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1 Indicator A D E FIAL 2015 Compared to FIAL 2016 s Medicare Hospital Outpatient Prospective System HOPPS (APC) uclear Medicine Procedures, Radiopharmaceuticals, and Drugs CY15 HOPPS Final Rule CY16 HOPPS Final Rule Updated version Service (s to status indicators for in Blue) Separately Payable Clinical Diagnostic Laboratory Services Discontinued Codes Items, Codes, and Services: For which pricing information is not available (ew in ) That are not covered by any Medicare outpatient benefit based on statutory exclusion (Deleted in ) ot covered by any Medicare outpatient benefit category Statutorily excluded by Medicare Status ot subject to deductible or coinsurance. ot paid under OPPS or any other Medicare payment system. ot paid by Medicare when submitted on outpatient claims (any outpatient bill type). ot Reasonable and necessary G K Q1 S T U X Pass-Through Drug/ Biologicals onpass-through Drugs and nonimplantable Biologicals, including Therapeutic Radiopharmaceuticals Items and Services packaged STV- Codes Procedure or Service, ot Discounted When Multiple Significant Procedure, Multiple Procedure Reduction Applies Brachytherapy Sources Ancillary Services (Deleted in ) Paid under OPPS; separate APC payment. Paid under OPPS; separate APC payment. Paid under OPPS; payment is packaged into payment for other services. Therefore, there is no separate APC payment. Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) APC payment if billed on the same date of service as a HCPCS code assigned status indicator S, T, or V. (2) In other circumstances, payment is made through a separate APC payment. Paid under OPPS; separate APC payment. Paid under OPPS; separate APC payment. Paid under OPPS; separate APC payment. Paid under OPPS; separate APC payment. HCPCS Description ame APC APC SI SI FIAL RULE FIAL RULE Injection procedure; radioactive tracer for identification of sentinel node Q1 Q1 $ $ Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure) (For injection of radioactive tracer for identification of sentinel node, use /A /A /A 38792) (Use in conjunction with 19302,19307,38500,38510, 38520,38525,38530,38542,38740,38745) Injection procedure (eg, contrast media) for evaluation of previously placed peritoneal-venous shunt (For radiological supervision and interpretation, see 75809, 78291) into Insertion of non-indwelling bladder catheter (eg, straight catheterization for Q1 Q1 $ $ residual urine) Insertion of temporary indwelling bladder catheter; simple (eg, Foley) Q1 Q1 $ $ Insertion of temporary indwelling bladder catheter; complicated (eg, altered T SI $ $ anatomy, fractured catheter/balloon) SMMI Reimbursement Hospital Educational Material Page 1 of 12

2 HCPCS Description ame APC APC SI SI 3D rendering with interpretation and reporting of computed of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation (Use in conjunction with codes(s) for base imaging procedure(s)) (Do not report in conjunction with 70496, 70498, , 71275, 71555, 72159, 72191, 72198, 73206, 73225, 73706, 73725, 74175, 74185, , 75635, 76377, , 0066T, 0067T, 0144T-0151T, 0159T) FIAL RULE FIAL RULE into 3D rendering with interpretation and reporting of computed of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation (Use in conjunction with codes(s) for base imaging procedure(s)) (Do not report in conjunction with 70496, 70498, , 71275, 71555, 72159, 72191, 72198, 73206, 73225, 73706, 73725, 74175, 74185, , 75635, 76376, , 0066T, 0067T, 0144T-0151T, 0159T) into Dual-energy X-ray absorptiometry, bone density study, 1 or more sites; axial S S $95.02 $ skeleton (eg, hips, pelvis, spine) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment Vertebral fractureassessment via dual-energy X-rayabsorptiometry (DXA) EW 0261 EW Q1 Q1 $95.02 $ Q1 Q1 $59.37 $ Special medical radiation physics consultation S S $ $ UCLEAR MEDICIE Modified in 2013 ITRODUCTORY SECTIO - The services listed do not include the radiopharmaceutical or drug. To separately report supply of diagnostic and therapeutic radiopharmaceutiacls nd drugs, use the appropriate supply code(s), in addition to the procedure code. Thyroid uptake, single or multiple quantitative measurement(s) (including S S $ $ stimulation, suppression, or discharge, when performed) Thyroid imaging (including vascular flow, when performed) S S $ $ Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, S S $ $ suppression, or discharge, when performed) Thyroid carcinoma metastases imaging; limited are (eg, neck and chest only) S S $ $ Thyroid carcinoma metastases imaging; with additional studies (eg, urinary S S $ $ recovery) Thyroid carcinoma metastases imaging; whole body S S $ $ Thyroid carcinoma metastases uptake (Use in conjunction with code /A /A only) into Parathyroid planar imaging (including subtraction, when performed) S S $ $ Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) S S $ $ Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) S S $ $ for anatomical localization Adrenal imaging, cortex and/or medulla S S $1, $1, Unlisted endocrine procedure, diagnostic nuclear medicine S S $ $ Bone marrow imaging; limited area S S $ $ Bone marrow imaging; multiple areas S S $ $ Bone marrow imaging; whole body S S $ $ Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling S S $ $ Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); multiple sampling S S $ $ Red cell volume determination (separate procedure); single sampling S S $ $ Red cell volume determination (separate procedure); multiple sampling S S $ $ SMMI Reimbursement Hospital Educational Material Page 2 of 12

3 HCPCS Description ame APC APC SI SI FIAL RULE FIAL RULE Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution S S $ $ technique) Red cell survival study; S S $ $ Red cell survival study; differential organ/tissue kinetics (eg, splenic and/or S S $ $ hepatic sequestration) Labeled red cell sequestration, differential organ/tissue, (eg, splenic and/or S S $ $ hepatic) Spleen imaging only, with or without vascular flow (If combined with liver S S $ $ study, use procedures and 78216) Kinetics, study of platelet survival, with or without differential organ/tissue S S $ $1, localization Platelet survival study S S $ $ Lymphatics and lymph nodes imaging (For sentinel node identification without S S $ $ scintigraphy imaging, use 38792) Unlisted hematopoietic, Reticuloendothelial and lymphatic procedure, S S $ $ diagnostic nuclear medicine Liver imaging; static only S S $ $ Liver imaging; with vascular flow S S $ $ Liver imaging (SPECT); S S $ $ Liver image (SPECT); with vascular flow S S $ $ Liver and spleen imaging; static only S S $ $ Liver and spleen imaging; with vascular flow S S $ $ Hepatobiliary system imaging, including gallbladder when present S S $ $ Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when S S $ $ performed Salivary gland imaging; S S $ $ Salivary gland imaging; with serial images S S $ $ Salivary gland function study S S $ $ Esophageal motility S S $ $ Gastric mucosa imaging S S $ $ Gastroesophageal reflux study S S $ $ Gastric Emptying Imaging Study (eg, solid, liquid or both) S S $ $ Gastric Emptying Imaging Study (eg, solid, liquid or both); with small bowel EW /A transit 5591 S A A $ /A Gastric Emptying Imaging Study (eg, solid, liquid or both); with small bowel EW /A and colon transit, multiple days 5592 S S A $ /A Urea breath test, C-14 (isotopic); acquisition for analysis A A Urea breath test, C-14 (isotopic); analysis A A Vit B-12 absorption study (eg, Schilling test); without intrinsic factor S S $ $ Vit B-12 absorption study (eg, Schilling test); with intrinsic factor S S $ $ Vit B-12 absorption study combined, with and without intrinsic factor S S $ $ Acute gastrointestinal blood loss imaging S S $ $ Gastrointestinal protein loss S S $ $ Intestine imaging (eg, ectopic gastric mucosa, Meckel s localization, volvulus) S S $ $ Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt) S S $ $ Unlisted gastrointestinal procedure, diagnostic nuclear medicine S S $ $ Bone and/or joint imaging; limited area S S $ $ Bone and/or joint imaging; multiple areas S S $ $ Bone and/or joint imaging; whole body S S $ $ Bone and/or joint imaging; 3 three phase study S S $ $ Bone and/or joint imaging; tomographic (SPECT) S S $ $ Bone density (bone mineral content) study, 1 or more sites; single photon E E /A /A /A absorptiometry SMMI Reimbursement Hospital Educational Material Page 3 of 12

4 HCPCS Description ame APC APC SI SI FIAL RULE FIAL RULE Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry one or more sites E E /A /A /A Unlisted musculoskeletal procedure, diagnostic nuclear medicine S S $ $ Determination of central c-v hemodynamics (non-imagine) (eg, ejection fraction with probe technique) with or without pharmacologic intervention or S S $ $ exercise, single or multiple determinations Cardiac shunt detection S S $ $ on-cardiac vascular flow imaging (ie, angiography, venography) S S $ $ Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single S S $1, $1, study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple S S $1, $1, studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or S S $1, $ pharmacologic) Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress S S $1, $1, (exercise or pharmacologic) and/or redistribution and/or rest reinjection Acute venous thrombus imaging, peptide S S $ $1, Venous thrombosis imaging, venogram; unilateral S S $ $ Venous thrombosis imaging, venogram; bilateral S S $ $ Myocardial imaging, positron emission tomography (PET), metabolic S S $1, $1, evaluation Myocardial imaging, infarct avid, planar; qualitative or quantitative S S $ $ Myocardial imaging, infarct avid, planar; with ejection fraction by first pass S S $ $ technique Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification S S $ $ Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing (or assessment of S S $ $ cardiac function by first pass technique, use 78496) Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or S S $ $ pharmacologic), with or without additional quantification Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus S S $ $ ejection fraction, with or without quantification Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus S S $1, $ ejection fraction, with or without quantification Myocardial imaging, positron emission tomography (PET), perfusion; single S S $1, $1, study at rest or stress Myocardial imaging, positron emission tomography (PET), perfusion; multiple S S $1, $1, studies at rest and/or stress Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion S S $ $ study plus ejection fraction, with or without quantitative processing Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (Use in conjunction with 78472) into Unlisted cardiovascular procedure, diagnostic nuclear medicine S S $ $ Myocardial sympathetic innervation, imaging, planar qualitative 0331T S S $1, $1, assessment SMMI Reimbursement Hospital Educational Material Page 4 of 12

5 HCPCS Description ame APC APC SI SI FIAL RULE FIAL RULE 0332T Myocardial sympathetic innervation, imaging, planar qualitative and quantitative assessment; with tomographic SPECT S S $1, $1, Pulmonary ventilation imaging (eg, aerosol or gas) S S $ $ Pulmonary perfusion imaging (eg, particulate) S S $ $ Pulmonary ventilation imaging (eg, aerosol or gas) and perfusion imaging S S $ $ Quantitative differential pulmonary perfusion, including imaging when S S $ $ performed Quantitative differential pulmonary perfusion and ventilation (eg aerosol or S S $ $ gas), including imaging when performed Unlisted respiratory procedure, diagnostic nuclear medicine S S $ $ Brain imaging, less than 4 static views; S S $ $ Brain imaging, less than 4 static views; with vascular flow S S $ $ Brain imaging, minimum 4 static views; S S $ $ Brain imaging, minimum 4 static views; with vascular flow S S $ $ Brain imaging, tomographic (SPECT) S S $1, $1, Brain imaging, positron emission tomography (PET); metabolic evaluation S S $1, $1, Brain imaging, positron emission tomography (PET); perfusion evaluation E E /A /A A Brain imaging, vascular flow only S S $ $ Cerebrospinal fluid flow, imaging (not including introduction of material); S S $ $ cisternography (For injection procedure, see , ) Cerebrospinal fluid flow, imaging (not including introduction of material); S S $ $ ventriculography (For injection procedure, see , ) Cerebrospinal fluid flow, imaging (not including introduction of material); S S $ $ shunt evaluation (For injection procedure, see , ) Cerebrospinal fluid flow, imaging (not including introduction of material); S S $ $1, tomographic (SPECT) Cerebrospinal fluid leakage detection and localization S S $ $1, Radiopharmaceutical dacryocystography S S $ $ Unlisted nervous system procedure, diagnostic nuclear medicine S S $ $ Kidney imaging morphology S S $ $ Kidney imaging morphology with vascular flow S S $ $ Kidney imaging morphology with vascular flow and function, single study S S $ $ without pharmacological intervention Kidney imaging morphology with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor S S $ $ and/or diuretic) Kidney imaging morphology with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting S S $ $ enzyme inhibitor and/or diuretic) Kidney imaging morphology tomographic (SPECT) S S $ $ Kidney function study, non-imaging radioisotopic study S S $ $ Urinary bladder residual study (List separately in addition to code for primary procedure) (Use in conjunction with 78740) (For measurement of postvoid residual urine and/or bladder capacity by ultrasound, nonimaging, use 51798) (For ultrasound imaging of the bladder only, with measurement of postvoid residual urine when performed, use 76857) into Ureteral reflux study (radiopharmaceutical voiding cystogram) For catheterization see 51701, 51702, S S $ $ Testicular imaging with vascular flow S S $ $ Unlisted genitourinary procedure; diagnostic nuclear medicine S S $ $ SMMI Reimbursement Hospital Educational Material Page 5 of 12

6 HCPCS Description ame APC APC SI SI FIAL RULE FIAL RULE Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area S S $ $ Radiopharmaceutical localization of tumor or distribution of S S $ $ radiopharmaceutical agent(s); multiple areas Radiopharmaceutical localization of tumor or distribution of S S $ $ radiopharmaceutical agent(s); whole body, single day imaging Radiopharmaceutical localization of tumor or distribution of S S $ $ radiopharmaceutical agent(s); tomographic (SPECT) Radiopharmaceutical localization of tumor or distribution of S S $1, $1, radiopharmaceutical agent(s); whole body, requiring 2 or more days imaging Radiopharmaceutical localization of inflammatory process; limited area S S $ $1, Radiopharmaceutical localization of inflammatory process; whole body S S $ $1, Radiopharmaceutical localization of inflammatory process; tomographic (SPECT) (For imaging bone infectious or inflammatory disease with a bone S S $ $ imaging radiopharmaceutical, see 78300, 78305, 78306) Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (eg, parathyroid adenoma) Q1 Q1 $ $ (For sentinel lymph node identification, use 38792) Positron emission tomography (PET) imaging; limited area (eg. chest, S S $1, $1, head/neck) Positron emission tomography (PET) imaging; skull base to mid-thigh S S $1, $1, Positron emission tomography (PET) imaging; whole body S S $1, $1, Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization S S $1, $1, imaging; limited area (eg, chest, head/neck) Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization S S $1, $1, imaging; skull base to mid-thigh Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization S S $1, $1, imaging; whole body (Report only once per imaging session) (Computed tomography (CT) performed for other than attenuation correction and anatomical localization is reported using the appropriate site specific CT code with modifier 59) Unlisted miscellaneous procedure, diagnostic nuclear medicine S S $ $ C9898 Radiolabeled product provided during a hospital inpatient stay /A /A A Radiopharmaceutical therapy, by oral administration (For monoclonal S S $ $ antibody by intravenous infusion, use 79403) Radiopharmaceutical therapy, by intravenous administration (Do not report in conjunction with 36400, 35410, 79403, 90780, 96408) (For monoclonal antibody by intravenous infusion, use 79403) (For infusion or S S $ $ instillation of non-antibody radioelement solution that includes three months follow-up care, use 77750) Radiopharmaceutical therapy, by intracavitary administration S S $ $ Radiopharmaceutical therapy, by interstitial radioactive colloid administration S S $ $ Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion (For pre-treatment imaging, see 78802, 78804) (Do not S S $ $ use in conjunction with 79101) Radiopharmaceutical therapy, by intra-articular administration S S $ $ Radiopharmaceutical therapy, by intra-arterial particulate administration (Do not report in conjunction with 90783, 96420) (Use appropriate procedural and radiological supervision and interpretation codes for the S S $ $ angiographic and interventional procedures provided pre-requisite to intraarterial radiopharmaceutical therapy) Radiopharmaceutical therapy, unlisted procedure S S $ $ Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological Q1 Q1 $ $ stress; tracing only, without interpretation and report SMMI Reimbursement Hospital Educational Material Page 6 of 12

7 HCPCS Description ame APC APC SI SI FIAL RULE FIAL RULE Chemotherapy administration, intravenous infusion technique; up to one S S $ $ hour, single or initial substance/drug G0219 PET imaging whole body; melanoma for non-covered indications E E A G0235 PET IMAGIG, AY SITE, OT OTHERWISE SPECIFIED E E A PET imaging, full & partial-ring PET scanner only, for initial diagnosis of G0252 breast cancer and/or surgical planning for breast cancer (eg, initial staging of E E A axillary lymph nodes) RADIOPHARMACEUTICALS & UCLEAR MEDICIE RELATED DRUGS FIAL FIAL Q9969 on-heu TC-99M Add-On per study dose Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study dose 95 percent O- HEU Product K K $10.00 $10.00 $0.00 A4641 A4642 A9500 Radiopharm dx agent noc RADIOPHARMACEUTICAL, DIAGOSTIC, OT OTHERWISE CLASSIFIED In111 satumomab IDIUM I-111 SATUMOMAB PEDETIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 6 Tc99m sestamibi TECHETIUM TC-99M SESTAMIBI, DIAGOSTIC, PER STUDY DOSE, UP TO 40 OC OCOSCIT CARDIOLITE / MIRALUMA into into into A9501 Technetium TC-99m teboroxime TECHETIUM TC-99M TEBOROXIME, DIAGOSTIC, PER STUDY DOSE CardioTec TEBO into A9502 Tc99m tetrofosmin TECHETIUM TC-99M TETROFOSMI, DIAGOSTIC, PER STUDY DOSE MYOVIEW into A9503 TECHETIUM TC-99M MEDROATE, DIAGOSTIC, PER STUDY DOSE, UP TO 30 MDP into Tc99m apcitide A9504 TECHETIUM TC-99M APCITIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 20 ACUTECT into A9505 TL201 thallium THALLIUM TL-201 THALLOUS CHLORIDE, DIAGOSTIC, PER MILLICURIE THALLIUM 201 into A9507 In111 capromab IDIUM I-111 CAPROMAB PEDETIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 10 PROSTASCIT into A9508 I131 iodobenguate, dx IODIE I-131 IOBEGUAE SULFATE, DIAGOSTIC, PER 0.5 MILLICURIE I-131 MIBG into A9509 Iodine I-123 sod iodide mil IODIE I-123 SODIUM IODIDE, DIAGOSTIC, PER MILLICURIE Tc99m disofenin Use for 1-4 mci doses of I-123 for whole body imaging for less than 1 mci and thyroid imaging see A9516 into A9510 TECHETIUM TC-99M DISOFEI, DIAGOSTIC, PER STUDY DOSE, UP TO 15 DISIDA into SMMI Reimbursement Hospital Educational Material Page 7 of 12

8 HCPCS Description ame APC APC SI SI A9512 Tc99m pertechnetate TECHETIUM TC- 99M PERTECHETATE, DIAGOSTIC, PER MILLICURIE Straight Tech Technescan Technelite FIAL RULE FIAL RULE into A9516 Iodine I-123 sod iodide mci IODIE I-123 SODIUM IODIDE, DIAGOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES Dx I-123 Capsules. Use for A9516 for Thyroid uptakes and scans, for 1 mci and greater and whole body imaging see A9509 into A9517 A9520 A9521 A9524 A9526 A9527 A9528 A9529 I131 iodide cap, rx IODIE I-131 SODIUM IODIDE CAPSULE(S), THERAPEUTIC, PER MILLICURIE Tc99 Tilmanocept Diag 0.5MCI TECHETIUM TC-99M TILMAOCEPT, DIAGOSTIC, UP TO 0.5 Tc99m exametazime TECHETIUM TC-99M EXAMETAZIME, DIAGOSTIC, PER STUDY DOSE, UP TO 25 I131 serum albumin, dx IODIE I-131 IODIATED SERUM ALBUMI, DIAGOSTIC, PER 5 MICROCURIES itrogen -13 ammonia ITROGE -13 AMMOIA, DIAGOSTIC, PER STUDY DOSE, UP TO 40 Iodine I-125 sodium iodide IODIE I-125, SODIUM IODIDE SOLUTIO, THERAPEUTIC, PER MILLICURIE Iodine I-131 iodide cap, dx IODIE I-131 SODIUM IODIDE CAPSULE(S), DIAGOSTIC, PER MILLICURIE I131 iodide sol, dx IODIE I-131 SODIUM IODIDE SOLUTIO, DIAGOSTIC, PER MILLICURIE Rx I-131 Capsules Lymphoseek 1463 CERETEC HMPAO K K $40.70 $ Off Passthrough I-131 Albumin -13 I-131 Dx caps per mci Dx I-131 sol per mci G $ into into into into U U $13.25 $ into into A9530 I131 iodide sol, rx IODIE I-131 SODIUM IODIDE SOLUTIO, THERAPEUTIC, PER MILLICURIE Rx I-131 sol per mci K K $10.28 $ A9531 I131 max 100uCi IODIE I-131 SODIUM IODIDE, DIAGOSTIC, PER MICROCURIE (UP TO 100 MICROCURIES) Dx I-131 up to 100 uci into A9532 A9536 I125 serum albumin, dx IODIE I-125 SERUM ALBUMI, DIAGOSTIC, PER 5 MICROCURIES Tc99m depreotide TECHETIUM TC-99M DEPREOTIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 35 EOTEC into into A9537 Tc99m mebrofenin TECHETIUM TC-99M MEBROFEI, DIAGOSTIC, PER STUDY DOSE, UP TO 15 CHOLETEC into A9538 Tc99m pyrophosphate TECHETIUM TC-99M PYROPHOSPHATE, DIAGOSTIC, PER STUDY DOSE, UP TO 25 PYROLITE *Use this code for myocardial infarct imaging. Do not use this code for GBP, RVG or MUGA procedures see A9560 into A9539 Tc99m pentetate TECHETIUM TC-99M PETETATE, DIAGOSTIC, PER STUDY DOSE, UP TO 25 Tc-99m DTPA into SMMI Reimbursement Hospital Educational Material Page 8 of 12

9 HCPCS Description ame APC APC SI SI A9540 A9541 A9542 A9543 A9544 A9545 A9546 A9547 Tc99m MAA TECHETIUM TC-99M MACROAGGREGATED ALBUMI, DIAGOSTIC, PER STUDY DOSE, UP TO 10 Tc99m sulfur colloid TECHETIUM TC-99M SULFUR COLLOID, DIAGOSTIC, PER STUDY DOSE, UP TO 20 In111 ibritumomab, dx IDIUM I-111 IBRITUMOMAB TIUXETA, DIAGOSTIC, PER STUDY DOSE, UP TO 5 Y90 ibritumomab, rx YTTRIUM Y-90 IBRITUMOMAB TIUXETA, THERAPEUTIC, PER TREATMET DOSE, UP TO 40 I131 tositumomab, dx IODIE I-131 TOSITUMOMAB, DIAGOSTIC, PER STUDY DOSE I131 tositumomab, rx IODIE I-131 TOSITUMOMAB, THERAPEUTIC, PER TREATMET DOSE Co57/58 COBALT CO-57/58, CYAOCOBALAMI, DIAGOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIE In111 oxyquinoline IDIUM I-111 OXYQUIOLIE, DIAGOSTIC, PER 0.5 MILLICURIE MAA SULFUR COLLOID (SC) Dx In-111 ZEVALI Rx Y-90 ZEVALI FIAL RULE FIAL RULE into into into K K $43, $46, Dx BEXXAR Rx BEXXAR E E YCOMED See new codes A9570 and A9571 for WBC and Platelet Imaging into into into into A9548 In111 pentetate IDIUM I-111 PETETATE, DIAGOSTIC, PER 0.5 MILLICURIE Indium DTPA into A9550 Tc99m gluceptate TECHETIUM TC-99M SODIUM GLUCEPTATE, DIAGOSTIC, PER STUDY DOSE, UP TO 25 GLUCOSCA into A9551 Tc99m succimer TECHETIUM TC-99M SUCCIMER, DIAGOSTIC, PER STUDY DOSE, UP TO 10 DMSA into A9552 A9553 A9554 F18 fdg FLUORODEOXYGLUCOSE F-18 FDG, DIAGOSTIC, PER STUDY DOSE, UP TO 45 Cr51 chromate CHROMIUM CR-51 SODIUM CHROMATE, DIAGOSTIC, PER STUDY DOSE, UP TO 250 MICROCURIES I125 iothalamate, dx IODIE I-125 SODIUM IOTHALAMATE, DIAGOSTIC, PER STUDY DOSE, UP TO 10 MICROCURIES Rb82 rubidium FDG / F-18 into into into A9555 RUBIDIUM RB-82, DIAGOSTIC, PER STUDY DOSE, UP TO 60 Rb-82 CardioGen82 into A9556 Ga67 gallium GALLIUM GA-67 CITRATE, DIAGOSTIC, PER MILLICURIE GALLIUM into A9557 Tc99m bicisate TECHETIUM TC-99M BICISATE, DIAGOSTIC, PER STUDY DOSE, UP TO 25 EUROLITE into A9558 Xe133 xenon 10mci XEO XE-133 GAS, DIAGOSTIC, PER 10 Xenon into SMMI Reimbursement Hospital Educational Material Page 9 of 12

10 HCPCS Description ame APC APC SI SI A9559 Co57 cyano COBALT CO-57 CYAOCOBALAMI, ORAL, DIAGOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIE Shillings Study Rubratope 57 Cobatope 57 FIAL RULE FIAL RULE into A9560 Tc99m labeled rbc TECHETIUM TC-99M LABELED RED BLOOD CELLS, DIAGOSTIC, PER STUDY DOSE, UP TO 30 ULTRATAG or Cold PYP + 99m Tc Code to be used for both the invivo/invitro methods of tagging Red Blood Cells into A9561 Tc99m oxidronate TECHETIUM TC-99M OXIDROATE, DIAGOSTIC, PER STUDY DOSE, UP TO 30 HDP into A9562 Tc99m mertiatide TECHETIUM TC-99M MERTIATIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 15 MAG-3 into A9563 P32 a phosphate SODIUM PHOSPHATE P-32, THERAPEUTIC, PER MILLICURIE K K $ $ A9564 P32 chromic phosphate CHROMIC PHOSPHATE P-32 SUSPESIO, THERAPEUTIC, PER MILLICURIE Phosphocol P K K $ $ A9566 Tc99m fanolesomab TECHETIUM TC-99M FAOLESOMAB, DIAGOSTIC, PER STUDY DOSE, UP TO 25 eutrospec into A9567 Technetium TC-99m aerosol TECHETIUM TC-99M PETETATE, DIAGOSTIC, AEROSOL, PER STUDY DOSE, UP TO 75 DTPA Aerosol For Lung Ventilation Studies into A9568 Technetium tc99m arcitumomab TECHETIUM TC-99M ARCITUMOMAB, DIAGOSTIC, PER STUDY DOSE, UP TO 45 CEA-SCA into A9569 Technetium TC-99m auto WBC TECHETIUM TC-99M EXAMETAZIME LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGOSTIC, PER STUDY DOSE Use this code for infection or inflammation imaging do not use this code for brain imaging see A9521 into A9570 Indium In-111 auto WBC 'IDIUM I-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGOSTIC, PER STUDY DOSE When prepared with patient WBC use this new code do not use A9547 into A9571 Indium I-111 auto platelet IDIUM I-111 LABELED AUTOLOGOUS PLATELETS, DIAGOSTIC, PER STUDY DOSE When prepared with patient platelets use this new code do not use A9547 into A9572 Indium In-111 pentetreotide 'IDIUM I-111 PETETREOTIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 6 Octreoscan into A9580 Sodium Fluoride F-18, Sodium Fluoride F-18, diagnostic, per study dose, up to 30 millicuries F-18, af, Sodium Fluoride into A9582 Iobenguane, I-123, diagnostic, per study dose, up to 15 millicuries I-123 MIBG AdreView DC into A9584 Iodine I-123 ioflupane, diagnostic, per study dose, (up to 5 millicuries) DaTscan DC # into SMMI Reimbursement Hospital Educational Material Page 10 of 12

11 HCPCS Description ame APC APC SI SI A9586 Florbetapir F18 FLORBETAPIR F18, DIAGOSTIC, PER STUDY DOSE, UP TO 10 Amyvid DC # FIAL RULE FIAL RULE G G $2, $2, C9458 *A9599 Florbetaben F-18, diagnostic per study does, up to 8.1 millicuries euraceq F-18 florbetaben - Piramal DC # /A ew 9458 K G $2, /A C9459 *A9599 A9600 Flutemetamol F-18, diagnostic, per study dose, up to 5 millicuries Sr89 strontium STROTIUM SR-89 CHLORIDE, THERAPEUTIC, PER MILLICURIE Vizamyl F-18 flutemetamol - G.E. DC # /A ew 9459 G $3, /A Rx METASTRO K K $1, $1, A9604 A9606 A9699 SAMARIUM SM-153 LEXIDROAMM, THERAPEUTIC, PER TREATMET DOSE, up to 150 Radium Ra-223 dichloride, therapeutic, per microcurie dose Radiopharm rx agent noc RADIOPHARMACEUTICAL, THERAPEUTIC, OT OTHERWISE CLASSIFIED Rx QUADRAMET K K $8, $10, Xofigo DC # K K $ $ RX OC into **ote final payment rates for status G codes have offset RP amounts posted on the CMS web site by CPT code. ADEOSCA J0153 Adenosine inj 1mg Replaces J0150, J0151 and J0152 J0280 Aminophyllin up to 250 MG, inj. J0461 Inj, atropine sulfate, 0.01 mg J1120 Acetazolamide sodium injection, up to 500 mg Diamox J1160 Inj, digoxin, up to 0.5 mg Lanoxin 1834 K J1245 Dipyridamole injection, per 10mg Persantine IV J1250 Inj dobutamine HCL/250 mg Dobutrex J1265 Injection, dopamine HCl, 40 mg Intropin into into into into $ into into into J1610 Glucagon hydrochloride per 1MG Glucagen K K $ $ J1800 Propranolol HCL injection, up to 1 mg Inderal J1940 Furosemide injection up to 20 mg Lasix into into J2270 Morphine sulfate injection, up to 10 mg Replaces J2271 into J2785 Injection, Regadenoson, 0.1 milligrams LexiScan DC into J2805 J3240 Sincalide injection IJECTIO, SICALIDE, 5 MICROGRAMS Thyrotropin injection 0.9 mg n 1.1 mg vial Kinevac Thyrogen Thytropar J3420 Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg J3490 Drugs Unclassified injection OC J3590 Unclassified biologics OC J7030 ormal saline solution infus (1000 CC) into K K $1, $1, into into into into SMMI Reimbursement Hospital Educational Material Page 11 of 12

12 FIAL RULE FIAL RULE HCPCS Description ame APC APC SI SI J7040 ormal saline solution infus (500ML=1) J7050 ormal saline solution infus (250 CC) into into J9310 Rituximab, 100 mg RituXan K K $ $ G3001 Q9968 Admin + supply, tositumomab, 450 mg (Use this Code for Bexxar) Injection, non-radioactive, non-contrast, visualization adjunct (e.g., Methylene Blue, Isosulfan Blue), 1mg on Radioactive Bexxar Plus Injection S S $1, $1, Methylene Blue K K $1.61 $ Disclaimer The opinions referenced are those of the members of the SMMI Coding and Reimbursement Committee and their consultants based on their coding experience. They are based on the commonly used codes in uclear Medicine, which are not all inclusive. Always check with your local insurance carriers as policies vary by region. The final decision for the coding of a procedure must be made by the physician considering regulations of insurance carriers and any local, state or federal laws that apply to the physicians practice. The SMMI and its representatives disclaim any liability arising from the use of these opinions. Legend: Blue triangle - current code revision has resulted in a substantially altered procedure descriptor Red circle - new procedure SMMI Reimbursement Hospital Educational Material Page 12 of 12