Paid under OPPS; separate APC payment. Separate cost-based pass-through payment; not subject to copayment. Paid under OPPS; separate APC payment

Transcription

1 FIAL 2011 Compared to PROPOSED 2012 Rates Medicare Hospital Outpatient Prospective Payment System HOPPS (APC) uclear Medicine Procedures, Radiopharmaceuticals, and Drugs CMS Website HOPPS CY2012 PROPOSED Rule Updated July 1, 2011 Indicator A B D E Service Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS Codes that are not recognized by OPPS when submitted on an Outpatient Hospital Part B type bill (12x and 13x) Discontinued Codes on-covered Items and Services Status ot Paid under Outpatient PPS. Paid by fiscal intermediaries/mac under a fee schedule or payment system other than OPPS. Services are subject to deductible or coinsurance unless indicated otherwise. ot Paid under Outpatient PPS. May be paid if bill type 75x. Deleted Effective Beginning of Calendar Year ot Paid under Outpatient PPS ot Paid Under OPPS or any other Medicare payment system (Any outpatient Bill Type) G Pass-Through Drug/ Biologicals Paid under OPPS; separate APC payment H K Pass-through Device Categories onpass-through Drugs and nonimplantable Biologicals, including Therapeutic Radiopharmaceuticals Items and Services packaged into Separate cost-based pass-through payment; not subject to copayment. Paid under OPPS; separate APC payment Paid Under OPPS; Payment is payment for other services. Therefore, there is not separate APC payment Q1 Q3 S T U STVX-Packaged Codes (e.g separately payable is only item on claim for SDOS) Codes that may be paid through a composite APC (e.g Ultrasound, MRI, MRA, CT and Cardiac CTA separately payable is only item on claim for SDOS) Significant Procedure, ot Discounted When Multiple Significant Procedure, Multiple Procedure Reduction Applies Brachytherapy Sources Paid under OPPS; Addendum B displays APC assignments when services are separately payable 1.) Packaged APC payment if billed on the SDOS as a HCPCS code assigned SI "S," "T,"V," or "X." 2.) In all other circumstances, payment is made through a separate APC payment. Paid under OPPS; Addendum B displays APC assignments when services are separately payable Addendium M displays composit APC assignments when codes are paid through a composite APC. 1.) Composite APC payment based on OPPS composite-specific payment criteria. Payment is packaged into a single pament for specific combinations of service. 2.) In all other circumstances, payment is made through a separate APC payment or packaged into payment of other services. Paid Under Outpatient PPS, separate APC payment Paid Under Outpatient PPS, separate APC payment Paid Under Outpatient PPS, separate APC payment X Ancillary Service Paid Under Outpatient PPS, separate APC payment HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection procedure; for identification of sentinel node (for nuclear Q1 Q1 $ $ % Injection procedure (eg, contrast media) for evaluation of previously placed peritoneal-venous shunt (For radiological supervision and interpretation, see 75809, 78291) /A Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) X X $46.23 $ % Insertion of temporary indwelling bladder catheter; simple (eg, X X $46.23 $ % Foley) Insertion of temporary indwelling bladder catheter; complicated T T $76.52 $ % (eg, altered anatomy, fractured catheter/balloon) SM Reimbursement Hospital Educational Material Page 1 of 11

2 HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection 3D rendering procedure; with interpretation for identification and reporting of sentinel of node computed (for nuclear 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) 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) Special medical radiation physics consultation X X $ $ % UCLEAR MEDICIE EW 2006 ITRODUCTORY LAGUAGE The services listed do not include the radiopharmaceutical or drug. Diagnostic and therapeutic radiopharmaceuticals and drugs supplied by the physician should be reported separately using the appropriate supply code(s), in addition to the procedure code Thyroid uptake; single determination S S $ $ % Thyroid uptake; multiple determinations S S $ $ % Thyroid uptake; stimulation, suppression or discharge (not S S $ $ % including initial uptake studies) Thyroid imaging with uptake; single determination S S $ $ % Thyroid imaging with uptake; multiple determinations S S $ $ % Thyroid imaging: only S S $ $ % Thyroid imaging: with vascular flow S S $ $ % Thyroid carcinoma metastases imaging; limited are (eg, neck and S S $ $ % chest only) Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery) S S $ $ % Thyroid carcinoma metastases imaging; whole body S S $ $ % Thyroid carcinoma metastases uptake (Use in conjunction with code only) /A Parathyroid imaging S S $ $ % Adrenal imaging, cortex and/or medulla 0408 CH 0414 S S $ $ % 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 S S $ $ % (separate procedure); multiple sampling Red cell volume determination (separate procedure); single S S $ $ % sampling Red cell volume determination (separate procedure); multiple S S $ $ % sampling Whole blood volume determination, including separate measurement of plasma volume and red cell volume S S $ $ % (radiopharmaceutical volume-dilution technique) Red cell survival study; S S $ $ % Red cell survival study; differential organ/tissue kinetics (eg, splenic and/or hepatic sequestration) S S $ $ % Labeled red cell sequestration, differential organ/tissue, (eg, S S $ $ % splenic and/or hepatic) Spleen imaging only, with or without vascular flow (If combined S S $ $ % with liver study, use procedures and 78216) Kinetics, study of platelet survival, with or without differential organ/tissue localization S S $ $ % Platelet survival study S S $ $ % Lymphatics and lymph nodes imaging (For sentinel node S S $ $ % identification without scintigraphy imaging, use 38792) Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine S S $ $ % Liver imaging; static only S S $ $ % /A /A SM Reimbursement Hospital Educational Material Page 2 of 11

3 HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection Liver imaging; procedure; with vascular for identification flow of sentinel node (for nuclear 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 $ $ % Liver function study with hepatobiliary agents, with serial images S S $ $ % Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative S S $ $ % measurement of gallbladder function Salivary gland imaging; Salivary gland imaging; with serial images Salivary gland function study Esophageal motility Gastric mucosa imaging Gastroesophageal reflux study Gastric emptying study Urea breath test, C-14 (isotopic); acquisition for analysis Urea breath test, C-14 (isotopic); analysis 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 Gastrointestinal protein loss Intestine imaging (eg, ectopic gastric mucosa, Meckel s localization, volvulus) Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt) Unlisted gastrointestinal procedure, diagnostic nuclear medicine 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 absorptiometry E E /A Bone density (bone mineral content) study, 1 or more sites; dual E E /A photon absorptiometry one or more sites 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 exercise, single or multiple determinations Cardiac shunt detection 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 S S $ $ % quantification, when performed); single 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 studies, at rest and/or S S $ $ % 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 S S $ $ % study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple S S $ $ % studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Acute venous thrombus imaging, peptide S S $ $ % Venous thrombosis imaging, venogram; unilateral S S $ $ % SM Reimbursement Hospital Educational Material Page 3 of 11

4 HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection Venous thrombosis procedure; imaging, for identification venogram; of sentinel bilateralnode (for nuclear S S $ $ % Myocardial imaging, positron emission tomography (PET), metabolic evaluation S S $1, $ % Myocardial imaging, infarct avid, planar; qualitative or quantitative Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification 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 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 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 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 ejection fraction, with or without quantification Myocardial imaging, positron emission tomography (PET), S S $1, $ % perfusion; single study at rest or stress Myocardial imaging, positron emission tomography (PET), S S $1, $ % perfusion; multiple studies at rest and/or stress Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion 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) Unlisted cardiovascular procedure, diagnostic nuclear medicine Lung perfusion imaging, particulate S S $ $ % Pulmonary perfusion imaging, particulate, with ventilation; single S S $ $ % breath Pulmonary perfusion imaging, particulate, with ventilation; S S $ $ % rebreathing and washout, with or without single breath Pulmonary ventilation imaging, aerosol; single projection S S $ $ % Pulmonary ventilation imaging, aerosol; multiple projections (eg, S S $ $ % anterior, posterior, lateral views) Pulmonary perfusion imaging, particulate, with ventilation S S $ $ % imaging, aerosol, 1 or multiple projections Pulmonary ventilation imaging, gaseous, single breath, single S S $ $ % projection Pulmonary ventilation imaging, gaseous, with rebreathing and S S $ $ % washout with or without single breath; single projection Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; multiple projections (eg, S S $ $ % anterior, posterior, lateral views) Pulmonary quantitative differential function (ventilation/perfusion) S S $ $ % study 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 $ $ % /A SM Reimbursement Hospital Educational Material Page 4 of 11

5 HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection Brain imaging, procedure; positron for identification emission tomography of sentinel (PET); node metabolic (for nuclear evaluation Brain imaging, positron emission tomography (PET); perfusion E E evaluation Brain imaging, vascular flow only S S $ $ % Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography (For injection procedure, see S S $ $ % 61070, ) Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography (For injection procedure, see S S $ $ % 61070, ) Cerebrospinal fluid flow, imaging (not including introduction of material); shunt evaluation (For injection procedure, see S S $ $ % 61070, ) Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT) S S $ $ % Cerebrospinal fluid leakage detection and localization S S $ $ % Radiopharmaceutical dacryocystography S S $ $ % Unlisted nervous system procedure, diagnostic nuclear medicine S S $ $ % Kidney imaging morphology Kidney imaging morphology with vascular flow Kidney imaging morphology with vascular flow and function, single study without pharmacological intervention Kidney imaging morphology with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) Kidney imaging morphology with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) Kidney imaging morphology tomographic (SPECT) 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 S S $ $ % imaging of the bladder only, with measurement of postvoid residual urine when performed, use 76857) Ureteral reflux study (radiopharmaceutical voiding cystogram) For catheterization see 51701, 51702, Testicular imaging with vascular flow Unlisted genitourinary procedure; diagnostic nuclear medicine 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 radiopharmaceutical agent(s); whole body, requiring 2 or more S S $ $ % days imaging Radiopharmaceutical localization of inflammatory process; limited S S $ $ % area Radiopharmaceutical localization of inflammatory process; whole S S $ $ % body Radiopharmaceutical localization of inflammatory process; tomographic (SPECT) (For imaging bone infectious or inflammatory disease with a bone imaging radiopharmaceutical, S S $ $ % see 78300, 78305, 78306) Injection procedure for radiopharmaceutical localization by nonimaging probe study, intravenous (eg, parathyroid adenoma) Q1 Q1 $ $ % (For sentinel lymph node identification, use 38792) Positron emission tomography (PET) imaging; limited area (eg. chest, head/neck) Positron emission tomography (PET) imaging; skull base to midthigh Positron emission tomography (PET) imaging; whole body SM Reimbursement Hospital Educational Material Page 5 of 11

6 HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection Positron emission procedure; tomography for identification (PET) of with sentinel concurrently node (for acquired nuclear computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 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 durig a hospital inpatient stay Radiopharmaceutical therapy, by oral administration (For S S $ $ % monoclonal antibody by intravenous infusion, use 79403) Radiopharmaceutical therapy, by intravenous administration (Do not report in conjunction with 36400, 35410, 79403, 90780, ) (For monoclonal antibody by intravenous infusion, use S S $ $ % 79403) (For infusion or 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 S S $ $ % administration Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion (For pre-treatment imaging, see 78802, S S $ $ % 78804) (Do not 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, ) (Use appropriate procedural and radiological supervision and interpretation codes for the angiographic and interventional S S $ $ % procedures provided pre-requisite to intra-arterial 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 stress; tracing only, without interpretation X X $ $ % and report Chemotherapy administration, intravenous infusion technique; up S S $ $ % to one hour, single or initial substance/drug G0219 PET imaging whole body; melanoma for non-covered indications E E G0235 PET IMAGIG, AY SITE, OT OTHERWISE SPECIFIED E E PET imaging, full & partial-ring PET scanner only, for initial G0252 diagnosis of breast cancer and/or surgical planning for breast E E cancer (eg, initial staging of axillary lymph nodes) /A RADIOPHARMACEUTICALS & UCLEAR MEDICIE RELATED DRUGS CY 2011 January CY 2012 January PROPOSED % Change A4641 Radiopharm dx agent noc RADIOPHARMACEUTICAL, DIAGOSTIC, OT OTHERWISE CLASSIFIED In111 satumomab A4642 IDIUM I-111 SATUMOMAB PEDETIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 6 Tc99m sestamibi OCOSCIT A9500 TECHETIUM TC-99M SESTAMIBI, DIAGOSTIC, PER STUDY DOSE, UP TO 40 CARDIOLITE / MIRALUMA SM Reimbursement Hospital Educational Material Page 6 of 11

7 HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection Technetium procedure; TC-99m for teboroxime identification of sentinel node (for nuclear A9501 TECHETIUM TC-99M TEBOROXIME, DIAGOSTIC, PER STUDY DOSE CardioTec TEBO A9502 Tc99m tetrofosmin TECHETIUM TC-99M TETROFOSMI, DIAGOSTIC, PER STUDY DOSE MYOVIEW Tc99m medronate A9503 TECHETIUM TC-99M MEDROATE, DIAGOSTIC, PER STUDY DOSE, UP TO 30 MDP Tc99m apcitide A9504 TECHETIUM TC-99M APCITIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 20 ACUTECT TL201 thallium A9505 THALLIUM TL-201 THALLOUS CHLORIDE, DIAGOSTIC, PER MILLICURIE THALLIUM 201 In111 capromab A9507 IDIUM I-111 CAPROMAB PEDETIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 10 PROSTASCIT I131 iodobenguate, dx A9508 IODIE I-131 IOBEGUAE SULFATE, DIAGOSTIC, PER 0.5 MILLICURIE I-131 MIBG 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 A9510 TECHETIUM TC-99M DISOFEI, DIAGOSTIC, PER STUDY DOSE, UP TO 15 DISIDA A9512 Tc99m pertechnetate TECHETIUM TC-99M PERTECHETATE, DIAGOSTIC, PER MILLICURIE Straight Tech Technescan Technelite A9516 Iodine I-123 sod iodide mic 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 A9517 I131 iodide cap, rx IODIE I-131 SODIUM IODIDE CAPSULE(S), Tc99m exametazime Rx I-131 Capsules K K $17.58 $ % A9521 TECHETIUM TC-99M EXAMETAZIME, DIAGOSTIC, PER STUDY DOSE, UP TO 25 CERETEC HMPAO A9524 I131 serum albumin, dx IODIE I-131 IODIATED SERUM ALBUMI, DIAGOSTIC, PER 5 MICROCURIES I-131 Albumin SM Reimbursement Hospital Educational Material Page 7 of 11

8 HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection procedure; for identification of sentinel node (for nuclear itrogen -13 ammonia A9526 ITROGE -13 AMMOIA, DIAGOSTIC, PER STUDY DOSE, UP TO A9527 Iodine I-125 sodium iodide IODIE I-125, SODIUM IODIDE SOLUTIO, U U $21.65 $ % A9528 Iodine I-131 iodide cap, dx IODIE I-131 SODIUM IODIDE CAPSULE(S), DIAGOSTIC, PER MILLICURIE I-131 Dx caps per mci A9529 I131 iodide sol, dx IODIE I-131 SODIUM IODIDE SOLUTIO, DIAGOSTIC, PER MILLICURIE Dx I-131 sol per mci A9530 I131 iodide sol, rx IODIE I-131 SODIUM IODIDE SOLUTIO, Rx I-131 sol per mci K K $13.26 $ % I131 max 100uCi A9531 IODIE I-131 SODIUM IODIDE, DIAGOSTIC, PER MICROCURIE (UP TO 100 MICROCURIES) Dx I-131 up to 100 uci A9532 I125 serum albumin, dx IODIE I-125 SERUM ALBUMI, DIAGOSTIC, PER 5 MICROCURIES Tc99m depreotide A9536 TECHETIUM TC-99M DEPREOTIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 35 EOTEC Tc99m mebrofenin A9537 TECHETIUM TC-99M MEBROFEI, DIAGOSTIC, PER STUDY DOSE, UP TO 15 CHOLETEC A9538 Tc99m pyrophosphate TECHETIUM TC-99M PYROPHOSPHATE, DIAGOSTIC, PER STUDY DOSE, UP TO 25 Tc99m pentetate PYROLITE *Use this code for myocardial infarct imaging. Do not use this code for GBP, RVG or MUGA procedures see A9539 TECHETIUM TC-99M PETETATE, DIAGOSTIC, PER STUDY DOSE, UP TO 25 Tc-99m DTPA Tc99m MAA A9540 TECHETIUM TC-99M MACROAGGREGATED ALBUMI, DIAGOSTIC, PER STUDY DOSE, UP TO 10 Tc99m sulfur colloid MAA A9541 TECHETIUM TC-99M SULFUR COLLOID, DIAGOSTIC, PER STUDY DOSE, UP TO 20 In111 ibritumomab, dx SULFUR COLLOID (SC) A9542 IDIUM I-111 IBRITUMOMAB TIUXETA, DIAGOSTIC, PER STUDY DOSE, UP TO 5 Dx In-111 ZEVALI SM Reimbursement Hospital Educational Material Page 8 of 11

9 HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection procedure; for identification of sentinel node (for nuclear Y90 ibritumomab, rx A9543 A9544 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 Rx Y-90 ZEVALI K K $30, $32, % Dx BEXXAR A9545 IODIE I-131 TOSITUMOMAB, THERAPEUTIC, PER TREATMET DOSE Rx BEXXAR K K $29, $29, % Co57/58 A9546 A9547 COBALT CO-57/58, CYAOCOBALAMI, DIAGOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIE In111 oxyquinoline IDIUM I-111 OXYQUIOLIE, DIAGOSTIC, PER 0.5 MILLICURIE YCOMED See new codes A9570 and A9571 for WBC and Platelet Imaging In111 pentetate A9548 IDIUM I-111 PETETATE, DIAGOSTIC, PER 0.5 MILLICURIE Indium DTPA Tc99m gluceptate A9550 TECHETIUM TC-99M SODIUM GLUCEPTATE, DIAGOSTIC, PER STUDY DOSE, UP TO 25 Tc99m succimer GLUCOSCA A9551 TECHETIUM TC-99M SUCCIMER, DIAGOSTIC, PER STUDY DOSE, UP TO 10 F18 fdg DMSA A9552 FLUORODEOXYGLUCOSE F-18 FDG, DIAGOSTIC, PER STUDY DOSE, UP TO 45 FDG / F-18 Cr51 chromate A9553 CHROMIUM CR-51 SODIUM CHROMATE, DIAGOSTIC, PER STUDY DOSE, UP TO 250 MICROCURIES I125 iothalamate, dx A9554 IODIE I-125 SODIUM IOTHALAMATE, DIAGOSTIC, PER STUDY DOSE, UP TO 10 MICROCURIES Rb82 rubidium A9555 RUBIDIUM RB-82, DIAGOSTIC, PER STUDY DOSE, UP TO 60 Rb-82 CardioGen82 A9556 Ga67 gallium GALLIUM GA-67 CITRATE, DIAGOSTIC, PER MILLICURIE GALLIUM Tc99m bicisate A9557 A9558 TECHETIUM TC-99M BICISATE, DIAGOSTIC, PER STUDY DOSE, UP TO 25 Xe133 xenon 10mci XEO XE-133 GAS, DIAGOSTIC, PER 10 EUROLITE Xenon SM Reimbursement Hospital Educational Material Page 9 of 11

10 HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection Co57 cyano procedure; for identification of sentinel node (for nuclear A9559 A9560 A9561 COBALT CO-57 CYAOCOBALAMI, ORAL, DIAGOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIE Tc99m labeled rbc TECHETIUM TC-99M LABELED RED BLOOD CELLS, DIAGOSTIC, PER STUDY DOSE, UP TO 30 Tc99m oxidronate TECHETIUM TC-99M OXIDROATE, DIAGOSTIC, PER STUDY DOSE, UP TO 30 Tc99m mertiatide Shillings Study Rubratope 57 Cobatope 57 ULTRATAG or Cold PYP + 99m Tc Code to be used for both the invivo/invitro methods of tagging Red Blood Cells HDP A9562 TECHETIUM TC-99M MERTIATIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 15 MAG-3 P32 a phosphate A9563 SODIUM PHOSPHATE P-32, K K $ $ % P32 chromic phosphate A9564 CHROMIC PHOSPHATE P-32 SUSPESIO, Phosphocol P K K $ $ % Tc99m fanolesomab A9566 A9567 A9568 A9569 A9570 A9571 A9572 CMS deleted A9565 A9580 A9582 TECHETIUM TC-99M FAOLESOMAB, DIAGOSTIC, PER STUDY DOSE, UP TO 25 Technetium TC-99m aerosol TECHETIUM TC-99M PETETATE, DIAGOSTIC, AEROSOL, PER STUDY DOSE, UP TO 75 Technetium tc99m arcitumomab TECHETIUM TC-99M ARCITUMOMAB, DIAGOSTIC, PER STUDY DOSE, UP TO 45 Technetium TC-99m auto WBC TECHETIUM TC-99M EXAMETAZIME LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGOSTIC, PER STUDY DOSE Indium In-111 auto WBC 'IDIUM I-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGOSTIC, PER STUDY DOSE Indium I-111 auto platelet IDIUM I-111 LABELED AUTOLOGOUS PLATELETS, DIAGOSTIC, PER STUDY DOSE Indium In-111 pentetreotide 'IDIUM I-111 PETETREOTIDE, DIAGOSTIC, PER STUDY DOSE, UP TO 6 Sodium Flouride F-18, Sodium Flouride F-18, diagnostic, per study dose, up to 30 millicuries Iobenguane, I-123, diagnostic, per study dose, up to 15 millicuries eutrospec DTPA Aerosol For Lung Ventilation Studies CEA-SCA Use this code for infection or inflammation imaging do not use this code for brain imaging see A9521 When prepared with patient WBC use this new code do not use A9547 When prepared with patient platelets use this new code do not use A9547 Octreoscan A9565 was deleted effective 2008 F-18, af, Sodium Flouride I-123 MIBG AdreView DC **ote final payment rates for status G codes have offset RP amounts posted on the CMS web site by CPT code G $2, APC rate RP of Pass- Through Status /A SM Reimbursement Hospital Educational Material Page 10 of 11

11 HCPCS Description ame APC APC SI SI CY 2011 PROPOSED Injection Sr89 strontium procedure; for identification of sentinel node (for nuclear A9600 Rx STROTIUM SR-89 CHLORIDE, METASTRO K K $ $ % Sm 153 lexidronm A9604 A9699 SAMARIUM SM-153 LEXIDROAMM, THERAPEUTIC, PER TREATMET DOSE, up to 150 Radiopharm rx agent noc RADIOPHARMACEUTICAL, THERAPEUTIC, OT OTHERWISE CLASSIFIED Rx QUADRAMET K K $7, $7, % RX OC EW C9406 J0150 Iodine I-123 ioflupane, diagnostic, per study dose, (up to 5 millicuries) Injection adenosine 6 mg Injection Adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) Adenosine injection, 30 mg DaTscan DC # /A 9406 /A G /A $1, ADEOCARD CH CH J0152 Injection Adenosine for diagnostic use, 30 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) ADEOSCA K K $84.21 $ % 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 J1245 Dipyridamole injection, per 10mg Persantine IV J1250 Inj dobutamine HCL/250 mg Dobutrex J1265 Dopamine injection Intropin IJECTIO, DOPAMIE HCL, 40 MG J1610 Glucagon hydrochloride per 1MG Glucagen K K $85.12 $ % J1642 Inj heparin sodium per 10 units (hep lock Heplock flush) J1800 Propranolol HCL injection, up to 1 mg Inderal J1940 Furosemide injection up to 20 mg Lasix J2270 Morphine sulfate injection, up to 10 mg J2271 Morphine sulfate injection, 100 mg J2785 Injection, Regadenoson, 0.1 milligrams LexiScan DC CH K K $50.80 $ % J2805 J3240 J3420 Sincalide injection IJECTIO, SICALIDE, 5 MICROGRAMS Thyrotropin injection 0.9 mg n 1.1 mg vial Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg Kinevac 1348 CH K CH $71.95 Thyrogen Thytropar J3490 Drugs Unclassified injection OC J3590 Unclassified biologics OC J7030 ormal saline solution infus (1000 CC) J7040 ormal saline solution infus (500ML=1) J7050 ormal saline solution infus (250 CC) K K $1, $1, % J9310 Rituximab, 100 mg RituXan K K $ $ % Admin + supply, tositumomab, 450 mg G S S $2, $1, % (Use this Code for Bexxar) Injection, non-radioactive, non-contrast, Q9968 visualization adjunct (e.g., Methylene Blue, Methylene Blue 1288 K CH $1.44 #VALUE! Isosulfan Blue), 1mg SM Reimbursement Hospital Educational Material Page 11 of 11