Not Paid under Outpatient PPS. Deleted Effective Beginning of Calendar Year Not Paid under Outpatient PPS

Transcription

1 Indicator A B 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) FINAL 2009 Compared to Final 2010 Rates Revised May 2010 Medicare Hospital Outpatient Prospective Payment System HOPPS (APC) Nuclear Medicine Procedures, Radiopharmaceuticals, and Drugs CMS Web Site HOPPS CY 2010 Final Rule Updated May 17, 2010 May 2010 CMS Update 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. Not Paid under Outpatient PPS Add On Code + New Code CPT Symbol D Discontinued Codes Deleted Effective Beginning of Calendar Year Not Paid under Outpatient PPS Revised Code E Non-covered Items and Services Not Paid Under OPPS or any other Medicare payment system Conscious Sedation G H K N Q1 Q3 S T Pass-Through Drug/ Biologicals Pass-through Device Categories NonPass-Through Drugs or Biologicals, including therapeutic Radiopharmaceuticals Items and Services packaged into APC rate 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 Separate APC Payment includes pass-through amount Separate cost-based pass-through payment; not subject to co-payment.apc Payment Paid under OPPS; separate APC payment 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. Comment Indicators (NI) New Interim Comments Accepted Paid under OPPS; Addendum B displays APC assignments when services are (NF) Indicates a new code, final separately payable APC assignment; comments 1.) Composite APC payment based on OPPS composite-specific payment were accepted on a proposed criteria. Payment is packaged into a single pament for specific combinations of APC assignment in the service. Proposed Rule; APC is no 2.) In all other circumstances, payment is made through a separate APC longer open to comment payment or packaged into payment of other services. Paid Under Outpatient PPS, separate APC payment Paid Under Outpatient PPS, separate APC payment Cross Reference Cr Ref (CH) Indicates a Change in APC assignment or Status Indicator or HCPCS code U X Brachytherapy Sources Ancillary Service Paid Under Outpatient PPS, separate APC payment Paid Under Outpatient PPS, separate APC payment Injection procedure; for identification of sentinel node (for nuclear medicine lymphatics and lymph gland imaging, use Q1 Q1 $ $ % Injection procedure (eg, contrast media) for evaluation of previously placed peritoneal-venous shunt (For radiological N N n/a supervision and interpretation, see 75809, 78291) Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) X X $42.69 $ % Insertion of temporary indwelling bladder catheter; simple (eg, Foley) X X $42.69 $ % Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon) T T $68.93 $ % Page 1 of 12

2 76376 Injection 3D rendering procedure; with interpretation for identification and reporting of sentinel of node computed (for 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)) N N n/a (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) D 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)) N N n/a (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 $ $ % 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 including initial uptake studies) 0392 CH 0389 S S $ $ % 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 chest only) S S $ $ % 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) N N n/a Parathyroid imaging S S $ $ % Adrenal imaging, cortex and/or medulla S S $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 Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); multiple sampling Red cell volume determination (separate procedure); single sampling Red cell volume determination (separate procedure); multiple sampling Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique) Red cell survival study; Red cell survival study; differential organ/tissue kinetics (eg, splenic and/or hepatic sequestration) Labeled red cell sequestration, differential organ/tissue, (eg, splenic and/or hepatic) Spleen imaging only, with or without vascular flow (If combined with liver study, use procedures and 78216) S S $ $ % 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 identification without scintigraphy imaging, use 38792) S S $ $ % Page 2 of 12

3 Injection Unlisted hematopoietic, procedure; for identification reticuloendothelial of sentinel and lymphatic node (for procedure, diagnostic nuclear medicine S S $ $ % Liver imaging; static only Liver imaging; with vascular flow Liver imaging (SPECT); Liver image (SPECT); with vascular flow Liver and spleen imaging; static only Liver and spleen imaging; with vascular flow Liver function study with hepatobiliary agents, with serial images Hepatobiliary ductal system imaging, including gallbladder, with 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 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 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 X n/a Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry one or more sites E E n/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 exercise, single or multiple determinations Cardiac shunt detection Non-cardiac vascular flow imaging (ie, angiography, venography) S S $ $ % New Code in Myocardial perfusion imaging, tomographic (SPECT) 2010 see (including attenuation correction, qualitative or quantitative deleted codes wall motion, ejection fraction by first pass or gated technique, & additional quantification, when performed); single study, at rest & or stress (exercise or pharmacologic) N/A NI-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); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection New Code in 2010 see deleted codes & & N/A NI-S $ $ % 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 pharmacologic) New Code in 2010 see deleted codes N/A NI-S $ $ % Page 3 of 12

4 Injection procedure; for identification of sentinel node (for 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 (exercise or pharmacologic) and/or redistribution and/or rest reinjection New Code in 2010 see deleted codes N/A NI-S $ $ % Acute venous thrombus imaging, peptide S S $ $ % Venous thrombosis imaging, venogram; unilateral S S $ $ % Venous thrombosis imaging, venogram; bilateral S S $ $ % Myocardial imaging, positron emission tomography (PET), metabolic evaluation S S $1, $1, % Myocardial perfusion imaging; (planar) single study, at rest or stress (exercise and/or pharmacologic), with or without quantification 0377 Deleted S D $ Deleted N/A Myocardial perfusion imaging; multiple studies, (planar) at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification 0377 Deleted S D $ Deleted N/A Myocardial perfusion imaging; tomographic (SPECT), single study (including attenuation correction when performed), at rest or stress (exercise and/or pharmacologic), with or without quantification 0377 Deleted S D $ Deleted N/A Myocardial perfusion imaging; tomographic (SPECT), multiple studies (including attenuation correction when performed), at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification 0377 Deleted S D $ Deleted N/A 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 Myocardial perfusion study with wall motion, qualitative or quantitative study (Use in conjunction with 78460, , 78464, 78465) N D See CPT n/a Myocardial perfusion study with ejection fraction (Use in conjunction with 78460, 78461, 78464, 78465) N D See CPT n/a 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), perfusion; single study at rest or stress S S $1, $1, % Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress S S $1, $1, % 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) N N n/a Unlisted cardiovascular procedure, diagnostic nuclear medicine Lung perfusion imaging, particulate S S $ $ % Page 4 of 12

5 Injection Pulmonary procedure; perfusion for imaging, identification particulate, of sentinel with ventilation; node (for single breath S S $ $ % Pulmonary perfusion imaging, particulate, with ventilation; rebreathing and washout, with or without single breath S S $ $ % Pulmonary ventilation imaging, aerosol; single projection S S $ $ % Pulmonary ventilation imaging, aerosol; multiple projections (eg, anterior, posterior, lateral views) S S $ $ % Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, 1 or multiple projections S S $ $ % Pulmonary ventilation imaging, gaseous, single breath, single projection S S $ $ % Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; single projection S S $ $ % Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; multiple projections (eg, anterior, posterior, lateral views) S S $ $ % Pulmonary quantitative differential function (ventilation/perfusion) study S S $ $ % 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 0403 CH 0402 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 evaluation S S $1, $1, % Brain imaging, positron emission tomography (PET); perfusion evaluation E E Brain imaging, vascular flow only 0402 CH 0403 S S $ $ % Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography (For injection procedure, see , ) S S $ $ % Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography (For injection procedure, see , ) S S $ $ % Cerebrospinal fluid flow, imaging (not including introduction of material); shunt evaluation (For injection procedure, see , ) S S $ $ % 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 S S $ $ % Kidney imaging morphology with vascular flow S S $ $ % Kidney imaging morphology with vascular flow and function, single study without pharmacological intervention S S $ $ % Kidney imaging morphology with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) S S $ $ % Kidney imaging morphology with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) S S $ $ % Kidney imaging morphology tomographic (SPECT) S S $ $ % Kidney function study, non-imaging radioisotopic study 0392 CH 0392 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 S S $ $ % Page 5 of 12

6 Injection procedure; for identification of sentinel node (for 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 $ $ % Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area S S $ $ % Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); multiple areas S S $ $ % Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, single day imaging S S $ $ % Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT) CH 0414 S S $1, $ % Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring 2 or more days imaging S S $1, $ % Radiopharmaceutical localization of inflammatory process; limited area S S $ $ % Radiopharmaceutical localization of inflammatory process; whole body S S $ $ % Radiopharmaceutical localization of inflammatory process; tomographic (SPECT) (For imaging bone infectious or inflammatory disease with a bone imaging radiopharmaceutical, see 78300, 78305, 78306) 0414 CH 0406 S S $ $ % Injection procedure for radiopharmaceutical localization by nonimaging probe study, intravenous (eg, parathyroid adenoma) (For sentinel lymph node identification, use 38792) Q1 Q1 $ $ % Positron emission tomography (PET) imaging; limited area (eg. chest, head/neck) S S $1, $1, % 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 imaging; limited area (eg, chest, head/neck) S S $1, $1, % Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh S S $1, $1, % Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body S S $1, $1, % (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) Please note the PET CPT code description changes are not PET coverage changes, there have been NO Medicare coverage changes for PET to date, current PET policies still apply. Unlisted miscellaneous procedure, diagnostic nuclear medicine S S $ $ % Radiolabeled product provided durig a hospital inpatient stay C9898 N N Radiopharmaceutical therapy, by oral administration (For monoclonal antibody by intravenous infusion, use 79403) S S $ $ % 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 instillation of nonantibody radioelement solution that includes three months follow-up care, use 77750) S S $ $ % Radiopharmaceutical therapy, by intracavitary administration S S $ $ % Radiopharmaceutical therapy, by interstitial radioactive colloid administration S S $ $ % N/A Page 6 of 12

7 Injection procedure; for identification of sentinel node (for Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion (For pre-treatment imaging, see 78802, 78804) (Do not use in conjunction with 79101) S S $ $ % 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 angiographic and interventional procedures provided pre-requisite to intraarterial radiopharmaceutical therapy) S S $ $ % 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 and report X X $ $ % Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug S S $ $ % G0219 G0235 G0252 PET imaging whole body; melanoma for non-covered indications PET IMAGING, ANY SITE, NOT OTHERWISE SPECIFIED PET imaging, full & partial-ring PET scanner only, for initial 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 E E E Final 2009 N N 2010 rates update % Change A4642 A9500 A9501 A9502 A9503 A9504 In111 satumomab INDIUM IN-111 SATUMOMAB PENDETIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 6 S Tc99m sestamibi TECHNETIUM TC-99M SESTAMIBI, 40 S Technetium TC-99m teboroxime TECHNETIUM TC-99M TEBOROXIME, DIAGNOSTIC, PER STUDY DOSE Tc99m tetrofosmin TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE Tc99m medronate TECHNETIUM TC-99M MEDRONATE, 30 S Tc99m apcitide TECHNETIUM TC-99M APCITIDE, 20 S ONCOSCINT N N CARDIOLITE / MIRALUMA CardioTec TEBO N N N N MYOVIEW N N MDP N N ACUTECT N N A9505 TL201 thallium THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER THALLIUM 201 N N Page 7 of 12

8 A9507 A9508 Injection In111 capromab procedure; for identification of sentinel PROSTASCINT node (for N N INDIUM IN-111 CAPROMAB PENDETIDE, 10 S I131 iodobenguate, dx IODINE I-131 IOBENGUANE SULFATE, DIAGNOSTIC, PER 0.5 I-131 MIBG N N A9509 A9510 A9512 A9516 A9517 A9521 A9524 A9526 A9527 A9528 A9529 Iodine I-123 sod iodide mil IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER Tc99m disofenin TECHNETIUM TC-99M DISOFENIN, 15 S Tc99m pertechnetate TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER Iodine I-123 sod iodide mic IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES I131 iodide cap, rx IODINE I-131 SODIUM IODIDE CAPSULE(S), THERAPEUTIC, PER Tc99m exametazime TECHNETIUM TC-99M EXAMETAZIME, 25 S I131 serum albumin, dx IODINE I-131 IODINATED SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIES Nitrogen N-13 ammonia NITROGEN N-13 AMMONIA, 40 S Iodine I-125 sodium iodide IODINE I-125, SODIUM IODIDE SOLUTION, THERAPEUTIC, PER Iodine I-131 iodide cap, dx IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER I131 iodide sol, dx IODINE I-131 SODIUM IODIDE SOLUTION, 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 DISIDA N N Straight Tech Technescan Technelite Dx I-123 Capsules. Use for A9516 for Thyroid uptakes and scans, for 1 mci and greater and whole body imaging see A9509 Rx I-131 Capsules CERETEC HMPAO N N N N 1064 H CH K CCR X N N I-131 Albumin N N N-13 I-131 Dx caps per mci Dx I-131 sol per mci N N U U CCR X N N N N $16.51 $ Page 8 of 12

9 A9530 A9531 A9532 A9535 A9536 A9537 A9538 A9539 A9540 A9541 A9542 A9543 Injection I131 iodide procedure; sol, rx for identification of sentinel node (for IODINE I-131 SODIUM IODIDE SOLUTION, THERAPEUTIC, PER I131 max 100uCi IODINE I-131 SODIUM IODIDE, DIAGNOSTIC, PER MICROCURIE (UP TO 100 MICROCURIES) I125 serum albumin, dx IODINE I-125 SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIES Injection, methylene blue INJECTION, METHYLENE BLUE, 1 ML Tc99m depreotide TECHNETIUM TC-99M DEPREOTIDE, 35 S Tc99m mebrofenin TECHNETIUM TC-99M MEBROFENIN, 15 S Tc99m pyrophosphate TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 S Tc99m pentetate TECHNETIUM TC-99M PENTETATE, 25 S Tc99m MAA TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, 10 S Tc99m sulfur colloid TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 S In111 ibritumomab, dx INDIUM IN-111 IBRITUMOMAB TIUXETAN, DIAGNOSTIC, PER STUDY DOSE, UP TO 5 S Y90 ibritumomab, rx YTTRIUM Y-90 IBRITUMOMAB TIUXETAN, THERAPEUTIC, PER TREATMENT DOSE, UP TO 40 S Rx I-131 sol per mci Dx I-131 up to 100 uci Used typically by Surgeon for Sentinel Node identification in OR alternative to Tc99m Filtered H CH K CCR X N N N N N N NEOTEC N N CHOLETEC N N PYROLITE *Use this code for myocardial infarct imaging. Do not use this code for GBP, RVG or MUGA procedures see N N Tc-99m DTPA N N MAA N N SULFUR COLLOID (SC) Dx In-111 ZEVALIN Rx Y-90 ZEVALIN N N N N H CH K CCR X $11.02 $30, A9544 I131 tositumomab, dx IODINE I-131 TOSITUMOMAB, DIAGNOSTIC, PER STUDY DOSE Dx BEXXAR N N A9545 I131 tositumomab, rx IODINE I-131 TOSITUMOMAB, THERAPEUTIC, PER TREATMENT DOSE Rx BEXXAR H CH K CCR X $22, Page 9 of 12

10 A9546 A9547 Injection Co57/58 procedure; for identification of sentinel NYCOMED node (for N N COBALT CO-57/58, CYANOCOBALAMIN, 1 MICROCURIE In111 oxyquinoline See new codes N N A9570 and A9571 INDIUM IN-111 OXYQUINOLINE, for WBC and DIAGNOSTIC, PER 0.5 Platelet Imaging A9548 A9550 A9551 A9552 A9553 In111 pentetate INDIUM IN-111 PENTETATE, DIAGNOSTIC, PER 0.5 Tc99m gluceptate TECHNETIUM TC-99M SODIUM GLUCEPTATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 S Tc99m succimer TECHNETIUM TC-99M SUCCIMER, 10 S F18 fdg FLUORODEOXYGLUCOSE F-18 FDG, 45 S Cr51 chromate CHROMIUM CR-51 SODIUM CHROMATE, 250 MICROCURIES Indium DTPA N N GLUCOSCAN N N DMSA N N FDG / F-18 N N N N A9554 A9555 A9556 A9557 A9558 A9559 A9560 I125 iothalamate, dx IODINE I-125 SODIUM IOTHALAMATE, 10 MICROCURIES Rb82 rubidium RUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60 S Ga67 gallium GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER Tc99m bicisate TECHNETIUM TC-99M BICISATE, 25 S Xe133 xenon 10mci XENON XE-133 GAS, DIAGNOSTIC, PER 10 S Co57 cyano COBALT CO-57 CYANOCOBALAMIN, ORAL, DIAGNOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIE Tc99m labeled rbc TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 S N N N N Rb-82 CardioGen82 GALLIUM N N NEUROLITE N N Xenon N N 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 N N N N Page 10 of 12

11 A9561 A9562 A9563 Injection Tc99m oxidronate procedure; for identification of sentinel HDP node (for N N TECHNETIUM TC-99M OXIDRONATE, 30 S Tc99m mertiatide MAG-3 N N TECHNETIUM TC-99M MERTIATIDE, 15 S P32 Na phosphate SODIUM PHOSPHATE P-32, THERAPEUTIC, PER H CH K CCR X $ A9564 A9566 A9567 A9568 A9569 A9570 A9571 A9572 CMS deleted A9565 A9580 A9582 A9600 A9604 P32 chromic phosphate CHROMIC PHOSPHATE P-32 SUSPENSION, THERAPEUTIC, PER Tc99m fanolesomab TECHNETIUM TC-99M FANOLESOMAB, 25 S Technetium TC-99m aerosol TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, AEROSOL, PER STUDY DOSE, UP TO 75 S Technetium tc99m arcitumomab TECHNETIUM TC-99M ARCITUMOMAB, 45 S Technetium TC-99m auto WBC TECHNETIUM TC-99M EXAMETAZIME LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE Indium In-111 auto WBC 'INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE Indium IN-111 auto platelet INDIUM IN-111 LABELED AUTOLOGOUS PLATELETS, DIAGNOSTIC, PER STUDY DOSE Phosphocol P H CH K CCR X NeutroSpec N N DTPA Aerosol For Lung Ventilation Studies N N CEA-SCAN N N 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 Indium In-111 pentetreotide Octreoscan A9565 was 'INDIUM IN-111 PENTETREOTIDE, deleted effective S 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 Sr89 strontium F-18, NaF, Sodium Flouride I-123 MIBG AdreView NDC See C9247 deleted in 2010 N N N N N N N N N N 9247 C9247 N - G G C9247 & $2, **Note final payment rates for status G codes have offset RP amounts posted on the CMS web site by CPT code. STRONTIUM SR-89 CHLORIDE, THERAPEUTIC, PER Sm 153 lexidronm SAMARIUM SM-153 LEXIDRONAMM, THERAPEUTIC, PER TREATMENT DOSE, up to 150 S Rx METASTRON Rx QUADRAMET H CH K CCR X See A H NI- CH- K New Code $ $2, N/A $ $5, Page 11 of 12

12 A9605 A9699 C9247 J0150 Injection Sm 153 lexidronm procedure; for identification of sentinel Rx node (for QUADRAMET SAMARIUM SM-153 LEXIDRONAMM, THERAPEUTIC, PER 50 S Radiopharm rx agent noc RADIOPHARMACEUTICAL, THERAPEUTIC, NOT OTHERWISE CLASSIFIED Iobenguane, I-123, diagnostic, per study dose, up to 10 millicuries Injection adenosine 6 mg 0702 D H D CCR X RX NOC N N I-123 MIBG AdreView NDC N - G D Deleted See new code A9604 $1, Deleted See A K K $9.25 $9.60 N/A J0152 Injection Adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) Adenosine injection, 30 mg ADENOCARD ADENOSCAN K K $69.44 $ % Injection Adenosine for diagnostic use, 30 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) 16.88% J0280 Aminophyllin up to 250 MG, inj. N N J0460 Atropine sulfate injection, up to 0.3 mg N N Atropen J1120 Acetazolamide sodium injection, up to 500 N N mg Diamox J1160 Inj, digoxin, up to 0.5 mg N N Lanoxin J1245 Dipyridamole injection, per 10mg N N Persantine IV J1250 Inj dobutamine HCL/250 mg N N Dobutrex J1265 Dopamine injection N N INJECTION, DOPAMINE HCL, 40 MG Intropin J1610 Glucagon hydrochloride per 1MG Glucagen K K $71.40 $ % J1642 Inj heparin sodium per 10 units (hep lock N N flush) Heplock J1800 Propranolol HCL injection, up to 1 mg N N Inderal J1940 Furosemide injection up to 20 mg N N Lasix J2270 Morphine sulfate injection, up to 10 mg N N J2271 Morphine sulfate injection, 100 mg N N J2785 Injection, Regadenoson, 0.1 milligrams LexiScan NDC $ Note the change in description from per.4 to per G G $ Note: CMS will publish an updated rate per.1 mg with the effective rate J2805 Sincalide injection 1224 CH K CH N $60.01 INJECTION, SINCALIDE, 5 MICROGRAMS Kinevac J3240 Thyrotropin injection 0.9 mg n 1.1 mg vial Thyrogen K K $ $1, Thytropar 7.51% J3420 Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg N N J3490 Drugs Unclassified injection N N NOC J3590 Unclassified biologics N N NOC J7030 Normal saline solution infus (1000 CC) N N J7040 Normal saline solution infus (500ML=1) N N J7050 Normal saline solution infus (250 CC) N N J9310 Rituximab, 100 mg RituXan K K $ $ % G3001 Admin + supply, tositumomab, 450 mg (Use this Code for Bexxar) S S $1, $1, % Q9968 Visualization adjunct 1288 K $ Page 12 of 12