test feces for trypsin 84490 A Assay of feces for trypsin 84510 A Assay of tyrosine 84512 A Assay of troponin, qual 84520 A Assay of urea nitrogen 84525 A Urea nitrogen semi-quant 84540 A Assay of urine/urea-n 84545 A Urea-N clearance test 84550 A Assay of blood/uric acid 84560 A Assay of urine/uric acid 84577 A Assay of feces/urobilinogen 84578 A Test urine urobilinogen 84580 A Assay of urine urobilinogen 84583 A Assay of urine urobilinogen 84585 A Assay of urine vma 84586 A Assay of vip 84588 A Assay of vasopressin 84590 A Assay of vitamin a 84597 A Assay of vitamin k 84600 A Assay of volatiles 84620 A Xylose tolerance test 84630 A Assay of zinc 84681 A Assay of c-peptide 84702 A Chorionic gonadotropin test 84703 A Chorionic gonadotropin assay 84830 A Ovulation tests 84999 A Clinical chemistry test 85002 A Bleeding time test 85007 A Differential WBC count 85008 A Nondifferential WBC count 85009 A Differential WBC count Start Printed Page 18644 85013 A Hematocrit 85014 A Hematocrit 85018 A Hemoglobin 85021 A Automated hemogram 85022 A Automated hemogram 85023 A Automated hemogram 85024 A Automated hemogram 85025 A Automated hemogram 85027 A Automated hemogram 85031 A Manual hemogram, cbc 85041 A Red blood cell (RBC) count 85044 A Reticulocyte count 85045 A Reticulocyte count 85046 A Reticyte/hgb concentrate 85048 A White blood cell (WBC) count 85060 X Blood smear interpretation 0342 0.26 $12.61 $8.03 $2.52 85095 T Bone marrow aspiration 0003 0.98 $47.52 $27.99 $9.50 85097 X Bone marrow interpretation 0344 0.79 $38.30 $23.63 $7.66 85102 T Bone marrow biopsy 0003 0.98 $47.52 $27.99 $9.50 85130 A Chromogenic substrate assay 85170 A Blood clot retraction 85175 A Blood clot lysis time 85210 A Blood clot factor II test 85220 A Blood clot factor V test 85230 A Blood clot factor VII test 85240 A Blood clot factor VIII test 85244 A Blood clot factor VIII test 85245 A Blood clot factor VIII test 85246 A Blood clot factor VIII test 85247 A Blood clot factor VIII test 85250 A Blood clot factor IX test 85260 A Blood clot factor X test 85270 A Blood clot factor XI test 85280 A Blood clot factor XII test 85290 A Blood clot factor XIII test 85291 A Blood clot factor XIII test 85292 A Blood clot factor assay 85293 A Blood clot factor assay 85300 A Antithrombin III test 85301 A Antithrombin III test 85302 A Blood clot inhibitor antigen 85303 A Blood clot inhibitor test 85305 A Blood clot inhibitor assay 85306 A Blood clot inhibitor test 85335 A Factor inhibitor test 85337 A Thrombomodulin 85345 A Coagulation time 85347 A Coagulation time 85348 A Coagulation time 85360 A Euglobulin lysis 85362 A Fibrin degradation products 85366 A Fibrinogen test 85370 A Fibrinogen test 85378 A Fibrin degradation 85379 A Fibrin degradation 85384 A Fibrinogen 85385 A Fibrinogen 85390 A Fibrinolysins screen 85400 A Fibrinolytic plasmin 85410 A Fibrinolytic antiplasmin 85415 A Fibrinolytic plasminogen 85420 A Fibrinolytic plasminogen 85421 A Fibrinolytic plasminogen 85441 A Heinz bodies, direct 85445 A Heinz bodies, induced 85460 A Hemoglobin, fetal 85461 A Hemoglobin, fetal 85475 A Hemolysin 85520 A Heparin assay 85525 A Heparin 85530 A Heparin-protamine tolerance 85535 A Iron stain, blood cells 85540 A Wbc alkaline phosphatase Start Printed Page 18645 85547 A RBC mechanical fragility 85549 A Muramidase 85555 A RBC osmotic fragility 85557 A RBC osmotic fragility 85576 A Blood platelet aggregation 85585 A Blood platelet estimation 85590 A Platelet count, manual 85595 A Platelet count, automated 85597 A Platelet neutralization 85610 A Prothrombin time 85611 A Prothrombin test 85612 A Viper venom prothrombin time 85613 A Russell viper venom, diluted 85635 A Reptilase test 85651 A Rbc sed rate, nonautomated 85652 A Rbc sed rate, automated 85660 A RBC sickle cell test 85670 A Thrombin time, plasma 85675 A Thrombin time, titer 85705 A Thromboplastin inhibition 85730 A Thromboplastin time, partial 85732 A Thromboplastin time, partial 85810 A Blood viscosity examination 85999 A Hematology procedure 86000 A Agglutinins, febrile 86003 A Allergen specific IgE 86005 A Allergen specific IgE 86021 A WBC antibody identification 86022 A Platelet antibodies 86023 A Immunoglobulin assay 86038 A Antinuclear antibodies 86039 A Antinuclear antibodies (ANA) 86060 A Antistreptolysin o, titer 86063 A Antistreptolysin o, screen 86077 X Physician blood bank service 0343 0.45 $21.82 $12.16 $4.36 86078 X Physician blood bank service 0344 0.79 $38.30 $23.63 $7.66 86079 X Physician blood bank service 0344 0.79 $38.30 $23.63 $7.66 86140 A C-reactive protein 86147 A Cardiolipin antibody 86148 A Phospholipid antibody 86155 A Chemotaxis assay 86156 A Cold agglutinin, screen 86157 A Cold agglutinin, titer 86160 A Complement, antigen 86161 A Complement/function activity 86162 A Complement, total (CH50) 86171 A Complement fixation, each 86185 A Counterimmunoelectrophoresis 86215 A Deoxyribonuclease, antibody 86225 A DNA antibody 86226 A DNA antibody, single strand 86235 A Nuclear antigen antibody 86243 A Fc receptor 86255 A Fluorescent antibody, screen 86256 A Fluorescent antibody, titer 86277 A Growth hormone antibody 86280 A Hemagglutination inhibition 86308 A Heterophile antibodies 86309 A Heterophile antibodies 86310 A Heterophile antibodies 86316 A Immunoassay, tumor antigen 86317 A Immunoassay, infectious agent 86318 A Immunoassay, infectious agent 86320 A Serum immunoelectrophoresis 86325 A Other immunoelectrophoresis 86327 A Immunoelectrophoresis assay 86329 A Immunodiffusion 86331 A Immunodiffusion ouchterlony 86332 A Immune complex assay 86334 A Immunofixation procedure 86337 A Insulin antibodies 86340 A Intrinsic factor antibody 86341 A Islet cell antibody Start Printed Page 18646 86343 A Leukocyte histamine release 86344 A Leukocyte phagocytosis 86353 A Lymphocyte transformation 86359 A T cells, total count 86360 A T cell, absolute count/ratio 86361 A T cell, absolute count 86376 A Microsomal antibody 86378 A Migration inhibitory factor 86382 A Neutralization test, viral 86384 A Nitroblue tetrazolium dye 86403 A Particle agglutination test 86406 A Particle agglutination test 86430 A Rheumatoid factor test 86431 A Rheumatoid factor, quant 86485 X Skin test, candida 0341 0.13 $6.30 $3.67 $1.26 86490 X Coccidioidomycosis skin test 0341 0.13 $6.30 $3.67 $1.26 86510 X Histoplasmosis skin test 0341 0.13 $6.30 $3.67 $1.26 86580 X TB intradermal test 0341 0.13 $6.30 $3.67 $1.26 86585 X TB tine test 0341 0.13 $6.30 $3.67 $1.26 86586 X Skin test, unlisted 0341 0.13 $6.30 $3.67 $1.26 86590 A Streptokinase, antibody 86592 A Blood serology, qualitative 86593 A Blood serology, quantitative 86602 A Antinomyces antibody 86603 A Adenovirus antibody 86606 A Aspergillus antibody 86609 A Bacterium antibody 86612 A Blastomyces antibody 86615 A Bordetella antibody 86617 A Lyme disease antibody 86618 A Lyme disease antibody 86619 A Borrelia antibody 86622 A Brucella antibody 86625 A Campylobacter antibody 86628 A Candida antibody 86631 A Chlamydia antibody 86632 A Chlamydia igm antibody 86635 A Coccidioides antibody 86638 A Q fever antibody 86641 A Cryptococcus antibody 86644 A CMV antibody 86645 A CMV antibody, IgM 86648 A Diphtheria antibody 86651 A Encephalitis antibody 86652 A Encephalitis antibody 86653 A Encephalitis antibody 86654 A Encephalitis antibody 86658 A Enterovirus antibody 86663 A Epstein-barr antibody 86664 A Epstein-barr antibody 86665 A Epstein-barr antibody 86668 A Francisella tularensis 86671 A Fungus antibody 86674 A Giardia lamblia antibody 86677 A Helicobacter pylori 86682 A Helminth antibody 86684 A Hemophilus influenza 86687 A Htlv-i antibody 86688 A Htlv-ii antibody 86689 A HTLV/HIV confirmatory test 86692 A Hepatitis, delta agent 86694 A Herpes simplex test 86695 A Herpes simplex test 86698 A Histoplasma 86701 A HIV-1 86702 A HIV-2 86703 A HIV-1/HIV-2, single assay 86704 A Hep b core antibody, igg/igm 86705 A Hep b core antibody, igm 86706 A Hep b surface antibody 86707 A Hep be antibody 86708 A Hep a antibody, igg/igm 86709 A Hep a antibody, igm Start Printed Page 18647 86710 A Influenza virus antibody 86713 A Legionella antibody 86717 A Leishmania antibody 86720 A Leptospira antibody 86723 A Listeria monocytogenes ab 86727 A Lymph choriomeningitis ab 86729 A Lympho venereum antibody 86732 A Mucormycosis antibody 86735 A Mumps antibody 86738 A Mycoplasma antibody 86741 A Neisseria meningitidis 86744 A Nocardia antibody 86747 A Parvovirus antibody 86750 A Malaria antibody 86753 A Protozoa antibody nos 86756 A Respiratory virus antibody 86759 A Rotavirus antibody 86762 A Rubella antibody 86765 A Rubeola antibody 86768 A Salmonella antibody 86771 A Shigella antibody 86774 A Tetanus antibody 86777 A Toxoplasma antibody 86778 A Toxoplasma antibody, igm 86781 A Treponema pallidum, confirm 86784 A Trichinella antibody 86787 A Varicella-zoster antibody 86790 A Virus antibody nos 86793 A Yersinia antibody 86800 A Thyroglobulin antibody 86803 A Hepatitis c ab test 86804 A Hep c ab test, confirm 86805 A Lymphocytotoxicity assay 86806 A Lymphocytotoxicity assay 86807 A Cytotoxic antibody screening 86808 A Cytotoxic antibody screening 86812 A HLA typing, A, B, or C 86813 A HLA typing, A, B, or C 86816 A HLA typing, DR/DQ 86817 A HLA typing, DR/DQ 86821 A Lymphocyte culture, mixed 86822 A Lymphocyte culture, primed 86849 A Immunology procedure 86850 A RBC antibody screen 86860 A RBC antibody elution 86870 A RBC antibody identification 86880 A Coombs test 86885 A Coombs test 86886 A Coombs test 86890 A Autologous blood process 86891 A Autologous blood, op salvage 86900 A Blood typing, ABO 86901 A Blood typing, Rh (D) 86903 A Blood typing, antigen screen 86904 A Blood typing, patient serum 86905 A Blood typing, RBC antigens 86906 A Blood typing, Rh phenotype 86910 E Blood typing, paternity test 86911 E Blood typing, antigen system 86915 A Bone marrow/stem cell prep 86920 A Compatibility test 86921 A Compatibility test 86922 A Compatibility test 86927 A Plasma, fresh frozen 86930 A Frozen blood prep 86931 A Frozen blood thaw 86932 A Frozen blood freeze/thaw 86940 A Hemolysins/agglutinins, auto 86941 A Hemolysins/agglutinins 86945 A Blood product/irradiation 86950 A Leukacyte transfusion 86965 A Pooling blood platelets 86970 A RBC pretreatment Start Printed Page 18648 86971 A RBC pretreatment 86972 A RBC pretreatment 86975 A RBC pretreatment, serum 86976 A RBC pretreatment, serum 86977 A RBC pretreatment, serum 86978 A RBC pretreatment, serum 86985 A Split blood or products 86999 A Transfusion procedure 87001 A Small animal inoculation 87003 A Small animal inoculation 87015 A Specimen concentration 87040 A Blood culture for bacteria 87045 A Stool culture for bacteria 87060 A Nose/throat culture, bact 87070 A Culture specimen, bacteria 87072 A Culture of specimen by kit 87075 A Culture specimen, bacteria 87076 A Bacteria identification 87081 A Bacteria culture screen 87082 A Culture of specimen by kit 87083 A Culture of specimen by kit 87084 A Culture of specimen by kit 87085 A Culture of specimen by kit 87086 A Urine culture/colony count 87087 A Urine bacteria culture 87088 A Urine bacteria culture 87101 A Skin fungus culture 87102 A Fungus isolation culture 87103 A Blood fungus culture 87106 A Fungus identification 87109 A Mycoplasma culture 87110 A Culture, chlamydia 87116 A Mycobacteria culture 87117 A Mycobacteria culture 87118 A Mycobacteria identification 87140 A Culture typing, fluorescent 87143 A Culture typing, GLC method 87145 A Culture typing, phage method 87147 A Culture typing, serologic 87151 A Culture typing, serologic 87155 A Culture typing, precipitin 87158 A Culture typing, added method 87163 A Special microbiology culture 87164 A Dark field examination 87166 A Dark field examination 87174 A Endotoxin, bacterial 87175 A Assay, endotoxin, bacterial 87176 A Endotoxin, bacterial 87177 A Ova and parasites smears 87181 A Antibiotic sensitivity, each 87184 A Antibiotic sensitivity, each 87186 A Antibiotic sensitivity, MIC 87187 A Antibiotic sensitivity, MBC 87188 A Antibiotic sensitivity, each 87190 A TB antibiotic sensitivity 87192 A Antibiotic sensitivity, each 87197 A Bactericidal level, serum 87205 A Smear, stain & interpret 87206 A Smear, stain & interpret 87207 A Smear, stain & interpret 87208 A Smear, stain & interpret 87210 A Smear, stain & interpret 87211 A Smear, stain & interpret 87220 A Tissue exam for fungi 87230 A Assay, toxin or antitoxin 87250 A Virus inoculation for test 87252 A Virus inoculation for test 87253 A Virus inoculation for test 87260 A Adenovirus ag, dfa 87265 A Pertussis ag, dfa 87270 A Chylmd trach ag, dfa 87272 A Cryptosporidum ag, dfa 87274 A Herpes simplex ag, dfa Start Printed Page 18649 87276 A Influenza ag, dfa 87278 A Legion pneumo ag, dfa 87280 A Resp syncytial ag, dfa 87285 A Trepon pallidum ag, dfa 87290 A Varicella ag, dfa 87299 A Ag detection nos, dfa 87301 A Adenovirus ag, eia 87320 A Chylmd trach ag, eia 87324 A Clostridium ag, eia 87328 A Cryptospor ag, eia 87332 A Cytomegalovirus ag, eia 87335 A E coli 0157 ag, eia 87338 A Hpylori, stool, eia 87340 A Hepatitis b surface ag, eia 87350 A Hepatitis be ag, eia 87380 A Hepatitis delta ag, eia 87385 A Histoplasma capsul ag, eia 87390 A Hiv-1 ag, eia 87391 A Hiv-2 ag, eia 87420 A Resp syncytial ag, eia 87425 A Rotavirus ag, eia 87430 A Strep a ag, eia 87449 A Ag detect nos, eia, mult 87450 A Ag detect nos, eia, single 87470 A Bartonella, dna, dir probe 87471 A Bartonella, dna, amp probe 87472 A Bartonella, dna, quant 87475 A Lyme dis, dna, dir probe 87476 A Lyme dis, dna, amp probe 87477 A Lyme dis, dna, quant 87480 A Candida, dna, dir probe 87481 A Candida, dna, amp probe 87482 A Candida, dna, quant 87485 A Chylmd pneum, dna, dir probe 87486 A Chylmd pneum, dna, amp probe 87487 A Chylmd pneum, dna, quant 87490 A Chylmd trach, dna, dir probe 87491 A Chylmd trach, dna, amp probe 87492 A Chylmd trach, dna, quant 87495 A Cytomeg, dna, dir probe 87496 A Cytomeg, dna, amp probe 87497 A Cytomeg, dna, quant 87510 A Gardner vag, dna, dir probe 87511 A Gardner vag, dna, amp probe 87512 A Gardner vag, dna, quant 87515 A Hepatitis b, dna, dir probe 87516 A Hepatitis b, dna, amp probe 87517 A Hepatitis b, dna, quant 87520 A Hepatitis c, rna, dir probe 87521 A Hepatitis c, rna, amp probe 87522 A Hepatitis c, rna, quant 87525 A Hepatitis g, dna, dir probe 87526 A Hepatitis g, dna, amp probe 87527 A Hepatitis g, dna, quant 87528 A Hsv, dna, dir probe 87529 A Hsv, dna, amp probe 87530 A Hsv, dna, quant 87531 A Hhv-6, dna, dir probe 87532 A Hhv-6, dna, amp probe 87533 A Hhv-6, dna, quant 87534 A Hiv-1, dna, dir probe 87535 A Hiv-1, dna, amp probe 87536 A Hiv-1, dna, quant 87537 A Hiv-2, dna, dir probe 87538 A Hiv-2, dna, amp probe 87539 A Hiv-2, dna, quant 87540 A Legion pneumo, dna, dir prob 87541 A Legion pneumo, dna, amp prob 87542 A Legion pneumo, dna, quant 87550 A Mycobacteria, dna, dir probe 87551 A Mycobacteria, dna, amp probe 87552 A Mycobacteria, dna, quant 87555 A M.tuberculo, dna, dir probe Start Printed Page 18650 87556 A M.tuberculo, dna, amp probe 87557 A M.tuberculo, dna, quant 87560 A M.avium-intra, dna, dir prob 87561 A M.avium-intra, dna, amp prob 87562 A M.avium-intra, dna, quant 87580 A M.pneumon, dna, dir probe 87581 A M.pneumon, dna, amp probe 87582 A M.pneumon, dna, quant 87590 A N.gonorrhoeae, dna, dir prob 87591 A N.gonorrhoeae, dna, amp prob 87592 A N.gonorrhoeae, dna, quant 87620 A Hpv, dna, dir probe 87621 A Hpv, dna, amp probe 87622 A Hpv, dna, quant 87650 A Strep a, dna, dir probe 87651 A Strep a, dna, amp probe 87652 A Strep a, dna, quant 87797 A Detect agent nos, dna, dir 87798 A Detect agent nos, dna, amp 87799 A Detect agent nos, dna, quant 87810 A Chylmd trach assay w/optic 87850 A N. gonorrhoeae assay w/optic 87880 A Strep a assay w/optic 87899 A Agent nos assay w/optic 87999 A Microbiology procedure 88000 E Autopsy (necropsy), gross 88005 E Autopsy (necropsy), gross 88007 E Autopsy (necropsy), gross 88012 E Autopsy (necropsy), gross 88014 E Autopsy (necropsy), gross 88016 E Autopsy (necropsy), gross 88020 E Autopsy (necropsy), complete 88025 E Autopsy (necropsy), complete 88027 E Autopsy (necropsy), complete 88028 E Autopsy (necropsy), complete 88029 E Autopsy (necropsy), complete 88036 E Limited autopsy 88037 E Limited autopsy 88040 E Forensic autopsy (necropsy) 88045 E Coroner's autopsy (necropsy) 88099 E Necropsy (autopsy) procedure 88104 X Cytopathology, fluids 0343 0.45 $21.82 $12.16 $4.36 88106 X Cytopathology, fluids 0343 0.45 $21.82 $12.16 $4.36 88107 X Cytopathology, fluids 0343 0.45 $21.82 $12.16 $4.36 88108 X Cytopath, concentrate tech 0343 0.45 $21.82 $12.16 $4.36 88125 X Forensic cytopathology 0343 0.45 $21.82 $12.16 $4.36 88130 A Sex chromatin identification 88140 A Sex chromatin identification 88141 N Cytopath, c/v, interpret 88142 A Cytopath, c/v, thin layer 88143 A Cytopath c/v thin layer redo 88144 A Cytopath, c/v thin lyr redo 88145 A Cytopath, c/v thin lyr sel 88147 A Cytopath, c/v, automated 88148 A Cytopath, c/v, auto rescreen 88150 A Cytopath, c/v, manual 88152 A Cytopath, c/v, auto redo 88153 A Cytopath, c/v, redo 88154 A Cytopath, c/v, select 88155 A Cytopath, c/v, index add-on 88160 X Cytopath smear, other source 0342 0.26 $12.61 $8.03 $2.52 88161 X Cytopath smear, other source 0343 0.45 $21.82 $12.16 $4.36 88162 X Cytopath smear, other source 0343 0.45 $21.82 $12.16 $4.36 88164 A Cytopath tbs, c/v, manual 88165 A Cytopath tbs, c/v, redo 88166 A Cytopath tbs, c/v, auto redo 88167 A Cytopath tbs, c/v, select 88170 T Fine needle aspiration 0002 0.62 $30.06 $17.66 $6.01 88171 T Fine needle aspiration 0002 0.62 $30.06 $17.66 $6.01 88172 X Evaluation of smear 0343 0.45 $21.82 $12.16 $4.36 88173 X Interpretation of smear 0343 0.45 $21.82 $12.16 $4.36 88180 X Cell marker study 0344 0.79 $38.30 $23.63 $7.66 88182 X Cell marker study 0344 0.79 $38.30 $23.63 $7.66 Start Printed Page 18651 88199 X Cytopathology procedure 0342 0.26 $12.61 $8.03 $2.52 88230 A Tissue culture, lymphocyte 88233 A Tissue culture, skin/biopsy 88235 A Tissue culture, placenta 88237 A Tissue culture, bone marrow 88239 A Tissue culture, tumor 88240 A Cell cryopreserve/storage 88241 A Frozen cell preparation 88245 A Chromosome analysis, 20-25 88248 A Chromosome analysis, 50-100 88249 A Chromosome analysis, 100 88261 A Chromosome analysis, 5 88262 A Chromosome analysis, 15-20 88263 A Chromosome analysis, 45 88264 A Chromosome analysis, 20-25 88267 A Chromosome analys, placenta 88269 A Chromosome analys, amniotic 88271 A Cytogenetics, dna probe 88272 A Cytogenetics, 3-5 88273 A Cytogenetics, 10-30 88274 A Cytogenetics, 25-99 88275 A Cytogenetics, 100-300 88280 A Chromosome karyotype study 88283 A Chromosome banding study 88285 A Chromosome count, additional 88289 A Chromosome study, additional 88291 A Cyto/molecular report 88299 A Cytogenetic study 88300 X Surgical path, gross 0342 0.26 $12.61 $8.03 $2.52 88302 X Tissue exam by pathologist 0342 0.26 $12.61 $8.03 $2.52 88304 X Tissue exam by pathologist 0343 0.45 $21.82 $12.16 $4.36 88305 X Tissue exam by pathologist 0343 0.45 $21.82 $12.16 $4.36 88307 X Tissue exam by pathologist 0344 0.79 $38.30 $23.63 $7.66 88309 X Tissue exam by pathologist 0344 0.79 $38.30 $23.63 $7.66 88311 X Decalcify tissue 0342 0.26 $12.61 $8.03 $2.52 88312 X Special stains 0343 0.45 $21.82 $12.16 $4.36 88313 X Special stains 0342 0.26 $12.61 $8.03 $2.52 88314 X Histochemical stain 0343 0.45 $21.82 $12.16 $4.36 88318 X Chemical histochemistry 0343 0.45 $21.82 $12.16 $4.36 88319 X Enzyme histochemistry 0342 0.26 $12.61 $8.03 $2.52 88321 X Microslide consultation 0342 0.26 $12.61 $8.03 $2.52 88323 X Microslide consultation 0343 0.45 $21.82 $12.16 $4.36 88325 X Comprehensive review of data 0343 0.45 $21.82 $12.16 $4.36 88329 X Pathology consult in surgery 0343 0.45 $21.82 $12.16 $4.36 88331 X Pathology consult in surgery 0343 0.45 $21.82 $12.16 $4.36 88332 X Pathology consult in surgery 0343 0.45 $21.82 $12.16 $4.36 88342 X Immunocytochemistry 0344 0.79 $38.30 $23.63 $7.66 88346 X Immunofluorescent study 0343 0.45 $21.82 $12.16 $4.36 88347 X Immunofluorescent study 0344 0.79 $38.30 $23.63 $7.66 88348 X Electron microscopy 0344 0.79 $38.30 $23.63 $7.66 88349 X Scanning electron microscopy 0344 0.79 $38.30 $23.63 $7.66 88355 X Analysis, skeletal muscle 0344 0.79 $38.30 $23.63 $7.66 88356 X Analysis, nerve 0344 0.79 $38.30 $23.63 $7.66 88358 X Analysis, tumor 0344 0.79 $38.30 $23.63 $7.66 88362 X Nerve teasing preparations 0343 0.45 $21.82 $12.16 $4.36 88365 X Tissue hybridization 0344 0.79 $38.30 $23.63 $7.66 88371 A Protein, western blot tissue 88372 A Protein analysis w/probe 88399 X Surgical pathology procedure 0342 0.26 $12.61 $8.03 $2.52 89050 A Body fluid cell count 89051 A Body fluid cell count 89060 A Exam, synovial fluid crystals 89100 X Sample intestinal contents 0361 3.53 $171.16 $88.09 $34.23 89105 X Sample intestinal contents 0360 1.38 $66.91 $34.75 $13.38 89125 A Specimen fat stain 89130 X Sample stomach contents 0360 1.38 $66.91 $34.75 $13.38 89132 X Sample stomach contents 0360 1.38 $66.91 $34.75 $13.38 89135 X Sample stomach contents 0360 1.38 $66.91 $34.75 $13.38 89136 X Sample stomach contents 0360 1.38 $66.91 $34.75 $13.38 89140 X Sample stomach contents 0360 1.38 $66.91 $34.75 $13.38 89141 X Sample stomach contents 0361 3.53 $171.16 $88.09 $34.23 89160 A Exam feces for meat fibers 89190 A Nasal smear for eosinophils Start Printed Page 18652 89250 A Fertilization of oocyte 89251 A Culture oocyte w/embryos 89252 A Assist oocyte fertilization 89253 A Embryo hatching 89254 A Oocyte identification 89255 A Prepare embryo for transfer 89256 A Prepare cryopreserved embryo 89257 A Sperm identification 89258 A Cryopreservation, embryo 89259 A Cryopreservation, sperm 89260 A Sperm isolation, simple 89261 A Sperm isolation, complex 89264 A Identify sperm tissue 89300 A Semen analysis 89310 A Semen analysis 89320 A Semen analysis 89325 A Sperm antibody test 89329 A Sperm evaluation test 89330 A Evaluation, cervical mucus 89350 X Sputum specimen collection 0344 0.79 $38.30 $23.63 $7.66 89355 A Exam feces for starch 89360 X Collect sweat for test 0344 0.79 $38.30 $23.63 $7.66 89365 A Water load test 89399 X Pathology lab procedure 0343 0.45 $21.82 $12.16 $4.36 90281 E Human ig, im 90283 E Human ig, iv 90287 X Botulinum antitoxin 0357 1.85 $89.70 $38.31 $17.94 90288 E Botulism ig, iv 90291 E Cmv ig, iv 90296 X Diphtheria antitoxin 0357 1.85 $89.70 $38.31 $17.94 90371 X Hep b ig, im 0356 0.36 $17.46 $4.82 $3.49 90375 X Rabies ig, im/sc 0357 1.85 $89.70 $38.31 $17.94 90376 X Rabies ig, heat treated 0357 1.85 $89.70 $38.31 $17.94 90378 X Rsv ig, im 0357 1.85 $89.70 $38.31 $17.94 90379 X Rsv ig, iv 0357 1.85 $89.70 $38.31 $17.94 90384 X Rh ig, full-dose, im 0357 1.85 $89.70 $38.31 $17.94 90385 X Rh ig, minidose, im 0357 1.85 $89.70 $38.31 $17.94 90386 X Rh ig, iv 0357 1.85 $89.70 $38.31 $17.94 90389 X Tetanus ig, im 0356 0.36 $17.46 $4.82 $3.49 90393 X Vaccina ig, im 0357 1.85 $89.70 $38.31 $17.94 90396 X Varicella-zoster ig, im 0356 0.36 $17.46 $4.82 $3.49 90399 E Immune globulin 90471 N Immunization admin 90472 N Immunization admin, each add 90476 X Adenovirus vaccine, type 4 0356 0.36 $17.46 $4.82 $3.49 90477 X Adenovirus vaccine, type 7 0356 0.36 $17.46 $4.82 $3.49 90581 X Anthrax vaccine, sc 0357 1.85 $89.70 $38.31 $17.94 90585 X Bcg vaccine, percut 0356 0.36 $17.46 $4.82 $3.49 90586 X Bcg vaccine, intravesical 0356 0.36 $17.46 $4.82 $3.49 90632 X Hep a vaccine, adult im 0356 0.36 $17.46 $4.82 $3.49 90633 X Hep a vacc, ped/adol, 2 dose 0356 0.36 $17.46 $4.82 $3.49 90634 X Hep a vacc, ped/adol, 3 dose 0356 0.36 $17.46 $4.82 $3.49 90636 X Hep a/hep b vacc, adult im 0357 1.85 $89.70 $38.31 $17.94 90645 X Hib vaccine, hboc, im 0355 0.19 $9.21 $5.05 $1.84 90646 X Hib vaccine, prp-d, im 0355 0.19 $9.21 $5.05 $1.84 90647 X Hib vaccine, prp-omp, im 0355 0.19 $9.21 $5.05 $1.84 90648 X Hib vaccine, prp-t, im 0355 0.19 $9.21 $5.05 $1.84 90657 X Flu vaccine, 6-35 mo, im 0355 0.19 $9.21 $5.05 $1.84 90658 X Flu vaccine, 3 yrs, im 0355 0.19 $9.21 $5.05 $1.84 90659 X Flu vaccine, whole, im 0355 0.19 $9.21 $5.05 $1.84 90660 X Flu vaccine, nasal 0355 0.19 $9.21 $5.05 $1.84 90665 X Lyme disease vaccine, im 0357 1.85 $89.70 $38.31 $17.94 90669 X Pneumococcal vaccine, ped 0357 1.85 $89.70 $38.31 $17.94 90675 X Rabies vaccine, im 0357 1.85 $89.70 $38.31 $17.94 90676 X Rabies vaccine, id 0357 1.85 $89.70 $38.31 $17.94 90680 X Rotovirus vaccine, oral 0356 0.36 $17.46 $4.82 $3.49 90690 X Typhoid vaccine, oral 0356 0.36 $17.46 $4.82 $3.49 90691 X Typhoid vaccine, im 0356 0.36 $17.46 $4.82 $3.49 90692 X Typhoid vaccine, h-p, sc/id 0356 0.36 $17.46 $4.82 $3.49 90693 X Typhoid vaccine, akd, sc 0356 0.36 $17.46 $4.82 $3.49 90700 X Dtap vaccine, im 0355 0.19 $9.21 $5.05 $1.84 90701 X Dtp vaccine, im 0356 0.36 $17.46 $4.82 $3.49 90702 X Dt vaccine, im 0355 0.19 $9.21 $5.05 $1.84 Start Printed Page 18653 90703 X Tetanus vaccine, im 0356 0.36 $17.46 $4.82 $3.49 90704 X Mumps vaccine, sc 0355 0.19 $9.21 $5.05 $1.84 90705 X Measles vaccine, sc 0357 1.85 $89.70 $38.31 $17.94 90706 X Rubella vaccine, sc 0358 6.98 $338.44 $126.74 $67.69 90707 X Mmr vaccine, sc 0356 0.36 $17.46 $4.82 $3.49 90708 X Measles-rubella vaccine, sc 0358 6.98 $338.44 $126.74 $67.69 90709 X Rubella & mumps vaccine, sc 0358 6.98 $338.44 $126.74 $67.69 90710 X Mmrv vaccine, sc 0356 0.36 $17.46 $4.82 $3.49 90712 X Oral poliovirus vaccine 0356 0.36 $17.46 $4.82 $3.49 90713 X Poliovirus, ipv, sc 0355 0.19 $9.21 $5.05 $1.84 90716 X Chicken pox vaccine, sc 0355 0.19 $9.21 $5.05 $1.84 90717 X Yellow fever vaccine, sc 0356 0.36 $17.46 $4.82 $3.49 90718 X Td vaccine, im 0356 0.36 $17.46 $4.82 $3.49 90719 X Diphtheria vaccine, im 0357 1.85 $89.70 $38.31 $17.94 90720 X Dtp/hib vaccine, im 0355 0.19 $9.21 $5.05 $1.84 90721 X Dtap/hib vaccine, im 0355 0.19 $9.21 $5.05 $1.84 90725 X Cholera vaccine, injectable 0358 6.98 $338.44 $126.74 $67.69 90727 X Plague vaccine, im 0355 0.19 $9.21 $5.05 $1.84 90732 X Pneumococcal vaccine, adult 0355 0.19 $9.21 $5.05 $1.84 90733 X Meningococcal vaccine, sc 0357 1.85 $89.70 $38.31 $17.94 90735 X Encephalitis vaccine, sc 0357 1.85 $89.70 $38.31 $17.94 90744 X Hep b vaccine, ped/adol, im 0356 0.36 $17.46 $4.82 $3.49 90746 X Hep b vaccine, adult, im 0356 0.36 $17.46 $4.82 $3.49 90747 X Hep b vaccine, ill pat, im 0356 0.36 $17.46 $4.82 $3.49 90748 X Hep b/hib vaccine, im 0358 6.98 $338.44 $126.74 $67.69 90749 X Vaccine toxoid 0355 0.19 $9.21 $5.05 $1.84 90780 E IV infusion therapy, 1 hour 90781 E IV infusion, additional hour 90782 X Injection, sc/im 0359 0.96 $46.55 $9.31 $9.31 90783 X Injection, ia 0359 0.96 $46.55 $9.31 $9.31 90784 X Injection, iv 0359 0.96 $46.55 $9.31 $9.31 90788 X Injection of antibiotic 0359 0.96 $46.55 $9.31 $9.31 90799 X Ther/prophylactic/dx inject 0359 0.96 $46.55 $9.31 $9.31 90801 S Psy dx interview 0323 1.85 $89.70 $22.48 $17.94 90802 S Intac psy dx interview 0323 1.85 $89.70 $22.48 $17.94 90804 S Psytx, office, 20-30 min 0322 1.32 $64.00 $14.22 $12.80 90805 S Psytx, off, 20-30 min w/e&m 0322 1.32 $64.00 $14.22 $12.80 90806 S Psytx, off, 45-50 min 0323 1.85 $89.70 $22.48 $17.94 90807 S Psytx, off, 45-50 min w/e&m 0323 1.85 $89.70 $22.48 $17.94 90808 S Psytx, office, 75-80 min 0323 1.85 $89.70 $22.48 $17.94 90809 S Psytx, off, 75-80, w/e&m 0323 1.85 $89.70 $22.48 $17.94 90810 S Intac psytx, off, 20-30 min 0322 1.32 $64.00 $14.22 $12.80 90811 S Intac psytx, 20-30, w/e&m 0322 1.32 $64.00 $14.22 $12.80 90812 S Intac psytx, off, 45-50 min 0323 1.85 $89.70 $22.48 $17.94 90813 S Intac psytx, 45-50 min w/e&m 0323 1.85 $89.70 $22.48 $17.94 90814 S Intac psytx, off, 75-80 min 0323 1.85 $89.70 $22.48 $17.94 90815 S Intac psytx, 75-80 w/e&m 0323 1.85 $89.70 $22.48 $17.94 90816 S Psytx, hosp, 20-30 min 0322 1.32 $64.00 $14.22 $12.80 90817 S Psytx, hosp, 20-30 min w/e&m 0322 1.32 $64.00 $14.22 $12.80 90818 S Psytx, hosp, 45-50 min 0323 1.85 $89.70 $22.48 $17.94 90819 S Psytx, hosp, 45-50 min w/e&m 0323 1.85 $89.70 $22.48 $17.94 90821 S Psytx, hosp, 75-80 min 0323 1.85 $89.70 $22.48 $17.94 90822 S Psytx, hosp, 75-80 min w/e&m 0323 1.85 $89.70 $22.48 $17.94 90823 S Intac psytx, hosp, 20-30 min 0322 1.32 $64.00 $14.22 $12.80 90824 S Intac psytx, hsp 20-30 w/e&m 0322 1.32 $64.00 $14.22 $12.80 90826 S Intac psytx, hosp, 45-50 min 0323 1.85 $89.70 $22.48 $17.94 90827 S Intac psytx, hsp 45-50 w/e&m 0323 1.85 $89.70 $22.48 $17.94 90828 S Intac psytx, hosp, 75-80 min 0323 1.85 $89.70 $22.48 $17.94 90829 S Intac psytx, hsp 75-80 w/e&m 0323 1.85 $89.70 $22.48 $17.94 90845 S Psychoanalysis 0323 1.85 $89.70 $22.48 $17.94 90846 S Family psytx w/o patient 0324 1.87 $90.67 $20.19 $18.13 90847 S Family psytx w/patient 0324 1.87 $90.67 $20.19 $18.13 90849 S Multiple family group psytx 0325 1.55 $75.16 $19.96 $15.03 90853 S Group psychotherapy 0325 1.55 $75.16 $19.96 $15.03 90857 S Intac group psytx 0325 1.55 $75.16 $19.96 $15.03 90862 X Medication management 0374 1.17 $56.73 $13.08 $11.35 90865 S Narcosynthesis 0323 1.85 $89.70 $22.48 $17.94 90870 S Electroconvulsive therapy 0320 3.68 $178.43 $80.06 $35.69 90871 S Electroconvulsive therapy 0320 3.68 $178.43 $80.06 $35.69 90875 E Psychophysiological therapy 90876 E Psychophysiological therapy 90880 S Hypnotherapy 0323 1.85 $89.70 $22.48 $17.94 90882 E Environmental manipulation Start Printed Page 18654 90885 N Psy evaluation of records 90887 N Consultation with family 90889 N Preparation of report 90899 S Psychiatric service/therapy 0322 1.32 $64.00 $14.22 $12.80 90901 S Biofeedback train, any meth 0321 1.26 $61.09 $29.25 $12.22 90911 S Biofeedback peri/uro/rectal 0321 1.26 $61.09 $29.25 $12.22 90918 A ESRD related services, month 90919 A ESRD related services, month 90920 A ESRD related services, month 90921 A ESRD related services, month 90922 A ESRD related services, day 90923 A Esrd related services, day 90924 A Esrd related services, day 90925 A Esrd related services, day 90935 S Hemodialysis, one evaluation 0170 6.68 $323.89 $72.26 $64.78 90937 E Hemodialysis, repeated eval 90945 S Dialysis, one evaluation 0170 6.68 $323.89 $72.26 $64.78 90947 E Dialysis, repeated eval 90989 E Dialysis training, complete 90993 E Dialysis training, incompl 90997 E Hemoperfusion 90999 E Dialysis procedure 91000 X Esophageal intubation 0361 3.53 $171.16 $88.09 $34.23 91010 X Esophagus motility study 0361 3.53 $171.16 $88.09 $34.23 91011 X Esophagus motility study 0361 3.53 $171.16 $88.09 $34.23 91012 X Esophagus motility study 0361 3.53 $171.16 $88.09 $34.23 91020 X Gastric motility 0361 3.53 $171.16 $88.09 $34.23 91030 X Acid perfusion of esophagus 0360 1.38 $66.91 $34.75 $13.38 91032 X Esophagus, acid reflux test 0361 3.53 $171.16 $88.09 $34.23 91033 X Prolonged acid reflux test 0361 3.53 $171.16 $88.09 $34.23 91052 X Gastric analysis test 0361 3.53 $171.16 $88.09 $34.23 91055 X Gastric intubation for smear 0360 1.38 $66.91 $34.75 $13.38 91060 X Gastric saline load test 0361 3.53 $171.16 $88.09 $34.23 91065 X Breath hydrogen test 0360 1.38 $66.91 $34.75 $13.38 91100 X Pass intestine bleeding tube 0360 1.38 $66.91 $34.75 $13.38 91105 X Gastric intubation treatment 0360 1.38 $66.91 $34.75 $13.38 91122 T Anal pressure record 0165 3.89 $188.61 $91.76 $37.72 91299 X Gastroenterology procedure 0360 1.38 $66.91 $34.75 $13.38 92002 V Eye exam, new patient 0601 1.00 $48.49 $9.70 $9.70 92004 V Eye exam, new patient 0602 1.66 $80.49 $16.29 $16.10 92012 V Eye exam established pat 0601 1.00 $48.49 $9.70 $9.70 92014 V Eye exam & treatment 0602 1.66 $80.49 $16.29 $16.10 92015 E Refraction 92018 S New eye exam & treatment 0231 2.64 $128.01 $59.87 $25.60 92019 S Eye exam & treatment 0231 2.64 $128.01 $59.87 $25.60 92020 S Special eye evaluation 0230 0.98 $47.52 $22.48 $9.50 92060 S Special eye evaluation 0230 0.98 $47.52 $22.48 $9.50 92065 S Orthoptic/pleoptic training 0230 0.98 $47.52 $22.48 $9.50 92070 N Fitting of contact lens 92081 S Visual field examination(s) 0230 0.98 $47.52 $22.48 $9.50 92082 S Visual field examination(s) 0230 0.98 $47.52 $22.48 $9.50 92083 S Visual field examination(s) 0230 0.98 $47.52 $22.48 $9.50 92100 N Serial tonometry exam(s) 92120 S Tonography & eye evaluation 0230 0.98 $47.52 $22.48 $9.50 92130 S Water provocation tonography 0230 0.98 $47.52 $22.48 $9.50 92135 S Opthalmic dx imaging 0231 2.64 $128.01 $59.87 $25.60 92140 S Glaucoma provocative tests 0231 2.64 $128.01 $59.87 $25.60 92225 S Special eye exam, initial 0230 0.98 $47.52 $22.48 $9.50 92226 S Special eye exam, subsequent 0231 2.64 $128.01 $59.87 $25.60 92230 S Eye exam with photos 0231 2.64 $128.01 $59.87 $25.60 92235 S Eye exam with photos 0231 2.64 $128.01 $59.87 $25.60 92240 S Icg angiography 0231 2.64 $128.01 $59.87 $25.60 92250 S Eye exam with photos 0230 0.98 $47.52 $22.48 $9.50 92260 S Ophthalmoscopy/dynamometry 0230 0.98 $47.52 $22.48 $9.50 92265 S Eye muscle evaluation 0230 0.98 $47.52 $22.48 $9.50 92270 S Electro-oculography 0230 0.98 $47.52 $22.48 $9.50 92275 S Electroretinography 0216 2.87 $139.16 $64.69 $27.83 92283 S Color vision examination 0230 0.98 $47.52 $22.48 $9.50 92284 S Dark adaptation eye exam 0231 2.64 $128.01 $59.87 $25.60 92285 S Eye photography 0230 0.98 $47.52 $22.48 $9.50 92286 S Internal eye photography 0231 2.64 $128.01 $59.87 $25.60 92287 T Internal eye photography 0231 2.64 $128.01 $59.87 $25.60 92310 E Contact lens fitting Start Printed Page 18655 92311 X Contact lens fitting 0362 0.51 $24.73 $9.63 $4.95 92312 X Contact lens fitting 0362 0.51 $24.73 $9.63 $4.95 92313 X Contact lens fitting 0362 0.51 $24.73 $9.63 $4.95 92314 E Prescription of contact lens 92315 X Prescription of contact lens 0362 0.51 $24.73 $9.63 $4.95 92316 X Prescription of contact lens 0362 0.51 $24.73 $9.63 $4.95 92317 X Prescription of contact lens 0362 0.51 $24.73 $9.63 $4.95 92325 X Modification of contact lens 0362 0.51 $24.73 $9.63 $4.95 92326 X Replacement of contact lens 0362 0.51 $24.73 $9.63 $4.95 92330 S Fitting of artificial eye 0230 0.98 $47.52 $22.48 $9.50 92335 N Fitting of artificial eye 92340 E Fitting of spectacles 92341 E Fitting of spectacles 92342 E Fitting of spectacles 92352 X Special spectacles fitting 0362 0.51 $24.73 $9.63 $4.95 92353 X Special spectacles fitting 0362 0.51 $24.73 $9.63 $4.95 92354 X Special spectacles fitting 0362 0.51 $24.73 $9.63 $4.95 92355 X Special spectacles fitting 0362 0.51 $24.73 $9.63 $4.95 92358 X Eye prosthesis service 0362 0.51 $24.73 $9.63 $4.95 92370 E Repair & adjust spectacles 92371 X Repair & adjust spectacles 0362 0.51 $24.73 $9.63 $4.95 92390 E Supply of spectacles 92391 E Supply of contact lenses 92392 E Supply of low vision aids 92393 E Supply of artificial eye 92395 E Supply of spectacles 92396 E Supply of contact lenses 92499 S Eye service or procedure 0230 0.98 $47.52 $22.48 $9.50 92502 T Ear and throat examination 0251 1.68 $81.46 $27.99 $16.29 92504 N Ear microscopy examination 92506 A Speech/hearing evaluation 92507 A Speech/hearing therapy 92508 A Speech/hearing therapy 92510 A Rehab for ear implant 92511 T Nasopharyngoscopy 0071 0.55 $26.67 $14.22 $5.33 92512 X Nasal function studies 0363 2.83 $137.22 $53.22 $27.44 92516 X Facial nerve function test 0363 2.83 $137.22 $53.22 $27.44 92520 X Laryngeal function studies 0363 2.83 $137.22 $53.22 $27.44 92525 A Oral function evaluation 92526 A Oral function therapy 92531 N Spontaneous nystagmus study 92532 N Positional nystagmus study 92533 N Caloric vestibular test 92534 N Optokinetic nystagmus 92541 X Spontaneous nystagmus test 0363 2.83 $137.22 $53.22 $27.44 92542 X Positional nystagmus test 0363 2.83 $137.22 $53.22 $27.44 92543 X Caloric vestibular test 0363 2.83 $137.22 $53.22 $27.44 92544 X Optokinetic nystagmus test 0363 2.83 $137.22 $53.22 $27.44 92545 X Oscillating tracking test 0363 2.83 $137.22 $53.22 $27.44 92546 X Sinusoidal rotational test 0363 2.83 $137.22 $53.22 $27.44 92547 X Supplemental electrical test 0363 2.83 $137.22 $53.22 $27.44 92548 X Posturography 0363 2.83 $137.22 $53.22 $27.44 92551 E Pure tone hearing test, air 92552 X Pure tone audiometry, air 0364 0.68 $32.97 $13.31 $6.59 92553 X Audiometry, air & bone 0364 0.68 $32.97 $13.31 $6.59 92555 X Speech threshold audiometry 0364 0.68 $32.97 $13.31 $6.59 92556 X Speech audiometry, complete 0364 0.68 $32.97 $13.31 $6.59 92557 X Comprehensive hearing test 0365 1.47 $71.28 $22.48 $14.26 92559 E Group audiometric testing 92560 E Bekesy audiometry, screen 92561 X Bekesy audiometry, diagnosis 0365 1.47 $71.28 $22.48 $14.26 92562 X Loudness balance test 0365 1.47 $71.28 $22.48 $14.26 92563 X Tone decay hearing test 0365 1.47 $71.28 $22.48 $14.26 92564 X Sisi hearing test 0365 1.47 $71.28 $22.48 $14.26 92565 X Stenger test, pure tone 0365 1.47 $71.28 $22.48 $14.26 92567 X Tympanometry 0364 0.68 $32.97 $13.31 $6.59 92568 X Acoustic reflex testing 0365 1.47 $71.28 $22.48 $14.26 92569 X Acoustic reflex decay test 0365 1.47 $71.28 $22.48 $14.26 92571 X Filtered speech hearing test 0365 1.47 $71.28 $22.48 $14.26 92572 X Staggered spondaic word test 0365 1.47 $71.28 $22.48 $14.26 92573 X Lombard test 0365 1.47 $71.28 $22.48 $14.26 92575 X Sensorineural acuity test 0365 1.47 $71.28 $22.48 $14.26 92576 X Synthetic sentence test 0365 1.47 $71.28 $22.48 $14.26 Start Printed Page 18656 92577 X Stenger test, speech 0365 1.47 $71.28 $22.48 $14.26 92579 X Visual audiometry (vra) 0365 1.47 $71.28 $22.48 $14.26 92582 X Conditioning play audiometry 0365 1.47 $71.28 $22.48 $14.26 92583 X Select picture audiometry 0365 1.47 $71.28 $22.48 $14.26 92584 X Electrocochleography 0363 2.83 $137.22 $53.22 $27.44 92585 S Auditory evoked potential 0216 2.87 $139.16 $64.69 $27.83 92587 X Evoked auditory test 0363 2.83 $137.22 $53.22 $27.44 92588 X Evoked auditory test 0363 2.83 $137.22 $53.22 $27.44 92589 X Auditory function test(s) 0365 1.47 $71.28 $22.48 $14.26 92590 E Hearing aid exam, one ear 92591 E Hearing aid exam, both ears 92592 E Hearing aid check, one ear 92593 E Hearing aid check, both ears 92594 E Electro hearng aid test, one 92595 E Electro hearng aid tst, both 92596 X Ear protector evaluation 0365 1.47 $71.28 $22.48 $14.26 92597 A Oral speech device eval 92598 A Modify oral speech device 92599 X ENT procedure/service 0364 0.68 $32.97 $13.31 $6.59 92950 S Heart/lung resuscitation cpr 0094 4.51 $218.68 $105.29 $43.74 92953 S Temporary external pacing 0094 4.51 $218.68 $105.29 $43.74 92960 S Cardioversion electric, ext 0094 4.51 $218.68 $105.29 $43.74 92961 S Cardioversion, electric, int 0094 4.51 $218.68 $105.29 $43.74 92970 C Cardioassist, internal 92971 C Cardioassist, external 92975 C Dissolve clot, heart vessel 92977 C Dissolve clot, heart vessel 92978 C Intravasc us, heart add-on 92979 C Intravasc us, heart add-on 92980 T Insert intracoronary stent 0083 45.79 $2,220.22 $1,322.95 $444.04 92981 T Insert intracoronary stent 0083 45.79 $2,220.22 $1,322.95 $444.04 92982 T Coronary artery dilation 0083 45.79 $2,220.22 $1,322.95 $444.04 92984 T Coronary artery dilation 0083 45.79 $2,220.22 $1,322.95 $444.04 92986 C Revision of aortic valve 92987 C Revision of mitral valve 92990 C Revision of pulmonary valve 92992 C Revision of heart chamber 92993 C Revision of heart chamber 92995 T Coronary atherectomy 0082 40.34 $1,955.97 $859.56 $391.19 92996 T Coronary atherectomy add-on 0082 40.34 $1,955.97 $859.56 $391.19 92997 C Pul art balloon repr, percut 92998 C Pul art balloon repr, percut 93000 E Electrocardiogram, complete 93005 X Electrocardiogram, tracing 0366 0.38 $18.43 $15.60 $3.69 93010 E Electrocardiogram report 93012 S Transmission of ECG 0099 0.38 $18.43 $14.68 $3.69 93014 E Report on transmitted ECG 93015 E Cardiovascular stress test 93016 E Cardiovascular stress test 93017 S Cardiovascular stress test 0097 1.62 $78.55 $62.40 $15.71 93018 E Cardiovascular stress test 93024 S Cardiac drug stress test 0097 1.62 $78.55 $62.40 $15.71 93040 E Rhythm ECG with report 93041 X Rhythm ECG, tracing 0366 0.38 $18.43 $15.60 $3.69 93042 E Rhythm ECG, report 93224 E ECG monitor/report, 24 hrs 93225 S ECG monitor/record, 24 hrs 0100 1.70 $82.43 $71.57 $16.49 93226 S ECG monitor/report, 24 hrs 0100 1.70 $82.43 $71.57 $16.49 93227 E ECG monitor/review, 24 hrs 93230 E ECG monitor/report, 24 hrs 93231 S ECG monitor/record, 24 hrs 0100 1.70 $82.43 $71.57 $16.49 93232 S ECG monitor/report, 24 hrs 0100 1.70 $82.43 $71.57 $16.49 93233 E ECG monitor/review, 24 hrs 93235 E ECG monitor/report, 24 hrs 93236 S ECG monitor/report, 24 hrs 0100 1.70 $82.43 $71.57 $16.49 93237 E ECG monitor/review, 24 hrs 93268 S ECG record/review 0100 1.70 $82.43 $71.57 $16.49 93270 S ECG recording 0099 0.38 $18.43 $14.68 $3.69 93271 S ECG/monitoring and analysis 0100 1.70 $82.43 $71.57 $16.49 93272 E ECG/review, interpret only 93278 S ECG/signal-averaged 0099 0.38 $18.43 $14.68 $3.69 93303 S Echo transthoracic 0269 4.40 $213.34 $114.01 $42.67 93304 S Echo transthoracic 0269 4.40 $213.34 $114.01 $42.67 Start Printed Page 18657 93307 S Echo exam of heart 0269 4.40 $213.34 $114.01 $42.67 93308 S Echo exam of heart 0269 4.40 $213.34 $114.01 $42.67 93312 S Echo transesophageal 0270 5.55 $269.10 $150.26 $53.82 93313 S Echo transesophageal 0270 5.55 $269.10 $150.26 $53.82 93314 N Echo transesophageal 93315 S Echo transesophageal 0270 5.55 $269.10 $150.26 $53.82 93316 S Echo transesophageal 0270 5.55 $269.10 $150.26 $53.82 93317 N Echo transesophageal 93320 S Doppler echo exam, heart 0269 4.40 $213.34 $114.01 $42.67 93321 S Doppler echo exam, heart 0269 4.40 $213.34 $114.01 $42.67 93325 S Doppler color flow add-on 0269 4.40 $213.34 $114.01 $42.67 93350 S Echo transthoracic 0269 4.40 $213.34 $114.01 $42.67 93501 T Right heart catheterization 0080 25.77 $1,249.51 $713.89 $249.90 93503 T Insert/place heart catheter 0080 25.77 $1,249.51 $713.89 $249.90 93505 T Biopsy of heart lining 0080 25.77 $1,249.51 $713.89 $249.90 93508 N Cath placement, angiography 93510 T Left heart catheterization 0080 25.77 $1,249.51 $713.89 $249.90 93511 T Left heart catheterization 0080 25.77 $1,249.51 $713.89 $249.90 93514 T Left heart catheterization 0080 25.77 $1,249.51 $713.89 $249.90 93524 T Left heart catheterization 0080 25.77 $1,249.51 $713.89 $249.90 93526 T Rt & Lt heart catheters 0080 25.77 $1,249.51 $713.89 $249.90 93527 T Rt & Lt heart catheters 0080 25.77 $1,249.51 $713.89 $249.90 93528 T Rt & Lt heart catheters 0080 25.77 $1,249.51 $713.89 $249.90 93529 T Rt, Lt heart catheterization 0080 25.77 $1,249.51 $713.89 $249.90 93530 T Rt heart cath, congenital 0080 25.77 $1,249.51 $713.89 $249.90 93531 T R & l heart cath, congenital 0080 25.77 $1,249.51 $713.89 $249.90 93532 T R & l heart cath, congenital 0080 25.77 $1,249.51 $713.89 $249.90 93533 T R & l heart cath, congenital 0080 25.77 $1,249.51 $713.89 $249.90 93536 T Insert circulation assi 0080 25.77 $1,249.51 $713.89 $249.90 93539 N Injection, cardiac cath 93540 N Injection, cardiac cath 93541 N Injection for lung angiogram 93542 N Injection for heart x-rays 93543 N Injection for heart x-rays 93544 N Injection for aortography 93545 N Inject for coronary x-rays 93555 N Imaging, cardiac cath 93556 N Imaging, cardiac cath 93561 N Cardiac output measurement 93562 N Cardiac output measurement 93571 N Heart flow reserve measure 93572 N Heart flow reserve measure 93600 S Bundle of His recording 0087 9.53 $462.08 $214.72 $92.42 93602 S Intra-atrial recording 0087 9.53 $462.08 $214.72 $92.42 93603 S Right ventricular recording 0087 9.53 $462.08 $214.72 $92.42 93607 S Left ventricular recording 0087 9.53 $462.08 $214.72 $92.42 93609 S Mapping of tachycardia 0087 9.53 $462.08 $214.72 $92.42 93610 S Intra-atrial pacing 0087 9.53 $462.08 $214.72 $92.42 93612 S Intraventricular pacing 0087 9.53 $462.08 $214.72 $92.42 93615 S Esophageal recording 0087 9.53 $462.08 $214.72 $92.42 93616 S Esophageal recording 0087 9.53 $462.08 $214.72 $92.42 93618 S Heart rhythm pacing 0087 9.53 $462.08 $214.72 $92.42 93619 S Electrophysiology evaluation 0085 27.06 $1,312.06 $654.48 $262.41 93620 S Electrophysiology evaluation 0085 27.06 $1,312.06 $654.48 $262.41 93621 S Electrophysiology evaluation 0085 27.06 $1,312.06 $654.48 $262.41 93622 S Electrophysiology evaluation 0085 27.06 $1,312.06 $654.48 $262.41 93623 S Stimulation, pacing heart 0087 9.53 $462.08 $214.72 $92.42 93624 S Electrophysiologic study 0087 9.53 $462.08 $214.72 $92.42 93631 S Heart pacing, mapping 0087 9.53 $462.08 $214.72 $92.42 93640 S Evaluation heart device 0084 10.70 $518.81 $177.79 $103.76 93641 S Electrophysiology evaluation 0084 10.70 $518.81 $177.79 $103.76 93642 S Electrophysiology evaluation 0084 10.70 $518.81 $177.79 $103.76 93650 S Ablate heart dysrhythm focus 0086 47.62 $2,308.95 $1,265.37 $461.79 93651 S Ablate heart dysrhythm focus 0086 47.62 $2,308.95 $1,265.37 $461.79 93652 S Ablate heart dysrhythm focus 0086 47.62 $2,308.95 $1,265.37 $461.79 93660 S Tilt table evaluation 0101 4.47 $216.74 $128.84 $43.35 93720 E Total body plethysmography 93721 S Plethysmography tracing 0096 2.06 $99.88 $61.48 $19.98 93722 E Plethysmography report 93724 S Analyze pacemaker system 0100 1.70 $82.43 $71.57 $16.49 93727 S Analyze ilr system 0102 0.45 $21.82 $12.62 $4.36 93731 S Analyze pacemaker system 0102 0.45 $21.82 $12.62 $4.36 93732 S Analyze pacemaker system 0102 0.45 $21.82 $12.62 $4.36 Start Printed Page 18658 93733 S Telephone analy, pacemaker 0102 0.45 $21.82 $12.62 $4.36 93734 S Analyze pacemaker system 0102 0.45 $21.82 $12.62 $4.36 93735 S Analyze pacemaker system 0102 0.45 $21.82 $12.62 $4.36 93736 S Telephone analy, pacemaker 0102 0.45 $21.82 $12.62 $4.36 93737 S Analyze cardio/defibrillator 0102 0.45 $21.82 $12.62 $4.36 93738 S Analyze cardio/defibrillator 0102 0.45 $21.82 $12.62 $4.36 93740 S Temperature gradient studies 0096 2.06 $99.88 $61.48 $19.98 93741 S Analyze ht pace device sngl 0102 0.45 $21.82 $12.62 $4.36 93742 S Analyze ht pace device sngl 0102 0.45 $21.82 $12.62 $4.36 93743 S Analyze ht pace device dual 0102 0.45 $21.82 $12.62 $4.36 93744 S Analyze ht pace device dual 0102 0.45 $21.82 $12.62 $4.36 93760 E Cephalic thermogram 93762 E Peripheral thermogram 93770 N Measure venous pressure 93784 E Ambulatory BP monitoring 93786 E Ambulatory BP recording 93788 E Ambulatory BP analysis 93790 E Review/report BP recording 93797 S Cardiac rehab 0095 0.64 $31.03 $16.98 $6.21 93798 S Cardiac rehab/monitor 0095 0.64 $31.03 $16.98 $6.21 93799 S Cardiovascular procedure 0096 2.06 $99.88 $61.48 $19.98 93875 S Extracranial study 0096 2.06 $99.88 $61.48 $19.98 93880 S Extracranial study 0267 2.72 $131.88 $80.06 $26.38 93882 S Extracranial study 0267 2.72 $131.88 $80.06 $26.38 93886 S Intracranial study 0267 2.72 $131.88 $80.06 $26.38 93888 S Intracranial study 0267 2.72 $131.88 $80.06 $26.38 93922 S Extremity study 0096 2.06 $99.88 $61.48 $19.98 93923 S Extremity study 0096 2.06 $99.88 $61.48 $19.98 93924 S Extremity study 0096 2.06 $99.88 $61.48 $19.98 93925 S Lower extremity study 0267 2.72 $131.88 $80.06 $26.38 93926 S Lower extremity study 0267 2.72 $131.88 $80.06 $26.38 93930 S Upper extremity study 0267 2.72 $131.88 $80.06 $26.38 93931 S Upper extremity study 0267 2.72 $131.88 $80.06 $26.38 93965 S Extremity study 0096 2.06 $99.88 $61.48 $19.98 93970 S Extremity study 0267 2.72 $131.88 $80.06 $26.38 93971 S Extremity study 0267 2.72 $131.88 $80.06 $26.38 93975 S Vascular study 0267 2.72 $131.88 $80.06 $26.38 93976 S Vascular study 0267 2.72 $131.88 $80.06 $26.38 93978 S Vascular study 0267 2.72 $131.88 $80.06 $26.38 93979 S Vascular study 0267 2.72 $131.88 $80.06 $26.38 93980 S Penile vascular study 0267 2.72 $131.88 $80.06 $26.38 93981 S Penile vascular study 0267 2.72 $131.88 $80.06 $26.38 93990 S Doppler flow testing 0267 2.72 $131.88 $80.06 $26.38 94010 X Breathing capacity test 0367 0.83 $40.24 $20.65 $8.05 94014 X Patient recorded spirometry 0369 2.34 $113.46 $58.50 $22.69 94015 X Patient recorded spirometry 0369 2.34 $113.46 $58.50 $22.69 94016 X Review patient spirometry 0369 2.34 $113.46 $58.50 $22.69 94060 X Evaluation of wheezing 0368 1.66 $80.49 $42.44 $16.10 94070 X Evaluation of wheezing 0369 2.34 $113.46 $58.50 $22.69 94150 N Vital capacity test 94200 X Lung function test (MBC/MVV) 0367 0.83 $40.24 $20.65 $8.05 94240 X Residual lung capacity 0368 1.66 $80.49 $42.44 $16.10 94250 X Expired gas collection 0367 0.83 $40.24 $20.65 $8.05 94260 X Thoracic gas volume 0368 1.66 $80.49 $42.44 $16.10 94350 X Lung nitrogen washout curve 0368 1.66 $80.49 $42.44 $16.10 94360 X Measure airflow resistance 0368 1.66 $80.49 $42.44 $16.10 94370 X Breath airway closing volume 0368 1.66 $80.49 $42.44 $16.10 94375 X Respiratory flow volume loop 0367 0.83 $40.24 $20.65 $8.05 94400 X CO2 breathing response curve 0367 0.83 $40.24 $20.65 $8.05 94450 X Hypoxia response curve 0367 0.83 $40.24 $20.65 $8.05 94620 X Pulmonary stress test/simple 0368 1.66 $80.49 $42.44 $16.10 94621 X Pulm stress test/complex 0369 2.34 $113.46 $58.50 $22.69 94640 S Airway inhalation treatment 0077 0.43 $20.85 $12.62 $4.17 94642 S Aerosol inhalation treatment 0078 1.34 $64.97 $29.13 $12.99 94650 S Pressure breathing (IPPB) 0077 0.43 $20.85 $12.62 $4.17 94651 S Pressure breathing (IPPB) 0077 0.43 $20.85 $12.62 $4.17 94652 C Pressure breathing (IPPB) 94656 S Initial ventilator mgmt 0079 3.18 $154.19 $107.70 $30.84 94657 S Continued ventilator mgmt 0079 3.18 $154.19 $107.70 $30.84 94660 S Pos airway pressure, CPAP 0079 3.18 $154.19 $107.70 $30.84 94662 S Neg press ventilation, cnp 0079 3.18 $154.19 $107.70 $30.84 94664 S Aerosol or vapor inhalations 0077 0.43 $20.85 $12.62 $4.17 94665 S Aerosol or vapor inhalations 0077 0.43 $20.85 $12.62 $4.17 Start Printed Page 18659 94667 S Chest wall manipulation 0077 0.43 $20.85 $12.62 $4.17 94668 S Chest wall manipulation 0077 0.43 $20.85 $12.62 $4.17 94680 X Exhaled air analysis, o2 0367 0.83 $40.24 $20.65 $8.05 94681 X Exhaled air analysis, o2/co2 0368 1.66 $80.49 $42.44 $16.10 94690 X Exhaled air analysis 0367 0.83 $40.24 $20.65 $8.05 94720 X Monoxide diffusing capacity 0367 0.83 $40.24 $20.65 $8.05 94725 X Membrane diffusion capacity 0368 1.66 $80.49 $42.44 $16.10 94750 X Pulmonary compliance study 0368 1.66 $80.49 $42.44 $16.10 94760 N Measure blood oxygen level 94761 N Measure blood oxygen level 94762 C Measure blood oxygen level 94770 X Exhaled carbon dioxide test 0367 0.83 $40.24 $20.65 $8.05 94772 X Breath recording, infant 0369 2.34 $113.46 $58.50 $22.69 94799 X Pulmonary service/procedure 0367 0.83 $40.24 $20.65 $8.05 95004 X Allergy skin tests 0370 0.57 $27.64 $11.81 $5.53 95010 X Sensitivity skin tests 0370 0.57 $27.64 $11.81 $5.53 95015 X Sensitivity skin tests 0370 0.57 $27.64 $11.81 $5.53 95024 X Allergy skin tests 0370 0.57 $27.64 $11.81 $5.53 95027 X Skin end point titration 0370 0.57 $27.64 $11.81 $5.53 95028 X Allergy skin tests 0370 0.57 $27.64 $11.81 $5.53 95044 X Allergy patch tests 0370 0.57 $27.64 $11.81 $5.53 95052 X Photo patch test 0370 0.57 $27.64 $11.81 $5.53 95056 X Photosensitivity tests 0370 0.57 $27.64 $11.81 $5.53 95060 X Eye allergy tests 0370 0.57 $27.64 $11.81 $5.53 95065 X Nose allergy test 0370 0.57 $27.64 $11.81 $5.53 95070 X Bronchial allergy tests 0369 2.34 $113.46 $58.50 $22.69 95071 X Bronchial allergy tests 0369 2.34 $113.46 $58.50 $22.69 95075 X Ingestion challenge test 0361 3.53 $171.16 $88.09 $34.23 95078 X Provocative testing 0370 0.57 $27.64 $11.81 $5.53 95115 X Immunotherapy, one injection 0371 0.32 $15.52 $3.67 $3.10 95117 X Immunotherapy injections 0371 0.32 $15.52 $3.67 $3.10 95120 E Immunotherapy, one injection 95125 E Immunotherapy, many antigens 95130 E Immunotherapy, insect venom 95131 E Immunotherapy, insect venoms 95132 E Immunotherapy, insect venoms 95133 E Immunotherapy, insect venoms 95134 E Immunotherapy, insect venoms 95144 X Antigen therapy services 0371 0.32 $15.52 $3.67 $3.10 95145 X Antigen therapy services 0371 0.32 $15.52 $3.67 $3.10 95146 X Antigen therapy services 0371 0.32 $15.52 $3.67 $3.10 95147 X Antigen therapy services 0371 0.32 $15.52 $3.67 $3.10 95148 X Antigen therapy services 0371 0.32 $15.52 $3.67 $3.10 95149 X Antigen therapy services 0371 0.32 $15.52 $3.67 $3.10 95165 X Antigen therapy services 0371 0.32 $15.52 $3.67 $3.10 95170 X Antigen therapy services 0371 0.32 $15.52 $3.67 $3.10 95180 X Rapid desensitization 0370 0.57 $27.64 $11.81 $5.53 95199 X Allergy immunology services 0370 0.57 $27.64 $11.81 $5.53 95805 S Multiple sleep latency test 0213 11.15 $540.63 $290.42 $108.13 95806 S Sleep study, unattended 0213 11.15 $540.63 $290.42 $108.13 95807 S Sleep study, attended 0213 11.15 $540.63 $290.42 $108.13 95808 S Polysomnography, 1-3 0213 11.15 $540.63 $290.42 $108.13 95810 S Polysomnography, 4 or more 0213 11.15 $540.63 $290.42 $108.13 95811 S Polysomnography w/cpap 0213 11.15 $540.63 $290.42 $108.13 95812 S Electroencephalogram (EEG) 0213 11.15 $540.63 $290.42 $108.13 95813 S Electroencephalogram (EEG) 0213 11.15 $540.63 $290.42 $108.13 95816 S Electroencephalogram (EEG) 0214 2.32 $112.49 $58.50 $22.50 95819 S Electroencephalogram (EEG) 0214 2.32 $112.49 $58.50 $22.50 95822 S Sleep electroencephalogram 0214 2.32 $112.49 $58.50 $22.50 95824 S Electroencephalography 0214 2.32 $112.49 $58.50 $22.50 95827 S Night electroencephalogram 0213 11.15 $540.63 $290.42 $108.13 95829 S Surgery electrocorticogram 0214 2.32 $112.49 $58.50 $22.50 95830 E Insert electrodes for EEG 95831 N Limb muscle testing, manual 95832 N Hand muscle testing, manual 95833 N Body muscle testing, manual 95834 N Body muscle testing, manual 95851 N Range of motion measurements 95852 N Range of motion measurements 95857 S Tensilon test 0215 1.15 $55.76 $30.05 $11.15 95858 S Tensilon test & myogram 0215 1.15 $55.76 $30.05 $11.15 95860 S Muscle test, one limb 0215 1.15 $55.76 $30.05 $11.15 95861 S Muscle test, two limbs 0215 1.15 $55.76 $30.05 $11.15 Start Printed Page 18660 95863 S Muscle test, 3 limbs 0216 2.87 $139.16 $64.69 $27.83 95864 S Muscle test, 4 limbs 0215 1.15 $55.76 $30.05 $11.15 95867 S Muscle test, head or neck 0216 2.87 $139.16 $64.69 $27.83 95868 S Muscle test, head or neck 0216 2.87 $139.16 $64.69 $27.83 95869 S Muscle test, thor paraspinal 0215 1.15 $55.76 $30.05 $11.15 95870 S Muscle test, nonparaspinal 0215 1.15 $55.76 $30.05 $11.15 95872 S Muscle test, one fiber 0215 1.15 $55.76 $30.05 $11.15 95875 S Limb exercise test 0217 5.87 $284.62 $156.68 $56.92 95900 S Motor nerve conduction test 0215 1.15 $55.76 $30.05 $11.15 95903 S Motor nerve conduction test 0215 1.15 $55.76 $30.05 $11.15 95904 S Sense/mixed n conduction tst 0215 1.15 $55.76 $30.05 $11.15 95920 C Intraop nerve test add-on 95921 S Autonomic nerv function test 0216 2.87 $139.16 $64.69 $27.83 95922 S Autonomic nerv function test 0216 2.87 $139.16 $64.69 $27.83 95923 S Autonomic nerv function test 0216 2.87 $139.16 $64.69 $27.83 95925 S Somatosensory testing 0216 2.87 $139.16 $64.69 $27.83 95926 S Somatosensory testing 0216 2.87 $139.16 $64.69 $27.83 95927 S Somatosensory testing 0216 2.87 $139.16 $64.69 $27.83 95930 S Visual evoked potential test 0216 2.87 $139.16 $64.69 $27.83 95933 S Blink reflex test 0215 1.15 $55.76 $30.05 $11.15 95934 S H-reflex test 0215 1.15 $55.76 $30.05 $11.15 95936 S H-reflex test 0216 2.87 $139.16 $64.69 $27.83 95937 S Neuromuscular junction test 0215 1.15 $55.76 $30.05 $11.15 95950 S Ambulatory eeg monitoring 0217 5.87 $284.62 $156.68 $56.92 95951 S EEG monitoring/videorecord 0213 11.15 $540.63 $290.42 $108.13 95953 S EEG monitoring/computer 0213 11.15 $540.63 $290.42 $108.13 95954 S EEG monitoring/giving drugs 0213 11.15 $540.63 $290.42 $108.13 95955 S EEG during surgery 0214 2.32 $112.49 $58.50 $22.50 95956 N Eeg monitoring, cable/radio 95957 N EEG digital analysis 95958 S EEG monitoring/function test 0213 11.15 $540.63 $290.42 $108.13 95961 C Electrode stimulation, brain 95962 C Electrode stim, brain add-on 95970 S Analyze neurostim, no prog 0102 0.45 $21.82 $12.62 $4.36 95971 S Analyze neurostim, simple 0102 0.45 $21.82 $12.62 $4.36 95972 S Analyze neurostim, complex 0102 0.45 $21.82 $12.62 $4.36 95973 S Analyze neurostim, complex 0102 0.45 $21.82 $12.62 $4.36 95974 S Cranial neurostim, complex 0102 0.45 $21.82 $12.62 $4.36 95975 S Cranial neurostim, complex 0102 0.45 $21.82 $12.62 $4.36 95999 N Neurological procedure 96100 X Psychological testing 0373 3.21 $155.64 $44.96 $31.13 96105 X Assessment of aphasia 0373 3.21 $155.64 $44.96 $31.13 96110 X Developmental test, lim 0373 3.21 $155.64 $44.96 $31.13 96111 X Developmental test, extend 0373 3.21 $155.64 $44.96 $31.13 96115 X Neurobehavior status exam 0373 3.21 $155.64 $44.96 $31.13 96117 X Neuropsych test battery 0373 3.21 $155.64 $44.96 $31.13 96400 E Chemotherapy, sc/im 96405 E Intralesional chemo admin 96406 E Intralesional chemo admin 96408 E Chemotherapy, push technique 96410 E Chemotherapy, infusion method 96412 E Chemo, infuse method add-on 96414 E Chemo, infuse method add-on 96420 E Chemotherapy, push technique 96422 E Chemotherapy, infusion method 96423 E Chemo, infuse method add-on 96425 E Chemotherapy, infusion method 96440 E Chemotherapy, intracavitary 96445 E Chemotherapy, intracavitary 96450 E Chemotherapy, into CNS 96520 E Pump refilling, maintenance 96530 E Pump refilling, maintenance 96542 E Chemotherapy injection 96545 E Provide chemotherapy agent 96549 E Chemotherapy, unspecified 96570 T Photodynamic tx, 30 min 0075 18.55 $899.44 $467.29 $179.89 96571 T Photodynamic tx, addl 15 min 0075 18.55 $899.44 $467.29 $179.89 96900 S Ultraviolet light therapy 0001 0.47 $22.79 $8.49 $4.56 96902 N Trichogram 96910 S Photochemotherapy with UV-B 0001 0.47 $22.79 $8.49 $4.56 96912 S Photochemotherapy with UV-A 0001 0.47 $22.79 $8.49 $4.56 96913 S Photochemotherapy, UV-A or B 0001 0.47 $22.79 $8.49 $4.56 96999 S Dermatological procedure 0001 0.47 $22.79 $8.49 $4.56 Start Printed Page 18661 97001 A Pt evaluation 97002 A Pt re-evaluation 97003 A Ot evaluation 97004 A Ot re-evaluation 97010 A Hot or cold packs therapy 97012 A Mechanical traction therapy 97014 A Electric stimulation therapy 97016 A Vasopneumatic device therapy 97018 A Paraffin bath therapy 97020 A Microwave therapy 97022 A Whirlpool therapy 97024 A Diathermy treatment 97026 A Infrared therapy 97028 A Ultraviolet therapy 97032 A Electrical stimulation 97033 A Electric current therapy 97034 A Contrast bath therapy 97035 A Ultrasound therapy 97036 A Hydrotherapy 97039 A Physical therapy treatment 97110 A Therapeutic exercises 97112 A Neuromuscular reeducation 97113 A Aquatic therapy/exercises 97116 A Gait training therapy 97124 A Massage therapy 97139 A Physical medicine procedure 97140 A Manual therapy 97150 A Group therapeutic procedures 97504 A Orthotic training 97520 A Prosthetic training 97530 A Therapeutic activities 97535 A Self care mngment training 97537 A Community/work reintegration 97542 A Wheelchair mngment training 97545 A Work hardening 97546 A Work hardening add-on 97703 A Prosthetic checkout 97750 A Physical performance test 97770 A Cognitive skills development 97780 E Acupuncture w/o stimul 97781 E Acupuncture w/stimul 97799 A Physical medicine procedure 98925 S Osteopathic manipulation 0060 0.77 $37.34 $7.80 $7.47 98926 S Osteopathic manipulation 0060 0.77 $37.34 $7.80 $7.47 98927 S Osteopathic manipulation 0060 0.77 $37.34 $7.80 $7.47 98928 S Osteopathic manipulation 0060 0.77 $37.34 $7.80 $7.47 98929 S Osteopathic manipulation 0060 0.77 $37.34 $7.80 $7.47 98940 S Chiropractic manipulation 0060 0.77 $37.34 $7.80 $7.47 98941 S Chiropractic manipulation 0060 0.77 $37.34 $7.80 $7.47 98942 S Chiropractic manipulation 0060 0.77 $37.34 $7.80 $7.47 98943 E Chiropractic manipulation 99000 E Specimen handling 99001 E Specimen handling 99002 E Device handling 99024 E Postop follow-up visit 99025 E Initial surgical evaluation 99050 E Medical services after hrs 99052 E Medical services at night 99054 E Medical servcs, unusual hrs 99056 E Non-office medical services 99058 E Office emergency care 99070 E Special supplies 99071 E Patient education materials 99075 E Medical testimony 99078 E Group health education 99080 E Special reports or forms 99082 E Unusual physician travel 99090 E Computer data analysis 99100 E Special anesthesia service 99116 E Anesthesia with hypothermia 99135 E Special anesthesia procedure 99140 E Emergency anesthesia 99141 N Sedation, iv/im or inhalant Start Printed Page 18662 99142 N Sedation, oral/rectal/nasal 99170 T Anogenital exam, child 0192 2.38 $115.40 $35.33 $23.08 99173 N Visual screening test 99175 N Induction of vomiting 99183 S Hyperbaric oxygen therapy 0031 3.00 $145.46 $140.85 $29.09 99185 N Regional hypothermia 99186 N Total body hypothermia 99190 C Special pump services 99191 C Special pump services 99192 C Special pump services 99195 X Phlebotomy 0372 0.43 $20.85 $10.09 $4.17 99199 E Special service/proc/report 99201 V Office/outpatient visit, new 0600 0.98 $47.52 $9.50 $9.50 99202 V Office/outpatient visit, new 0600 0.98 $47.52 $9.50 $9.50 99203 V Office/outpatient visit, new 0601 1.00 $48.49 $9.70 $9.70 99204 V Office/outpatient visit, new 0602 1.66 $80.49 $16.29 $16.10 99205 V Office/outpatient visit, new 0602 1.66 $80.49 $16.29 $16.10 99211 V Office/outpatient visit, est 0600 0.98 $47.52 $9.50 $9.50 99212 V Office/outpatient visit, est 0600 0.98 $47.52 $9.50 $9.50 99213 V Office/outpatient visit, est 0601 1.00 $48.49 $9.70 $9.70 99214 V Office/outpatient visit, est 0602 1.66 $80.49 $16.29 $16.10 99215 V Office/outpatient visit, est 0602 1.66 $80.49 $16.29 $16.10 99217 N Observation care discharge 99218 N Observation care 99219 N Observation care 99220 N Observation care 99221 E Initial hospital care 99222 E Initial hospital care 99223 E Initial hospital care 99231 E Subsequent hospital care 99232 E Subsequent hospital care 99233 E Subsequent hospital care 99234 C Observ/hosp same date 99235 C Observ/hosp same date 99236 C Observ/hosp same date 99238 E Hospital discharge day 99239 E Hospital discharge day 99241 V Office consultation 0600 0.98 $47.52 $9.50 $9.50 99242 V Office consultation 0600 0.98 $47.52 $9.50 $9.50 99243 V Office consultation 0601 1.00 $48.49 $9.70 $9.70 99244 V Office consultation 0602 1.66 $80.49 $16.29 $16.10 99245 V Office consultation 0602 1.66 $80.49 $16.29 $16.10 99251 C Initial inpatient consult 99252 C Initial inpatient consult 99253 C Initial inpatient consult 99254 C Initial inpatient consult 99255 C Initial inpatient consult 99261 C Follow-up inpatient consult 99262 C Follow-up inpatient consult 99263 C Follow-up inpatient consult 99271 V Confirmatory consultation 0600 0.98 $47.52 $9.50 $9.50 99272 V Confirmatory consultation 0600 0.98 $47.52 $9.50 $9.50 99273 V Confirmatory consultation 0601 1.00 $48.49 $9.70 $9.70 99274 V Confirmatory consultation 0602 1.66 $80.49 $16.29 $16.10 99275 V Confirmatory consultation 0602 1.66 $80.49 $16.29 $16.10 99281 V Emergency dept visit 0610 1.34 $64.97 $20.65 $12.99 99282 V Emergency dept visit 0610 1.34 $64.97 $20.65 $12.99 99283 V Emergency dept visit 0611 2.11 $102.31 $36.47 $20.46 99284 V Emergency dept visit 0612 3.19 $154.67 $54.14 $30.93 99285 V Emergency dept visit 0612 3.19 $154.67 $54.14 $30.93 99288 E Direct advanced life support 99291 S Critical care, first hour 0620 8.60 $416.99 $152.78 $83.40 99292 N Critical care, addl 30 min 99295 C Neonatal critical care 99296 C Neonatal critical care 99297 C Neonatal critical care 99298 C Neonatal critical care 99301 E Nursing facility care 99302 E Nursing facility care 99303 E Nursing facility care 99311 E Nursing fac care, subseq 99312 E Nursing fac care, subseq 99313 E Nursing fac care, subseq Start Printed Page 18663 99315 E Nursing fac discharge day 99316 E Nursing fac discharge day 99321 E Rest home visit, new patient 99322 E Rest home visit, new patient 99323 E Rest home visit, new patient 99331 E Rest home visit, est pat 99332 E Rest home visit, est pat 99333 E Rest home visit, est pat 99341 E Home visit, new patient 99342 E Home visit, new patient 99343 E Home visit, new patient 99344 E Home visit, new patient 99345 E Home visit, new patient 99347 E Home visit, est patient 99348 E Home visit, est patient 99349 E Home visit, est patient 99350 E Home visit, est patient 99354 N Prolonged service, office 99355 N Prolonged service, office 99356 C Prolonged service, inpatient 99357 C Prolonged service, inpatient 99358 N Prolonged serv, w/o contact 99359 N Prolonged serv, w/o contact 99360 E Physician standby services 99361 E Physician/team conference 99362 E Physician/team conference 99371 E Physician phone consultation 99372 E Physician phone consultation 99373 E Physician phone consultation 99374 E Home health care supervision 99375 E Home health care supervision 99377 E Hospice care supervision 99378 E Hospice care supervision 99379 E Nursing fac care supervision 99380 E Nursing fac care supervision 99381 E Prev visit, new, infant 99382 E Prev visit, new, age 1-4 99383 E Prev visit, new, age 5-11 99384 E Prev visit, new, age 12-17 99385 E Prev visit, new, age 18-39 99386 E Prev visit, new, age 40-64 99387 E Prev visit, new, 65 & over 99391 E Prev visit, est, infant 99392 E Prev visit, est, age 1-4 99393 E Prev visit, est, age 5-11 99394 E Prev visit, est, age 12-17 99395 E Prev visit, est, age 18-39 99396 E Prev visit, est, age 40-64 99397 E Prev visit, est, 65 & over 99401 E Preventive counseling, indiv 99402 E Preventive counseling, indiv 99403 E Preventive counseling, indiv 99404 E Preventive counseling, indiv 99411 E Preventive counseling, group 99412 E Preventive counseling, group 99420 E Health risk assessment test 99429 E Unlisted preventive service 99431 N Initial care, normal newborn 99432 N Newborn care, not in hosp 99433 C Normal newborn care/hospital 99435 E Newborn discharge day hosp 99436 N Attendance, birth 99440 S Newborn resuscitation 0094 4.51 $218.68 $105.29 $43.74 99450 E Life/disability evaluation 99455 E Disability examination 99456 E Disability examination 99499 E Unlisted e&m service A0021 E Outside state ambulance serv A0030 A Air ambulance service A0040 A Helicopter ambulance service A0050 A Water amb service emergency A0080 E Noninterest escort in non er A0090 E Interest escort in non er Start Printed Page 18664 A0100 E Nonemergency transport taxi A0110 E Nonemergency transport bus A0120 E Noner transport mini-bus A0130 E Noner transport wheelch van A0140 E Nonemergency transport air A0160 E Noner transport case worker A0170 E Noner transport parking fees A0180 E Noner transport lodgng recip A0190 E Noner transport meals recip A0200 E Noner transport lodgng escrt A0210 E Noner transport meals escort A0225 A Neonatal emergency transport A0300 A Ambulance basic non-emer all A0302 A Ambulance basic emergeny all A0304 A Amb adv non-er no serv all A0306 A Amb adv non-er spec serv all A0308 A Amb adv er no spec serv all A0310 A Amb adv er spec serv all A0320 A Amb basic non-er + supplies A0322 A Amb basic emerg + supplies A0324 A Adv non-er serv sep mileage A0326 A Adv non-er no serv sep mile A0328 A Adv er no serv sep mileage A0330 A Adv er spec serv sep mile A0340 A Amb basic non-er + mileage A0342 A Ambul basic emer + mileage A0344 A Amb adv non-er no serv +mile A0346 A Amb adv non-er serv + mile A0348 A Adv emer no spec serv + mile A0350 A Adv emer spec serv + mileage A0360 A Basic non-er sep mile & supp A0362 A Basic emer sep mile & supply A0364 A Adv non-er no serv sep mi&su A0366 A Adv non-er serv sep mil&supp A0368 A Adv er no serv sep mile&supp A0370 A Adv er spec serv sep mi&supp A0380 A Basic life support mileage A0382 A Basic support routine suppls A0384 A Bls defibrillation supplies A0390 A Advanced life support mileag A0392 A Als defibrillation supplies A0394 A Als IV drug therapy supplies A0396 A Als esophageal intub suppls A0398 A Als routine disposble suppls A0420 A Ambulance waiting 1/2 hr A0422 A Ambulance 02 life sustaining A0424 A Extra ambulance attendant A0888 E Noncovered ambulance mileage A0999 A Unlisted ambulance service A4206 A 1 CC sterile syringe & needle A4207 A 2 CC sterile syringe & needle A4208 A 3 CC sterile syringe & needle A4209 A 5+ CC sterile syringe & needle A4210 E Nonneedle injection device A4211 A Supp for self-adm injections A4212 A Non coring needle or stylet A4213 A 20+ CC syringe only A4214 A 30 CC sterile water/saline A4215 A Sterile needle A4220 A Infusion pump refill kit A4221 A Maint drug infus cath per wk A4222 A Drug infusion pump supplies A4230 E Infus insulin pump non needl A4231 E Infusion insulin pump needle A4232 E Syringe w/needle insulin 3cc A4244 A Alcohol or peroxide per pint A4245 A Alcohol wipes per box A4246 A Betadine/phisohex solution A4247 A Betadine/iodine swabs/wipes A4250 E Urine reagent strips/tablets A4253 A Blood glucose/reagent strips A4254 A Battery for glucose monitor A4255 A Glucose monitor platforms Start Printed Page 18665 A4256 A Calibrator solution/chips A4258 A Lancet device each A4259 A Lancets per box A4260 E Levonorgestrel implant A4261 E Cervical cap contraceptive A4262 N Temporary tear duct plug A4263 A Permanent tear duct plug A4265 A Paraffin A4270 A Disposable endoscope sheath A4280 A Brst prsths adhsv attchmnt A4300 A Cath impl vasc access portal A4301 A Implantable access syst perc A4305 A Drug delivery system >=50 ML A4306 A Drug delivery system <=5 ML A4310 A Insert tray w/o bag/cath A4311 A Catheter w/o bag 2-way latex A4312 A Cath w/o bag 2-way silicone A4313 A Catheter w/bag 3-way A4314 A Cath w/drainage 2-way latex A4315 A Cath w/drainage 2-way silcne A4316 A Cath w/drainage 3-way A4320 A Irrigation tray A4321 A Cath therapeutic irrig agent A4322 A Irrigation syringe A4323 A Saline irrigation solution A4326 A Male external catheter A4327 A Fem urinary collect dev cup A4328 A Fem urinary collect pouch A4329 A External catheter start set A4330 A Stool collection pouch A4335 A Incontinence supply A4338 A Indwelling catheter latex A4340 A Indwelling catheter special A4344 A Cath indw foley 2 way silicn A4346 A Cath indw foley 3 way A4347 A Male external catheter A4351 A Straight tip urine catheter A4352 A Coude tip urinary catheter A4353 A Intermittent urinary cath A4354 A Cath insertion tray w/bag A4355 A Bladder irrigation tubing A4356 A Ext ureth clmp or compr dvc A4357 A Bedside drainage bag A4358 A Urinary leg bag A4359 A Urinary suspensory w/o leg b A4361 A Ostomy face plate A4362 A Solid skin barrier A4364 A Ostomy/cath adhesive A4365 A Ostomy adhesive remover wipe A4367 A Ostomy belt A4368 A Ostomy filter A4369 A Skin barrier liquid per oz A4370 A Skin barrier paste per oz A4371 A Skin barrier powder per oz A4372 A Skin barrier solid 4x4 equiv A4373 A Skin barrier with flange A4374 A Skin barrier extended wear A4375 A Drainable plastic pch w fcpl A4376 A Drainable rubber pch w fcplt A4377 A Drainable plstic pch w/o fp A4378 A Drainable rubber pch w/o fp A4379 A Urinary plastic pouch w fcpl A4380 A Urinary rubber pouch w fcplt A4381 A Urinary plastic pouch w/o fp A4382 A Urinary hvy plstc pch w/o fp A4383 A Urinary rubber pouch w/o fp A4384 A Ostomy faceplt/silicone ring A4385 A Ost skn barrier sld ext wear A4386 A Ost skn barrier w flng ex wr A4387 A Ost clsd pouch w att st barr A4388 A Drainable pch w ex wear barr A4389 A Drainable pch w st wear barr A4390 A Drainable pch ex wear convex Start Printed Page 18666 A4391 A Urinary pouch w ex wear barr A4392 A Urinary pouch w st wear barr A4393 A Urine pch w ex wear bar conv A4394 A Ostomy pouch liq deodorant A4395 A Ostomy pouch solid deodorant A4397 A Irrigation supply sleeve A4398 A Ostomy irrigation bag A4399 A Ostomy irrig cone/cath w brs A4400 A Ostomy irrigation set A4402 A Lubricant per ounce A4404 A Ostomy ring each A4421 A Ostomy supply misc A4454 A Tape all types all sizes A4455 A Adhesive remover per ounce A4460 A Elastic compression bandage A4462 A Abdmnl drssng holder/binder A4465 A Non-elastic extremity binder A4470 A Gravlee jet washer A4480 A Vabra aspirator A4481 A Tracheostoma filter A4483 A Moisture exchanger A4490 E Above knee surgical stocking A4495 E Thigh length surg stocking A4500 E Below knee surgical stocking A4510 E Full length surg stocking A4550 E Surgical trays A4554 E Disposable underpads A4556 A Electrodes, pair A4557 A Lead wires, pair A4558 A Conductive paste or gel A4560 A Pessary A4565 A Slings A4570 A Splint A4572 A Rib belt A4575 E Hyperbaric o2 chamber disps A4580 A Cast supplies (plaster) A4590 A Special casting material A4595 A TENS suppl 2 lead per month A4611 A Heavy duty battery A4612 A Battery cables A4613 A Battery charger A4614 A Hand-held PEFR meter A4615 A Cannula nasal A4616 A Tubing (oxygen) per foot A4617 A Mouth piece A4618 A Breathing circuits A4619 A Face tent A4620 A Variable concentration mask A4621 A Tracheotomy mask or collar A4622 A Tracheostomy or larngectomy A4623 A Tracheostomy inner cannula A4624 A Tracheal suction tube A4625 A Trach care kit for new trach A4626 A Tracheostomy cleaning brush A4627 E Spacer bag/reservoir A4628 A Oropharyngeal suction cath A4629 A Tracheostomy care kit A4630 A Repl bat t.e.n.s. own by pt A4631 A Wheelchair battery A4635 A Underarm crutch pad A4636 A Handgrip for cane etc A4637 A Repl tip cane/crutch/walker A4640 A Alternating pressure pad A4641 N Diagnostic imaging agent 3 A4642 X Satumomab pendetide per dose 0704 $63.13 A4643 N High dose contrast MRI A4644 N Contrast 100-199 MGs iodine A4645 N Contrast 200-299 MGs iodine A4646 N Contrast 300-399 MGs iodine A4647 N Supp-paramagnetic contr mat A4649 A Surgical supplies A4650 A Supp esrd centrifuge A4655 A Esrd syringe/needle Start Printed Page 18667 A4660 A Esrd blood pressure device A4663 A Esrd blood pressure cuff A4670 E Auto blood pressure monitor A4680 A Activated carbon filters A4690 A Dialyzers A4700 A Standard dialysate solution A4705 A Bicarb dialysate solution A4712 A Sterile water A4714 A Treated water for dialysis A4730 A Fistula cannulation set dial A4735 A Local/topical anesthetics A4740 A Esrd shunt accessory A4750 A Arterial or venous tubing A4755 A Arterial and venous tubing A4760 A Standard testing solution A4765 A Dialysate concentrate A4770 A Blood testing supplies A4771 A Blood clotting time tube A4772 A Dextrostick/glucose strips A4773 A Hemostix A4774 A Ammonia test paper A4780 A Esrd sterilizing agent A4790 A Esrd cleansing agents A4800 A Heparin/antidote dialysis A4820 A Supplies hemodialysis kit A4850 A Rubber tipped hemostats A4860 A Disposable catheter caps A4870 A Plumbing/electrical work A4880 A Water storage tanks A4890 A Contracts/repair/maintenance A4900 A Capd supply kit A4901 A Ccpd supply kit A4905 A Ipd supply kit A4910 A Esrd nonmedical supplies A4912 A Gomco drain bottle A4913 A Esrd supply A4914 A Preparation kit A4918 A Venous pressure clamp A4919 A Supp dialysis dialyzer holde A4920 A Harvard pressure clamp A4921 A Measuring cylinder A4927 A Gloves A5051 A Pouch clsd w barr attached A5052 A Clsd ostomy pouch w/o barr A5053 A Clsd ostomy pouch faceplate A5054 A Clsd ostomy pouch w/flange A5055 A Stoma cap A5061 A Pouch drainable w barrier at A5062 A Drnble ostomy pouch w/o barr A5063 A Drain ostomy pouch w/flange A5064 E Drain ostomy pouch w/fceplte A5065 E Drain ostomy pouch on fcplte A5071 A Urinary pouch w/barrier A5072 A Urinary pouch w/o barrier A5073 A Urinary pouch on barr w/flng A5074 E Urinary pouch w/faceplate A5075 E Urinary pouch on faceplate A5081 A Continent stoma plug A5082 A Continent stoma catheter A5093 A Ostomy accessory convex inse A5102 A Bedside drain btl w/wo tube A5105 A Urinary suspensory A5112 A Urinary leg bag A5113 A Latex leg strap A5114 A Foam/fabric leg strap A5119 A Skin barrier wipes box pr 50 A5121 A Solid skin barrier 6x6 A5122 A Solid skin barrier 8x8 A5123 A Skin barrier with flange A5126 A Disk/foam pad +or- adhesive A5131 A Appliance cleaner A5149 A Incontinence/ostomy supply A5200 A Percutaneous catheter anchor Start Printed Page 18668 A5500 A Diab shoe for density insert A5501 A Diabetic custom molded shoe A5502 A Diabetic shoe density insert A5503 A Diabetic shoe w/roller/rockr A5504 A Diabetic shoe with wedge A5505 A Diab shoe w/metatarsal bar A5506 A Diabetic shoe w/off set heel A5507 A Modification diabetic shoe A5508 A Diabetic deluxe shoe A6020 A Collagen wound dressing A6025 E Silicone gel sheet, each A6154 A Wound pouch each A6196 A Alginate dressing <=16 sq in A6197 A Alginate drsg >16 <=48 sq in A6198 A alginate dressing > 48 sq in A6199 A Alginate drsg wound filler A6200 A Compos drsg <=16 no border A6201 A Compos drsg >16<=48 no bdr A6202 A Compos drsg >48 no border A6203 A Composite drsg <= 16 sq in A6204 A Composite drsg >16<=48 sq in A6205 A Composite drsg > 48 sq in A6206 A Contact layer <= 16 sq in A6207 A Contact layer >16<= 48 sq in A6208 A Contact layer > 48 sq in A6209 A Foam drsg <=16 sq in w/o bdr A6210 A Foam drg >16<=48 sq in w/o b A6211 A Foam drg > 48 sq in w/o brdr A6212 A Foam drg <=16 sq in w/border A6213 A Foam drg >16<=48 sq in w/bdr A6214 A Foam drg > 48 sq in w/border A6215 A Foam dressing wound filler A6216 A Non-sterile gauze<=16 sq in A6217 A Non-sterile gauze>16<=48 sq A6218 A Non-sterile gauze > 48 sq in A6219 A Gauze <= 16 sq in w/border A6220 A Gauze >16 <=48 sq in w/bordr A6221 A Gauze > 48 sq in w/border A6222 A Gauze <=16 in no w/sal w/o b A6223 A Gauze >16<=48 no w/sal w/o b A6224 A Gauze > 48 in no w/sal w/o b A6228 A Gauze <= 16 sq in water/sal A6229 A Gauze >16<=48 sq in watr/sal A6230 A Gauze > 48 sq in water/salne A6234 A Hydrocolld drg <=16 w/o bdr A6235 A Hydrocolld drg >16<=48 w/o b A6236 A Hydrocolld drg > 48 in w/o b A6237 A Hydrocolld drg <=16 in w/bdr A6238 A Hydrocolld drg >16<=48 w/bdr A6239 A Hydrocolld drg > 48 in w/bdr A6240 A Hydrocolld drg filler paste A6241 A Hydrocolloid drg filler dry A6242 A Hydrogel drg <=16 in w/o bdr A6243 A Hydrogel drg >16<=48 w/o bdr A6244 A Hydrogel drg >48 in w/o bdr A6245 A Hydrogel drg <= 16 in w/bdr A6246 A Hydrogel drg >16<=48 in w/b A6247 A Hydrogel drg > 48 sq in w/b A6248 A Hydrogel drsg gel filler A6250 A Skin seal protect moisturizr A6251 A Absorpt drg <=16 sq in w/o b A6252 A Absorpt drg >16 <=48 w/o bdr A6253 A Absorpt drg > 48 sq in w/o b A6254 A Absorpt drg <=16 sq in w/bdr A6255 A Absorpt drg >16<=48 in w/bdr A6256 A Absorpt drg > 48 sq in w/bdr A6257 A Transparent film <= 16 sq in A6258 A Transparent film >16<=48 in A6259 A Transparent film > 48 sq in A6260 A Wound cleanser any type/size A6261 A Wound filler gel/paste/oz A6262 A Wound filler dry form/gram A6263 A Non-sterile elastic gauze/yd Start Printed Page 18669 A6264 A Non-sterile no elastic gauze A6265 A Tape per 18 sq inches A6266 A Impreg gauze no h20/sal/yard A6402 A Sterile gauze <= 16 sq in A6403 A Sterile gauze>16 <= 48 sq in A6404 A Sterile gauze > 48 sq in A6405 A Sterile elastic gauze/yd A6406 A Sterile non-elastic gauze/yd A7000 A Disposable canister for pump A7001 A Nondisposable pump canister A7002 A Tubing used w suction pump A7003 A Nebulizer administration set A7004 A Disposable nebulizer sml vol A7005 A Nondisposable nebulizer set A7006 A Filtered nebulizer admin set A7007 A Lg vol nebulizer disposable A7008 A Disposable nebulizer prefill A7009 A Nebulizer reservoir bottle A7010 A Disposable corrugated tubing A7011 A Nondispos corrugated tubing A7012 A Nebulizer water collec devic A7013 A Disposable compressor filter A7014 A Compressor nondispos filter A7015 A Aerosol mask used w nebulize A7016 A Nebulizer dome & mouthpiece A7017 A Nebulizer not used w oxygen A9150 E Misc/exper non-prescript dru A9160 E Podiatrist non-covered servi A9170 E Chiropractor non-covered ser A9190 E Misc/expe personal comfort i A9270 E Non-covered item or service A9300 E Exercise equipment A9500 N Technetium TC 99m sestamibi 3 A9502 X Technetium TC99M tetrofosmin 0705 $71.08 A9503 N Technetium TC 99m medronate A9504 N Technetium tc 99m apcitide A9505 N Thallous chloride TL 201/mci A9507 N Indium/111 capromab pendetid 3 A9600 X Strontium-89 chloride 0701 $84.76 3 A9605 X Samarium sm153 lexidronamm 0702 $139.06 A9900 E Supply/accessory/service A9901 E Delivery/set up/dispensing B4034 A Enter feed supkit syr by day B4035 A Enteral feed supp pump per d B4036 A Enteral feed sup kit grav by B4081 A Enteral ng tubing w/stylet B4082 A Enteral ng tubing w/o stylet B4083 A Enteral stomach tube levine B4084 A Gastrostomy/jejunostomy tubi B4085 A Gastrostomy tube w/ring each B4150 A Enteral formulae category i B4151 A Enteral formulae category i- B4152 A Enteral formulae category ii B4153 A Enteral formulae category ii B4154 A Enteral formulae category IV B4155 A Enteral formulae category v B4156 A Enteral formulae category vi B4164 A Parenteral 50% dextrose solu B4168 A Parenteral sol amino acid 3. B4172 A Parenteral sol amino acid 5. B4176 A Parenteral sol amino acid 7- B4178 A Parenteral sol amino acid > B4180 A Parenteral sol carb > 50% B4184 A Parenteral sol lipids 10% B4186 A Parenteral sol lipids 20% B4189 A Parenteral sol amino acid & B4193 A Parenteral sol 52-73 gm prot B4197 A Parenteral sol 74-100 gm pro B4199 A Parenteral sol > 100gm prote B4216 A Parenteral nutrition additiv B4220 A Parenteral supply kit premix B4222 A Parenteral supply kit homemi B4224 A Parenteral administration ki Start Printed Page 18670 B5000 A Parenteral sol renal-amirosy B5100 A Parenteral sol hepatic-fream B5200 A Parenteral sol stres-brnch c B9000 A Enter infusion pump w/o alrm B9002 A Enteral infusion pump w/ala B9004 A Parenteral infus pump portab B9006 A Parenteral infus pump statio B9998 A Enteral supp not otherwise c B9999 A Parenteral supp not othrws c D0120 E Periodic oral evaluation D0140 E Limit oral eval problm focus D0150 S Comprehensve oral evaluation 0330 1.51 $73.22 $14.64 $14.64 D0160 E Extensv oral eval prob focus D0170 E Re-eval, est pt, problem focus D0210 E Intraor complete film series D0220 E Intraoral periapical first f D0230 E Intraoral periapical ea add D0240 S Intraoral occlusal film 0330 1.51 $73.22 $14.64 $14.64 D0250 S Extraoral first film 0330 1.51 $73.22 $14.64 $14.64 D0260 S Extraoral ea additional film 0330 1.51 $73.22 $14.64 $14.64 D0270 S Dental bitewing single film 0330 1.51 $73.22 $14.64 $14.64 D0272 S Dental bitewings two films 0330 1.51 $73.22 $14.64 $14.64 D0274 S Dental bitewings four films 0330 1.51 $73.22 $14.64 $14.64 D0277 E Vert bitewings-sev to eight D0290 E Dental film skull/facial bon D0310 E Dental saliography D0320 E Dental tmj arthrogram incl i D0321 E Dental other tmj films D0322 E Dental tomographic survey D0330 E Dental panoramic film D0340 E Dental cephalometric film D0350 E Oral/facial images D0415 E Bacteriologic study D0425 E Caries susceptibility test D0460 S Pulp vitality test 0330 1.51 $73.22 $14.64 $14.64 D0470 E Diagnostic casts D0472 E Gross exam, prep & report D0473 E Micro exam, prep & report D0474 E Micro w exam of surg margins D0480 E Cytopath smear prep & report D0501 S Histopathologic examinations 0330 1.51 $73.22 $14.64 $14.64 D0502 S Other oral pathology procedu 0330 1.51 $73.22 $14.64 $14.64 D0999 S Unspecified diagnostic proce 0330 1.51 $73.22 $14.64 $14.64 D1110 E Dental prophylaxis adult D1120 E Dental prophylaxis child D1201 E Topical fluor w prophy child D1203 E Topical fluor w/o prophy chi D1204 E Topical fluor w/o prophy adu D1205 E Topical fluoride w/prophy a D1310 E Nutri counsel-control caries D1320 E Tobacco counseling D1330 E Oral hygiene instruction D1351 E Dental sealant per tooth D1510 S Space maintainer fxd unilat 0330 1.51 $73.22 $14.64 $14.64 D1515 S Fixed bilat space maintainer 0330 1.51 $73.22 $14.64 $14.64 D1520 S Remove unilat space maintain 0330 1.51 $73.22 $14.64 $14.64 D1525 S Remove bilat space maintain 0330 1.51 $73.22 $14.64 $14.64 D1550 S Recement space maintainer 0330 1.51 $73.22 $14.64 $14.64 D2110 E Amalgam one surface primary D2120 E Amalgam two surfaces primary D2130 E Amalgam three surfaces prima D2131 E Amalgam four/more surf prima D2140 E Amalgam one surface permanen D2150 E Amalgam two surfaces permane D2160 E Amalgam three surfaces perma D2161 E Amalgam 4 or > surfaces perm D2330 E Resin one surface-anterior D2331 E Resin two surfaces-anterior D2332 E Resin three surfaces-anterio D2335 E Resin 4/> surf or w incis an D2336 E Composite resin crown D2337 E Compo resin crown ant-perm D2380 E Resin one surf poster primar Start Printed Page 18671 D2381 E Resin two surf poster primar D2382 E Resin three/more surf post p D2385 E Resin one surf poster perman D2386 E Resin two surf poster perman D2387 E Resin three/more surf post p D2388 E Resin four/more, post perm D2410 E Dental gold foil one surface D2420 E Dental gold foil two surface D2430 E Dental gold foil three surfa D2510 E Dental inlay metalic 1 surf D2520 E Dental inlay metallic 2 surf D2530 E Dental inlay metl 3/more sur D2542 E Dental onlay metallic 2 surf D2543 E Dental onlay metallic 3 surf D2544 E Dental onlay metl 4/more sur D2610 E Inlay porcelain/ceramic 1 su D2620 E Inlay porcelain/ceramic 2 su D2630 E Dental onlay porc 3/more sur D2642 E Dental onlay porcelin 2 surf D2643 E Dental onlay porcelin 3 surf D2644 E Dental onlay porc 4/more sur D2650 E Inlay composite/resin one su D2651 E Inlay composite/resin two su D2652 E Dental inlay resin 3/mre sur D2662 E Dental onlay resin 2 surface D2663 E Dental onlay resin 3 surface D2664 E Dental onlay resin 4/mre sur D2710 E Crown resin laboratory D2720 E Crown resin w/high noble me D2721 E Crown resin w/base metal D2722 E Crown resin w/noble metal D2740 E Crown porcelain/ceramic subs D2750 E Crown porcelain w/h noble m D2751 E Crown porcelain fused base m D2752 E Crown porcelain w/noble met D2780 E Crown 3/4 cast hi noble met D2781 E Crown 3/4 cast base metal D2782 E Crown 3/4 cast noble metal D2783 E Crown 3/4 porcelain/ceramic D2790 E Crown full cast high noble m D2791 E Crown full cast base metal D2792 E Crown full cast noble metal D2799 E Provisional crown D2910 E Dental recement inlay D2920 E Dental recement crown D2930 E Prefab stnlss steel crwn pri D2931 E Prefab stnlss steel crown pe D2932 E Prefabricated resin crown D2933 E Prefab stainless steel crown D2940 E Dental sedative filling D2950 E Core build-up incl any pins D2951 E Tooth pin retention D2952 E Post and core cast + crown D2953 E Each addtnl cast post D2954 E Prefab post/core + crown D2955 E Post removal D2957 E Each addtnl prefab post D2960 E Laminate labial veneer D2961 E Lab labial veneer resin D2962 E Lab labial veneer porcelain D2970 S Temporary-fractured tooth 0330 1.51 $73.22 $14.64 $14.64 D2980 E Crown repair D2999 S Dental unspec restorative pr 0330 1.51 $73.22 $14.64 $14.64 D3110 E Pulp cap direct D3120 E Pulp cap indirect D3220 E Therapeutic pulpotomy D3221 E Gross pulpal debridement D3230 E Pulpal therapy anterior prim D3240 E Pulpal therapy posterior pri D3310 E Anterior D3320 E Root canal therapy 2 canals D3330 E Root canal therapy 3 canals D3331 E Non-surg tx root canal obs Start Printed Page 18672 D3332 E Incomplete endodontic tx D3333 E Internal root repair D3346 E Retreat root canal anterior D3347 E Retreat root canal bicuspid D3348 E Retreat root canal molar D3351 E Apexification/recalc initial D3352 E Apexification/recalc interim D3353 E Apexification/recalc final D3410 E Apicoect/perirad surg anter D3421 E Root surgery bicuspid D3425 E Root surgery molar D3426 E Root surgery ea add root D3430 E Retrograde filling D3450 E Root amputation D3460 S Endodontic endosseous implan 0330 1.51 $73.22 $14.64 $14.64 D3470 E Intentional replantation D3910 E Isolation-tooth w rubb dam D3920 E Tooth splitting D3950 E Canal prep/fitting of dowel D3999 S Endodontic procedure 0330 1.51 $73.22 $14.64 $14.64 D4210 E Gingivectomy/plasty per quad D4211 E Gingivectomy/plasty per toot D4220 E Gingival curettage per quadr D4240 E Gingival flap proc w/planin D4245 E Apically positioned flap D4249 E Crown lengthen hard tissue D4260 S Osseous surgery per quadrant 0330 1.51 $73.22 $14.64 $14.64 D4263 S Bone replce graft first site 0330 1.51 $73.22 $14.64 $14.64 D4264 S Bone replce graft each add 0330 1.51 $73.22 $14.64 $14.64 D4266 E Guided tiss regen resorble D4267 E Guided tiss regen nonresorb D4268 E Surgical revision procedure D4270 S Pedicle soft tissue graft pr 0330 1.51 $73.22 $14.64 $14.64 D4271 S Free soft tissue graft proc 0330 1.51 $73.22 $14.64 $14.64 D4273 S Subepithelial tissue graft 0330 1.51 $73.22 $14.64 $14.64 D4274 E Distal/proximal wedge proc D4320 E Provision splnt intracoronal D4321 E Provisional splint extracoro D4341 E Periodontal scaling & root D4355 S Full mouth debridement 0330 1.51 $73.22 $14.64 $14.64 D4381 S Localized chemo delivery 0330 1.51 $73.22 $14.64 $14.64 D4910 E Periodontal maint procedures D4920 E Unscheduled dressing change D4999 E Unspecified periodontal proc D5110 E Dentures complete maxillary D5120 E Dentures complete mandible D5130 E Dentures immediat maxillary D5140 E Dentures immediat mandible D5211 E Dentures maxill part resin D5212 E Dentures mand part resin D5213 E Dentures maxill part metal D5214 E Dentures mandibl part metal D5281 E Removable partial denture D5410 E Dentures adjust cmplt maxil D5411 E Dentures adjust cmplt mand D5421 E Dentures adjust part maxill D5422 E Dentures adjust part mandbl D5510 E Dentur repr broken compl bas D5520 E Replace denture teeth complt D5610 E Dentures repair resin base D5620 E Rep part denture cast frame D5630 E Rep partial denture clasp D5640 E Replace part denture teeth D5650 E Add tooth to partial denture D5660 E Add clasp to partial denture D5710 E Dentures rebase cmplt maxil D5711 E Dentures rebase cmplt mand D5720 E Dentures rebase part maxill D5721 E Dentures rebase part mandbl D5730 E Denture reln cmplt maxil ch D5731 E Denture reln cmplt mand chr D5740 E Denture reln part maxil chr D5741 E Denture reln part mand chr Start Printed Page 18673 D5750 E Denture reln cmplt max lab D5751 E Denture reln cmplt mand lab D5760 E Denture reln part maxil lab D5761 E Denture reln part mand lab D5810 E Denture interm cmplt maxill D5811 E Denture interm cmplt mandbl D5820 E Denture interm part maxill D5821 E Denture interm part mandbl D5850 E Denture tiss conditn maxill D5851 E Denture tiss condtin mandbl D5860 E Overdenture complete D5861 E Overdenture partial D5862 E Precision attachment D5867 E Replacement of precision att D5875 E Prosthesis modification D5899 E Removable prosthodontic proc D5911 S Facial moulage sectional 0330 1.51 $73.22 $14.64 $14.64 D5912 S Facial moulage complete 0330 1.51 $73.22 $14.64 $14.64 D5913 E Nasal prosthesis D5914 E Auricular prosthesis D5915 E Orbital prosthesis D5916 E Ocular prosthesis D5919 E Facial prosthesis D5922 E Nasal septal prosthesis D5923 E Ocular prosthesis interim D5924 E Cranial prosthesis D5925 E Facial augmentation implant D5926 E Replacement nasal prosthesis D5927 E Auricular replacement D5928 E Orbital replacement D5929 E Facial replacement D5931 E Surgical obturator D5932 E Postsurgical obturator D5933 E Refitting of obturator D5934 E Mandibular flange prosthesis D5935 E Mandibular denture prosth D5936 E Temp obturator prosthesis D5937 E Trismus appliance D5951 E Feeding aid D5952 E Pediatric speech aid D5953 E Adult speech aid D5954 E Superimposed prosthesis D5955 E Palatal lift prosthesis D5958 E Intraoral con def inter plt D5959 E Intraoral con def mod palat D5960 E Modify speech aid prosthesis D5982 E Surgical stent D5983 S Radiation applicator 0330 1.51 $73.22 $14.64 $14.64 D5984 S Radiation shield 0330 1.51 $73.22 $14.64 $14.64 D5985 S Radiation cone locator 0330 1.51 $73.22 $14.64 $14.64 D5986 E Fluoride applicator D5987 S Commissure splint 0330 1.51 $73.22 $14.64 $14.64 D5988 E Surgical splint D5999 E Maxillofacial prosthesis D6010 E Odontics endosteal implant D6020 E Odontics abutment placement D6040 E Odontics eposteal implant D6050 E Odontics transosteal implnt D6055 E Implant connecting bar D6056 E Prefabricated abutment D6057 E Custom abutment D6058 E Abutment supported crown D6059 E Abutment supported mtl crown D6060 E Abutment supported mtl crown D6061 E Abutment supported mtl crown D6062 E Abutment supported mtl crown D6063 E Abutment supported mtl crown D6064 E Abutment supported mtl crown D6065 E Implant supported crown D6066 E Implant supported mtl crown D6067 E Implant supported mtl crown D6068 E Abutment supported retainer D6069 E Abutment supported retainer Start Printed Page 18674 D6070 E Abutment supported retainer D6071 E Abutment supported retainer D6072 E Abutment supported retainer D6073 E Abutment supported retainer D6074 E Abutment supported retainer D6075 E Implant supported retainer D6076 E Implant supported retainer D6077 E Implant supported retainer D6078 E Implnt/abut suprtd fixd dent D6079 E Implnt/abut suprtd fixd dent D6080 E Implant maintenance D6090 E Repair implant D6095 E Odontics repr abutment D6100 E Removal of implant D6199 E Implant procedure D6210 E Prosthodont high noble metal D6211 E Bridge base metal cast D6212 E Bridge noble metal cast D6240 E Bridge porcelain high noble D6241 E Bridge porcelain base metal D6242 E Bridge porcelain nobel metal D6245 E Bridge porcelain/ceramic D6250 E Bridge resin w/high noble D6251 E Bridge resin base metal D6252 E Bridge resin w/noble metal D6519 E Inlay/onlay porce/ceramic D6520 E Dental retainer two surfaces D6530 E Retainer metallic 3+ surface D6543 E Dental retainr onlay 3 surf D6544 E Dental retainr onlay 4/more D6545 E Dental retainr cast metl D6548 E Porcelain/ceramic retainer D6720 E Retain crown resin w hi nble D6721 E Crown resin w/base metal D6722 E Crown resin w/noble metal D6740 E Crown porcelain/ceramic D6750 E Crown porcelain high noble D6751 E Crown porcelain base metal D6752 E Crown porcelain noble metal D6780 E Crown 3/4 high noble metal D6781 E Crown 3/4 cast based metal D6782 E Crown 3/4 cast noble metal D6783 E Crown 3/4 porcelain/ceramic D6790 E Crown full high noble metal D6791 E Crown full base metal cast D6792 E Crown full noble metal cast D6920 S Dental connector bar 0330 1.51 $73.22 $14.64 $14.64 D6930 E Dental recement bridge D6940 E Stress breaker D6950 E Precision attachment D6970 E Post & core plus retainer D6971 E Cast post bridge retainer D6972 E Prefab post & core plus reta D6973 E Core build up for retainer D6975 E Coping metal D6976 E Each addtnl cast post D6977 E Each addtl prefab post D6980 E Bridge repair D6999 E Fixed prosthodontic proc D7110 S Oral surgery single tooth 0330 1.51 $73.22 $14.64 $14.64 D7120 S Each add tooth extraction 0330 1.51 $73.22 $14.64 $14.64 D7130 S Tooth root removal 0330 1.51 $73.22 $14.64 $14.64 D7210 S Rem imp tooth w mucoper flp 0330 1.51 $73.22 $14.64 $14.64 D7220 S Impact tooth remov soft tiss 0330 1.51 $73.22 $14.64 $14.64 D7230 S Impact tooth remov part bony 0330 1.51 $73.22 $14.64 $14.64 D7240 S Impact tooth remov comp bony 0330 1.51 $73.22 $14.64 $14.64 D7241 S Impact tooth rem bony w/comp 0330 1.51 $73.22 $14.64 $14.64 D7250 S Tooth root removal 0330 1.51 $73.22 $14.64 $14.64 D7260 S Oral antral fistula closure 0330 1.51 $73.22 $14.64 $14.64 D7270 E Tooth reimplantation D7272 E Tooth transplantation D7280 E Exposure impact tooth orthod D7281 E Exposure tooth aid eruption Start Printed Page 18675 D7285 E Biopsy of oral tissue hard D7286 E Biopsy of oral tissue soft D7290 E Repositioning of teeth D7291 S Transseptal fiberotomy 0330 1.51 $73.22 $14.64 $14.64 D7310 E Alveoplasty w/extraction D7320 E Alveoplasty w/o extraction D7340 E Vestibuloplasty ridge extens D7350 E Vestibuloplasty exten graft D7410 E Rad exc lesion up to 1.25 cm D7420 E Lesion > 1.25 cm D7430 E Exc benign tumor to 1.25 cm D7431 E Benign tumor exc > 1.25 cm D7440 E Malig tumor exc to 1.25 cm D7441 E Malig tumor > 1.25 cm D7450 E Rem odontogen cyst to 1.25cm D7451 E Rem odontogen cyst > 1.25 cm D7460 E Rem nonodonto cyst to 1.25cm D7461 E Rem nonodonto cyst > 1.25 cm D7465 E Lesion destruction D7471 E Rem exostosis any site D7480 E Partial ostectomy D7490 E Mandible resection D7510 E I&d absc intraoral soft tiss D7520 E I&d abscess extraoral D7530 E Removal fb skin/areolar tiss D7540 E Removal of fb reaction D7550 E Removal of sloughed off bone D7560 E Maxillary sinusotomy D7610 E Maxilla open reduct simple D7620 E Clsd reduct simpl maxilla fx D7630 E Open red simpl mandible fx D7640 E Clsd red simpl mandible fx D7650 E Open red simp malar/zygom fx D7660 E Clsd red simp malar/zygom fx D7670 E Closd rductn splint alveolus D7680 E Reduct simple facial bone fx D7710 E Maxilla open reduct compound D7720 E Clsd reduct compd maxilla fx D7730 E Open reduct compd mandble fx D7740 E Clsd reduct compd mandble fx D7750 E Open red comp malar/zygma fx D7760 E Clsd red comp malar/zygma fx D7770 E Open reduc compd alveolus fx D7780 E Reduct compnd facial bone fx D7810 E Tmj open reduct-dislocation D7820 E Closed tmp manipulation D7830 E Tmj manipulation under anest D7840 E Removal of tmj condyle D7850 E Tmj meniscectomy D7852 E Tmj repair of joint disc D7854 E Tmj excisn of joint membrane D7856 E Tmj cutting of a muscle D7858 E Tmj reconstruction D7860 E Tmj cutting into joint D7865 E Tmj reshaping components D7870 E Tmj aspiration joint fluid D7871 E Lysis + lavage w catheters D7872 E Tmj diagnostic arthroscopy D7873 E Tmj arthroscopy lysis adhesn D7874 E Tmj arthroscopy disc reposit D7875 E Tmj arthroscopy synovectomy D7876 E Tmj arthroscopy discectomy D7877 E Tmj arthroscopy debridement D7880 E Occlusal orthotic appliance D7899 E Tmj unspecified therapy D7910 E Dent sutur recent wnd to 5cm D7911 E Dental suture wound to 5 cm D7912 E Suture complicate wnd > 5 cm D7920 E Dental skin graft D7940 S Reshaping bone orthognathic 0330 1.51 $73.22 $14.64 $14.64 D7941 E Bone cutting ramus closed D7943 E Cutting ramus open w/graft D7944 E Bone cutting segmented Start Printed Page 18676 D7945 E Bone cutting body mandible D7946 E Reconstruction maxilla total D7947 E Reconstruct maxilla segment D7948 E Reconstruct midface no graft D7949 E Reconstruct midface w/graft D7950 E Mandible graft D7955 E Repair maxillofacial defects D7960 E Frenulectomy/frenulotomy D7970 E Excision hyperplastic tissue D7971 E Excision pericoronal gingiva D7980 E Sialolithotomy D7981 E Excision of salivary gland D7982 E Sialodochoplasty D7983 E Closure of salivary fistula D7990 E Emergency tracheotomy D7991 E Dental coronoidectomy D7995 E Synthetic graft facial bones D7996 E Implant mandible for augment D7997 E Appliance removal D7999 E Oral surgery procedure D8010 E Limited dental tx primary D8020 E Limited dental tx transition D8030 E Limited dental tx adolescent D8040 E Limited dental tx adult D8050 E Intercep dental tx primary D8060 E Intercep dental tx transitn D8070 E Compre dental tx transition D8080 E Compre dental tx adolescent D8090 E Compre dental tx adult D8210 E Orthodontic rem appliance tx D8220 E Fixed appliance therapy habt D8660 E Preorthodontic tx visit D8670 E Periodic orthodontc tx visit D8680 E Orthodontic retention D8690 E Orthodontic treatment D8691 E Repair ortho appliance D8692 E Replacement retainer D8999 E Orthodontic procedure D9110 N Tx dental pain minor proc D9210 E Dent anesthesia w/o surgery D9211 E Regional block anesthesia D9212 E Trigeminal block anesthesia D9215 E Local anesthesia D9220 E General anesthesia D9221 E General anesthesia ea ad 15m D9230 N Analgesia D9241 E Intravenous sedation D9242 E IV sedation ea ad 30 m D9248 E Sedation (non-iv) D9310 E Dental consultation D9410 E Dental house call D9420 E Hospital call D9430 E Office visit during hours D9440 E Office visit after hours D9610 E Dent therapeutic drug inject D9630 S Other drugs/medicaments 0330 1.51 $73.22 $14.64 $14.64 D9910 E Dent appl desensitizing med D9911 E Appl desensitizing resin D9920 E Behavior management D9930 S Treatment of complications 0330 1.51 $73.22 $14.64 $14.64 D9940 S Dental occlusal guard 0330 1.51 $73.22 $14.64 $14.64 D9941 E Fabrication athletic guard D9950 S Occlusion analysis 0330 1.51 $73.22 $14.64 $14.64 D9951 S Limited occlusal adjustment 0330 1.51 $73.22 $14.64 $14.64 D9952 S Complete occlusal adjustment 0330 1.51 $73.22 $14.64 $14.64 D9970 E Enamel microabrasion D9971 E Odontoplasty 1-2 teeth D9972 E Extrnl bleaching per arch D9973 E Extrnl bleaching per tooth D9974 E Intrnl bleaching per tooth D9999 E Adjunctive procedure E0100 A Cane adjust/fixed with tip E0105 A Cane adjust/fixed quad/3 pro Start Printed Page 18677 E0110 A Crutch forearm pair E0111 A Crutch forearm each E0112 A Crutch underarm pair wood E0113 A Crutch underarm each wood E0114 A Crutch underarm pair no wood E0116 A Crutch underarm each no wood E0130 A Walker rigid adjust/fixed ht E0135 A Walker folding adjust/fixed E0141 A Rigid walker wheeled wo seat E0142 A Walker rigid wheeled with se E0143 A Walker folding wheeled w/o s E0144 A Enclosed walker w rear seat E0145 A Walker whled seat/crutch att E0146 A Folding walker wheels w seat E0147 A Walker variable wheel resist E0153 A Forearm crutch platform atta E0154 A Walker platform attachment E0155 A Walker wheel attachment, pair E0156 A Walker seat attachment E0157 A Walker crutch attachment E0158 A Walker leg extenders set of4 E0159 A Brake for wheeled walker E0160 A Sitz type bath or equipment E0161 A Sitz bath/equipment w/faucet E0162 A Sitz bath chair E0163 A Commode chair stationry fxd E0164 A Commode chair mobile fixed a E0165 A Commode chair stationry det E0166 A Commode chair mobile detach E0167 A Commode chair pail or pan E0175 A Commode chair foot rest E0176 A Air pressre pad/cushion nonp E0177 A Water press pad/cushion nonp E0178 A Gel pressre pad/cushion nonp E0179 A Dry pressre pad/cushion nonp E0180 A Press pad alternating w pump E0181 A Press pad alternating w/pum E0182 A Pressure pad alternating pum E0184 A Dry pressure mattress E0185 A Gel pressure mattress pad E0186 A Air pressure mattress E0187 A Water pressure mattress E0188 E Synthetic sheepskin pad E0189 E Lambswool sheepskin pad E0191 A Protector heel or elbow E0192 A Pad wheelchr low press/posit E0193 A Powered air flotation bed E0194 A Air fluidized bed E0196 A Gel pressure mattress E0197 A Air pressure pad for mattres E0198 A Water pressure pad for mattr E0199 A Dry pressure pad for mattres E0200 A Heat lamp without stand E0202 A Phototherapy light w/photom E0205 A Heat lamp with stand E0210 A Electric heat pad standard E0215 A Electric heat pad moist E0217 A Water circ heat pad w pump E0218 A Water circ cold pad w pump E0220 A Hot water bottle E0225 A Hydrocollator unit E0230 A Ice cap or collar E0235 A Paraffin bath unit portable E0236 A Pump for water circulating p E0238 A Heat pad non-electric moist E0239 A Hydrocollator unit portable E0241 E Bath tub wall rail E0242 E Bath tub rail floor E0243 E Toilet rail E0244 E Toilet seat raised E0245 E Tub stool or bench E0246 A Transfer tub rail attachment E0249 A Pad water circulating heat u Start Printed Page 18678 E0250 A Hosp bed fixed ht w/mattres E0251 A Hosp bed fixd ht w/o mattres E0255 A Hospital bed var ht w/mattr E0256 A Hospital bed var ht w/o matt E0260 A Hosp bed semi-electr w/matt E0261 A Hosp bed semi-electr w/o mat E0265 A Hosp bed total electr w/mat E0266 A Hosp bed total elec w/o matt E0270 A Hospital bed institutional t E0271 A Mattress innerspring E0272 A Mattress foam rubber E0273 A Bed board E0274 A Over-bed table E0275 A Bed pan standard E0276 A Bed pan fracture E0277 A Powered pres-redu air mattrs E0280 A Bed cradle E0290 A Hosp bed fx ht w/o rails w/m E0291 A Hosp bed fx ht w/o rail w/o E0292 A Hosp bed var ht w/o rail w/o E0293 A Hosp bed var ht w/o rail w/ E0294 A Hosp bed semi-elect w/mattr E0295 A Hosp bed semi-elect w/o matt E0296 A Hosp bed total elect w/matt E0297 A Hosp bed total elect w/o mat E0305 A Rails bed side half length E0310 A Rails bed side full length E0315 A Bed accessory brd/tbl/supprt E0325 A Urinal male jug-type E0326 A Urinal female jug-type E0350 A Control unit bowel system E0352 A Disposable pack w/bowel syst E0370 A Air elevator for heel E0371 A Nonpower mattress overlay E0372 A Powered air mattress overlay E0373 A Nonpowered pressure mattress E0424 A Stationary compressed gas 02 E0425 A Gas system stationary compre E0430 A Oxygen system gas portable E0431 A Portable gaseous 02 E0434 A Portable liquid 02 E0435 A Oxygen system liquid portabl E0439 A Stationary liquid 02 E0440 A Oxygen system liquid station E0441 A Oxygen contents gas per/unit E0442 A Oxygen contents liq per/unit E0443 A Port 02 contents gas/unit E0444 A Port 02 contents liq/unit E0450 A Volume vent stationary/porta E0455 A Oxygen tent excl croup/ped t E0457 A Chest shell E0459 A Chest wrap E0460 A Neg press vent portabl/statn E0462 A Rocking bed w/ or w/o side r E0480 A Percussor elect/pneum home m E0500 A Ippb all types E0550 A Humidif extens supple w ippb E0555 A Humidifier for use w/regula E0560 A Humidifier supplemental w/i E0565 A Compressor air power source E0570 A Nebulizer with compression E0575 A Nebulizer ultrasonic E0580 A Nebulizer for use w/regulat E0585 A Nebulizer w/compressor & he E0590 A Dispensing fee dme neb drug E0600 A Suction pump portab hom modl E0601 A Cont airway pressure device E0602 A Breast pump E0605 A Vaporizer room type E0606 A Drainage board postural E0607 A Blood glucose monitor home E0608 A Apnea monitor E0609 A Blood gluc mon w/special fea Start Printed Page 18679 E0610 A Pacemaker monitr audible/vis E0615 A Pacemaker monitr digital/vis E0616 A Cardiac event recorder E0621 A Patient lift sling or seat E0625 A Patient lift bathroom or toi E0627 A Seat lift incorp lift-chair E0628 A Seat lift for pt furn-electr E0629 A Seat lift for pt furn-non-el E0630 A Patient lift hydraulic E0635 A Patient lift electric E0650 A Pneuma compresor non-segment E0651 A Pneum compressor segmental E0652 A Pneum compres w/cal pressure E0655 A Pneumatic appliance half arm E0660 A Pneumatic appliance full leg E0665 A Pneumatic appliance full arm E0666 A Pneumatic appliance half leg E0667 A Seg pneumatic appl full leg E0668 A Seg pneumatic appl full arm E0669 A Seg pneumatic appli half leg E0671 A Pressure pneum appl full leg E0672 A Pressure pneum appl full arm E0673 A Pressure pneum appl half leg E0690 A Ultraviolet cabinet E0700 A Safety equipment E0710 A Restraints any type E0720 A Tens two lead E0730 A Tens four lead E0731 A Conductive garment for tens/ E0740 A Incontinence treatment systm E0744 A Neuromuscular stim for scoli E0745 A Neuromuscular stim for shock E0746 A Electromyograph biofeedback E0747 A Elec osteogen stim not spine E0748 A Elec osteogen stim spinal E0749 A Elec osteogen stim implanted E0751 A Pulse generator or receiver E0753 A Neurostimulator electrodes E0755 A Electronic salivary reflex s E0760 A Osteogen ultrasound stimltor E0776 A Iv pole E0779 A Amb infusion pump mechanical E0780 A Mech amb infusion pump <8hrs E0781 A External ambulatory infus pu E0782 A Non-programble infusion pump E0783 A Programmable infusion pump E0784 A Ext amb infusn pump insulin E0785 A Replacement impl pump cathet E0791 A Parenteral infusion pump sta E0840 A Tract frame attach headboard E0850 A Traction stand free standing E0855 A Cervical traction equipment E0860 A Tract equip cervical tract E0870 A Tract frame attach footboard E0880 A Trac stand free stand extrem E0890 A Traction frame attach pelvic E0900 A Trac stand free stand pelvic E0910 A Trapeze bar attached to bed E0920 A Fracture frame attached to b E0930 A Fracture frame free standing E0935 A Exercise device passive moti E0940 A Trapeze bar free standing E0941 A Gravity assisted traction de E0942 A Cervical head harness/halter E0943 A Cervical pillow E0944 A Pelvic belt/harness/boot E0945 A Belt/harness extremity E0946 A Fracture frame dual w cross E0947 A Fracture frame attachmnts pe E0948 A Fracture frame attachmnts ce E0950 A Tray E0951 A Loop heel E0952 A Loop tie Start Printed Page 18680 E0953 A Pneumatic tire E0954 A Wheelchair semi-pneumatic ca E0958 A Whlchr att-conv 1 arm drive E0959 A Amputee adapter E0961 A Wheelchair brake extension E0962 A Wheelchair 1 inch cushion E0963 A Wheelchair 2 inch cushion E0964 A Wheelchair 3 inch cushion E0965 A Wheelchair 4 inch cushion E0966 A Wheelchair head rest extensi E0967 A Wheelchair hand rims E0968 A Wheelchair commode seat E0969 A Wheelchair narrowing device E0970 A Wheelchair no. 2 footplates E0971 A Wheelchair anti-tipping devi E0972 A Transfer board or device E0973 A Wheelchair adjustabl height E0974 A Wheelchair grade-aid E0975 A Wheelchair reinforced seat u E0976 A Wheelchair reinforced back u E0977 A Wheelchair wedge cushion E0978 A Wheelchair belt w/airplane b E0979 A Wheelchair belt with velcro E0980 A Wheelchair safety vest E0990 A Whellchair elevating leg res E0991 A Wheelchair upholstry seat E0992 A Wheelchair solid seat insert E0993 A Wheelchair back upholstery E0994 A Wheelchair arm rest E0995 A Wheelchair calf rest E0996 A Wheelchair tire solid E0997 A Wheelchair caster w/a fork E0998 A Wheelchair caster w/o a fork E0999 A Wheelchr pneumatic tire w/wh E1000 A Wheelchair tire pneumatic ca E1001 A Wheelchair wheel E1031 A Rollabout chair with casters E1050 A Whelchr fxd full length arms E1060 A Wheelchair detachable arms E1065 A Wheelchair power attachment E1066 A Wheelchair battery charger E1069 A Wheelchair deep cycle batter E1070 A Wheelchair detachable foot r E1083 A Hemi-wheelchair fixed arms E1084 A Hemi-wheelchair detachable a E1085 A Hemi-wheelchair fixed arms E1086 A Hemi-wheelchair detachable a E1087 A Wheelchair lightwt fixed arm E1088 A Wheelchair lightweight det a E1089 A Wheelchair lightwt fixed arm E1090 A Wheelchair lightweight det a E1091 A Wheelchair youth E1092 A Wheelchair wide w/leg rests E1093 A Wheelchair wide w/foot rest E1100 A Whchr s-recl fxd arm leg res E1110 A Wheelchair semi-recl detach E1130 A Whlchr stand fxd arm ft rest E1140 A Wheelchair standard detach a E1150 A Wheelchair standard w/leg r E1160 A Wheelchair fixed arms E1170 A Whlchr ampu fxd arm leg rest E1171 A Wheelchair amputee w/o leg r E1172 A Wheelchair amputee detach ar E1180 A Wheelchair amputee w/foot r E1190 A Wheelchair amputee w/leg re E1195 A Wheelchair amputee heavy dut E1200 A Wheelchair amputee fixed arm E1210 A Whlchr moto ful arm leg rest E1211 A Wheelchair motorized w/det E1212 A Wheelchair motorized w full E1213 A Wheelchair motorized w/det E1220 A Whlchr special size/constrc E1221 A Wheelchair spec size w foot Start Printed Page 18681 E1222 A Wheelchair spec size w/leg E1223 A Wheelchair spec size w foot E1224 A Wheelchair spec size w/leg E1225 A Wheelchair spec sz semi-recl E1226 A Wheelchair spec sz full-recl E1227 A Wheelchair spec sz spec ht a E1228 A Wheelchair spec sz spec ht b E1230 A Power operated vehicle E1240 A Whchr litwt det arm leg rest E1250 A Wheelchair lightwt fixed arm E1260 A Wheelchair lightwt foot rest E1270 A Wheelchair lightweight leg r E1280 A Whchr h-duty det arm leg res E1285 A Wheelchair heavy duty fixed E1290 A Wheelchair hvy duty detach a E1295 A Wheelchair heavy duty fixed E1296 A Wheelchair special seat heig E1297 A Wheelchair special seat dept E1298 A Wheelchair spec seat depth/w E1300 A Whirlpool portable E1310 A Whirlpool non-portable E1340 A Repair for DME, per 15 min E1353 A Oxygen supplies regulator E1355 A Oxygen supplies stand/rack E1372 A Oxy suppl heater for nebuliz E1375 A Oxygen suppl nebulizer porta E1377 A Oxygen concentrator to 244 c E1378 A Oxygen concentrator to 488 c E1379 A Oxygen concentrator to 732 c E1380 A Oxygen concentrator to 976 c E1381 A Oxygen concentrat to 1220 cu E1382 A Oxygen concentrat to 1464 cu E1383 A Oxygen concentrat to 1708 cu E1384 A Oxygen concentrat to 1952 cu E1385 A Oxygen concentrator > 1952 c E1390 A Oxygen concentrator E1399 A Durable medical equipment mi E1405 A O2/water vapor enrich w/heat E1406 A O2/water vapor enrich w/o he E1510 A Kidney dialysate delivry sys E1520 A Heparin infusion pump for di E1530 A Air bubble detector for dial E1540 A Pressure alarm for dialysis E1550 A Bath conductivity meter E1560 A Blood leak detector for dial E1570 A Adjustable chair for esrd pt E1575 A Transducer protector/fluid b E1580 A Unipuncture control system E1590 A Hemodialysis machine E1592 A Auto interm peritoneal dialy E1594 A Cycler dialysis machine E1600 A Deliv/install equip for dial E1610 A Reverse osmosis water purifi E1615 A Deionizer water purification E1620 A Blood pump for dialysis E1625 A Water softening system E1630 A Reciprocating peritoneal dia E1632 A Wearable artificial kidney E1635 A Compact travel hemodialyzer E1636 A Sorbent cartridges for dialy E1640 A Replacement components for d E1699 A Dialysis equipment unspecifi E1700 A Jaw motion rehab system E1701 A Repl cushions for jaw motion E1702 A Repl measr scales jaw motion E1800 A Adjust elbow ext/flex device E1805 A Adjust wrist ext/flex device E1810 A Adjust knee ext/flex device E1815 A Adjust ankle ext/flex device E1820 A Soft interface material E1825 A Adjust finger ext/flex devc E1830 A Adjust toe ext/flex device E1900 A Speech communication device Start Printed Page 18682 G0001 A Drawing blood for specimen G0002 N Temporary urinary catheter G0004 S ECG transm phys review & int 0100 1.70 $82.43 $71.57 $16.49 G0005 S ECG 24 hour recording 0099 0.38 $18.43 $14.68 $3.69 G0006 S ECG transmission & analysis 0100 1.70 $82.43 $71.57 $16.49 G0007 N ECG phy review & interpret 2 G0008 X Admin influenza virus vac 0354 0.13 $6.19 G0009 N Admin pneumococcal vaccine G0010 N Admin hepatitis b vaccine G0015 S Post symptom ECG tracing 0099 0.38 $18.43 $14.68 $3.69 G0016 N Post symptom ECG md review G0025 X Collagen skin test kit 0343 0.45 $21.82 $12.16 $4.36 G0026 A Fecal leukocyte examination G0027 A Semen analysis G0030 S PET imaging prev PET single 0285 15.06 $730.22 $415.21 $146.04 G0031 S PET imaging prev PET multple 0285 15.06 $730.22 $415.21 $146.04 G0032 S PET follow SPECT 78464 singl 0285 15.06 $730.22 $415.21 $146.04 G0033 S PET follow SPECT 78464 mult 0285 15.06 $730.22 $415.21 $146.04 G0034 S PET follow SPECT 76865 singl 0285 15.06 $730.22 $415.21 $146.04 G0035 S PET follow SPECT 78465 mult 0285 15.06 $730.22 $415.21 $146.04 G0036 S PET follow cornry angio sing 0285 15.06 $730.22 $415.21 $146.04 G0037 S PET follow cornry angio mult 0285 15.06 $730.22 $415.21 $146.04 G0038 S PET follow myocard perf sing 0285 15.06 $730.22 $415.21 $146.04 G0039 S PET follow myocard perf mult 0285 15.06 $730.22 $415.21 $146.04 G0040 S PET follow stress echo singl 0285 15.06 $730.22 $415.21 $146.04 G0041 S PET follow stress echo mult 0285 15.06 $730.22 $415.21 $146.04 G0042 S PET follow ventriculogm sing 0285 15.06 $730.22 $415.21 $146.04 G0043 S PET follow ventriculogm mult 0285 15.06 $730.22 $415.21 $146.04 G0044 S PET following rest ECG singl 0285 15.06 $730.22 $415.21 $146.04 G0045 S PET following rest ECG mult 0285 15.06 $730.22 $415.21 $146.04 G0046 S PET follow stress ECG singl 0285 15.06 $730.22 $415.21 $146.04 G0047 S PET follow stress ECG mult 0285 15.06 $730.22 $415.21 $146.04 G0050 S Residual urine by ultrasound 0265 1.17 $56.73 $38.08 $11.35 G0101 V CA screen; pelvic/breast exam 0601 1.00 $48.49 $9.70 $9.70 G0102 E Prostate ca screening; dre G0103 E Psa, total screening 1 G0104 S CA screen; flexi sigmoidscope 0158 7.98 $386.93 $96.73 1 G0105 S Colorectal scrn; hi risk ind 0159 2.83 $137.22 $34.31 2 G0106 S Colon CA screen; barium enema 0157 1.79 $86.79 $17.36 G0107 A CA screen; fecal blood test G0108 A Diab manage trn per indiv G0109 A Diab manage trn ind/group G0110 A Nett pulm-rehab educ; ind G0111 A Nett pulm-rehab educ; group G0112 A Nett; nutrition guid, initial G0113 A Nett; nutrition guid, subseqnt G0114 A Nett; psychosocial consult G0115 A Nett; psychological testing G0116 A Nett; psychosocial counsel 2 G0120 S Colon ca scrn; barium enema 0157 1.79 $86.79 $17.36 G0121 E Colon ca scrn not hi rsk ind G0122 E Colon ca scrn; barium enema G0123 E Screen cerv/vag thin layer G0124 E Screen c/v thin layer by MD 2 G0125 T Lung image (PET) 0980 38.67 $1,875.00 $375.00 2 G0126 T Lung image (PET) staging 0980 38.67 $1,875.00 $375.00 G0127 T Trim nail(s) 0009 0.74 $35.88 $9.63 $7.18 G0128 E CORF skilled nursing service G0129 P Partial hosp prog service 0033 4.17 $202.19 $48.17 $40.44 G0130 X Single energy x-ray study 0261 1.38 $66.91 $38.77 $13.38 G0131 X CT scan, bone density study 0261 1.38 $66.91 $38.77 $13.38 G0132 X CT scan, bone density study 0261 1.38 $66.91 $38.77 $13.38 G0141 E Scr c/v cyto, autosys and md G0143 E Scr c/v cyto, thinlayer, rescr G0144 E Scr c/v cyto, thinlayer, rescr G0145 E Scr c/v cyto, thinlayer, rescr G0147 E Scr c/v cyto, automated sys G0148 E Scr c/v cyto, autosys, rescr G0151 E HHCP-serv of pt, ea 15 min G0152 E HHCP-serv of ot, ea 15 min G0153 E HHCP-svs of s/l path, ea 15mn G0154 E HHCP-svs of rn, ea 15 min G0155 E HHCP-svs of csw, ea 15 min Start Printed Page 18683 G0156 E HHCP-svs of aide, ea 15 min G0159 T Perc declot dialysis graft 0088 26.49 $1,284.42 $678.68 $256.88 G0160 C Cryo. ablation, prostate G0161 X Echo guide for cryo probes 0268 2.23 $108.13 $69.51 $21.63 2 G0163 T Pet for rec of colorectal ca 0980 38.67 $1,875.00 $375.00 2 G0164 T Pet for lymphoma staging 0980 38.67 $1,875.00 $375.00 2 G0165 T Pet, rec of melanoma/met ca 0980 38.67 $1,875.00 $375.00 2 G0166 T Extrnl counterpulse, per tx 0972 3.09 $149.83 $29.97 G0167 S Hyperbaric oz tx; no md reqrd 0031 3.00 $145.46 $140.85 $29.09 G0168 T Wound closure by adhesive 0026 12.11 $587.18 $277.92 $117.44 G0169 T Removal tissue; no anesthsia 0026 12.11 $587.18 $277.92 $117.44 G0170 T Skin biograft 0026 12.11 $587.18 $277.92 $117.44 G0171 T Skin biograft add-on 0026 12.11 $587.18 $277.92 $117.44 G0172 P Partial hosp prog service 0033 4.17 $202.19 $48.17 $40.44 G0173 S Stereotactic, one session 0302 8.21 $398.08 $216.55 $79.62 G0174 S Stereotactic, mult session 0302 8.21 $398.08 $216.55 $79.62 G0175 V Multidisciplinary team visit 0603 1.66 $80.49 $16.29 $16.10 J0120 N Tetracyclin injection J0130 N Abciximab injection 2 J0150 X Injection adenosine 6 MG 0917 0.36 $17.46 $3.49 J0151 E Adenosine injection J0170 N Adrenalin epinephrin inject J0190 N Inj biperiden lactate/5 mg J0200 N Alatrofloxacin mesylate 3 J0205 X Alglucerase injection 0900 $5.14 3 J0207 X Amifostine 7000 $41.99 J0210 N Methyldopate hcl injection 3 J0256 X Alpha 1 proteinase inhibitor 0901 $15.22 J0270 E Alprostadil for injection J0275 E Alprostadil urethral suppos J0280 N Aminophyllin 250 MG inj J0285 N Amphotericin B 3 J0286 X Amphotericin B lipid complex 7001 $12.12 J0290 N Ampicillin 500 MG inj J0295 N Ampicillin sodium per 1.5 gm J0300 N Amobarbital 125 MG inj J0330 N Succinycholine chloride inj J0340 N Nandrolon phenpropionate inj J0350 N Injection anistreplase 30 u J0360 N Hydralazine hcl injection J0380 N Inj metaraminol bitartrate J0390 N Chloroquine injection J0395 N Arbutamine HCl injection J0400 N Inj trimethaphan camsylate J0456 N Azithromycin J0460 N Atropine sulfate injection J0470 N Dimecaprol injection J0475 N Baclofen 10 MG injection 3 J0476 X Baclofen intrathecal trial 7021 $.10 J0500 N Dicyclomine injection J0510 N Benzquinamide injection J0515 N Inj benztropine mesylate J0520 N Bethanechol chloride inject J0530 N Penicillin g benzathine inj J0540 N Penicillin g benzathine inj J0550 N Penicillin g benzathine inj J0560 N Penicillin g benzathine inj J0570 N Penicillin g benzathine inj J0580 N Penicillin g benzathine inj 3 J0585 X Botulinum toxin a per unit 0902 $56.05 J0590 N Ethylnorepinephrine hcl inj J0600 N Edetate calcium disodium inj J0610 N Calcium gluconate injection J0620 N Calcium glycer & lact/10 ML J0630 N Calcitonin salmon injection J0635 N Calcitriol injection 3 J0640 X Leucovorin calcium injection 0725 $1.07 J0670 N Inj mepivacaine HCL/10 ml J0690 N Cefazolin sodium injection J0694 N Cefoxitin sodium injection J0695 N Cefonocid sodium injection J0696 N Ceftriaxone sodium injection J0697 N Sterile cefuroxime injection Start Printed Page 18684 J0698 N Cefotaxime sodium injection J0702 N Betamethasone acet & sod phosp J0704 N Betamethasone sod phosp/4 MG J0710 N Cephapirin sodium injection J0713 N Inj ceftazidime per 500 mg J0715 N Ceftizoxime sodium/500 MG J0720 N Chloramphenicol sodium injec J0725 N Chorionic gonadotropin/1000u J0730 N Chlorpheniramin maleate inj 3 J0735 X Clonidine hydrochloride 7002 $4.17 J0740 N Cidofovir injection J0743 N Cilastatin sodium injection J0745 N Inj codeine phosphate/30 MG J0760 N Colchicine injection J0770 N Colistimethate sodium inj J0780 N Prochlorperazine injection J0800 N Corticotropin injection J0810 N Cortisone injection J0835 N Inj cosyntropin per 0.25 MG 3 J0850 X Cytomegalovirus imm IV/vial 0903 $54.11 J0895 N Deferoxamine mesylate inj J0900 N Testosterone enanthate inj J0945 N Brompheniramine maleate inj J0970 N Estradiol valerate injection J1000 N Depo-estradiol cypionate inj J1020 N Methylprednisolone 20 MG inj J1030 N Methylprednisolone 40 MG inj J1040 N Methylprednisolone 80 MG inj J1050 N Medroxyprogesterone inj J1055 E Medrxyprogester acetate inj J1060 N Testosterone cypionate 1 ML J1070 N Testosterone cypionat 100 MG J1080 N Testosterone cypionat 200 MG J1090 N Testosterone cypionate 50 MG J1095 N Inj dexamethasone acetate J1100 N Dexamethasone sodium phos J1110 N Inj dihydroergotamine mesylt J1120 N Acetazolamid sodium injectio J1160 N Digoxin injection J1165 N Phenytoin sodium injection J1170 N Hydromorphone injection J1180 N Dyphylline injection 3 J1190 X Dexrazoxane HCl injection 0726 $18.81 J1200 N Diphenhydramine hcl injectio J1205 N Chlorothiazide sodium inj J1212 N Dimethyl sulfoxide 50% 50 ML J1230 N Methadone injection J1240 N Dimenhydrinate injection 2 J1245 X Dipyridamole injection 0917 0.36 $17.46 $3.49 J1250 N Inj dobutamine HCL/250 mg 3 J1260 X Dolasetron mesylate 0750 $1.94 J1320 N Amitriptyline injection 3 J1325 X Epoprostenol injection 7003 $2.23 J1327 N Eptifibatide injection J1330 N Ergonovine maleate injection J1362 N Erythromycin glucep/250 MG J1364 N Erythro lactobionate/500 MG J1380 N Estradiol valerate 10 MG inj J1390 N Estradiol valerate 20 MG inj J1410 N Inj estrogen conjugate 25 MG J1435 N Injection estrone per 1 MG J1436 X Etidronate disodium inj 0727 $9.31 J1438 N Etanercept injection 3 J1440 X Filgrastim 300 mcg injeciton 0728 $25.21 J1441 E Filgrastim 480 mcg injection J1450 N Fluconazole J1455 N Foscarnet sodium injection J1460 N Gamma globulin 1 CC inj J1470 E Gamma globulin 2 CC inj J1480 E Gamma globulin 3 CC inj J1490 E Gamma globulin 4 CC inj J1500 E Gamma globulin 5 CC inj J1510 E Gamma globulin 6 CC inj Start Printed Page 18685 J1520 E Gamma globulin 7 CC inj J1530 E Gamma globulin 8 CC inj J1540 E Gamma globulin 9 CC inj J1550 E Gamma globulin 10 CC inj J1560 E Gamma globulin > 10 CC inj 3 J1561 X Immune globulin 500 mg 0905 $6.40 3 J1562 X Immune globulin 5 gms 7004 $45.48 3 J1565 X RSV-ivig 0906 $85.53 2 J1570 X Ganciclovir sodium injection 0907 0.51 $24.73 $4.95 J1580 N Garamycin gentamicin inj J1600 N Gold sodium thiomaleate inj J1610 N Glucagon hydrochloride/1 MG 3 J1620 X Gonadorelin hydroch/100 mcg 7005 $9.12 3 J1626 X Granisetron HCl injection 0764 $2.33 J1630 N Haloperidol injection J1631 N Haloperidol decanoate inj J1642 N Inj heparin sodium per 10 u J1644 N Inj heparin sodium per 1000u J1645 N Dalteparin sodium J1650 N Inj enoxaparin sodium 2 J1670 X Tetanus immune globulin inj 0908 0.90 $43.64 $8.73 J1690 N Prednisolone tebutate inj J1700 N Hydrocortisone acetate inj J1710 N Hydrocortisone sodium ph inj J1720 N Hydrocortisone sodium succ i J1730 N Diazoxide injection J1739 N Hydroxyprogesterone cap 125 J1741 N Hydroxyprogesterone cap 250 J1742 N Ibutilide fumarate injection 3 J1745 X Infliximab injection 7043 $6.89 J1750 N Iron dextran 3 J1785 X Injection imiglucerase/unit 0916 $.58 J1790 N Droperidol injection J1800 N Propranolol injection J1810 N Droperidol/fentanyl inj J1820 N Insulin injection 3 J1825 X Interferon beta-1a 0909 $28.70 3 J1830 X Interferon beta-1b/.25 MG 0910 $8.44 J1840 N Kanamycin sulfate 500 MG inj J1850 N Kanamycin sulfate 75 MG inj J1885 N Ketorolac tromethamine inj J1890 N Cephalothin sodium injection J1910 N Kutapressin injection J1930 N Propiomazine injection J1940 N Furosemide injection 3 J1950 X Leuprolide acetate/3.75 MG 0800 $68.56 J1955 E Inj levocarnitine per 1 gm J1956 N Levofloxacin injection J1960 N Levorphanol tartrate inj J1970 N Methotrimeprazine injection J1980 N Hyoscyamine sulfate inj J1990 N Chlordiazepoxide injection J2000 N Lidocaine injection J2010 N Lincomycin injection J2060 N Lorazepam injection J2150 N Mannitol injection J2175 N Meperidine hydrochl/100 MG J2180 N Meperidine/promethazine inj J2210 N Methylergonovin maleate inj J2240 N Metocurine iodide injection J2250 N Inj midazolam hydrochloride 2 J2260 X Inj milrinone lactate/5 ML 7007 0.47 $22.79 $4.56 J2270 N Morphine sulfate injection J2271 N Morphine so4 injection 100mg 3 J2275 X Morphine sulfate injection 7010 $.68 J2300 N Inj nalbuphine hydrochloride J2310 N Inj naloxone hydrochloride J2320 N Nandrolone decanoate 50 MG J2321 N Nandrolone decanoate 100 MG J2322 N Nandrolone decanoate 200 MG J2330 N Thiothixene injection J2350 N Niacinamide/niacin injection 3 J2352 N Octreotide acetate injection 7031 $5.43 Start Printed Page 18686 3 J2355 X Oprelvekin injection 7011 $30.35 J2360 N Orphenadrine injection J2370 N Phenylephrine hcl injection J2400 N Chloroprocaine hcl injection 3 J2405 X Ondansetron hcl injection 0768 $.87 J2410 N Oxymorphone hcl injection 3 J2430 X Pamidronate disodium/30 MG 0730 $30.93 J2440 N Papaverin hcl injection J2460 N Oxytetracycline injection J2480 N Hydrochlorides of opium inj J2500 N Paricalcitol J2510 N Penicillin g procaine inj J2512 N Inj pentagastrin per 2 ML J2515 N Pentobarbital sodium inj J2540 N Penicillin g potassium inj J2543 N Piperacillin/tazobactam 3 J2545 X Pentamidine isethionte/300mg 7012 $8.73 J2550 N Promethazine hcl injection J2560 N Phenobarbital sodium inj J2590 N Oxytocin injection J2597 E Inj desmopressin acetate J2640 N Prednisolone sodium ph inj J2650 N Prednisolone acetate inj J2670 N Totazoline hcl injection J2675 N Inj progesterone per 50 MG J2680 N Fluphenazine decanoate 25 MG J2690 N Procainamide hcl injection J2700 N Oxacillin sodium injeciton J2710 N Neostigmine methylslfte inj J2720 N Inj protamine sulfate/10 MG J2725 N Inj protirelin per 250 mcg J2730 N Pralidoxime chloride inj J2760 N Phentolaine mesylate inj 3 J2765 X Metoclopramide hcl injection 0754 $.19 J2780 N Ranitidine hydrochloride inj 3 J2790 X Rho d immune globulin inj 0884 $3.78 J2792 N Rho(D) immune globulin h, sd J2800 N Methocarbamol injection J2810 N Inj theophylline per 40 MG 3 J2820 X Sargramostim injection 0731 $16.97 J2860 N Secobarbital sodium inj J2910 N Aurothioglucose injeciton J2912 N Sodium chloride injection J2920 N Methylprednisolone injection J2930 N Methylprednisolone injection J2950 N Promazine hcl injeciton J2970 N Methicillin sodium injection 2 J2994 X Reteplase double bolus 0914 38.20 $1,852.21 $370.44 2 J2995 X Inj streptokinase/250000 IU 0911 1.64 $79.69 $15.94 2 J2996 X Alteplase recombinant inj 0915 5.85 $283.70 $56.74 J3000 N Streptomycin injection 3 J3010 X Fentanyl citrate injeciton 7014 $.19 J3030 N Sumatriptan succinate/6 MG J3070 N Pentazocine hcl injeciton J3080 N Chlorprothixene injection J3105 N Terbutaline sulfate inj J3120 N Testosterone enanthate inj J3130 N Testosterone enanthate inj J3140 N Testosterone suspension inj J3150 N Testosteron propionate inj J3230 N Chlorpromazine hcl injection J3240 N Thyrotropin injection 2 J3245 X Tirofiban hydrochloride 7041 0.02 $.97 $.19 J3250 N Trimethobenzamide hcl inj J3260 N Tobramycin sulfate injection J3265 N Injection torsemide 10 mg/ml J3270 N Imipramine hcl injection 3 J3280 X Thiethylperazine maleate inj 0755 $.68 J3301 N Triamcinolone acetonide inj J3302 N Triamcinolone diacetate inj J3303 N Triamcinolone hexacetonl inj 3 J3305 X Inj trimetrexate glucoronate 7045 $8.15 J3310 N Perphenazine injeciton Start Printed Page 18687 J3320 N Spectinomycn di-hcl inj J3350 N Urea injection J3360 N Diazepam injection J3364 N Urokinase 5000 IU injection 2 J3365 X Urokinase 250,000 IU inj 7036 0.73 $35.40 $7.08 J3370 N Vancomycin hcl injeciton J3390 N Methoxamine injection J3400 N Triflupromazine hcl inj J3410 N Hydroxyzine hcl injeciton J3420 N Vitamin b12 injection J3430 N Vitamin k phytonadione inj J3450 N Mephentermine sulfate inj J3470 N Hyaluronidase injection J3475 N Inj magnesium sulfate J3480 N Inj potassium chloride J3490 N Drugs unclassified injection J3520 E Edetate disodium per 150 mg J3530 N Nasal vaccine inhalation J3535 E Metered dose inhaler drug J3570 E Laetrile amygdalin vit B17 J7030 N Normal saline solution infus J7040 N Normal saline solution infus J7042 N 5% dextrose/normal saline J7050 N Normal saline solution infus J7051 N Sterile saline/water J7060 N 5% dextrose/water J7070 N D5w infusion J7100 N Dextran 40 infusion J7110 N Dextran 75 infusion J7120 N Ringers lactate infusion J7130 N Hypertonic saline solution 3 J7190 X Factor viii 0925 $.19 3 J7191 X Factor VIII (porcine) 0926 $.19 3 J7192 X Factor viii recombinant 0927 $.19 3 J7194 X Factor ix complex 0928 $.08 3 J7197 X Antithrombin iii injection 0930 $.19 3 J7198 X Anti-inhibitor 0929 $.27 J7199 E Hemophilia clot factor noc J7300 E Intraut copper contraceptive 3 J7310 X Ganciclovir long act implant 0913 $701.51 J7315 N Sodium hyaluronate injection J7320 N Hylan G-F 20 injection 2 J7500 X Azathioprine oral 50mg 0886 0.02 $.97 $.19 2 J7501 X Azathioprine parenteral 0887 1.40 $67.88 $13.58 2 J7502 X Cyclosporine oral 100 mg 0888 0.08 $3.88 $.78 2 J7504 X Lymphocyte immune globulin 0890 3.79 $183.77 $36.75 3 J7505 E Monoclonal antibodies 7038 $89.60 J7506 N Prednisone oral 2 J7507 X Tacrolimus oral per 1 MG 0891 3.15 $152.73 $30.55 J7508 E Tacrolimus oral per 5 MG J7509 N Methylprednisolone oral J7510 N Prednisolone oral per 5 mg J7513 X Daclizumab, parenteral J7515 N Cyclosporine oral 25 mg 2 J7516 X Cyclosporin parenteral 250mg 0889 0.36 $17.46 $3.49 J7517 N Mycophenolate mofetil oral J7599 E Immunosuppressive drug noc J7608 A Acetylcysteine inh sol u d J7610 A Acetylcysteine 10% injection J7615 A Acetylcysteine 20% injection J7618 A Albuterol inh sol con J7619 A Albuterol inh sol u d J7620 A Albuterol sulfate .083%/ml J7625 A Albuterol sulfate .5% inj J7627 A Bitolterolmesylate inhal sol J7628 A Bitolterol mes inhal sol con J7629 A Bitolterol mes inh sol u d J7630 A Cromolyn sodium injeciton J7631 A Cromolyn sodium inh sol u d J7635 A Atropine inhal sol con J7636 A Atropine inhal sol unit dose J7637 A Dexamethasone inhal sol con J7638 A Dexamethasone inhal sol u d Start Printed Page 18688 J7639 A Dornase alpha inhal sol u d J7640 A Epinephrine injection J7642 A Glycopyrrolate inhal sol con J7643 A Glycopyrrolate inhal sol u d J7644 A Ipratropium brom inh sol u d J7645 A Ipratropium bromide .02%/ml J7648 A Isoetharine hcl inh sol con J7649 A Isoetharine hcl inh sol u d J7650 A Isoetharine hcl .1% inj J7651 A Isoetharine hcl .125% inj J7652 A Isoetharine hcl .167% inj J7653 A Isoetharine hcl .2%/inj J7654 A Isoetharine hcl .25% inj J7655 A Isoetharine hcl 1% inj J7658 A Isoproterenolhcl inh sol con J7659 A Isoproterenol hcl inh sol ud J7660 A Isoproterenol hcl .5% inj J7665 A Isoproterenol hcl 1% inj J7668 A Metaproterenol inh sol con J7669 A Metaproterenol inh sol u d J7670 A Metaproterenol sulfate .4% J7672 A Metaproterenol sulfate .6% J7675 A Metaproterenol sulfate 5% J7680 A Terbutaline so4 inh sol con J7681 A Terbutaline so4 inh sol u d J7682 A Tobramycin inhalation sol J7683 A Triamcinolone inh sol con J7684 A Triamcinolone inh sol u d J7699 A Inhalation solution for DME J7799 A Non-inhalation drug for DME 3 J7913 X Daclizumab, Parenteral, 25 m 0892 $54.11 J8499 E Oral prescrip drug non chemo 3 J8510 X Oral busulfan 7015 $.19 3 J8520 X Capecitabine, oral, 150 mg 7042 $.19 J8521 N Capecitabine, oral, 500 mg 3 J8530 X Cyclophosphamide oral 25 MG 0801 $.19 3 J8560 X Etoposide oral 50 MG 0802 $3.10 3 J8600 X Melphalan oral 2 MG 0803 $.19 3 J8610 X Methotrexate oral 2.5 MG 0826 $.29 J8999 E Oral prescription drug chemo 3 J9000 X Doxorubic hcl 10 MG vl chemo 0847 $2.81 3 J9001 X Doxorubicin hcl liposome inj 7046 $39.18 3 J9015 X Aldesleukin/single use vial 0807 $65.07 3 J9020 X Asparaginase injection 0814 $8.34 3 J9031 X Bcg live intravesical vac 0809 $19.78 3 J9040 X Bleomycin sulfate injection 0857 $48.29 3 J9045 X Carboplatin injection 0811 $13.96 3 J9050 X Carmus bischl nitro inj 0812 $10.57 3 J9060 X Cisplatin 10 MG injeciton 0813 $4.56 J9062 E Cisplatin 50 MG injeciton 3 J9065 X Inj cladribine per 1 MG 0858 $8.24 3 J9070 X Cyclophosphamide 100 MG inj 0815 $.48 J9080 E Cyclophosphamide 200 MG inj J9090 E Cyclophosphamide 500 MG inj J9091 E Cyclophosphamide 1.0 grm inj J9092 E Cyclophosphamide 2.0 grm inj 3 J9093 X Cyclophosphamide lyophilized 0816 $1.16 J9094 E Cyclophosphamide lyophilized J9095 E Cyclophosphamide lyophilized J9096 E Cyclophosphamide lyophilized J9097 E Cyclophosphamide lyophilized 3 J9100 X Cytarabine hcl 100 MG inj 0817 $.68 J9110 E Cytarabine hcl 500 MG inj 3 J9120 X Dactinomycin actinomycin d 0818 $1.75 3 J9130 X Dacarbazine 10 MG inj 0819 $1.26 J9140 E Dacarbazine 200 MG inj 3 J9150 X Daunorubicin 0820 $11.64 3 J9151 X Daunorubicin citrate liposom 0821 $7.76 3 J9165 X Diethylstilbestrol injection 0822 $2.13 3 J9170 X Docetaxel 0823 $34.72 3 J9181 X Etoposide 10 MG inj 0824 $.58 J9182 E Etoposide 100 MG inj 3 J9185 X Fludarabine phosphate inj 0842 $30.84 Start Printed Page 18689 3 J9190 X Fluorouracil injection 0859 $.19 3 J9200 X Floxuridine injection 0827 $18.81 3 J9201 X Gemcitabine HCl 0828 $9.31 3 J9202 X Goserelin acetate implant 0810 $59.74 3 J9206 X Irinotecan injection 0830 $14.16 3 J9208 X Ifosfomide injection 0831 $13.58 3 J9209 X Mesna injection 0732 $2.42 3 J9211 X Idarubicin hcl injeciton 0832 $46.45 3 J9212 X Interferon alfacon-1 0833 $.19 3 J9213 X Interferon alfa-2a inj 0834 $3.20 3 J9214 X Interferon alfa-2b inj 0836 $1.36 3 J9215 X Interferon alfa-n3 inj 0865 $1.07 3 J9216 X Interferon gamma 1-b inj 0838 $22.79 J9217 E Leuprolide acetate suspnsion 3 J9218 X Leuprolide acetate injeciton 0861 $19.39 3 J9230 X Mechlorethamine hcl inj 0839 $1.65 3 J9245 X Inj melphalan hydrochl 50 MG 0840 $44.71 3 J9250 X Methotrexate sodium inj 0841 $.10 J9260 E Methotrexate sodium inj 3 J9265 X Paclitaxel injection 0863 $30.16 3 J9266 X Pegaspargase/singl dose vial 0843 $178.72 3 J9268 X Pentostatin injection 0844 $133.73 3 J9270 X Plicamycin (mithramycin) inj 0860 $1.36 3 J9280 X Mitomycin 5 MG inj 0862 $19.88 J9290 E Mitomycin 20 MG inj J9291 E Mitomycin 40 MG inj 3 J9293 X Mitoxantrone hydrochl/5 MG 0864 $25.80 3 J9310 X Rituximab cancer treatment 0849 $51.40 3 J9320 X Streptozocin injection 0850 $14.64 3 J9340 X Thiotepa injection 0851 $9.50 3 J9350 X Topotecan 0852 $73.22 J9355 N Trastuzumab J9357 N Valrubicin, 200 mg 3 J9360 X Vinblastine sulfate inj 0853 $.39 3 J9370 X Vincristine sulfate 1 MG inj 0854 $2.23 J9375 E Vincristine sulfate 2 MG inj J9380 E Vincristine sulfate 5 MG inj 3 J9390 X Vinorelbine tartrate/10 mg 0855 $9.60 3 J9600 X Porfimer sodium 0856 $34.62 J9999 E Chemotherapy drug K0001 A Standard wheelchair K0002 A Stnd hemi (low seat) whlchr K0003 A Lightweight wheelchair K0004 A High strength ltwt whlchr K0005 A Ultralightweight wheelchair K0006 A Heavy duty wheelchair K0007 A Extra heavy duty wheelchair K0008 A Cstm manual wheelchair/base K0009 A Other manual wheelchair/base K0010 A Stnd wt frame power whlchr K0011 A Stnd wt pwr whlchr w control K0012 A Ltwt portbl power whlchr K0013 A Custom power whlchr base K0014 A Other power whlchr base K0015 A Detach non-adjus hght armrst K0016 A Detach adjust armrst cmplete K0017 A Detach adjust armrest base K0018 A Detach adjust armrst upper K0019 A Arm pad each K0020 A Fixed adjust armrest pair K0021 A Anti-tipping device each K0022 A Reinforced back upholstery K0023 A Planr back insrt foam w/strp K0024 A Plnr back insrt foam w/hrdwr K0025 A Hook-on headrest extension K0026 A Back upholst lgtwt whlchr K0027 A Back upholst other whlchr K0028 A Manual fully reclining back K0029 A Reinforced seat upholstery K0030 A Solid plnr seat sngl dnsfoam K0031 A Safety belt/pelvic strap K0032 A Seat uphols lgtwt whlchr K0033 A Seat upholstery other whlchr Start Printed Page 18690 K0034 A Heel loop each K0035 A Heel loop with ankle strap K0036 A Toe loop each K0037 A High mount flip-up footrest K0038 A Leg strap each K0039 A Leg strap h style each K0040 A Adjustable angle footplate K0041 A Large size footplate each K0042 A Standard size footplate each K0043 A Ftrst lower extension tube K0044 A Ftrst upper hanger bracket K0045 A Footrest complete assembly K0046 A Elevat legrst low extension K0047 A Elevat legrst up hangr brack K0048 A Elevate legrest complete K0049 A Calf pad each K0050 A Ratchet assembly K0051 A Cam relese assem ftrst/lgrst K0052 A Swingaway detach footrest K0053 A Elevate footrest articulate K0054 A Seat wdth 10-12/15/17/20 wc K0055 A Seat dpth 15/17/18 ltwt wc K0056 A Seat ht <17 or >=21 ltwt wc K0057 A Seat wdth 19/20 hvy dty wc K0058 A Seat dpth 17/18 power wc K0059 A Plastic coated handrim each K0060 A Steel handrim each K0061 A Aluminum handrim each K0062 A Handrim 8-10 vert/obliq proj K0063 A Hndrm 12-16 vert/obliq proj K0064 A Zero pressure tube flat free K0065 A Spoke protectors K0066 A Solid tire any size each K0067 A Pneumatic tire any size each K0068 A Pneumatic tire tube each K0069 A Rear whl complete solid tire K0070 A Rear whl compl pneum tire K0071 A Front castr compl pneum tire K0072 A Frnt cstr cmpl sem-pneum tir K0073 A Caster pin lock each K0074 A Pneumatic caster tire each K0075 A Semi-pneumatic caster tire K0076 A Solid caster tire each K0077 A Front caster assem complete K0078 A Pneumatic caster tire tube K0079 A Wheel lock extension pair K0080 A Anti-rollback device pair K0081 A Wheel lock assembly complete K0082 A 22 nf deep cycl acid battery K0083 A 22 nf gel cell battery each K0084 A Grp 24 deep cycl acid battry K0085 A Group 24 gel cell battery K0086 A U-1 lead acid battery each K0087 A U-1 gel cell battery each K0088 A Battry chrgr acid/gel cell K0089 A Battery charger dual mode K0090 A Rear tire power wheelchair K0091 A Rear tire tube power whlchr K0092 A Rear assem cmplt powr whlchr K0093 A Rear zero pressure tire tube K0094 A Wheel tire for power base K0095 A Wheel tire tube each base K0096 A Wheel assem powr base complt K0097 A Wheel zero presure tire tube K0098 A Drive belt power wheelchair K0099 A Pwr wheelchair front caster K0100 A Amputee adapter pair K0101 A One-arm drive attachment K0102 A Crutch and cane holder K0103 A Transfer board < 25″ K0104 A Cylinder tank carrier K0105 A Iv hanger K0106 A Arm trough each Start Printed Page 18691 K0107 A Wheelchair tray K0108 A W/c component-accessory NOS K0112 A Trunk vest supprt innr frame K0113 A Trunk vest suprt w/o inr frm K0114 A Whlchr back suprt inr frame K0115 A Back module orthotic system K0116 A Back & seat modul orthot sys K0182 A Water distilled w/nebulizer K0183 A Nasal application device K0184 A Nasal pillows/seals pair K0185 A Pos airway pressure headgear K0186 A Pos airway prssure chinstrap K0187 A Pos airway pressure tubing K0188 A Pos airway pressure filter K0189 A Filter nondisposable w PAP K0195 A Elevating whlchair leg rests K0268 A Humidifier nonheated w PAP K0269 A Aerosol compressor cpap dev K0270 A Ultrasonic generator w nebul K0280 A Extension drainage tubing K0281 A Lubricant catheter insertion K0283 A Saline solution dispenser K0407 A Urinary cath skin attachment K0408 A Urinary cath leg strap K0409 A Sterile H2O irrigation solut K0410 A Male ext cath w/adh coating K0411 A Male ext cath w/adh strip K0415 E RX antiemetic drg, oral NOS K0416 E Rx antiemetic drg, rectal NOS K0440 A Nasal prosthesis K0441 A Midfacial prosthesis K0442 A Orbital prosthesis K0443 A Upper facial prosthesis K0444 A Hemi-facial prosthesis K0445 A Auricular prosthesis K0446 A Partial facial prosthesis K0447 A Nasal septal prosthesis K0448 A Unspec maxillofacial prosth K0449 A Repair maxillofacial prosth K0450 A Liq adhes for facial prosth K0451 A Adhesive remover wipes K0452 A Wheelchair bearings K0455 A Pump uninterrupted infusion K0456 A Heavyduty/xtra wide hosp bed K0457 A Heavyduty/wide commode chair K0458 A Heavyduty walker no wheels K0459 A Heavy duty wheeled walker K0460 A WC power add-on joystick K0461 A WC power add-on tiller cntrl K0462 A Temporary replacement eqpmnt K0501 A Aerosol compressor for svneb K0529 A Sterile H20 or nss w lv neb K0531 A Heated humidifier used w pap K0532 A Noninvasive assist wo backup K0533 A Noninvasive assist w backup K0534 A Invasive assist w backup L0100 A Cerv craniosten helmet mold L0110 A Cerv craniostenosis hel non- L0120 A Cerv flexible non-adjustable L0130 A Flex thermoplastic collar mo L0140 A Cervical semi-rigid adjustab L0150 A Cerv semi-rig adj molded chn L0160 A Cerv semi-rig wire occ/mand L0170 A Cervical collar molded to pt L0172 A Cerv col thermplas foam 2 pi L0174 A Cerv col foam 2 piece w thor L0180 A Cer post col occ/man sup adj L0190 A Cerv collar supp adj cerv ba L0200 A Cerv col supp adj bar & thor L0210 A Thoracic rib belt L0220 A Thor rib belt custom fabrica L0300 A TLSO flex surgical support L0310 A Tlso flexible custom fabrica Start Printed Page 18692 L0315 A Tlso flex elas rigid post pa L0317 A Tlso flex hypext elas post p L0320 A Tlso a-p contrl w apron frnt L0330 A Tlso ant-pos-lateral control L0340 A Tlso a-p-l-rotary with apron L0350 A Tlso flex compress jacket cu L0360 A Tlso flex compress jacket mo L0370 A Tlso a-p-l-rotary hyperexten L0380 A Tlso a-p-l-rot w/pos extens L0390 A Tlso a-p-l control molded L0400 A Tlso a-p-l w interface mater L0410 A Tlso a-p-l two piece constr L0420 A Tlso a-p-l 2 piece w interfa L0430 A Tlso a-p-l w interface custm L0440 A Tlso a-p-l overlap frnt cust L0500 A Lso flex surgical support L0510 A Lso flexible custom fabricat L0515 A Lso flex elas w/rig post pa L0520 A Lso a-p-l control with apron L0530 A Lso ant-pos control w apron L0540 A Lso lumbar flexion a-p-l L0550 A Lso a-p-l control molded L0560 A Lso a-p-l w interface L0565 A Lso a-p-l control custom L0600 A Sacroiliac flex surg support L0610 A Sacroiliac flexible custm fa L0620 A Sacroiliac semi-rig w apron L0700 A Ctlso a-p-l control molded L0710 A Ctlso a-p-l control w/inter L0810 A Halo cervical into jckt vest L0820 A Halo cervical into body jack L0830 A Halo cerv into milwaukee typ L0860 A Magnetic resonanc image comp L0900 A Torso/ptosis support L0910 A Torso & ptosis supp custm fa L0920 A Torso/pendulous abd support L0930 A Pendulous abdomen supp custm L0940 A Torso/postsurgical support L0950 A Post surg support custom fab L0960 A Post surgical support pads L0970 A Tlso corset front L0972 A Lso corset front L0974 A Tlso full corset L0976 A Lso full corset L0978 A Axillary crutch extension L0980 A Peroneal straps pair L0982 A Stocking supp grips set of f L0984 A Protective body sock each L0999 A Add to spinal orthosis NOS L1000 A Ctlso milwauke initial model L1010 A Ctlso axilla sling L1020 A Kyphosis pad L1025 A Kyphosis pad floating L1030 A Lumbar bolster pad L1040 A Lumbar or lumbar rib pad L1050 A Sternal pad L1060 A Thoracic pad L1070 A Trapezius sling L1080 A Outrigger L1085 A Outrigger bil w/vert extens L1090 A Lumbar sling L1100 A Ring flange plastic/leather L1110 A Ring flange plas/leather mol L1120 A Covers for upright each L1200 A Furnsh initial orthosis only L1210 A Lateral thoracic extension L1220 A Anterior thoracic extension L1230 A Milwaukee type superstructur L1240 A Lumbar derotation pad L1250 A Anterior asis pad L1260 A Anterior thoracic derotation L1270 A Abdominal pad L1280 A Rib gusset (elastic) each Start Printed Page 18693 L1290 A Lateral trochanteric pad L1300 A Body jacket mold to patient L1310 A Post-operative body jacket L1499 A Spinal orthosis NOS L1500 A Thkao mobility frame L1510 A Thkao standing frame L1520 A Thkao swivel walker L1600 A Abduct hip flex frejka w cvr L1610 A Abduct hip flex frejka covr L1620 A Abduct hip flex pavlik harne L1630 A Abduct control hip semi-flex L1640 A Pelv band/spread bar thigh c L1650 A HO abduction hip adjustable L1660 A HO abduction static plastic L1680 A Pelvic & hip control thigh c L1685 A Post-op hip abduct custom fa L1686 A HO post-op hip abduction L1690 A Combination bilateral HO L1700 A Leg perthes orth toronto typ L1710 A Legg perthes orth newington L1720 A Legg perthes orthosis trilat L1730 A Legg perthes orth scottish r L1750 A Legg perthes sling L1755 A Legg perthes patten bottom t L1800 A Knee orthoses elas w stays L1810 A Ko elastic with joints L1815 A Elastic with condylar pads L1820 A Ko elas w/condyle pads & jo L1825 A Ko elastic knee cap L1830 A Ko immobilizer canvas longit L1832 A KO adj jnt pos rigid support L1834 A Ko w/0 joint rigid molded to L1840 A Ko derot ant cruciate custom L1843 A KO single upright custom fit L1844 A Ko w/adj jt rot cntrl molded L1845 A Ko w/adj flex/ext rotat cus L1846 A Ko w adj flex/ext rotat mold L1847 A KO adjustable w air chambers L1850 A Ko swedish type L1855 A Ko plas doub upright jnt mol L1858 A Ko polycentric pneumatic pad L1860 A Ko supracondylar socket mold L1870 A Ko doub upright lacers molde L1880 A Ko doub upright cuffs/lacers L1885 A Knee upright w/resistance L1900 A Afo sprng wir drsflx calf bd L1902 A Afo ankle gauntlet L1904 A Afo molded ankle gauntlet L1906 A Afo multiligamentus ankle su L1910 A Afo sing bar clasp attach sh L1920 A Afo sing upright w/adjust s L1930 A Afo plastic L1940 A Afo molded to patient plasti L1945 A Afo molded plas rig ant tib L1950 A Afo spiral molded to pt plas L1960 A Afo pos solid ank plastic mo L1970 A Afo plastic molded w/ankle j L1980 A Afo sing solid stirrup calf L1990 A Afo doub solid stirrup calf L2000 A Kafo sing fre stirr thi/calf L2010 A Kafo sng solid stirrup w/o j L2020 A Kafo dbl solid stirrup band/ L2030 A Kafo dbl solid stirrup w/o j L2035 A KAFO plastic pediatric size L2036 A Kafo plas doub free knee mol L2037 A Kafo plas sing free knee mol L2038 A Kafo w/o joint multi-axis an L2039 A KAFO, plstic, medlat rotat con L2040 A Hkafo torsion bil rot straps L2050 A Hkafo torsion cable hip pelv L2060 A Hkafo torsion ball bearing j L2070 A Hkafo torsion unilat rot str L2080 A Hkafo unilat torsion cable Start Printed Page 18694 L2090 A Hkafo unilat torsion ball br L2102 A Afo tibial fx cast plstr mol L2104 A Afo tib fx cast synthetic mo L2106 A Afo tib fx cast plaster mold L2108 A Afo tib fx cast molded to pt L2112 A Afo tibial fracture soft L2114 A Afo tib fx semi-rigid L2116 A Afo tibial fracture rigid L2122 A Kafo fem fx cast plaster mol L2124 A Kafo fem fx cast synthet mol L2126 A Kafo fem fx cast thermoplas L2128 A Kafo fem fx cast molded to p L2132 A Kafo femoral fx cast soft L2134 A Kafo fem fx cast semi-rigid L2136 A Kafo femoral fx cast rigid L2180 A Plas shoe insert w ank joint L2182 A Drop lock knee L2184 A Limited motion knee joint L2186 A Adj motion knee jnt lerman t L2188 A Quadrilateral brim L2190 A Waist belt L2192 A Pelvic band & belt thigh fla L2200 A Limited ankle motion ea jnt L2210 A Dorsiflexion assist each joi L2220 A Dorsi & plantar flex ass/res L2230 A Split flat caliper stirr & p L2240 A Round caliper and plate atta L2250 A Foot plate molded stirrup at L2260 A Reinforced solid stirrup L2265 A Long tongue stirrup L2270 A Varus/valgus strap padded/li L2275 A Plastic mod low ext pad/line L2280 A Molded inner boot L2300 A Abduction bar jointed adjust L2310 A Abduction bar-straight L2320 A Non-molded lacer L2330 A Lacer molded to patient mode L2335 A Anterior swing band L2340 A Pre-tibial shell molded to p L2350 A Prosthetic type socket molde L2360 A Extended steel shank L2370 A Patten bottom L2375 A Torsion ank & half solid sti L2380 A Torsion straight knee joint L2385 A Straight knee joint heavy du L2390 A Offset knee joint each L2395 A Offset knee joint heavy duty L2397 A Suspension sleeve lower ext L2405 A Knee joint drop lock ea jnt L2415 A Knee joint cam lock each joi L2425 A Knee disc/dial lock/adj flex L2430 A Knee jnt ratchet lock ea jnt L2435 A Knee joint polycentric joint L2492 A Knee lift loop drop lock rin L2500 A Thi/glut/ischia wgt bearing L2510 A Th/wght bear quad-lat brim m L2520 A Th/wght bear quad-lat brim c L2525 A Th/wght bear nar m-l brim mo L2526 A Th/wght bear nar m-l brim cu L2530 A Thigh/wght bear lacer non-mo L2540 A Thigh/wght bear lacer molded L2550 A Thigh/wght bear high roll cu L2570 A Hip clevis type 2 posit jnt L2580 A Pelvic control pelvic sling L2600 A Hip clevis/thrust bearing fr L2610 A Hip clevis/thrust bearing lo L2620 A Pelvic control hip heavy dut L2622 A Hip joint adjustable flexion L2624 A Hip adj flex ext abduct cont L2627 A Plastic mold recipro hip & c L2628 A Metal frame recipro hip & ca L2630 A Pelvic control band & belt u L2640 A Pelvic control band & belt b Start Printed Page 18695 L2650 A Pelv & thor control gluteal L2660 A Thoracic control thoracic ba L2670 A Thorac cont paraspinal uprig L2680 A Thorac cont lat support upri L2750 A Plating chrome/nickel pr bar L2755 A Carbon graphite lamination L2760 A Extension per extension per L2770 A Low ext orthosis per bar/jnt L2780 A Non-corrosive finish L2785 A Drop lock retainer each L2795 A Knee control full kneecap L2800 A Knee cap medial or lateral p L2810 A Knee control condylar pad L2820 A Soft interface below knee se L2830 A Soft interface above knee se L2840 A Tibial length sock fx or equ L2850 A Femoral lgth sock fx or equa L2860 A Torsion mechanism knee/ankle L2999 A Lower extremity orthosis NOS L3000 A Ft insert ucb berkeley shell L3001 A Foot insert remov molded spe L3002 A Foot insert plastazote or eq L3003 A Foot insert silicone gel eac L3010 A Foot longitudinal arch suppo L3020 A Foot longitud/metatarsal sup L3030 A Foot arch support remov prem L3040 A Ft arch suprt premold longit L3050 A Foot arch supp premold metat L3060 A Foot arch supp longitud/meta L3070 A Arch suprt att to sho longit L3080 A Arch supp att to shoe metata L3090 A Arch supp att to shoe long/m L3100 A Hallus-valgus nght dynamic s L3140 A Abduction rotation bar shoe L3150 A Abduct rotation bar w/o shoe L3160 A Shoe styled positioning dev L3170 A Foot plastic heel stabilizer L3201 A Oxford w supinat/pronat inf L3202 A Oxford w/supinat/pronator c L3203 A Oxford w/supinator/pronator L3204 A Hightop w/supp/pronator inf L3206 A Hightop w/supp/pronator chi L3207 A Hightop w/supp/pronator jun L3208 A Surgical boot each infant L3209 A Surgical boot each child L3211 A Surgical boot each junior L3212 A Benesch boot pair infant L3213 A Benesch boot pair child L3214 A Benesch boot pair junior L3215 A Orthopedic ftwear ladies oxf L3216 A Orthoped ladies shoes dpth i L3217 A Ladies shoes hightop depth i L3218 A Ladies surgical boot each L3219 A Orthopedic mens shoes oxford L3221 A Orthopedic mens shoes dpth i L3222 A Mens shoes hightop depth inl L3223 A Mens surgical boot each L3224 A Woman's shoe oxford brace L3225 A Man's shoe oxford brace L3230 A Custom shoes depth inlay L3250 A Custom mold shoe remov prost L3251 A Shoe molded to pt silicone s L3252 A Shoe molded plastazote cust L3253 A Shoe molded plastazote cust L3254 A Orth foot non-stndard size/w L3255 A Orth foot non-standard size/ L3257 A Orth foot add charge split s L3260 A Ambulatory surgical boot eac L3265 A Plastazote sandal each L3300 A Sho lift taper to metatarsal L3310 A Shoe lift elev heel/sole neo L3320 A Shoe lift elev heel/sole cor L3330 A Lifts elevation metal extens Start Printed Page 18696 L3332 A Shoe lifts tapered to one-ha L3334 A Shoe lifts elevation heel/i L3340 A Shoe wedge sach L3350 A Shoe heel wedge L3360 A Shoe sole wedge outside sole L3370 A Shoe sole wedge between sole L3380 A Shoe clubfoot wedge L3390 A Shoe outflare wedge L3400 A Shoe metatarsal bar wedge ro L3410 A Shoe metatarsal bar between L3420 A Full sole/heel wedge btween L3430 A Sho heel count plast reinfor L3440 A Heel leather reinforced L3450 A Shoe heel sach cushion type L3455 A Shoe heel new leather standa L3460 A Shoe heel new rubber standar L3465 A Shoe heel thomas with wedge L3470 A Shoe heel thomas extend to b L3480 A Shoe heel pad & depress for L3485 A Shoe heel pad removable for L3500 A Ortho shoe add leather insol L3510 A Orthopedic shoe add rub insl L3520 A O shoe add felt w leath insl L3530 A Ortho shoe add half sole L3540 A Ortho shoe add full sole L3550 A O shoe add standard toe tap L3560 A O shoe add horseshoe toe tap L3570 A O shoe add instep extension L3580 A O shoe add instep velcro clo L3590 A O shoe convert to sof counte L3595 A Ortho shoe add march bar L3600 A Trans shoe calip plate exist L3610 A Trans shoe caliper plate new L3620 A Trans shoe solid stirrup exi L3630 A Trans shoe solid stirrup new L3640 A Shoe dennis browne splint bo L3649 A Orthopedic shoe modifica NOS L3650 A Shlder fig 8 abduct restrain L3660 A Abduct restrainer canvas & web L3670 A Acromio/clavicular canvas & we L3675 A Canvas vest SO L3700 A Elbow orthoses elas w stays L3710 A Elbow elastic with metal joi L3720 A Forearm/arm cuffs free motio L3730 A Forearm/arm cuffs ext/flex a L3740 A Cuffs adj lock w/active con L3800 A Whfo short opponen no attach L3805 A Whfo long opponens no attach L3807 A Whfo w inflatable airchamber L3810 A Whfo thumb abduction bar L3815 A Whfo second m.p. abduction a L3820 A Whfo ip ext asst w/mp ext s L3825 A Whfo m.p. extension stop L3830 A Whfo m.p. extension assist L3835 A Whfo m.p. spring extension a L3840 A Whfo spring swivel thumb L3845 A Whfo thumb ip ext ass w/mp L3850 A Action wrist w/dorsiflex as L3855 A Whfo adj m.p. flexion contro L3860 A Whfo adj m.p. flex ctrl & i. L3890 A Torsion mechanism wrist/elbo L3900 A Hinge extension/flex wrist/f L3901 A Hinge ext/flex wrist finger L3902 A Whfo ext power compress gas L3904 A Whfo electric custom fitted L3906 A Wrist gauntlet molded to pt L3907 A Whfo wrst gauntlt thmb spica L3908 A Wrist cock-up non-molded L3910 A Whfo swanson design L3912 A Flex glove w/elastic finger L3914 A WHO wrist extension cock-up L3916 A Whfo wrist extens w/outrigg L3918 A HFO knuckle bender Start Printed Page 18697 L3920 A Knuckle bender with outrigge L3922 A Knuckle bend 2 seg to flex j L3924 A Oppenheimer L3926 A Thomas suspension L3928 A Finger extension w/clock sp L3930 A Finger extension with wrist L3932 A Safety pin spring wire L3934 A Safety pin modified L3936 A Palmer L3938 A Dorsal wrist L3940 A Dorsal wrist w/outrigger at L3942 A Reverse knuckle bender L3944 A Reverse knuckle bend w/outr L3946 A HFO composite elastic L3948 A Finger knuckle bender L3950 A Oppenheimer w/knuckle bend L3952 A Oppenheimer w/rev knuckle 2 L3954 A Spreading hand L3956 A Add joint upper ext orthosis L3960 A Sewho airplan desig abdu pos L3962 A Sewho erbs palsey design abd L3963 A Molded w/articulating elbow L3964 A Seo mobile arm sup att to wc L3965 A Arm supp att to wc rancho ty L3966 A Mobile arm supports reclinin L3968 A Friction dampening arm supp L3969 A Monosuspension arm/hand supp L3970 A Elevat proximal arm support L3972 A Offset/lat rocker arm w/ela L3974 A Mobile arm support supinator L3980 A Upp ext fx orthosis humeral L3982 A Upper ext fx orthosis rad/ul L3984 A Upper ext fx orthosis wrist L3985 A Forearm hand fx orth w/wr h L3986 A Humeral rad/ulna wrist fx or L3995 A Sock fracture or equal each L3999 A Upper limb orthosis NOS L4000 A Repl girdle milwaukee orth L4010 A Replace trilateral socket br L4020 A Replace quadlat socket brim L4030 A Replace socket brim cust fit L4040 A Replace molded thigh lacer L4045 A Replace non-molded thigh lac L4050 A Replace molded calf lacer L4055 A Replace non-molded calf lace L4060 A Replace high roll cuff L4070 A Replace prox & dist upright L4080 A Repl met band kafo-afo prox L4090 A Repl met band kafo-afo calf/ L4100 A Repl leath cuff kafo prox th L4110 A Repl leath cuff kafo-afo cal L4130 A Replace pretibial shell L4205 A Ortho dvc repair per 15 min L4210 A Orth dev repair/repl minor p L4350 A Pneumatic ankle cntrl splint L4360 A Pneumatic walking splint L4370 A Pneumatic full leg splint L4380 A Pneumatic knee splint L4392 A Replace AFO soft interface L4394 A Replace foot drop spint L4396 A Static AFO L4398 A Foot drop splint recumbent L5000 A Sho insert w arch toe filler L5010 A Mold socket ank hgt w/toe f L5020 A Tibial tubercle hgt w/toe f L5050 A Ank symes mold sckt sach ft L5060 A Symes met fr leath socket ar L5100 A Molded socket shin sach foot L5105 A Plast socket jts/thgh lacer L5150 A Mold sckt ext knee shin sach L5160 A Mold socket bent knee shin s L5200 A Kne sing axis fric shin sach L5210 A No knee/ankle joints w/ft b Start Printed Page 18698 L5220 A No knee joint with artic ali L5230 A Fem focal defic constant fri L5250 A Hip canad sing axi cons fric L5270 A Tilt table locking hip sing L5280 A Hemipelvect canad sing axis L5300 A Bk sach soft cover & finish L5310 A Knee disart sach soft cv/fin L5320 A Ak open end sach soft cv/fin L5330 A Hip canadian sach sft cv/fin L5340 A Hemipelvectomy canad cv/fin L5400 A Postop dress & 1 cast chg bk L5410 A Postop dsg bk ea add cast ch L5420 A Postop dsg & 1 cast chg ak/d L5430 A Postop dsg ak ea add cast ch L5450 A Postop app non-wgt bear dsg L5460 A Postop app non-wgt bear dsg L5500 A Init bk ptb plaster direct L5505 A Init ak ischal plstr direct L5510 A Prep BK ptb plaster molded L5520 A Perp BK ptb thermopls direct L5530 A Prep BK ptb thermopls molded L5535 A Prep BK ptb open end socket L5540 A Prep BK ptb laminated socket L5560 A Prep AK ischial plast molded L5570 A Prep AK ischial direct form L5580 A Prep AK ischial thermo mold L5585 A Prep AK ischial open end L5590 A Prep AK ischial laminated L5595 A Hip disartic sach thermopls L5600 A Hip disart sach laminat mold L5610 A Above knee hydracadence L5611 A Ak 4 bar link w/fric swing L5613 A Ak 4 bar ling w/hydraul swig L5614 A 4-bar link above knee w/swng L5616 A Ak univ multiplex sys frict L5617 A AK/BK self-aligning unit ea L5618 A Test socket symes L5620 A Test socket below knee L5622 A Test socket knee disarticula L5624 A Test socket above knee L5626 A Test socket hip disarticulat L5628 A Test socket hemipelvectomy L5629 A Below knee acrylic socket L5630 A Syme typ expandabl wall sckt L5631 A Ak/knee disartic acrylic soc L5632 A Symes type ptb brim design s L5634 A Symes type poster opening so L5636 A Symes type medial opening so L5637 A Below knee total contact L5638 A Below knee leather socket L5639 A Below knee wood socket L5640 A Knee disarticulat leather so L5642 A Above knee leather socket L5643 A Hip flex inner socket ext fr L5644 A Above knee wood socket L5645 A Ak flexibl inner socket ext L5646 A Below knee air cushion socke L5647 A Below knee suction socket L5648 A Above knee air cushion socke L5649 A Isch containmt/narrow m-l so L5650 A Tot contact ak/knee disart s L5651 A Ak flex inner socket ext fra L5652 A Suction susp ak/knee disart L5653 A Knee disart expand wall sock L5654 A Socket insert symes L5655 A Socket insert below knee L5656 A Socket insert knee articulat L5658 A Socket insert above knee L5660 A Sock insrt syme silicone gel L5661 A Multi-durometer symes L5662 A Socket insert bk silicone ge L5663 A Sock knee disartic silicone L5664 A Socket insert ak silicone ge Start Printed Page 18699 L5665 A Multi-durometer below knee L5666 A Below knee cuff suspension L5667 A Socket insert w lock lower L5668 A Socket insert w/o lock lower L5669 A Below knee socket w/o lock L5670 A Bk molded supracondylar susp L5672 A Bk removable medial brim sus L5674 A Bk latex sleeve suspension/e L5675 A Bk latex sleeve susp/eq hvy L5676 A Bk knee joints single axis p L5677 A Bk knee joints polycentric p L5678 A Bk joint covers pair L5680 A Bk thigh lacer non-molded L5682 A Bk thigh lacer glut/ischia m L5684 A Bk fork strap L5686 A Bk back check L5688 A Bk waist belt webbing L5690 A Bk waist belt padded and lin L5692 A Ak pelvic control belt light L5694 A Ak pelvic control belt pad/l L5695 A Ak sleeve susp neoprene/equa L5696 A Ak/knee disartic pelvic join L5697 A Ak/knee disartic pelvic band L5698 A Ak/knee disartic silesian ba L5699 A Shoulder harness L5700 A Replace socket below knee L5701 A Replace socket above knee L5702 A Replace socket hip L5704 A Custom shape covr below knee L5705 A Custm shape cover above knee L5706 A Custm shape cvr knee disart L5707 A Custm shape cover hip disart L5710 A Kne-shin exo sng axi mnl loc L5711 A Knee-shin exo mnl lock ultra L5712 A Knee-shin exo frict swg & st L5714 A Knee-shin exo variable frict L5716 A Knee-shin exo mech stance ph L5718 A Knee-shin exo frct swg & sta L5722 A Knee-shin pneum swg frct exo L5724 A Knee-shin exo fluid swing ph L5726 A Knee-shin ext jnts fld swg e L5728 A Knee-shin fluid swg & stance L5780 A Knee-shin pneum/hydra pneum L5785 A Exoskeletal bk ultralt mater L5790 A Exoskeletal ak ultra-light m L5795 A Exoskel hip ultra-light mate L5810 A Endoskel knee-shin mnl lock L5811 A Endo knee-shin mnl lck ultra L5812 A Endo knee-shin frct swg & st L5814 A Endo knee-shin hydral swg ph L5816 A Endo knee-shin polyc mch sta L5818 A Endo knee-shin frct swg & st L5822 A Endo knee-shin pneum swg frc L5824 A Endo knee-shin fluid swing p L5826 A Miniature knee joint L5828 A Endo knee-shin fluid swg/sta L5830 A Endo knee-shin pneum/swg pha L5840 A Multi-axial knee/shin system L5845 A Knee-shin sys stance flexion L5846 A Knee-shin sys microprocessor L5850 A Endo ak/hip knee extens assi L5855 A Mech hip extension assist L5910 A Endo below knee alignable sy L5920 A Endo ak/hip alignable system L5925 A Above knee manual lock L5930 A High activity knee frame L5940 A Endo bk ultra-light material L5950 A Endo ak ultra-light material L5960 A Endo hip ultra-light materia L5962 A Below knee flex cover system L5964 A Above knee flex cover system L5966 A Hip flexible cover system L5968 A Multiaxial ankle w dorsiflex Start Printed Page 18700 L5970 A Foot external keel sach foot L5972 A Flexible keel foot L5974 A Foot single axis ankle/foot L5975 A Combo ankle/foot prosthesis L5976 A Energy storing foot L5978 A Ft prosth multiaxial ankl/ft L5979 A Multi-axial ankle/ft prosth L5980 A Flex foot system L5981 A Flex-walk sys low ext prosth L5982 A Exoskeletal axial rotation u L5984 A Endoskeletal axial rotation L5985 A Lwr ext dynamic prosth pylon L5986 A Multi-axial rotation unit L5987 A Shank ft w vert load pylon L5988 A Vertical shock reducing pylo L5999 A Lowr extremity prosthes NOS L6000 A Par hand robin-aids thum rem L6010 A Hand robin-aids little/ring L6020 A Part hand robin-aids no fing L6050 A Wrst MLd sck flx hng tri pad L6055 A Wrst mold sock w/exp interfa L6100 A Elb mold sock flex hinge pad L6110 A Elbow mold sock suspension t L6120 A Elbow mold doub splt soc ste L6130 A Elbow stump activated lock h L6200 A Elbow mold outsid lock hinge L6205 A Elbow molded w/expand inter L6250 A Elbow inter loc elbow forarm L6300 A Shlder disart int lock elbow L6310 A Shoulder passive restor comp L6320 A Shoulder passive restor cap L6350 A Thoracic intern lock elbow L6360 A Thoracic passive restor comp L6370 A Thoracic passive restor cap L6380 A Postop dsg cast chg wrst/elb L6382 A Postop dsg cast chg elb dis/ L6384 A Postop dsg cast chg shlder/t L6386 A Postop ea cast chg & realign L6388 A Postop applicat rigid dsg on L6400 A Below elbow prosth tiss shap L6450 A Elb disart prosth tiss shap L6500 A Above elbow prosth tiss shap L6550 A Shldr disar prosth tiss shap L6570 A Scap thorac prosth tiss shap L6580 A Wrist/elbow bowden cable mol L6582 A Wrist/elbow bowden cbl dir f L6584 A Elbow fair lead cable molded L6586 A Elbow fair lead cable dir fo L6588 A Shdr fair lead cable molded L6590 A Shdr fair lead cable direct L6600 A Polycentric hinge pair L6605 A Single pivot hinge pair L6610 A Flexible metal hinge pair L6615 A Disconnect locking wrist uni L6616 A Disconnect insert locking wr L6620 A Flexion-friction wrist unit L6623 A Spring-ass rot wrst w/latch L6625 A Rotation wrst w/cable lock L6628 A Quick disconn hook adapter o L6629 A Lamination collar w/couplin L6630 A Stainless steel any wrist L6632 A Latex suspension sleeve each L6635 A Lift assist for elbow L6637 A Nudge control elbow lock L6640 A Shoulder abduction joint pai L6641 A Excursion amplifier pulley t L6642 A Excursion amplifier lever ty L6645 A Shoulder flexion-abduction j L6650 A Shoulder universal joint L6655 A Standard control cable extra L6660 A Heavy duty control cable L6665 A Teflon or equal cable lining L6670 A Hook to hand cable adapter Start Printed Page 18701 L6672 A Harness chest/shlder saddle L6675 A Harness figure of 8 sing con L6676 A Harness figure of 8 dual con L6680 A Test sock wrist disart/bel e L6682 A Test sock elbw disart/above L6684 A Test socket shldr disart/tho L6686 A Suction socket L6687 A Frame typ socket bel elbow/w L6688 A Frame typ sock above elb/dis L6689 A Frame typ socket shoulder di L6690 A Frame typ sock interscap-tho L6691 A Removable insert each L6692 A Silicone gel insert or equal L6693 A Lockingelbow forearm cntrbal L6700 A Terminal device model #3 L6705 A Terminal device model #5 L6710 A Terminal device model #5x L6715 A Terminal device model #5xa L6720 A Terminal device model #6 L6725 A Terminal device model #7 L6730 A Terminal device model #7lo L6735 A Terminal device model #8 L6740 A Terminal device model #8x L6745 A Terminal device model #88x L6750 A Terminal device model #10p L6755 A Terminal device model #10x L6765 A Terminal device model #12p L6770 A Terminal device model #99x L6775 A Terminal device model #555 L6780 A Terminal device model #ss555 L6790 A Hooks-accu hook or equal L6795 A Hooks-2 load or equal L6800 A Hooks-aprl vc or equal L6805 A Modifier wrist flexion unit L6806 A Trs grip vc or equal L6807 A Term device grip 1/2 or equal L6808 A Term device infant or child L6809 A Trs super sport passive L6810 A Pincher tool otto bock or eq L6825 A Hands dorrance vo L6830 A Hand aprl vc L6835 A Hand sierra vo L6840 A Hand becker imperial L6845 A Hand becker lock grip L6850 A Term dvc-hand becker plylite L6855 A Hand robin-aids vo L6860 A Hand robin-aids vo soft L6865 A Hand passive hand L6867 A Hand detroit infant hand L6868 A Passive inf hand steeper/hos L6870 A Hand child mitt L6872 A Hand nyu child hand L6873 A Hand mech inf steeper or equ L6875 A Hand bock vc L6880 A Hand bock vo L6890 A Production glove L6895 A Custom glove L6900 A Hand restorat thumb/1 finger L6905 A Hand restoration multiple fi L6910 A Hand restoration no fingers L6915 A Hand restoration replacmnt g L6920 A Wrist disarticul switch ctrl L6925 A Wrist disart myoelectronic c L6930 A Below elbow switch control L6935 A Below elbow myoelectronic ct L6940 A Elbow disarticulation switch L6945 A Elbow disart myoelectronic c L6950 A Above elbow switch control L6955 A Above elbow myoelectronic ct L6960 A Shldr disartic switch contro L6965 A Shldr disartic myoelectronic L6970 A Interscapular-thor switch ct L6975 A Interscap-thor myoelectronic Start Printed Page 18702 L7010 A Hand otto back steeper/eq sw L7015 A Hand sys teknik village swit L7020 A Electronic greifer switch ct L7025 A Electron hand myoelectronic L7030 A Hand sys teknik vill myoelec L7035 A Electron greifer myoelectro L7040 A Prehensile actuator hosmer s L7045 A Electron hook child michigan L7170 A Electronic elbow hosmer swit L7180 A Electronic elbow utah myoele L7185 A Electron elbow adolescent sw L7186 A Electron elbow child switch L7190 A Elbow adolescent myoelectron L7191 A Elbow child myoelectronic ct L7260 A Electron wrist rotator otto L7261 A Electron wrist rotator utah L7266 A Servo control steeper or equ L7272 A Analogue control unb or equa L7274 A Proportional ctl 12 volt uta L7360 A Six volt bat otto bock/eq ea L7362 A Battery chrgr six volt otto L7364 A Twelve volt battery utah/equ L7366 A Battery chrgr 12 volt utah/e L7499 A Upper extremity prosthes NOS L7500 A Prosthetic dvc repair hourly L7510 A Prosthetic device repair rep L7520 A Repair prosthesis per 15 min L7900 A Vacuum erection system L8000 A Mastectomy bra L8010 A Mastectomy sleeve L8015 A Ext breastprosthesis garment L8020 A Mastectomy form L8030 A Breast prosthesis silicone/e L8035 A Custom breast prosthesis L8039 A Breast prosthesis NOS L8100 A Compression stocking BK18-30 L8110 A Compression stocking BK30-40 L8120 A Compression stocking BK40-50 L8130 A Gc stocking thighlngth 18-30 L8140 A Gc stocking thighlngth 30-40 L8150 A Gc stocking thighlngth 40-50 L8160 A Gc stocking full lngth 18-30 L8170 A Gc stocking full lngth 30-40 L8180 A Gc stocking full lngth 40-50 L8190 A Gc stocking waistlngth 18-30 L8195 A Gc stocking waistlngth 30-40 L8200 A Gc stocking waistlngth 40-50 L8210 A Gc stocking custom made L8220 A Gc stocking lymphedema L8230 A Gc stocking garter belt L8239 A G compression stocking NOS L8300 A Truss single w/standard pad L8310 A Truss double w/standard pad L8320 A Truss addition to std pad wa L8330 A Truss add to std pad scrotal L8400 A Sheath below knee L8410 A Sheath above knee L8415 A Sheath upper limb L8417 A Pros sheath/sock w gel cushn L8420 A Prosthetic sock multi ply BK L8430 A Prosthetic sock multi ply AK L8435 A Pros sock multi ply upper lm L8440 A Shrinker below knee L8460 A Shrinker above knee L8465 A Shrinker upper limb L8470 A Pros sock single ply BK L8480 A Pros sock single ply AK L8485 A Pros sock single ply upper l L8490 A Air seal suction reten systm L8499 A Unlisted misc prosthetic ser L8500 A Artificial larynx L8501 A Tracheostomy speaking valve L8600 A Implant breast silicone/eq Start Printed Page 18703 L8603 A Collagen imp urinary 2.5 CC L8610 A Ocular implant L8612 A Aqueous shunt prosthesis L8613 A Ossicular implant L8614 A Cochlear device/system L8619 A Replace cochlear processor L8630 A Metacarpophalangeal implant L8641 A Metatarsal joint implant L8642 A Hallux implant L8658 A Interphalangeal joint implnt L8670 A Vascular graft, synthetic L8699 A Prosthetic implant NOS L9900 A O&P supply/accessory/service M0064 X Visit for drug monitoring 0374 1.17 $56.73 $13.08 $11.35 M0075 E Cellular therapy M0076 E Prolotherapy M0100 E Intragastric hypothermia M0300 E IV chelationtherapy M0301 E Fabric wrapping of aneurysm M0302 E Assessment of cardiac output P2028 A Cephalin floculation test P2029 A Congo red blood test P2031 E Hair analysis P2033 A Blood thymol turbidity P2038 A Blood mucoprotein P3000 A Screen pap by tech w md supv P3001 E Screening pap smear by phys P7001 E Culture bacterial urine 2 P9010 S Whole blood for transfusion 0950 2.08 $101.02 $20.20 P9011 S Blood split unit 2 P9012 S Cryoprecipitate each unit 0952 0.70 $33.92 $6.78 2 P9013 S Unit/s blood fibrinogen 0953 0.48 $23.27 $4.65 2 P9016 S Leukocyte poor blood, unit 0954 2.83 $137.21 $27.44 2 P9017 S One donor fresh frozn plasma 0955 2.26 $109.35 $21.87 2 P9018 S Plasma protein fract, unit 0956 1.26 $61.09 $12.22 2 P9019 S Platelet concentrate unit 0957 0.98 $47.46 $9.49 2 P9020 S Platelet rich plasma unit 0958 1.16 $56.25 $11.25 2 P9021 S Red blood cells unit 0959 2.04 $99.04 $19.81 2 P9022 S Washed red blood cells unit 0960 3.81 $184.53 $36.91 2 P9023 S Frozen plasma, pooled, sd 0949 3.49 $169.22 $33.84 P9603 A One-way allow prorated miles P9604 A One-way allow prorated trip P9612 N Catheterize for urine spec P9615 N Urine specimen collect mult 2 0034 X Admin of influenza vaccine 0354 0.13 $6.19 Q0035 X Cardiokymography 0366 0.38 $18.43 $15.60 $3.69 Q0081 S Infusion ther other than che 0120 1.66 $80.49 $42.67 $16.10 Q0082 P Activity therapy w/partial h 0033 4.17 $202.19 $48.17 $40.44 Q0083 S Chemo by other than infusion 0116 2.34 $113.46 $22.69 $22.69 Q0084 S Chemotherapy by infusion 0117 1.84 $89.22 $71.80 $17.84 Q0085 S Chemo by both infusion and o 0118 2.90 $140.61 $72.03 $28.12 Q0086 A Physical therapy evaluation/ Q0091 T Obtaining screen pap smear 0191 1.19 $57.70 $17.43 $11.54 Q0092 N Set up port x-ray equipment Q0111 A Wet mounts/w preparations Q0112 A Potassium hydroxide preps Q0113 A Pinworm examinations Q0114 A Fern test Q0115 A Post-coital mucous exam 3 Q0136 X Non esrd epoetin alpha inj 0733 $1.75 Q0144 E Azithromycin dihydrate, oral 2 Q0156 X Human albumin 5% 0961 2.77 $134.31 $26.86 2 Q0157 X Human albumin 25% 0962 1.38 $66.91 $13.38 3 Q0160 X Factor IX non-recombinant 0931 $.04 3 Q0161 X Factor IX recombinant 0932 $.10 3 Q0163 X Diphenhydramine HCl 50mg 0761 $.10 3 Q0164 X Prochlorperazine maleate 5mg 0761 $.10 Q0165 E Prochlorperazine maleate10mg 3 Q0166 X Granisetron HCl 1 mg oral 0765 $3.20 3 Q0167 X Dronabinol 2.5mg oral 0762 $.48 Q0168 E Dronabinol 5mg oral 3 Q0169 X Promethazine HCl 12.5mg oral 0761 $.10 Q0170 E Promethazine HCl 25 mg oral Start Printed Page 18704 3 Q0171 X Chlorpromazine HCl 10mg oral 0761 $.10 Q0172 E Chlorpromazine HCl 25mg oral 3 Q0173 X Trimethobenzamide HCl 250mg 0761 $.10 3 Q0174 X Thiethylperazine maleate10mg 0761 $.10 3 Q0175 X Perphenazine 4mg oral 0761 $.10 Q0176 E Perphenazine 8mg oral 3 Q0177 X Hydroxyzine pamoate 25mg 0761 $.10 Q0178 E Hydroxyzine pamoate 50mg 3 Q0179 X Ondansetron HCl 8mg oral 0769 $2.62 3 Q0180 X Dolasetron mesylate oral 0763 $8.53 Q0181 E Unspecified oral anti-emetic Q0183 N Nonmetabolic active tissue Q0184 N Metabolically active tissue Q0185 N Metabolic active D/E tissue Q0186 E Paramedic intercept, rural 3 Q0187 X Factor viia recombinant 0929 $.27 Q1001 E Ntiol category 1 Q1002 E Ntiol category 2 Q1003 E Ntiol category 3 Q1004 E Ntiol category 4 Q1005 E Ntiol category 5 Q2001 E Cabergoline, 0.5 mg, oral 3 Q2002 X Elliot's B solution 7022 $19.20 3 Q2003 X Aprotinin, 10,000 kiu 7019 $2.42 3 Q2004 X Treatment for bladder calcul 7023 $4.46 3 Q2005 X Corticorelin ovine triflutat 7024 $45.77 3 Q2006 X Digoxin immune FAB (Ovine), 7025 $14.06 3 Q2007 X Ethanolamine oleate, 1000 ml 7026 $2.13 3 Q2008 X Fomepizole, 1.5 G 7027 $141.29 3 Q2009 X Fosphenytoin, 50 mg 7028 $.78 3 Q2010 X Glatiramer acetate, 25 mgeny 7029 $3.59 3 Q2011 X Hemin, 1 mg 7030 $.10 3 Q2012 X Pegademase bovine inj 25 I.U 7039 $1.16 3 Q2013 X Pentastarch 10% inj, 100 ml 7040 $2.04 3 Q2014 X Sermorelin acetate, 0.5 mg 7032 $53.34 3 Q2015 X Somatrem, 5 mg 7033 $28.03 3 Q2016 X Somatropin, 1 mg 7034 $5.04 3 Q2017 X Teniposide, 50 mg 7035 $20.85 3 Q2018 X Urofollitropin, 75 I.U. 7037 $8.24 3 Q3001 S Brachytherapy Seeds 0918 $9.99 Q9920 A Epoetin with hct <= 20 Q9921 A Epoetin with hct = 21 Q9922 A Epoetin with hct = 22 Q9923 A Epoetin with hct = 23 Q9924 A Epoetin with hct = 24 Q9925 A Epoetin with hct = 25 Q9926 A Epoetin with hct = 26 Q9927 A Epoetin with hct = 27 Q9928 A Epoetin with hct = 28 Q9929 A Epoetin with hct = 29 Q9930 A Epoetin with hct = 30 Q9931 A Epoetin with hct = 31 Q9932 A Epoetin with hct = 32 Q9933 A Epoetin with hct = 33 Q9934 A Epoetin with hct = 34 Q9935 A Epoetin with hct = 35 Q9936 A Epoetin with hct = 36 Q9937 A Epoetin with hct = 37 Q9938 A Epoetin with hct = 38 Q9939 A Epoetin with hct = 39 Q9940 A Epoetin with hct >= 40 R0070 N Transport portable x-ray R0075 N Transport port x-ray multipl R0076 N Transport portable EKG V2020 A Vision svcs frames purchases V2025 E Eyeglasses delux frames V2100 A Lens spher single plano 4.00 V2101 A Single visn sphere 4.12-7.00 V2102 A Singl visn sphere 7.12-20.00 V2103 A Spherocylindr 4.00d/12-2.00d V2104 A Spherocylindr 4.00d/2.12-4d V2105 A Spherocylinder 4.00d/4.25-6d V2106 A Spherocylinder 4.00d/>6.00d Start Printed Page 18705 V2107 A Spherocylinder 4.25d/12-2d V2108 A Spherocylinder 4.25d/2.12-4d V2109 A Spherocylinder 4.25d/4.25-6d V2110 A Spherocylinder 4.25d/over 6d V2111 A Spherocylindr 7.25d/.25-2.25 V2112 A Spherocylindr 7.25d/2.25-4d V2113 A Spherocylindr 7.25d/4.25-6d V2114 A Spherocylinder over 12.00d V2115 A Lens lenticular bifocal V2116 A Nonaspheric lens bifocal V2117 A Aspheric lens bifocal V2118 A Lens aniseikonic single V2199 A Lens single vision not oth c V2200 A Lens spher bifoc plano 4.00d V2201 A Lens sphere bifocal 4.12-7.0 V2202 A Lens sphere bifocal 7.12-20. V2203 A Lens sphcyl bifocal 4.00d/.1 V2204 A Lens sphcy bifocal 4.00d/2.1 V2205 A Lens sphcy bifocal 4.00d/4.2 V2206 A Lens sphcy bifocal 4.00d/ove V2207 A Lens sphcy bifocal 4.25-7d/. V2208 A Lens sphcy bifocal 4.25-7/2. V2209 A Lens sphcy bifocal 4.25-7/4. V2210 A Lens sphcy bifocal 4.25-7/ov V2211 A Lens sphcy bifo 7.25-12/.25- V2212 A Lens sphcyl bifo 7.25-12/2.2 V2213 A Lens sphcyl bifo 7.25-12/4.2 V2214 A Lens sphcyl bifocal over 12. V2215 A Lens lenticular bifocal V2216 A Lens lenticular nonaspheric V2217 A Lens lenticular aspheric bif V2218 A Lens aniseikonic bifocal V2219 A Lens bifocal seg width over V2220 A Lens bifocal add over 3.25d V2299 A Lens bifocal speciality V2300 A Lens sphere trifocal 4.00d V2301 A Lens sphere trifocal 4.12-7. V2302 A Lens sphere trifocal 7.12-20 V2303 A Lens sphcy trifocal 4.0/.12- V2304 A Lens sphcy trifocal 4.0/2.25 V2305 A Lens sphcy trifocal 4.0/4.25 V2306 A Lens sphcyl trifocal 4.00/>6 V2307 A Lens sphcy trifocal 4.25-7/. V2308 A Lens sphc trifocal 4.25-7/2. V2309 A Lens sphc trifocal 4.25-7/4. V2310 A Lens sphc trifocal 4.25-7/>6 V2311 A Lens sphc trifo 7.25-12/.25- V2312 A Lens sphc trifo 7.25-12/2.25 V2313 A Lens sphc trifo 7.25-12/4.25 V2314 A Lens sphcyl trifocal over 12 V2315 A Lens lenticular trifocal V2316 A Lens lenticular nonaspheric V2317 A Lens lenticular aspheric tri V2318 A Lens aniseikonic trifocal V2319 A Lens trifocal seg width > 28 V2320 A Lens trifocal add over 3.25d V2399 A Lens trifocal speciality V2410 A Lens variab asphericity sing V2430 A Lens variable asphericity bi V2499 A Variable asphericity lens V2500 A Contact lens pmma spherical V2501 A Cntct lens pmma-toric/prism V2502 A Contact lens pmma bifocal V2503 A Cntct lens pmma color vision V2510 A Cntct gas permeable sphericl V2511 A Cntct toric prism ballast V2512 A Cntct lens gas permbl bifocl V2513 A Contact lens extended wear V2520 A Contact lens hydrophilic V2521 A Cntct lens hydrophilic toric V2522 A Cntct lens hydrophil bifocl V2523 A Cntct lens hydrophil extend V2530 A Contact lens gas impermeable Start Printed Page 18706 V2531 A Contact lens gas permeable V2599 A Contact lens/es other type V2600 A Hand held low vision aids V2610 A Single lens spectacle mount V2615 A Telescop/othr compound lens V2623 A Plastic eye prosth custom V2624 A Polishing artifical eye V2625 A Enlargemnt of eye prosthesis V2626 A Reduction of eye prosthesis V2627 A Scleral cover shell V2628 A Fabrication & fitting V2629 A Prosthetic eye other type V2630 N Anter chamber intraocul lens V2631 N Iris support intraoclr lens V2632 N Post chmbr intraocular lens V2700 A Balance lens V2710 A Glass/plastic slab off prism V2715 A Prism lens/es V2718 A Fresnell prism press-on lens V2730 A Special base curve V2740 A Rose tint plastic V2741 A Non-rose tint plastic V2742 A Rose tint glass V2743 A Non-rose tint glass V2744 A Tint photochromatic lens/es V2750 A Anti-reflective coating V2755 A UV lens/es V2760 A Scratch resistant coating V2770 A Occluder lens/es V2780 A Oversize lens/es V2781 A Progressive lens per lens V2785 A Corneal tissue processing V2799 A Miscellaneous vision service V5008 E Hearing screening V5010 E Assessment for hearing aid V5011 E Hearing aid fitting/checking V5014 E Hearing aid repair/modifying V5020 E Conformity evaluation V5030 E Body-worn hearing aid air V5040 E Body-worn hearing aid bone V5050 E Body-worn hearing aid in ear V5060 E Behind ear hearing aid V5070 E Glasses air conduction V5080 E Glasses bone conduction V5090 E Hearing aid dispensing fee V5100 E Body-worn bilat hearing aid V5110 E Hearing aid dispensing fee V5120 E Body-worn binaur hearing aid V5130 E In ear binaural hearing aid V5140 E Behind ear binaur hearing ai V5150 E Glasses binaural hearing aid V5160 E Dispensing fee binaural V5170 E Within ear cros hearing aid V5180 E Behind ear cros hearing aid V5190 E Glasses cros hearing aid V5200 E Cros hearing aid dispens fee V5210 E In ear bicros hearing aid V5220 E Behind ear bicros hearing ai V5230 E Glasses bicros hearing aid V5240 E Dispensing fee bicros V5299 A Hearing service V5336 E Repair communication device V5362 A Speech screening V5363 A Language screening V5364 A Dysphagia screening —————————— CPT codes and descriptions only are copyright American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Copyright American Dental Association. All rights reserved.Addendum C.—Proposed Hospital Outpatient Department (HOPD) Payment for Procedures by APC
APC CPT/ HCPCS HCPCS Description Status Indicator Relative Weight Payment Rate National Unadjusted Coinsurance Minimum Unadjusted Coinsurance 0001 Photochemotherapy S 0.47 $22.79 $8.49 $4.56 Start Printed Page 18707 96900 Ultraviolet light therapy 96910 Photochemotherapy with UV-B 96912 Photochemotherapy with UV-A 96913 Photochemotherapy, UV-A or B 96999 Dermatological procedure 0002 Fine needle Biopsy/Aspiration T 0.62 $30.06 $17.66 $6.01 60001 Aspirate/inject thyriod cyst 88170 Fine needle aspiration 88171 Fine needle aspiration 0003 Bone Marrow Biopsy/Aspiration T 0.98 $47.52 $27.99 $9.50 85095 Bone marrow aspiration 85102 Bone marrow biopsy 0004 Level I Needle Biopsy/Aspiration Except Bone Marrow T 1.84 $89.22 $32.57 $17.84 17999 Skin tissue procedure 19000 Drainage of breast lesion 19001 Drain breast lesion add-on 20615 Treatment of bone cyst 42400 Biopsy of salivary gland 54800 Biopsy of epididymis 55000 Drainage of hydrocele 60100 Biopsy of thyroid 60699 Endocrine surgery procedure 0005 Level II Needle Biopsy/Aspiration Except Bone Marrow T 5.41 $262.32 $119.75 $52.46 19100 Biopsy of breast 20206 Needle biopsy, muscle 32400 Needle biopsy chest lining 32405 Biopsy, lung or mediastinum 38505 Needle biopsy, lymph nodes 47000 Needle biopsy of liver 47399 Liver surgery procedure 48102 Needle biopsy, pancreas 48999 Pancreas surgery procedure 49180 Biopsy, abdominal mass 50200 Biopsy of kidney 50390 Drainage of kidney lesion 54500 Biopsy of testis 62269 Needle biopsy, spinal cord 0006 Level I Incision & Drainage T 2.00 $96.97 $33.95 $19.39 10040 Acne surgery of skin abscess 10060 Drainage of skin abscess 10061 Drainage of skin abscess 10080 Drainage of pilonidal cyst 10120 Remove foreign body 10160 Puncture drainage of lesion 20000 Incision of abscess 26010 Drainage of finger abscess 69000 Drain external ear lesion 69020 Drain outer ear canal lesion 0007 Level II Incision & Drainage T 3.68 $178.43 $72.03 $35.69 10081 Drainage of pilonidal cyst 10140 Drainage of hematoma/fluid 10180 Complex drainage, wound 26011 Drainage of finger abscess 69005 Drain external ear lesion 0008 Level III Incision & Drainage T 6.15 $298.20 $113.67 $59.64 19020 Incision of breast lesion 20950 Fluid pressure, muscle 21501 Drain neck/chest lesion 21700 Revision of neck muscle 21720 Revision of neck muscle 21725 Revision of neck muscle 23030 Drain shoulder lesion 23031 Drain shoulder bursa 23930 Drainage of arm lesion 23931 Drainage of arm bursa 27301 Drain thigh/knee lesion 27603 Drain lower leg lesion 28001 Drainage of bursa of foot 38300 Drainage, lymph node lesion 38305 Drainage, lymph node lesion 38999 Blood/lymph system procedure 51080 Drainage of bladder abscess 54015 Drain penis lesion Start Printed Page 18708 54115 Treatment of penis lesion 55100 Drainage of scrotum abscess 0009 Nail Procedures T 0.74 $35.88 $9.63 $7.18 11719 Trim nail(s) 11720 Debride nail, 1-5 11721 Debride nail, 6 or more 11740 Drain blood from under nail G0127 Trim nail(s) 0010 Level I Destruction of Lesion T 0.55 $26.67 $9.86 $5.33 17000 Destroy benign/premal lesion 17003 Destroy lesions, 2-14 17110 Destruct lesion, 1-14 0011 Level II Destruction of Lesion T 2.72 $131.88 $50.01 $26.38 17004 Destroy lesions, 15 or more 17106 Destruction of skin lesions 17107 Destruction of skin lesions 17108 Destruction of skin lesions 17111 Destruct lesion, 15 or more 0012 Level I Debridement & Destruction T 0.53 $25.70 $9.18 $5.14 11732 Remove nail plate, add-on 11900 Injection into skin lesions 15852 Dressing change, not for burn 17340 Cryotherapy of skin 69220 Clean out mastoid cavity 0013 Level II Debridement & Destruction T 0.91 $44.12 $17.66 $8.82 11300 Shave skin lesion 11301 Shave skin lesion 11305 Shave skin lesion 11306 Shave skin lesion 11310 Shave skin lesion 11311 Shave skin lesion 11730 Removal of nail plate 11901 Added skin lesions injection 15786 Abrasion, lesion, single 15788 Chemical peel, face, epiderm 15850 Removal of sutures 15851 Removal of sutures 17260 Destruction of skin lesions 17261 Destruction of skin lesions 17262 Destruction of skin lesions 17263 Destruction of skin lesions 17271 Destruction of skin lesions 17272 Destruction of skin lesions 54050 Destruction, penis lesion(s) 54056 Cryosurgery, penis lesion(s) 0014 Level III Debridement & Destruction T 1.50 $72.73 $24.55 $14.55 11302 Shave skin lesion 11307 Shave skin lesion 16025 Treatment of burn(s) 17250 Chemical cautery, tissue 46917 Laser surgery, anal lesions 0015 Level IV Debridement & Destruction T 1.77 $85.82 $31.20 $17.16 11000 Debride infected skin 11001 Debride infected skin add-on 11040 Debride skin, partial 11041 Debride skin, full 11055 Trim skin lesion 11056 Trim skin lesions, 2 to 4 11057 Trim skin lesions, over 4 11200 Removal of skin tags 11201 Remove skin tags add-on 11303 Shave skin lesion 11308 Shave skin lesion 11312 Shave skin lesion 11765 Excision of nail fold, toe 15783 Abrasion treatment of skin 15789 Chemical peel, face, dermal 16000 Initial treatment of burn(s) 16010 Treatment of burn(s) 16020 Treatment of burn(s) 16030 Treatment of burn(s) 17264 Destruction of skin lesions 17270 Destruction of skin lesions Start Printed Page 18709 17273 Destruction of skin lesions 17274 Destruction of skin lesions 17276 Destruction of skin lesions 17280 Destruction of skin lesions 17281 Destruction of skin lesions 17282 Destruction of skin lesions 17283 Destruction of skin lesions 0016 Level V Debridement & Destruction T 3.53 $171.16 $74.67 $34.23 11042 Debride skin/tissue 11043 Debride tissue/muscle 11313 Shave skin lesion 15787 Abrasion, lesions, add-on 15792 Chemical peel, nonfacial 15793 Chemical peel, nonfacial 15810 Salabrasion 17266 Destruction of skin lesions 17284 Destruction of skin lesions 17286 Destruction of skin lesions 17360 Skin peel therapy 17380 Hair removal by electrolysis 46900 Destruction, anal lesion(s) 46910 Destruction, anal lesion(s) 46916 Cryosurgery, anal lesion(s) 54055 Destruction, penis lesion(s) 56501 Destruction, vulva lesion(s) 0017 Level VI Debridement & Destruction T 12.45 $603.66 $289.16 $120.73 11044 Debride tissue/muscle/bone 16015 Treatment of burn(s) 46922 Excision of anal lesion(s) 46924 Destruction, anal lesion(s) 54057 Laser surg, penis lesion(s) 54060 Excision of penis lesion(s) 54065 Destruction, penis lesion(s) 56515 Destruction, vulva lesion(s) 0018 Biopsy Skin, Subcutaneous Tissue or Mucous Membrane T 0.94 $45.58 $17.66 $9.12 11100 Biopsy of skin lesion 11101 Biopsy, skin add-on 0019 Level I Excision/Biopsy T 4.00 $193.95 $78.91 $38.79 11400 Removal of skin lesion 11401 Removal of skin lesion 11402 Removal of skin lesion 11420 Removal of skin lesion 11421 Removal of skin lesion 11422 Removal of skin lesion 11440 Removal of skin lesion 11441 Removal of skin lesion 11442 Removal of skin lesion 11600 Removal of skin lesion 11601 Removal of skin lesion 11602 Removal of skin lesion 11620 Removal of skin lesion 11621 Removal of skin lesion 11622 Removal of skin lesion 11640 Removal of skin lesion 11641 Removal of skin lesion 11642 Removal of skin lesion 11750 Removal of nail bed 11755 Biopsy, nail unit 11976 Removal of contraceptive cap 20220 Bone biopsy, trocar/needle 20520 Removal of foreign body 21550 Biopsy of neck/chest 23330 Remove shoulder foreign body 24200 Removal of arm foreign body 27086 Remove hip foreign body 28190 Removal of foot foreign body 56605 Biopsy of vulva/perineum 56606 Biopsy of vulva/perineum 58999 Genital surgery procedure 69100 Biopsy of external ear 0020 Level II Excision/Biopsy T 6.51 $315.65 $130.53 $63.13 10121 Remove foreign body 11403 Removal of skin lesion Start Printed Page 18710 11404 Removal of skin lesion 11406 Removal of skin lesion 11423 Removal of skin lesion 11424 Removal of skin lesion 11443 Removal of skin lesion 11444 Removal of skin lesion 11603 Removal of skin lesion 11604 Removal of skin lesion 11623 Removal of skin lesion 11624 Removal of skin lesion 11643 Removal of skin lesion 11644 Removal of skin lesion 16035 Incision of burn scab 17304 Chemosurgery of skin lesion 17305 2nd stage chemosurgery 17306 3rd stage chemosurgery 17307 Followup skin lesion therapy 17310 Extensive skin chemosurgery 20200 Muscle biopsy 20225 Bone biopsy, trocar/needle 21920 Biopsy soft tissue of back 24065 Biopsy arm/elbow soft tissue 24066 Biopsy arm/elbow soft tissue 25065 Biopsy forearm soft tissues 25075 Removal of forearm lesion 26320 Removal of implant from hand 27613 Biopsy lower leg soft tissue 28193 Removal of foot foreign body 37609 Temporal artery procedure 37799 Vascular surgery procedure 54100 Biopsy of penis 69110 Remove external ear, partial 69145 Remove ear canal lesion(s) 0021 Level III Excision/Biopsy T 10.49 $508.63 $236.51 $101.73 11606 Removal of skin lesion 11770 Removal of pilonidal lesion 20205 Deep muscle biopsy 20670 Removal of support implant 23000 Removal of calcium deposits 23065 Biopsy shoulder tissues 23075 Removal of shoulder lesion 24075 Remove arm/elbow lesion 24201 Removal of arm foreign body 27040 Biopsy of soft tissues 27323 Biopsy, thigh soft tissues 27618 Remove lower leg lesion 28043 Excision of foot lesion 28192 Removal of foot foreign body 54105 Biopsy of penis 0022 Level IV Excision/Biopsy T 12.49 $605.60 $292.94 $121.12 11010 Debride skin, fx 11011 Debride skin/muscle, fx 11012 Debride skin/muscle/bone, fx 11426 Removal of skin lesion 11446 Removal of skin lesion 11450 Removal, sweat gland lesion 11451 Removal, sweat gland lesion 11462 Removal, sweat gland lesion 11463 Removal, sweat gland lesion 11470 Removal, sweat gland lesion 11471 Removal, sweat gland lesion 11626 Removal of skin lesion 11646 Removal of skin lesion 11752 Remove nail bed/finger tip 11771 Removal of pilonidal lesion 11772 Removal of pilonidal lesion 11971 Remove tissue expander(s) 15780 Abrasion treatment of skin 15781 Abrasion treatment of skin 15782 Abrasion treatment of skin 15811 Salabrasion 15838 Excise excessive skin tissue 15920 Removal of tail bone ulcer Start Printed Page 18711 15931 Remove sacrum pressure sore 15933 Remove sacrum pressure sore 15940 Remove hip pressure sore 15941 Remove hip pressure sore 15950 Remove thigh pressure sore 15951 Remove thigh pressure sore 15999 Removal of pressure sore 20240 Bone biopsy, excisional 20245 Bone biopsy, excisional 20525 Removal of foreign body 20680 Removal of support implant 21555 Remove lesion, neck/chest 21556 Remove lesion, neck/chest 21925 Biopsy soft tissue of back 21930 Remove lesion, back or flank 21935 Remove tumor, back 22900 Remove abdominal wall lesion 22999 Abdomen surgery procedure 23066 Biopsy shoulder tissues 23076 Removal of shoulder lesion 23077 Remove tumor of shoulder 23331 Remove shoulder foreign body 24076 Remove arm/elbow lesion 24077 Remove tumor of arm/elbow 25066 Biopsy forearm soft tissues 25076 Removal of forearm lesion 25077 Remove tumor, forearm/wrist 26115 Removal of hand lesion 26116 Removal of hand lesion 26117 Remove tumor, hand/finger 27041 Biopsy of soft tissues 27047 Remove hip/pelvis lesion 27048 Remove hip/pelvis lesion 27049 Remove tumor, hip/pelvis 27324 Biopsy, thigh soft tissues 27327 Removal of thigh lesion 27328 Removal of thigh lesion 27329 Remove tumor, thigh/knee 27372 Removal of foreign body 27614 Biopsy lower leg soft tissue 27619 Remove lower leg lesion 69205 Clear outer ear canal 0023 Exploration Penetrating Wound T 1.98 $96.00 $40.37 $19.20 20100 Explore wound, neck 20103 Explore wound, extremity 0024 Level I Skin Repair T 2.43 $117.82 $44.50 $23.56 11760 Repair of nail bed 11762 Reconstruction of nail bed 11920 Correct skin color defects 11921 Correct skin color defects 11922 Correct skin color defects 11950 Therapy for contour defects 11951 Therapy for contour defects 11952 Therapy for contour defects 11954 Therapy for contour defects 12001 Repair superficial wound(s) 12002 Repair superficial wound(s) 12004 Repair superficial wound(s) 12005 Repair superficial wound(s) 12006 Repair superficial wound(s) 12007 Repair superficial wound(s) 12011 Repair superficial wound(s) 12013 Repair superficial wound(s) 12014 Repair superficial wound(s) 12015 Repair superficial wound(s) 12016 Repair superficial wound(s) 12017 Repair superficial wound(s) 12018 Repair superficial wound(s) 12020 Closure of split wound 12021 Closure of split wound 12031 Layer closure of wound(s) 12032 Layer closure of wound(s) 12034 Layer closure of wound(s) Start Printed Page 18712 12035 Layer closure of wound(s) 12036 Layer closure of wound(s) 12041 Layer closure of wound(s) 12042 Layer closure of wound(s) 12044 Layer closure of wound(s) 12045 Layer closure of wound(s) 12046 Layer closure of wound(s) 12051 Layer closure of wound(s) 12052 Layer closure of wound(s) 12053 Layer closure of wound(s) 12054 Layer closure of wound(s) 12055 Layer closure of wound(s) 12056 Layer closure of wound(s) 0025 Level II Skin Repair T 3.74 $181.34 $70.66 $36.27 13100 Repair of wound or lesion 13101 Repair of wound or lesion 13102 Repair wound/lesion add-on 13120 Repair of wound or lesion 13121 Repair of wound or lesion 13122 Repair wound/lesion add-on 13131 Repair of wound or lesion 13132 Repair of wound or lesion 13133 Repair wound/lesion add-on 13151 Repair of wound or lesion 13152 Repair of wound or lesion 13153 Repair wound/lesion add-on 43870 Repair stomach opening 0026 Level III Skin Repair T 12.11 $587.18 $277.92 $117.44 11960 Insert tissue expander(s) 11970 Replace tissue expander 12037 Layer closure of wound(s) 12047 Layer closure of wound(s) 12057 Layer closure of wound(s) 13150 Repair of wound or lesion 13160 Late closure of wound 14000 Skin tissue rearrangement 14001 Skin tissue rearrangement 14020 Skin tissue rearrangement 14021 Skin tissue rearrangement 14040 Skin tissue rearrangement 14041 Skin tissue rearrangement 14060 Skin tissue rearrangement 14061 Skin tissue rearrangement 14300 Skin tissue rearrangement 14350 Skin tissue rearrangement 15000 Skin graft 15001 Skin graft add-on 15050 Skin pinch graft 15100 Skin split graft 15101 Skin split graft add-on 15120 Skin split graft 15121 Skin split graft add-on 15200 Skin full graft 15201 Skin full graft add-on 15220 Skin full graft 15221 Skin full graft add-on 15240 Skin full graft 15241 Skin full graft add-on 15260 Skin full graft 15261 Skin full graft add-on 15350 Skin homograft 15351 Skin homograft add-on 15400 Skin heterograft 15401 Skin heterograft add-on 15570 Form skin pedicle flap 15572 Form skin pedicle flap 15574 Form skin pedicle flap 15576 Form skin pedicle flap 15600 Skin graft 15610 Skin graft 15620 Skin graft 15630 Skin graft 15650 Transfer skin pedicle flap Start Printed Page 18713 15775 Hair transplant punch grafts 15776 Hair transplant punch grafts 15819 Plastic surgery, neck 15820 Revision of lower eyelid 15821 Revision of lower eyelid 15822 Revision of upper eyelid 15823 Revision of upper eyelid 15825 Removal of neck wrinkles 15829 Removal of skin wrinkles 15835 Excise excessive skin tissue 20101 Explore wound, chest 20102 Explore wound, abdomen 20910 Remove cartilage for graft 20912 Remove cartilage for graft 20920 Removal of fascia for graft 20922 Removal of fascia for graft 20926 Removal of tissue for graft 23921 Amputation follow-up surgery 25929 Amputation follow-up surgery 33222 Revise pocket, pacemaker 33223 Revise pocket, pacing-defib 44312 Revision of ileostomy 44340 Revision of colostomy G0168 Wound closure by adhesive G0169 Removal tissue; no anesthsia G0170 Skin biograft G0171 Skin biograft add-on 0027 Level IV Skin Repair T 15.80 $766.10 $383.10 $153.22 15732 Muscle-skin graft, head/neck 15734 Muscle-skin graft, trunk 15736 Muscle-skin graft, arm 15738 Muscle-skin graft, leg 15740 Island pedicle flap graft 15750 Neurovascular pedicle graft 15760 Composite skin graft 15770 Derma-fat-fascia graft 15824 Removal of forehead wrinkles 15826 Removal of brow wrinkles 15828 Removal of face wrinkles 15831 Excise excessive skin tissue 15832 Excise excessive skin tissue 15833 Excise excessive skin tissue 15834 Excise excessive skin tissue 15836 Excise excessive skin tissue 15837 Excise excessive skin tissue 15839 Excise excessive skin tissue 15840 Graft for face nerve palsy 15841 Graft for face nerve palsy 15842 Graft for face nerve palsy 15845 Skin and muscle repair, face 15876 Suction assisted lipectomy 15877 Suction assisted lipectomy 15878 Suction assisted lipectomy 15879 Suction assisted lipectomy 15922 Removal of tail bone ulcer 15934 Remove sacrum pressure sore 15935 Remove sacrum pressure sore 15936 Remove sacrum pressure sore 15937 Remove sacrum pressure sore 15944 Remove hip pressure sore 15945 Remove hip pressure sore 15946 Remove hip pressure sore 15952 Remove thigh pressure sore 15953 Remove thigh pressure sore 15956 Remove thigh pressure sore 15958 Remove thigh pressure sore 0029 Incision/Excision Breast T 12.85 $623.06 $303.50 $124.61 19101 Biopsy of breast 19110 Nipple exploration 19112 Excise breast duct fistula 19120 Removal of breast lesion 19125 Excision, breast lesion 19126 Excision, addl breast lesion Start Printed Page 18714 19140 Removal of breast tissue 19290 Place needle wire, breast 19291 Place needle wire, breast 19396 Design custom breast implant 19499 Breast surgery procedure 0030 Breast Reconstruction/Mastectomy T 20.19 $978.95 $523.95 $195.79 19160 Removal of breast tissue 19162 Remove breast tissue, nodes 19180 Removal of breast 19182 Removal of breast 19316 Suspension of breast 19318 Reduction of large breast 19324 Enlarge breast 19325 Enlarge breast with implant 19328 Removal of breast implant 19330 Removal of implant material 19340 Immediate breast prosthesis 19342 Delayed breast prosthesis 19350 Breast reconstruction 19355 Correct inverted nipple(s) 19357 Breast reconstruction 19366 Breast reconstruction 19370 Surgery of breast capsule 19371 Removal of breast capsule 19380 Revise breast reconstruction 0031 Hyperbaric Oxygen S 3.00 $145.46 $140.85 $29.09 99183 Hyperbaric oxygen therapy G0167 Hyperbaric oz tx; no md reqrd 0032 Placement Transvenous Catheters/Arterial Cutdown T 5.40 $261.83 $119.52 $52.37 36420 Establish access to vein 36425 Establish access to vein 36488 Insertion of catheter, vein 36489 Insertion of catheter, vein 36490 Insertion of catheter, vein 36491 Insertion of catheter, vein 36493 Repositioning of cvc 36640 Insertion catheter, artery 0033 Partial Hospitalization P 4.17 $202.19 $48.17 $40.44 G0129 Partial hosp prog service G0172 Partial hosp prog service Q0082 Activity therapy w/partial h 0040 Arthrocentesis & Ligament/Tendon Injection T 2.11 $102.31 $40.60 $20.46 20550 Inject tendon/ligament/cyst 20600 Drain/inject, joint/bursa 20605 Drain/inject, joint/bursa 20610 Drain/inject, joint/bursa 0041 Arthroscopy T 24.57 $1,191.33 $592.08 $238.27 29800 Jaw arthroscopy/surgery 29804 Jaw arthroscopy/surgery 29815 Shoulder arthroscopy 29819 Shoulder arthroscopy/surgery 29820 Shoulder arthroscopy/surgery 29821 Shoulder arthroscopy/surgery 29822 Shoulder arthroscopy/surgery 29823 Shoulder arthroscopy/surgery 29825 Shoulder arthroscopy/surgery 29826 Shoulder arthroscopy/surgery 29830 Elbow arthroscopy 29834 Elbow arthroscopy/surgery 29835 Elbow arthroscopy/surgery 29836 Elbow arthroscopy/surgery 29837 Elbow arthroscopy/surgery 29838 Elbow arthroscopy/surgery 29840 Wrist arthroscopy 29843 Wrist arthroscopy/surgery 29844 Wrist arthroscopy/surgery 29845 Wrist arthroscopy/surgery 29846 Wrist arthroscopy/surgery 29847 Wrist arthroscopy/surgery 29848 Wrist endoscopy/surgery 29860 Hip arthroscopy, dx 29861 Hip arthroscopy/surgery 29862 Hip arthroscopy/surgery Start Printed Page 18715 29863 Hip arthroscopy/surgery 29870 Knee arthroscopy, dx 29871 Knee arthroscopy/drainage 29874 Knee arthroscopy/surgery 29875 Knee arthroscopy/surgery 29876 Knee arthroscopy/surgery 29877 Knee arthroscopy/surgery 29879 Knee arthroscopy/surgery 29880 Knee arthroscopy/surgery 29881 Knee arthroscopy/surgery 29882 Knee arthroscopy/surgery 29883 Knee arthroscopy/surgery 29884 Knee arthroscopy/surgery 29886 Knee arthroscopy/surgery 29887 Knee arthroscopy/surgery 29891 Ankle arthroscopy/surgery 29894 Ankle arthroscopy/surgery 29895 Ankle arthroscopy/surgery 29897 Ankle arthroscopy/surgery 29898 Ankle arthroscopy/surgery 29909 Arthroscopy of joint 0042 Arthroscopically-Aided Procedures T 29.22 $1,416.79 $804.74 $283.36 29850 Knee arthroscopy/surgery 29851 Knee arthroscopy/surgery 29855 Tibial arthroscopy/surgery 29856 Tibial arthroscopy/surgery 29885 Knee arthroscopy/surgery 29888 Knee arthroscopy/surgery 29889 Knee arthroscopy/surgery 29892 Ankle arthroscopy/surgery 0043 Closed Treatment Fracture Finger/Toe/Trunk T 1.64 $79.52 $25.46 $15.90 21800 Treatment of rib fracture 21820 Treat sternum fracture 22305 Treat spine process fracture 22310 Treat spine fracture 22315 Treat spine fracture 22899 Spine surgery procedure 23500 Treat clavicle fracture 23505 Treat clavicle fracture 23520 Treat clavicle dislocation 23525 Treat clavicle dislocation 23540 Treat clavicle dislocation 23545 Treat clavicle dislocation 23570 Treat shoulder blade fx 23575 Treat shoulder blade fx 23650 Treat shoulder dislocation 23929 Shoulder surgery procedure 26700 Treat knuckle dislocation 26720 Treat finger fracture, each 26725 Treat finger fracture, each 26740 Treat finger fracture, each 26750 Treat finger fracture, each 26755 Treat finger fracture, each 26770 Treat finger dislocation 26989 Hand/finger surgery 27200 Treat tail bone fracture 27299 Pelvis/hip joint surgery 28490 Treat big toe fracture 28495 Treat big toe fracture 28510 Treatment of toe fracture 28515 Treatment of toe fracture 28630 Treat toe dislocation 28660 Treat toe dislocation 28899 Foot/toes surgery procedure 0044 Closed Treatment Fracture/Dislocation Except Finger/Toe/Trunk T 2.17 $105.22 $38.08 $21.04 23600 Treat humerus fracture 23605 Treat humerus fracture 23620 Treat humerus fracture 23625 Treat humerus fracture 23665 Treat dislocation/fracture 23675 Treat dislocation/fracture 24500 Treat humerus fracture 24505 Treat humerus fracture Start Printed Page 18716 24530 Treat humerus fracture 24535 Treat humerus fracture 24560 Treat humerus fracture 24565 Treat humerus fracture 24576 Treat humerus fracture 24577 Treat humerus fracture 24600 Treat elbow dislocation 24620 Treat elbow fracture 24640 Treat elbow dislocation 24650 Treat radius fracture 24655 Treat radius fracture 24670 Treat ulnar fracture 24675 Treat ulnar fracture 24999 Upper arm/elbow surgery 25500 Treat fracture of radius 25505 Treat fracture of radius 25520 Treat fracture of radius 25530 Treat fracture of ulna 25535 Treat fracture of ulna 25560 Treat fracture radius & ulna 25565 Treat fracture radius & ulna 25600 Treat fracture radius/ulna 25605 Treat fracture radius/ulna 25622 Treat wrist bone fracture 25624 Treat wrist bone fracture 25630 Treat wrist bone fracture 25635 Treat wrist bone fracture 25650 Treat wrist bone fracture 25660 Treat wrist dislocation 25675 Treat wrist dislocation 25680 Treat wrist fracture 25690 Treat wrist dislocation 25999 Forearm or wrist surgery 26600 Treat metacarpal fracture 26605 Treat metacarpal fracture 26607 Treat metacarpal fracture 26641 Treat thumb dislocation 26645 Treat thumb fracture 26670 Treat hand dislocation 26706 Pin knuckle dislocation 26742 Treat finger fracture, each 27193 Treat pelvic ring fracture 27220 Treat hip socket fracture 27230 Treat thigh fracture 27238 Treat thigh fracture 27246 Treat thigh fracture 27250 Treat hip dislocation 27256 Treat hip dislocation 27265 Treat hip dislocation 27500 Treatment of thigh fracture 27501 Treatment of thigh fracture 27502 Treatment of thigh fracture 27503 Treatment of thigh fracture 27508 Treatment of thigh fracture 27510 Treatment of thigh fracture 27516 Treat thigh fx growth plate 27517 Treat thigh fx growth plate 27520 Treat kneecap fracture 27530 Treat knee fracture 27532 Treat knee fracture 27538 Treat knee fracture(s) 27550 Treat knee dislocation 27560 Treat kneecap dislocation 27599 Leg surgery procedure 27750 Treatment of tibia fracture 27752 Treatment of tibia fracture 27760 Treatment of ankle fracture 27762 Treatment of ankle fracture 27780 Treatment of fibula fracture 27781 Treatment of fibula fracture 27786 Treatment of ankle fracture 27788 Treatment of ankle fracture 27808 Treatment of ankle fracture Start Printed Page 18717 27810 Treatment of ankle fracture 27816 Treatment of ankle fracture 27818 Treatment of ankle fracture 27824 Treat lower leg fracture 27825 Treat lower leg fracture 27830 Treat lower leg dislocation 27840 Treat ankle dislocation 27899 Leg/ankle surgery procedure 28400 Treatment of heel fracture 28405 Treatment of heel fracture 28430 Treatment of ankle fracture 28435 Treatment of ankle fracture 28450 Treat midfoot fracture, each 28455 Treat midfoot fracture, each 28470 Treat metatarsal fracture 28475 Treat metatarsal fracture 28530 Treat sesamoid bone fracture 28540 Treat foot dislocation 28570 Treat foot dislocation 28600 Treat foot dislocation 0045 Bone/Joint Manipulation Under Anesthesia T 11.02 $534.33 $277.12 $106.87 22505 Manipulation of spine 23655 Treat shoulder dislocation 23700 Fixation of shoulder 24605 Treat elbow dislocation 26675 Treat hand dislocation 26705 Treat knuckle dislocation 26775 Treat finger dislocation 27194 Treat pelvic ring fracture 27252 Treat hip dislocation 27257 Treat hip dislocation 27275 Manipulation of hip joint 27552 Treat knee dislocation 27562 Treat kneecap dislocation 27570 Fixation of knee joint 27831 Treat lower leg dislocation 27842 Treat ankle dislocation 27860 Fixation of ankle joint 28545 Treat foot dislocation 28575 Treat foot dislocation 28605 Treat foot dislocation 28635 Treat toe dislocation 28665 Treat toe dislocation 0046 Open/Percutaneous Treatment Fracture or Dislocation T 22.29 $1,080.78 $535.76 $216.16 21336 Treat nasal septal fracture 21805 Treatment of rib fracture 23515 Treat clavicle fracture 23530 Treat clavicle dislocation 23532 Treat clavicle dislocation 23550 Treat clavicle dislocation 23552 Treat clavicle dislocation 23585 Treat scapula fracture 23615 Treat humerus fracture 23616 Treat humerus fracture 23630 Treat humerus fracture 23660 Treat shoulder dislocation 23670 Treat dislocation/fracture 23680 Treat dislocation/fracture 24515 Treat humerus fracture 24516 Treat humerus fracture 24538 Treat humerus fracture 24545 Treat humerus fracture 24546 Treat humerus fracture 24566 Treat humerus fracture 24575 Treat humerus fracture 24579 Treat humerus fracture 24582 Treat humerus fracture 24586 Treat elbow fracture 24587 Treat elbow fracture 24615 Treat elbow dislocation 24635 Treat elbow fracture 24665 Treat radius fracture 24666 Treat radius fracture Start Printed Page 18718 24685 Treat ulnar fracture 25515 Treat fracture of radius 25525 Treat fracture of radius 25526 Treat fracture of radius 25545 Treat fracture of ulna 25574 Treat fracture radius & ulna 25575 Treat fracture radius/ulna 25611 Treat fracture radius/ulna 25620 Treat fracture radius/ulna 25628 Treat wrist bone fracture 25645 Treat wrist bone fracture 25670 Treat wrist dislocation 25676 Treat wrist dislocation 25685 Treat wrist fracture 25695 Treat wrist dislocation 26608 Treat metacarpal fracture 26615 Treat metacarpal fracture 26650 Treat thumb fracture 26665 Treat thumb fracture 26676 Pin hand dislocation 26685 Treat hand dislocation 26686 Treat hand dislocation 26715 Treat knuckle dislocation 26727 Treat finger fracture, each 26735 Treat finger fracture, each 26746 Treat finger fracture, each 26756 Pin finger fracture, each 26765 Treat finger fracture, each 26776 Pin finger dislocation 26785 Treat finger dislocation 27202 Treat tail bone fracture 27509 Treatment of thigh fracture 27556 Treat knee dislocation 27566 Treat kneecap dislocation 27615 Remove tumor, lower leg 27756 Treatment of tibia fracture 27758 Treatment of tibia fracture 27759 Treatment of tibia fracture 27766 Treatment of ankle fracture 27784 Treatment of fibula fracture 27792 Treatment of ankle fracture 27814 Treatment of ankle fracture 27822 Treatment of ankle fracture 27823 Treatment of ankle fracture 27826 Treat lower leg fracture 27827 Treat lower leg fracture 27828 Treat lower leg fracture 27829 Treat lower leg joint 27832 Treat lower leg dislocation 27846 Treat ankle dislocation 27848 Treat ankle dislocation 28406 Treatment of heel fracture 28415 Treat heel fracture 28420 Treat/graft heel fracture 28436 Treatment of ankle fracture 28445 Treat ankle fracture 28456 Treat midfoot fracture 28465 Treat midfoot fracture, each 28476 Treat metatarsal fracture 28485 Treat metatarsal fracture 28496 Treat big toe fracture 28505 Treat big toe fracture 28525 Treat toe fracture 28531 Treat sesamoid bone fracture 28546 Treat foot dislocation 28555 Repair foot dislocation 28576 Treat foot dislocation 28585 Repair foot dislocation 28606 Treat foot dislocation 28615 Repair foot dislocation 28636 Treat toe dislocation 28645 Repair toe dislocation 28666 Treat toe dislocation Start Printed Page 18719 28675 Repair of toe dislocation 0047 Arthroplasty without Prosthesis T 22.09 $1,071.08 $537.03 $214.22 24360 Reconstruct elbow joint 24365 Reconstruct head of radius 25332 Revise wrist joint 25447 Repair wrist joint(s) 25449 Remove wrist joint implant 26530 Revise knuckle joint 26535 Revise finger joint 27266 Treat hip dislocation 27437 Revise kneecap 27440 Revision of knee joint 27441 Revision of knee joint 27442 Revision of knee joint 27443 Revision of knee joint 27700 Revision of ankle joint 0048 Arthroplasty with Prosthesis T 29.06 $1,409.03 $725.94 $281.81 24361 Reconstruct elbow joint 24362 Reconstruct elbow joint 24363 Replace elbow joint 24366 Reconstruct head of radius 25441 Reconstruct wrist joint 25442 Reconstruct wrist joint 25443 Reconstruct wrist joint 25444 Reconstruct wrist joint 25445 Reconstruct wrist joint 25446 Wrist replacement 26531 Revise knuckle with implant 26536 Revise/implant finger joint 27438 Revise kneecap with implant 0049 Level I Musculoskeletal Procedures Except Hand and Foot T 15.04 $729.25 $356.95 $145.85 20005 Incision of deep abscess 20250 Open bone biopsy 20251 Open bone biopsy 20650 Insert and remove bone pin 20693 Adjust bone fixation device 20694 Remove bone fixation device 20975 Electrical bone stimulation 20979 Us bone stimulation 23100 Biopsy of shoulder joint 23140 Removal of bone lesion 23935 Drain arm/elbow bone lesion 24100 Biopsy elbow joint lining 24105 Removal of elbow bursa 24110 Remove humerus lesion 24120 Remove elbow lesion 24310 Revision of arm tendon 24925 Amputation follow-up surgery 25000 Incision of tendon sheath 25020 Decompression of forearm 25028 Drainage of forearm lesion 25031 Drainage of forearm bursa 25035 Treat forearm bone lesion 25085 Incision of wrist capsule 25100 Biopsy of wrist joint 25110 Remove wrist tendon lesion 25115 Remove wrist/forearm lesion 25116 Remove wrist/forearm lesion 25248 Remove forearm foreign body 25295 Release wrist/forearm tendon 25907 Amputation follow-up surgery 25922 Amputate hand at wrist 26990 Drainage of pelvis lesion 26991 Drainage of pelvis bursa 27000 Incision of hip tendon 27050 Biopsy of sacroiliac joint 27052 Biopsy of hip joint 27060 Removal of ischial bursa 27062 Remove femur lesion/bursa 27065 Removal of hip bone lesion 27087 Remove hip foreign body 27305 Incise thigh tendon & fascia 27306 Incision of thigh tendon Start Printed Page 18720 27307 Incision of thigh tendons 27340 Removal of kneecap bursa 27345 Removal of knee cyst 27347 Remove knee cyst 27380 Repair of kneecap tendon 27381 Repair/graft kneecap tendon 27385 Repair of thigh muscle 27386 Repair/graft of thigh muscle 27390 Incision of thigh tendon 27391 Incision of thigh tendons 27392 Incision of thigh tendons 27496 Decompression of thigh/knee 27497 Decompression of thigh/knee 27498 Decompression of thigh/knee 27499 Decompression of thigh/knee 27594 Amputation follow-up surgery 27600 Decompression of lower leg 27601 Decompression of lower leg 27602 Decompression of lower leg 27604 Drain lower leg bursa 27606 Incision of achilles tendon 27607 Treat lower leg bone lesion 27630 Removal of tendon lesion 27656 Repair leg fascia defect 27658 Repair of leg tendon, each 27659 Repair of leg tendon, each 27664 Repair of leg tendon, each 27675 Repair lower leg tendons 27704 Removal of ankle implant 27707 Incision of fibula 27884 Amputation follow-up surgery 27892 Decompression of leg 27893 Decompression of leg 27894 Decompression of leg 28002 Treatment of foot infection 28003 Treatment of foot infection 0050 Level II Musculoskeletal Procedures Except Hand and Foot T 21.13 $1,024.53 $513.86 $204.91 20690 Apply bone fixation device 20692 Apply bone fixation device 20900 Removal of bone for graft 20902 Removal of bone for graft 20924 Removal of tendon for graft 21502 Drain chest lesion 21600 Partial removal of rib 21610 Partial removal of rib 23040 Exploratory shoulder surgery 23044 Exploratory shoulder surgery 23101 Shoulder joint surgery 23105 Remove shoulder joint lining 23106 Incision of collarbone joint 23107 Explore treat shoulder joint 23145 Removal of bone lesion 23146 Removal of bone lesion 23150 Removal of humerus lesion 23155 Removal of humerus lesion 23156 Removal of humerus lesion 23170 Remove collar bone lesion 23172 Remove shoulder blade lesion 23174 Remove humerus lesion 23180 Remove collar bone lesion 23182 Remove shoulder blade lesion 23184 Remove humerus lesion 23190 Partial removal of scapula 23405 Incision of tendon & muscle 23406 Incise tendon(s) & muscle(s) 24000 Exploratory elbow surgery 24006 Release elbow joint 24101 Explore/treat elbow joint 24102 Remove elbow joint lining 24115 Remove/graft bone lesion 24116 Remove/graft bone lesion 24125 Remove/graft bone lesion 24126 Remove/graft bone lesion Start Printed Page 18721 24130 Removal of head of radius 24134 Removal of arm bone lesion 24136 Remove radius bone lesion 24138 Remove elbow bone lesion 24140 Partial removal of arm bone 24145 Partial removal of radius 24147 Partial removal of elbow 24160 Remove elbow joint implant 24164 Remove radius head implant 24301 Muscle/tendon transfer 24305 Arm tendon lengthening 24350 Repair of tennis elbow 24351 Repair of tennis elbow 24352 Repair of tennis elbow 24354 Repair of tennis elbow 24356 Revision of tennis elbow 24400 Revision of humerus 24410 Revision of humerus 24495 Decompression of forearm 25023 Decompression of forearm 25040 Explore/treat wrist joint 25101 Explore/treat wrist joint 25105 Remove wrist joint lining 25107 Remove wrist joint cartilage 25118 Excise wrist tendon sheath 25119 Partial removal of ulna 25120 Removal of forearm lesion 25125 Remove/graft forearm lesion 25126 Remove/graft forearm lesion 25130 Removal of wrist lesion 25135 Remove & graft wrist lesion 25136 Remove & graft wrist lesion 25145 Remove forearm bone lesion 25150 Partial removal of ulna 25151 Partial removal of radius 25230 Partial removal of radius 25240 Partial removal of ulna 25250 Removal of wrist prosthesis 25251 Removal of wrist prosthesis 25260 Repair forearm tendon/muscle 25263 Repair forearm tendon/muscle 25265 Repair forearm tendon/muscle 25270 Repair forearm tendon/muscle 25272 Repair forearm tendon/muscle 25274 Repair forearm tendon/muscle 25280 Revise wrist/forearm tendon 25290 Incise wrist/forearm tendon 25300 Fusion of tendons at wrist 25301 Fusion of tendons at wrist 25360 Revision of ulna 25365 Revise radius & ulna 25400 Repair radius or ulna 25415 Repair radius & ulna 27001 Incision of hip tendon 27003 Incision of hip tendon 27066 Removal of hip bone lesion 27067 Remove/graft hip bone lesion 27080 Removal of tail bone 27097 Revision of hip tendon 27098 Transfer tendon to pelvis 27310 Exploration of knee joint 27330 Biopsy, knee joint lining 27331 Explore/treat knee joint 27332 Removal of knee cartilage 27333 Removal of knee cartilage 27334 Remove knee joint lining 27335 Remove knee joint lining 27350 Removal of kneecap 27355 Remove femur lesion 27356 Remove femur lesion/graft 27357 Remove femur lesion/graft 27358 Remove femur lesion/fixation 27360 Partial removal, leg bone(s) Start Printed Page 18722 27393 Lengthening of thigh tendon 27394 Lengthening of thigh tendons 27396 Transplant of thigh tendon 27403 Repair of knee cartilage 27425 Lateral retinacular release 27610 Explore/treat ankle joint 27612 Exploration of ankle joint 27620 Explore/treat ankle joint 27625 Remove ankle joint lining 27626 Remove ankle joint lining 27635 Remove lower leg bone lesion 27637 Remove/graft leg bone lesion 27638 Remove/graft leg bone lesion 27641 Partial removal of fibula 27665 Repair of leg tendon, each 27676 Repair lower leg tendons 27680 Release of lower leg tendon 27681 Release of lower leg tendons 27685 Revision of lower leg tendon 27686 Revise lower leg tendons 27687 Revision of calf tendon 27695 Repair of ankle ligament 27696 Repair of ankle ligaments 27698 Repair of ankle ligament 27709 Incision of tibia & fibula 27730 Repair of tibia epiphysis 27732 Repair of fibula epiphysis 27734 Repair lower leg epiphyses 27740 Repair of leg epiphyses 27889 Amputation of foot at ankle 0051 Level III Musculoskeletal Procedures Except Hand and Foot T 27.76 $1,346.00 $675.24 $269.20 20150 Excise epiphyseal bar 23020 Release shoulder joint 23120 Partial removal, collar bone 23130 Remove shoulder bone, part 23415 Release of shoulder ligament 23480 Revision of collar bone 23485 Revision of collar bone 23490 Reinforce clavicle 23491 Reinforce shoulder bones 23800 Fusion of shoulder joint 23802 Fusion of shoulder joint 24155 Removal of elbow joint 24320 Repair of arm tendon 24330 Revision of arm muscles 24331 Revision of arm muscles 24340 Repair of biceps tendon 24341 Repair arm tendon/muscle 24342 Repair of ruptured tendon 24420 Revision of humerus 24430 Repair of humerus 24435 Repair humerus with graft 24470 Revision of elbow joint 24498 Reinforce humerus 24800 Fusion of elbow joint 24802 Fusion/graft of elbow joint 25310 Transplant forearm tendon 25312 Transplant forearm tendon 25315 Revise palsy hand tendon(s) 25316 Revise palsy hand tendon(s) 25320 Repair/revise wrist joint 25335 Realignment of hand 25337 Reconstruct ulna/radioulnar 25350 Revision of radius 25355 Revision of radius 25370 Revise radius or ulna 25375 Revise radius & ulna 25425 Repair/graft radius or ulna 25426 Repair/graft radius & ulna 25440 Repair/graft wrist bone 25450 Revision of wrist joint 25455 Revision of wrist joint 25490 Reinforce radius Start Printed Page 18723 25491 Reinforce ulna 25492 Reinforce radius and ulna 25800 Fusion of wrist joint 25805 Fusion/graft of wrist joint 25810 Fusion/graft of wrist joint 25830 Fusion, radioulnar jnt/ulna 27033 Exploration of hip joint 27100 Transfer of abdominal muscle 27105 Transfer of spinal muscle 27110 Transfer of iliopsoas muscle 27111 Transfer of iliopsoas muscle 27395 Lengthening of thigh tendons 27397 Transplants of thigh tendons 27400 Revise thigh muscles/tendons 27405 Repair of knee ligament 27407 Repair of knee ligament 27409 Repair of knee ligaments 27418 Repair degenerated kneecap 27420 Revision of unstable kneecap 27422 Revision of unstable kneecap 27424 Revision/removal of kneecap 27430 Revision of thigh muscles 27435 Incision of knee joint 27640 Partial removal of tibia 27647 Extensive ankle/heel surgery 27650 Repair achilles tendon 27652 Repair/graft achilles tendon 27654 Repair of achilles tendon 27690 Revise lower leg tendon 27691 Revise lower leg tendon 27692 Revise additional leg tendon 27705 Incision of tibia 27742 Repair of leg epiphyses 27745 Reinforce tibia 27870 Fusion of ankle joint 27871 Fusion of tibiofibular joint 0052 Level IV Musculoskeletal Procedures Except Hand and Foot T 36.16 $1,753.29 $930.91 $350.66 23410 Repair of tendon(s) 23412 Repair of tendon(s) 23420 Repair of shoulder 23430 Repair biceps tendon 23450 Repair shoulder capsule 23455 Repair shoulder capsule 23460 Repair shoulder capsule 23462 Repair shoulder capsule 23465 Repair shoulder capsule 23466 Repair shoulder capsule 24935 Revision of amputation 27427 Reconstruction, knee 27428 Reconstruction, knee 27429 Reconstruction, knee 0053 Level I Hand Musculoskeletal Procedures T 11.32 $548.87 $253.49 $109.77 25111 Remove wrist tendon lesion 25112 Reremove wrist tendon lesion 25820 Fusion of hand bones 26020 Drain hand tendon sheath 26025 Drainage of palm bursa 26030 Drainage of palm bursa(s) 26034 Treat hand bone lesion 26035 Decompress fingers/hand 26037 Decompress fingers/hand 26055 Incise finger tendon sheath 26060 Incision of finger tendon 26070 Explore/treat hand joint 26075 Explore/treat finger joint 26080 Explore/treat finger joint 26100 Biopsy hand joint lining 26105 Biopsy finger joint lining 26110 Biopsy finger joint lining 26130 Remove wrist joint lining 26140 Revise finger joint, each 26145 Tendon excision, palm/finger 26160 Remove tendon sheath lesion Start Printed Page 18724 26170 Removal of palm tendon, each 26180 Removal of finger tendon 26185 Remove finger bone 26200 Remove hand bone lesion 26210 Removal of finger lesion 26215 Remove/graft finger lesion 26230 Partial removal of hand bone 26235 Partial removal, finger bone 26236 Partial removal, finger bone 26250 Extensive hand surgery 26260 Extensive finger surgery 26261 Extensive finger surgery 26262 Partial removal of finger 26410 Repair hand tendon 26418 Repair finger tendon 26432 Repair finger tendon 26433 Repair finger tendon 26437 Realignment of tendons 26440 Release palm/finger tendon 26445 Release hand/finger tendon 26450 Incision of palm tendon 26455 Incision of finger tendon 26460 Incise hand/finger tendon 26471 Fusion of finger tendons 26474 Fusion of finger tendons 26476 Tendon lengthening 26477 Tendon shortening 26478 Lengthening of hand tendon 26479 Shortening of hand tendon 26500 Hand tendon reconstruction 26508 Release thumb contracture 26520 Release knuckle contracture 26525 Release finger contracture 26540 Repair hand joint 26542 Repair hand joint with graft 26560 Repair of web finger 26587 Reconstruct extra finger 26593 Release muscles of hand 26951 Amputation of finger/thumb 26952 Amputation of finger/thumb 0054 Level II Hand Musculoskeletal Procedures T 19.66 $953.26 $472.33 $190.65 25210 Removal of wrist bone 25215 Removal of wrist bones 25825 Fuse hand bones with graft 26040 Release palm contracture 26045 Release palm contracture 26121 Release palm contracture 26123 Release palm contracture 26125 Release palm contracture 26135 Revise finger joint, each 26205 Remove/graft bone lesion 26255 Extensive hand surgery 26350 Repair finger/hand tendon 26352 Repair/graft hand tendon 26356 Repair finger/hand tendon 26357 Repair finger/hand tendon 26358 Repair/graft hand tendon 26370 Repair finger/hand tendon 26372 Repair/graft hand tendon 26373 Repair finger/hand tendon 26390 Revise hand/finger tendon 26392 Repair/graft hand tendon 26412 Repair/graft hand tendon 26415 Excision, hand/finger tendon 26416 Graft hand or finger tendon 26420 Repair/graft finger tendon 26426 Repair finger/hand tendon 26428 Repair/graft finger tendon 26434 Repair/graft finger tendon 26442 Release palm & finger tendon 26449 Release forearm/hand tendon 26480 Transplant hand tendon 26483 Transplant/graft hand tendon Start Printed Page 18725 26485 Transplant palm tendon 26489 Transplant/graft palm tendon 26490 Revise thumb tendon 26492 Tendon transfer with graft 26494 Hand tendon/muscle transfer 26496 Revise thumb tendon 26497 Finger tendon transfer 26498 Finger tendon transfer 26499 Revision of finger 26502 Hand tendon reconstruction 26504 Hand tendon reconstruction 26510 Thumb tendon transfer 26516 Fusion of knuckle joint 26517 Fusion of knuckle joints 26518 Fusion of knuckle joints 26541 Repair hand joint with graft 26545 Reconstruct finger joint 26546 Repair nonunion hand 26548 Reconstruct finger joint 26550 Construct thumb replacement 26555 Positional change of finger 26561 Repair of web finger 26562 Repair of web finger 26565 Correct metacarpal flaw 26567 Correct finger deformity 26568 Lengthen metacarpal/finger 26580 Repair hand deformity 26585 Repair finger deformity 26590 Repair finger deformity 26591 Repair muscles of hand 26596 Excision constricting tissue 26597 Release of scar contracture 26820 Thumb fusion with graft 26841 Fusion of thumb 26842 Thumb fusion with graft 26843 Fusion of hand joint 26844 Fusion/graft of hand joint 26850 Fusion of knuckle 26852 Fusion of knuckle with graft 26860 Fusion of finger joint 26861 Fusion of finger jnt, add-on 26862 Fusion/graft of finger joint 26863 Fuse/graft added joint 26910 Amputate metacarpal bone 0055 Level I Foot Musculoskeletal Procedures T 15.47 $750.10 $355.34 $150.02 27605 Incision of achilles tendon 28005 Treat foot bone lesion 28008 Incision of foot fascia 28010 Incision of toe tendon 28011 Incision of toe tendons 28020 Exploration of foot joint 28022 Exploration of foot joint 28024 Exploration of toe joint 28045 Excision of foot lesion 28046 Resection of tumor, foot 28050 Biopsy of foot joint lining 28052 Biopsy of foot joint lining 28054 Biopsy of toe joint lining 28080 Removal of foot lesion 28086 Excise foot tendon sheath 28088 Excise foot tendon sheath 28090 Removal of foot lesion 28092 Removal of toe lesions 28100 Removal of ankle/heel lesion 28104 Removal of foot lesion 28108 Removal of toe lesions 28111 Part removal of metatarsal 28112 Part removal of metatarsal 28113 Part removal of metatarsal 28114 Removal of metatarsal heads 28116 Revision of foot 28118 Removal of heel bone 28119 Removal of heel spur Start Printed Page 18726 28120 Part removal of ankle/heel 28122 Partial removal of foot bone 28124 Partial removal of toe 28126 Partial removal of toe 28130 Removal of ankle bone 28140 Removal of metatarsal 28150 Removal of toe 28153 Partial removal of toe 28160 Partial removal of toe 28171 Extensive foot surgery 28173 Extensive foot surgery 28175 Extensive foot surgery 28200 Repair of foot tendon 28208 Repair of foot tendon 28210 Repair/graft of foot tendon 28220 Release of foot tendon 28222 Release of foot tendons 28225 Release of foot tendon 28226 Release of foot tendons 28230 Incision of foot tendon(s) 28232 Incision of toe tendon 28234 Incision of foot tendon 28240 Release of big toe 28270 Release of foot contracture 28272 Release of toe joint, each 28280 Fusion of toes 28285 Repair of hammertoe 28286 Repair of hammertoe 28310 Revision of big toe 28312 Revision of toe 28313 Repair deformity of toe 28315 Removal of sesamoid bone 28340 Resect enlarged toe tissue 28341 Resect enlarged toe 28737 Revision of foot bones 28750 Fusion of big toe joint 28755 Fusion of big toe joint 28810 Amputation toe & metatarsal 28820 Amputation of toe 28825 Partial amputation of toe 29893 Scope, plantar fasciotomy 0056 Level II Foot Musculoskeletal Procedures T 17.30 $838.83 $405.81 $167.77 28060 Partial removal, foot fascia 28062 Removal of foot fascia 28070 Removal of foot joint lining 28072 Removal of foot joint lining 28102 Remove/graft foot lesion 28103 Remove/graft foot lesion 28106 Remove/graft foot lesion 28107 Remove/graft foot lesion 28202 Repair/graft of foot tendon 28238 Revision of foot tendon 28250 Revision of foot fascia 28260 Release of midfoot joint 28261 Revision of foot tendon 28262 Revision of foot and ankle 28264 Release of midfoot joint 28288 Partial removal of foot bone 28289 Repair hallux rigidus 28300 Incision of heel bone 28302 Incision of ankle bone 28304 Incision of midfoot bones 28305 Incise/graft midfoot bones 28306 Incision of metatarsal 28307 Incision of metatarsal 28308 Incision of metatarsal 28309 Incision of metatarsals 28320 Repair of foot bones 28322 Repair of metatarsals 28344 Repair extra toe(s) 28345 Repair webbed toe(s) 28360 Reconstruct cleft foot 28705 Fusion of foot bones Start Printed Page 18727 28715 Fusion of foot bones 28725 Fusion of foot bones 28730 Fusion of foot bones 28735 Fusion of foot bones 28740 Fusion of foot bones 28760 Fusion of big toe joint 0057 Bunion Procedures T 21.00 $1,018.23 $496.65 $203.65 28110 Part removal of metatarsal 28290 Correction of bunion 28292 Correction of bunion 28293 Correction of bunion 28294 Correction of bunion 28296 Correction of bunion 28297 Correction of bunion 28298 Correction of bunion 28299 Correction of bunion 0058 Level I Strapping and Cast Application S 1.09 $52.85 $19.27 $10.57 29505 Application, long leg splint 29515 Application lower leg splint 29520 Strapping of hip 29530 Strapping of knee 29540 Strapping of ankle 29550 Strapping of toes 29580 Application of paste boot 29590 Application of foot splint 29700 Removal/revision of cast 29705 Removal/revision of cast 29710 Removal/revision of cast 29715 Removal/revision of cast 29720 Repair of body cast 29730 Windowing of cast 29740 Wedging of cast 29750 Wedging of clubfoot cast 29799 Casting/strapping procedure 0059 Level II Strapping and Cast Application S 1.74 $84.37 $29.59 $16.87 29000 Application of body cast 29010 Application of body cast 29015 Application of body cast 29020 Application of body cast 29025 Application of body cast 29035 Application of body cast 29040 Application of body cast 29044 Application of body cast 29046 Application of body cast 29049 Application of figure eight 29055 Application of shoulder cast 29058 Application of shoulder cast 29065 Application of long arm cast 29075 Application of forearm cast 29085 Apply hand/wrist cast 29105 Apply long arm splint 29125 Apply forearm splint 29126 Apply forearm splint 29130 Application of finger splint 29131 Application of finger splint 29200 Strapping of chest 29220 Strapping of low back 29240 Strapping of shoulder 29260 Strapping of elbow or wrist 29280 Strapping of hand or finger 29305 Application of hip cast 29325 Application of hip casts 29345 Application of long leg cast 29355 Application of long leg cast 29358 Apply long leg cast brace 29365 Application of long leg cast 29405 Apply short leg cast 29425 Apply short leg cast 29435 Apply short leg cast 29440 Addition of walker to cast 29445 Apply rigid leg cast 29450 Application of leg cast 0060 Manipulation Therapy S 0.77 $37.34 $7.80 $7.47 Start Printed Page 18728 98925 Osteopathic manipulation 98926 Osteopathic manipulation 98927 Osteopathic manipulation 98928 Osteopathic manipulation 98929 Osteopathic manipulation 98940 Chiropractic manipulation 98941 Chiropractic manipulation 98942 Chiropractic manipulation 0070 Thoracentesis/Lavage Procedures T 3.64 $176.49 $79.60 $35.30 32000 Drainage of chest 32002 Treatment of collapsed lung 32005 Treat lung lining chemically 32020 Insertion of chest tube 32420 Puncture/clear lung 32960 Therapeutic pneumothorax 32999 Chest surgery procedure 33010 Drainage of heart sac 33011 Repeat drainage of heart sac 33999 Cardiac surgery procedure 49080 Puncture, peritoneal cavity 49081 Removal of abdominal fluid 0071 Level I Endoscopy Upper Airway T 0.55 $26.67 $14.22 $5.33 31231 Nasal endoscopy, dx 31575 Diagnostic laryngoscopy 92511 Nasopharyngoscopy 0072 Level II Endoscopy Upper Airway T 1.26 $61.09 $41.52 $12.22 31233 Nasal/sinus endoscopy, dx 31505 Diagnostic laryngoscopy 31511 Remove foreign body, larynx 31520 Diagnostic laryngoscopy 31700 Insertion of airway catheter 31720 Clearance of airways 0073 Level III Endoscopy Upper Airway T 4.11 $199.28 $91.07 $39.86 31513 Injection into vocal cord 31577 Remove foreign body, larynx 31579 Diagnostic laryngoscopy 31717 Bronchial brush biopsy 31730 Intro, windpipe wire/tube 0074 Level IV Endoscopy Upper Airway T 13.61 $659.91 $347.54 $131.98 31235 Nasal/sinus endoscopy, dx 31237 Nasal/sinus endoscopy, surg 31238 Nasal/sinus endoscopy, surg 31240 Nasal/sinus endoscopy, surg 31510 Laryngoscopy with biopsy 31512 Removal of larynx lesion 31515 Laryngoscopy for aspiration 31525 Diagnostic laryngoscopy 31526 Diagnostic laryngoscopy 31528 Laryngoscopy and dilatation 31529 Laryngoscopy and dilatation 31576 Laryngoscopy with biopsy 31578 Removal of larynx lesion 0075 Level V Endoscopy Upper Airway T 18.55 $899.44 $467.29 $179.89 31239 Nasal/sinus endoscopy, surg 31254 Revision of ethmoid sinus 31255 Removal of ethmoid sinus 31256 Exploration maxillary sinus 31267 Endoscopy, maxillary sinus 31276 Sinus endoscopy, surgical 31287 Nasal/sinus endoscopy, surg 31288 Nasal/sinus endoscopy, surg 31527 Laryngoscopy for treatment 31530 Operative laryngoscopy 31531 Operative laryngoscopy 31535 Operative laryngoscopy 31536 Operative laryngoscopy 31540 Operative laryngoscopy 31541 Operative laryngoscopy 31560 Operative laryngoscopy 31561 Operative laryngoscopy 31570 Laryngoscopy with injection 31571 Laryngoscopy with injection 96570 Photodynamic tx, 30 min Start Printed Page 18729 96571 Photodynamic tx, addl 15 min 0076 Endoscopy Lower Airway T 8.06 $390.81 $197.05 $78.16 31615 Visualization of windpipe 31622 Dx bronchoscope/wash 31623 Dx bronchoscope/brush 31624 Dx bronchoscope/lavage 31625 Bronchoscopy with biopsy 31628 Bronchoscopy with biopsy 31629 Bronchoscopy with biopsy 31630 Bronchoscopy with repair 31631 Bronchoscopy with dilation 31635 Remove foreign body, airway 31640 Bronchoscopy & remove lesion 31641 Bronchoscopy, treat blockage 31643 Diag bronchoscope/catheter 31645 Bronchoscopy, clear airways 31646 Bronchoscopy, reclear airway 31656 Bronchoscopy, inj for x-ray 31899 Airways surgical procedure 32601 Thoracoscopy, diagnostic 32602 Thoracoscopy, diagnostic 32603 Thoracoscopy, diagnostic 32604 Thoracoscopy, diagnostic 32605 Thoracoscopy, diagnostic 32606 Thoracoscopy, diagnostic 39400 Visualization of chest 0077 Level I Pulmonary Treatment S 0.43 $20.85 $12.62 $4.17 94640 Airway inhalation treatment 94650 Pressure breathing (IPPB) 94651 Pressure breathing (IPPB) 94664 Aerosol or vapor inhalations 94665 Aerosol or vapor inhalations 94667 Chest wall manipulation 94668 Chest wall manipulation 0078 Level II Pulmonary Treatment S 1.34 $64.97 $29.13 $12.99 94642 Aerosol inhalation treatment 0079 Ventilation Initiation and Management S 3.18 $154.19 $107.70 $30.84 94656 Initial ventilator mgmt 94657 Continued ventilator mgmt 94660 Pos airway pressure, CPAP 94662 Neg press ventilation, cnp 0080 Diagnostic Cardiac Catheterization T 25.77 $1,249.51 $713.89 $249.90 93501 Right heart catheterization 93503 Insert/place heart catheter 93505 Biopsy of heart lining 93510 Left heart catheterization 93511 Left heart catheterization 93514 Left heart catheterization 93524 Left heart catheterization 93526 Rt & Lt heart catheters 93527 Rt & Lt heart catheters 93528 Rt & Lt heart catheters 93529 Rt, Lt heart catheterization 93530 Rt heart cath, congenital 93531 R & l heart cath, congenital 93532 R & l heart cath, congenital 93533 R & l heart cath, congenital 93536 Insert circulation assi 0081 Non-Coronary Angioplasty or Atherectomy T 19.36 $938.71 $434.25 $187.74 35180 Repair blood vessel lesion 35184 Repair blood vessel lesion 35190 Repair blood vessel lesion 35201 Repair blood vessel lesion 35206 Repair blood vessel lesion 35226 Repair blood vessel lesion 35231 Repair blood vessel lesion 35236 Repair blood vessel lesion 35256 Repair blood vessel lesion 35261 Repair blood vessel lesion 35266 Repair blood vessel lesion 35286 Repair blood vessel lesion 35321 Rechanneling of artery 35459 Repair arterial blockage Start Printed Page 18730 35460 Repair venous blockage 35470 Repair arterial blockage 35471 Repair arterial blockage 35472 Repair arterial blockage 35473 Repair arterial blockage 35474 Repair arterial blockage 35475 Repair arterial blockage 35476 Repair venous blockage 35484 Atherectomy, open 35485 Atherectomy, open 35490 Atherectomy, percutaneous 35491 Atherectomy, percutaneous 35492 Atherectomy, percutaneous 35493 Atherectomy, percutaneous 35494 Atherectomy, percutaneous 35495 Atherectomy, percutaneous 35500 Harvest vein for bypass 37204 Transcatheter occlusion 37205 Transcatheter stent 37206 Transcatheter stent add-on 37207 Transcatheter stent 37208 Transcatheter stent add-on 37209 Exchange arterial catheter 37250 Iv us first vessel add-on 37251 Iv us each add vessel add-on 37565 Ligation of neck vein 37600 Ligation of neck artery 0082 Coronary Atherectomy T 40.34 $1,955.97 $859.56 $391.19 92995 Coronary atherectomy 92996 Coronary atherectomy add-on 0083 Coronary Angiosplasty T 45.79 $2,220.22 $1,322.95 $444.04 92980 Insert intracoronary stent 92981 Insert intracoronary stent 92982 Coronary artery dilation 92984 Coronary artery dilation 0084 Level I Electrophysiologic Evaluation S 10.70 $518.81 $177.79 $103.76 93640 Evaluation heart device 93641 Electrophysiology evaluation 93642 Electrophysiology evaluation 0085 Level II Electrophysiologic Evaluation S 27.06 $1,312.06 $654.48 $262.41 93619 Electrophysiology evaluation 93620 Electrophysiology evaluation 93621 Electrophysiology evaluation 93622 Electrophysiology evaluation 0086 Ablate Heart Dysrhythm Focus S 47.62 $2,308.95 $1,265.37 $461.79 93650 Ablate heart dysrhythm focus 93651 Ablate heart dysrhythm focus 93652 Ablate heart dysrhythm focus 0087 Cardiac Electrophysiologic Recording/Mapping S 9.53 $462.08 $214.72 $92.42 93600 Bundle of His recording 93602 Intra-atrial recording 93603 Right ventricular recording 93607 Left ventricular recording 93609 Mapping of tachycardia 93610 Intra-atrial pacing 93612 Intraventricular pacing 93615 Esophageal recording 93616 Esophageal recording 93618 Heart rhythm pacing 93623 Stimulation, pacing heart 93624 Electrophysiologic study 93631 Heart pacing, mapping 0088 Thrombectomy T 26.49 $1,284.42 $678.68 $256.88 34101 Removal of artery clot 34111 Removal of arm artery clot 34201 Removal of artery clot 34203 Removal of leg artery clot 34471 Removal of vein clot 34490 Removal of vein clot 34501 Repair valve, femoral vein 34510 Transposition of vein valve 34520 Cross-over vein graft 34530 Leg vein fusion Start Printed Page 18731 35188 Repair blood vessel lesion 35207 Repair blood vessel lesion 35875 Removal of clot in graft 35876 Removal of clot in graft 35879 Revise graft w/vein 35881 Revise graft w/vein 36821 Av fusion direct any site 36825 Artery-vein graft 36830 Artery-vein graft 36831 Av fistula excision 36832 Av fistula revision 36833 Av fistula revision G0159 Perc declot dialysis graft 0089 Level I Implantation/Removal/Revision of Pacemaker, AICD or Vascular Device T 6.49 $314.68 $130.07 $62.94 33210 Insertion of heart electrode 33211 Insertion of heart electrode 33220 Revise eltrd pacing-defib 33241 Remove pulse generator 36261 Revision of infusion pump 36262 Removal of infusion pump 36299 Vessel injection procedure 36531 Revision of infusion pump 36532 Removal of infusion pump 36534 Revision of access device 36535 Removal of access device 37203 Transcatheter retrieval 0090 Level II Implantation/Removal/Revision of Pacemaker, AICD or Vascular Device T 20.96 $1,016.29 $573.04 $203.26 33206 Insertion of heart pacemaker 33207 Insertion of heart pacemaker 33208 Insertion of heart pacemaker 33212 Insertion of pulse generator 33213 Insertion of pulse generator 33214 Upgrade of pacemaker system 33216 Revise eltrd pacing-defib 33217 Revise eltrd pacing-defib 33218 Revise eltrd pacing-defib 33233 Removal of pacemaker system 33234 Removal of pacemaker system 33235 Removal pacemaker electrode 33240 Insert pulse generator 33244 Remove eltrd, transven 33249 Eltrd/insert pace-defib 36860 External cannula declotting 36861 Cannula declotting 0091 Level I Vascular Ligation T 14.79 $717.12 $348.23 $143.42 30915 Ligation, nasal sinus artery 37605 Ligation of neck artery 37606 Ligation of neck artery 37615 Ligation of neck artery 37650 Revision of major vein 37700 Revise leg vein 37760 Revision of leg veins 37780 Revision of leg vein 37785 Revise secondary varicosity 0092 Level II Vascular Ligation T 20.21 $979.92 $505.37 $195.98 30920 Ligation, upper jaw artery 37607 Ligation of a-v fistula 37720 Removal of leg vein 37730 Removal of leg veins 37735 Removal of leg veins/lesion 0093 Vascular Repair/Fistula Construction T 17.95 $870.34 $422.33 $174.07 36260 Insertion of infusion pump 36530 Insertion of infusion pump 36533 Insertion of access device 36800 Insertion of cannula 36810 Insertion of cannula 36815 Insertion of cannula 36819 Av fusion by basilic vein 36835 Artery to vein shunt 0094 Resuscitation and Cardioversion S 4.51 $218.68 $105.29 $43.74 31500 Insert emergency airway 92950 Heart/lung resuscitation cpr 92953 Temporary external pacing Start Printed Page 18732 92960 Cardioversion electric, ext 92961 Cardioversion, electric, int 99440 Newborn resuscitation 0095 Cardiac Rehabilitation S 0.64 $31.03 $16.98 $6.21 93797 Cardiac rehab 93798 Cardiac rehab/monitor 0096 Non-Invasive Vascular Studies S 2.06 $99.88 $61.48 $19.98 93721 Plethysmography tracing 93740 Temperature gradient studies 93799 Cardiovascular procedure 93875 Extracranial study 93922 Extremity study 93923 Extremity study 93924 Extremity study 93965 Extremity study 0097 Cardiovascular Stress Test S 1.62 $78.55 $62.40 $15.71 93017 Cardiovascular stress test 93024 Cardiac drug stress test 0098 Injection of Sclerosing Solution T 1.19 $57.70 $20.88 $11.54 36468 Injection(s), spider veins 36469 Injection(s), spider veins 36470 Injection therapy of vein 36471 Injection therapy of veins 45520 Treatment of rectal prolapse 0099 Continuous Cardiac Monitoring S 0.38 $18.43 $14.68 $3.69 93012 Transmission of ecg 93270 ECG recording 93278 ECG/signal-averaged G0005 ECG 24 hour recording G0015 Post symptom ECG tracing 0100 Continuous ECG S 1.70 $82.43 $71.57 $16.49 93225 ECG monitor/record, 24 hrs 93226 ECG monitor/report, 24 hrs 93231 Ecg monitor/record, 24 hrs 93232 ECG monitor/report, 24 hrs 93236 ECG monitor/report, 24 hrs 93268 ECG record/review 93271 Ecg/monitoring and analysis 93724 Analyze pacemaker system G0004 ECG transm phys review & int G0006 ECG transmission & analysis 0101 Tilt Table Evaluation S 4.47 $216.74 $128.84 $43.35 93660 Tilt table evaluation 0102 Electronic Analysis of Pacemakers/other Devices S 0.45 $21.82 $12.62 $4.36 62367 Analyze spine infusion pump 62368 Analyze spine infusion pump 93727 Analyze ilr system 93731 Analyze pacemaker system 93732 Analyze pacemaker system 93733 Telephone analy, pacemaker 93734 Analyze pacemaker system 93735 Analyze pacemaker system 93736 Telephone analy, pacemaker 93737 Analyze cardio/defibrillator 93738 Analyze cardio/defibrillator 93741 Analyze ht pace device sngl 93742 Analyze ht pace device sngl 93743 Analyze ht pace device dual 93744 Analyze ht pace device dual 95970 Analyze neurostim, no prog 95971 Analyze neurostim, simple 95972 Analyze neurostim, complex 95973 Analyze neurostim, complex 95974 Cranial neurostim, complex 95975 Cranial neurostim, complex 0109 Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant S 4.13 $200.25 $40.05 $40.05 38230 Bone marrow collection 38240 Bone marrow/stem transplant 38241 Bone marrow/stem transplant 0110 Transfusion S 5.83 $282.68 $122.73 $56.54 36430 Blood transfusion service 36440 Blood transfusion service 36450 Exchange transfusion service Start Printed Page 18733 36455 Exchange transfusion service 36460 Transfusion service, fetal 0111 Blood Product Exchange S 14.17 $687.06 $300.74 $137.41 36520 Plasma and/or cell exchange 36521 Apheresis w/adsorp/reinfuse 38231 Stem cell collection 0112 Extracorporeal Photopheresis S 39.60 $1,920.09 $663.65 $384.02 36522 Photopheresis 0113 Excision Lymphatic System T 13.89 $673.49 $326.55 $134.70 38308 Incision of lymph channels 38500 Biopsy/removal, lymph nodes 38510 Biopsy/removal, lymph nodes 38520 Biopsy/removal, lymph nodes 38525 Biopsy/removal, lymph nodes 38530 Biopsy/removal, lymph nodes 38550 Removal, neck/armpit lesion 0114 Thyroid/Lymphadenectomy Procedures T 19.56 $948.41 $493.78 $189.68 38542 Explore deep node(s), neck 38555 Removal, neck/armpit lesion 38720 Removal of lymph nodes, neck 38740 Remove armpit lymph nodes 38745 Remove armpit lymph nodes 38760 Remove groin lymph nodes 60200 Remove thyroid lesion 60210 Partial thyroid excision 60220 Partial removal of thyroid 60225 Partial removal of thyroid 60240 Removal of thyroid 60280 Remove thyroid duct lesion 60281 Remove thyroid duct lesion 0116 Chemotherapy Administration by Other Technique Except Infusion S 2.34 $113.46 $22.69 $22.69 Q0083 Chemo by other than infusion 0117 Chemotherapy Administration by Infusion Only S 1.84 $89.22 $71.80 $17.84 Q0084 Chemotherapy by infusion 0118 Chemotherapy Administration by Both Infusion and Other Technique S 2.90 $140.61 $72.03 $28.12 Q0085 Chemo by both infusion and o 0120 Infusion Therapy Except Chemotherapy S 1.66 $80.49 $42.67 $16.10 36680 Insert needle, bone cavity Q0081 Infusion ther other than che 0121 Level I Tube changes and Repositioning T 2.36 $114.43 $52.53 $22.89 31502 Change of windpipe airway 43760 Change gastrostomy tube 43761 Reposition gastrostomy tube 43999 Stomach surgery procedure 47530 Revise/reinsert bile tube 47999 Bile tract surgery procedure 49999 Abdomen surgery procedure 50688 Change of ureter tube 51705 Change of bladder tube 51710 Change of bladder tube 62194 Replace/irrigate catheter 62225 Replace/irrigate catheter 0122 Level II Tube changes and Repositioning T 5.04 $244.37 $114.93 $48.88 47525 Change bile duct catheter 50398 Change kidney tube 0123 Level III Tube changes and Repositioning T 13.89 $673.49 $350.75 $134.70 49422 Remove perm cannula/catheter 49429 Removal of shunt 0130 Level I Laparoscopy T 25.36 $1,229.63 $659.53 $245.93 38129 Laparoscope proc, spleen 38589 Laparoscope proc, lymphatic 43289 Laparoscope proc, esoph 43659 Laparoscope proc, stom 44209 Laparoscope proc, intestine 44970 Laparoscopy, appendectomy 44979 Laparoscope proc, app 47560 Laparoscopy w/cholangio 47561 Laparo w/cholangio/biopsy 47579 Laparoscope proc, biliary 49320 Diag laparo separate proc 49321 Laparoscopy, biopsy 49322 Laparoscopy, aspiration 49323 Laparo drain lymphocele Start Printed Page 18734 49329 Laparo proc, abdm/per/oment 50549 Laparoscope proc, renal 54699 Laparoscope proc, testis 55559 Laparo proc, spermatic cord 58679 Laparo proc, oviduct-ovary 59898 Laparo proc, ob care/deliver 60659 Laparo proc, endocrine 0131 Level II Laparoscopy T 41.81 $2,027.24 $1,089.88 $405.45 38120 Laparoscopy, splenectomy 38570 Laparoscopy, lymph node biop 38572 Laparoscopy, lymphadenectomy 43653 Laparoscopy, gastrostomy 44200 Laparoscopy, enterolysis 44201 Laparoscopy, jejunostomy 47562 Laparoscopic cholecystectomy 47563 Laparo cholecystectomy/graph 47564 Laparo cholecystectomy/explr 47570 Laparo cholecystoenterostomy 49650 Laparo hernia repair initial 49651 Laparo hernia repair recur 49659 Laparo proc, hernia repair 50541 Laparo ablate renal cyst 50544 Laparoscopy, pyeloplasty 50945 Laparoscopy ureterolithotomy 51990 Laparo urethral suspension 54690 Laparoscopy, orchiectomy 55550 Laparo ligate spermatic vein 58551 Laparoscopy, remove myoma 58660 Laparoscopy, lysis 58661 Laparoscopy, remove adnexa 58662 Laparoscopy, excise lesions 58670 Laparoscopy, tubal cautery 58671 Laparoscopy, tubal block 58672 Laparoscopy, fimbrioplasty 58673 Laparoscopy, salpingostomy 59150 Treat ectopic pregnancy 59151 Treat ectopic pregnancy 0132 Level III Laparoscopy T 48.91 $2,371.50 $1,239.22 $474.30 38571 Laparoscopy, lymphadenectomy 43280 Laparoscopy, fundoplasty 43651 Laparoscopy, vagus nerve 43652 Laparoscopy, vagus nerve 50548 Laparo-asst remove k/ureter 51992 Laparo sling operation 54692 Laparoscopy, orchiopexy 58550 Laparo-asst vag hysterectomy 0140 Esophageal Dilation without Endoscopy T 4.74 $229.83 $107.24 $45.97 43450 Dilate esophagus 43453 Dilate esophagus 43456 Dilate esophagus 43458 Dilate esophagus 43499 Esophagus surgery procedure 0141 Upper GI Procedures T 7.15 $346.68 $184.67 $69.34 43200 Esophagus endoscopy 43202 Esophagus endoscopy, biopsy 43204 Esophagus endoscopy & inject 43205 Esophagus endoscopy/ligation 43215 Esophagus endoscopy 43216 Esophagus endoscopy/lesion 43217 Esophagus endoscopy 43219 Esophagus endoscopy 43220 Esoph endoscopy, dilation 43226 Esoph endoscopy, dilation 43227 Esoph endoscopy, repair 43228 Esoph endoscopy, ablation 43234 Upper GI endoscopy, exam 43235 Uppr gi endoscopy, diagnosis 43239 Upper GI endoscopy, biopsy 43241 Upper GI endoscopy with tube 43243 Upper gi endoscopy & inject 43244 Upper GI endoscopy/ligation 43245 Operative upper GI endoscopy 43246 Place gastrostomy tube Start Printed Page 18735 43247 Operative upper GI endoscopy 43248 Uppr gi endoscopy/guide wire 43249 Esoph endoscopy, dilation 43250 Upper GI endoscopy/tumor 43251 Operative upper GI endoscopy 43255 Operative upper GI endoscopy 43258 Operative upper GI endoscopy 43259 Endoscopic ultrasound exam 43600 Biopsy of stomach 43750 Place gastrostomy tube 43830 Place gastrostomy tube 43831 Place gastrostomy tube 44100 Biopsy of bowel 0142 Small Intestine Endoscopy T 7.45 $361.23 $162.42 $72.25 44360 Small bowel endoscopy 44361 Small bowel endoscopy/biopsy 44363 Small bowel endoscopy 44364 Small bowel endoscopy 44365 Small bowel endoscopy 44366 Small bowel endoscopy 44369 Small bowel endoscopy 44372 Small bowel endoscopy 44373 Small bowel endoscopy 44376 Small bowel endoscopy 44377 Small bowel endoscopy/biopsy 44378 Small bowel endoscopy 44380 Small bowel endoscopy 44382 Small bowel endoscopy 44799 Intestine surgery procedure 0143 Lower GI Endoscopy T 7.98 $386.93 $199.12 $77.39 44385 Endoscopy of bowel pouch 44386 Endoscopy, bowel pouch/biop 44388 Colon endoscopy 44389 Colonoscopy with biopsy 44390 Colonoscopy for foreign body 44391 Colonoscopy for bleeding 44392 Colonoscopy & polypectomy 44393 Colonoscopy, lesion removal 44394 Colonoscopy w/snare 45355 Surgical colonoscopy 45378 Diagnostic colonoscopy 45379 Colonoscopy 45380 Colonoscopy and biopsy 45382 Colonoscopy/control bleeding 45383 Lesion removal colonoscopy 45384 Colonoscopy 45385 Lesion removal colonoscopy 0144 Diagnostic Anoscopy T 2.23 $108.13 $49.32 $21.63 46604 Anoscopy and dilation 46608 Anoscopy/remove for body 0145 Therapeutic Anoscopy T 7.46 $361.71 $179.39 $72.34 46606 Anoscopy and biopsy 46610 Anoscopy/remove lesion 46611 Anoscopy 46612 Anoscopy/remove lesions 46614 Anoscopy/control bleeding 46615 Anoscopy 0146 Level I Sigmoidoscopy T 2.83 $137.22 $65.15 $27.44 45300 Proctosigmoidoscopy 45303 Proctosigmoidoscopy 45305 Proctosigmoidoscopy & biopsy 45307 Proctosigmoidoscopy 45317 Proctosigmoidoscopy 45330 Diagnostic sigmoidoscopy 45331 Sigmoidoscopy and biopsy 45332 Sigmoidoscopy 0147 Level II Sigmoidoscopy T 6.26 $303.53 $149.11 $60.71 45308 Proctosigmoidoscopy 45309 Proctosigmoidoscopy 45315 Proctosigmoidoscopy 45320 Proctosigmoidoscopy 45321 Proctosigmoidoscopy 45333 Sigmoidoscopy & polypectomy Start Printed Page 18736 45334 Sigmoidoscopy for bleeding 45337 Sigmoidoscopy & decompress 45338 Sigmoidoscopy 45339 Sigmoidoscopy 0148 Level I Anal/Rectal Procedure T 2.34 $113.46 $43.59 $22.69 45005 Drainage of rectal abscess 45900 Reduction of rectal prolapse 45915 Remove rectal obstruction 45999 Rectum surgery procedure 46040 Incision of rectal abscess 46050 Incision of anal abscess 46070 Incision of anal septum 46083 Incise external hemorrhoid 46221 Ligation of hemorrhoid(s) 46320 Removal of hemorrhoid clot 46500 Injection into hemorrhoids 46934 Destruction of hemorrhoids 46935 Destruction of hemorrhoids 46945 Ligation of hemorrhoids 46946 Ligation of hemorrhoids 0149 Level II Anal/Rectal Procedure T 12.86 $623.54 $293.06 $124.71 45000 Drainage of pelvic abscess 45020 Drainage of rectal abscess 45100 Biopsy of rectum 45905 Dilation of anal sphincter 45910 Dilation of rectal narrowing 46030 Removal of rectal marker 46080 Incision of anal sphincter 46210 Removal of anal crypt 46220 Removal of anal tab 46230 Removal of anal tabs 46754 Removal of suture from anus 46936 Destruction of hemorrhoids 46940 Treatment of anal fissure 46942 Treatment of anal fissure 46999 Anus surgery procedure 0150 Level III Anal/Rectal Procedure T 17.68 $857.25 $437.12 $171.45 45108 Removal of anorectal lesion 45150 Excision of rectal stricture 45160 Excision of rectal lesion 45170 Excision of rectal lesion 45190 Destruction, rectal tumor 45500 Repair of rectum 45505 Repair of rectum 45560 Repair of rectocele 46045 Incision of rectal abscess 46060 Incision of rectal abscess 46200 Removal of anal fissure 46211 Removal of anal crypts 46250 Hemorrhoidectomy 46255 Hemorrhoidectomy 46257 Remove hemorrhoids & fissure 46258 Remove hemorrhoids & fistula 46260 Hemorrhoidectomy 46261 Remove hemorrhoids & fissure 46262 Remove hemorrhoids & fistula 46270 Removal of anal fistula 46275 Removal of anal fistula 46280 Removal of anal fistula 46285 Removal of anal fistula 46288 Repair anal fistula 46700 Repair of anal stricture 46750 Repair of anal sphincter 46753 Reconstruction of anus 46760 Repair of anal sphincter 46761 Repair of anal sphincter 46762 Implant artificial sphincter 46937 Cryotherapy of rectal lesion 46938 Cryotherapy of rectal lesion 0151 Endoscopic Retrograde Cholangio-Pancreatography (ERCP) T 10.53 $510.57 $245.46 $102.11 43260 Endo cholangiopancreatograph 43261 Endo cholangiopancreatograph 43262 Endo cholangiopancreatograph Start Printed Page 18737 43263 Endo cholangiopancreatograph 43264 Endo cholangiopancreatograph 43265 Endo cholangiopancreatograph 43267 Endo cholangiopancreatograph 43268 Endo cholangiopancreatograph 43269 Endo cholangiopancreatograph 43271 Endo cholangiopancreatograph 43272 Endo cholangiopancreatograph 0152 Percutaneous Biliary Endoscopic Procedures T 8.22 $398.56 $207.38 $79.71 47510 Insert catheter, bile duct 47511 Insert bile duct drain 47552 Biliary endoscopy thru skin 47553 Biliary endoscopy thru skin 47554 Biliary endoscopy thru skin 47555 Biliary endoscopy thru skin 47556 Biliary endoscopy thru skin 47630 Remove bile duct stone 0153 Peritoneal and Abdominal Procedures T 19.62 $951.32 $496.31 $190.26 49085 Remove abdomen foreign body 49250 Excision of umbilicus 49420 Insert abdominal drain 49421 Insert abdominal drain 49423 Exchange drainage catheter 49426 Revise abdomen-venous shunt 0154 Hernia/Hydrocele Procedures T 22.43 $1,087.57 $556.98 $217.51 49495 Repair inguinal hernia, init 49496 Repair inguinal hernia, init 49500 Repair inguinal hernia 49501 Repair inguinal hernia, init 49505 Repair inguinal hernia 49507 Repair inguinal hernia 49520 Rerepair inguinal hernia 49521 Repair inguinal hernia, rec 49525 Repair inguinal hernia 49540 Repair lumbar hernia 49550 Repair femoral hernia 49553 Repair femoral hernia, init 49555 Repair femoral hernia 49557 Repair femoral hernia, recur 49560 Repair abdominal hernia 49561 Repair incisional hernia 49565 Rerepair abdominal hernia 49566 Repair incisional hernia 49568 Hernia repair w/mesh 49570 Repair epigastric hernia 49572 Repair epigastric hernia 49580 Repair umbilical hernia 49582 Repair umbilical hernia 49585 Repair umbilical hernia 49587 Repair umbilical hernia 49590 Repair abdominal hernia 49600 Repair umbilical lesion 51500 Removal of bladder cyst 54530 Removal of testis 54550 Exploration for testis 54640 Suspension of testis 55040 Removal of hydrocele 55041 Removal of hydroceles 55535 Revise spermatic cord veins 55540 Revise hernia & sperm veins 2 0157 Colorectal Cancer Screening: Barium Enema S 1.79 $86.79 $17.36 G0106 Colon CA screen; barium enema G0120 Colon ca scrn; barium enema 1 0158 Colorectal Cancer Screening: Colonoscopy S 7.98 $386.93 $96.73 G0104 CA screen; flexi sigmoidscope 1 0159 Colorectal Cancer Screening: Flexible Sigmoidoscopy S 7.98 $137.22 $34.31 G0105 Colorectal scrn; hi risk ind 0160 Level I Cystourethroscopy and other Genitourinary Procedures T 5.43 $263.28 $110.11 $52.66 50392 Insert kidney drain 50393 Insert ureteral tube 50395 Create passage to kidney 52000 Cystoscopy 52265 Cystoscopy and treatment Start Printed Page 18738 0161 Level II Cystourethroscopy and other Genitourinary Procedures T 10.94 $530.45 $249.36 $106.09 50551 Kidney endoscopy 50553 Kidney endoscopy 50555 Kidney endoscopy & biopsy 50557 Kidney endoscopy & treatment 50559 Renal endoscopy/radiotracer 50561 Kidney endoscopy & treatment 52005 Cystoscopy & ureter catheter 52007 Cystoscopy and biopsy 52010 Cystoscopy & duct catheter 52204 Cystoscopy 52214 Cystoscopy and treatment 52224 Cystoscopy and treatment 52260 Cystoscopy and treatment 52270 Cystoscopy & revise urethra 52275 Cystoscopy & revise urethra 52276 Cystoscopy and treatment 52281 Cystoscopy and treatment 52283 Cystoscopy and treatment 52285 Cystoscopy and treatment 52290 Cystoscopy and treatment 52300 Cystoscopy and treatment 52301 Cystoscopy and treatment 52305 Cystoscopy and treatment 52310 Cystoscopy and treatment 52315 Cystoscopy and treatment 52327 Cystoscopy, inject material 52510 Dilation prostatic urethra 53605 Dilate urethra stricture 0162 Level III Cystourethroscopy and other Genitourinary Procedures T 17.49 $848.04 $427.49 $169.61 50951 Endoscopy of ureter 50953 Endoscopy of ureter 50955 Ureter endoscopy & biopsy 50957 Ureter endoscopy & treatment 50959 Ureter endoscopy & tracer 50961 Ureter endoscopy & treatment 51020 Incise & treat bladder 51030 Incise & treat bladder 51040 Incise & drain bladder 51045 Incise bladder/drain ureter 51050 Removal of bladder stone 51065 Removal of ureter stone 51520 Removal of bladder lesion 51880 Repair of bladder opening 52234 Cystoscopy and treatment 52235 Cystoscopy and treatment 52250 Cystoscopy and radiotracer 52277 Cystoscopy and treatment 52282 Cystoscopy, implant stent 52317 Remove bladder stone 52318 Remove bladder stone 52320 Cystoscopy and treatment 52325 Cystoscopy, stone removal 52330 Cystoscopy and treatment 52332 Cystoscopy and treatment 52334 Create passage to kidney 52335 Endoscopy of urinary tract 52336 Cystoscopy, stone removal 52337 Cystoscopy, stone removal 52338 Cystoscopy and treatment 52339 Cystoscopy and treatment 52340 Cystoscopy and treatment 52450 Incision of prostate 52500 Revision of bladder neck 52606 Control postop bleeding 52640 Relieve bladder contracture 52700 Drainage of prostate abscess 55720 Drainage of prostate abscess 55725 Drainage of prostate abscess 55859 Percut/needle insert, pros 0163 Level IV Cystourethroscopy and other Genitourinary Procedures T 28.98 $1,405.16 $792.58 $281.03 50080 Removal of kidney stone 50081 Removal of kidney stone Start Printed Page 18739 52240 Cystoscopy and treatment 52601 Prostatectomy (TURP) 52612 Prostatectomy, first stage 52614 Prostatectomy, second stage 52620 Remove residual prostate 52630 Remove prostate regrowth 52647 Laser surgery of prostate 52648 Laser surgery of prostate 0164 Level I Urinary and Anal Procedures T 2.17 $105.23 $33.03 $21.05 51005 Drainage of bladder 51700 Irrigation of bladder 51736 Urine flow measurement 51741 Electro-uroflowmetry, first 51784 Anal/urinary muscle study 51785 Anal/urinary muscle study 51795 Urine voiding pressure study 51797 Intraabdominal pressure test 53600 Dilate urethra stricture 53601 Dilate urethra stricture 53621 Dilate urethra stricture 53660 Dilation of urethra 53661 Dilation of urethra 53675 Insert urinary catheter 54235 Penile injection 54240 Penis study 55899 Genital surgery procedure 0165 Level II Urinary and Anal Procedures T 3.89 $188.61 $91.76 $37.72 50396 Measure kidney pressure 50686 Measure ureter pressure 51000 Drainage of bladder 51010 Drainage of bladder 51720 Treatment of bladder lesion 51725 Simple cystometrogram 51726 Complex cystometrogram 51772 Urethra pressure profile 51792 Urinary reflex study 53620 Dilate urethra stricture 53899 Urology surgery procedure 54200 Treatment of penis lesion 54220 Treatment of penis lesion 54231 Dynamic cavernosometry 54250 Penis study 54450 Preputial stretching 91122 Anal pressure record 0166 Level I Urethral Procedures T 10.17 $493.11 $218.73 $98.62 53000 Incision of urethra 53010 Incision of urethra 53020 Incision of urethra 53025 Incision of urethra 53040 Drainage of urethra abscess 53060 Drainage of urethra abscess 53080 Drainage of urinary leakage 53200 Biopsy of urethra 53250 Removal of urethra gland 53260 Treatment of urethra lesion 53265 Treatment of urethra lesion 53275 Repair of urethra defect 53442 Remove perineal prosthesis 53502 Repair of urethra injury 53510 Repair of urethra injury 53665 Dilation of urethra 54000 Slitting of prepuce 54001 Slitting of prepuce 0167 Level II Urethral Procedures T 21.06 $1,021.14 $555.84 $204.23 51715 Endoscopic injection/implant 53270 Removal of urethra gland 53505 Repair of urethra injury 0168 Level III Urethral Procedures T 24.94 $1,209.27 $536.11 $241.85 53210 Removal of urethra 53215 Removal of urethra 53220 Treatment of urethra lesion 53230 Removal of urethra lesion 53235 Removal of urethra lesion Start Printed Page 18740 53240 Surgery for urethra pouch 53400 Revise urethra, stage 1 53405 Revise urethra, stage 2 53410 Reconstruction of urethra 53420 Reconstruct urethra, stage 1 53425 Reconstruct urethra, stage 2 53430 Reconstruction of urethra 53447 Remove artificial sphincter 53449 Correct artificial sphincter 53450 Revision of urethra 53460 Revision of urethra 53515 Repair of urethra injury 53520 Repair of urethra defect 0169 Lithotripsy T 46.72 $2,265.32 $1,384.20 $453.06 50590 Fragmenting of kidney stone 0170 Dialysis for Other Than ESRD Patients S 6.68 $323.89 $72.26 $64.78 90935 Hemodialysis, one evaluation 90945 Dialysis, one evaluation 0180 Circumcision T 13.62 $660.39 $304.87 $132.08 54150 Circumcision 54152 Circumcision 54160 Circumcision 54161 Circumcision 0181 Penile Procedures T 32.37 $1,569.53 $906.36 $313.91 37790 Penile venous occlusion 54110 Treatment of penis lesion 54111 Treat penis lesion, graft 54112 Treat penis lesion, graft 54120 Partial removal of penis 54205 Treatment of penis lesion 54300 Revision of penis 54304 Revision of penis 54308 Reconstruction of urethra 54312 Reconstruction of urethra 54316 Reconstruction of urethra 54318 Reconstruction of urethra 54322 Reconstruction of urethra 54324 Reconstruction of urethra 54326 Reconstruction of urethra 54328 Revise penis/urethra 54340 Secondary urethral surgery 54344 Secondary urethral surgery 54348 Secondary urethral surgery 54352 Reconstruct urethra/penis 54360 Penis plastic surgery 54380 Repair penis 54385 Repair penis 54402 Remove penis prosthesis 54407 Remove multi-comp prosthesis 54409 Revise penis prosthesis 54420 Revision of penis 54435 Revision of penis 54440 Repair of penis 0182 Insertion of Penile Prosthesis T 52.11 $2,526.66 $1,525.05 $505.33 53440 Correct bladder function 53445 Correct urine flow control 54400 Insert semi-rigid prosthesis 54401 Insert self-contd prosthesis 54405 Insert multi-comp prosthesis 0183 Testes/Epididymis Procedures T 18.26 $885.37 $448.94 $177.07 54505 Biopsy of testis 54510 Removal of testis lesion 54520 Removal of testis 54600 Reduce testis torsion 54620 Suspension of testis 54660 Revision of testis 54670 Repair testis injury 54680 Relocation of testis(es) 54700 Drainage of scrotum 54820 Exploration of epididymis 54830 Remove epididymis lesion 54840 Remove epididymis lesion 54860 Removal of epididymis Start Printed Page 18741 54861 Removal of epididymis 54900 Fusion of spermatic ducts 54901 Fusion of spermatic ducts 55060 Repair of hydrocele 55110 Explore scrotum 55120 Removal of scrotum lesion 55150 Removal of scrotum 55175 Revision of scrotum 55180 Revision of scrotum 55200 Incision of sperm duct 55250 Removal of sperm duct(s) 55400 Repair of sperm duct 55450 Ligation of sperm duct 55500 Removal of hydrocele 55520 Removal of sperm cord lesion 55530 Revise spermatic cord veins 55680 Remove sperm pouch lesion 0184 Prostate Biopsy T 4.94 $239.53 $122.96 $47.91 55700 Biopsy of prostate 55705 Biopsy of prostate 0190 Surgical Hysteroscopy T 17.85 $865.49 $443.89 $173.10 58558 Hysteroscopy, biopsy 58559 Hysteroscopy, lysis 58560 Hysteroscopy, resect septum 58561 Hysteroscopy, remove myoma 58562 Hysteroscopy, remove fb 58563 Hysteroscopy, ablation 58578 Laparo proc, uterus 58579 Hysteroscope procedure 0191 Level I Female Reproductive Procedures T 1.19 $57.70 $17.43 $11.54 57160 Insert pessary/other device 57170 Fitting of diaphragm/cap 57452 Examination of vagina 58100 Biopsy of uterus lining 58301 Remove intrauterine device 58555 Hysteroscopy, dx, sep proc 59200 Insert cervical dilator Q0091 Obtaining screen pap smear 0192 Level II Female Reproductive Procedures T 2.38 $115.40 $35.33 $23.08 56405 I & D of vulva/perineum 56420 Drainage of gland abscess 57100 Biopsy of vagina 57150 Treat vagina infection 57180 Treat vaginal bleeding 57454 Vagina examination & biopsy 57505 Endocervical curettage 57511 Cryocautery of cervix 99170 Anogenital exam, child 0193 Level III Female Reproductive Procedures T 8.93 $432.99 $171.13 $86.60 56441 Lysis of labial lesion(s) 56720 Incision of hymen 57020 Drainage of pelvic fluid 57460 Cervix excision 57500 Biopsy of cervix 57510 Cauterization of cervix 57513 Laser surgery of cervix 57800 Dilation of cervical canal 0194 Level IV Female Reproductive Procedures T 16.21 $785.98 $395.94 $157.20 56440 Surgery for vulva lesion 56700 Partial removal of hymen 56740 Remove vagina gland lesion 56800 Repair of vagina 56810 Repair of perineum 57000 Exploration of vagina 57010 Drainage of pelvic abscess 57061 Destruction vagina lesion(s) 57065 Destruction vagina lesion(s) 57105 Biopsy of vagina 57106 Remove vagina wall, partial 57107 Remove vagina tissue, part 57109 Vaginectomy partial w/nodes 57130 Remove vagina lesion 57135 Remove vagina lesion Start Printed Page 18742 57200 Repair of vagina 57210 Repair vagina/perineum 57230 Repair of urethral lesion 57400 Dilation of vagina 57410 Pelvic examination 57415 Remove vaginal foreign body 57520 Conization of cervix 57700 Revision of cervix 57720 Revision of cervix 58345 Reopen fallopian tube 58350 Reopen fallopian tube 58970 Retrieval of oocyte 59300 Episiotomy or vaginal repair 59320 Revision of cervix 59871 Remove cerclage suture 0195 Level V Female Reproductive Procedures T 18.68 $905.74 $483.80 $181.15 56620 Partial removal of vulva 56625 Complete removal of vulva 57220 Revision of urethra 57240 Repair bladder & vagina 57250 Repair rectum & vagina 57260 Repair of vagina 57265 Extensive repair of vagina 57268 Repair of bowel bulge 57284 Repair paravaginal defect 57288 Repair bladder defect 57289 Repair bladder & vagina 57291 Construction of vagina 57300 Repair rectum-vagina fistula 57522 Conization of cervix 57530 Removal of cervix 57550 Removal of residual cervix 57555 Remove cervix/repair vagina 57556 Remove cervix, repair bowel 58145 Removal of uterus lesion 58800 Drainage of ovarian cyst(s) 58820 Drain ovary abscess, open 58900 Biopsy of ovary(s) 58920 Partial removal of ovary(s) 58925 Removal of ovarian cyst(s) 0196 Dilatation & Curettage T 14.47 $701.61 $357.98 $140.32 57820 D & c of residual cervix 58120 Dilation and curettage 59160 D & c after delivery 0197 Infertility Procedures T 2.40 $116.37 $49.55 $23.27 55870 Electroejaculation 58321 Artificial insemination 58322 Artificial insemination 58323 Sperm washing 58974 Transfer of embryo 58976 Transfer of embryo 0198 Pregnancy and Neonatal Care Procedures T 1.34 $64.97 $33.03 $12.99 59000 Amniocentesis 59012 Fetal cord puncture, prenatal 59015 Chorion biopsy 59020 Fetal contract stress test 59025 Fetal non-stress test 59030 Fetal scalp blood sample 59050 Fetal monitor w/report 59899 Maternity care procedure 0199 Vaginal Delivery T 11.20 $543.06 $157.83 $108.61 59409 Obstetrical care 59412 Antepartum manipulation 59414 Deliver placenta 59612 Vbac delivery only 0200 Therapeutic Abortion T 13.89 $673.49 $373.23 $134.70 59840 Abortion 59841 Abortion 0201 Spontaneous Abortion T 13.00 $630.33 $329.65 $126.07 59812 Treatment of miscarriage 59820 Care of miscarriage 59821 Treatment of miscarriage 59870 Evacuate mole of uterus Start Printed Page 18743 0210 Spinal Tap T 3.00 $145.46 $62.40 $29.09 62270 Spinal fluid tap, diagnostic 62272 Drain spinal fluid 0211 Level I Nervous System Injections T 3.32 $160.98 $74.78 $32.20 64400 Injection for nerve block 64402 Injection for nerve block 64405 Injection for nerve block 64408 Injection for nerve block 64410 Injection for nerve block 64412 Injection for nerve block 64413 Injection for nerve block 64415 Injection for nerve block 64417 Injection for nerve block 64418 Injection for nerve block 64420 Injection for nerve block 64421 Injection for nerve block 64425 Injection for nerve block 64430 Injection for nerve block 64435 Injection for nerve block 64445 Injection for nerve block 64450 Injection for nerve block 64470 Inj paravertebral c/t 64472 Inj paravertebral c/t add-on 64475 Inj paravertebral l/s 64476 Inj paravertebral l/s add-on 64479 Inj foramen epidural c/t 64480 Inj foramen epidural add-on 64483 Inj foramen epidural l/s 64484 Inj foramen epidural add-on 64505 Injection for nerve block 64508 Injection for nerve block 64510 Injection for nerve block 64520 Injection for nerve block 64530 Injection for nerve block 64600 Injection treatment of nerve 64605 Injection treatment of nerve 64610 Injection treatment of nerve 64612 Destroy nerve, face muscle 64613 Destroy nerve, spine muscle 64620 Injection treatment of nerve 64622 Destr paravertebrl nerve l/s 64623 Destr paravertebral n add-on 64626 Destr paravertebrl nerve c/t 64627 Destr paravertebral n add-on 64630 Injection treatment of nerve 64640 Injection treatment of nerve 64680 Injection treatment of nerve 64999 Nervous system surgery 0212 Level II Nervous System Injections T 3.64 $176.49 $88.78 $35.30 61000 Remove cranial cavity fluid 61001 Remove cranial cavity fluid 61020 Remove brain cavity fluid 61026 Injection into brain canal 61050 Remove brain canal fluid 61055 Injection into brain canal 61070 Brain canal shunt procedure 62263 Lysis epidural adhesions 62268 Drain spinal cord cyst 62273 Treat epidural spine lesion 62280 Treat spinal cord lesion 62281 Treat spinal cord lesion 62282 Treat spinal canal lesion 62292 Injection into disk lesion 62294 Injection into spinal artery 62310 Inject spine c/t 62311 Inject spine l/s (cd) 62318 Inject spine w/cath, c/t 62319 Inject spine w/cath l/s (cd) 0213 Extended EEG Studies and Sleep Studies S 11.15 $540.63 $290.42 $108.13 95805 Multiple sleep latency test 95806 Sleep study, unattended 95807 Sleep study, attended 95808 Polysomnography, 1-3 Start Printed Page 18744 95810 Polysomnography, 4 or more 95811 Polysomnography w/cpap 95812 Electroencephalogram (EEG) 95813 Electroencephalogram (EEG) 95827 Night electroencephalogram 95951 EEG monitoring/videorecord 95953 EEG monitoring/computer 95954 EEG monitoring/giving drugs 95958 EEG monitoring/function test 0214 Electroencephalogram S 2.32 $112.49 $58.50 $22.50 95816 Electroencephalogram (EEG) 95819 Electroencephalogram (EEG) 95822 Sleep electroencephalogram 95824 Electroencephalography 95829 Surgery electrocorticogram 95955 EEG during surgery 0215 Level I Nerve and Muscle Tests S 1.15 $55.76 $30.05 $11.15 95857 Tensilon test 95858 Tensilon test & myogram 95860 Muscle test, one limb 95861 Muscle test, two limbs 95864 Muscle test, 4 limbs 95869 Muscle test, thor paraspinal 95870 Muscle test, nonparaspinal 95872 Muscle test, one fiber 95900 Motor nerve conduction test 95903 Motor nerve conduction test 95904 Sense/mixed n conduction tst 95933 Blink reflex test 95934 H-reflex test 95937 Neuromuscular junction test 0216 Level II Nerve and Muscle Tests S 2.87 $139.16 $64.69 $27.83 92275 Electroretinography 92585 Auditory evoked potential 95863 Muscle test, 3 limbs 95867 Muscle test, head or neck 95868 Muscle test, head or neck 95921 Autonomic nerv function test 95922 Autonomic nerv function test 95923 Autonomic nerv function test 95925 Somatosensory testing 95926 Somatosensory testing 95927 Somatosensory testing 95930 Visual evoked potential test 95936 H-reflex test 0217 Level III Nerve and Muscle Tests S 5.87 $284.62 $156.68 $56.92 95875 Limb exercise test 95950 Ambulatory eeg monitoring 0220 Level I Nerve Procedures T 13.96 $676.88 $326.21 $135.38 27315 Partial removal, thigh nerve 27320 Partial removal, thigh nerve 28030 Removal of foot nerve 28035 Decompression of tibia nerve 61790 Treat trigeminal nerve 62287 Percutaneous diskectomy 63600 Remove spinal cord lesion 63610 Stimulation of spinal cord 63615 Remove lesion of spinal cord 64702 Revise finger/toe nerve 64704 Revise hand/foot nerve 64708 Revise arm/leg nerve 64712 Revision of sciatic nerve 64713 Revision of arm nerve(s) 64714 Revise low back nerve(s) 64716 Revision of cranial nerve 64718 Revise ulnar nerve at elbow 64719 Revise ulnar nerve at wrist 64721 Carpal tunnel surgery 64722 Relieve pressure on nerve(s) 64726 Release foot/toe nerve 64727 Internal nerve revision 64732 Incision of brow nerve 64734 Incision of cheek nerve Start Printed Page 18745 64736 Incision of chin nerve 64738 Incision of jaw nerve 64740 Incision of tongue nerve 64742 Incision of facial nerve 64744 Incise nerve, back of head 64746 Incise diaphragm nerve 64761 Incision of pelvis nerve 64771 Sever cranial nerve 64772 Incision of spinal nerve 64774 Remove skin nerve lesion 64776 Remove digit nerve lesion 64778 Digit nerve surgery add-on 64782 Remove limb nerve lesion 64783 Limb nerve surgery add-on 64784 Remove nerve lesion 64787 Implant nerve end 64788 Remove skin nerve lesion 64790 Removal of nerve lesion 64795 Biopsy of nerve 0221 Level II Nerve Procedures T 18.36 $890.22 $463.62 $178.04 64786 Remove sciatic nerve lesion 64792 Removal of nerve lesion 64831 Repair of digit nerve 64832 Repair nerve add-on 64834 Repair of hand or foot nerve 64835 Repair of hand or foot nerve 64836 Repair of hand or foot nerve 64837 Repair nerve add-on 64840 Repair of leg nerve 64856 Repair/transpose nerve 64857 Repair arm/leg nerve 64858 Repair sciatic nerve 64859 Nerve surgery 64861 Repair of arm nerves 64862 Repair of low back nerves 64864 Repair of facial nerve 64865 Repair of facial nerve 64870 Fusion of facial/other nerve 64872 Subsequent repair of nerve 64874 Repair & revise nerve add-on 64876 Repair nerve/shorten bone 64885 Nerve graft, head or neck 64886 Nerve graft, head or neck 64890 Nerve graft, hand or foot 64891 Nerve graft, hand or foot 64892 Nerve graft, arm or leg 64893 Nerve graft, arm or leg 64895 Nerve graft, hand or foot 64896 Nerve graft, hand or foot 64897 Nerve graft, arm or leg 64898 Nerve graft, arm or leg 64901 Nerve graft add-on 64902 Nerve graft add-on 64905 Nerve pedicle transfer 64907 Nerve pedicle transfer 0222 Implantation of Neurological Device T 25.48 $1,235.45 $780.07 $247.09 61215 Insert brain-fluid device 61885 Implant neurostim one array 62360 Insert spine infusion device 62361 Implant spine infusion pump 62362 Implant spine infusion pump 63685 Implant neuroreceiver 64590 Implant neuroreceiver 0223 Level I Revision/Removal Neurological Device T 6.34 $307.41 $153.24 $61.48 62350 Implant spinal canal cath 62355 Remove spinal canal catheter 63746 Removal of spinal shunt 0224 Level II Revision/Removal Neurological Device T 15.94 $772.88 $374.61 $154.58 62230 Replace/revise brain shunt 62365 Remove spine infusion device 63650 Implant neuroelectrodes 63660 Revise/remove neuroelectrode 63688 Revise/remove neuroreceiver Start Printed Page 18746 63744 Revision of spinal shunt 0225 Implantation of Neurostimulator Electrodes T 3.43 $166.31 $64.46 $33.26 64553 Implant neuroelectrodes 64555 Implant neuroelectrodes 64560 Implant neuroelectrodes 64565 Implant neuroelectrodes 64573 Implant neuroelectrodes 64575 Implant neuroelectrodes 64577 Implant neuroelectrodes 64580 Implant neuroelectrodes 64585 Revise/remove neuroelectrode 64595 Revise/remove neuroreceiver 0230 Level I Eye Tests S 0.98 $47.52 $22.48 $9.50 68200 Treat eyelid by injection 92020 Special eye evaluation 92060 Special eye evaluation 92065 Orthoptic/pleoptic training 92081 Visual field examination(s) 92082 Visual field examination(s) 92083 Visual field examination(s) 92120 Tonography & eye evaluation 92130 Water provocation tonography 92225 Special eye exam, initial 92250 Eye exam with photos 92260 Ophthalmoscopy/dynamometry 92265 Eye muscle evaluation 92270 Electro-oculography 92283 Color vision examination 92285 Eye photography 92330 Fitting of artificial eye 92499 Eye service or procedure 0231 Level II Eye Tests S 2.64 $128.01 $59.87 $25.60 65205 Remove foreign body from eye 65210 Remove foreign body from eye 65220 Remove foreign body from eye 65222 Remove foreign body from eye 65430 Corneal smear 67350 Biopsy eye muscle 67500 Inject/treat eye socket 68110 Remove eyelid lining lesion 68761 Close tear duct opening 68801 Dilate tear duct opening 68810 Probe nasolacrimal duct 68840 Explore/irrigate tear ducts 68899 Tear duct system surgery 92018 New eye exam & treatment 92019 Eye exam & treatment 92135 Opthalmic dx imaging 92140 Glaucoma provocative tests 92226 Special eye exam, subsequent 92230 Eye exam with photos 92235 Eye exam with photos 92240 Icg angiography 92284 Dark adaptation eye exam 92286 Internal eye photography 92287 Internal eye photography 0232 Level I Anterior Segment Eye T 6.04 $292.86 $134.66 $58.57 65235 Remove foreign body from eye 65272 Repair of eye wound 65286 Repair of eye wound 65400 Removal of eye lesion 65436 Curette/treat cornea 65450 Treatment of corneal lesion 65772 Correction of astigmatism 65800 Drainage of eye 65820 Relieve inner eye pressure 65880 Incise inner eye adhesions 65900 Remove eye lesion 66020 Injection treatment of eye 66030 Injection treatment of eye 66500 Incision of iris 66505 Incision of iris 66625 Removal of iris Start Printed Page 18747 66700 Destruction, ciliary body 66710 Destruction, ciliary body 66720 Destruction, ciliary body 66820 Incision, secondary cataract 66830 Removal of lens lesion 67880 Revision of eyelid 68100 Biopsy of eyelid lining 0233 Level II Anterior Segment Eye T 13.79 $668.64 $331.60 $133.73 65275 Repair of eye wound 65280 Repair of eye wound 65410 Biopsy of cornea 65420 Removal of eye lesion 65426 Removal of eye lesion 65775 Correction of astigmatism 65805 Drainage of eye 65810 Drainage of eye 65815 Drainage of eye 65865 Incise inner eye adhesions 65870 Incise inner eye adhesions 65875 Incise inner eye adhesions 65920 Remove implant from eye 65930 Remove blood clot from eye 66130 Remove eye lesion 66150 Glaucoma surgery 66250 Follow-up surgery of eye 66600 Remove iris and lesion 66605 Removal of iris 66630 Removal of iris 66635 Removal of iris 66680 Repair iris & ciliary body 66682 Repair iris & ciliary body 66740 Destruction, ciliary body 66825 Reposition intraocular lens 68130 Remove eyelid lining lesion 68330 Revise eyelid lining 0234 Level III Anterior Segment Eye Procedures T 20.64 $1,000.77 $502.16 $200.15 65285 Repair of eye wound 65850 Incision of eye 66155 Glaucoma surgery 66160 Glaucoma surgery 66165 Glaucoma surgery 66170 Glaucoma surgery 66172 Incision of eye 66180 Implant eye shunt 66185 Revise eye shunt 66225 Repair/graft eye lesion 68360 Revise eyelid lining 68362 Revise eyelid lining 0235 Level I Posterior Segment Eye Procedures T 2.94 $142.55 $78.91 $28.51 67141 Treatment of retina 67208 Treatment of retinal lesion 67227 Treatment of retinal lesion 0236 Level II Posterior Segment Eye Procedures T 6.70 $324.86 $147.96 $64.97 66220 Repair eye lesion 67028 Injection eye drug 67030 Incise inner eye strands 67101 Repair detached retina 67110 Repair detached retina 67115 Release encircling material 67120 Remove eye implant material 0237 Level III Posterior Segment Eye Procedures T 33.96 $1,646.62 $852.68 $329.32 65260 Remove foreign body from eye 65265 Remove foreign body from eye 67005 Partial removal of eye fluid 67010 Partial removal of eye fluid 67015 Release of eye fluid 67025 Replace eye fluid 67027 Implant eye drug system 67036 Removal of inner eye fluid 67038 Strip retinal membrane 67039 Laser treatment of retina 67040 Laser treatment of retina 67107 Repair detached retina Start Printed Page 18748 67108 Repair detached retina 67112 Rerepair detached retina 67121 Remove eye implant material 67218 Treatment of retinal lesion 67220 Treatment of choroid lesion 67255 Reinforce/graft eye wall 0238 Level I Repair and Plastic Eye Procedures T 2.80 $135.76 $58.96 $27.15 67345 Destroy nerve of eye muscle 67505 Inject/treat eye socket 67700 Drainage of eyelid abscess 67800 Remove eyelid lesion 67805 Remove eyelid lesions 67810 Biopsy of eyelid 67820 Revise eyelashes 67825 Revise eyelashes 67938 Remove eyelid foreign body 68400 Incise/drain tear gland 68440 Incise tear duct opening 68705 Revise tear duct opening 68760 Close tear duct opening 0239 Level II Repair and Plastic Eye Procedures T 6.26 $303.53 $123.42 $60.71 65435 Curette/treat cornea 67415 Aspiration, orbital contents 67515 Inject/treat eye socket 67599 Orbit surgery procedure 67710 Incision of eyelid 67801 Remove eyelid lesions 67830 Revise eyelashes 67840 Remove eyelid lesion 67850 Treat eyelid lesion 67875 Closure of eyelid by suture 67915 Repair eyelid defect 67922 Repair eyelid defect 68040 Treatment of eyelid lesions 68115 Remove eyelid lining lesion 68135 Remove eyelid lining lesion 68399 Eyelid lining surgery 0240 Level III Repair and Plastic Eye Procedures T 13.47 $653.12 $315.31 $130.62 65125 Revise ocular implant 65175 Removal of ocular implant 65270 Repair of eye wound 65600 Revision of cornea 67250 Reinforce eye wall 67715 Incision of eyelid fold 67808 Remove eyelid lesion(s) 67835 Revise eyelashes 67882 Revision of eyelid 67900 Repair brow defect 67901 Repair eyelid defect 67902 Repair eyelid defect 67903 Repair eyelid defect 67904 Repair eyelid defect 67906 Repair eyelid defect 67908 Repair eyelid defect 67909 Revise eyelid defect 67911 Revise eyelid defect 67914 Repair eyelid defect 67916 Repair eyelid defect 67917 Repair eyelid defect 67921 Repair eyelid defect 67923 Repair eyelid defect 67924 Repair eyelid defect 67930 Repair eyelid wound 67935 Repair eyelid wound 67950 Revision of eyelid 67961 Revision of eyelid 67966 Revision of eyelid 67975 Reconstruction of eyelid 67999 Revision of eyelid 68020 Incise/drain eyelid lining 68320 Revise/graft eyelid lining 68340 Separate eyelid adhesions 68420 Incise/drain tear sac Start Printed Page 18749 68510 Biopsy of tear gland 68525 Biopsy of tear sac 68530 Clearance of tear duct 68770 Close tear system fistula 68811 Probe nasolacrimal duct 68815 Probe nasolacrimal duct 0241 Level IV Repair and Plastic Eye Procedures T 16.60 $804.89 $384.47 $160.98 65093 Revise eye with implant 65130 Insert ocular implant 65135 Insert ocular implant 65150 Revise ocular implant 67400 Explore/biopsy eye socket 67405 Explore/drain eye socket 67412 Explore/treat eye socket 67413 Explore/treat eye socket 67560 Revise eye socket implant 67971 Reconstruction of eyelid 67973 Reconstruction of eyelid 67974 Reconstruction of eyelid 68326 Revise/graft eyelid lining 68328 Revise/graft eyelid lining 68335 Revise/graft eyelid lining 68500 Removal of tear gland 68505 Partial removal, tear gland 68520 Removal of tear sac 68540 Remove tear gland lesion 68700 Repair tear ducts 68745 Create tear duct drain 0242 Level V Repair and Plastic Eye Procedures T 23.70 $1,149.14 $597.36 $229.83 65091 Revise eye 65101 Removal of eye 65103 Remove eye/insert implant 65105 Remove eye/attach implant 65110 Removal of eye 65112 Remove eye/revise socket 65114 Remove eye/revise socket 65140 Attach ocular implant 65155 Reinsert ocular implant 67414 Explr/decompress eye socket 67420 Explore/treat eye socket 67430 Explore/treat eye socket 67440 Explore/drain eye socket 67445 Explr/decompress eye socket 67450 Explore/biopsy eye socket 67550 Insert eye socket implant 67570 Decompress optic nerve 68325 Revise/graft eyelid lining 68550 Remove tear gland lesion 68720 Create tear sac drain 68750 Create tear duct drain 0243 Strabismus/Muscle Procedures T 17.99 $872.28 $431.39 $174.46 65290 Repair of eye socket wound 67311 Revise eye muscle 67312 Revise two eye muscles 67314 Revise eye muscle 67316 Revise two eye muscles 67318 Revise eye muscle(s) 67320 Revise eye muscle(s) add-on 67331 Eye surgery follow-up add-on 67332 Rerevise eye muscles add-on 67334 Revise eye muscle w/suture 67335 Eye suture during surgery 67340 Revise eye muscle add-on 67343 Release eye tissue 67399 Eye muscle surgery procedure 0244 Corneal Transplant T 32.88 $1,594.26 $851.42 $318.85 65710 Corneal transplant 65730 Corneal transplant 65750 Corneal transplant 65755 Corneal transplant 65770 Revise cornea with implant 0245 Cataract Procedures without IOL Insert T 26.55 $1,287.33 $623.85 $257.47 66840 Removal of lens material Start Printed Page 18750 66850 Removal of lens material 66852 Removal of lens material 66920 Extraction of lens 66930 Extraction of lens 66940 Extraction of lens 0246 Cataract Procedures with IOL Insert T 26.55 $1,287.33 $623.85 $257.47 66983 Remove cataract/insert lens 66984 Remove cataract/insert lens 66985 Insert lens prosthesis 66986 Exchange lens prosthesis 0247 Laser Eye Procedures Except Retinal T 4.89 $237.10 $112.86 $47.42 65855 Laser surgery of eye 65860 Incise inner eye adhesions 66761 Revision of iris 66762 Revision of iris 66770 Removal of inner eye lesion 66821 After cataract laser surgery 66999 Eye surgery procedure 67031 Laser surgery, eye strands 0248 Laser Retinal Procedures T 4.19 $203.16 $94.05 $40.63 67105 Repair detached retina 67145 Treatment of retina 67210 Treatment of retinal lesion 67228 Treatment of retinal lesion 67299 Eye surgery procedure 0250 Nasal Cauterization/Packing T 2.21 $107.16 $38.54 $21.43 30901 Control of nosebleed 30903 Control of nosebleed 30905 Control of nosebleed 30906 Repeat control of nosebleed 42960 Control throat bleeding 42970 Control nose/throat bleeding 0251 Level I ENT Procedures T 1.68 $81.46 $27.99 $16.29 21450 Treat lower jaw fracture 21480 Reset dislocated jaw 30000 Drainage of nose lesion 30020 Drainage of nose lesion 30300 Remove nasal foreign body 30560 Release of nasal adhesions 30999 Nasal surgery procedure 31000 Irrigation, maxillary sinus 40800 Drainage of mouth lesion 40804 Removal, foreign body, mouth 40806 Incision of lip fold 40808 Biopsy of mouth lesion 40818 Excise oral mucosa for graft 40830 Repair mouth laceration 41005 Drainage of mouth lesion 41009 Drainage of mouth lesion 41250 Repair tongue laceration 41599 Tongue and mouth surgery 41800 Drainage of gum lesion 42000 Drainage mouth roof lesion 42180 Repair palate 42280 Preparation, palate mold 42299 Palate/uvula surgery 42310 Drainage of salivary gland 42320 Drainage of salivary gland 42700 Drainage of tonsil abscess 42809 Remove pharynx foreign body 69400 Inflate middle ear canal 92502 Ear and throat examination 0252 Level II ENT Procedures T 5.18 $251.16 $114.24 $50.23 20500 Injection of sinus tract 21400 Treat eye socket fracture 21493 Treat hyoid bone fracture 21494 Treat hyoid bone fracture 21899 Neck/chest surgery procedure 30100 Intranasal biopsy 30124 Removal of nose lesion 30210 Nasal sinus therapy 30220 Insert nasal septal button 30801 Cauterization, inner nose Start Printed Page 18751 31002 Irrigation, sphenoid sinus 31299 Sinus surgery procedure 40490 Biopsy of lip 40801 Drainage of mouth lesion 40805 Removal, foreign body, mouth 40812 Excise/repair mouth lesion 40819 Excise lip or cheek fold 40899 Mouth surgery procedure 41015 Drainage of mouth lesion 41100 Biopsy of tongue 41108 Biopsy of floor of mouth 41820 Excision, gum, each quadrant 41821 Excision of gum flap 42100 Biopsy roof of mouth 42140 Excision of uvula 42325 Create salivary cyst drain 42326 Create salivary cyst drain 42330 Removal of salivary stone 42650 Dilation of salivary duct 42660 Dilation of salivary duct 42800 Biopsy of throat 42999 Throat surgery procedure 69399 Outer ear surgery procedure 69405 Catheterize middle ear canal 69410 Inset middle ear (baffle) 69420 Incision of eardrum 69424 Remove ventilating tube 69433 Create eardrum opening 69979 Temporal bone surgery 0253 Level III ENT Procedures T 12.02 $582.81 $284.00 $116.56 21031 Remove exostosis, mandible 21032 Remove exostosis, maxilla 21040 Removal of jaw bone lesion 21085 Prepare face/oral prosthesis 21089 Prepare face/oral prosthesis 21282 Revision of eyelid 21295 Revision of jaw muscle/bone 21299 Cranio/maxillofacial surgery 21300 Treatment of skull fracture 21310 Treatment of nose fracture 21315 Treatment of nose fracture 21320 Treatment of nose fracture 21325 Treatment of nose fracture 21337 Treat nasal septal fracture 21401 Treat eye socket fracture 21440 Treat dental ridge fracture 21452 Treat lower jaw fracture 21485 Reset dislocated jaw 21497 Interdental wiring 21499 Head surgery procedure 30110 Removal of nose polyp(s) 30115 Removal of nose polyp(s) 30117 Removal of intranasal lesion 30120 Revision of nose 30130 Removal of turbinate bones 30140 Removal of turbinate bones 30200 Injection treatment of nose 30310 Remove nasal foreign body 30320 Remove nasal foreign body 30802 Cauterization, inner nose 30930 Therapy, fracture of nose 31020 Exploration, maxillary sinus 31585 Treat larynx fracture 31599 Larynx surgery procedure 31612 Puncture/clear windpipe 31820 Closure of windpipe lesion 40500 Partial excision of lip 40520 Partial excision of lip 40650 Repair lip 40652 Repair lip 40799 Lip surgery procedure 40810 Excision of mouth lesion 40814 Excise/repair mouth lesion Start Printed Page 18752 40816 Excision of mouth lesion 40820 Treatment of mouth lesion 40831 Repair mouth laceration 41000 Drainage of mouth lesion 41006 Drainage of mouth lesion 41007 Drainage of mouth lesion 41008 Drainage of mouth lesion 41010 Incision of tongue fold 41016 Drainage of mouth lesion 41017 Drainage of mouth lesion 41018 Drainage of mouth lesion 41105 Biopsy of tongue 41110 Excision of tongue lesion 41112 Excision of tongue lesion 41113 Excision of tongue lesion 41115 Excision of tongue fold 41116 Excision of mouth lesion 41251 Repair tongue laceration 41252 Repair tongue laceration 41500 Fixation of tongue 41510 Tongue to lip surgery 41520 Reconstruction, tongue fold 41805 Removal foreign body, gum 41806 Removal foreign body, jawbone 41822 Excision of gum lesion 41823 Excision of gum lesion 41825 Excision of gum lesion 41826 Excision of gum lesion 41827 Excision of gum lesion 41828 Excision of gum lesion 41830 Removal of gum tissue 41850 Treatment of gum lesion 41870 Gum graft 41872 Repair gum 41874 Repair tooth socket 41899 Dental surgery procedure 42104 Excision lesion, mouth roof 42106 Excision lesion, mouth roof 42160 Treatment mouth roof lesion 42260 Repair nose to lip fistula 42281 Insertion, palate prosthesis 42300 Drainage of salivary gland 42305 Drainage of salivary gland 42335 Removal of salivary stone 42340 Removal of salivary stone 42405 Biopsy of salivary gland 42408 Excision of salivary cyst 42409 Drainage of salivary cyst 42450 Excise sublingual gland 42600 Closure of salivary fistula 42665 Ligation of salivary duct 42699 Salivary surgery procedure 42720 Drainage of throat abscess 42802 Biopsy of throat 42804 Biopsy of upper nose/throat 42806 Biopsy of upper nose/throat 42808 Excise pharynx lesion 42810 Excision of neck cyst 42900 Repair throat wound 42972 Control nose/throat bleeding 60000 Drain thyroid/tongue cyst 69105 Biopsy of external ear canal 69120 Removal of external ear 69222 Clean out mastoid cavity 69421 Incision of eardrum 69436 Create eardrum opening 69440 Exploration of middle ear 69540 Remove ear lesion 69610 Repair of eardrum 69620 Repair of eardrum 69799 Middle ear surgery procedure 69949 Inner ear surgery procedure 0254 Level IV ENT Procedures T 12.45 $603.66 $272.41 $120.73 Start Printed Page 18753 21010 Incision of jaw joint 21015 Resection of facial tumor 21030 Removal of face bone lesion 21076 Prepare face/oral prosthesis 21110 Interdental fixation 21120 Reconstruction of chin 21121 Reconstruction of chin 21122 Reconstruction of chin 21123 Reconstruction of chin 21125 Augmentation, lower jaw bone 21137 Reduction of forehead 21181 Contour cranial bone lesion 21235 Ear cartilage graft 21296 Revision of jaw muscle/bone 21330 Treatment of nose fracture 21335 Treatment of nose fracture 21338 Treat nasoethmoid fracture 21339 Treat nasoethmoid fracture 21345 Treat nose/jaw fracture 21421 Treat mouth roof fracture 21445 Treat dental ridge fracture 21451 Treat lower jaw fracture 21454 Treat lower jaw fracture 30118 Removal of intranasal lesion 30430 Revision of nose 30630 Repair nasal septum defect 31040 Exploration behind upper jaw 31070 Exploration of frontal sinus 31600 Incision of windpipe 31601 Incision of windpipe 31603 Incision of windpipe 31605 Incision of windpipe 31610 Incision of windpipe 31611 Surgery/speech prosthesis 31613 Repair windpipe opening 31825 Repair of windpipe defect 31830 Revise windpipe scar 40510 Partial excision of lip 40525 Reconstruct lip with flap 40527 Reconstruct lip with flap 40530 Partial removal of lip 40654 Repair lip 40840 Reconstruction of mouth 40842 Reconstruction of mouth 40843 Reconstruction of mouth 41114 Excision of tongue lesion 42107 Excision lesion, mouth roof 42145 Repair palate, pharynx/uvula 42235 Repair palate 42500 Repair salivary duct 42950 Reconstruction of throat 42955 Surgical opening of throat 43020 Incision of esophagus 69140 Remove ear canal lesion(s) 69300 Revise external ear 69650 Release middle ear bone 0256 Level V ENT Procedures T 25.40 $1,231.57 $623.05 $246.31 21025 Excision of bone, lower jaw 21026 Excision of facial bone(s) 21029 Contour of face bone lesion 21034 Removal of face bone lesion 21041 Removal of jaw bone lesion 21044 Removal of jaw bone lesion 21050 Removal of jaw joint 21060 Remove jaw joint cartilage 21070 Remove coronoid process 21077 Prepare face/oral prosthesis 21079 Prepare face/oral prosthesis 21080 Prepare face/oral prosthesis 21081 Prepare face/oral prosthesis 21082 Prepare face/oral prosthesis 21083 Prepare face/oral prosthesis 21084 Prepare face/oral prosthesis Start Printed Page 18754 21086 Prepare face/oral prosthesis 21087 Prepare face/oral prosthesis 21088 Prepare face/oral prosthesis 21100 Maxillofacial fixation 21127 Augmentation, lower jaw bone 21138 Reduction of forehead 21139 Reduction of forehead 21198 Reconstruct lower jaw bone 21206 Reconstruct upper jaw bone 21208 Augmentation of facial bones 21209 Reduction of facial bones 21210 Face bone graft 21215 Lower jaw bone graft 21230 Rib cartilage graft 21240 Reconstruction of jaw joint 21242 Reconstruction of jaw joint 21243 Reconstruction of jaw joint 21244 Reconstruction of lower jaw 21245 Reconstruction of jaw 21246 Reconstruction of jaw 21248 Reconstruction of jaw 21249 Reconstruction of jaw 21260 Revise eye sockets 21261 Revise eye sockets 21263 Revise eye sockets 21267 Revise eye sockets 21270 Augmentation, cheek bone 21275 Revision, orbitofacial bones 21280 Revision of eyelid 21340 Treatment of nose fracture 21355 Treat cheek bone fracture 21406 Treat eye socket fracture 21407 Treat eye socket fracture 21453 Treat lower jaw fracture 21461 Treat lower jaw fracture 21462 Treat lower jaw fracture 21465 Treat lower jaw fracture 21470 Treat lower jaw fracture 21490 Repair dislocated jaw 30125 Removal of nose lesion 30150 Partial removal of nose 30160 Removal of nose 30400 Reconstruction of nose 30410 Reconstruction of nose 30420 Reconstruction of nose 30435 Revision of nose 30450 Revision of nose 30460 Revision of nose 30462 Revision of nose 30520 Repair of nasal septum 30540 Repair nasal defect 30545 Repair nasal defect 30580 Repair upper jaw fistula 30600 Repair mouth/nose fistula 30620 Intranasal reconstruction 31030 Exploration, maxillary sinus 31032 Explore sinus, remove polyps 31050 Exploration, sphenoid sinus 31051 Sphenoid sinus surgery 31075 Exploration of frontal sinus 31080 Removal of frontal sinus 31081 Removal of frontal sinus 31084 Removal of frontal sinus 31085 Removal of frontal sinus 31086 Removal of frontal sinus 31087 Removal of frontal sinus 31090 Exploration of sinuses 31200 Removal of ethmoid sinus 31201 Removal of ethmoid sinus 31205 Removal of ethmoid sinus 31300 Removal of larynx lesion 31320 Diagnostic incision, larynx 31375 Partial removal of larynx Start Printed Page 18755 31400 Revision of larynx 31420 Removal of epiglottis 31580 Revision of larynx 31586 Treat larynx fracture 31588 Revision of larynx 31590 Reinnervate larynx 31595 Larynx nerve surgery 31614 Repair windpipe opening 31750 Repair of windpipe 31755 Repair of windpipe 40700 Repair cleft lip/nasal 40701 Repair cleft lip/nasal 40702 Repair cleft lip/nasal 40720 Repair cleft lip/nasal 40761 Repair cleft lip/nasal 40844 Reconstruction of mouth 40845 Reconstruction of mouth 41120 Partial removal of tongue 42120 Remove palate/lesion 42182 Repair palate 42200 Reconstruct cleft palate 42205 Reconstruct cleft palate 42210 Reconstruct cleft palate 42215 Reconstruct cleft palate 42220 Reconstruct cleft palate 42225 Reconstruct cleft palate 42226 Lengthening of palate 42227 Lengthening of palate 42410 Excise parotid gland/lesion 42415 Excise parotid gland/lesion 42420 Excise parotid gland/lesion 42425 Excise parotid gland/lesion 42440 Excise submaxillary gland 42505 Repair salivary duct 42507 Parotid duct diversion 42508 Parotid duct diversion 42509 Parotid duct diversion 42510 Parotid duct diversion 42725 Drainage of throat abscess 42815 Excision of neck cyst 42844 Extensive surgery of throat 42890 Partial removal of pharynx 42892 Revision of pharyngeal walls 42962 Control throat bleeding 60500 Explore parathyroid glands 61330 Decompress eye socket 69310 Rebuild outer ear canal 69320 Rebuild outer ear canal 69450 Eardrum revision 69501 Mastoidectomy 69505 Remove mastoid structures 69511 Extensive mastoid surgery 69530 Extensive mastoid surgery 69550 Remove ear lesion 69552 Remove ear lesion 69601 Mastoid surgery revision 69602 Mastoid surgery revision 69603 Mastoid surgery revision 69604 Mastoid surgery revision 69605 Mastoid surgery revision 69631 Repair eardrum structures 69632 Rebuild eardrum structures 69633 Rebuild eardrum structures 69635 Repair eardrum structures 69636 Rebuild eardrum structures 69637 Rebuild eardrum structures 69641 Revise middle ear & mastoid 69642 Revise middle ear & mastoid 69643 Revise middle ear & mastoid 69644 Revise middle ear & mastoid 69645 Revise middle ear & mastoid 69646 Revise middle ear & mastoid 69660 Revise middle ear bone Start Printed Page 18756 69661 Revise middle ear bone 69662 Revise middle ear bone 69666 Repair middle ear structures 69667 Repair middle ear structures 69670 Remove mastoid air cells 69676 Remove middle ear nerve 69700 Close mastoid fistula 69711 Remove/repair hearing aid 69720 Release facial nerve 69725 Release facial nerve 69740 Repair facial nerve 69745 Repair facial nerve 69801 Incise inner ear 69802 Incise inner ear 69805 Explore inner ear 69806 Explore inner ear 69820 Establish inner ear window 69840 Revise inner ear window 69905 Remove inner ear 69910 Remove inner ear & mastoid 69915 Incise inner ear nerve 69955 Release facial nerve 69960 Release inner ear canal 0257 Implantation of Cochlear Device T 115.31 $5,591.04 $3,498.58 $1,118.21 69930 Implant cochlear device 0258 Tonsil and Adenoid Procedures T 18.62 $902.83 $462.81 $180.57 42820 Remove tonsils and adenoids 42821 Remove tonsils and adenoids 42825 Removal of tonsils 42826 Removal of tonsils 42830 Removal of adenoids 42831 Removal of adenoids 42835 Removal of adenoids 42836 Removal of adenoids 42860 Excision of tonsil tags 42870 Excision of lingual tonsil 0260 Level I Plain Film Except Teeth X 0.79 $38.30 $22.02 $7.66 70030 X-ray eye for foreign body 70100 X-ray exam of jaw 70110 X-ray exam of jaw 70120 X-ray exam of mastoids 70130 X-ray exam of mastoids 70140 X-ray exam of facial bones 70150 X-ray exam of facial bones 70160 X-ray exam of nasal bones 70190 X-ray exam of eye sockets 70200 X-ray exam of eye sockets 70210 X-ray exam of sinuses 70220 X-ray exam of sinuses 70240 X-ray exam, pituitary saddle 70250 X-ray exam of skull 70328 X-ray exam of jaw joint 70330 X-ray exam of jaw joints 70350 X-ray head for orthodontia 70355 Panoramic x-ray of jaws 70360 X-ray exam of neck 70380 X-ray exam of salivary gland 71010 Chest x-ray 71015 Chest x-ray 71020 Chest x-ray 71021 Chest x-ray 71022 Chest x-ray 71030 Chest x-ray 71035 Chest x-ray 71100 X-ray exam of ribs 71101 X-ray exam of ribs/chest 71110 X-ray exam of ribs 71120 X-ray exam of breastbone 71130 X-ray exam of breastbone 72020 X-ray exam of spine 72040 X-ray exam of neck spine 72069 X-ray exam of trunk spine 72070 X-ray exam of thoracic spine Start Printed Page 18757 72072 X-ray exam of thoracic spine 72074 X-ray exam of thoracic spine 72080 X-ray exam of trunk spine 72090 X-ray exam of trunk spine 72100 X-ray exam of lower spine 72120 X-ray exam of lower spine 72170 X-ray exam of pelvis 72190 X-ray exam of pelvis 72200 X-ray exam sacroiliac joints 72202 X-ray exam sacroiliac joints 72220 X-ray exam of tailbone 73000 X-ray exam of collar bone 73010 X-ray exam of shoulder blade 73020 X-ray exam of shoulder 73030 X-ray exam of shoulder 73050 X-ray exam of shoulders 73060 X-ray exam of humerus 73070 X-ray exam of elbow 73080 X-ray exam of elbow 73090 X-ray exam of forearm 73092 X-ray exam of arm, infant 73100 X-ray exam of wrist 73110 X-ray exam of wrist 73120 X-ray exam of hand 73130 X-ray exam of hand 73140 X-ray exam of finger(s) 73500 X-ray exam of hip 73510 X-ray exam of hip 73520 X-ray exam of hips 73540 X-ray exam of pelvis & hips 73550 X-ray exam of thigh 73560 X-ray exam of knee, 1 or 2 73562 X-ray exam of knee, 3 73564 X-ray exam, knee, 4 or more 73565 X-ray exam of knees 73590 X-ray exam of lower leg 73600 X-ray exam of ankle 73610 X-ray exam of ankle 73620 X-ray exam of foot 73630 X-ray exam of foot 73650 X-ray exam of heel 73660 X-ray exam of toe(s) 74000 X-ray exam of abdomen 74010 X-ray exam of abdomen 74020 X-ray exam of abdomen 74710 X-ray measurement of pelvis 76010 X-ray, nose to rectum 76040 X-rays, bone evaluation 76066 Joint(s) survey, single film 76098 X-ray exam, breast specimen 76150 X-ray exam, dry process 76499 Radiographic procedure 77417 Radiology port film(s) 0261 Level II Plain Film Except Teeth Including Bone Density Measurement X 1.38 $66.91 $38.77 $13.38 70134 X-ray exam of middle ear 70260 X-ray exam of skull 71111 X-ray exam of ribs/chest 72010 X-ray exam of spine 72050 X-ray exam of neck spine 72052 X-ray exam of neck spine 72110 X-ray exam of lower spine 72114 X-ray exam of lower spine 73530 X-ray exam of hip 73592 X-ray exam of leg, infant 74022 X-ray exam series, abdomen 76006 X-ray stress view 76020 X-rays for bone age 76061 X-rays, bone survey 76062 X-rays, bone survey 76065 X-rays, bone evaluation 76075 Dual energy x-ray study 76076 Dual energy x-ray study 76078 Photodensitometry Start Printed Page 18758 76100 X-ray exam of body section 76120 Cinematic x-rays 76125 Cinematic x-rays add-on 78350 Bone mineral, single photon G0130 Single energy x-ray study G0131 CT scan, bone density study G0132 CT scan, bone density study 0262 Plain Film of Teeth X 0.40 $19.39 $10.90 $3.88 70300 X-ray exam of teeth 70310 X-ray exam of teeth 70320 Full mouth x-ray of teeth 0263 Level I Miscellaneous Radiology Procedures X 1.68 $81.46 $45.88 $16.29 70170 X-ray exam of tear duct 70373 Contrast x-ray of larynx 70390 X-ray exam of salivary duct 71040 Contrast x-ray of bronchi 71060 Contrast x-ray of bronchi 74190 X-ray exam of peritoneum 74305 X-ray bile ducts/pancreas 76080 X-ray exam of fistula 76086 X-ray of mammary duct 76088 X-ray of mammary ducts 76096 X-ray of needle wire, breast 76101 Complex body section x-ray 0264 Level II Miscellaneous Radiology Procedures X 3.83 $185.71 $108.97 $37.14 74320 Contrast x-ray of bile ducts 74328 X-ray bile duct endoscopy 74329 X-ray for pancreas endoscopy 74330 X-ray bile/panc endoscopy 74350 X-ray guide, stomach tube 74355 X-ray guide, intestinal tube 74470 X-ray exam of kidney lesion 74740 X-ray, female genital tract 74742 X-ray, fallopian tube 75801 Lymph vessel x-ray, arm/leg 75803 Lymph vessel x-ray, arms/legs 75805 Lymph vessel x-ray, trunk 75807 Lymph vessel x-ray, trunk 75809 Nonvascular shunt, x-ray 75898 Follow-up angiogram 76095 Stereotactic breast biopsy 76102 Complex body section x-rays 0265 Level I Diagnostic Ultrasound Except Vascular S 1.17 $56.73 $38.08 $11.35 76513 Echo exam of eye, water bath 76529 Echo exam of eye 76536 Echo exam of head and neck 76645 Echo exam of breast(s) 76810 Echo exam of pregnant uterus 76815 Echo exam of pregnant uterus 76816 Echo exam follow-up/repeat 76857 Echo exam of pelvis 76970 Ultrasound exam follow-up 76977 Us bone density measure G0050 Residual urine by ultrasound 0266 Level II Diagnostic Ultrasound Except Vascular S 1.79 $86.79 $57.35 $17.36 76506 Echo exam of head 76511 Echo exam of eye 76512 Echo exam of eye 76516 Echo exam of eye 76519 Echo exam of eye 76604 Echo exam of chest 76700 Echo exam of abdomen 76705 Echo exam of abdomen 76770 Echo exam abdomen back wall 76775 Echo exam abdomen back wall 76778 Echo exam kidney transplant 76800 Echo exam spinal canal 76805 Echo exam of pregnant uterus 76818 Fetal biophysical profile 76830 Echo exam, transvaginal 76831 Echo exam, uterus 76856 Echo exam of pelvis 76870 Echo exam of scrotum Start Printed Page 18759 76872 Echo exam, transrectal 76873 Echograp trans r, pros study 76880 Echo exam of extremity 76885 Echo exam, infant hips 76886 Echo exam, infant hips 76975 GI endoscopic ultrasound 76986 Echo exam at surgery 76999 Echo examination procedure 0267 Vascular Ultrasound S 2.72 $131.88 $80.06 $26.38 93880 Extracranial study 93882 Extracranial study 93886 Intracranial study 93888 Intracranial study 93925 Lower extremity study 93926 Lower extremity study 93930 Upper extremity study 93931 Upper extremity study 93970 Extremity study 93971 Extremity study 93975 Vascular study 93976 Vascular study 93978 Vascular study 93979 Vascular study 93980 Penile vascular study 93981 Penile vascular study 93990 Doppler flow testing 0268 Guidance Under Ultrasound X 2.23 $108.13 $69.51 $21.63 76930 Echo guide for heart sac tap 76932 Echo guide for heart biopsy 76934 Echo guide for chest tap 76936 Echo guide for artery repair 76938 Echo exam for drainage 76941 Echo guide for transfusion 76942 Echo guide for biopsy 76945 Echo guide, villus sampling 76946 Echo guide for amniocentesis 76948 Echo guide, ova aspiration 76950 Echo guidance radiotherapy 76960 Echo guidance radiotherapy 76965 Echo guidance radiotherapy G0161 Echo guide for cryo probes 0269 Echocardiogram Except Transesophageal S 4.40 $213.34 $114.01 $42.67 76825 Echo exam of fetal heart 76826 Echo exam of fetal heart 76827 Echo exam of fetal heart 76828 Echo exam of fetal heart 93303 Echo transthoracic 93304 Echo transthoracic 93307 Echo exam of heart 93308 Echo exam of heart 93320 Doppler echo exam, heart 93321 Doppler echo exam, heart 93325 Doppler color flow add-on 93350 Echo transthoracic 0270 Transesophageal Echocardiogram S 5.55 $269.10 $150.26 $53.82 93312 Echo transesophageal 93313 Echo transesophageal 93315 Echo transesophageal 93316 Echo transesophageal 0271 Mammography S 0.70 $33.94 $19.50 $6.79 76090 Mammogram, one breast 76091 Mammogram, both breasts 0272 Level I Fluoroscopy X 1.40 $67.88 $39.00 $13.58 70371 Speech evaluation, complex 71023 Chest x-ray and fluoroscopy 71034 Chest x-ray and fluoroscopy 74340 X-ray guide for GI tube 76000 Fluoroscope examination 76003 Needle localization by x-ray 0273 Level II Fluoroscopy X 2.49 $120.73 $61.02 $24.15 70370 Throat x-ray & fluoroscopy 71036 X-ray guidance for biopsy 71090 X-ray & pacemaker insertion Start Printed Page 18760 75989 Abscess drainage under x-ray 76001 Fluoroscope exam, extensive 76005 Fluoroguide for spine inject 0274 Myelography S 4.83 $234.19 $128.12 $46.84 70010 Contrast x-ray of brain 70015 Contrast x-ray of brain 72240 Contrast x-ray of neck spine 72255 Contrast x-ray, thorax spine 72265 Contrast x-ray, lower spine 72270 Contrast x-ray of spine 72275 Epidurography 72285 X-ray c/t spine disk 72295 X-ray of lower spine disk 0275 Arthrography S 2.74 $132.85 $72.26 $26.57 70332 X-ray exam of jaw joint 73040 Contrast x-ray of shoulder 73085 Contrast x-ray of elbow 73115 Contrast x-ray of wrist 73525 Contrast x-ray of hip 73542 X-ray exam, sacroiliac joint 73580 Contrast x-ray of knee joint 73615 Contrast x-ray of ankle 0276 Level I Digestive Radiology S 1.79 $86.79 $49.78 $17.36 74210 Contrst x-ray exam of throat 74220 Contrast x-ray, esophagus 74230 Cinema x-ray, throat/esoph 74240 X-ray exam, upper gi tract 74241 X-ray exam, upper gi tract 74246 Contrst x-ray uppr gi tract 74247 Contrst x-ray uppr gi tract 74250 X-ray exam of small bowel 74270 Contrast x-ray exam of colon 74283 Contrast x-ray exam of colon 74290 Contrast x-ray, gallbladder 74291 Contrast x-rays, gallbladder 0277 Level II Digestive Radiology S 2.47 $119.76 $69.28 $23.95 74245 X-ray exam, upper gi tract 74249 Contrst x-ray uppr gi tract 74251 X-ray exam of small bowel 74260 X-ray exam of small bowel 74280 Contrast x-ray exam of colon 0278 Diagnostic Urography S 2.85 $138.19 $81.67 $27.64 74400 Contrst x-ray, urinary tract 74410 Contrst x-ray, urinary tract 74415 Contrst x-ray, urinary tract 74420 Contrst x-ray, urinary tract 74425 Contrst x-ray, urinary tract 74430 Contrast x-ray, bladder 74440 X-ray, male genital tract 74445 X-ray exam of penis 74450 X-ray, urethra/bladder 74455 X-ray, urethra/bladder 74775 X-ray exam of perineum 0279 Level I Diagnostic Angiography and Venography Except Extremity S 6.30 $305.47 $174.57 $61.09 75660 Artery x-rays, head & neck 75662 Artery x-rays, head & neck 75685 Artery x-rays, spine 75705 Artery x-rays, spine 75741 Artery x-rays, lung 75746 Artery x-rays, lung 75756 Artery x-rays, chest 75810 Vein x-ray, spleen/liver 75825 Vein x-ray, trunk 75827 Vein x-ray, chest 75831 Vein x-ray, kidney 75833 Vein x-ray, kidneys 75840 Vein x-ray, adrenal gland 75842 Vein x-ray, adrenal glands 75860 Vein x-ray, neck 75870 Vein x-ray, skull 75872 Vein x-ray, skull 75880 Vein x-ray, eye socket 75885 Vein x-ray, liver Start Printed Page 18761 75889 Vein x-ray, liver 75891 Vein x-ray, liver 0280 Level II Diagnostic Angiography and Venography Except Extremity S 14.98 $726.34 $380.12 $145.27 75600 Contrast x-ray exam of aorta 75605 Contrast x-ray exam of aorta 75625 Contrast x-ray exam of aorta 75630 X-ray aorta, leg arteries 75650 Artery x-rays, head & neck 75658 Artery x-rays, arm 75665 Artery x-rays, head & neck 75671 Artery x-rays, head & neck 75676 Artery x-rays, neck 75680 Artery x-rays, neck 75710 Artery x-rays, arm/leg 75716 Artery x-rays, arms/legs 75722 Artery x-rays, kidney 75724 Artery x-rays, kidneys 75726 Artery x-rays, abdomen 75731 Artery x-rays, adrenal gland 75733 Artery x-rays, adrenals 75736 Artery x-rays, pelvis 75743 Artery x-rays, lungs 75774 Artery x-ray, each vessel 75887 Vein x-ray, liver 0281 Venography of Extremity S 4.40 $213.34 $115.16 $42.67 75790 Visualize A-V shunt 75820 Vein x-ray, arm/leg 75822 Vein x-ray, arms/legs 0282 Level I Computerized Axial Tomography S 2.38 $115.40 $94.51 $23.08 70486 Cat scan of face/jaw 76370 CAT scan for therapy guide 76375 3d/holograph reconstr add-on 76380 CAT scan follow-up study 0283 Level II Computerized Axial Tomography S 4.89 $237.10 $179.39 $47.42 70450 CAT scan of head or brain 70460 Contrast CAT scan of head 70470 Contrast CAT scans of head 70480 CAT scan of skull 70481 Contrast CAT scan of skull 70482 Contrast CAT scans of skull 70487 Contrast CAT scan, face/jaw 70488 Contrast cat scans, face/jaw 70490 CAT scan of neck tissue 70491 Contrast CAT of neck tissue 70492 Contrast CAT of neck tissue 71250 Cat scan of chest 71260 Contrast CAT scan of chest 71270 Contrast CAT scans of chest 72125 CAT scan of neck spine 72126 Contrast CAT scan of neck 72127 Contrast CAT scans of neck 72128 CAT scan of thorax spine 72129 Contrast CAT scan of thorax 72130 Contrast CAT scans of thorax 72131 CAT scan of lower spine 72132 Contrast CAT of lower spine 72133 Contrst cat scans, low spine 72192 CAT scan of pelvis 72193 Contrast CAT scan of pelvis 72194 Contrast CAT scans of pelvis 73200 CAT scan of arm 73201 Contrast CAT scan of arm 73202 Contrast CAT scans of arm 73700 CAT scan of leg 73701 Contrast CAT scan of leg 73702 Contrast CAT scans of leg 74150 CAT scan of abdomen 74160 Contrast CAT scan of abdomen 74170 Contrast CAT scans, abdomen 76355 CAT scan for localization 76360 CAT scan for needle biopsy 76365 CAT scan for cyst aspiration 0284 Magnetic Resonance Imaging S 8.02 $388.87 $257.39 $77.77 Start Printed Page 18762 70336 Magnetic image, jaw joint 70540 Magnetic image, face/neck 70541 Magnetic image, head (MRA) 70551 Magnetic image, brain (MRI) 70552 Magnetic image, brain (MRI) 70553 Magnetic image, brain (mri) 71550 Magnetic image, chest (mri) 72141 Magnetic image, neck spine 72142 Magnetic image, neck spine 72146 Magnetic image, chest spine 72147 Magnetic image, chest spine 72148 Magnetic image, lumbar spine 72149 Magnetic image, lumbar spine 72156 Magnetic image, neck spine 72157 Magnetic image, chest spine 72158 Magnetic image, lumbar spine 72196 Magnetic image, pelvis 73220 Magnetic image, arm/hand 73221 Magnetic image, joint of arm 73720 Magnetic image, leg/foot 73721 Magnetic image, joint of leg 74181 Magnetic image/abdomen (mri) 75552 Magnetic image, myocardium 75553 Magnetic image, myocardium 75554 Cardiac MRI/function 75555 Cardiac MRI/limited study 76093 Magnetic image, breast 76094 Magnetic image, both breasts 76390 Mr spectroscopy 76400 Magnetic image, bone marrow 0285 Positron Emission Tomography (PET) S 15.06 $730.22 $415.21 $146.04 G0030 PET imaging prev PET single G0031 PET imaging prev PET multple G0032 PET follow SPECT 78464 singl G0033 PET follow SPECT 78464 mult G0034 PET follow SPECT 76865 singl G0035 PET follow SPECT 78465 mult G0036 PET follow cornry angio sing G0037 PET follow cornry angio mult G0038 PET follow myocard perf sing G0039 PET follow myocard perf mult G0040 PET follow stress echo singl G0041 PET follow stress echo mult G0042 PET follow ventriculogm sing G0043 PET follow ventriculogm mult G0044 PET following rest ECG singl G0045 PET following rest ECG mult G0046 PET follow stress ECG singl G0047 PET follow stress ECG mult 0286 Myocardial Scans S 7.28 $352.99 $200.04 $70.60 78460 Heart muscle blood, single 78461 Heart muscle blood, multiple 78464 Heart image (3d), single 78465 Heart image (3d), multiple 78472 Gated heart, planar, single 78473 Gated heart, multiple 78478 Heart wall motion add-on 78480 Heart function add-on 78481 Heart first pass, single 78483 Heart first pass, multiple 0290 Standard Non-Imaging Nuclear Medicine S 1.94 $94.06 $55.51 $18.81 78000 Thyroid, single uptake 78001 Thyroid, multiple uptakes 78003 Thyroid suppress/stimul 78010 Thyroid imaging 78011 Thyroid imaging with flow 78099 Endocrine nuclear procedure 78199 Blood/lymph nuclear exam 78270 Vit B-12 absorption exam 78271 Vit B-12 absorp exam, IF 78282 GI protein loss exam 78299 GI nuclear procedure 78399 Musculoskeletal nuclear exam Start Printed Page 18763 0291 Level I Diagnostic Nuclear Medicine Excluding Myocardial Scans S 3.15 $152.73 $93.14 $30.55 78006 Thyroid imaging with uptake 78007 Thyroid image, mult uptakes 78015 Thyroid met imaging 78102 Bone marrow imaging, ltd 78110 Plasma volume, single 78111 Plasma volume, multiple 78120 Red cell mass, single 78121 Red cell mass, multiple 78185 Spleen imaging 78190 Platelet survival, kinetics 78191 Platelet survival 78201 Liver imaging 78202 Liver imaging with flow 78215 Liver and spleen imaging 78216 Liver & spleen image/flow 78230 Salivary gland imaging 78231 Serial salivary imaging 78232 Salivary gland function exam 78258 Esophageal motility study 78261 Gastric mucosa imaging 78262 Gastroesophageal reflux exam 78272 Vit B-12 absorp, combined 78290 Meckel's divert exam 78300 Bone imaging, limited area 78445 Vascular flow imaging 78455 Venous thrombosis study 78456 Acute venous thrombus image 78457 Venous thrombosis imaging 78458 Ven thrombosis images, bilat 78580 Lung perfusion imaging 78591 Vent image, 1 breath, 1 proj 78599 Respiratory nuclear exam 78605 Brain imaging, complete 78610 Brain flow imaging only 78660 Nuclear exam of tear flow 78700 Kidney imaging, static 78701 Kidney imaging with flow 78715 Renal vascular flow exam 78725 Kidney function study 78730 Urinary bladder retention 78740 Ureteral reflux study 78760 Testicular imaging 78761 Testicular imaging/flow 78999 Nuclear diagnostic exam 0292 Level II Diagnostic Nuclear Medicine Excluding Myocardial Scans S 4.36 $211.40 $126.63 $42.28 78016 Thyroid met imaging/studies 78018 Thyroid met imaging, body 78020 Thyroid met uptake 78070 Parathyroid nuclear imaging 78075 Adrenal nuclear imaging 78103 Bone marrow imaging, mult 78104 Bone marrow imaging, body 78122 Blood volume 78130 Red cell survival study 78135 Red cell survival kinetics 78140 Red cell sequestration 78160 Plasma iron turnover 78162 Iron absorption exam 78170 Red cell iron utilization 78172 Total body iron estimation 78195 Lymph system imaging 78205 Liver imaging (3D) 78206 Liver image (3d) w/flow 78220 Liver function study 78223 Hepatobiliary imaging 78264 Gastric emptying study 78278 Acute GI blood loss imaging 78291 Leveen/shunt patency exam 78305 Bone imaging, multiple areas 78306 Bone imaging, whole body 78315 Bone imaging, 3 phase 78320 Bone imaging (3D) Start Printed Page 18764 78414 Non-imaging heart function 78428 Cardiac shunt imaging 78466 Heart infarct image 78468 Heart infarct image (ef) 78469 Heart infarct image (3D) 78499 Cardiovascular nuclear exam 78584 Lung V/Q image single breath 78585 Lung V/Q imaging 78586 Aerosol lung image, single 78587 Aerosol lung image, multiple 78588 Perfusion lung image 78593 Vent image, 1 proj, gas 78594 Vent image, mult proj, gas 78596 Lung differential function 78600 Brain imaging, ltd static 78601 Brain imaging, ltd w/flow 78606 Brain imaging, compl w/flow 78607 Brain imaging (3D) 78615 Cerebral blood flow imaging 78630 Cerebrospinal fluid scan 78635 CSF ventriculography 78645 CSF shunt evaluation 78647 Cerebrospinal fluid scan 78650 CSF leakage imaging 78699 Nervous system nuclear exam 78704 Imaging renogram 78707 Kidney flow/function image 78708 Kidney flow/function image 78709 Kidney flow/function image 78710 Kidney imaging (3D) 78799 Genitourinary nuclear exam 78800 Tumor imaging, limited area 78801 Tumor imaging, mult areas 78802 Tumor imaging, whole body 78803 Tumor imaging (3D) 78805 Abscess imaging, ltd area 78806 Abscess imaging, whole body 78807 Nuclear localization/abscess 0294 Level I Therapeutic Nuclear Medicine S 5.13 $248.74 $144.06 $49.75 79000 Init hyperthyroid therapy 79001 Repeat hyperthyroid therapy 79020 Thyroid ablation 79030 Thyroid ablation, carcinoma 79035 Thyroid metastatic therapy 79100 Hematopoetic nuclear therapy 79300 Interstitial nuclear therapy 79440 Nuclear joint therapy 79999 Nuclear medicine therapy 0295 Level II Therapeutic Nuclear Medicine S 19.85 $962.47 $609.17 $192.49 79200 Intracavitary nuclear trmt 79400 Nonhemato nuclear therapy 79420 Intravascular nuclear ther 0296 Level I Therapeutic Radiologic Procedures S 3.57 $173.10 $100.25 $34.62 74235 Remove esophagus obstruction 74327 X-ray bile stone removal 74360 X-ray guide, GI dilation 74485 X-ray guide, GU dilation 75984 X-ray control catheter change 78494 Heart image, spect 78496 Heart first pass add-on 0297 Level II Therapeutic Radiologic Procedures S 6.13 $297.23 $172.51 $59.45 74363 X-ray, bile duct dilation 74475 X-ray control, cath insert 74480 X-ray control, cath insert 75894 X-rays, transcath therapy 75896 X-rays, transcath therapy 75980 Contrast x-ray exam bile duct 75982 Contrast x-ray exam bile duct 0300 Level I Radiation Therapy S 1.98 $96.00 $47.72 $19.20 77401 Radiation treatment delivery 77402 Radiation treatment delivery 77403 Radiation treatment delivery 77404 Radiation treatment delivery Start Printed Page 18765 77406 Radiation treatment delivery 77407 Radiation treatment delivery 77408 Radiation treatment delivery 77409 Radiation treatment delivery 77414 Radiation treatment delivery 77789 Radioelement application 0301 Level II Radiation Therapy S 2.21 $107.16 $52.53 $21.43 77411 Radiation treatment delivery 77412 Radiation treatment delivery 77413 Radiation treatment delivery 77416 Radiation treatment delivery 77520 Proton beam delivery 77523 Proton beam delivery 77750 Infuse radioactive materials 0302 Level III Radiation Therapy S 8.21 $398.08 $216.55 $79.62 77470 Special radiation treatment G0173 Stereotactic, one session G0174 Stereotactic, mult session 0303 Treatment Device Construction X 2.83 $137.22 $69.28 $27.44 77332 Radiation treatment aid(s) 77333 Radiation treatment aid(s) 77334 Radiation treatment aid(s) 0304 Level I Therapeutic Radiation Treatment Preparation X 1.49 $72.25 $41.52 $14.45 77280 Set radiation therapy field 77300 Radiation therapy dose plan 77305 Radiation therapy dose plan 77310 Radiation therapy dose plan 77331 Special radiation dosimetry 0305 Level II Therapeutic Radiation Treatment Preparation X 4.06 $196.86 $97.50 $39.37 77285 Set radiation therapy field 77290 Set radiation therapy field 77315 Radiation therapy dose plan 77321 Radiation therapy port plan 77326 Radiation therapy dose plan 77327 Radiation therapy dose plan 77328 Radiation therapy dose plan 0310 Level III Therapeutic Radiation Treatment Preparation X 13.98 $677.85 $339.05 $135.57 77295 Set radiation therapy field 0311 Radiation Physics Services X 1.32 $64.00 $31.66 $12.80 77336 Radiation physics consult 77370 Radiation physics consult 77399 External radiation dosimetry 0312 Radioelement Applications S 4.09 $198.31 $109.65 $39.66 77761 Radioelement application 77762 Radioelement application 77763 Radioelement application 77776 Radioelement application 77777 Radioelement application 77778 Radioelement application 0313 Brachytherapy S 7.89 $382.56 $164.02 $76.51 77781 High intensity brachytherapy 77782 High intensity brachytherapy 77783 High intensity brachytherapy 77784 High intensity brachytherapy 77799 Radium/radioisotope therapy 0314 Hyperthermic Therapies S 5.88 $285.10 $150.95 $57.02 77600 Hyperthermia treatment 77605 Hyperthermia treatment 77610 Hyperthermia treatment 77615 Hyperthermia treatment 77620 Hyperthermia treatment 0320 Electroconvulsive Therapy S 3.68 $178.43 $80.06 $35.69 90870 Electroconvulsive therapy 90871 Electroconvulsive therapy 0321 Biofeedback and Other Training S 1.26 $61.09 $29.25 $12.22 90901 Biofeedback train, any meth 90911 Biofeedback peri/uro/rectal 0322 Brief Individual Psychotherapy S 1.32 $64.00 $14.22 $12.80 90804 Psytx, office, 20-30 min 90805 Psytx, off, 20-30 min w/e&m 90810 Intac psytx, off, 20-30 min 90811 Intac psytx, 20-30, w/e&m 90816 Psytx, hosp, 20-30 min Start Printed Page 18766 90817 Psytx, hosp, 20-30 min w/e&m 90823 Intac psytx, hosp, 20-30 min 90824 Intac psytx, hsp 20-30 w/e&m 90899 Psychiatric service/therapy 0323 Extended Individual Psychotherapy S 1.85 $89.70 $22.48 $17.94 90801 Psy dx interview 90802 Intac psy dx interview 90806 Psytx, off, 45-50 min 90807 Psytx, off, 45-50 min w/e&m 90808 Psytx, office, 75-80 min 90809 Psytx, off, 75-80, w/e&m 90812 Intac psytx, off, 45-50 min 90813 Intac psytx, 45-50 min w/e&m 90814 Intac psytx, off, 75-80 min 90815 Intac psytx, 75-80 w/e&m 90818 Psytx, hosp, 45-50 min 90819 Psytx, hosp, 45-50 min w/e&m 90821 Psytx, hosp, 75-80 min 90822 Psytx, hosp, 75-80 min w/e&m 90826 Intac psytx, hosp, 45-50 min 90827 Intac psytx, hsp 45-50 w/e&m 90828 Intac psytx, hosp, 75-80 min 90829 Intac psytx, hsp 75-80 w/e&m 90845 Psychoanalysis 90865 Narcosynthesis 90880 Hypnotherapy 0324 Family Psychotherapy S 1.87 $90.67 $20.19 $18.13 90846 Family psytx w/o patient 90847 Family psytx w/patient 0325 Group Psychotherapy S 1.55 $75.16 $19.96 $15.03 90849 Multiple family group psytx 90853 Group psychotherapy 90857 Intac group psytx 0330 Dental Procedures S 1.51 $73.22 $14.64 $14.64 D0150 Comprehensve oral evaluation D0240 Intraoral occlusal film D0250 Extraoral first film D0260 Extraoral ea additional film D0270 Dental bitewing single film D0272 Dental bitewings two films D0274 Dental bitewings four films D0460 Pulp vitality test D0501 Histopathologic examinations D0502 Other oral pathology procedu D0999 Unspecified diagnostic proce D1510 Space maintainer fxd unilat D1515 Fixed bilat space maintainer D1520 Remove unilat space maintain D1525 Remove bilat space maintain D1550 Recement space maintainer D2970 Temporary-fractured tooth D2999 Dental unspec restorative pr D3460 Endodontic endosseous implan D3999 Endodontic procedure D4260 Osseous surgery per quadrant D4263 Bone replce graft first site D4264 Bone replce graft each add D4270 Pedicle soft tissue graft pr D4271 Free soft tissue graft proc D4273 Subepithelial tissue graft D4355 Full mouth debridement D4381 Localized chemo delivery D5911 Facial moulage sectional D5912 Facial moulage complete D5983 Radiation applicator D5984 Radiation shield D5985 Radiation cone locator D5987 Commissure splint D6920 Dental connector bar D7110 Oral surgery single tooth D7120 Each add tooth extraction D7130 Tooth root removal D7210 Rem imp tooth w mucoper flp Start Printed Page 18767 D7220 Impact tooth remov soft tiss D7230 Impact tooth remov part bony D7240 Impact tooth remov comp bony D7241 Impact tooth rem bony w/comp D7250 Tooth root removal D7260 Oral antral fistula closure D7291 Transseptal fiberotomy D7940 Reshaping bone orthognathic D9630 Other drugs/medicaments D9930 Treatment of complications D9940 Dental occlusal guard D9950 Occlusion analysis D9951 Limited occlusal adjustment D9952 Complete occlusal adjustment 0340 Minor Ancillary Procedures X 1.04 $50.43 $12.85 $10.09 69200 Clear outer ear canal 69210 Remove impacted ear wax 0341 Immunology Tests X 0.13 $6.30 $3.67 $1.26 86485 Skin test, candida 86490 Coccidioidomycosis skin test 86510 Histoplasmosis skin test 86580 TB intradermal test 86585 TB tine test 86586 Skin test, unlisted 0342 Level I Pathology X 0.26 $12.61 $8.03 $2.52 85060 Blood smear interpretation 88160 Cytopath smear, other source 88199 Cytopathology procedure 88300 Surgical path, gross 88302 Tissue exam by pathologist 88311 Decalcify tissue 88313 Special stains 88319 Enzyme histochemistry 88321 Microslide consultation 88399 Surgical pathology procedure 0343 Level II Pathology X 0.45 $21.82 $12.16 $4.36 80500 Lab pathology consultation 80502 Lab pathology consultation 86077 Physician blood bank service 88104 Cytopathology, fluids 88106 Cytopathology, fluids 88107 Cytopathology, fluids 88108 Cytopath, concentrate tech 88125 Forensic cytopathology 88161 Cytopath smear, other source 88162 Cytopath smear, other source 88172 Evaluation of smear 88173 Interpretation of smear 88304 Tissue exam by pathologist 88305 Tissue exam by pathologist 88312 Special stains 88314 Histochemical stain 88318 Chemical histochemistry 88323 Microslide consultation 88325 Comprehensive review of data 88329 Pathology consult in surgery 88331 Pathology consult in surgery 88332 Pathology consult in surgery 88346 Immunofluorescent study 88362 Nerve teasing preparations 89399 Pathology lab procedure G0025 Collagen skin test kit 0344 Level III Pathology X 0.79 $38.30 $23.63 $7.66 85097 Bone marrow interpretation 86078 Physician blood bank service 86079 Physician blood bank service 88180 Cell marker study 88182 Cell marker study 88307 Tissue exam by pathologist 88309 Tissue exam by pathologist 88342 Immunocytochemistry 88347 Immunofluorescent study 88348 Electron microscopy Start Printed Page 18768 88349 Scanning electron microscopy 88355 Analysis, skeletal muscle 88356 Analysis, nerve 88358 Analysis, tumor 88365 Tissue hybridization 89350 Sputum specimen collection 89360 Collect sweat for test 2 0354 Administration of Influenza Vaccine X 0.13 $6.19 G0008 Admin influenza virus vac Q0034 Admin of influenza vaccine 0355 Level I Immunizations X 0.19 $9.21 $5.05 $1.84 90645 Hib vaccine, hboc, im 90646 Hib vaccine, prp-d, im 90647 Hib vaccine, prp-omp, im 90648 Hib vaccine, prp-t, im 90657 Flu vaccine, 6-35 mo, im 90658 Flu vaccine, 3 yrs, im 90659 Flu vaccine, whole, im 90660 Flu vaccine, nasal 90700 Dtap vaccine, im 90702 Dt vaccine, im 90704 Mumps vaccine, sc 90713 Poliovirus, ipv, sc 90716 Chicken pox vaccine, sc 90720 Dtp/hib vaccine, im 90721 Dtap/hib vaccine, im 90727 Plague vaccine, im 90732 Pneumococcal vaccine, adult 90749 Vaccine toxoid 0356 Level II Immunizations X 0.36 $17.46 $4.82 $3.49 90371 Hep b ig, im 90389 Tetanus ig, im 90396 Varicella-zoster ig, im 90476 Adenovirus vaccine, type 4 90477 Adenovirus vaccine, type 7 90585 Bcg vaccine, percut 90586 Bcg vaccine, intravesical 90632 Hep a vaccine, adult im 90633 Hep a vacc, ped/adol, 2 dose 90634 Hep a vacc, ped/adol, 3 dose 90680 Rotovirus vaccine, oral 90690 Typhoid vaccine, oral 90691 Typhoid vaccine, im 90692 Typhoid vaccine, h-p, sc/id 90693 Typhoid vaccine, akd, sc 90701 Dtp vaccine, im 90703 Tetanus vaccine, im 90707 Mmr vaccine, sc 90710 Mmrv vaccine, sc 90712 Oral poliovirus vaccine 90717 Yellow fever vaccine, sc 90718 Td vaccine, im 90744 Hep b vaccine, ped/adol, im 90746 Hep b vaccine, adult, im 90747 Hep b vaccine, ill pat, im 0357 Level III Immunizations X 1.85 $89.70 $38.31 $17.94 90287 Botulinum antitoxin 90296 Diphtheria antitoxin 90375 Rabies ig, im/sc 90376 Rabies ig, heat treated 90378 Rsv ig, im 90379 Rsv ig, iv 90384 Rh ig, full-dose, im 90385 Rh ig, minidose, im 90386 Rh ig, iv 90393 Vaccina ig, im 90581 Anthrax vaccine, sc 90636 Hep a/hep b vacc, adult im 90665 Lyme disease vaccine, im 90669 Pneumococcal vaccine, ped 90675 Rabies vaccine, im 90676 Rabies vaccine, id 90705 Measles vaccine, sc Start Printed Page 18769 90719 Diphtheria vaccine, im 90733 Meningococcal vaccine, sc 90735 Encephalitis vaccine, sc 0358 Level IV Immunizations X 6.98 $338.44 $126.74 $67.69 90706 Rubella vaccine, sc 90708 Measles-rubella vaccine, sc 90709 Rubella & mumps vaccine, sc 90725 Cholera vaccine, injectable 90748 Hep b/hib vaccine, im 0359 Injections X 0.96 $46.55 $9.31 $9.31 90782 Injection, sc/im 90783 Injection, ia 90784 Injection, iv 90788 Injection of antibiotic 90799 Ther/prophylactic/dx inject 0360 Level I Alimentary Tests X 1.38 $66.91 $34.75 $13.38 89105 Sample intestinal contents 89130 Sample stomach contents 89132 Sample stomach contents 89135 Sample stomach contents 89136 Sample stomach contents 89140 Sample stomach contents 91030 Acid perfusion of esophagus 91055 Gastric intubation for smear 91065 Breath hydrogen test 91100 Pass intestine bleeding tube 91105 Gastric intubation treatment 91299 Gastroenterology procedure 0361 Level II Alimentary Tests X 3.53 $171.16 $88.09 $34.23 89100 Sample intestinal contents 89141 Sample stomach contents 91000 Esophageal intubation 91010 Esophagus motility study 91011 Esophagus motility study 91012 Esophagus motility study 91020 Gastric motility 91032 Esophagus, acid reflux test 91033 Prolonged acid reflux test 91052 Gastric analysis test 91060 Gastric saline load test 95075 Ingestion challenge test 0362 Fitting of Vision Aids X 0.51 $24.73 $9.63 $4.95 92311 Contact lens fitting 92312 Contact lens fitting 92313 Contact lens fitting 92315 Prescription of contact lens 92316 Prescription of contact lens 92317 Prescription of contact lens 92325 Modification of contact lens 92326 Replacement of contact lens 92352 Special spectacles fitting 92353 Special spectacles fitting 92354 Special spectacles fitting 92355 Special spectacles fitting 92358 Eye prosthesis service 92371 Repair & adjust spectacles 0363 Otorhinolaryngologic Function Tests X 2.83 $137.22 $53.22 $27.44 92512 Nasal function studies 92516 Facial nerve function test 92520 Laryngeal function studies 92541 Spontaneous nystagmus test 92542 Positional nystagmus test 92543 Caloric vestibular test 92544 Optokinetic nystagmus test 92545 Oscillating tracking test 92546 Sinusoidal rotational test 92547 Supplemental electrical test 92548 Posturography 92584 Electrocochleography 92587 Evoked auditory test 92588 Evoked auditory test 0364 Level I Audiometry X 0.68 $32.97 $13.31 $6.59 92552 Pure tone audiometry, air Start Printed Page 18770 92553 Audiometry, air & bone 92555 Speech threshold audiometry 92556 Speech audiometry, complete 92567 Tympanometry 92599 ENT procedure/service 0365 Level II Audiometry X 1.47 $71.28 $22.48 $14.26 92557 Comprehensive hearing test 92561 Bekesy audiometry, diagnosis 92562 Loudness balance test 92563 Tone decay hearing test 92564 Sisi hearing test 92565 Stenger test, pure tone 92568 Acoustic reflex testing 92569 Acoustic reflex decay test 92571 Filtered speech hearing test 92572 Staggered spondaic word test 92573 Lombard test 92575 Sensorineural acuity test 92576 Synthetic sentence test 92577 Stenger test, speech 92579 Visual audiometry (vra) 92582 Conditioning play audiometry 92583 Select picture audiometry 92589 Auditory function test(s) 92596 Ear protector evaluation 0366 Electrocardiogram (ECG) X 0.38 $18.43 $15.60 $3.69 93005 Electrocardiogram, tracing 93041 Rhythm ECG, tracing Q0035 Cardiokymography 0367 Level I Pulmonary Test X 0.83 $40.24 $20.65 $8.05 94010 Breathing capacity test 94200 Lung function test (MBC/MVV) 94250 Expired gas collection 94375 Respiratory flow volume loop 94400 CO2 breathing response curve 94450 Hypoxia response curve 94680 Exhaled air analysis, o2 94690 Exhaled air analysis 94720 Monoxide diffusing capacity 94770 Exhaled carbon dioxide test 94799 Pulmonary service/procedure 0368 Level II Pulmonary Tests X 1.66 $80.49 $42.44 $16.10 94060 Evaluation of wheezing 94240 Residual lung capacity 94260 Thoracic gas volume 94350 Lung nitrogen washout curve 94360 Measure airflow resistance 94370 Breath airway closing volume 94620 Pulmonary stress test/simple 94681 Exhaled air analysis, o2/co2 94725 Membrane diffusion capacity 94750 Pulmonary compliance study 0369 Level III Pulmonary Tests X 2.34 $113.46 $58.50 $22.69 94014 Patient recorded spirometry 94015 Patient recorded spirometry 94016 Review patient spirometry 94070 Evaluation of wheezing 94621 Pulm stress test/complex 94772 Breath recording, infant 95070 Bronchial allergy tests 95071 Bronchial allergy tests 0370 Allergy Tests X 0.57 $27.64 $11.81 $5.53 95004 Allergy skin tests 95010 Sensitivity skin tests 95015 Sensitivity skin tests 95024 Allergy skin tests 95027 Skin end point titration 95028 Allergy skin tests 95044 Allergy patch tests 95052 Photo patch test 95056 Photosensitivity tests 95060 Eye allergy tests 95065 Nose allergy test Start Printed Page 18771 95078 Provocative testing 95180 Rapid desensitization 95199 Allergy immunology services 0371 Allergy Injections X 0.32 $15.52 $3.67 $3.10 95115 Immunotherapy, one injection 95117 Immunotherapy injections 95144 Antigen therapy services 95145 Antigen therapy services 95146 Antigen therapy services 95147 Antigen therapy services 95148 Antigen therapy services 95149 Antigen therapy services 95165 Antigen therapy services 95170 Antigen therapy services 0372 Therapeutic Phlebotomy X 0.43 $20.85 $10.09 $4.17 99195 Phlebotomy 0373 Neuropsychological Testing X 3.21 $155.64 $44.96 $31.13 96100 Psychological testing 96105 Assessment of aphasia 96110 Developmental test, lim 96111 Developmental test, extend 96115 Neurobehavior status exam 96117 Neuropsych test battery 0374 Monitoring Psychiatric Drugs X 1.17 $56.73 $13.08 $11.35 90862 Medication management M0064 Visit for drug monitoring 0600 Low Level Clinic Visits V 0.98 $47.52 $9.50 $9.50 99201 Office/outpatient visit, new 99202 Office/outpatient visit, new 99211 Office/outpatient visit, est 99212 Office/outpatient visit, est 99241 Office consultation 99242 Office consultation 99271 Confirmatory consultation 99272 Confirmatory consultation 0601 Mid Level Clinic Visits V 1.00 $48.49 $9.70 $9.70 92002 Eye exam, new patient 92012 Eye exam established pat 99203 Office/outpatient visit, new 99213 Office/outpatient visit, est 99243 Office consultation 99273 Confirmatory consultation G0101 CA screen; pelvic/breast exam 0602 High Level Clinic Visits V 1.66 $80.49 $16.29 $16.10 92004 Eye exam, new patient 92014 Eye exam & treatment 99204 Office/outpatient visit, new 99205 Office/outpatient visit, new 99214 Office/outpatient visit, est 99215 Office/outpatient visit, est 99244 Office consultation 99245 Office consultation 99274 Confirmatory consultation 99275 Confirmatory consultation 0603 Interdisciplinary Team Conference V 1.66 $80.49 $16.29 $16.10 G0175 Multidisciplinary team visit 0610 Low Level Emergency Visits V 1.34 $64.97 $20.65 $12.99 99281 Emergency dept visit 99282 Emergency dept visit 0611 Mid Level Emergency Visits V 2.11 $102.31 $36.47 $20.46 99283 Emergency dept visit 0612 High Level Emergency Visits V 3.19 $154.67 $54.14 $30.93 99284 Emergency dept visit 99285 Emergency dept visit 0620 Critical Care S 8.60 $416.99 $152.78 $83.40 99291 Critical care, first hour 3 0701 Strontium X $84.76 A9600 Strontium-89 chloride 3 0702 Samariam X $139.06 A9605 Samarium sm153 lexidronamm 3 0704 Satumomab Pendetide X $63.13 A4642 Satumomab pendetide per dose 3 0705 Tc99 Tetrofosmin X $71.08 Start Printed Page 18772 A9502 Technetium TC99M tetrofosmin 3 0725 Leucovorin Calcium X $1.07 J0640 Leucovorin calcium injection 3 0726 Dexrazoxane Hydrochloride X $18.81 J1190 Dexrazoxane HCl injection 3 0727 Injection, Etidronate Disodium X $9.31 J1436 Etidronate disodium inj 3 0728 Filgrastim (G-CSF) X $25.21 J1440 Filgrastim 300 mcg injection 3 0730 Pamidronate Disodium X $30.93 J2430 Pamidronate disodium/30 MG 3 0731 Sargramostim (GM-CSF) X $16.97 J2820 Sargramostim injection 3 0732 Mesna X $2.42 J9209 Mesna injection 3 0733 Epoetin Alpha X $1.75 Q0136 Non esrd epoetin alpha inj 3 0750 Dolasetron Mesylate 10 mg X $1.94 J1260 Dolasetron mesylate 3 0754 Metoclopramide HCL X $0.19 J2765 Metoclopramide hcl injection 3 0755 Thiethylperazine Maleate X $0.68 J3280 Thiethylperazine maleate inj 3 0761 Oral Substitute for IV Antiemtic X $0.10 Q0163 Diphenhydramine HCl 50mg Q0164 Prochlorperazine maleate 5mg Q0169 Promethazine HCl 12.5mg oral Q0171 Chlorpromazine HCl 10mg oral Q0173 Trimethobenzamide HCl 250mg Q0174 Thiethylperazine maleate10mg Q0175 Perphenazine 4mg oral Q0177 Hydroxyzine pamoate 25mg 3 0762 Dronabinol X $0.48 Q0167 Dronabinol 2.5mg oral 3 0763 Dolasetron Mesylate 100 mg Oral X $8.53 Q0180 Dolasetron mesylate oral 3 0764 Granisetron HCL, 100 mcg X $2.33 J1626 Granisetron HCl injection 3 0765 Granisetron HCL, 1mg Oral X $3.20 Q0166 Granisetron HCl 1 mg oral 3 0768 Ondansetron Hydrochloride per 1 mg Injection X $0.87 J2405 Ondansetron hcl injection 3 0769 Ondansetron Hydrochloride 8 mg oral X $2.62 Q0179 Ondansetron HCl 8mg oral 3 0800 Leuprolide Acetate per 3.75 mg X $68.56 J1950 Leuprolide acetate/3.75 MG 3 0801 Cyclophosphamide X $.19 J8530 Cyclophosphamide oral 25 MG 3 0802 Etoposide X $3.10 J8560 Etoposide oral 50 MG 3 0803 Melphalan X $0.19 J8600 Melphalan oral 2 MG 3 0807 Aldesleukin single use vial X $65.07 J9015 Aldesleukin/single use vial 3 0809 BCG (Intravesical) one vial X $19.78 J9031 Bcg live intravesical vac 3 0810 Goserelin Acetate Implant, per 3.6 mg X $59.74 J9202 Goserelin acetate implant 3 0811 Carboplatin 50 mg X $13.96 J9045 Carboplatin injection 3 0812 Carmustine 100 mg X $10.57 J9050 Carmus bischl nitro inj 3 0813 Cisplatin 10 mg X $4.56 J9060 Cisplatin 10 MG injeciton 3 0814 Asparaginase, 10,000 units X $8.34 J9020 Asparaginase injection 3 0815 Cyclophosphamide 100 mg X $0.48 J9070 Cyclophosphamide 100 MG inj 3 0816 Cyclophosphamide, Lyophilized 100 mg X $1.16 J9093 Cyclophosphamide lyophilized 3 0817 Cytrabine 100 mg X $0.68 J9100 Cytarabine hcl 100 MG inj 3 0818 Dactinomycin 0.5 mg X $1.75 Start Printed Page 18773 J9120 Dactinomycin actinomycin d 3 0819 Dacarbazine 100 mg X $1.26 J9130 Dacarbazine 10 MG inj 3 0820 Daunorubicin HCI 10 mg X $11.64 J9150 Daunorubicin 3 0821 Daunorubicin Citrate, Liposomal Formulation, 10 mg X $7.76 J9151 Daunorubicin citrate liposom 3 0822 Diethylstibestrol Diphosphate 250 mg X $2.13 J9165 Diethylstilbestrol injection 3 0823 Docetaxel 20 mg X $34.72 J9170 Docetaxel 3 0824 Etoposide 10 mg X $.58 J9181 Etoposide 10 MG inj 3 0826 Methotrexate Oral 2.5 mg X $.29 J8610 Methotrexate oral 2.5 MG 3 0827 Floxuridine 500 mg X $18.81 J9200 Floxuridine injection 3 0828 Gemcitabine HCL 200 mg X $9.31 J9201 Gemcitabine HCl 3 0830 Irinotecan 20 mg X $14.16 J9206 Irinotecan injection 3 0831 Ifosfamide per 1 gram X $13.58 J9208 Ifosfomide injection 3 0832 Idarubicin Hydrochloride 5 mg X $46.45 J9211 Idarubicin hcl injeciton 3 0833 Interferon Alfacon-1, Recombinant, 1 mcg X $0.19 J9212 Interferon alfacon-1 3 0834 Interferon, Alfa-2A, Recombinant 3 million units X $3.20 J9213 Interferon alfa-2a inj 3 0836 Interferon, Alfa-2B, Recombinant, 1 million units X $1.36 J9214 Interferon alfa-2b inj 3 0838 Interferon, Gamma 1-B, 3 million units X $22.79 J9216 Interferon gamma 1-b inj 3 0839 Mechlorethamine HCI 10 mg X $1.65 J9230 Mechlorethamine hcl inj 3 0840 Melphalan HCI 50 mg X $44.71 J9245 Inj melphalan hydrochl 50 MG 3 0841 Methotrexate Sodium 5 mg X $.10 J9250 Methotrexate sodium inj 3 0842 Fludarabine Phosphate 50 mg X $30.84 J9185 Fludarabine phosphate inj 3 0843 Pegaspargase per single dose vial X $178.72 J9266 Pegaspargase/singl dose vial 3 0844 Pentostatin 10 mg X $133.73 J9268 Pentostatin injection 3 0847 Doxorubicin HCL 10 mg X $2.81 J9000 Doxorubic hcl 10 MG vl chemo 3 0849 Rituximab, 100 mg X $51.40 J9310 Rituximab cancer treatment 3 0850 Streptozocin 1 gm X $14.64 J9320 Streptozocin injection 3 0851 Thiotepa 15 mg X $9.50 J9340 Thiotepa injection 3 0852 Topotecan 4 mg X $73.22 J9350 Topotecan 3 0853 Vinblastine Sulfate 1 mg X $.39 J9360 Vinblastine sulfate inj 3 0854 Vincristine Sulfate 1 mg X $2.23 J9370 Vincristine sulfate 1 MG inj 3 0855 Vinorelbine Tartrate per 10 mg X $9.60 J9390 Vinorelbine tartrate/10 mg 3 0856 Porfimer Sodium 75 mg X $34.62 J9600 Porfimer sodium 3 0857 Bleomycin Sulfate 15 units X $48.29 J9040 Bleomycin sulfate injection 3 0858 Cladribine, 1mg X $8.24 J9065 Inj cladribine per 1 MG 3 0859 Fluorouracil X $0.19 J9190 Fluorouracil injection 3 0860 Plicamycin 2.5 mg X $1.36 J9270 Plicamycin (mithramycin) inj 3 0861 Leuprolide Acetate 1 mg X $19.39 J9218 Leuprolide acetate injeciton Start Printed Page 18774 3 0862 Mitomycin, 5mg X $19.88 J9280 Mitomycin 5 MG inj 3 0863 Paclitaxel, 30mg X $30.16 J9265 Paclitaxel injection 3 0864 Mitoxantrone HCl, per 5mg X $25.80 J9293 Mitoxantrone hydrochl/5 MG 3 0865 Interferon alfa-N3, 250,000 IU X $1.07 J9215 Interferon alfa-n3 inj 3 0884 Rho (D) Immune Globulin, Human one dose pack X $3.78 J2790 Rho d immune globulin inj 2 0886 Azathioprine, 50 mg oral X 0.02 $.97 $0.19 J7500 Azathioprine oral 50mg 2 0887 Azathioprine, Parenteral 100 mg, 20 ml each injection X 1.40 $67.88 $13.58 J7501 Azathioprine parenteral 2 0888 Cyclosporine, Oral 100 mg X 0.08 $3.88 $0.78 J7502 Cyclosporine oral 100 mg 2 0889 Cyclosporine, Parenteral X 0.36 $17.46 $3.49 J7516 Cyclosporin parenteral 250mg 2 0890 Lymphocyte Immune Globulin 50 mg/ml, 5 ml each X 3.79 $183.77 $36.75 J7504 Lymphocyte immune globulin 2 0891 Tacrolimus per 1 mg oral X 3.15 $152.73 $30.55 J7507 Tacrolimus oral per 1 MG 3 0892 Daclizumab, Parenteral, 25 mg X $54.11 J7913 Daclizumab, Parenteral, 25 m 3 0900 Injection, Alglucerase per 10 units X $5.14 J0205 Alglucerase injection 3 0901 Alpha I, Proteinase Inhibitor, Human per 10mg X $15.22 J0256 Alpha 1 proteinase inhibitor 3 0902 Botulinum Toxin, Type A per unit X $56.05 J0585 Botulinum toxin a per unit 3 0903 CMV Immune Globulin X $54.11 J0850 Cytomegalovirus imm IV/vial 3 0905 Immune Globulin per 500 mg X $6.40 J1561 Immune globulin 500 mg 3 0906 RSV Immune Globulin X $85.53 J1565 RSV-ivig 2 0907 Ganciclovir Sodium 500 mg injection X 0.51 $24.73 $4.95 J1570 Ganciclovir sodium injection 2 0908 Tetanus Immune Globulin, Human, up to 250 units X 0.90 $43.64 $8.73 J1670 Tetanus immune globulin inj 3 0909 Interferon Beta-1a 33 mcg X $28.70 J1825 Interferon beta-1a 3 0910 Interferon Beta-1b 0.25 mg X $8.44 J1830 Interferon beta-1b/.25 MG 2 0911 Streptokinase per 250,000 iu X 1.64 $79.69 $15.94 J2995 Inj streptokinase/250000 IU 3 0913 Ganciclovir 4.5 mg, Implant X $701.51 J7310 Ganciclovir long act implant 2 0914 Reteplase, 37.6 mg (Two Single Use Vials) X 38.20 $1,852.21 $370.44 J2994 Reteplase double bolus 2 0915 Alteplase recombinant, 10mg X 5.85 $283.70 $56.74 J2996 Alteplase recombinant inj 3 0916 Imiglucerase per unit X $0.58 J1785 Injection imiglucerase/unit 2 0917 Dipyridamole, 10 mg/Adenosine 6MG X 0.36 $17.46 $3.49 J0150 Injection adenosine 6 MG J1245 Dipyridamole injection 3 0918 Brachytherapy Seeds, Any type, Each S $9.99 Q3001 Brachytherapy Seeds 3 0925 Factor VIII (Antihemophilic Factor, Human) per iu X $0.19 J7190 Factor viii 3 0926 Factor VIII (Antihemophilic Factor, Porcine) per iu X $0.19 J7191 Factor VIII (porcine) 3 0927 Factor VIII (Antihemophilic Factor, Recombinant) per iu X $0.19 J7192 Factor viii recombinant 3 0928 Factor IX, Complex X $0.08 J7194 Factor ix complex 3 0929 Other Hemophilia Clotting Factors per iu X $0.27 J7198 Anti-inhibitor Q0187 Factor viia recombinant 3 0930 Antithrombin III (Human) per iu X $0.19 J7197 Antithrombin iii injection 3 0931 Factor IX (Antihemophilic Factor, Purified, Non-Recombinant) X $0.04 Start Printed Page 18775 Q0160 Factor IX non-recombinant 3 0932 Factor IX (Antihemophilic Factor, Recombinant) X $0.10 Q0161 Factor IX recombinant 2 0949 Plasma, Pooled Multiple Donor, Solvent/Detergent Treated, Frozen S 3.49 $169.22 $33.84 P9023 Frozen plasma, pooled, sd 2 0950 Blood (Whole) For Transfusion S 2.08 $101.02 $20.20 P9010 Whole blood for transfusion 2 0952 Cryoprecipitate S 0.70 $33.92 $6.78 P9012 Cryoprecipitate each unit 2 0953 Fibrinogen Unit S 0.48 $23.27 $4.65 P9013 Unit/s blood fibrinogen 2 0954 Leukocyte Poor Blood S 2.83 $137.21 $27.44 P9016 Leukocyte poor blood, unit 2 0955 Plasma, Fresh Frozen S 2.26 $109.35 $21.87 P9017 One donor fresh frozn plasma 2 0956 Plasma Protein Fraction S 1.26 $61.09 $12.22 P9018 Plasma protein fract, unit 2 0957 Platelet Concentrate S 0.98 $47.46 $9.49 P9019 Platelet concentrate unit 2 0958 Platelet Rich Plasma S 1.16 $56.25 $11.25 P9020 Platelet rich plasma unit 2 0959 Red Blood Cells S 2.04 $99.04 $19.81 P9021 Red blood cells unit 2 0960 Washed Red Blood Cells S 3.81 $184.53 $36.91 P9022 Washed red blood cells unit 2 0961 Infusion, Albumin (Human) 5%, 500 ml X 2.77 $134.31 $26.86 Q0156 Human albumin 5% 2 0962 Infusion, Albumin (Human) 25%, 50 ml X 1.38 $66.91 $13.38 Q0157 Human albumin 25% 2 0970 New Technology - Level I ($0-$50) T 0.52 $25.21 $5.04 78268 Breath test analysis, c-14 2 0971 New Technology - Level II ($50-$100) S 1.55 $75.16 $15.03 78267 Breath tst attain/anal c-14 2 0972 New Technology - Level III ($100-$200) T 3.09 $149.83 $29.97 G0166 Extrnl counterpulse, per tx 2 0980 New Technology - Level XI ($1750-$2000) S 38.67 $1,875.00 $375.00 53850 Prostatic microwave thermotx 53852 Prostatic rf thermotx G0125 Lung image (PET) G0126 Lung image (PET) staging G0163 Pet for rec of colorectal ca G0164 Pet for lymphoma staging G0165 Pet, rec of melanoma/met ca 3 7000 Amifostine, 500 mg X $41.99 J0207 Amifostine 3 7001 Amphotericin B lipid complex, 50 mg, Inj X $12.12 J0286 Amphotericin B lipid complex 3 7002 Clonidine, HCl, 1 MG X $4.17 J0735 Clonidine hydrochloride 3 7003 Epoprostenol, 0.5 MG, inj X $2.23 J1325 Epoprostenol injection 3 7004 Immune globulin intravenous human 5g, inj X $45.48 J1562 Immune globulin 5 gms 3 7005 Gonadorelin hcI, 100 mcg X $9.12 J1620 Gonadorelin hydroch/100 mcg 2 7007 Milrinone lacetate, per 5 ml, inj X 0.47 $22.79 $4.56 J2260 Inj milrinone lactate/5 ML 3 7010 Morphine sulfate concentrate (preservative free) per 10 mg X $.68 J2275 Morphine sulfate injection 3 7011 Oprelevekin, inj, 5 mg X $30.35 J2355 Oprelvekin injection 3 7012 Pentamidine isethionate, 300 mg X $8.73 J2545 Pentamidine isethionte/300mg 3 7014 Fentanyl citrate, inj, up to 2 ml X $.19 J3010 Fentanyl citrate injeciton 3 7015 Busulfan, oral 2 mg X $0.19 J8510 Oral busulfan 3 7019 Aprotinin, 10,000 kiu X $2.42 Q2003 Aprotinin, 10,000 kiu 3 7021 Baclofen, intrathecal, 50 mcg X $0.10 J0476 Baclofen intrathecal trial 3 7022 Elliotts B Solution, per ml X $19.20 Q2002 Elliot's B solution Start Printed Page 18776 3 7023 Treatment for bladder calculi, I.e. Renacidin per 500 ml X $4.46 Q2004 Treatment for bladder calcul 3 7024 Corticorelin ovine triflutate, 0.1 mg X $45.77 Q2005 Corticorelin ovine triflutat 3 7025 Digoxin immune FAB (Ovine), 10 mg X $14.06 Q2006 Digoxin immune FAB (Ovine), 3 7026 Ethanolamine oleate, 1000 ml X $2.13 Q2007 Ethanolamine oleate, 1000 ml 3 7027 Fomepizole, 1.5 G X $141.29 Q2008 Fomepizole, 1.5 G 3 7028 Fosphenytoin, 50 mg X $0.78 Q2009 Fosphenytoin, 50 mg 3 7029 Glatiramer acetate, 25 mg X $3.59 Q2010 Glatiramer acetate, 25 mgeny 3 7030 Hemin, 1 mg X $0.10 Q2011 Hemin, 1 mg 3 7031 Octreotide Acetate, 500 mcg X $5.43 J2352 Octreotide acetate injection 3 7032 Sermorelin acetate, 0.5 mg X $53.34 Q2014 Sermorelin acetate, 0.5 mg 3 7033 Somatrem, 5 mg X $28.03 Q2015 Somatrem, 5 mg 3 7034 Somatropin, 1 mg X $5.04 Q2016 Somatropin, 1 mg 3 7035 Teniposide, 50 mg X $20.85 Q2017 Teniposide, 50 mg 2 7036 Urokinase, inj, IV, 250,000 I.U. X 0.73 $35.40 $7.08 J3365 Urokinase 250,000 IU inj 3 7037 Urofollitropin, 75 I.U. X $8.24 Q2018 Urofollitropin, 75 I.U. 3 7038 Muromonab-CD3, 5 mg X $89.60 J7505 Monoclonal antibodies 3 7039 Pegademase bovine inj 25 I.U. X $1.16 Q2012 Pegademase bovine inj 25 I.U 3 7040 Pentastarch 10% inj, 100 ml X $2.04 Q2013 Pentastarch 10% inj, 100 ml 2 7041 Tirofiban HCL, 0.5 mg X 0.02 $.97 $0.19 J3245 Tirofiban hydrochloride 3 7042 Capecitabine, oral 150 mg X $0.19 J8520 Capecitabine, oral, 150 mg 3 7043 Infliximab, 10 MG X $6.89 J1745 Infliximab injection 3 7045 Trimetrexate Glucoronate X $8.15 J3305 Inj trimetrexate glucoronate 3 7046 Doxorubicin Hcl Liposome X $39.18 J9001 Doxorubicin hcl liposome inj —————————— CPT codes and descriptions only are copyright American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Copyright American Dental Association. All rights reserved.Addendum D.—1996 HCPC Codes Used To Calculate Pay
CPT/HCPCS Termination Date 00420 12/31/1999 01000 12/31/1999 01110 12/31/1999 01240 12/31/1999 01300 12/31/1999 01460 12/31/1999 01600 12/31/1999 01700 12/31/1999 01800 12/31/1999 01900 12/31/1999 01902 12/31/1999 11050 12/31/1997 11051 12/31/1997 11052 12/31/1997 11700 12/31/1996 11701 12/31/1996 11710 12/31/1996 11711 12/31/1996 11731 12/31/1998 13300 12/31/1999 15580 12/31/1999 15625 12/31/1999 15755 12/31/1996 16040 12/31/1998 16041 12/31/1998 16042 12/31/1998 17001 12/31/1997 17002 12/31/1997 17010 12/31/1997 17100 12/31/1997 17101 12/31/1997 17102 12/31/1997 17104 12/31/1997 17105 12/31/1997 17200 12/31/1997 17201 12/31/1997 20960 12/31/1996 20971 12/31/1996 25330 12/31/1996 25331 12/31/1996 26552 12/31/1996 26557 12/31/1996 26558 12/31/1996 26559 12/31/1996 32001 12/31/1999 33242 12/31/1999 33247 12/31/1999 42880 12/31/1996 Start Printed Page 18777 53640 12/31/1996 56300 12/31/1999 56301 12/31/1999 56302 12/31/1999 56303 12/31/1999 56304 12/31/1999 56305 12/31/1999 56306 12/31/1999 56307 12/31/1999 56308 12/31/1999 56309 12/31/1999 56310 12/31/1999 56311 12/31/1999 56312 12/31/1999 56313 12/31/1999 56314 12/31/1999 56315 12/31/1999 56316 12/31/1999 56317 12/31/1999 56318 12/31/1999 56320 12/31/1999 56321 12/31/1999 56322 12/31/1999 56323 12/31/1999 56324 12/31/1999 56340 12/31/1999 56341 12/31/1999 56342 12/31/1999 56343 12/31/1999 56344 12/31/1999 56345 12/31/1999 56346 12/31/1999 56347 12/31/1999 56348 12/31/1999 56349 12/31/1999 56350 12/31/1999 56351 12/31/1999 56352 12/31/1999 56353 12/31/1999 56354 12/31/1999 56355 12/31/1999 56356 12/31/1999 56360 12/31/1996 56361 12/31/1996 56362 12/31/1999 56363 12/31/1999 56399 12/31/1999 57108 12/31/1998 61106 12/31/1998 61130 12/31/1998 61712 12/31/1998 61855 12/31/1999 61865 12/31/1999 62274 12/31/1999 62275 12/31/1999 62276 12/31/1999 62277 12/31/1999 62278 12/31/1999 62279 12/31/1999 62288 12/31/1999 62289 12/31/1999 62298 12/31/1999 63690 12/31/1998 63691 12/31/1998 64440 12/31/1999 64441 12/31/1999 64442 12/31/1999 64443 12/31/1999 64830 12/31/1998 68800 12/31/1996 68820 12/31/1996 68825 12/31/1996 68830 12/31/1996 71038 12/31/1998 74405 12/31/1998 77380 12/31/1999 77381 12/31/1999 77419 12/31/1999 77420 12/31/1999 77425 12/31/1999 77430 12/31/1999 78017 12/31/1998 78726 12/31/1997 78727 12/31/1997 80002 12/31/1997 80003 12/31/1997 80004 12/31/1997 80005 12/31/1997 80006 12/31/1997 80007 12/31/1997 80008 12/31/1997 80009 12/31/1997 80010 12/31/1997 80011 12/31/1997 80012 12/31/1997 80016 12/31/1997 80018 12/31/1997 80019 12/31/1997 80049 12/31/1999 80054 12/31/1999 80058 12/31/1999 80059 12/31/1999 80091 12/31/1999 80092 12/31/1999 82130 12/31/1998 82250 12/31/1998 83019 12/31/1998 83717 12/31/1998 85029 12/31/1998 85030 12/31/1998 86287 12/31/1997 86289 12/31/1997 86290 12/31/1997 86291 12/31/1997 86293 12/31/1997 86295 12/31/1997 86296 12/31/1997 86299 12/31/1997 86302 12/31/1997 86303 12/31/1997 86306 12/31/1997 86311 12/31/1997 86313 12/31/1997 86315 12/31/1997 86588 12/31/1999 87178 12/31/1997 87179 12/31/1997 88151 12/31/1997 88156 12/31/1998 88157 12/31/1997 88158 12/31/1998 88250 12/31/1998 88260 12/31/1998 90592 12/31/1999 90711 12/31/1998 90714 12/31/1998 90724 12/31/1998 90726 12/31/1998 90728 12/31/1998 90730 12/31/1998 90737 12/31/1998 90741 12/31/1998 90742 12/31/1998 90745 12/31/1999 90820 12/31/1997 90825 12/31/1997 90835 12/31/1997 90841 12/31/1997 90842 12/31/1997 90843 12/31/1997 90844 12/31/1997 90855 12/31/1997 90900 12/31/1996 90902 12/31/1996 90904 12/31/1996 90906 12/31/1996 90908 12/31/1996 90910 12/31/1996 90915 12/31/1996 93201 12/31/1996 93202 12/31/1996 93204 12/31/1996 93205 12/31/1996 93208 12/31/1996 93209 12/31/1996 93210 12/31/1996 93220 12/31/1996 93221 12/31/1996 93222 12/31/1996 94160 12/31/1996 97122 12/31/1998 97250 12/31/1998 97260 12/31/1998 97261 12/31/1998 97265 12/31/1998 97500 12/31/1996 97501 12/31/1996 97521 12/31/1996 99351 12/31/1997 99352 12/31/1997 99353 12/31/1997 99376 12/31/1997 A2000 12/31/1997 A4190 12/31/1996 A4200 12/31/1996 A4202 12/31/1996 A4203 12/31/1996 A4204 12/31/1996 A4205 12/31/1996 A4363 12/31/1999 A4581 12/31/1996 A4610 12/31/1996 D0471 12/31/1999 D2210 12/31/1999 D2810 12/31/1999 D3960 12/31/1999 D4250 12/31/1999 D7470 12/31/1999 Start Printed Page 18778 D7942 12/31/1999 D9240 12/31/1999 E0237 12/31/1996 E0452 12/31/1999 E0453 12/31/1999 E1350 12/31/1996 E1400 12/31/1999 E1401 12/31/1999 E1402 12/31/1999 E1403 12/31/1999 E1404 12/31/1999 G0051 12/31/1997 G0052 12/31/1997 G0053 12/31/1997 G0054 09/30/1996 G0055 09/30/1996 G0056 09/30/1996 G0057 09/30/1996 G0058 12/31/1997 G0059 12/31/1997 G0060 12/31/1997 G0061 12/31/1996 G0062 12/31/1997 G0063 12/31/1997 G0064 12/31/1997 G0065 12/31/1997 G0066 12/31/1997 G0071 12/31/1997 G0072 12/31/1997 G0073 12/31/1997 G0074 12/31/1997 G0075 12/31/1997 G0076 12/31/1997 G0077 12/31/1997 G0078 12/31/1997 G0079 12/31/1997 G0080 12/31/1997 G0081 12/31/1997 G0082 12/31/1997 G0083 12/31/1997 G0084 12/31/1997 G0085 12/31/1997 G0086 12/31/1997 G0087 12/31/1997 G0088 12/31/1997 G0089 12/31/1997 G0090 12/31/1997 G0091 12/31/1997 G0092 12/31/1997 G0093 12/31/1997 G0094 12/31/1997 G0095 12/31/1997 G0096 12/31/1997 G0097 12/31/1997 G0098 12/31/1997 G0100 12/31/1997 G0133 12/31/1998 H5300 12/31/1997 J1625 12/31/1997 J1760 12/31/1999 J1770 12/31/1999 J1780 12/31/1999 J2050 12/31/1996 J3005 12/31/1997 J7140 12/31/1996 J7150 12/31/1996 J7196 12/31/1999 J7503 12/31/1999 J9010 12/31/1996 K0109 09/30/1999 K0110 12/31/1996 K0111 12/31/1996 K0119 12/31/1999 K0120 12/31/1999 K0121 12/31/1999 K0122 12/31/1999 K0123 12/31/1999 K0124 12/31/1996 K0125 12/31/1996 K0126 12/31/1996 K0127 12/31/1996 K0128 12/31/1996 K0129 12/31/1996 K0130 12/31/1996 K0137 12/31/1999 K0138 12/31/1999 K0139 12/31/1999 K0140 03/31/1997 K0141 03/31/1997 K0142 03/31/1997 K0143 03/31/1997 K0144 03/31/1997 K0145 03/31/1997 K0146 03/31/1997 K0152 12/31/1996 K0154 12/31/1996 K0163 12/31/1996 K0168 12/31/1999 K0169 12/31/1999 K0170 12/31/1999 K0171 12/31/1999 K0172 12/31/1999 K0173 12/31/1999 K0174 12/31/1999 K0175 12/31/1999 K0176 12/31/1999 K0177 12/31/1999 K0178 12/31/1999 K0179 12/31/1999 K0180 12/31/1999 K0181 12/31/1999 K0190 12/31/1999 K0191 12/31/1999 K0192 12/31/1999 K0193 09/30/1999 K0194 09/30/1999 K0196 12/31/1996 K0197 12/31/1996 K0198 12/31/1996 K0199 12/31/1996 K0203 12/31/1996 K0204 12/31/1996 K0205 12/31/1996 K0206 12/31/1996 K0207 12/31/1996 K0208 12/31/1996 K0209 12/31/1996 K0210 12/31/1996 K0211 12/31/1996 K0212 12/31/1996 K0213 12/31/1996 K0214 12/31/1996 K0215 12/31/1996 K0216 12/31/1996 K0217 12/31/1996 K0218 12/31/1996 K0219 12/31/1996 K0220 12/31/1996 K0221 12/31/1996 K0222 12/31/1996 K0223 12/31/1996 K0224 12/31/1996 K0228 12/31/1996 K0229 12/31/1996 K0230 12/31/1996 K0234 12/31/1996 K0235 12/31/1996 K0236 12/31/1996 K0237 12/31/1996 K0238 12/31/1996 K0239 12/31/1996 K0240 12/31/1996 K0241 12/31/1996 K0242 12/31/1996 K0243 12/31/1996 K0244 12/31/1996 K0245 12/31/1996 K0246 12/31/1996 K0247 12/31/1996 K0248 12/31/1996 K0249 12/31/1996 K0250 12/31/1996 K0251 12/31/1996 K0252 12/31/1996 K0253 12/31/1996 K0254 12/31/1996 K0255 12/31/1996 K0256 12/31/1996 K0257 12/31/1996 K0258 12/31/1996 K0259 12/31/1996 K0260 12/31/1996 K0261 12/31/1996 K0262 12/31/1996 K0263 12/31/1996 K0264 12/31/1996 K0265 12/31/1996 K0266 12/31/1996 K0271 06/30/1996 K0272 06/30/1996 K0273 06/30/1996 K0274 06/30/1996 K0275 06/30/1996 K0276 06/30/1996 K0277 12/31/1999 K0278 12/31/1999 K0279 12/31/1999 K0284 12/31/1999 K0285 12/31/1996 K0400 12/31/1999 K0401 12/31/1999 K0402 12/31/1996 K0403 12/31/1996 K0404 12/31/1996 K0405 12/31/1996 K0406 12/31/1996 K0412 12/31/1999 K0413 12/31/1997 Start Printed Page 18779 K0414 12/31/1997 K0417 12/31/1999 K0418 12/31/1999 K0419 12/31/1999 K0420 12/31/1999 K0421 12/31/1999 K0422 12/31/1999 K0423 12/31/1999 K0424 12/31/1999 K0425 12/31/1999 K0426 12/31/1999 K0427 12/31/1999 K0428 12/31/1999 K0429 12/31/1999 K0430 12/31/1999 K0431 12/31/1999 K0432 12/31/1999 K0433 12/31/1999 K0434 12/31/1999 K0435 12/31/1999 K0436 12/31/1999 K0437 12/31/1999 K0438 12/31/1999 K0439 12/31/1999 K0453 12/31/1998 K0454 12/31/1997 K0503 12/31/1999 K0504 12/31/1999 K0505 12/31/1999 K0506 12/31/1999 K0507 12/31/1999 K0508 12/31/1999 K0509 12/31/1999 K0511 12/31/1999 K0512 12/31/1999 K0513 12/31/1999 K0514 12/31/1999 K0515 12/31/1999 K0516 12/31/1999 K0518 12/31/1999 K0519 12/31/1999 K0520 12/31/1999 K0521 12/31/1999 K0522 12/31/1999 K0523 12/31/1999 K0524 12/31/1999 K0525 12/31/1999 K0526 12/31/1999 K0527 12/31/1999 K0528 12/31/1999 K0530 12/31/1999 L4200 12/31/1996 L4310 12/31/1998 L4320 12/31/1998 L4390 12/31/1998 L7160 12/31/1996 L7165 12/31/1996 L8605 12/31/1997 L8611 12/31/1997 L8615 12/31/1997 L8616 12/31/1997 L8617 12/31/1997 L8618 12/31/1997 L8620 12/31/1997 L8621 12/31/1997 L8622 12/31/1997 L8623 12/31/1997 L8624 12/31/1997 L8625 12/31/1997 L8626 12/31/1997 L8627 12/31/1997 L8628 12/31/1997 L8629 12/31/1997 L8640 12/31/1997 L8655 12/31/1997 L8656 12/31/1997 L8657 12/31/1997 L8680 12/31/1997 L8690 12/31/1997 L9999 12/31/1996 M0005 12/31/1997 M0006 12/31/1997 M0007 12/31/1997 M0008 12/31/1997 M0101 12/31/1998 P9014 12/31/1998 P9015 12/31/1998 P9610 12/31/1998 Q0068 12/31/1999 Q0103 12/31/1997 Q0104 12/31/1997 Q0109 12/31/1997 Q0110 12/31/1997 Q0116 09/30/1996 Q0132 12/31/1999 Q0158 12/31/1997 Q0159 12/31/1998 Q0162 12/31/1998 Q0182 12/31/1998 Addendum E.—CPT Codes Which Would Be Paid Only As Inpatient Procedures
CPT/HCPCS HOPD Status Indicator Description 00174 C Anesth, pharyngeal surgery 00176 C Anesth, pharyngeal surgery 00192 C Anesth, facial bone surgery 00214 C Anesth, skull drainage 00215 C Anesth, skull fracture 00404 C Anesth, surgery of breast 00406 C Anesth, surgery of breast 00452 C Anesth, surgery of shoulder 00474 C Anesth, surgery of rib(s) 00524 C Anesth, chest drainage 00530 C Anesth, pacemaker insertion 00540 C Anesth, chest surgery 00542 C Anesth, release of lung 00544 C Anesth, chest lining removal 00546 C Anesth, lung, chest wall surg 00560 C Anesth, open heart surgery 00562 C Anesth, open heart surgery 00580 C Anesth heart/lung transplant 00604 C Anesth, surgery of vertebra 00622 C Anesth, removal of nerves 00632 C Anesth, removal of nerves 00634 C Anesth for chemonucleolysis 00670 C Anesth, spine, cord surgery 00792 C Anesth, part liver removal 00794 C Anesth, pancreas removal 00796 C Anesth, for liver transplant 00802 C Anesth, fat layer removal 00844 C Anesth, pelvis surgery 00846 C Anesth, hysterectomy 00848 C Anesth, pelvic organ surg 00850 C Anesth, cesarean section 00855 C Anesth, hysterectomy 00857 C Analgesia, labor & c-section 00864 C Anesth, removal of bladder 00865 C Anesth, removal of prostate 00866 C Anesth, removal of adrenal 00868 C Anesth, kidney transplant 00882 C Anesth, major vein ligation 00884 C Anesth, major vein revision 00904 C Anesth, perineal surgery 00908 C Anesth, removal of prostate 00928 C Anesth, removal of testis 00932 C Anesth, amputation of penis 00934 C Anesth, penis, nodes removal 00936 C Anesth, penis, nodes removal 00944 C Anesth, vaginal hysterectomy 00955 C Analgesia, vaginal delivery 01140 C Anesth, amputation at pelvis 01150 C Anesth, pelvic tumor surgery 01190 C Anesth, pelvis nerve removal 01212 C Anesth, hip disarticulation 01214 C Anesth, replacement of hip 01232 C Anesth, amputation of femur 01234 C Anesth, radical femur surg 01272 C Anesth, femoral artery surg 01274 C Anesth, femoral embolectomy 01402 C Anesth, replacement of knee 01404 C Anesth, amputation at knee 01442 C Anesth, knee artery surg 01444 C Anesth, knee artery repair 01486 C Anesth, ankle replacement 01502 C Anesth, lwr leg embolectomy 01632 C Anesth, surgery of shoulder 01634 C Anesth, shoulder joint amput 01636 C Anesth, forequarter amput 01638 C Anesth, shoulder replacement 01652 C Anesth, shoulder vessel surg 01654 C Anesth, shoulder vessel surg 01656 C Anesth, arm-leg vessel surg 01756 C Anesth, radical humerus surg 01772 C Anesth, uppr arm embolectomy 01782 C Anesth, uppr arm vein repair 01842 C Anesth, lwr arm embolectomy 01852 C Anesth, lwr arm vein repair 01904 C Anesth, skull x-ray inject 01990 C Support for organ donor 15756 C Free muscle flap, microvasc 15757 C Free skin flap, microvasc 15758 C Free fascial flap, microvasc 19200 C Removal of breast 19220 C Removal of breast 19240 C Removal of breast 19260 C Removal of chest wall lesion 19271 C Revision of chest wall 19272 C Extensive chest wall surgery 19361 C Breast reconstruction 19364 C Breast reconstruction 19367 C Breast reconstruction 19368 C Breast reconstruction 19369 C Breast reconstruction 20660 C Apply, remove fixation device 20661 C Application of head brace 20662 C Application of pelvis brace 20663 C Application of thigh brace 20664 C Halo brace application 20802 C Replantation, arm, complete 20805 C Replant, forearm, complete Start Printed Page 18780 20808 C Replantation hand, complete 20816 C Replantation digit, complete 20822 C Replantation digit, complete 20824 C Replantation thumb, complete 20827 C Replantation thumb, complete 20838 C Replantation foot, complete 20930 C Spinal bone allograft 20931 C Spinal bone allograft 20936 C Spinal bone autograft 20937 C Spinal bone autograft 20938 C Spinal bone autograft 20955 C Fibula bone graft, microvasc 20956 C Iliac bone graft, microvasc 20957 C Mt bone graft, microvasc 20962 C Other bone graft, microvasc 20969 C Bone/skin graft, microvasc 20970 C Bone/skin graft, iliac crest 20972 C Bone/skin graft, metatarsal 20973 C Bone/skin graft, great toe 21045 C Extensive jaw surgery 21141 C Reconstruct midface, lefort 21142 C Reconstruct midface, lefort 21143 C Reconstruct midface, lefort 21145 C Reconstruct midface, lefort 21146 C Reconstruct midface, lefort 21147 C Reconstruct midface, lefort 21150 C Reconstruct midface, lefort 21151 C Reconstruct midface, lefort 21154 C Reconstruct midface, lefort 21155 C Reconstruct midface, lefort 21159 C Reconstruct midface, lefort 21160 C Reconstruct midface, lefort 21172 C Reconstruct orbit/forehead 21175 C Reconstruct orbit/forehead 21179 C Reconstruct entire forehead 21180 C Reconstruct entire forehead 21182 C Reconstruct cranial bone 21183 C Reconstruct cranial bone 21184 C Reconstruct cranial bone 21188 C Reconstruction of midface 21193 C Reconstruct lower jaw bone 21194 C Reconstruct lower jaw bone 21195 C Reconstruct lower jaw bone 21196 C Reconstruct lower jaw bone 21247 C Reconstruct lower jaw bone 21255 C Reconstruct lower jaw bone 21256 C Reconstruction of orbit 21268 C Revise eye sockets 21343 C Treatment of sinus fracture 21344 C Treatment of sinus fracture 21346 C Treat nose/jaw fracture 21347 C Treat nose/jaw fracture 21348 C Treat nose/jaw fracture 21356 C Treat cheek bone fracture 21360 C Treat cheek bone fracture 21365 C Treat cheek bone fracture 21366 C Treat cheek bone fracture 21385 C Treat eye socket fracture 21386 C Treat eye socket fracture 21387 C Treat eye socket fracture 21390 C Treat eye socket fracture 21395 C Treat eye socket fracture 21408 C Treat eye socket fracture 21422 C Treat mouth roof fracture 21423 C Treat mouth roof fracture 21431 C Treat craniofacial fracture 21432 C Treat craniofacial fracture 21433 C Treat craniofacial fracture 21435 C Treat craniofacial fracture 21436 C Treat craniofacial fracture 21495 C Treat hyoid bone fracture 21510 C Drainage of bone lesion 21557 C Remove tumor, neck/chest 21615 C Removal of rib 21616 C Removal of rib and nerves 21620 C Partial removal of sternum 21627 C Sternal debridement 21630 C Extensive sternum surgery 21632 C Extensive sternum surgery 21705 C Revision of neck muscle/rib 21740 C Reconstruction of sternum 21750 C Repair of sternum separation 21810 C Treatment of rib fracture(s) 21825 C Treat sternum fracture 22100 C Remove part of neck vertebra 22101 C Remove part, thorax vertebra 22102 C Remove part, lumbar vertebra 22103 C Remove extra spine segment 22110 C Remove part of neck vertebra 22112 C Remove part, thorax vertebra 22114 C Remove part, lumbar vertebra 22116 C Remove extra spine segment 22210 C Revision of neck spine 22212 C Revision of thorax spine 22214 C Revision of lumbar spine 22216 C Revise, extra spine segment 22220 C Revision of neck spine 22222 C Revision of thorax spine 22224 C Revision of lumbar spine 22226 C Revise, extra spine segment 22318 C Treat odontoid fx w/o graft 22319 C Treat odontoid fx w/graft 22325 C Treat spine fracture 22326 C Treat neck spine fracture 22327 C Treat thorax spine fracture 22328 C Treat each add spine fx 22548 C Neck spine fusion 22554 C Neck spine fusion 22556 C Thorax spine fusion 22558 C Lumbar spine fusion 22585 C Additional spinal fusion 22590 C Spine & skull spinal fusion 22595 C Neck spinal fusion 22600 C Neck spine fusion 22610 C Thorax spine fusion 22612 C Lumbar spine fusion 22614 C Spine fusion, extra segment 22630 C Lumbar spine fusion 22632 C Spine fusion, extra segment 22800 C Fusion of spine 22802 C Fusion of spine 22804 C Fusion of spine 22808 C Fusion of spine 22810 C Fusion of spine 22812 C Fusion of spine 22818 C Kyphectomy, 1-2 segments 22819 C Kyphectomy, 3 or more 22830 C Exploration of spinal fusion 22840 C Insert spine fixation device 22841 C Insert spine fixation device 22842 C Insert spine fixation device 22843 C Insert spine fixation device 22844 C Insert spine fixation device 22845 C Insert spine fixation device 22846 C Insert spine fixation device 22847 C Insert spine fixation device 22848 C Insert pelv fixation device 22849 C Reinsert spinal fixation 22850 C Remove spine fixation device 22851 C Apply spine prosth device 22852 C Remove spine fixation device 22855 C Remove spine fixation device 23035 C Drain shoulder bone lesion 23125 C Removal of collar bone 23195 C Removal of head of humerus 23200 C Removal of collar bone 23210 C Removal of shoulder blade 23220 C Partial removal of humerus 23221 C Partial removal of humerus 23222 C Partial removal of humerus 23332 C Remove shoulder foreign body 23395 C Muscle transfer, shoulder/arm 23397 C Muscle transfers 23400 C Fixation of shoulder blade 23440 C Remove/transplant tendon 23470 C Reconstruct shoulder joint 23472 C Reconstruct shoulder joint 23900 C Amputation of arm & girdle 23920 C Amputation at shoulder joint 24149 C Radical resection of elbow 24150 C Extensive humerus surgery 24151 C Extensive humerus surgery 24152 C Extensive radius surgery 24153 C Extensive radius surgery 24900 C Amputation of upper arm 24920 C Amputation of upper arm 24930 C Amputation follow-up surgery 24931 C Amputate upper arm & implant 24940 C Revision of upper arm 25170 C Extensive forearm surgery 25390 C Shorten radius or ulna 25391 C Lengthen radius or ulna 25392 C Shorten radius & ulna 25393 C Lengthen radius & ulna 25405 C Repair/graft radius or ulna 25420 C Repair/graft radius & ulna 25900 C Amputation of forearm 25905 C Amputation of forearm 25909 C Amputation follow-up surgery 25915 C Amputation of forearm 25920 C Amputate hand at wrist 25924 C Amputation follow-up surgery 25927 C Amputation of hand 25931 C Amputation follow-up surgery 26551 C Great toe-hand transfer 26553 C Single transfer, toe-hand 26554 C Double transfer, toe-hand 26556 C Toe joint transfer 26992 C Drainage of bone lesion 27005 C Incision of hip tendon 27006 C Incision of hip tendons 27025 C Incision of hip/thigh fascia 27030 C Drainage of hip joint 27035 C Denervation of hip joint 27036 C Excision of hip joint/muscle 27054 C Removal of hip joint lining 27070 C Partial removal of hip bone 27071 C Partial removal of hip bone 27075 C Extensive hip surgery 27076 C Extensive hip surgery 27077 C Extensive hip surgery 27078 C Extensive hip surgery 27079 C Extensive hip surgery 27090 C Removal of hip prosthesis 27091 C Removal of hip prosthesis 27120 C Reconstruction of hip socket 27122 C Reconstruction of hip socket 27125 C Partial hip replacement 27130 C Total hip replacement 27132 C Total hip replacement 27134 C Revise hip joint replacement 27137 C Revise hip joint replacement 27138 C Revise hip joint replacement 27140 C Transplant femur ridge 27146 C Incision of hip bone 27147 C Revision of hip bone Start Printed Page 18781 27151 C Incision of hip bones 27156 C Revision of hip bones 27158 C Revision of pelvis 27161 C Incision of neck of femur 27165 C Incision/fixation of femur 27170 C Repair/graft femur head/neck 27175 C Treat slipped epiphysis 27176 C Treat slipped epiphysis 27177 C Treat slipped epiphysis 27178 C Treat slipped epiphysis 27179 C Revise head/neck of femur 27181 C Treat slipped epiphysis 27185 C Revision of femur epiphysis 27187 C Reinforce hip bones 27215 C Treat pelvic fracture(s) 27216 C Treat pelvic ring fracture 27217 C Treat pelvic ring fracture 27218 C Treat pelvic ring fracture 27222 C Treat hip socket fracture 27226 C Treat hip wall fracture 27227 C Treat hip fracture(s) 27228 C Treat hip fracture(s) 27232 C Treat thigh fracture 27235 C Treat thigh fracture 27236 C Treat thigh fracture 27240 C Treat thigh fracture 27244 C Treat thigh fracture 27245 C Treat thigh fracture 27248 C Treat thigh fracture 27253 C Treat hip dislocation 27254 C Treat hip dislocation 27258 C Treat hip dislocation 27259 C Treat hip dislocation 27280 C Fusion of sacroiliac joint 27282 C Fusion of pubic bones 27284 C Fusion of hip joint 27286 C Fusion of hip joint 27290 C Amputation of leg at hip 27295 C Amputation of leg at hip 27303 C Drainage of bone lesion 27365 C Extensive leg surgery 27445 C Revision of knee joint 27446 C Revision of knee joint 27447 C Total knee replacement 27448 C Incision of thigh 27450 C Incision of thigh 27454 C Realignment of thigh bone 27455 C Realignment of knee 27457 C Realignment of knee 27465 C Shortening of thigh bone 27466 C Lengthening of thigh bone 27468 C Shorten/lengthen thighs 27470 C Repair of thigh 27472 C Repair/graft of thigh 27475 C Surgery to stop leg growth 27477 C Surgery to stop leg growth 27479 C Surgery to stop leg growth 27485 C Surgery to stop leg growth 27486 C Revise/replace knee joint 27487 C Revise/replace knee joint 27488 C Removal of knee prosthesis 27495 C Reinforce thigh 27506 C Treatment of thigh fracture 27507 C Treatment of thigh fracture 27511 C Treatment of thigh fracture 27513 C Treatment of thigh fracture 27514 C Treatment of thigh fracture 27519 C Treat thigh fx growth plate 27524 C Treat kneecap fracture 27535 C Treat knee fracture 27536 C Treat knee fracture 27540 C Treat knee fracture 27557 C Treat knee dislocation 27558 C Treat knee dislocation 27580 C Fusion of knee 27590 C Amputate leg at thigh 27591 C Amputate leg at thigh 27592 C Amputate leg at thigh 27596 C Amputation follow-up surgery 27598 C Amputate lower leg at knee 27645 C Extensive lower leg surgery 27646 C Extensive lower leg surgery 27702 C Reconstruct ankle joint 27703 C Reconstruction, ankle joint 27712 C Realignment of lower leg 27715 C Revision of lower leg 27720 C Repair of tibia 27722 C Repair/graft of tibia 27724 C Repair/graft of tibia 27725 C Repair of lower leg 27727 C Repair of lower leg 27880 C Amputation of lower leg 27881 C Amputation of lower leg 27882 C Amputation of lower leg 27886 C Amputation follow-up surgery 27888 C Amputation of foot at ankle 28800 C Amputation of midfoot 28805 C Amputation thru metatarsal 31225 C Removal of upper jaw 31230 C Removal of upper jaw 31290 C Nasal/sinus endoscopy, surg 31291 C Nasal/sinus endoscopy, surg 31292 C Nasal/sinus endoscopy, surg 31293 C Nasal/sinus endoscopy, surg 31294 C Nasal/sinus endoscopy, surg 31360 C Removal of larynx 31365 C Removal of larynx 31367 C Partial removal of larynx 31368 C Partial removal of larynx 31370 C Partial removal of larynx 31380 C Partial removal of larynx 31382 C Partial removal of larynx 31390 C Removal of larynx & pharynx 31395 C Reconstruct larynx & pharynx 31582 C Revision of larynx 31584 C Treat larynx fracture 31587 C Revision of larynx 31725 C Clearance of airways 31760 C Repair of windpipe 31766 C Reconstruction of windpipe 31770 C Repair/graft of bronchus 31775 C Reconstruct bronchus 31780 C Reconstruct windpipe 31781 C Reconstruct windpipe 31785 C Remove windpipe lesion 31786 C Remove windpipe lesion 31800 C Repair of windpipe injury 31805 C Repair of windpipe injury 32035 C Exploration of chest 32036 C Exploration of chest 32095 C Biopsy through chest wall 32100 C Exploration/biopsy of chest 32110 C Explore/repair chest 32120 C Re-exploration of chest 32124 C Explore chest free adhesions 32140 C Removal of lung lesion(s) 32141 C Remove/treat lung lesions 32150 C Removal of lung lesion(s) 32151 C Remove lung foreign body 32160 C Open chest heart massage 32200 C Drain, open, lung lesion 32201 C Drain, percut, lung lesion 32215 C Treat chest lining 32220 C Release of lung 32225 C Partial release of lung 32310 C Removal of chest lining 32320 C Free/remove chest lining 32402 C Open biopsy chest lining 32440 C Removal of lung 32442 C Sleeve pneumonectomy 32445 C Removal of lung 32480 C Partial removal of lung 32482 C Bilobectomy 32484 C Segmentectomy 32486 C Sleeve lobectomy 32488 C Completion pneumonectomy 32491 C Lung volume reduction 32500 C Partial removal of lung 32501 C Repair bronchus add-on 32520 C Remove lung & revise chest 32522 C Remove lung & revise chest 32525 C Remove lung & revise chest 32540 C Removal of lung lesion 32650 C Thoracoscopy, surgical 32651 C Thoracoscopy, surgical 32652 C Thoracoscopy, surgical 32653 C Thoracoscopy, surgical 32654 C Thoracoscopy, surgical 32655 C Thoracoscopy, surgical 32656 C Thoracoscopy, surgical 32657 C Thoracoscopy, surgical 32658 C Thoracoscopy, surgical 32659 C Thoracoscopy, surgical 32660 C Thoracoscopy, surgical 32661 C Thoracoscopy, surgical 32662 C Thoracoscopy, surgical 32663 C Thoracoscopy, surgical 32664 C Thoracoscopy, surgical 32665 C Thoracoscopy, surgical 32800 C Repair lung hernia 32810 C Close chest after drainage 32815 C Close bronchial fistula 32820 C Reconstruct injured chest 32850 C Donor pneumonectomy 32851 C Lung transplant, single 32852 C Lung transplant with bypass 32853 C Lung transplant, double 32854 C Lung transplant with bypass 32900 C Removal of rib(s) 32905 C Revise & repair chest wall 32906 C Revise & repair chest wall 32940 C Revision of lung 32997 C Total lung lavage 33015 C Incision of heart sac 33020 C Incision of heart sac 33025 C Incision of heart sac 33030 C Partial removal of heart sac 33031 C Partial removal of heart sac 33050 C Removal of heart sac lesion 33120 C Removal of heart lesion 33130 C Removal of heart lesion 33140 C Heart revascularize (tmr) 33200 C Insertion of heart pacemaker 33201 C Insertion of heart pacemaker 33236 C Remove electrode/thoracotomy 33237 C Remove electrode/thoracotomy 33238 C Remove electrode/thoracotomy 33243 C Remove eltrd/thoracotomy 33245 C Insert epic eltrd pace-defib 33246 C Insert epic eltrd/generator 33250 C Ablate heart dysrhythm focus 33251 C Ablate heart dysrhythm focus 33253 C Reconstruct atria Start Printed Page 18782 33261 C Ablate heart dysrhythm focus 33282 C Implant pat-active ht record 33284 C Remove pat-active ht record 33300 C Repair of heart wound 33305 C Repair of heart wound 33310 C Exploratory heart surgery 33315 C Exploratory heart surgery 33320 C Repair major blood vessel(s) 33321 C Repair major vessel 33322 C Repair major blood vessel(s) 33330 C Insert major vessel graft 33332 C Insert major vessel graft 33335 C Insert major vessel graft 33400 C Repair of aortic valve 33401 C Valvuloplasty, open 33403 C Valvuloplasty, w/cp bypass 33404 C Prepare heart-aorta conduit 33405 C Replacement of aortic valve 33406 C Replacement of aortic valve 33410 C Replacement of aortic valve 33411 C Replacement of aortic valve 33412 C Replacement of aortic valve 33413 C Replacement of aortic valve 33414 C Repair of aortic valve 33415 C Revision, subvalvular tissue 33416 C Revise ventricle muscle 33417 C Repair of aortic valve 33420 C Revision of mitral valve 33422 C Revision of mitral valve 33425 C Repair of mitral valve 33426 C Repair of mitral valve 33427 C Repair of mitral valve 33430 C Replacement of mitral valve 33460 C Revision of tricuspid valve 33463 C Valvuloplasty, tricuspid 33464 C Valvuloplasty, tricuspid 33465 C Replace tricuspid valve 33468 C Revision of tricuspid valve 33470 C Revision of pulmonary valve 33471 C Valvotomy, pulmonary valve 33472 C Revision of pulmonary valve 33474 C Revision of pulmonary valve 33475 C Replacement, pulmonary valve 33476 C Revision of heart chamber 33478 C Revision of heart chamber 33496 C Repair, prosth valve clot 33500 C Repair heart vessel fistula 33501 C Repair heart vessel fistula 33502 C Coronary artery correction 33503 C Coronary artery graft 33504 C Coronary artery graft 33505 C Repair artery w/tunnel 33506 C Repair artery, translocation 33510 C CABG, vein, single 33511 C CABG, vein, two 33512 C CABG, vein, three 33513 C CABG, vein, four 33514 C CABG, vein, five 33516 C Cabg, vein, six or more 33517 C CABG, artery-vein, single 33518 C CABG, artery-vein, two 33519 C CABG, artery-vein, three 33521 C CABG, artery-vein, four 33522 C CABG, artery-vein, five 33523 C Cabg, art-vein, six or more 33530 C Coronary artery, bypass/reop 33533 C CABG, arterial, single 33534 C CABG, arterial, two 33535 C CABG, arterial, three 33536 C Cabg, arterial, four or more 33542 C Removal of heart lesion 33545 C Repair of heart damage 33572 C Open coronary endarterectomy 33600 C Closure of valve 33602 C Closure of valve 33606 C Anastomosis/artery-aorta 33608 C Repair anomaly w/conduit 33610 C Repair by enlargement 33611 C Repair double ventricle 33612 C Repair double ventricle 33615 C Repair, simple fontan 33617 C Repair, modified fontan 33619 C Repair single ventricle 33641 C Repair heart septum defect 33645 C Revision of heart veins 33647 C Repair heart septum defects 33660 C Repair of heart defects 33665 C Repair of heart defects 33670 C Repair of heart chambers 33681 C Repair heart septum defect 33684 C Repair heart septum defect 33688 C Repair heart septum defect 33690 C Reinforce pulmonary artery 33692 C Repair of heart defects 33694 C Repair of heart defects 33697 C Repair of heart defects 33702 C Repair of heart defects 33710 C Repair of heart defects 33720 C Repair of heart defect 33722 C Repair of heart defect 33730 C Repair heart-vein defect(s) 33732 C Repair heart-vein defect 33735 C Revision of heart chamber 33736 C Revision of heart chamber 33737 C Revision of heart chamber 33750 C Major vessel shunt 33755 C Major vessel shunt 33762 C Major vessel shunt 33764 C Major vessel shunt & graft 33766 C Major vessel shunt 33767 C Major vessel shunt 33770 C Repair great vessels defect 33771 C Repair great vessels defect 33774 C Repair great vessels defect 33775 C Repair great vessels defect 33776 C Repair great vessels defect 33777 C Repair great vessels defect 33778 C Repair great vessels defect 33779 C Repair great vessels defect 33780 C Repair great vessels defect 33781 C Repair great vessels defect 33786 C Repair arterial trunk 33788 C Revision of pulmonary artery 33800 C Aortic suspension 33802 C Repair vessel defect 33803 C Repair vessel defect 33813 C Repair septal defect 33814 C Repair septal defect 33820 C Revise major vessel 33822 C Revise major vessel 33824 C Revise major vessel 33840 C Remove aorta constriction 33845 C Remove aorta constriction 33851 C Remove aorta constriction 33852 C Repair septal defect 33853 C Repair septal defect 33860 C Ascending aortic graft 33861 C Ascending aortic graft 33863 C Ascending aortic graft 33870 C Transverse aortic arch graft 33875 C Thoracic aortic graft 33877 C Thoracoabdominal graft 33910 C Remove lung artery emboli 33915 C Remove lung artery emboli 33916 C Surgery of great vessel 33917 C Repair pulmonary artery 33918 C Repair pulmonary atresia 33919 C Repair pulmonary atresia 33920 C Repair pulmonary atresia 33922 C Transect pulmonary artery 33924 C Remove pulmonary shunt 33930 C Removal of donor heart/lung 33935 C Transplantation, heart/lung 33940 C Removal of donor heart 33945 C Transplantation of heart 33960 C External circulation assist 33961 C External circulation assist 33968 C Remove aortic assist device 33970 C Aortic circulation assist 33971 C Aortic circulation assist 33973 C Insert balloon device 33974 C Remove intra-aortic balloon 33975 C Implant ventricular device 33976 C Implant ventricular device 33977 C Remove ventricular device 33978 C Remove ventricular device 34001 C Removal of artery clot 34051 C Removal of artery clot 34151 C Removal of artery clot 34401 C Removal of vein clot 34421 C Removal of vein clot 34451 C Removal of vein clot 34502 C Reconstruct vena cava 35001 C Repair defect of artery 35002 C Repair artery rupture, neck 35005 C Repair defect of artery 35011 C Repair defect of artery 35013 C Repair artery rupture, arm 35021 C Repair defect of artery 35022 C Repair artery rupture, chest 35045 C Repair defect of arm artery 35081 C Repair defect of artery 35082 C Repair artery rupture, aorta 35091 C Repair defect of artery 35092 C Repair artery rupture, aorta 35102 C Repair defect of artery 35103 C Repair artery rupture, groin 35111 C Repair defect of artery 35112 C Repair artery rupture, spleen 35121 C Repair defect of artery 35122 C Repair artery rupture, belly 35131 C Repair defect of artery 35132 C Repair artery rupture, groin 35141 C Repair defect of artery 35142 C Repair artery rupture, thigh 35151 C Repair defect of artery 35152 C Repair artery rupture, knee 35161 C Repair defect of artery 35162 C Repair artery rupture 35182 C Repair blood vessel lesion 35189 C Repair blood vessel lesion 35211 C Repair blood vessel lesion 35216 C Repair blood vessel lesion 35221 C Repair blood vessel lesion 35241 C Repair blood vessel lesion 35246 C Repair blood vessel lesion 35251 C Repair blood vessel lesion 35271 C Repair blood vessel lesion 35276 C Repair blood vessel lesion 35281 C Repair blood vessel lesion 35301 C Rechanneling of artery 35311 C Rechanneling of artery 35331 C Rechanneling of artery 35341 C Rechanneling of artery 35351 C Rechanneling of artery Start Printed Page 18783 35355 C Rechanneling of artery 35361 C Rechanneling of artery 35363 C Rechanneling of artery 35371 C Rechanneling of artery 35372 C Rechanneling of artery 35381 C Rechanneling of artery 35390 C Reoperation, carotid add-on 35400 C Angioscopy 35450 C Repair arterial blockage 35452 C Repair arterial blockage 35454 C Repair arterial blockage 35456 C Repair arterial blockage 35458 C Repair arterial blockage 35480 C Atherectomy, open 35481 C Atherectomy, open 35482 C Atherectomy, open 35483 C Atherectomy, open 35501 C Artery bypass graft 35506 C Artery bypass graft 35507 C Artery bypass graft 35508 C Artery bypass graft 35509 C Artery bypass graft 35511 C Artery bypass graft 35515 C Artery bypass graft 35516 C Artery bypass graft 35518 C Artery bypass graft 35521 C Artery bypass graft 35526 C Artery bypass graft 35531 C Artery bypass graft 35533 C Artery bypass graft 35536 C Artery bypass graft 35541 C Artery bypass graft 35546 C Artery bypass graft 35548 C Artery bypass graft 35549 C Artery bypass graft 35551 C Artery bypass graft 35556 C Artery bypass graft 35558 C Artery bypass graft 35560 C Artery bypass graft 35563 C Artery bypass graft 35565 C Artery bypass graft 35566 C Artery bypass graft 35571 C Artery bypass graft 35582 C Vein bypass graft 35583 C Vein bypass graft 35585 C Vein bypass graft 35587 C Vein bypass graft 35601 C Artery bypass graft 35606 C Artery bypass graft 35612 C Artery bypass graft 35616 C Artery bypass graft 35621 C Artery bypass graft 35623 C Bypass graft, not vein 35626 C Artery bypass graft 35631 C Artery bypass graft 35636 C Artery bypass graft 35641 C Artery bypass graft 35642 C Artery bypass graft 35645 C Artery bypass graft 35646 C Artery bypass graft 35650 C Artery bypass graft 35651 C Artery bypass graft 35654 C Artery bypass graft 35656 C Artery bypass graft 35661 C Artery bypass graft 35663 C Artery bypass graft 35665 C Artery bypass graft 35666 C Artery bypass graft 35671 C Artery bypass graft 35681 C Composite bypass graft 35682 C Composite bypass graft 35683 C Composite bypass graft 35691 C Arterial transposition 35693 C Arterial transposition 35694 C Arterial transposition 35695 C Arterial transposition 35700 C Reoperation, bypass graft 35701 C Exploration, carotid artery 35721 C Exploration, femoral artery 35741 C Exploration popliteal artery 35761 C Exploration of artery/vein 35800 C Explore neck vessels 35820 C Explore chest vessels 35840 C Explore abdominal vessels 35860 C Explore limb vessels 35870 C Repair vessel graft defect 35901 C Excision, graft, neck 35903 C Excision, graft, extremity 35905 C Excision, graft, thorax 35907 C Excision, graft, abdomen 36510 C Insertion of catheter, vein 36550 C Declot vascular device 36660 C Insertion catheter, artery 36822 C Insertion of cannula(s) 36823 C Insertion of cannula(s) 36834 C Repair A-V aneurysm 37140 C Revision of circulation 37145 C Revision of circulation 37160 C Revision of circulation 37180 C Revision of circulation 37181 C Splice spleen/kidney veins 37195 C Thrombolytic therapy, stroke 37200 C Transcatheter biopsy 37201 C Transcatheter therapy infuse 37202 C Transcatheter therapy infuse 37616 C Ligation of chest artery 37617 C Ligation of abdomen artery 37620 C Revision of major vein 37660 C Revision of major vein 37788 C Revascularization, penis 38100 C Removal of spleen, total 38101 C Removal of spleen, partial 38102 C Removal of spleen, total 38115 C Repair of ruptured spleen 38380 C Thoracic duct procedure 38381 C Thoracic duct procedure 38382 C Thoracic duct procedure 38562 C Removal, pelvic lymph nodes 38564 C Removal, abdomen lymph nodes 38700 C Removal of lymph nodes, neck 38724 C Removal of lymph nodes, neck 38746 C Remove thoracic lymph nodes 38747 C Remove abdominal lymph nodes 38765 C Remove groin lymph nodes 38770 C Remove pelvis lymph nodes 38780 C Remove abdomen lymph nodes 39000 C Exploration of chest 39010 C Exploration of chest 39200 C Removal chest lesion 39220 C Removal chest lesion 39499 C Chest procedure 39501 C Repair diaphragm laceration 39502 C Repair paraesophageal hernia 39503 C Repair of diaphragm hernia 39520 C Repair of diaphragm hernia 39530 C Repair of diaphragm hernia 39531 C Repair of diaphragm hernia 39540 C Repair of diaphragm hernia 39541 C Repair of diaphragm hernia 39545 C Revision of diaphragm 39560 C Resect diaphragm, simple 39561 C Resect diaphragm, complex 39599 C Diaphragm surgery procedure 41130 C Partial removal of tongue 41135 C Tongue and neck surgery 41140 C Removal of tongue 41145 C Tongue removal, neck surgery 41150 C Tongue, mouth, jaw surgery 41153 C Tongue, mouth, neck surgery 41155 C Tongue, jaw, & neck surgery 42426 C Excise parotid gland/lesion 42842 C Extensive surgery of throat 42845 C Extensive surgery of throat 42894 C Revision of pharyngeal walls 42953 C Repair throat, esophagus 42961 C Control throat bleeding 42971 C Control nose/throat bleeding 43030 C Throat muscle surgery 43045 C Incision of esophagus 43100 C Excision of esophagus lesion 43101 C Excision of esophagus lesion 43107 C Removal of esophagus 43108 C Removal of esophagus 43112 C Removal of esophagus 43113 C Removal of esophagus 43116 C Partial removal of esophagus 43117 C Partial removal of esophagus 43118 C Partial removal of esophagus 43121 C Partial removal of esophagus 43122 C Parital removal of esophagus 43123 C Partial removal of esophagus 43124 C Removal of esophagus 43130 C Removal of esophagus pouch 43135 C Removal of esophagus pouch 43300 C Repair of esophagus 43305 C Repair esophagus and fistula 43310 C Repair of esophagus 43312 C Repair esophagus and fistula 43320 C Fuse esophagus & stomach 43324 C Revise esophagus & stomach 43325 C Revise esophagus & stomach 43326 C Revise esophagus & stomach 43330 C Repair of esophagus 43331 C Repair of esophagus 43340 C Fuse esophagus & intestine 43341 C Fuse esophagus & intestine 43350 C Surgical opening, esophagus 43351 C Surgical opening, esophagus 43352 C Surgical opening, esophagus 43360 C Gastrointestinal repair 43361 C Gastrointestinal repair 43400 C Ligate esophagus veins 43401 C Esophagus surgery for veins 43405 C Ligate/staple esophagus 43410 C Repair esophagus wound 43415 C Repair esophagus wound 43420 C Repair esophagus opening 43425 C Repair esophagus opening 43460 C Pressure treatment esophagus 43496 C Free jejunum flap, microvasc 43500 C Surgical opening of stomach 43501 C Surgical repair of stomach 43502 C Surgical repair of stomach 43510 C Surgical opening of stomach 43520 C Incision of pyloric muscle 43605 C Biopsy of stomach 43610 C Excision of stomach lesion 43611 C Excision of stomach lesion 43620 C Removal of stomach 43621 C Removal of stomach 43622 C Removal of stomach 43631 C Removal of stomach, partial 43632 C Removal of stomach, partial Start Printed Page 18784 43633 C Removal of stomach, partial 43634 C Removal of stomach, partial 43635 C Removal of stomach, partial 43638 C Removal of stomach, partial 43639 C Removal of stomach, partial 43640 C Vagotomy & pylorus repair 43641 C Vagotomy & pylorus repair 43800 C Reconstruction of pylorus 43810 C Fusion of stomach and bowel 43820 C Fusion of stomach and bowel 43825 C Fusion of stomach and bowel 43832 C Place gastrostomy tube 43840 C Repair of stomach lesion 43842 C Gastroplasty for obesity 43843 C Gastroplasty for obesity 43846 C Gastric bypass for obesity 43847 C Gastric bypass for obesity 43848 C Revision gastroplasty 43850 C Revise stomach-bowel fusion 43855 C Revise stomach-bowel fusion 43860 C Revise stomach-bowel fusion 43865 C Revise stomach-bowel fusion 43880 C Repair stomach-bowel fistula 44005 C Freeing of bowel adhesion 44010 C Incision of small bowel 44015 C Insert needle cath bowel 44020 C Exploration of small bowel 44021 C Decompress small bowel 44025 C Incision of large bowel 44050 C Reduce bowel obstruction 44055 C Correct malrotation of bowel 44110 C Excision of bowel lesion(s) 44111 C Excision of bowel lesion(s) 44120 C Removal of small intestine 44121 C Removal of small intestine 44125 C Removal of small intestine 44130 C Bowel to bowel fusion 44139 C Mobilization of colon 44140 C Partial removal of colon 44141 C Partial removal of colon 44143 C Partial removal of colon 44144 C Partial removal of colon 44145 C Partial removal of colon 44146 C Partial removal of colon 44147 C Partial removal of colon 44150 C Removal of colon 44151 C Removal of colon/ileostomy 44152 C Removal of colon/ileostomy 44153 C Removal of colon/ileostomy 44155 C Removal of colon/ileostomy 44156 C Removal of colon/ileostomy 44160 C Removal of colon 44202 C Laparo, resect intestine 44300 C Open bowel to skin 44310 C Ileostomy/jejunostomy 44314 C Revision of ileostomy 44316 C Devise bowel pouch 44320 C Colostomy 44322 C Colostomy with biopsies 44345 C Revision of colostomy 44346 C Revision of colostomy 44500 C Intro, gastrointestinal tube 44602 C Suture, small intestine 44603 C Suture, small intestine 44604 C Suture, large intestine 44605 C Repair of bowel lesion 44615 C Intestinal stricturoplasty 44620 C Repair bowel opening 44625 C Repair bowel opening 44626 C Repair bowel opening 44640 C Repair bowel-skin fistula 44650 C Repair bowel fistula 44660 C Repair bowel-bladder fistula 44661 C Repair bowel-bladder fistula 44680 C Surgical revision, intestine 44700 C Suspend bowel w/prosthesis 44800 C Excision of bowel pouch 44820 C Excision of mesentery lesion 44850 C Repair of mesentery 44899 C Bowel surgery procedure 44900 C Drain app abscess, open 44901 C Drain app abscess, percut 44950 C Appendectomy 44955 C Appendectomy add-on 44960 C Appendectomy 45110 C Removal of rectum 45111 C Partial removal of rectum 45112 C Removal of rectum 45113 C Partial proctectomy 45114 C Partial removal of rectum 45116 C Partial removal of rectum 45119 C Remove rectum w/reservoir 45120 C Removal of rectum 45121 C Removal of rectum and colon 45123 C Partial proctectomy 45126 C Pelvic exenteration 45130 C Excision of rectal prolapse 45135 C Excision of rectal prolapse 45540 C Correct rectal prolapse 45541 C Correct rectal prolapse 45550 C Repair rectum/remove sigmoid 45562 C Exploration/repair of rectum 45563 C Exploration/repair of rectum 45800 C Repair rect/bladder fistula 45805 C Repair fistula w/colostomy 45820 C Repair rectourethral fistula 45825 C Repair fistula w/colostomy 46705 C Repair of anal stricture 46715 C Repair of anovaginal fistula 46716 C Repair of anovaginal fistula 46730 C Construction of absent anus 46735 C Construction of absent anus 46740 C Construction of absent anus 46742 C Repair of imperforated anus 46744 C Repair of cloacal anomaly 46746 C Repair of cloacal anomaly 46748 C Repair of cloacal anomaly 46751 C Repair of anal sphincter 47001 C Needle biopsy, liver add-on 47010 C Open drainage, liver lesion 47011 C Percut drain, liver lesion 47015 C Inject/aspirate liver cyst 47100 C Wedge biopsy of liver 47120 C Partial removal of liver 47122 C Extensive removal of liver 47125 C Partial removal of liver 47130 C Partial removal of liver 47133 C Removal of donor liver 47134 C Partial removal, donor liver 47135 C Transplantation of liver 47136 C Transplantation of liver 47300 C Surgery for liver lesion 47350 C Repair liver wound 47360 C Repair liver wound 47361 C Repair liver wound 47362 C Repair liver wound 47400 C Incision of liver duct 47420 C Incision of bile duct 47425 C Incision of bile duct 47460 C Incise bile duct sphincter 47480 C Incision of gallbladder 47490 C Incision of gallbladder 47550 C Bile duct endoscopy add-on 47600 C Removal of gallbladder 47605 C Removal of gallbladder 47610 C Removal of gallbladder 47612 C Removal of gallbladder 47620 C Removal of gallbladder 47700 C Exploration of bile ducts 47701 C Bile duct revision 47711 C Excision of bile duct tumor 47712 C Excision of bile duct tumor 47715 C Excision of bile duct cyst 47716 C Fusion of bile duct cyst 47720 C Fuse gallbladder & bowel 47721 C Fuse upper gi structures 47740 C Fuse gallbladder & bowel 47741 C Fuse gallbladder & bowel 47760 C Fuse bile ducts and bowel 47765 C Fuse liver ducts & bowel 47780 C Fuse bile ducts and bowel 47785 C Fuse bile ducts and bowel 47800 C Reconstruction of bile ducts 47801 C Placement, bile duct support 47802 C Fuse liver duct & intestine 47900 C Suture bile duct injury 48000 C Drainage of abdomen 48001 C Placement of drain, pancreas 48005 C Resect/debride pancreas 48020 C Removal of pancreatic stone 48100 C Biopsy of pancreas 48120 C Removal of pancreas lesion 48140 C Partial removal of pancreas 48145 C Partial removal of pancreas 48146 C Pancreatectomy 48148 C Removal of pancreatic duct 48150 C Partial removal of pancreas 48152 C Pancreatectomy 48153 C Pancreatectomy 48154 C Pancreatectomy 48155 C Removal of pancreas 48180 C Fuse pancreas and bowel 48400 C Injection, intraop add-on 48500 C Surgery of pancreas cyst 48510 C Drain pancreatic pseudocyst 48511 C Drain pancreatic pseudocyst 48520 C Fuse pancreas cyst and bowel 48540 C Fuse pancreas cyst and bowel 48545 C Pancreatorrhaphy 48547 C Duodenal exclusion 48556 C Removal, allograft pancreas 49000 C Exploration of abdomen 49002 C Reopening of abdomen 49010 C Exploration behind abdomen 49020 C Drain abdominal abscess 49021 C Drain abdominal abscess 49040 C Drain, open, abdom abscess 49041 C Drain, percut, abdom abscess 49060 C Drain, open, retrop abscess 49061 C Drain, percut, retroper absc 49062 C Drain to peritoneal cavity 49200 C Removal of abdominal lesion 49201 C Removal of abdominal lesion 49215 C Excise sacral spine tumor 49220 C Multiple surgery, abdomen 49255 C Removal of omentum 49425 C Insert abdomen-venous drain 49428 C Ligation of shunt 49605 C Repair umbilical lesion 49606 C Repair umbilical lesion 49610 C Repair umbilical lesion 49611 C Repair umbilical lesion 49900 C Repair of abdominal wall 49905 C Omental flap 49906 C Free omental flap, microvasc 50010 C Exploration of kidney Start Printed Page 18785 50020 C Renal abscess, open drain 50021 C Renal abscess, percut drain 50040 C Drainage of kidney 50045 C Exploration of kidney 50060 C Removal of kidney stone 50065 C Incision of kidney 50070 C Incision of kidney 50075 C Removal of kidney stone 50100 C Revise kidney blood vessels 50120 C Exploration of kidney 50125 C Explore and drain kidney 50130 C Removal of kidney stone 50135 C Exploration of kidney 50205 C Biopsy of kidney 50220 C Removal of kidney 50225 C Removal of kidney 50230 C Removal of kidney 50234 C Removal of kidney & ureter 50236 C Removal of kidney & ureter 50240 C Partial removal of kidney 50280 C Removal of kidney lesion 50290 C Removal of kidney lesion 50300 C Removal of donor kidney 50320 C Removal of donor kidney 50340 C Removal of kidney 50360 C Transplantation of kidney 50365 C Transplantation of kidney 50370 C Remove transplanted kidney 50380 C Reimplantation of kidney 50400 C Revision of kidney/ureter 50405 C Revision of kidney/ureter 50500 C Repair of kidney wound 50520 C Close kidney-skin fistula 50525 C Repair renal-abdomen fistula 50526 C Repair renal-abdomen fistula 50540 C Revision of horseshoe kidney 50546 C Laparoscopic nephrectomy 50547 C Laparo removal donor kidney 50570 C Kidney endoscopy 50572 C Kidney endoscopy 50574 C Kidney endoscopy & biopsy 50575 C Kidney endoscopy 50576 C Kidney endoscopy & treatment 50578 C Renal endoscopy/radiotracer 50580 C Kidney endoscopy & treatment 50600 C Exploration of ureter 50605 C Insert ureteral support 50610 C Removal of ureter stone 50620 C Removal of ureter stone 50630 C Removal of ureter stone 50650 C Removal of ureter 50660 C Removal of ureter 50700 C Revision of ureter 50715 C Release of ureter 50722 C Release of ureter 50725 C Release/revise ureter 50727 C Revise ureter 50728 C Revise ureter 50740 C Fusion of ureter & kidney 50750 C Fusion of ureter & kidney 50760 C Fusion of ureters 50770 C Splicing of ureters 50780 C Reimplant ureter in bladder 50782 C Reimplant ureter in bladder 50783 C Reimplant ureter in bladder 50785 C Reimplant ureter in bladder 50800 C Implant ureter in bowel 50810 C Fusion of ureter & bowel 50815 C Urine shunt to bowel 50820 C Construct bowel bladder 50825 C Construct bowel bladder 50830 C Revise urine flow 50840 C Replace ureter by bowel 50845 C Appendico-vesicostomy 50860 C Transplant ureter to skin 50900 C Repair of ureter 50920 C Closure ureter/skin fistula 50930 C Closure ureter/bowel fistula 50940 C Release of ureter 50970 C Ureter endoscopy 50972 C Ureter endoscopy & catheter 50974 C Ureter endoscopy & biopsy 50976 C Ureter endoscopy & treatment 50978 C Ureter endoscopy & tracer 50980 C Ureter endoscopy & treatment 51060 C Removal of ureter stone 51525 C Removal of bladder lesion 51530 C Removal of bladder lesion 51535 C Repair of ureter lesion 51550 C Partial removal of bladder 51555 C Partial removal of bladder 51565 C Revise bladder & ureter(s) 51570 C Removal of bladder 51575 C Removal of bladder & nodes 51580 C Remove bladder/revise tract 51585 C Removal of bladder & nodes 51590 C Remove bladder/revise tract 51595 C Remove bladder/revise tract 51596 C Remove bladder/create pouch 51597 C Removal of pelvic structures 51800 C Revision of bladder/urethra 51820 C Revision of urinary tract 51840 C Attach bladder/urethra 51841 C Attach bladder/urethra 51845 C Repair bladder neck 51860 C Repair of bladder wound 51865 C Repair of bladder wound 51900 C Repair bladder/vagina lesion 51920 C Close bladder-uterus fistula 51925 C Hysterectomy/bladder repair 51940 C Correction of bladder defect 51960 C Revision of bladder & bowel 51980 C Construct bladder opening 53085 C Drainage of urinary leakage 53415 C Reconstruction of urethra 53443 C Reconstruction of urethra 54125 C Removal of penis 54130 C Remove penis & nodes 54135 C Remove penis & nodes 54332 C Revise penis/urethra 54336 C Revise penis/urethra 54390 C Repair penis and bladder 54430 C Revision of penis 54535 C Extensive testis surgery 54560 C Exploration for testis 54650 C Orchiopexy (Fowler-Stephens) 55600 C Incise sperm duct pouch 55605 C Incise sperm duct pouch 55650 C Remove sperm duct pouch 55801 C Removal of prostate 55810 C Extensive prostate surgery 55812 C Extensive prostate surgery 55815 C Extensive prostate surgery 55821 C Removal of prostate 55831 C Removal of prostate 55840 C Extensive prostate surgery 55842 C Extensive prostate surgery 55845 C Extensive prostate surgery 55860 C Surgical exposure, prostate 55862 C Extensive prostate surgery 55865 C Extensive prostate surgery 56630 C Extensive vulva surgery 56631 C Extensive vulva surgery 56632 C Extensive vulva surgery 56633 C Extensive vulva surgery 56634 C Extensive vulva surgery 56637 C Extensive vulva surgery 56640 C Extensive vulva surgery 56805 C Repair clitoris 57110 C Remove vagina wall, complete 57111 C Remove vagina tissue, compl 57112 C Vaginectomy w/nodes, compl 57120 C Closure of vagina 57270 C Repair of bowel pouch 57280 C Suspension of vagina 57282 C Repair of vaginal prolapse 57292 C Construct vagina with graft 57305 C Repair rectum-vagina fistula 57307 C Fistula repair & colostomy 57308 C Fistula repair, transperine 57310 C Repair urethrovaginal lesion 57311 C Repair urethrovaginal lesion 57320 C Repair bladder-vagina lesion 57330 C Repair bladder-vagina lesion 57335 C Repair vagina 57531 C Removal of cervix, radical 57540 C Removal of residual cervix 57545 C Remove cervix/repair pelvis 58140 C Removal of uterus lesion 58150 C Total hysterectomy 58152 C Total hysterectomy 58180 C Partial hysterectomy 58200 C Extensive hysterectomy 58210 C Extensive hysterectomy 58240 C Removal of pelvis contents 58260 C Vaginal hysterectomy 58262 C Vaginal hysterectomy 58263 C Vaginal hysterectomy 58267 C Hysterectomy & vagina repair 58270 C Hysterectomy & vagina repair 58275 C Hysterectomy/revise vagina 58280 C Hysterectomy/revise vagina 58285 C Extensive hysterectomy 58400 C Suspension of uterus 58410 C Suspension of uterus 58520 C Repair of ruptured uterus 58540 C Revision of uterus 58600 C Division of fallopian tube 58605 C Division of fallopian tube 58611 C Ligate oviduct(s) add-on 58615 C Occlude fallopian tube(s) 58700 C Removal of fallopian tube 58720 C Removal of ovary/tube(s) 58740 C Revise fallopian tube(s) 58750 C Repair oviduct 58752 C Revise ovarian tube(s) 58760 C Remove tubal obstruction 58770 C Create new tubal opening 58805 C Drainage of ovarian cyst(s) 58822 C Drain ovary abscess, percut 58823 C Drain pelvic abscess, percut 58825 C Transposition, ovary(s) 58940 C Removal of ovary(s) 58943 C Removal of ovary(s) 58950 C Resect ovarian malignancy 58951 C Resect ovarian malignancy 58952 C Resect ovarian malignancy 58960 C Exploration of abdomen 59100 C Remove uterus lesion 59120 C Treat ectopic pregnancy 59121 C Treat ectopic pregnancy 59130 C Treat ectopic pregnancy 59135 C Treat ectopic pregnancy 59136 C Treat ectopic pregnancy 59140 C Treat ectopic pregnancy 59325 C Revision of cervix Start Printed Page 18786 59350 C Repair of uterus 59514 C Cesarean delivery only 59525 C Remove uterus after cesarean 59620 C Attempted vbac delivery only 59830 C Treat uterus infection 59850 C Abortion 59851 C Abortion 59852 C Abortion 59855 C Abortion 59856 C Abortion 59857 C Abortion 59866 C Abortion (mpr) 60212 C Parital thyroid excision 60252 C Removal of thyroid 60254 C Extensive thyroid surgery 60260 C Repeat thyroid surgery 60270 C Removal of thyroid 60271 C Removal of thyroid 60502 C Re-explore parathyroids 60505 C Explore parathyroid glands 60512 C Autotransplant parathyroid 60520 C Removal of thymus gland 60521 C Removal of thymus gland 60522 C Removal of thymus gland 60540 C Explore adrenal gland 60545 C Explore adrenal gland 60600 C Remove carotid body lesion 60605 C Remove carotid body lesion 60650 C Laparoscopy adrenalectomy 61105 C Twist drill hole 61107 C Drill skull for implantation 61108 C Drill skull for drainage 61120 C Burr hole for puncture 61140 C Pierce skull for biopsy 61150 C Pierce skull for drainage 61151 C Pierce skull for drainage 61154 C Pierce skull & remove clot 61156 C Pierce skull for drainage 61210 C Pierce skull, implant device 61250 C Pierce skull & explore 61253 C Pierce skull & explore 61304 C Open skull for exploration 61305 C Open skull for exploration 61312 C Open skull for drainage 61313 C Open skull for drainage 61314 C Open skull for drainage 61315 C Open skull for drainage 61320 C Open skull for drainage 61321 C Open skull for drainage 61332 C Explore/biopsy eye socket 61333 C Explore orbit/remove lesion 61334 C Explore orbit/remove object 61340 C Relieve cranial pressure 61343 C Incise skull (press relief) 61345 C Relieve cranial pressure 61440 C Incise skull for surgery 61450 C Incise skull for surgery 61458 C Incise skull for brain wound 61460 C Incise skull for surgery 61470 C Incise skull for surgery 61480 C Incise skull for surgery 61490 C Incise skull for surgery 61500 C Removal of skull lesion 61501 C Remove infected skull bone 61510 C Removal of brain lesion 61512 C Remove brain lining lesion 61514 C Removal of brain abscess 61516 C Removal of brain lesion 61518 C Removal of brain lesion 61519 C Remove brain lining lesion 61520 C Removal of brain lesion 61521 C Removal of brain lesion 61522 C Removal of brain abscess 61524 C Removal of brain lesion 61526 C Removal of brain lesion 61530 C Removal of brain lesion 61531 C Implant brain electrodes 61533 C Implant brain electrodes 61534 C Removal of brain lesion 61535 C Remove brain electrodes 61536 C Removal of brain lesion 61538 C Removal of brain tissue 61539 C Removal of brain tissue 61541 C Incision of brain tissue 61542 C Removal of brain tissue 61543 C Removal of brain tissue 61544 C Remove & treat brain lesion 61545 C Excision of brain tumor 61546 C Removal of pituitary gland 61548 C Removal of pituitary gland 61550 C Release of skull seams 61552 C Release of skull seams 61556 C Incise skull/sutures 61557 C Incise skull/sutures 61558 C Excision of skull/sutures 61559 C Excision of skull/sutures 61563 C Excision of skull tumor 61564 C Excision of skull tumor 61570 C Remove foreign body, brain 61571 C Incise skull for brain wound 61575 C Skull base/brainstem surgery 61576 C Skull base/brainstem surgery 61580 C Craniofacial approach, skull 61581 C Craniofacial approach, skull 61582 C Craniofacial approach, skull 61583 C Craniofacial approach, skull 61584 C Orbitocranial approach/skull 61585 C Orbitocranial approach/skull 61586 C Resect nasopharynx, skull 61590 C Infratemporal approach/skull 61591 C Infratemporal approach/skull 61592 C Orbitocranial approach/skull 61595 C Transtemporal approach/skull 61596 C Transcochlear approach/skull 61597 C Transcondylar approach/skull 61598 C Transpetrosal approach/skull 61600 C Resect/excise cranial lesion 61601 C Resect/excise cranial lesion 61605 C Resect/excise cranial lesion 61606 C Resect/excise cranial lesion 61607 C Resect/excise cranial lesion 61608 C Resect/excise cranial lesion 61609 C Transect artery, sinus 61610 C Transect artery, sinus 61611 C Transect artery, sinus 61612 C Transect artery, sinus 61613 C Remove aneurysm, sinus 61615 C Resect/excise lesion, skull 61616 C Resect/excise lesion, skull 61618 C Repair dura 61619 C Repair dura 61624 C Occlusion/embolization cath 61626 C Occlusion/embolization cath 61680 C Intracranial vessel surgery 61682 C Intracranial vessel surgery 61684 C Intracranial vessel surgery 61686 C Intracranial vessel surgery 61690 C Intracranial vessel surgery 61692 C Intracranial vessel surgery 61700 C Inner skull vessel surgery 61702 C Inner skull vessel surgery 61703 C Clamp neck artery 61705 C Revise circulation to head 61708 C Revise circulation to head 61710 C Revise circulation to head 61711 C Fusion of skull arteries 61720 C Incise skull/brain surgery 61735 C Incise skull/brain surgery 61750 C Incise skull/brain biopsy 61751 C Brain biopsy w/ct/mr guide 61760 C Implant brain electrodes 61770 C Incise skull for treatment 61791 C Treat trigeminal tract 61795 C Brain surgery using computer 61850 C Implant neuroelectrodes 61860 C Implant neuroelectrodes 61862 C Implant neurostimul, subcort 61870 C Implant neuroelectrodes 61875 C Implant neuroelectrodes 61880 C Revise/remove neuroelectrode 61886 C Implant neurostim arrays 61888 C Revise/remove neuroreceiver 62000 C Treat skull fracture 62005 C Treat skull fracture 62010 C Treatment of head injury 62100 C Repair brain fluid leakage 62115 C Reduction of skull defect 62116 C Reduction of skull defect 62117 C Reduction of skull defect 62120 C Repair skull cavity lesion 62121 C Incise skull repair 62140 C Repair of skull defect 62141 C Repair of skull defect 62142 C Remove skull plate/flap 62143 C Replace skull plate/flap 62145 C Repair of skull & brain 62146 C Repair of skull with graft 62147 C Repair of skull with graft 62180 C Establish brain cavity shunt 62190 C Establish brain cavity shunt 62192 C Establish brain cavity shunt 62200 C Establish brain cavity shunt 62201 C Establish brain cavity shunt 62220 C Establish brain cavity shunt 62223 C Establish brain cavity shunt 62256 C Remove brain cavity shunt 62258 C Replace brain cavity shunt 62351 C Implant spinal canal cath 63001 C Removal of spinal lamina 63003 C Removal of spinal lamina 63005 C Removal of spinal lamina 63011 C Removal of spinal lamina 63012 C Removal of spinal lamina 63015 C Removal of spinal lamina 63016 C Removal of spinal lamina 63017 C Removal of spinal lamina 63020 C Neck spine disk surgery 63030 C Low back disk surgery 63035 C Spinal disk surgery add-on 63040 C Neck spine disk surgery 63042 C Low back disk surgery 63045 C Removal of spinal lamina 63046 C Removal of spinal lamina 63047 C Removal of spinal lamina 63048 C Remove spinal lamina add-on 63055 C Decompress spinal cord 63056 C Decompress spinal cord 63057 C Decompress spine cord add-on 63064 C Decompress spinal cord 63066 C Decompress spine cord add-on 63075 C Neck spine disk surgery 63076 C Neck spine disk surgery 63077 C Spine disk surgery, thorax 63078 C Spine disk surgery, thorax Start Printed Page 18787 63081 C Removal of vertebral body 63082 C Remove vertebral body add-on 63085 C Removal of vertebral body 63086 C Remove vertebral body add-on 63087 C Removal of vertebral body 63088 C Remove vertebral body add-on 63090 C Removal of vertebral body 63091 C Remove vertebral body add-on 63170 C Incise spinal cord tract(s) 63172 C Drainage of spinal cyst 63173 C Drainage of spinal cyst 63180 C Revise spinal cord ligaments 63182 C Revise spinal cord ligaments 63185 C Incise spinal column/nerves 63190 C Incise spinal column/nerves 63191 C Incise spinal column/nerves 63194 C Incise spinal column & cord 63195 C Incise spinal column & cord 63196 C Incise spinal column & cord 63197 C Incise spinal column & cord 63198 C Incise spinal column & cord 63199 C Incise spinal column & cord 63200 C Release of spinal cord 63250 C Revise spinal cord vessels 63251 C Revise spinal cord vessels 63252 C Revise spinal cord vessels 63265 C Excise intraspinal lesion 63266 C Excise intraspinal lesion 63267 C Excise intraspinal lesion 63268 C Excise intraspinal lesion 63270 C Excise intraspinal lesion 63271 C Excise intraspinal lesion 63272 C Excise intraspinal lesion 63273 C Excise intraspinal lesion 63275 C Biopsy/excise spinal tumor 63276 C Biopsy/excise spinal tumor 63277 C Biopsy/excise spinal tumor 63278 C Biopsy/excise spinal tumor 63280 C Biopsy/excise spinal tumor 63281 C Biopsy/excise spinal tumor 63282 C Biopsy/excise spinal tumor 63283 C Biopsy/excise spinal tumor 63285 C Biopsy/excise spinal tumor 63286 C Biopsy/excise spinal tumor 63287 C Biopsy/excise spinal tumor 63290 C Biopsy/excise spinal tumor 63300 C Removal of vertebral body 63301 C Removal of vertebral body 63302 C Removal of vertebral body 63303 C Removal of vertebral body 63304 C Removal of vertebral body 63305 C Removal of vertebral body 63306 C Removal of vertebral body 63307 C Removal of vertebral body 63308 C Remove vertebral body add-on 63655 C Implant neuroelectrodes 63700 C Repair of spinal herniation 63702 C Repair of spinal herniation 63704 C Repair of spinal herniation 63706 C Repair of spinal herniation 63707 C Repair spinal fluid leakage 63709 C Repair spinal fluid leakage 63710 C Graft repair of spine defect 63740 C Install spinal shunt 63741 C Install spinal shunt 64752 C Incision of vagus nerve 64755 C Incision of stomach nerves 64760 C Incision of vagus nerve 64763 C Incise hip/thigh nerve 64766 C Incise hip/thigh nerve 64802 C Remove sympathetic nerves 64804 C Remove sympathetic nerves 64809 C Remove sympathetic nerves 64818 C Remove sympathetic nerves 64820 C Remove sympathetic nerves 64866 C Fusion of facial/other nerve 64868 C Fusion of facial/other nerve 65273 C Repair of eye wound 69150 C Extensive ear canal surgery 69155 C Extensive ear/neck surgery 69502 C Mastoidectomy 69535 C Remove part of temporal bone 69554 C Remove ear lesion 69950 C Incise inner ear nerve 69970 C Remove inner ear lesion 74300 C X-ray bile ducts/pancreas 74301 C X-rays at surgery add-on 75900 C Arterial catheter exchange 75940 C X-ray placement, vein filter 75945 C Intravascular us 75946 C Intravascular us add-on 75960 C Transcatheter intro, stent 75961 C Retrieval, broken catheter 75962 C Repair arterial blockage 75964 C Repair artery blockage, each 75966 C Repair arterial blockage 75968 C Repair artery blockage, each 75970 C Vascular biopsy 75978 C Repair venous blockage 75992 C Atherectomy, x-ray exam 75993 C Atherectomy, x-ray exam 75994 C Atherectomy, x-ray exam 75995 C Atherectomy, x-ray exam 75996 C Atherectomy, x-ray exam 92970 C Cardioassist, internal 92971 C Cardioassist, external 92975 C Dissolve clot, heart vessel 92977 C Dissolve clot, heart vessel 92978 C Intravasc us, heart add-on 92979 C Intravasc us, heart add-on 92986 C Revision of aortic valve 92987 C Revision of mitral valve 92990 C Revision of pulmonary valve 92992 C Revision of heart chamber 92993 C Revision of heart chamber 92997 C Pul art balloon repr, percut 92998 C Pul art balloon repr, percut 94652 C Pressure breathing (IPPB) 94762 C Measure blood oxygen level 95920 C Intraop nerve test add-on 95961 C Electrode stimulation, brain 95962 C Electrode stim, brain add-on 99190 C Special pump services 99191 C Special pump services 99192 C Special pump services 99234 C Observ/hosp same date 99235 C Observ/hosp same date 99236 C Observ/hosp same date 99251 C Initial inpatient consult 99252 C Initial inpatient consult 99253 C Initial inpatient consult 99254 C Initial inpatient consult 99255 C Initial inpatient consult 99261 C Follow-up inpatient consult 99262 C Follow-up inpatient consult 99263 C Follow-up inpatient consult 99295 C Neonatal critical care 99296 C Neonatal critical care 99297 C Neonatal critical care 99298 C Neonatal critical care 99356 C Prolonged service, inpatient 99357 C Prolonged service, inpatient 99433 C Normal newborn care/hospital G0160 C Cryo. ablation, prostate Start Printed Page 18788Addendum F.—Status Indicators: How Various Services Are Treated Under Outpatient PPS
Indicator Service Status A Pulmonary Rehabilitation Clinical Trial Not Paid Under PPS C Inpatient Procedures Admit Patient; Bill as Inpatient A Durable Medical Equipment, Prosthetics and DMEPOS Fee Schedule E Non-Covered Items and Services Non-paid A Physical, Occupational and SpeechTherapy Rehabilitation Fee Schedule A Ambulance Ambulance Fee Schedule A EPO for ESRD Patients National Rate A Clinical Diagnostic Laboratory Services Laboratory Fee Schedule A Physican Services for ESRD Patients Not Paid Under PPS A Screening Mammography National Rate N Incidental Services, packaged into APC Rat Packaged P Partial Hospitalization Paid Per Diem APC S Significant Procedure, Not Discounted When Paid T Procedure, Multiple When Discount Applies Paid V Visit to Clinic or Emergency Department Paid X Ancillary Service Paid —————————— 1 Large Urban Area 2 Hospitals geographically located in the area are assigned the statewide rural wage index for FY 2000.Addendum G.—Service Mix Indices by Hospital
Hospital SMI 010001 3.13 010004 1.77 010005 2.17 010006 3.08 010007 1.70 010008 1.86 010009 1.69 010010 2.44 010011 2.56 010012 2.21 010015 2.29 010016 2.55 010018 6.45 010019 2.41 010021 1.74 010022 2.02 010023 2.85 010024 2.88 010025 2.14 010027 1.10 010029 3.22 010031 2.04 010032 1.28 010033 1.53 010034 2.69 010035 3.05 010036 2.72 010038 4.48 010039 2.19 010040 2.62 010043 2.32 010044 2.21 010045 2.00 010046 2.09 010047 1.67 010049 3.06 010050 1.93 010051 1.60 010052 1.60 010053 2.00 010054 1.88 010055 2.86 010056 2.70 010058 1.25 010059 1.90 010061 2.62 010062 1.81 010064 3.43 010065 2.41 010066 1.42 010068 1.39 010069 2.34 010072 2.61 010073 2.61 010078 2.55 010079 2.52 010080 1.08 010083 2.25 010084 4.17 010087 2.71 010089 2.61 010090 2.43 010091 1.63 010092 2.55 010094 2.50 010095 1.50 010097 2.07 010098 1.75 010099 2.14 010100 2.79 010101 2.38 010102 1.32 010103 2.38 010104 2.66 010108 1.95 010109 2.24 010110 1.20 010112 1.87 010113 2.85 010114 2.48 010115 1.47 010118 2.56 010119 2.13 010120 2.04 010123 3.11 010124 3.42 010125 1.44 010126 2.11 010127 3.32 010128 1.40 010129 1.84 010130 1.67 010131 2.80 010134 1.56 010137 1.57 010138 1.32 010139 2.72 010143 2.02 010144 2.70 010145 1.61 010146 3.10 010148 1.94 010149 2.84 010150 2.15 010152 2.14 010155 1.63 013025 1.64 013027 1.11 013028 0.93 013300 1.48 014002 1.41 020001 2.78 020002 2.30 020004 1.92 020005 1.07 020006 2.04 020007 0.87 020008 2.33 020009 1.05 020010 0.58 020011 1.02 020012 3.41 020013 1.89 020014 1.78 020017 3.41 020024 1.84 020025 1.06 024001 1.65 030001 2.73 030002 2.64 030003 2.15 030004 0.86 030006 2.79 030007 2.55 030009 1.43 030010 2.87 030011 3.75 030012 1.90 030013 2.56 030014 3.09 030016 1.86 030017 2.92 030018 3.33 030019 2.49 030022 1.73 030023 2.74 030024 3.70 030025 1.79 030027 1.63 030030 3.06 030033 2.60 030034 1.39 030035 3.18 030036 2.49 030037 4.59 030038 3.33 030040 1.99 030041 1.30 030043 2.57 030044 2.07 030047 1.68 030049 0.78 030054 0.83 030055 2.47 030059 2.66 030060 2.25 030061 2.09 030062 2.47 030064 2.59 030065 3.18 030067 1.59 030068 2.56 030069 3.02 030080 2.74 030083 2.58 030085 2.55 030086 2.27 030087 3.66 030088 2.22 030089 2.78 030092 2.94 030093 1.63 030094 2.11 030095 3.28 030099 2.09 033025 1.82 033026 2.18 033028 1.64 034004 1.58 034008 3.05 034009 1.55 034010 1.55 034013 1.57 034019 1.52 040001 2.42 040002 2.24 040003 1.98 040004 3.62 040005 2.05 040007 4.24 040008 1.31 040010 3.21 040011 2.11 040014 2.81 040015 1.77 040016 2.02 040017 2.57 040018 2.87 040019 2.10 040020 3.01 040021 3.28 040022 2.43 040024 1.80 Start Printed Page 18789 040025 1.76 040026 2.63 040027 3.19 040028 2.17 040029 3.57 040030 1.37 040032 0.92 040035 1.17 040036 3.29 040037 2.01 040039 2.51 040040 1.35 040041 3.36 040042 2.13 040044 1.40 040045 1.65 040047 1.77 040048 2.46 040050 2.88 040051 2.07 040053 1.60 040054 3.26 040055 2.81 040058 2.42 040060 1.45 040062 2.58 040064 1.41 040066 3.53 040067 1.19 040070 1.77 040072 2.31 040074 2.91 040075 1.74 040076 1.79 040077 1.77 040078 2.74 040080 1.87 040081 0.93 040082 1.77 040084 3.12 040085 1.90 040088 3.29 040090 1.43 040091 1.73 040093 1.37 040100 2.39 040105 1.29 040106 2.06 040107 1.59 040109 2.02 040114 5.13 040116 2.93 040118 2.82 040119 3.14 040124 2.53 040126 1.95 040132 0.96 043026 1.30 043027 0.85 043028 1.17 043029 1.86 043031 0.82 043032 3.76 043300 1.57 044004 1.54 044005 1.57 044006 1.64 044010 1.65 044012 1.59 050002 2.06 050006 2.44 050007 2.29 050009 2.97 050013 3.22 050014 2.86 050015 2.38 050016 2.13 050017 5.03 050018 2.55 050021 2.26 050022 2.85 050024 2.28 050025 2.34 050026 2.34 050028 2.52 050029 2.32 050030 1.88 050032 3.20 050033 2.24 050036 2.67 050038 1.49 050039 2.85 050042 3.26 050043 2.85 050045 3.17 050046 2.32 050047 3.05 050051 1.60 050054 1.75 050055 1.93 050056 3.46 050057 3.51 050058 2.74 050060 2.11 050061 5.22 050063 2.75 050065 2.53 050066 2.43 050067 1.93 050068 2.71 050069 2.78 050077 3.23 050078 2.67 050079 2.20 050080 2.13 050081 1.14 050082 2.90 050084 2.44 050088 1.44 050089 2.10 050090 2.52 050091 2.57 050092 1.87 050093 3.76 050095 3.98 050096 3.94 050097 3.79 050099 2.27 050100 2.75 050101 2.80 050102 2.14 050103 3.29 050104 2.27 050107 2.69 050108 2.76 050109 2.26 050110 3.28 050111 5.30 050112 2.67 050113 1.35 050114 2.76 050115 2.18 050116 2.99 050117 3.02 050118 2.63 050121 3.26 050122 2.54 050124 2.32 050125 3.20 050126 2.94 050127 2.04 050128 2.45 050129 2.73 050131 2.45 050132 2.98 050133 2.08 050135 1.59 050136 2.67 050144 2.46 050145 2.76 050146 1.41 050148 2.31 050149 2.40 050150 2.44 050152 2.31 050153 2.58 050155 2.14 050158 3.58 050159 1.48 050167 1.42 050168 3.40 050169 2.78 050170 2.83 050172 1.89 050173 2.82 050174 3.38 050175 3.37 050177 1.89 050179 2.63 050180 2.32 050183 1.30 050186 1.96 050188 3.77 050189 2.48 050191 2.69 050192 1.60 050193 1.89 050194 2.70 050195 2.38 050196 2.39 050197 2.76 050204 3.22 050205 2.35 050207 3.48 050208 2.09 050211 2.71 050213 1.28 050214 2.05 050215 3.07 050217 2.15 050219 1.98 050222 2.61 050224 2.71 050225 2.28 050226 2.85 050228 1.17 050230 2.91 050231 3.44 050232 2.92 050233 3.37 050234 1.67 050235 2.64 050236 2.17 Start Printed Page 18790 050238 2.14 050239 2.64 050240 2.66 050241 2.55 050242 2.23 050243 2.05 050245 1.24 050248 1.49 050251 2.23 050253 2.29 050254 3.23 050256 1.39 050257 1.90 050260 1.38 050261 2.11 050262 2.22 050264 2.24 050267 2.80 050270 2.61 050272 2.14 050274 1.56 050276 1.32 050277 2.59 050278 2.70 050279 1.93 050280 2.70 050281 3.99 050282 2.17 050283 1.16 050286 1.02 050289 2.76 050290 2.40 050291 1.73 050292 1.41 050293 1.42 050295 2.63 050296 2.45 050298 2.08 050299 3.08 050300 2.95 050301 2.95 050302 2.87 050305 2.12 050307 3.67 050308 2.42 050309 3.00 050310 2.96 050312 2.71 050313 3.15 050315 1.20 050317 1.84 050320 1.26 050324 3.46 050325 1.73 050327 2.36 050328 2.69 050329 1.93 050331 2.12 050333 1.10 050334 3.36 050335 1.34 050336 2.48 050337 1.78 050342 2.84 050343 3.36 050348 1.87 050349 1.17 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530011 2.24 530012 2.33 530014 2.79 530015 2.27 530016 2.03 530017 2.10 530018 1.65 530019 1.56 530022 2.09 530023 1.65 530025 2.01 530026 1.52 530027 1.58 530029 1.01 530031 1.02 530032 2.22 534003 1.56 650001 2.01 —————————— 1 All counties within state are classified as urban.Addendum H.—Wage Index for Urban Areas
Urban Code Urban Area (Constituent Counties) Wage Index 0040 Abilene, TX Taylor, TX 0.8179 0060 2 Aguadilla, PR Aguada, PR Aguadilla, PR Moca, PR 0.4249 0080 Akron, OH Portage, OH Summit, OH 1.0163 0120 Albany, GA Dougherty, GA Lee, GA 1.0372 0160 Albany-Schenectady-Troy, NY Albany, NY Montgomery, NY Rensselaer, NY Saratoga, NY Schenectady, NY Schoharie, NY 0.8754 0200 Albuquerque, NM Bernalillo, NM Sandoval, NM Valencia, NM 0.8499 0220 Alexandria, LA Rapides, LA 0.7910 0240 Allentown-Bethlehem-Easton, PA Carbon, PA Lehigh, PA Northampton, PA 0.9550 0280 Altoona, PA Blair, PA 0.9342 0320 Amarillo, TX Potter, TX Randall, TX 0.8435 0380 Anchorage, AK Anchorage, AK 1.3009 0440 Ann Arbor, MI Lenawee, MI Livingston, MI Washtenaw, MI 1.1483 0450 Anniston, AL Calhoun, AL 0.8462 0460 Appleton-Oshkosh-Neenah, WI Calumet, WI Outagamie, WI Winnebago, WI 0.8913 0470 Arecibo, PR Arecibo, PR Camuy, PR Hatillo, PR 0.4815 0480 Asheville, NC Buncombe, NC Madison, NC 0.8884 0500 Athens, GA Clarke, GA Madison, GA Oconee, GA 0.9800 0520 1 Atlanta, GA Barrow, GA Bartow, GA Carroll, GA Cherokee, GA Clayton, GA Cobb, GA Coweta, GA DeKalb, GA Douglas, GA Fayette, GA Forsyth, GA Fulton, GA Gwinnett, GA Henry, GA Newton, GA Paulding, GA Pickens, GA Rockdale, GA Spalding, GA Walton 1.0050 0560 Atlantic-Cape May, NJ Atlantic, NJ Cape May, NJ 1.1050 0580 Auburn-Opelika, AL Lee, AL 0.7748 0600 Augusta-Aiken, GA-SC Columbia, GA McDuffie, GA Richmond, GA Aiken, SC Edgefield, SC 0.9013 0640 1 Austin-San Marcos, TX Bastrop, TX Caldwell, TX Hays, TX Travis, TX Williamson, TX 0.9081 0680 2 Bakersfield, CA Kern, CA 0.9951 0720 1 Baltimore, MD Anne Arundel, MD Baltimore, MD Baltimore City, MD Carroll, MD Harford, MD Howard, MD Queen Anne's, MD 0.9891 0733 Bangor, ME Penobscot, ME 0.9609 0743 Barnstable-Yarmouth, MA Barnstable, MA 1.3302 0760 Baton Rouge, LA Ascension, LA East Baton Rouge, LA Livingston, LA West Baton Rouge, LA 0.8707 0840 Beaumont-Port Arthur, TX Hardin, TX Jefferson, TX Orange, TX 0.8624 0860 Bellingham, WA Whatcom, WA 1.1394 0870 2 Benton Harbor, MI Berrien, MI 0.8831 0875 1 Bergen-Passaic, NJ Bergen, NJ Passaic, NJ 1.1833 0880 Billings, MT Yellowstone, MT 1.0038 0920 Biloxi-Gulfport-Pascagoula, MS Hancock, MS Harrison, MS Jackson, MS 0.7949 0960 Binghamton, NY Broome, NY Tioga, NY 0.8750 1000 Birmingham, AL Blount, AL Jefferson, AL St. Clair, AL Shelby, AL 0.8994 1010 Bismarck, ND Burleigh, ND Morton, ND 0.7893 1020 Bloomington, IN Monroe, IN 0.8593 1040 Bloomington-Normal, IL McLean, IL 0.8993 1080 Boise City, ID Ada, ID Canyon, ID 0.9086 1123 1 2 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (MA Hospitals) Bristol, MA Essex, MA Middlesex, MA Norfolk, MA Plymouth, MA Suffolk, MA Worcester, MA Hillsborough, NH Merrimack, NH Rockingham, NH Strafford, NH 1.1369 1123 1 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (NH Hospitals) Bristol, MA Essex, MA Middlesex, MA Norfolk, MA Plymouth, MA Suffolk, MA Worcester, MA Hillsborough, NH Merrimack, NH Rockingham, NH Strafford, NH 1.1358 Start Printed Page 18814 1125 Boulder-Longmont, CO Boulder, CO 0.9944 1145 Brazoria, TX Brazoria, TX 0.8516 1150 Bremerton, WA Kitsap, WA 1.1011 1240 Brownsville-Harlingen-San Benito, TX Cameron, TX 0.9212 1260 Bryan-College Station, TX Brazos, TX 0.8501 1280 1 Buffalo-Niagara Falls, NY Erie, NY Niagara, NY 0.9604 1303 Burlington, VT Chittenden, VT Franklin, VT Grand Isle, VT 1.0558 1310 Caguas, PR Caguas, PR Cayey, PR Cidra, PR Gurabo, PR San Lorenzo, PR 0.4561 1320 2 Canton-Massillon, OH Carroll, OH Stark, OH 0.8649 1350 Casper, WY Natrona, WY 0.9199 1360 Cedar Rapids, IA Linn, IA 0.9018 1400 Champaign-Urbana, IL Champaign, IL 0.9163 1440 Charleston-North Charleston, SC Berkeley, SC Charleston, SC Dorchester, SC 0.8988 1480 Charleston, WV Kanawha, WV Putnam, WV 0.9095 1520 1 Charlotte-Gastonia-Rock Hill, NC-SC Cabarrus, NC Gaston, NC Lincoln, NC Mecklenburg, NC Rowan, NC Stanly, NC Union, NC York, SC 0.9433 1540 Charlottesville, VA Albemarle, VA Charlottesville City, VA Fluvanna, VA Greene, VA 1.0573 1560 Chattanooga, TN-GA Catoosa, GA Dade, GA Walker, GA Hamilton, TN Marion, TN 0.9731 1580 2 Cheyenne, WY Laramie, WY 0.8859 1600 1 Chicago, IL Cook, IL DeKalb, IL DuPage, IL Grundy, IL Kane, IL Kendall, IL Lake, IL McHenry, IL Will, IL 1.0872 1620 Chico-Paradise, CA Butte, CA 1.0390 1640 1 Cincinnati, OH-KY-IN Dearborn, IN Ohio, IN Boone, KY Campbell, KY Gallatin, KY Grant, KY Kenton, KY Pendleton, KY Brown, OH Clermont, OH Hamilton, OH Warren, OH 0.9434 1660 Clarksville-Hopkinsville, TN-KY Christian, KY Montgomery, TN 0.8283 1680 1 Cleveland-Lorain-Elyria, OH Ashtabula, OH Cuyahoga, OH Geauga, OH Lake, OH Lorain, OH Medina, OH 0.9688 1720 Colorado Springs, CO El Paso, CO 0.9218 1740 Columbia, MO Boone, MO 0.8904 1760 Columbia, SC Lexington, SC Richland, SC 0.9357 1800 Columbus, GA-AL Russell, AL Chattahoochee, GA Harris, GA Muscogee, GA 0.8510 1840 1 Columbus, OH Delaware, OH Fairfield, OH Franklin, OH Licking, OH Madison, OH Pickaway, OH 0.9907 1880 Corpus Christi, TX Nueces, TX San Patricio, TX 0.8702 1890 Corvallis, OR Benton, OR 1.1087 1900 Cumberland, MD-WV (Maryland Hospitals) Allegany, MD Mineral, WV 0.8801 1920 1 Dallas, TX Collin, TX Dallas, TX Denton, TX Ellis, TX Henderson, TX Hunt, TX Kaufman, TX Rockwall, TX 0.9589 1950 Danville, VA Danville City, VA Pittsylvania, VA 0.9061 1960 Davenport-Moline-Rock Island, IA-IL Scott, IA Henry, IL Rock Island, IL 0.8706 2000 Dayton-Springfield, OH Clark, OH Greene, OH Miami, OH Montgomery, OH 0.9336 2020 2 Daytona Beach, FL Flagler, FL Volusia, FL 0.8986 2030 Decatur, AL Lawrence, AL Morgan, AL 0.8679 2040 Decatur, IL Macon, IL 0.8321 2080 1 Denver, CO Adams, CO Arapahoe, CO Denver, CO Douglas, CO Jefferson, CO 1.0197 2120 Des Moines, IA Dallas, IA Polk, IA Warren, IA 0.8754 2160 1 Detroit, MI Lapeer, MI Macomb, MI Monroe, MI Oakland, MI St. Clair, MI Wayne, MI 1.0421 2180 Dothan, AL Dale, AL Houston, AL 0.7836 2190 Dover, DE Kent, DE 0.9335 2200 Dubuque, IA Dubuque, IA 0.8520 2240 Duluth-Superior, MN-WI St. Louis, MN Douglas, WI 1.0165 2281 Dutchess County, NY Dutchess, NY 0.9872 2290 Eau Claire, WI Chippewa, WI Eau Claire, WI 0.8957 2320 El Paso, TX El Paso, TX 0.8947 2330 Elkhart-Goshen, IN Elkhart, IN 0.9379 2335 2 Elmira, NY Chemung, NY 0.8636 2340 Enid, OK Garfield, OK 0.7953 2360 Erie, PA Erie, PA 0.9023 2400 Eugene-Springfield, OR Lane, OR 1.0765 2440 2 Evansville-Henderson, IN-KY (IN Hospitals) Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 0.8396 2440 Evansville-Henderson, IN-KY (KY Hospitals) Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 0.8303 2520 Fargo-Moorhead, ND-MN Clay, MN Cass, ND 0.8620 2560 Fayetteville, NC Cumberland, NC 0.8494 2580 Fayetteville-Springdale-Rogers, AR Benton, AR Washington, AR 0.7773 2620 Flagstaff, AZ-UT Coconino, AZ Kane, UT 1.0348 2640 Flint, MI Genesee, MI 1.1020 2650 Florence, AL Colbert, AL Lauderdale, AL 0.7927 2655 Florence, SC Florence, SC 0.8618 2670 Fort Collins-Loveland, CO Larimer, CO 1.0302 2680 1 Ft. Lauderdale, FL Broward, FL 1.0172 2700 2 Fort Myers-Cape Coral, FL Lee, FL 0.8986 Start Printed Page 18815 2710 Fort Pierce-Port St. Lucie, FL Martin, FL St. Lucie, FL 1.0109 2720 Fort Smith, AR-OK Crawford, AR Sebastian, AR Sequoyah, OK 0.7844 2750 2 Fort Walton Beach, FL Okaloosa, FL 0.8986 2760 Fort Wayne, IN Adams, IN Allen, IN De Kalb, IN Huntington, IN Wells, IN Whitley, IN 0.9096 2800 1 Forth Worth-Arlington, TX Hood, TX Johnson, TX Parker, TX Tarrant, TX 0.9835 2840 Fresno, CA Fresno, CA Madera, CA 1.0262 2880 Gadsden, AL Etowah, AL 0.8754 2900 Gainesville, FL Alachua, FL 1.0102 2920 Galveston-Texas City, TX Galveston, TX 0.9732 2960 Gary, IN Lake, IN Porter, IN 0.9369 2975 2 Glens Falls, NY Warren, NY Washington, NY 0.8636 2980 Goldsboro, NC Wayne, NC 0.8333 2985 Grand Forks, ND-MN Polk, MN Grand Forks, ND 0.9097 2995 Grand Junction, CO Mesa, CO 0.9188 3000 1 Grand Rapids-Muskegon-Holland, MI Allegan, MI Kent, MI Muskegon, MI Ottawa, MI 1.0135 3040 Great Falls, MT Cascade, MT 1.0459 3060 Greeley, CO Weld, CO 0.9722 3080 Green Bay, WI Brown, WI 0.9215 3120 1 Greensboro-Winston-Salem-High Point, NC Alamance, NC Davidson, NC Davie, NC Forsyth, NC Guilford, NC Randolph, NC Stokes, NC Yadkin, NC 0.9037 3150 Greenville, NC Pitt, NC 0.9500 3160 Greenville-Spartanburg-Anderson, SC Anderson, SC Cherokee, SC Greenville, SC Pickens, SC Spartanburg, SC 0.9188 3180 Hagerstown, MD Washington, MD 0.8853 3200 Hamilton-Middletown, OH Butler, OH 0.8989 3240 Harrisburg-Lebanon-Carlisle, PA Cumberland, PA Dauphin, PA Lebanon, PA Perry, PA 0.9917 3283 1 2 Hartford, CT Hartford, CT Litchfield, CT Middlesex, CT Tolland, CT 1.2413 3285 2 Hattiesburg, MS Forrest, MS Lamar, MS 0.7306 3290 Hickory-Morganton-Lenoir, NC Alexander, NC Burke, NC Caldwell, NC Catawba, NC 0.9148 3320 Honolulu, HI Honolulu, HI 1.1479 3350 Houma, LA Lafourche, LA Terrebonne, LA 0.7837 3360 1 Houston, TX Chambers, TX Fort Bend, TX Harris, TX Liberty, TX Montgomery, TX Waller, TX 0.9387 3400 Huntington-Ashland, WV-KY-OH Boyd, KY Carter, KY Greenup, KY Lawrence, OH Cabell, WV Wayne, WV 0.9757 3440 Huntsville, AL Limestone, AL Madison, AL 0.8822 3480 1 Indianapolis, IN Boone, IN Hamilton, IN Hancock, IN Hendricks, IN Johnson, IN Madison, IN Marion, IN Morgan, IN Shelby, IN 0.9792 3500 Iowa City, IA Johnson, IA 0.9607 3520 Jackson, MI Jackson, MI 0.8840 3560 Jackson, MS Hinds, MS Madison, MS Rankin, MS 0.8387 3580 Jackson, TN Madison, TN Chester, TN 0.8600 3600 1 2 Jacksonville, FL Clay, FL Duval, FL Nassau, FL St. Johns, FL 0.8986 3605 2 Jacksonville, NC Onslow, NC 0.8290 3610 2 Jamestown, NY Chautauqua, NY 0.8636 3620 Janesville-Beloit, WI Rock, WI 0.9656 3640 Jersey City, NJ Hudson, NJ 1.1674 3660 Johnson City-Kingsport-Bristol, TN-VA Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN Bristol City, VA Scott, VA Washington, VA 0.8894 3680 2 Johnstown, PA Cambria, PA Somerset, PA 0.8524 3700 Jonesboro, AR Craighead, AR 0.7251 3710 2 Joplin, MO Jasper, MO Newton, MO 0.7723 3720 Kalamazoo-Battlecreek, MI Calhoun, MI Kalamazoo, MI Van Buren, MI 0.9981 3740 Kankakee, IL Kankakee, IL 0.8598 3760 1 Kansas City, KS-MO Johnson, KS Leavenworth, KS Miami, KS Wyandotte, KS Cass, MO Clay, MO Clinton, MO Jackson, MO Lafayette, MO Platte, MO Ray, MO 0.9322 3800 Kenosha, WI Kenosha, WI 0.9033 3810 Killeen-Temple, TX Bell, TX Coryell, TX 0.9932 3840 Knoxville, TN Anderson, TN Blount, TN Knox, TN Loudon, TN Sevier, TN Union, TN 0.9199 3850 Kokomo, IN Howard, IN Tipton, IN 0.8984 3870 La Crosse, WI-MN Houston, MN La Crosse, WI 0.8933 3880 Lafayette, LA Acadia, LA Lafayette, LA St. Landry, LA St. Martin, LA 0.8397 3920 Lafayette, IN Clinton, IN Tippecanoe, IN 0.8809 3960 Lake Charles, LA Calcasieu, LA 0.7966 3980 2 Lakeland-Winter Haven, FL Polk, FL 0.8986 4000 Lancaster, PA Lancaster, PA 0.9255 4040 Lansing-East Lansing, MI Clinton, MI Eaton, MI Ingham, MI 0.9977 4080 Laredo, TX Webb, TX 0.8323 4100 Las Cruces, NM Dona Ana, NM 0.8590 4120 1 Las Vegas, NV-AZ Mohave, AZ Clark, NV Nye, NV 1.1258 Start Printed Page 18816 4150 Lawrence, KS Douglas, KS 0.8222 4200 Lawton, OK Comanche, OK 0.9532 4243 Lewiston-Auburn, ME Androscoggin, ME 0.8899 4280 Lexington, KY Bourbon, KY Clark, KY Fayette, KY Jessamine, KY Madison, KY Scott, KY Woodford, KY 0.8552 4320 Lima, OH Allen, OH Auglaize, OH 0.9108 4360 Lincoln, NE Lancaster, NE 0.9670 4400 Little Rock-North Little Rock, AR Faulkner, AR Lonoke, AR Pulaski, AR Saline, AR 0.8614 4420 Longview-Marshall, TX Gregg, TX Harrison, TX Upshur, TX 0.8738 4480 1 Los Angeles-Long Beach, CA Los Angeles, CA 1.2085 4520 Louisville, KY-IN Clark, IN Floyd, IN Harrison, IN Scott, IN Bullitt, KY Jefferson, KY Oldham, KY 0.9381 4600 Lubbock, TX Lubbock, TX 0.8411 4640 Lynchburg, VA Amherst, VA Bedford, VA Bedford City, VA Campbell, VA Lynchburg City, VA 0.8814 4680 Macon, GA Bibb, GA Houston, GA Jones, GA Peach, GA Twiggs, GA 0.8530 4720 Madison, WI Dane, WI 0.9729 4800 2 Mansfield, OH Crawford, OH Richland, OH 0.8649 4840 Mayaguez, PR Anasco, PR Cabo Rojo, PR Hormigueros, PR Mayaguez, PR Sabana Grande, PR San German, PR 0.4674 4880 McAllen-Edinburg-Mission, TX Hidalgo, TX 0.8120 4890 Medford-Ashland, OR Jackson, OR 1.0492 4900 Melbourne-Titusville-Palm Bay, FL Brevard, Fl 0.9296 4920 1 Memphis, TN-AR-MS Crittenden, AR DeSoto, MS Fayette, TN Shelby, TN Tipton, TN 0.8244 4940 Merced, CA Merced, CA 1.0509 5000 1 Miami, FL Dade, FL 1.0233 5015 1 Middlesex-Somerset-Hunterdon, NJ Hunterdon, NJ Middlesex, NJ Somerset, NJ 1.0876 5080 1 Milwaukee-Waukesha, WI Milwaukee, WI Ozaukee, WI Washington, WI Waukesha, WI 0.9845 5120 1 Minneapolis-St. Paul, MN-WI Anoka, MN Carver, MN Chisago, MN Dakota, MN Hennepin, MN Isanti, MN Ramsey, MN Scott, MN Sherburne, MN Washington, MN Wright, MN Pierce, WI St. Croix, WI 1.0929 5140 Missoula, MT Missoula, MT 0.9085 5160 Mobile, AL Baldwin, AL Mobile, AL 0.8267 5170 Modesto, CA Stanislaus, CA 1.0111 5190 1 Monmouth-Ocean, NJ Monmouth, NJ Ocean, NJ 1.1258 5200 Monroe, LA Ouachita, LA 0.8221 5240 Montgomery, AL Autauga, AL Elmore, AL Montgomery, AL 0.7724 5280 Muncie, IN Delaware, IN 1.0834 5330 Myrtle Beach, SC Horry, SC 0.8529 5345 Naples, FL Collier, FL 0.9839 5360 1 Nashville, TN Cheatham, TN Davidson, TN Dickson, TN Robertson, TN Rutherford TN Sumner, TN Williamson, TN Wilson, TN 0.9449 5380 1 Nassau-Suffolk, NY Nassau, NY Suffolk, NY 1.4074 5483 1 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT Fairfield, CT New Haven, CT 1.2417 5523 New London-Norwich, CT New London, CT 1.2428 5560 1 New Orleans, LA Jefferson, LA Orleans, LA Plaquemines, LA St. Bernard, LA St. Charles, LA St. James, LA St. John The Baptist, LA St. Tammany, LA 0.9089 5600 1 New York, NY Bronx, NY Kings, NY New York, NY Putnam, NY Queens, NY Richmond, NY Rockland, NY Westchester, NY 1.4517 5640 1 Newark, NJ Essex, NJ Morris, NJ Sussex, NJ Union, NJ Warren, NJ 1.0772 5660 Newburgh, NY-PA Orange, NY Pike, PA 1.0908 5720 1 Norfolk-Virginia Beach-Newport News, VA-NC Currituck, NC Chesapeake City, VA Gloucester, VA Hampton City, VA Isle of Wight, VA James City, VA Mathews, VA Newport News City, VA Norfolk City, VA Poquoson City, VA Portsmouth City, VA Suffolk C 0.8442 5775 1 Oakland, CA Alameda, CA Contra Costa, CA 1.5095 5790 Ocala, FL Marion, FL 0.9615 5800 Odessa-Midland, TX Ector, TX Midland, TX 0.8873 5880 1 Oklahoma City, OK Canadian, OK Cleveland, OK Logan, OK McClain, OK Oklahoma, OK Pottawatomie, OK 0.8589 5910 Olympia, WA Thurston, WA 1.0932 5920 Omaha, NE-IA Pottawattamie, IA Cass, NE Douglas, NE Sarpy, NE Washington, NE 1.0455 5945 1 Orange County, CA Orange, CA 1.1592 5960 1 Orlando, FL Lake, FL Orange, FL Osceola, FL Seminole, FL 0.9806 5990 Owensboro, KY Daviess, KY 0.8104 6015 Panama City, FL Bay, FL 0.9169 6020 Parkersburg-Marietta, WV-OH (WV Hospitals) Washington, OH Wood, WV 0.8414 6020 2 Parkersburg-Marietta, WV-OH (OH Hospitals) Washington, OH Wood, WV 0.8649 6080 2 Pensacola, FL Escambia, FL Santa Rosa, FL 0.8986 6120 Peoria-Pekin, IL Peoria, IL Tazewell, IL Woodford, IL 0.8399 6160 1 Philadelphia, PA-NJ Burlington, NJ Camden, NJ Gloucester, NJ Salem, NJ Bucks, PA Chester, PA Delaware, PA Montgomery, PA Philadelphia, PA 1.1186 6200 1 Phoenix-Mesa, AZ Maricopa, AZ Pinal, AZ 0.9464 6240 Pine Bluff, AR Jefferson, AR 0.7697 Start Printed Page 18817 6280 1 Pittsburgh, PA Allegheny, PA Beaver, PA Butler, PA Fayette, PA Washington, PA Westmoreland, PA 0.9634 6323 2 Pittsfield, MA Berkshire, MA 1.1369 6340 Pocatello, ID Bannock, ID 0.8973 6360 Ponce, PR Guayanilla, PR Juana Diaz, PR Penuelas, PR Ponce, PR Villalba, PR Yauco, PR 0.4971 6403 Portland, ME Cumberland, ME Sagadahoc, ME York, ME 0.9487 6440 1 Portland-Vancouver, OR-WA Clackamas, OR Columbia, OR Multnomah, OR Washington, OR Yamhill, OR Clark, WA 1.0996 6483 1 Providence-Warwick-Pawtucket, RI Bristol, RI Kent, RI Newport, RI Providence, RI Washington, RI 1.0690 6520 Provo-Orem, UT Utah, UT 0.9818 6560 Pueblo, CO Pueblo, CO 0.8853 6580 Punta Gorda, FL Charlotte, FL 0.9508 6600 Racine, WI Racine, WI 0.9216 6640 1 Raleigh-Durham-Chapel Hill, NC Chatham, NC Durham, NC Franklin, NC Johnston, NC Orange, NC Wake, NC 0.9544 6660 Rapid City, SD Pennington, SD 0.8363 6680 Reading, PA Berks, PA 0.9436 6690 Redding, CA Shasta, CA 1.1263 6720 Reno, NV Washoe, NV 1.0655 6740 Richland-Kennewick-Pasco, WA Benton, WA Franklin, WA 1.1224 6760 Richmond-Petersburg, VA Charles City County, VA Chesterfield, VA Colonial Heights City, VA Dinwiddie, VA Goochland, VA Hanover, VA Henrico, VA Hopewell City, VA New Kent, VA Petersburg City, VA Powhatan, VA Prince George, VA Richmond City, V 0.9545 6780 1 Riverside-San Bernardino, CA Riverside, CA San Bernardino, CA 1.1061 6800 Roanoke, VA Botetourt, VA Roanoke, VA Roanoke City, VA Salem City, VA 0.8142 6820 Rochester, MN Olmsted, MN 1.1429 6840 1 Rochester, NY Genesee, NY Livingston, NY Monroe, NY Ontario, NY Orleans, NY Wayne, NY 0.9184 6880 Rockford, IL Boone, IL Ogle, IL Winnebago, IL 0.8783 6895 Rocky Mount, NC Edgecombe, NC Nash, NC 0.8735 6920 1 Sacramento, CA El Dorado, CA Placer, CA Sacramento, CA 1.2284 6960 Saginaw-Bay City-Midland, MI Bay, MI Midland, MI Saginaw, MI 0.9294 6980 St. Cloud, MN Benton, MN Stearns, MN 0.9608 7000 St. Joseph, MO Andrew, MO Buchanan, MO 0.8943 7040 1 St. Louis, MO-IL Clinton, IL Jersey, IL Madison, IL Monroe, IL St. Clair, IL Franklin, MO Jefferson, MO Lincoln, MO St. Charles, MO St. Louis, MO St. Louis City, MO Warren, MO 0.9052 7080 Salem, OR Marion, OR Polk, OR 0.9949 7120 Salinas, CA Monterey, CA 1.4710 7160 1 Salt Lake City-Ogden, UT Davis, UT Salt Lake, UT Weber, UT 0.9854 7200 San Angelo, TX Tom Green, TX 0.7845 7240 1 San Antonio, TX Bexar, TX Comal, TX Guadalupe, TX Wilson, TX 0.8318 7320 1 San Diego, CA San Diego, CA 1.1955 7360 1 San Francisco, CA Marin, CA San Francisco, CA San Mateo, CA 1.3784 7400 1 San Jose, CA Santa Clara, CA 1.3492 7440 1 San Juan-Bayamon, PR Aguas Buenas, PR Barceloneta, PR Bayamon, PR Canovanas, PR Carolina, PR Catano, PR Ceiba, PR Comerio, PR Corozal, PR Dorado, PR Fajardo, PR Florida, PR Guaynabo, PR Humacao, PR Juncos, PR Los Piedras, PR Loiza, PR Lug 0.4657 7460 San Luis Obispo-Atascadero-Paso Robles, CA San Luis Obispo, CA 1.0470 7480 Santa Barbara-Santa Maria-Lompoc, CA Santa Barbara, CA 1.0819 7485 Santa Cruz-Watsonville, CA Santa Cruz, CA 1.3927 7490 Santa Fe, NM Los Alamos, NM Santa Fe, NM 1.0437 7500 Santa Rosa, CA Sonoma, CA 1.3000 7510 Sarasota-Bradenton, FL Manatee, FL Sarasota, FL 0.9905 7520 Savannah, GA Bryan, GA Chatham, GA Effingham, GA 0.9953 7560 2 Scranton—Wilkes-Barre—Hazleton, PA Columbia, PA Lackawanna, PA Luzerne, PA Wyoming, PA 0.8524 7600 1 Seattle-Bellevue-Everett, WA Island, WA King, WA Snohomish, WA 1.1289 7610 2 Sharon, PA Mercer, PA 0.8524 7620 2 Sheboygan, WI Sheboygan, WI 0.8759 7640 Sherman-Denison, TX Grayson, TX 0.9329 7680 Shreveport-Bossier City, LA Bossier, LA Caddo, LA Webster, LA 0.9049 7720 Sioux City, IA-NE Woodbury, IA Dakota, NE 0.8549 7760 Sioux Falls, SD Lincoln, SD Minnehaha, SD 0.8776 7800 South Bend, IN St. Joseph, IN 0.9793 7840 Spokane, WA Spokane, WA 1.0799 7880 Springfield, IL Menard, IL Sangamon, IL 0.8684 7920 Springfield, MO Christian, MO Greene, MO Webster, MO 0.7991 8003 2 Springfield, MA Hampden, MA Hampshire, MA 1.1369 8050 State College, PA Centre, PA 0.9138 8080 2 Steubenville-Weirton, OH-WV (OH Hospitals) Jefferson, OH Brooke, WV Hancock, WV 0.8649 8080 Steubenville-Weirton, OH-WV (WV Hospitals) Jefferson, OH Brooke, WV Hancock, WV 0.8614 8120 Stockton-Lodi, CA San Joaquin, CA 1.0518 Start Printed Page 18818 8140 2 Sumter, SC Sumter, SC 0.8264 8160 Syracuse, NY Cayuga, NY Madison, NY Onondaga, NY Oswego, NY 0.9441 8200 Tacoma, WA Pierce, WA 1.1631 8240 2 Tallahassee, FL Gadsden, FL Leon, FL 0.8986 8280 1 Tampa-St. Petersburg-Clearwater, FL Hernando, FL Hillsborough, FL Pasco, FL Pinellas, FL 0.9119 8320 Terre Haute, IN Clay, IN Vermillion, IN Vigo, IN 0.8570 8360 Texarkana, AR-Texarkana, TX Miller, AR Bowie, TX 0.8174 8400 Toledo, OH Fulton, OH Lucas, OH Wood, OH 0.9593 8440 Topeka, KS Shawnee, KS 0.9326 8480 Trenton, NJ Mercer, NJ 0.9955 8520 Tucson, AZ Pima, AZ 0.8742 8560 Tulsa, OK Creek, OK Osage, OK Rogers, OK Tulsa, OK Wagoner, OK 0.8086 8600 Tuscaloosa, AL Tuscaloosa, AL 0.8064 8640 Tyler, TX Smith, TX 0.9369 8680 2 Utica-Rome, NY Herkimer, NY Oneida, NY 0.8636 8720 Vallejo-Fairfield-Napa, CA Napa, CA Solano, CA 1.2655 8735 Ventura, CA Ventura, CA 1.0952 8750 Victoria, TX Victoria, TX 0.8378 8760 Vineland-Millville-Bridgeton, NJ Cumberland, NJ 1.0517 8780 Visalia-Tulare-Porterville, CA Tulare, CA 1.0411 8800 Waco, TX McLennan, TX 0.8075 8840 1 Washington, DC-MD-VA-WV District of Columbia, DC Calvert, MD Charles, MD Frederick, MD Montgomery, MD Prince Georges, MD Alexandria City, VA Arlington, VA Clarke, VA Culpeper, VA Fairfax, VA Fairfax City, VA Falls Church City, VA Fauquier, 8920 Waterloo-Cedar Falls, IA Black Hawk, IA 0.8841 8940 Wausau, WI Marathon, WI 0.9445 8960 1 West Palm Beach-Boca Raton, FL Palm Beach, FL 0.9909 9000 2 Wheeling, WV-OH (WV Hospitals) Belmont, OH Marshall, WV Ohio, WV 0.8068 9000 2 Wheeling, WV-OH (OH Hospitals) Belmont, OH Marshall, WV Ohio, WV 0.8649 9040 Wichita, KS Butler, KS Harvey, KS Sedgwick, KS 0.9421 9080 Wichita Falls, TX Archer, TX Wichita, TX 0.7652 9140 2 Williamsport, PA Lycoming, PA 0.8524 9160 Wilmington-Newark, DE-MD New Castle, DE Cecil, MD 1.1274 9200 Wilmington, NC New Hanover, NC Brunswick, NC 0.9707 9260 2 Yakima, WA Yakima, WA 1.0446 9270 Yolo, CA Yolo, CA 1.0485 9280 York, PA York, PA 0.9309 9320 Youngstown-Warren, OH Columbiana, OH Mahoning, OH Trumbull, OH 0.9996 9340 Yuba City, CA Sutter, CA Yuba, CA 1.0662 9360 Yuma, AZ Yuma, AZ 0.9924 Start Printed Page 18819Addendum I.—Wage Index for Rural Areas
Nonurban Area Wage Index Alabama 0.7390 Alaska 1.2057 Arizona 0.8544 Arkansas 0.7236 California 0.9951 Colorado 0.8813 Connecticut 1.2413 Delaware 0.9166 Florida 0.8986 Georgia 0.8094 Hawaii 1.0726 Idaho 0.8651 Illinois 0.8047 Indiana 0.8396 Iowa 0.7926 Kansas 0.7460 Kentucky 0.8043 Louisiana 0.7486 Maine 0.8639 Maryland 0.8631 Massachusetts 1.1369 Michigan 0.8831 Minnesota 0.8669 Mississippi 0.7306 Missouri 0.7723 Montana 0.8398 Nebraska 0.8007 Nevada 0.9097 New Hampshire 0.9905 1 New Jersey New Mexico 0.8378 New York 0.8636 North Carolina 0.8290 North Dakota 0.7647 Ohio 0.8649 Oklahoma 0.7255 Oregon 0.9873 Pennsylvania 0.8524 Puerto Rico 0.4249 1 Rhode Island South Carolina 0.8264 South Dakota 0.7576 Tennessee 0.7650 Texas 0.7471 Utah 0.8906 Vermont 0.9427 Virginia 0.7916 Washington 1.0446 West Virginia 0.8068 Wisconsin 0.8759 Wyoming 0.8859 —————————— CPT codes and descriptions only are copyright American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. Copyright American Dental Association. All rights reserved. Start Printed Page 18820Addendum J.—Wage Index for Hospitals That Are Reclassified
Area Wage Index Abilene, TX 0.8179 Akron, OH 0.9981 Albany, GA 0.9544 Alexandria, LA 0.7910 Amarillo, TX 0.8435 Anchorage, AK 1.3009 Ann Arbor, MI 1.1343 Atlanta, GA 1.0050 Austin-San Marcos, TX 0.9081 Baltimore, MD 0.9891 Baton Rouge, LA 0.8707 Beaumont-Port Arthur, TX 0.8624 Benton Harbor, MI 0.8831 Bergen-Passaic, NJ 1.1833 Billings, MT 1.0038 Biloxi-Gulfport-Pascagoula, MS 0.7949 Binghamton, NY 0.8750 Birmingham, AL 0.8994 Bismarck, ND 0.7893 Boise City, ID 0.9086 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH 1.1358 Burlington, VT 1.0122 Caguas, PR 0.4561 Champaign-Urbana, IL 0.9163 Charleston-North Charleston, SC 0.8988 Charleston, WV 0.8861 Charlotte-Gastonia-Rock Hill, NC-SC 0.9433 Chattanooga, TN-GA 0.9453 Chicago, IL 1.0872 Cincinnati, OH-KY-IN 0.9434 Clarksville-Hopkinsville, TN-KY 0.8283 Cleveland-Lorain-Elyria, OH 0.9688 Columbia, MO 0.8736 Columbia, SC 0.9215 Columbus, GA-AL 0.8318 Columbus, OH 0.9728 Corpus Christi, TX 0.8599 Dallas, TX 0.9589 Danville, VA 0.8706 Davenport-Moline-Rock Island, IA-IL 0.8606 Dayton-Springfield, OH 0.9231 Denver, CO 1.0197 Des Moines, IA 0.8754 Dothan, AL 0.7836 Dover, DE 1.0511 Duluth-Superior, MN-WI 1.0165 Elkhart-Goshen, IN 0.9379 Eugene-Springfield, OR 1.0765 Evansville-Henderson, IN-KY 0.8396 Fargo-Moorhead, ND-MN (ND and SD Hospitals) 0.8620 Fargo-Moorhead, ND-MN (MN Hospital) 0.8669 Fayetteville, NC 0.8494 Flagstaff, AZ-UT 0.9860 Flint, MI 1.0918 Fort Collins-Loveland, CO 1.0197 Fort Pierce-Port St. Lucie, FL 1.0109 Fort Smith, AR-OK 0.7696 Fort Walton Beach, FL 0.8713 Forth Worth-Arlington, TX 0.9835 Fresno, CA 1.0262 Gadsden, AL 0.8754 Gainesville, FL 0.9963 Goldsboro, NC 0.8333 Grand Forks, ND-MN 0.9097 Grand Rapids-Muskegon-Holland, MI 1.0017 Great Falls, MT 1.0459 Greeley, CO 0.9449 Green Bay, WI 0.9215 Greensboro-Winston-Salem-High Point, NC 0.9037 Greenville, NC 0.9237 Greenville-Spartanburg-Anderson, SC 0.9188 Hagerstown, MD 0.8853 Harrisburg-Lebanon-Carlisle, PA 0.9793 Hartford, CT 1.1715 Hickory-Morganton-Lenoir, NC 0.9148 Honolulu, HI 1.1479 Houston, TX 0.9387 Huntington-Ashland, WV-KY-OH 0.9436 Huntsville, AL 0.8608 Indianapolis, IN 0.9792 Iowa City, IA 0.9460 Jackson, MS 0.8268 Jackson, TN 0.8447 Jacksonville, FL 0.8957 Johnson City-Kingsport-Bristol, TN-VA 0.8894 Jonesboro, AR 0.7251 Joplin, MO 0.7678 Kalamazoo-Battlecreek, MI 0.9981 Kansas City, KS-MO 0.9322 Knoxville, TN 0.9199 Kokomo, IN 0.8984 Lafayette, LA 0.8397 Lansing-East Lansing, MI 0.9834 Las Vegas, NV-AZ 1.1258 Lexington, KY 0.8552 Lima, OH 0.9108 Lincoln, NE 0.9451 Little Rock-North Little Rock, AR 0.8432 Longview-Marshall, TX 0.8541 Los Angeles-Long Beach, CA 1.2085 Louisville, KY-IN 0.9381 Macon, GA 0.8530 Madison, WI 0.9729 Mansfield, OH 0.8649 Memphis, TN-AR-MS 0.8244 Merced, CA 1.0509 Milwaukee-Waukesha, WI 0.9845 Minneapolis-St. Paul, MN-WI 1.0929 Missoula, MT 0.9085 Monmouth-Ocean, NJ 1.1258 Monroe, LA 0.8062 Montgomery, AL 0.7724 Myrtle Beach, SC 0.8357 Nashville, TN 0.9254 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT 1.2417 New London-Norwich, CT 1.2328 New Orleans, LA 0.9089 New York, NY 1.4399 Newark, NJ 1.0772 Newburgh, NY-PA 1.0837 Norfolk-Virginia Beach-Newport News, VA-NC 0.8442 Oakland, CA 1.5095 Oklahoma City, OK 0.8589 Omaha, NE-IA 1.0455 Orange County, CA 1.1592 Orlando, FL 0.9806 Peoria-Pekin, IL 0.8399 Philadelphia, PA-NJ 1.1186 Phoenix-Mesa, AZ 0.9464 Pittsburgh, PA 0.9496 Pocatello, ID 0.8651 Portland, ME 0.9487 Portland-Vancouver, OR-WA 1.0996 Provo-Orem, UT 0.9818 Raleigh-Durham-Chapel Hill, NC 0.9544 Roanoke, VA 0.8142 Rockford, IL 0.8783 Sacramento, CA 1.2284 Saginaw-Bay City-Midland, MI 0.9294 St. Cloud, MN 0.9608 St. Louis, MO-IL 0.9052 Salt Lake City-Ogden, UT 0.9854 San Diego, CA 1.1955 Santa Fe, NM 0.9911 Santa Rosa, CA 1.3000 Seattle-Bellevue-Everett, WA 1.1289 Sharon, PA 0.8524 Sherman-Denison, TX 0.8833 Sioux City, IA-NE 0.8549 South Bend, IN 0.9692 Springfield, IL 0.8684 Springfield, MO 0.7991 Syracuse, NY 0.9441 Tallahassee, FL 0.8274 Tampa-St. Petersburg-Clearwater, FL 0.9119 Texarkana, AR-Texarkana, TX 0.8174 Toledo, OH 0.9593 Topeka, KS 0.9326 Tulsa, OK 0.7931 Tuscaloosa, AL 0.8064 Tyler, TX 0.9199 Vallejo-Fairfield-Napa, CA 1.2167 Victoria, TX 0.8378 Waco, TX 0.8075 Washington, DC-MD-VA-WV 1.1053 Waterloo-Cedar Falls, IA 0.8841 Wausau, WI 0.9445 Wichita, KS 0.9082 Rural Colorado 0.8813 Rural Florida 0.8986 Rural Illinois 0.8047 Rural Louisiana 0.7486 Rural Michigan 0.8831 Rural Minnesota 0.8669 Rural Missouri 0.7723 Rural Montana 0.8398 Rural Oregon 0.9873 Rural Tennessee 0.7650 Rural Texas 0.7471 Rural Virginia (KY Hospital) 0.8043 Rural Washington 1.0333 Rural Wyoming 0.8859 End Supplemental InformationAddendum K.—Codes Eligible for Pass-Through Payment
CPT/ HCPCS Description A4642 Satumomab pendetide per dose A9502 Technetium TC99M tetrofosmin A9600 Strontium-89 chloride A9605 Samarium sm153 lexidronamm J0205 Alglucerase injection J0207 Amifostine J0256 Alpha 1 proteinase inhibitor J0286 Amphotericin B lipid complex J0476 Baclofen intrathecal trial J0585 Botulinum toxin a per unit J0640 Leucovorin calcium injection J0735 Clonidine hydrochloride J0850 Cytomegalovirus imm IV/vial J1190 Dexrazoxane HCl injection J1260 Dolasetron mesylate J1325 Epoprostenol injection J1436 Etidronate disodium inj J1440 Filgrastim 300 mcg injeciton J1561 Immune globulin 500 mg J1562 Immune globulin 5 gms J1565 RSV-ivig J1620 Gonadorelin hydroch/100 mcg J1626 Granisetron HCl injection J1745 Infliximab injection J1785 Injection imiglucerase/unit J1825 Interferon beta-1a J1830 Interferon beta-1b/.25 MG J1950 Leuprolide acetate/3.75 MG J2275 Morphine sulfate injection J2352 Octreotide acetate injection J2355 Oprelvekin injection J2405 Ondansetron hcl injection J2430 Pamidronate disodium/30 MG J2545 Pentamidine isethionte/300mg J2765 Metoclopramide hcl injection J2790 Rho d immune globulin inj J2820 Sargramostim injection J3010 Fentanyl citrate injeciton J3280 Thiethylperazine maleate inj J3305 Inj trimetrexate glucoronate J7190 Factor viii J7191 Factor VIII (porcine) J7192 Factor viii recombinant J7194 Factor ix complex J7197 Antithrombin iii injection J7198 Anti-inhibitor J7310 Ganciclovir long act implant J7505 Monoclonal antibodies J7913 Daclizumab, Parenteral, 25 m J8510 Oral busulfan J8520 Capecitabine, oral, 150 mg J8530 Cyclophosphamide oral 25 MG J8560 Etoposide oral 50 MG J8600 Melphalan oral 2 MG J8610 Methotrexate oral 2.5 MG J9000 Doxorubic hcl 10 MG vl chemo J9001 Doxorubicin hcl liposome inj J9015 Aldesleukin/single use vial J9020 Asparaginase injection J9031 Bcg live intravesical vac J9040 Bleomycin sulfate injection J9045 Carboplatin injection J9050 Carmus bischl nitro inj J9060 Cisplatin 10 MG injeciton J9065 Inj cladribine per 1 MG J9070 Cyclophosphamide 100 MG inj J9093 Cyclophosphamide lyophilized J9100 Cytarabine hcl 100 MG inj J9120 Dactinomycin actinomycin d J9130 Dacarbazine 10 MG inj J9150 Daunorubicin J9151 Daunorubicin citrate liposom J9165 Diethylstilbestrol injection J9170 Docetaxel J9181 Etoposide 10 MG inj J9185 Fludarabine phosphate inj J9190 Fluorouracil injection J9200 Floxuridine injection J9201 Gemcitabine HCl J9202 Goserelin acetate implant J9206 Irinotecan injection J9208 Ifosfomide injection J9209 Mesna injection J9211 Idarubicin hcl injeciton J9212 Interferon alfacon-1 J9213 Interferon alfa-2a inj J9214 Interferon alfa-2b inj J9215 Interferon alfa-n3 inj J9216 Interferon gamma 1-b inj J9218 Leuprolide acetate injeciton J9230 Mechlorethamine hcl inj J9245 Inj melphalan hydrochl 50 MG J9250 Methotrexate sodium inj J9265 Paclitaxel injection J9266 Pegaspargase/singl dose vial J9268 Pentostatin injection J9270 Plicamycin (mithramycin) inj J9280 Mitomycin 5 MG inj J9293 Mitoxantrone hydrochl/5 MG J9310 Rituximab cancer treatment J9320 Streptozocin injection J9340 Thiotepa injection J9350 Topotecan J9360 Vinblastine sulfate inj J9370 Vincristine sulfate 1 MG inj J9390 Vinorelbine tartrate/10 mg J9600 Porfimer sodium Q0136 Non esrd epoetin alpha inj Q0160 Factor IX non-recombinant Q0161 Factor IX recombinant Q0163 Diphenhydramine HCl 50mg Q0164 Prochlorperazine maleate 5mg Q0166 Granisetron HCl 1 mg oral Q0167 Dronabinol 2.5mg oral Q0169 Promethazine HCl 12.5mg oral Q0171 Chlorpromazine HCl 10mg oral Q0173 Trimethobenzamide HCl 250mg Q0174 Thiethylperazine maleate10mg Q0175 Perphenazine 4mg oral Q0177 Hydroxyzine pamoate 25mg Q0179 Ondansetron HCl 8mg oral Q0180 Dolasetron mesylate oral Q0187 Factor viia recombinant Q2002 Elliot's B solution Q2003 Aprotinin, 10,000 kiu Q2004 Treatment for bladder calcul Q2005 Corticorelin ovine triflutat Q2006 Digoxin immune FAB (Ovine), Q2007 Ethanolamine oleate, 1000 ml Q2008 Fomepizole, 1.5 G Q2009 Fosphenytoin, 50 mg Q2010 Glatiramer acetate, 25 mgeny Q2011 Hemin, 1 mg Q2012 Pegademase bovine inj 25 I.U Q2013 Pentastarch 10% inj, 100 ml Q2014 Sermorelin acetate, 0.5 mg Q2015 Somatrem, 5 mg Q2016 Somatropin, 1 mg Q2017 Teniposide, 50 mg Q2018 Urofollitropin, 75 I.U. Q3001 Brachytherapy Seeds [FR Doc. 00-8215 Filed 3-31-00 11:00 am]
BILLING CODE 4120-01-P
Document Information
- Published:
- 04/07/2000
- Department:
- Health Care Finance Administration
- Entry Type:
- Rule
- Action:
- Final rule with comment period.
- Document Number:
- 00-8215
- Pages:
- 18433-18820 (388 pages)
- Docket Numbers:
- HCFA-1005-FC
- RINs:
- 0938-AI56: Medicare Program; Prospective Payment System for Hospital Outpatient Services (HCFA-1005-F)
- RIN Links:
- https://www.federalregister.gov/regulations/0938-AI56/medicare-program-prospective-payment-system-for-hospital-outpatient-services-hcfa-1005-f-
- Topics:
- Administrative practice and procedure, Archives and records, Emergency medical services, Grant programs-social programs, Health facilities, Health professions, Hospitals, Kidney diseases, Laboratories, Maternal and child health, Medicaid, Medicare, Penalties, Puerto Rico, Reporting and recordkeeping requirements, Rural areas, X-rays
- PDF File:
- 00-8215.pdf
- CFR: (40)
- 42 CFR 409.10
- 42 CFR 410.2
- 42 CFR 410.27
- 42 CFR 410.28
- 42 CFR 410.42
- More ...