Medicare APCs Effective 7/1/00 - 6/30/01
Source: Federal Register Friday, April 7, 2000
Addendum A.--List of Hospital Outpatient Ambulatory Payment Classes With Status Indicators, Relative Weights,
Payment Rates, and Coinsurance Amounts
----------------------------------------------------------------------------------------------------------------
National Minimum
APC Group Title Status Indicator Relative Payment Rate Unadjusted Unadjusted
Weight Coinsurance Coinsurance
----------------------------------------------------------------------------------------------------------------
0001 Photochemotherapy. S 0.47 $22.79 $8.49 $4.56
0002 Fine needle Biopsy/ T 0.62 $30.06 $17.66 $6.01
Aspiration.
0003 Bone Marrow Biopsy/ T 0.98 $47.52 $27.99 $9.50
Aspiration.
0004 Level I Needle T 1.84 $89.22 $32.57 $17.84
Biopsy/Aspiration
Except Bone
Marrow.
0005 Level II Needle T 5.41 $262.32 $119.75 $52.46
Biopsy/Aspiration
Except Bone
Marrow.
0006 Level I Incision & T 2.00 $96.97 $33.95 $19.39
Drainage.
0007 Level II Incision T 3.68 $178.43 $72.03 $35.69
& Drainage.
0008 Level III Incision T 6.15 $298.20 $113.67 $59.64
& Drainage.
0009 Nail Procedures... T 0.74 $35.88 $9.63 $7.18
0010 Level I T 0.55 $26.67 $9.86 $5.33
Destruction of
Lesion.
0011 Level II T 2.72 $131.88 $50.01 $26.38
Destruction of
Lesion.
0012 Level I T 0.53 $25.70 $9.18 $5.14
Debridement &
Destruction.
0013 Level II T 0.91 $44.12 $17.66 $8.82
Debridement &
Destruction.
0014 Level III T 1.50 $72.73 $24.55 $14.55
Debridement &
Destruction.
0015 Level IV T 1.77 $85.82 $31.20 $17.16
Debridement &
Destruction.
0016 Level V T 3.53 $171.16 $74.67 $34.23
Debridement &
Destruction.
0017 Level VI T 12.45 $603.66 $289.16 $120.73
Debridement &
Destruction.
0018 Biopsy Skin, T 0.94 $45.58 $17.66 $9.12
Subcutaneous
Tissue or Mucous
Membrane.
0019 Level I Excision/ T 4.00 $193.95 $78.91 $38.79
Biopsy.
0020 Level II Excision/ T 6.51 $315.65 $130.53 $63.13
Biopsy.
0021 Level III Excision/ T 10.49 $508.63 $236.51 $101.73
Biopsy.
0022 Level IV Excision/ T 12.49 $605.60 $292.94 $121.12
Biopsy.
0023 Exploration T 1.98 $96.00 $40.37 $19.20
Penetrating Wound.
0024 Level I Skin T 2.43 $117.82 $44.50 $23.56
Repair.
0025 Level II Skin T 3.74 $181.34 $70.66 $36.27
Repair.
0026 Level III Skin T 12.11 $587.18 $277.92 $117.44
Repair.
0027 Level IV Skin T 15.80 $766.10 $383.10 $153.22
Repair.
0029 Incision/Excision T 12.85 $623.06 $303.50 $124.61
Breast.
0030 Breast T 20.19 $978.95 $523.95 $195.79
Reconstruction/
Mastectomy.
0031 Hyperbaric Oxygen. S 3.00 $145.46 $140.85 $29.09
0032 Placement T 5.40 $261.83 $119.52 $52.37
Transvenous
Catheters/
Arterial Cutdown.
0033 Partial P 4.17 $202.19 $48.17 $40.44
Hospitalization.
0040 Arthrocentesis & T 2.11 $102.31 $40.60 $20.46
Ligament/Tendon
Injection.
0041 Arthroscopy....... T 24.57 $1,191.33 $592.08 $238.27
0042 Arthroscopically- T 29.22 $1,416.79 $804.74 $283.36
Aided Procedures.
0043 Closed Treatment T 1.64 $79.52 $25.46 $15.90
Fracture Finger/
Toe/Trunk.
0044 Closed Treatment T 2.17 $105.22 $38.08 $21.04
Fracture/
Dislocation
Except Finger/Toe/
Trunk.
0045 Bone/Joint T 11.02 $534.33 $277.12 $106.87
Manipulation
Under Anesthesia.
0046 Open/Percutaneous T 22.29 $1,080.78 $535.76 $216.16
Treatment
Fracture or
Dislocation.
0047 Arthroplasty T 22.09 $1,071.08 $537.03 $214.22
without
Prosthesis.
0048 Arthroplasty with T 29.06 $1,409.03 $725.94 $281.81
Prosthesis.
0049 Level I T 15.04 $729.25 $356.95 $145.85
Musculoskeletal
Procedures Except
Hand and Foot.
0050 Level II T 21.13 $1,024.53 $513.86 $204.91
Musculoskeletal
Procedures Except
Hand and Foot.
0051 Level III T 27.76 $1,346.00 $675.24 $269.20
Musculoskeletal
Procedures Except
Hand and Foot.
0052 Level IV T 36.16 $1,753.29 $930.91 $350.66
Musculoskeletal
Procedures Except
Hand and Foot.
0053 Level I Hand T 11.32 $548.87 $253.49 $109.77
Musculoskeletal
Procedures.
0054 Level II Hand T 19.66 $953.26 $472.33 $190.65
Musculoskeletal
Procedures.
0055 Level I Foot T 15.47 $750.10 $355.34 $150.02
Musculoskeletal
Procedures.
0056 Level II Foot T 17.30 $838.83 $405.81 $167.77
Musculoskeletal
Procedures.
[[Page 18552]]
0057 Bunion Procedures. T 21.00 $1,018.23 $496.65 $203.65
0058 Level I Strapping S 1.09 $52.85 $19.27 $10.57
and Cast
Application.
0059 Level II Strapping S 1.74 $84.37 $29.59 $16.87
and Cast
Application.
0060 Manipulation S 0.77 $37.34 $7.80 $7.47
Therapy.
0070 Thoracentesis/ T 3.64 $176.49 $79.60 $35.30
Lavage Procedures.
0071 Level I Endoscopy T 0.55 $26.67 $14.22 $5.33
Upper Airway.
0072 Level II Endoscopy T 1.26 $61.09 $41.52 $12.22
Upper Airway.
0073 Level III T 4.11 $199.28 $91.07 $39.86
Endoscopy Upper
Airway.
0074 Level IV Endoscopy T 13.61 $659.91 $347.54 $131.98
Upper Airway.
0075 Level V Endoscopy T 18.55 $899.44 $467.29 $179.89
Upper Airway.
0076 Endoscopy Lower T 8.06 $390.81 $197.05 $78.16
Airway.
0077 Level I Pulmonary S 0.43 $20.85 $12.62 $4.17
Treatment.
0078 Level II Pulmonary S 1.34 $64.97 $29.13 $12.99
Treatment.
0079 Ventilation S 3.18 $154.19 $107.70 $30.84
Initiation and
Management.
0080 Diagnostic Cardiac T 25.77 $1,249.51 $713.89 $249.90
Catheterization.
0081 Non-Coronary T 19.36 $938.71 $434.25 $187.74
Angioplasty or
Atherectomy.
0082 Coronary T 40.34 $1,955.97 $859.56 $391.19
Atherectomy.
0083 Coronary T 45.79 $2,220.22 $1,322.95 $444.04
Angiosplasty.
0084 Level I S 10.70 $518.81 $177.79 $103.76
Electrophysiologi
c Evaluation.
0085 Level II S 27.06 $1,312.06 $654.48 $262.41
Electrophysiologi
c Evaluation.
0086 Ablate Heart S 47.62 $2,308.95 $1,265.37 $461.79
Dysrhythm Focus.
0087 Cardiac S 9.53 $462.08 $214.72 $92.42
Electrophysiologi
c Recording/
Mapping.
0088 Thrombectomy...... T 26.49 $1,284.42 $678.68 $256.88
0089 Level I T 6.49 $314.68 $130.07 $62.94
Implantation/
Removal/Revision
of Pacemaker,
AICD or Vascular
Device.
0090 Level II T 20.96 $1,016.29 $573.04 $203.26
Implantation/
Removal/Revision
of Pacemaker,
AICD or Vascular
Device.
0091 Level I Vascular T 14.79 $717.12 $348.23 $143.42
Ligation.
0092 Level II Vascular T 20.21 $979.92 $505.37 $195.98
Ligation.
0093 Vascular Repair/ T 17.95 $870.34 $422.33 $174.07
Fistula
Construction.
0094 Resuscitation and S 4.51 $218.68 $105.29 $43.74
Cardioversion.
0095 Cardiac S 0.64 $31.03 $16.98 $6.21
Rehabilitation.
0096 Non-Invasive S 2.06 $99.88 $61.48 $19.98
Vascular Studies.
0097 Cardiovascular S 1.62 $78.55 $62.40 $15.71
Stress Test.
0098 Injection of T 1.19 $57.70 $20.88 $11.54
Sclerosing
Solution.
0099 Continuous Cardiac S 0.38 $18.43 $14.68 $3.69
Monitoring.
0100 Continuous ECG.... S 1.70 $82.43 $71.57 $16.49
0101 Tilt Table S 4.47 $216.74 $128.84 $43.35
Evaluation.
0102 Electronic S 0.45 $21.82 $12.62 $4.36
Analysis of
Pacemakers/other
Devices.
0109 Bone Marrow S 4.13 $200.25 $40.05 $40.05
Harvesting and
Bone Marrow/Stem
Cell Transplant.
0110 Transfusion....... S 5.83 $282.68 $122.73 $56.54
0111 Blood Product S 14.17 $687.06 $300.74 $137.41
Exchange.
0112 Extracorporeal S 39.60 $1,920.09 $663.65 $384.02
Photopheresis.
0113 Excision Lymphatic T 13.89 $673.49 $326.55 $134.70
System.
0114 Thyroid/ T 19.56 $948.41 $493.78 $189.68
Lymphadenectomy
Procedures.
0116 Chemotherapy S 2.34 $113.46 $22.69 $22.69
Administration by
Other Technique
Except Infusion.
0117 Chemotherapy S 1.84 $89.22 $71.80 $17.84
Administration by
Infusion Only.
0118 Chemotherapy S 2.90 $140.61 $72.03 $28.12
Administration by
Both Infusion and
Other Technique.
0120 Infusion Therapy S 1.66 $80.49 $42.67 $16.10
Except
Chemotherapy.
0121 Level I Tube T 2.36 $114.43 $52.53 $22.89
changes and
Repositioning.
0122 Level II Tube T 5.04 $244.37 $114.93 $48.88
changes and
Repositioning.
0123 Level III Tube T 13.89 $673.49 $350.75 $134.70
changes and
Repositioning.
0130 Level I T 25.36 $1,229.63 $659.53 $245.93
Laparoscopy.
0131 Level II T 41.81 $2,027.24 $1,089.88 $405.45
Laparoscopy.
0132 Level III T 48.91 $2,371.50 $1,239.22 $474.30
Laparoscopy.
0140 Esophageal T 4.74 $229.83 $107.24 $45.97
Dilation without
Endoscopy.
0141 Upper GI T 7.15 $346.68 $184.67 $69.34
Procedures.
0142 Small Intestine T 7.45 $361.23 $162.42 $72.25
Endoscopy.
0143 Lower GI Endoscopy T 7.98 $386.93 $199.12 $77.39
0144 Diagnostic T 2.23 $108.13 $49.32 $21.63
Anoscopy.
0145 Therapeutic T 7.46 $361.71 $179.39 $72.34
Anoscopy.
0146 Level I T 2.83 $137.22 $65.15 $27.44
Sigmoidoscopy.
0147 Level II T 6.26 $303.53 $149.11 $60.71
Sigmoidoscopy.
0148 Level I Anal/ T 2.34 $113.46 $43.59 $22.69
Rectal Procedure.
0149 Level II Anal/ T 12.86 $623.54 $293.06 $124.71
Rectal Procedure.
0150 Level III Anal/ T 17.68 $857.25 $437.12 $171.45
Rectal Procedure.
0151 Endoscopic T 10.53 $510.57 $245.46 $102.11
Retrograde
Cholangio-
Pancreatography
(ERCP).
0152 Percutaneous T 8.22 $398.56 $207.38 $79.71
Biliary
Endoscopic
Procedures.
0153 Peritoneal and T 19.62 $951.32 $496.31 $190.26
Abdominal
Procedures.
0154 Hernia/Hydrocele T 22.43 $1,087.57 $556.98 $217.51
Procedures.
2 0157 Colorectal Cancer S 1.79 $86.79 .............. $17.36
Screening: Barium
Enema.
1 0158 Colorectal Cancer S 7.98 $386.93 .............. $96.73
Screening:
Colonoscopy.
1 0159 Colorectal Cancer S 7.98 $137.22 .............. $34.31
Screening:
Flexible
Sigmoidoscopy.
[[Page 18553]]
0160 Level I T 5.43 $263.28 $110.11 $52.66
Cystourethroscopy
and other
Genitourinary
Procedures.
0161 Level II T 10.94 $530.45 $249.36 $106.09
Cystourethroscopy
and other
Genitourinary
Procedures.
0162 Level III T 17.49 $848.04 $427.49 $169.61
Cystourethroscopy
and other
Genitourinary
Procedures.
0163 Level IV T 28.98 $1,405.16 $792.58 $281.03
Cystourethroscopy
and other
Genitourinary
Procedures.
0164 Level I Urinary T 2.17 $105.23 $33.03 $21.05
and Anal
Procedures.
0165 Level II Urinary T 3.89 $188.61 $91.76 $37.72
and Anal
Procedures.
0166 Level I Urethral T 10.17 $493.11 $218.73 $98.62
Procedures.
0167 Level II Urethral T 21.06 $1,021.14 $555.84 $204.23
Procedures.
0168 Level III Urethral T 24.94 $1,209.27 $536.11 $241.85
Procedures.
0169 Lithotripsy....... T 46.72 $2,265.32 $1,384.20 $453.06
0170 Dialysis for Other S 6.68 $323.89 $72.26 $64.78
Than ESRD
Patients.
0180 Circumcision...... T 13.62 $660.39 $304.87 $132.08
0181 Penile Procedures. T 32.37 $1,569.53 $906.36 $313.91
0182 Insertion of T 52.11 $2,526.66 $1,525.05 $505.33
Penile Prosthesis.
0183 Testes/Epididymis T 18.26 $885.37 $448.94 $177.07
Procedures.
0184 Prostate Biopsy... T 4.94 $239.53 $122.96 $47.91
0190 Surgical T 17.85 $865.49 $443.89 $173.10
Hysteroscopy.
0191 Level I Female T 1.19 $57.70 $17.43 $11.54
Reproductive
Procedures.
0192 Level II Female T 2.38 $115.40 $35.33 $23.08
Reproductive
Procedures.
0193 Level III Female T 8.93 $432.99 $171.13 $86.60
Reproductive
Procedures.
0194 Level IV Female T 16.21 $785.98 $395.94 $157.20
Reproductive
Procedures.
0195 Level V Female T 18.68 $905.74 $483.80 $181.15
Reproductive
Procedures.
0196 Dilatation & T 14.47 $701.61 $357.98 $140.32
Curettage.
0197 Infertility T 2.40 $116.37 $49.55 $23.27
Procedures.
0198 Pregnancy and T 1.34 $64.97 $33.03 $12.99
Neonatal Care
Procedures.
0199 Vaginal Delivery.. T 11.20 $543.06 $157.83 $108.61
0200 Therapeutic T 13.89 $673.49 $373.23 $134.70
Abortion.
0201 Spontaneous T 13.00 $630.33 $329.65 $126.07
Abortion.
0210 Spinal Tap........ T 3.00 $145.46 $62.40 $29.09
0211 Level I Nervous T 3.32 $160.98 $74.78 $32.20
System Injections.
0212 Level II Nervous T 3.64 $176.49 $88.78 $35.30
System Injections.
0213 Extended EEG S 11.15 $540.63 $290.42 $108.13
Studies and Sleep
Studies.
0214 Electroencephalogr S 2.32 $112.49 $58.50 $22.50
am.
0215 Level I Nerve and S 1.15 $55.76 $30.05 $11.15
Muscle Tests.
0216 Level II Nerve and S 2.87 $139.16 $64.69 $27.83
Muscle Tests.
0217 Level III Nerve S 5.87 $284.62 $156.68 $56.92
and Muscle Tests.
0220 Level I Nerve T 13.96 $676.88 $326.21 $135.38
Procedures.
0221 Level II Nerve T 18.36 $890.22 $463.62 $178.04
Procedures.
0222 Implantation of T 25.48 $1,235.45 $780.07 $247.09
Neurological
Device.
0223 Level I Revision/ T 6.34 $307.41 $153.24 $61.48
Removal
Neurological
Device.
0224 Level II Revision/ T 15.94 $772.88 $374.61 $154.58
Removal
Neurological
Device.
0225 Implantation of T 3.43 $166.31 $64.46 $33.26
Neurostimulator
Electrodes.
0230 Level I Eye Tests. S 0.98 $47.52 $22.48 $9.50
0231 Level II Eye Tests S 2.64 $128.01 $59.87 $25.60
0232 Level I Anterior T 6.04 $292.86 $134.66 $58.57
Segment Eye.
0233 Level II Anterior T 13.79 $668.64 $331.60 $133.73
Segment Eye.
0234 Level III Anterior T 20.64 $1,000.77 $502.16 $200.15
Segment Eye
Procedures.
0235 Level I Posterior T 2.94 $142.55 $78.91 $28.51
Segment Eye
Procedures.
0236 Level II Posterior T 6.70 $324.86 $147.96 $64.97
Segment Eye
Procedures.
0237 Level III T 33.96 $1,646.62 $852.68 $329.32
Posterior Segment
Eye Procedures.
0238 Level I Repair and T 2.80 $135.76 $58.96 $27.15
Plastic Eye
Procedures.
0239 Level II Repair T 6.26 $303.53 $123.42 $60.71
and Plastic Eye
Procedures.
0240 Level III Repair T 13.47 $653.12 $315.31 $130.62
and Plastic Eye
Procedures.
0241 Level IV Repair T 16.60 $804.89 $384.47 $160.98
and Plastic Eye
Procedures.
0242 Level V Repair and T 23.70 $1,149.14 $597.36 $229.83
Plastic Eye
Procedures.
0243 Strabismus/Muscle T 17.99 $872.28 $431.39 $174.46
Procedures.
0244 Corneal Transplant T 32.88 $1,594.26 $851.42 $318.85
0245 Cataract T 26.55 $1,287.33 $623.85 $257.47
Procedures
without IOL
Insert.
0246 Cataract T 26.55 $1,287.33 $623.85 $257.47
Procedures with
IOL Insert.
0247 Laser Eye T 4.89 $237.10 $112.86 $47.42
Procedures Except
Retinal.
0248 Laser Retinal T 4.19 $203.16 $94.05 $40.63
Procedures.
0250 Nasal T 2.21 $107.16 $38.54 $21.43
Cauterization/
Packing.
0251 Level I ENT T 1.68 $81.46 $27.99 $16.29
Procedures.
0252 Level II ENT T 5.18 $251.16 $114.24 $50.23
Procedures.
0253 Level III ENT T 12.02 $582.81 $284.00 $116.56
Procedures.
0254 Level IV ENT T 12.45 $603.66 $272.41 $120.73
Procedures.
0256 Level V ENT T 25.40 $1,231.57 $623.05 $246.31
Procedures.
0257 Implantation of T 115.31 $5,591.04 $3,498.58 $1,118.21
Cochlear Device.
0258 Tonsil and Adenoid T 18.62 $902.83 $462.81 $180.57
Procedures.
0260 Level I Plain Film X 0.79 $38.30 $22.02 $7.66
Except Teeth.
0261 Level II Plain X 1.38 $66.91 $38.77 $13.38
Film Except Teeth
Including Bone
Density
Measurement.
0262 Plain Film of X 0.40 $19.39 $10.90 $3.88
Teeth.
[[Page 18554]]
0263 Level I X 1.68 $81.46 $45.88 $16.29
Miscellaneous
Radiology
Procedures.
0264 Level II X 3.83 $185.71 $108.97 $37.14
Miscellaneous
Radiology
Procedures.
0265 Level I Diagnostic S 1.17 $56.73 $38.08 $11.35
Ultrasound Except
Vascular.
0266 Level II S 1.79 $86.79 $57.35 $17.36
Diagnostic
Ultrasound Except
Vascular.
0267 Vascular S 2.72 $131.88 $80.06 $26.38
Ultrasound.
0268 Guidance Under X 2.23 $108.13 $69.51 $21.63
Ultrasound.
0269 Echocardiogram S 4.40 $213.34 $114.01 $42.67
Except
Transesophageal.
0270 Transesophageal S 5.55 $269.10 $150.26 $53.82
Echocardiogram.
0271 Mammography....... S 0.70 $33.94 $19.50 $6.79
0272 Level I X 1.40 $67.88 $39.00 $13.58
Fluoroscopy.
0273 Level II X 2.49 $120.73 $61.02 $24.15
Fluoroscopy.
0274 Myelography....... S 4.83 $234.19 $128.12 $46.84
0275 Arthrography...... S 2.74 $132.85 $72.26 $26.57
0276 Level I Digestive S 1.79 $86.79 $49.78 $17.36
Radiology.
0277 Level II Digestive S 2.47 $119.76 $69.28 $23.95
Radiology.
0278 Diagnostic S 2.85 $138.19 $81.67 $27.64
Urography.
0279 Level I Diagnostic S 6.30 $305.47 $174.57 $61.09
Angiography and
Venography Except
Extremity.
0280 Level II S 14.98 $726.34 $380.12 $145.27
Diagnostic
Angiography and
Venography Except
Extremity.
0281 Venography of S 4.40 $213.34 $115.16 $42.67
Extremity.
0282 Level I S 2.38 $115.40 $94.51 $23.08
Computerized
Axial Tomography.
0283 Level II S 4.89 $237.10 $179.39 $47.42
Computerized
Axial Tomography.
0284 Magnetic Resonance S 8.02 $388.87 $257.39 $77.77
Imaging.
0285 Positron Emission S 15.06 $730.22 $415.21 $146.04
Tomography (PET).
0286 Myocardial Scans.. S 7.28 $352.99 $200.04 $70.60
0290 Standard Non- S 1.94 $94.06 $55.51 $18.81
Imaging Nuclear
Medicine.
0291 Level I Diagnostic S 3.15 $152.73 $93.14 $30.55
Nuclear Medicine
Excluding
Myocardial Scans.
0292 Level II S 4.36 $211.40 $126.63 $42.28
Diagnostic
Nuclear Medicine
Excluding
Myocardial Scans.
0294 Level I S 5.13 $248.74 $144.06 $49.75
Therapeutic
Nuclear Medicine.
0295 Level II S 19.85 $962.47 $609.17 $192.49
Therapeutic
Nuclear Medicine.
0296 Level I S 3.57 $173.10 $100.25 $34.62
Therapeutic
Radiologic
Procedures.
0297 Level II S 6.13 $297.23 $172.51 $59.45
Therapeutic
Radiologic
Procedures.
0300 Level I Radiation S 1.98 $96.00 $47.72 $19.20
Therapy.
0301 Level II Radiation S 2.21 $107.16 $52.53 $21.43
Therapy.
0302 Level III S 8.21 $398.08 $216.55 $79.62
Radiation Therapy.
0303 Treatment Device X 2.83 $137.22 $69.28 $27.44
Construction.
0304 Level I X 1.49 $72.25 $41.52 $14.45
Therapeutic
Radiation
Treatment
Preparation.
0305 Level II X 4.06 $196.86 $97.50 $39.37
Therapeutic
Radiation
Treatment
Preparation.
0310 Level III X 13.98 $677.85 $339.05 $135.57
Therapeutic
Radiation
Treatment
Preparation.
0311 Radiation Physics X 1.32 $64.00 $31.66 $12.80
Services.
0312 Radioelement S 4.09 $198.31 $109.65 $39.66
Applications.
0313 Brachytherapy..... S 7.89 $382.56 $164.02 $76.51
0314 Hyperthermic S 5.88 $285.10 $150.95 $57.02
Therapies.
0320 Electroconvulsive S 3.68 $178.43 $80.06 $35.69
Therapy.
0321 Biofeedback and S 1.26 $61.09 $29.25 $12.22
Other Training.
0322 Brief Individual S 1.32 $64.00 $14.22 $12.80
Psychotherapy.
0323 Extended S 1.85 $89.70 $22.48 $17.94
Individual
Psychotherapy.
0324 Family S 1.87 $90.67 $20.19 $18.13
Psychotherapy.
0325 Group S 1.55 $75.16 $19.96 $15.03
Psychotherapy.
0330 Dental Procedures. S 1.51 $73.22 $14.64 $14.64
0340 Minor Ancillary X 1.04 $50.43 $12.85 $10.09
Procedures.
0341 Immunology Tests.. X 0.13 $6.30 $3.67 $1.26
0342 Level I Pathology. X 0.26 $12.61 $8.03 $2.52
0343 Level II Pathology X 0.45 $21.82 $12.16 $4.36
0344 Level III X 0.79 $38.30 $23.63 $7.66
Pathology.
2 0354 Administration of X 0.13 $6.19 .............. ..............
Influenza Vaccine.
0355 Level I X 0.19 $9.21 $5.05 $1.84
Immunizations.
0356 Level II X 0.36 $17.46 $4.82 $3.49
Immunizations.
0357 Level III X 1.85 $89.70 $38.31 $17.94
Immunizations.
0358 Level IV X 6.98 $338.44 $126.74 $67.69
Immunizations.
0359 Injections........ X 0.96 $46.55 $9.31 $9.31
0360 Level I Alimentary X 1.38 $66.91 $34.75 $13.38
Tests.
0361 Level II X 3.53 $171.16 $88.09 $34.23
Alimentary Tests.
0362 Fitting of Vision X 0.51 $24.73 $9.63 $4.95
Aids.
0363 Otorhinolaryngolog X 2.83 $137.22 $53.22 $27.44
ic Function Tests.
0364 Level I Audiometry X 0.68 $32.97 $13.31 $6.59
0365 Level II X 1.47 $71.28 $22.48 $14.26
Audiometry.
0366 Electrocardiogram X 0.38 $18.43 $15.60 $3.69
(ECG).
0367 Level I Pulmonary X 0.83 $40.24 $20.65 $8.05
Test.
0368 Level II Pulmonary X 1.66 $80.49 $42.44 $16.10
Tests.
0369 Level III X 2.34 $113.46 $58.50 $22.69
Pulmonary Tests.
0370 Allergy Tests..... X 0.57 $27.64 $11.81 $5.53
0371 Allergy Injections X 0.32 $15.52 $3.67 $3.10
0372 Therapeutic X 0.43 $20.85 $10.09 $4.17
Phlebotomy.
[[Page 18555]]
0373 Neuropsychological X 3.21 $155.64 $44.96 $31.13
Testing.
0374 Monitoring X 1.17 $56.73 $13.08 $11.35
Psychiatric Drugs.
0600 Low Level Clinic V 0.98 $47.52 $9.50 $9.50
Visits.
0601 Mid Level Clinic V 1.00 $48.49 $9.70 $9.70
Visits.
0602 High Level Clinic V 1.66 $80.49 $16.29 $16.10
Visits.
0603 Interdisciplinary V 1.66 $80.49 $16.29 $16.10
Team Conference.
0610 Low Level V 1.34 $64.97 $20.65 $12.99
Emergency Visits.
0611 Mid Level V 2.11 $102.31 $36.47 $20.46
Emergency Visits.
0612 High Level V 3.19 $154.67 $54.14 $30.93
Emergency Visits.
0620 Critical Care..... S 8.60 $416.99 $152.78 $83.40
3 0701 Strontium......... X .............. .............. .............. $84.76
3 0702 Samariam.......... X .............. .............. .............. $139.06
3 0704 Satumomab X .............. .............. .............. $63.13
Pendetide.
3 0705 Tc99 Tetrofosmin.. X .............. .............. .............. $71.08
3 0725 Leucovorin Calcium X .............. .............. .............. $1.07
3 0726 Dexrazoxane X .............. .............. .............. $18.81
Hydrochloride.
3 0727 Injection, X .............. .............. .............. $9.31
Etidronate
Disodium.
3 0728 Filgrastim (G-CSF) X .............. .............. .............. $25.21
3 0730 Pamidronate X .............. .............. .............. $30.93
Disodium.
3 0731 Sargramostim (GM- X .............. .............. .............. $16.97
CSF).
3 0732 Mesna............. X .............. .............. .............. $2.42
3 0733 Epoetin Alpha..... X .............. .............. .............. $1.75
3 0750 Dolasetron X .............. .............. .............. $1.94
Mesylate 10 mg.
3 0754 Metoclopramide HCL X .............. .............. .............. $.19
3 0755 Thiethylperazine X .............. .............. .............. $.68
Maleate.
3 0761 Oral Substitute X .............. .............. .............. $.10
for IV Antiemtic.
3 0762 Dronabinol........ X .............. .............. .............. $.48
3 0763 Dolasetron X .............. .............. .............. $8.53
Mesylate 100 mg
Oral.
3 0764 Granisetron HCL, X .............. .............. .............. $2.33
100 mcg.
3 0765 Granisetron HCL, X .............. .............. .............. $3.20
1mg Oral.
3 0768 Ondansetron X .............. .............. .............. $.87
Hydrochloride per
1 mg Injection.
3 0769 Ondansetron X .............. .............. .............. $2.62
Hydrochloride 8
mg oral.
3 0800 Leuprolide Acetate X .............. .............. .............. $68.56
per 3.75 mg.
3 0801 Cyclophosphamide.. X .............. .............. .............. $.19
3 0802 Etoposide......... X .............. .............. .............. $3.10
3 0803 Melphalan......... X .............. .............. .............. $.19
3 0807 Aldesleukin single X .............. .............. .............. $65.07
use vial.
3 0809 BCG (Intravesical) X .............. .............. .............. $19.78
one vial.
3 0810 Goserelin Acetate X .............. .............. .............. $59.74
Implant, per 3.6
mg.
3 0811 Carboplatin 50 mg. X .............. .............. .............. $13.96
3 0812 Carmustine 100 mg. X .............. .............. .............. $10.57
3 0813 Cisplatin 10 mg... X .............. .............. .............. $4.56
3 0814 Asparaginase, X .............. .............. .............. $8.34
10,000 units.
3 0815 Cyclophosphamide X .............. .............. .............. $.48
100 mg.
3 0816 Cyclophosphamide, X .............. .............. .............. $1.16
Lyophilized 100
mg.
3 0817 Cytrabine 100 mg.. X .............. .............. .............. $.68
3 0818 Dactinomycin 0.5 X .............. .............. .............. $1.75
mg.
3 0819 Dacarbazine 100 mg X .............. .............. .............. $1.26
3 0820 Daunorubicin HCI X .............. .............. .............. $11.64
10 mg.
3 0821 Daunorubicin X .............. .............. .............. $7.76
Citrate,
Liposomal
Formulation, 10
mg.
3 0822 Diethylstibestrol X .............. .............. .............. $2.13
Diphosphate 250
mg.
3 0823 Docetaxel 20 mg... X .............. .............. .............. $34.72
3 0824 Etoposide 10 mg... X .............. .............. .............. $.58
3 0826 Methotrexate Oral X .............. .............. .............. $.29
2.5 mg.
3 0827 Floxuridine 500 mg X .............. .............. .............. $18.81
3 0828 Gemcitabine HCL X .............. .............. .............. $9.31
200 mg.
3 0830 Irinotecan 20 mg.. X .............. .............. .............. $14.16
3 0831 Ifosfamide per 1 X .............. .............. .............. $13.58
gram.
3 0832 Idarubicin X .............. .............. .............. $46.45
Hydrochloride 5
mg.
3 0833 Interferon Alfacon- X .............. .............. .............. $.19
1, Recombinant, 1
mcg.
3 0834 Interferon, Alfa- X .............. .............. .............. $3.20
2A, Recombinant 3
million units.
3 0836 Interferon, Alfa- X .............. .............. .............. $1.36
2B, Recombinant,
1 million units.
3 0838 Interferon, Gamma X .............. .............. .............. $22.79
1-B, 3 million
units.
3 0839 Mechlorethamine X .............. .............. .............. $1.65
HCI 10 mg.
3 0840 Melphalan HCI 50 X .............. .............. .............. $44.71
mg.
3 0841 Methotrexate X .............. .............. .............. $.10
Sodium 5 mg.
3 0842 Fludarabine X .............. .............. .............. $30.84
Phosphate 50 mg.
3 0843 Pegaspargase per X .............. .............. .............. $178.72
single dose vial.
3 0844 Pentostatin 10 mg. X .............. .............. .............. $133.73
3 0847 Doxorubicin HCL 10 X .............. .............. .............. $2.81
mg.
3 0849 Rituximab, 100 mg. X .............. .............. .............. $51.40
3 0850 Streptozocin 1 gm. X .............. .............. .............. $14.64
3 0851 Thiotepa 15 mg.... X .............. .............. .............. $9.50
[[Page 18556]]
3 0852 Topotecan 4 mg.... X .............. .............. .............. $73.22
3 0853 Vinblastine X .............. .............. .............. $.39
Sulfate 1 mg.
3 0854 Vincristine X .............. .............. .............. $2.23
Sulfate 1 mg.
3 0855 Vinorelbine X .............. .............. .............. $9.60
Tartrate per 10
mg.
3 0856 Porfimer Sodium 75 X .............. .............. .............. $34.62
mg.
3 0857 Bleomycin Sulfate X .............. .............. .............. $48.29
15 units.
3 0858 Cladribine, 1mg... X .............. .............. .............. $8.24
3 0859 Fluorouracil...... X .............. .............. .............. $.19
3 0860 Plicamycin 2.5 mg. X .............. .............. .............. $1.36
3 0861 Leuprolide X .............. .............. .............. $19.39
Acetate 1 mg.
3 0862 Mitomycin, 5mg.... X .............. .............. .............. $19.88
3 0863 Paclitaxel, 30mg.. X .............. .............. .............. $30.16
3 0864 Mitoxantrone HCl, X .............. .............. .............. $25.80
per 5mg.
3 0865 Interferon alfa- X .............. .............. .............. $1.07
N3, 250,000 IU.
3 0884 Rho (D) Immune X .............. .............. .............. $3.78
Globulin, Human
one dose pack.
2 0886 Azathioprine, 50 X 0.02 $.97 .............. $.19
mg oral.
2 0887 Azathioprine, X 1.40 $67.88 .............. $13.58
Parenteral 100
mg, 20 ml each
injection.
2 0888 Cyclosporine, Oral X 0.08 $3.88 .............. $.78
100 mg.
2 0889 Cyclosporine, X 0.36 $17.46 .............. $3.49
Parenteral.
2 0890 Lymphocyte Immune X 3.79 $183.77 .............. $36.75
Globulin 50 mg/
ml, 5 ml each.
2 0891 Tacrolimus per 1 X 3.15 $152.73 .............. $30.55
mg oral.
3 0892 Daclizumab, X .............. .............. .............. $54.11
Parenteral, 25 mg.
3 0900 Injection, X .............. .............. .............. $5.14
Alglucerase per
10 units.
3 0901 Alpha I, X .............. .............. .............. $15.22
Proteinase
Inhibitor, Human
per 10mg.
3 0902 Botulinum Toxin, X .............. .............. .............. $56.05
Type A per unit.
3 0903 CMV Immune X .............. .............. .............. $54.11
Globulin.
3 0905 Immune Globulin X .............. .............. .............. $6.40
per 500 mg.
3 0906 RSV Immune X .............. .............. .............. $85.53
Globulin.
2 0907 Ganciclovir Sodium X 0.51 $24.73 .............. $4.95
500 mg injection.
2 0908 Tetanus Immune X 0.90 $43.64 .............. $8.73
Globulin, Human,
up to 250 units.
3 0909 Interferon Beta-- X .............. .............. .............. $28.70
1a 33 mcg.
3 0910 Interferon Beta-- X .............. .............. .............. $8.44
1b 0.25 mg.
2 0911 Streptokinase per X 1.64 $79.69 .............. $15.94
250,000 iu.
3 0913 Ganciclovir 4.5 X .............. .............. .............. $701.51
mg, Implant.
2 0914 Reteplase, 37.6 mg X 38.20 $1,852.21 .............. $370.44
(Two Single Use
Vials).
2 0915 Alteplase X 5.85 $283.70 .............. $56.74
recombinant, 10mg.
3 0916 Imiglucerase per X .............. .............. .............. $.58
unit.
2 0917 Dipyridamole, 10mg X 0.36 $17.46 .............. $3.49
Adenosine 6MG.
3 0918 Brachytherapy S .............. .............. .............. $9.99
Seeds, Any type,
Each.
3 0925 Factor VIII X .............. .............. .............. $.19
(Antihemophilic
Factor, Human)
per iu.
3 0926 Factor VIII X .............. .............. .............. $.19
(Antihemophilic
Factor, Porcine)
per iu.
3 0927 Factor VIII X .............. .............. .............. $.19
(Antihemophilic
Factor,
Recombinant) per
iu.
3 0928 Factor IX, Complex X .............. .............. .............. $.08
3 0929 Other Hemophilia X .............. .............. .............. $.27
Clotting Factors
per iu.
3 0930 Antithrombin III X .............. .............. .............. $.19
(Human) per iu.
3 0931 Factor IX X .............. .............. .............. $.04
(Antihemophilic
Factor, Purified,
Non-Recombinant).
3 0932 Factor IX X .............. .............. .............. $.10
(Antihemophilic
Factor,
Recombinant).
2 0949 Plasma, Pooled S 3.49 $169.22 .............. $33.84
Multiple Donor,
Solvent/Detergent
Treated, Frozen.
2 0950 Blood (Whole) For S 2.08 $101.02 .............. $20.20
Transfusion.
2 0952 Cryoprecipitate... S 0.70 $33.92 .............. $6.78
2 0953 Fibrinogen Unit... S 0.48 $23.27 .............. $4.65
2 0954 Leukocyte Poor S 2.83 $137.21 .............. $27.44
Blood.
2 0955 Plasma, Fresh S 2.26 $109.35 .............. $21.87
Frozen.
2 0956 Plasma Protein S 1.26 $61.09 .............. $12.22
Fraction.
2 0957 Platelet S 0.98 $47.46 .............. $9.49
Concentrate.
2 0958 Platelet Rich S 1.16 $56.25 .............. $11.25
Plasma.
2 0959 Red Blood Cells... S 2.04 $99.04 .............. $19.81
2 0960 Washed Red Blood S 3.81 $184.53 .............. $36.91
Cells.
2 0961 Infusion, Albumin X 2.77 $134.31 .............. $26.86
(Human) 5%, 500
ml.
2 0962 Infusion, Albumin X 1.38 $66.91 .............. $13.38
(Human) 25%, 50
ml.
2 0970 New Technology-- T 0.52 $25.21 .............. $5.04
Level I ($0-$50).
2 0971 New Technology-- S 1.55 $75.16 .............. $15.03
Level II ($50-
$100).
2 0972 New Technology-- T 3.09 $149.83 .............. $29.97
Level III ($100-
$200).
2 0973 New Technology-- T 5.16 $250.19 .............. $50.04
Level IV ($200-
$300).
2 0974 New Technology-- T 8.25 $400.02 .............. $80.00
Level V ($300-
$500).
2 0975 New Technology-- T 12.90 $625.48 .............. $125.10
Level VI ($500-
$750).
2 0976 New Technology-- T 18.05 $875.19 .............. $175.04
Level VII ($750-
$1000).
2 0977 New Technology-- T 23.20 $1,124.90 .............. $224.98
Level VIII ($1000-
$1250).
2 0978 New Technology-- T 28.36 $1,375.09 .............. $275.02
Level IX ($1250-
$1500).
2 0979 New Technology-- T 33.51 $1,624.80 .............. $324.96
Level X ($1500-
$1750).
2 0980 New Technology-- S 38.67 $1,875.00 .............. $375.00
Level XI ($1750-
$2000).
2 0981 New Technology-- T 46.40 $2,249.80 .............. $449.96
Level XII ($2000-
$2500).
2 0982 New Technology-- T 61.87 $2,999.90 .............. $599.98
Level XIII ($2500-
$3500).
[[Page 18557]]
2 0983 New Technology-- T 87.65 $4,249.89 .............. $849.98
Level XIV ($3500-
$5000).
2 0984 New Technology-- T 113.43 $5,499.89 .............. $1,099.98
Level XV ($5000-
$6000).
3 7000 Amifostine, 500 mg X .............. .............. .............. $41.99
3 7001 Amphotericin B X .............. .............. .............. $12.12
lipid complex, 50
mg, Inj.
3 7002 Clonidine, HCl, 1 X .............. .............. .............. $4.17
MG.
3 7003 Epoprostenol, 0.5 X .............. .............. .............. $2.23
MG, inj.
3 7004 Immune globulin X .............. .............. .............. $45.48
intravenous human
5g, inj.
3 7005 Gonadorelin hcI, X .............. .............. .............. $9.12
100 mcg.
2 7007 Milrinone X 0.47 $22.79 .............. $4.56
lacetate, per 5
ml, inj.
3 7010 Morphine sulfate X .............. .............. .............. $.68
concentrate
(preservative
free) per 10 mg.
3 7011 Oprelevekin, inj, X .............. .............. .............. $30.35
5 mg.
3 7012 Pentamidine X .............. .............. .............. $8.73
isethionate, 300
mg.
3 7014 Fentanyl citrate, X .............. .............. .............. $.19
inj, up to 2 ml.
3 7015 Busulfan, oral 2 X .............. .............. .............. $.19
mg.
3 7019 Aprotinin, 10,000 X .............. .............. .............. $2.42
kiu.
3 7021 Baclofen, X .............. .............. .............. $.10
intrathecal, 50
mcg.
3 7022 Elliotts B X .............. .............. .............. $19.20
Solution, per ml.
3 7023 Treatment for X .............. .............. .............. $4.46
bladder calculi,
I.e. Renacidin
per 500 ml.
3 7024 Corticorelin ovine X .............. .............. .............. $45.77
triflutate, 0.1
mg.
3 7025 Digoxin immune FAB X .............. .............. .............. $14.06
(Ovine), 10 mg.
3 7026 Ethanolamine X .............. .............. .............. $2.13
oleate, 1000 ml.
3 7027 Fomepizole, 1.5 G. X .............. .............. .............. $141.29
3 7028 Fosphenytoin, 50 X .............. .............. .............. $.78
mg.
3 7029 Glatiramer X .............. .............. .............. $3.59
acetate, 25 mg.
3 7030 Hemin, 1 mg....... X .............. .............. .............. $.10
3 7031 Octreotide X .............. .............. .............. $5.43
Acetate, 500 mcg.
3 7032 Sermorelin X .............. .............. .............. $53.34
acetate, 0.5 mg.
3 7033 Somatrem, 5 mg.... X .............. .............. .............. $28.03
3 7034 Somatropin, 1 mg.. X .............. .............. .............. $5.04
3 7035 Teniposide, 50 mg. X .............. .............. .............. $20.85
2 7036 Urokinase, inj, X 0.73 $35.40 .............. $7.08
IV, 250,000 I.U..
3 7037 Urofollitropin, 75 X .............. .............. .............. $8.24
I.U..
3 7038 Muromonab-CD3, 5 X .............. .............. .............. $89.60
mg.
3 7039 Pegademase bovine X .............. .............. .............. $1.16
inj 25 I.U..
3 7040 Pentastarch 10% X .............. .............. .............. $2.04
inj, 100 ml.
2 7041 Tirofiban HCL, 0.5 X 0.02 $.97 .............. $.19
mg.
3 7042 Capecitabine, oral X .............. .............. .............. $.19
150 mg.
3 7043 Infliximab, 10 MG. X .............. .............. .............. $6.89
3 7045 Trimetrexate X .............. .............. .............. $8.15
Glucoronate.
3 7046 Doxorubicin Hcl X .............. .............. .............. $39.18
Liposome.
----------------------------------------------------------------------------------------------------------------
--------------------
CPT codes and descriptions only are copyright American Medical
Association. All Rights Reserved. Applicable FARS/DFARS Apply.
Copyright American Dental Association. All rights reserved.
\1\ Not subject to national coinsurance. Minimum unadjusted coinsurance
is 25% of the payment rate. The payment rate is the lower of the HOPD
payment rate or the Ambulatory Surgical Center payment.
\2\ Not subject to national coinsurance.
\3\ Eligible for pass-through payments. See Preamble for payment rate
determination. See Addendum K for complete list of pass-through codes.