Deleted Effective Beginning of Calendar Year Not Paid under Outpatient PPS Not Paid Under OPPS or any other Medicare payment system

Transcription

1 FINAL 2010 Compared to FINAL 2011 Rates Medicare Hospital Outpatient Prospective Payment System HOPPS (APC) Nuclear Medicine Procedures, Radiopharmaceuticals, and Drugs CMS Website HOPPS CY2011 FINAL Rule Updated November 2, 2010 Indicator A Service Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS Status Not Paid under Outpatient PPS. Paid by fiscal intermediaries/mac under a fee schedule or payment system other than OPPS. Not subject to deductible or coinsurance. B D E Codes that are not recognized by OPPS when submitted on an Outpatient Hospital Part B type bill (12x and 13x) Discontinued Codes Non-covered Items and Services Not Paid under Outpatient PPS Deleted Effective Beginning of Calendar Year Not Paid under Outpatient PPS Not Paid Under OPPS or any other Medicare payment system G Pass-Through Drug/ Biologicals Separate APC Payment includes pass-through amount H K Pass-through Device Categories NonPass-Through Drugs or Biologicals, including therapeutic Radiopharmaceuticals Separate cost-based pass-through payment; not subject to copayment.apc Payment Paid under OPPS; separate APC payment N Q1 Q3 S T U X Items and Services packaged into 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, Not Discounted When Multiple Significant Procedure, Multiple Procedure Reduction Applies Brachytherapy Sources Ancillary Service Paid Under OPPS; Payment is payment for other services, including outliers. Therefore, there is not separate APC payment 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 1.) Composite APC payment based on OPPS compositespecific 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 Paid Under Outpatient PPS, separate APC payment Injection procedure; for identification of sentinel node (for nuclear Q1 Q1 $ $ % medicine lymphatics and lymph gland imaging, use 78195) Injection procedure (eg, contrast media) for evaluation of N N N/A previously placed peritoneal-venous shunt (For radiological supervision and interpretation, see 75809, 78291) Insertion of non-indwelling bladder catheter (eg, straight X X $45.00 $ % catheterization for residual urine) Insertion of temporary indwelling bladder catheter; simple (eg, X X $45.00 $ % Foley) Insertion of temporary indwelling bladder catheter; complicated T T $73.68 $ % (eg, altered anatomy, fractured catheter/balloon) Page 1 of 11

2 76376 Injection 3D rendering procedure; with interpretation for identification and reporting of sentinel of node computed (for nuclear of computed tomography, magnetic resonance imaging, ultrasound, N 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) N/A D rendering with interpretation and reporting of computed of computed tomography, magnetic resonance imaging, ultrasound, N 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) N/A Special medical radiation physics consultation X X $ $ % NUCLEAR MEDICINE NEW 2006 INTRODUCTORY LANGUAGE 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 CH 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 S S $ $ % (eg, urinary recovery) Thyroid carcinoma metastases imaging; whole body S S $ $ % Thyroid carcinoma metastases uptake (Use in conjunction with N N N/A code only) Parathyroid imaging S S $ $ % Adrenal imaging, cortex and/or medulla 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 S S $ $ % (separate procedure); single sampling 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 S S $ $ % measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique) Red cell survival study; S S $ $ % Red cell survival study; differential organ/tissue kinetics (eg, S S $ $ % splenic and/or hepatic sequestration) 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 S S $ $ % organ/tissue localization 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 S S $ $ % procedure, diagnostic nuclear medicine Liver imaging; static only S S $ $ % Page 2 of 11

3 78202 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 S S $ $ % or without pharmacologic intervention, with or without quantitative 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 A Urea breath test, C-14 (isotopic); analysis A Vit B-12 absorption study (eg, Schilling test); without intrinsic S S $ $ % factor Vit B-12 absorption study (eg, Schilling test); with intrinsic factor S S $ $ % Vit B-12 absorption study combined, with and without intrinsic S S $ $ % factor 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; X E N/A single photon absorptiometry Bone density (bone mineral content) study, 1 or more sites; dual E E N/A photon absorptiometry one or more sites Unlisted musculoskeletal procedure, diagnostic nuclear medicine S S $ $ % Determination of central c-v hemodynamics (non-imagine) (eg, S S $ $ % ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations Cardiac shunt detection S S $ $ % Non-cardiac vascular flow imaging (ie, angiography, venography) S S $ $ % Myocardial perfusion imaging, tomographic (SPECT) (including NI-S S $ $ % attenuation correction, 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 pharmacologic) Myocardial perfusion imaging, tomographic (SPECT) (including NI-S S $ $ % 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 stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Myocardial perfusion imaging, planar (including qualitative or NI-S S $ $ % quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, planar (including qualitative or NI-S S $ $ % quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple 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 $ $ % Venous thrombosis imaging, venogram; bilateral S S $ $ % Page 3 of 11

4 78459 Injection Myocardial procedure; imaging, for positron identification emission of tomography sentinel node (PET), (for nuclear S S $1, $1, % metabolic evaluation Myocardial imaging, infarct avid, planar; qualitative or quantitative S S $ $ % Myocardial imaging, infarct avid, planar; with ejection fraction by S S $ $ % first pass technique Myocardial imaging, infarct avid, planar; tomographic SPECT with S S $ $ % or without quantification Cardiac blood pool imaging, gated equilibrium; planar, single S S $ $ % 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, S S $ $ % 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 S S $ $ % 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 S S $ $ % 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, $1, % perfusion; single study at rest or stress Myocardial imaging, positron emission tomography (PET), S S $1, $1, % perfusion; multiple studies at rest and/or stress Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, S S $ $ % wall motion study plus ejection fraction, with or without quantitative processing Cardiac blood pool imaging, gated equilibrium, single study, at N N rest, with right ventricular ejection fraction by first pass technique (Use in conjunction with 78472) Unlisted cardiovascular procedure, diagnostic nuclear medicine S S $ $ % 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 N/A Pulmonary ventilation imaging, gaseous, with rebreathing and S S $ $ % washout with or without single breath; multiple projections (eg, 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 CH 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 $ $ % Brain imaging, positron emission tomography (PET); metabolic S S $1, $1, % evaluation Page 4 of 11

5 78609 Injection Brain imaging, procedure; positron for identification emission tomography of sentinel (PET); node perfusion (for nuclear E E evaluation Brain imaging, vascular flow only CH S S $ $ % Cerebrospinal fluid flow, imaging (not including introduction of S S $ $ % material); cisternography (For injection procedure, see , ) Cerebrospinal fluid flow, imaging (not including introduction of S S $ $ % material); ventriculography (For injection procedure, see , ) Cerebrospinal fluid flow, imaging (not including introduction of S S $ $ % material); shunt evaluation (For injection procedure, see , ) Cerebrospinal fluid flow, imaging (not including introduction of S S $ $ % material); tomographic (SPECT) 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 S S $ $ % 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) 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 S S $ $ % radiopharmaceutical agent(s); limited area 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 CH S S $ $ % radiopharmaceutical agent(s); tomographic (SPECT) Radiopharmaceutical localization of tumor or distribution of S S $ $ % radiopharmaceutical agent(s); whole body, requiring 2 or more 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; CH S S $ $ % tomographic (SPECT) (For imaging bone infectious or inflammatory disease with a bone imaging radiopharmaceutical, see 78300, 78305, 78306) Injection procedure for radiopharmaceutical localization by nonimaging Q1 Q1 $ $ % probe study, intravenous (eg, parathyroid adenoma) (For sentinel lymph node identification, use 38792) Positron emission tomography (PET) imaging; limited area (eg S S $1, $1, % chest, head/neck) Positron emission tomography (PET) imaging; skull base to midthigh S S $1, $1, % Positron emission tomography (PET) imaging; whole body S S $1, $1, % Positron emission tomography (PET) with concurrently acquired S S $1, $1, % computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) Positron emission tomography (PET) with concurrently acquired S S $1, $1, % computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh Positron emission tomography (PET) with concurrently acquired S S $1, $1, % computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body Page 5 of 11

6 (Report Injection only procedure; once per for imaging identification session) of sentinel (Computed node tomography (for nuclear (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 N Radiopharmaceutical therapy, by oral administration (For S S $ $ % monoclonal antibody by intravenous infusion, use 79403) Radiopharmaceutical therapy, by intravenous administration (Do S S $ $ % not report in conjunction with 36400, 35410, 79403, 90780, 96408) (For monoclonal antibody by intravenous infusion, use 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 S S $ $ % by intravenous infusion (For pre-treatment imaging, see 78802, 78804) (Do not use in conjunction with 79101) Radiopharmaceutical therapy, by intra-articular administration S S $ $ % Radiopharmaceutical therapy, by intra-arterial particulate S S $ $ % administration (Do not report in conjunction with 90783, 96420) (Use appropriate procedural and radiological supervision and interpretation codes for the angiographic and interventional procedures provided pre-requisite to intra-arterial radiopharmaceutical therapy) Radiopharmaceutical therapy, unlisted procedure S S $ $ % Cardiovascular stress test using maximal or submaximal treadmill X X $ $ % or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation 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 N/A G0235 PET imaging, any site, not otherwise specified E E G0252 PET imaging, full & partial-ring PET scanner only, for initial E E diagnosis of breast cancer and/or surgical planning for breast cancer (eg, initial staging of axillary lymph nodes) RADIOPHARMACEUTICALS & NUCLEAR MEDICINE RELATED DRUGS A4641 Radiopharm dx agent noc Radiopharmaceutical, diagnostic, not otherwise classified 4th Quarter Oct 2010 Update NOC N N CY 2011 January % Change A4642 In-111 satumomab, dx. Indium In-111 satumomab pendetide, diagnostic, per study dose, up to 6 s Oncoscint N N A9500 Tc-99m sestamibi, dx. Technetium Tc-99m sestamibi, diagnostic, per study dose Cardiolite / Miraluma N N A9501 Tc-99m teboroxime, dx. Technetium Tc-99m teboroxime, diagnostic, per study dose CardioTec TEBO N N A9502 Tc-99m tetrofosmin, dx. Technetium Tc-99m tetrofosmin, diagnostic, per study dose Myoview N N A9503 Tc-99m medronate, dx. Technetium Tc-99m medronate, diagnostic, per study dose, up to 30 s MDP N N A9504 Tc-99m apcitide, dx. Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20 s Acutect N N Page 6 of 11

7 A9505 Injection TL-201 thallium, procedure; dx. for identification of sentinel node Thallium (for nuclear 201 N N Thallium Tl-201 thallous chloride, diagnostic, per A9507 In-111 capromab, dx. Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 s Prostascint N N A9508 I-131 iodobenguate, dx. Iodine I-131 lobenguane sulfate, diagnostic, per 0.5 I-131 MIBG N N A9509 I-123 sodium iodide, dx. Iodine I-123 sodium iodide, diagnostic, per Use for 1-4 mci doses of I-123 for whole body imaging for less than 1 mci and thyroid imaging see A9516 N N A9510 Tc-99m disofenin, dx. Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 s DISIDA N N A9512 Tc-99m pertechnetate, dx. Technetium Tc-99m pertechnetate, diagnostic, per Straight Tech Technescan Technelite N N A9516 I-123 sodium iodide, dx. Iodine I-123 sodium iodide, diagnostic, 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 N N A9517 I-131 capsule, rx. Iodine I-131 sodium iodide capsule(s), therapeutic, per Rx I-131 Capsules CH K K $16.51 $ % A9521 Tc-99m exametazime, dx. Technetium Tc-99m exametazime, diagnostic, per study dose, up to 25 s Ceretec HMPAO N N A9524 I-131 serum albumen, dx. Iodine I-131 iodinated serum albumin, diagnostic, per 5 microcuries I-131 Albumin N N A9526 N-13 ammonia, dx. Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 s N-13 N N A9527 I-125 sodium iodide, rx. Iodine I-125, sodium iodide solution, therapeutic, per U U $37.83 $ % A9528 I-131 iodide capsule, dx. Iodine I-131 sodium iodide capsule(s), diagnostic, per I-131 Dx caps per mci N N A9529 I-131 sodium iodide solution, dx. Iodine I-131 sodium iodide solution, diagnostic, per Dx I-131 sol per mci N N Page 7 of 11

8 A9530 Injection I-131 sodium procedure; iodide solution, for identification rx. of sentinel node Rx I-131 (for nuclear sol per CH K K $11.02 $ % Iodine I-131 sodium iodide solution, therapeutic, per mci A9531 I-131 sodium iodide, dx. Iodine I-131 sodium iodide, diagnostic, per microcurie (up to 100 microcuries) Dx I-131 up to 100 uci N N A9532 I-125 serum albumin, dx. Iodine I-125 serum albumin, diagnostic, per 5 microcuries N N A9536 Tc-99m depreotide, dx. Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35 s Neotec N N A9537 Tc-99m mebrofenin, dx. Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 s Choletec N N A9538 Tc-99m pyrophosphate, dx. Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 s Pyrolit3e *Use this code for myocardial infarct imaging. Do not use this code for GBP, RVG or MUGA procedures see A9560 N N A9539 Tc-99m pentetate, dx. Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25 s Tc-99m DTPA N N A9540 Tc-99m MAA, dx. Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 s MAA N N A9541 Tc-99m sulfur colloid, dx. Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 s Sulfur colloid (SC) N N A9542 In-111 ibritumomab, dx. Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 s Dx In-111 Zevalin N N A9543 Y-90 ibritumomab, rx. Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 s Rx Y-90 Zevalin CH K K $30, $30, % A9544 I-131 tositumomab, dx. Iodine I-131 tositumomab, diagnostic, per study dose Dx Bexxar N N A9545 I-131 tositumomab, rx. Iodine I-131 tositumomab, therapeutic, per treatment dose Rx Bexxar CH K K $29, $29, % A9546 Co-57/58, dx. Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 microcurie Nycomed N N Page 8 of 11

9 A9547 Injection In-111 oxyquinoline, procedure; for dx. identification of sentinel node (for nuclear Indium In-111 oxyquinoline, diagnostic, per 0.5 N N A9548 In-111 pentetate, dx. Indium In-111 pentetate, diagnostic, per 0.5 Indium DTPA N N A9550 Tc-99m gluceptate, dx. Technetium Tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 s Glucoscan N N A9551 Tc-99m succimer, dx. Technetium Tc-99m succimer, diagnostic, per study dose, up to 10 s DMSA N N A9552 F-18 FDG, dx. Fluorodeoxyglucose F-18 fdg, diagnostic, per study dose, up to 45 s FDG / F-18 N N A9553 Cr-51 chromate, dx. Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to 250 microcuries N N A9554 I-125 iothalamate, dx. Iodine I-125 sodium iothalamate, diagnostic, per study dose, up to 10 microcuries N N A9555 Rb-82 rubidium, dx. Rubidium Rb-82, diagnostic, per study dose, up to 60 s Rb-82 CardioGen82 N N A9556 Ga-67 gallium, dx. Gallium Ga-67 citrate, diagnostic, per Gallium N N A9557 Tc-99m bicisate, dx. Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25 s Neurolite N N A9558 Xe-133 gas, dx. Xenon Xe-133 gas, diagnostic, per 10 s Xenon N N A9559 Co-57 cyano, dx. Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 microcurie Shillings Study Rubratope 57 Cobatope 57 N N A9560 Tc-99m labeled rbc, dx. Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 s ULTRATAG or Cold PYP + 99m Tc Code to be used for both the invivo/invitro methods of tagging Red Blood Cells N N A9561 Tc-99m oxidronate, dx. Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30 s HDP N N A9562 Tc-99m mertiatide, dx. Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15 s MAG-3 N N Page 9 of 11

10 A9563 Injection P-32 Na phosphate, procedure; for rx. identification of sentinel node (for nuclear CH K K $ $ % Sodium phosphate P-32, therapeutic, per A9564 P-32 chromic phosphate, rx. Chromic phosphate P-32 suspension, therapeutic, per Phosphocol / P CH K K $ $ % A9566 Tc-99m fanolesomab, dx. Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to 25 s NeutroSpec N N A9567 Tc-99m pentetate, dx., aerosol Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 s DTPA aerosol for lung ventilation studies N N A9568 Tc-99m arcitumomab, dx. Technetium Tc-99m arcitumomab, diagnostic, per study dose, up to 45 s CEA scan N N A9569 Tc-99m auto WBC, dx. Technetium Tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose Use this code for infection or inflammation imaging, do not use this code for brain imaging see A9521 N N A9570 In-111 auto WBC, dx. Indium In-111 labeled autologous white blood cells, diagnostic, per study dose When prepared with patient WBC use this code, do not use A9547 N N A9571 In-111 auto platelet, dx. Indium In-111 labeled autologous platelets, diagnostic, per study dose When prepared with patient platelets use this code, do not use A9547 N N A9572 In-111 pentetreotide, dx. Indium In-111 pentetreotide, diagnostic, per study dose, up to 6 s Octreoscan N N A9580 F-18 sodium fluoride, dx. Sodium fluoride F-18, diagnostic, per study dose, up to 30 s F-18, NaF, Sodium Flouride N N A9582 I-123 lobenguane, dx. Iodine I-123 lobenguane, diagnostic, per study dose, up to 15 s I-123 MIBG / AdreView G G $2, $2, N/A **Note final payment rates for status G codes have offset RP amounts posted on the CMS web site by CPT code. A9600 Sr-89 strontium, rx. Rx Metastron CH K K $ $ % A9604 Strontium Sr-89 chloride, therapeutic, per Sm-153 lexidronam, rx. Samarium Sm-153 lexidronam, therapeutic, per treatment dose, up to 150 s Rx Quadramet NI- CH- K K $7, $7, % A9699 Radiopharm rx. agent noc Radiopharmaceutical, therapeutic, not otherwise classified NOC N N J0150 Adenosine tx., 6 mg, inj. Injection adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) Adenocard 0379 K CH N $ Page 10 of 11

11 J0152 Injection Adenosine procedure; dx., 30 mg, for inj. identification of sentinel node Adenoscan (for nuclear K K $83.41 $ % Injection adenosine for diagnostic use, 30 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) J0280 Aminophyllin up to 250 mg, inj. N N J0461 Atropine sulfate, 0.01 mg, inj. N N J1120 Acetazolamide sodium injection, up to 500 Diamox N N mg, inj. J1160 Digoxin, up to 0.5 mg, inj. Lanoxin N N J1245 Dipyridamole, per 10mg, inj. Persantine IV N N J1250 Dobutamine hcl, per 250 mg, inj. Dobutrex N N J1265 Dopamine hcl., 40 mg, inj. Intropin N N J1610 Glucagon hcl, per 1 mg, inj. Glucagen K K $84.30 $ % J1642 Heparin sodium, per 10 units, inj. Heplock N N J1800 Propranolol hcl, up to 1 mg, inj. Inderal N N J1940 Furosemide, up to 20 mg, inj. Lasix N N J2270 Morphine sulfate, up to 10 mg, inj. N N J2271 Morphine sulfate, 100 mg, inj. N N J2785 Regadenoson, 0.1 mg, inj. LexiScan NDC G CH K $51.29 $ % J2805 Sincalide, 5 mcg, inj. Kinevac 1348 CH N CH K $71.95 J3240 Thyrotropin alpha, 0.9 mg, inj. Thyrogen K K $1, $1, % Thytropar J3420 Vitamin B-12 cyanocobalamin, up to 1000 mcg, inj. N N J3490 Drugs, unclassified, inj. NOC N N J3590 Biologics, unclassified NOC N N J7030 Normal saline solution, 1000 cc, infusion N N J7040 Normal saline solution (500 ml=1 unit), infusion N N J7050 Normal saline solution, 250 cc, infusion N N J9310 Rituximab, 100 mg RituXan K K $ $ % G3001 Tositumomab, 450 mg, admin & supply S S $1, $2, % (Use this Code for Bexxar) Q9968 Non-radioactive, non-contrast, visualization adjunct (e.g., methylene blue, isosulfan blue), 1 mg, inj. Methylene Blue K K $1.43 $ % Page 11 of 11