Aspiration Except Bone Marrow T $85.64 $22.10 $17.13

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NP...
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ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC 0001 0002 0003 0004 0005 0006 0007 0008 0009 0010 0011 0012 0013 0015 0016 0017 0018 0019 0020 0021 0022 0023 0024 0025 0027 0028 0029 0030 0032 0033 0035 0041 0042 0043 0045 0046 0047 0048 0049 0050 0051

Status Relative Indicator Weights

Group Title Level I Photochemotherapy Fine needle Biopsy/Aspiration Bone Marrow Biopsy/Aspiration Level I Needle Biopsy/ Aspiration Except Bone Marrow Level II Needle Biopsy /Aspiration Except Bone Marrow Level I Incision & Drainage Level II Incision & Drainage Level III Incision and Drainage Nail Procedures Level I Destruction of Lesion Level II Destruction of Lesion Level I Debridement & Destruction Level II Debridement & Destruction Level III Debridement & Destruction Level IV Debridement & Destruction Level VI Debridement & Destruction Biopsy of Skin/Puncture of Lesion Level I Excision/ Biopsy Level II Excision/ Biopsy Level III Excision/ Biopsy Level IV Excision/ Biopsy Exploration Penetrating Wound Level I Skin Repair Level II Skin Repair Level IV Skin Repair Level I Breast Surgery Level II Breast Surgery Level III Breast Surgery Insertion of Central Venous/Arterial Catheter Partial Hospitalization Placement of Arterial or Central Venous Catheter Level I Arthroscopy Level II Arthroscopy Closed Treatment Fracture Finger/Toe/Trunk Bone/Joint Manipulation Under Anesthesia Open/Percutaneous Treatment Fracture or Dislocation Arthroplasty without Prosthesis Arthroplasty with Prosthesis Level I Musculoskeletal Procedures Except Hand and Foot Level II Musculoskeletal Procedures Except Hand and Foot Level III Musculoskeletal Procedures Except Hand and Foot

Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

S T T

0.3940 1.0937 2.2627

$21.39 $59.38 $122.84

$7.09

$4.28 $11.88 $24.57

T

1.5774

$85.64

$22.10

$17.13

T T T T T T T T T T T T T T T T T T T T T T T T T P T T T T T

3.3675 1.7487 11.4943 16.8303 0.6597 0.6806 2.1800 0.8203 1.1420 1.5832 2.7343 16.7332 0.9567 3.9807 7.3105 14.5749 18.6725 3.1587 1.7847 6.2703 15.8319 17.7459 29.2783 37.2809 11.5584 3.8397 0.2236 27.2538 42.8551 1.9233 13.5546

$182.82 $94.94 $624.01 $913.70 $35.81 $36.95 $118.35 $44.53 $62.00 $85.95 $148.44 $908.43 $51.94 $216.11 $396.88 $791.26 $1,013.71 $171.48 $96.89 $340.41 $859.50 $963.41 $1,589.49 $2,023.94 $627.49 $208.45 $12.14 $1,479.58 $2,326.56 $104.41 $735.87

$71.59 $24.12

$268.47

$36.56 $18.99 $124.80 $182.74 $7.16 $7.39 $23.67 $8.91 $12.40 $17.19 $29.69 $181.69 $10.39 $43.22 $79.38 $158.25 $202.74 $34.30 $19.38 $68.08 $171.90 $192.68 $317.90 $404.79 $125.50 $41.69 $2.43 $295.92 $465.31 $20.88 $147.17

T T T

31.9719 30.3786 47.4707

$1,735.72 $1,649.22 $2,577.14

$535.76 $537.03 $695.60

$347.14 $329.84 $515.43

T

19.9376

$1,082.39

$216.48

T

25.1166

$1,363.56

$272.71

T

34.9381

$1,896.75

$379.35

Page 1 of 30

$8.34 $10.08 $27.88 $11.18 $14.20 $20.35 $57.31 $227.84 $16.04 $71.87 $113.25 $219.48 $354.45 $40.37 $34.75 $115.49 $329.72 $303.74 $632.64 $763.55 $41.83 $3.51 $804.74

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC

Status Relative Indicator Weights

Group Title

Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

0089

Level IV Musculoskeletal Procedures Except Hand and Foot Level I Hand Musculoskeletal Procedures Level II Hand Musculoskeletal Procedures Level I Foot Musculoskeletal Procedures Level II Foot Musculoskeletal Procedures Bunion Procedures Level I Strapping and Cast Application Manipulation Therapy CPAP Initiation Thoracoscopy Thoracentesis/Lavage Procedures Level I Endoscopy Upper Airway Level II Endoscopy Upper Airway Level III Endoscopy Upper Airway Level IV Endoscopy Upper Airway Level V Endoscopy Upper Airway Level I Endoscopy Lower Airway Level I Pulmonary Treatment Level II Pulmonary Treatment Ventilation Initiation and Management Diagnostic Cardiac Catheterization Non-Coronary Angioplasty or Atherectomy Coronary Atherectomy Coronary Angioplasty and Percutaneous Valvuloplasty Level I Electrophysiologic Evaluation Level II Electrophysiologic Evaluation Ablate Heart Dysrhythm Focus Cardiac Electrophysiologic Recording/Mapping Thrombectomy Insertion/Replacement of Permanent Pacemaker and Electrodes

0090 0091 0092

Insertion/Replacement of Pacemaker Pulse Generator Level II Vascular Ligation Level I Vascular Ligation

T T T

87.2850 28.5187 25.1347

$4,738.62 $1,548.25 $1,364.54

$1,705.90 $348.23 $505.37

$947.72 $309.65 $272.91

0093 0094 0095 0096

Vascular Reconstruction/Fistula Repair without Device Level I Resuscitation and Cardioversion Cardiac Rehabilitation Non-Invasive Vascular Studies

T S S S

20.6662 2.6412 0.5984 1.7332

$1,121.95 $143.39 $32.49 $94.09

$277.34 $48.46 $16.24 $47.05

$224.39 $28.68 $6.50 $18.82

0097 0098 0099 0100 0101

Cardiac and Ambulatory Blood Pressure Monitoring Injection of Sclerosing Solution Electrocardiograms Cardiac Stress Tests Tilt Table Evaluation

X T S X S

1.0565 1.1630 0.3708 1.6726 4.3675

$57.36 $63.14 $20.13 $90.80 $237.11

$23.80 $15.17

$11.47 $12.63 $4.03 $18.16 $47.42

0052 0053 0054 0055 0056 0057 0058 0060 0068 0069 0070 0071 0072 0073 0074 0075 0076 0077 0078 0079 0080 0081 0082 0083 0084 0085 0086 0087 0088

T T T T T T S S S T T T T T T T T S S S T T T

42.6430 14.8188 24.2685 18.8851 25.1591 25.4248 1.0785 0.3151 1.1234 28.6334 3.1393 0.9012 1.6987 3.4396 14.4952 20.4113 9.3560 0.2772 0.7731 2.2837 36.0982 34.8355 100.3996

$2,315.05 $804.50 $1,317.51 $1,025.25 $1,365.86 $1,380.29 $58.55 $17.11 $60.99 $1,554.48 $170.43 $48.93 $92.22 $186.73 $786.93 $1,108.11 $507.93 $15.05 $41.97 $123.98 $1,959.74 $1,891.18 $5,450.59

T S T T T T

59.3417 10.3392 36.3284 44.5652 40.4579 34.6065

$3,221.60 $561.30 $1,972.23 $2,419.40 $2,196.42 $1,878.75

$435.09 $822.28 $655.22

$644.32 $112.26 $394.45 $483.88 $439.28 $375.75

T

116.1611

$6,306.27

$1,722.59

$1,261.25

Page 2 of 30

$253.49 $355.34 $405.81 $475.91 $3.43 $30.49 $591.64 $12.89 $26.68 $73.38 $295.70 $445.92 $189.82 $7.52 $14.55 $838.92 $1,293.59

$41.44 $105.27

$463.01 $160.90 $263.50 $205.05 $273.17 $276.06 $11.71 $3.42 $12.20 $310.90 $34.09 $9.79 $18.44 $37.35 $157.39 $221.62 $101.59 $3.01 $8.39 $24.80 $391.95 $378.24 $1,090.12

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC

Status Relative Indicator Weights

Group Title

Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

0103 0104

Miscellaneous Vascular Procedures Transcatheter Placement of Intracoronary Stents

T T

12.1256 80.8877

$658.29 $4,391.31

$223.63

$131.66 $878.26

0105

Revision/Removal of Pacemakers, AICD, or Vascular Insertion/Replacement/Repair of Pacemaker and/or Electrodes Insertion of Cardioverter-Defibrillator Insertion/Replacement/Repair of CardioverterDefibrillator Leads Removal of Implanted Devices Transfusion Blood Product Exchange Apheresis, Photopheresis, and Plasmapheresis Excision Lymphatic System Thyroid/Lymphadenectomy Procedures Cannula/Access Device Procedures Implantation of Infusion Pump Level I Tube changes and Repositioning Level II Tube changes and Repositioning Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant Revision of Implanted Infusion Pump Refilling of Infusion Pump Level I Laparoscopy Level II Laparoscopy Level III Laparoscopy Esophageal Dilation without Endoscopy Upper GI Procedures Small Intestine Endoscopy Lower GI Endoscopy Level I Sigmoidoscopy Level II Sigmoidoscopy Level I Anal/Rectal Procedure Level III Anal/Rectal Procedure Level IV Anal/Rectal Procedure Endoscopic Retrograde Cholangio-Pancreatography (ERCP) Percutaneous Abdominal and Biliary Procedures Peritoneal and Abdominal Procedures Hernia/Hydrocele Procedures Level II Anal/Rectal Procedure Level II Urinary and Anal Procedures Colorectal Cancer Screening: Barium Enema Colorectal Cancer Screening: Colonoscopy

T

18.9084

$1,026.52

$370.40

$205.30

T T

49.9534 290.5429

$2,711.92 $15,773.28

$542.39 $3,429.62

$542.38 $3,154.66

T T S S S T T T T T T

489.5275 7.7075 3.7128 14.0169 34.8318 19.9529 37.3583 25.6233 129.8988 2.2058 8.4398

$26,575.96 $418.43 $201.56 $760.96 $1,890.98 $1,083.22 $2,028.14 $1,391.06 $7,052.08 $119.75 $458.19

S T T T T T T T T T T T T T T

4.0076 27.4545 2.5105 32.5959 40.8955 56.6318 6.3480 7.8542 9.0138 8.3227 3.9986 7.5876 4.1171 16.8557 22.2565

$217.57 $1,490.48 $136.29 $1,769.60 $2,220.18 $3,074.48 $344.63 $426.40 $489.35 $451.83 $217.08 $411.92 $223.51 $915.08 $1,208.28

T T T T T T S T

18.8763 8.2940 21.2745 26.8861 9.9148 3.1438 2.4771 7.4187

$1,024.78 $450.27 $1,154.97 $1,459.62 $538.26 $170.67 $134.48 $402.75

$245.46 $113.02 $410.87 $464.85 $188.89 $46.55 $100.69

$204.96 $90.05 $230.99 $291.92 $107.65 $34.13 $26.90 $80.55

S

2.7168

$147.49

$36.87

$29.50

T

6.8152

$369.99

$105.06

$74.00

0106 0107 0108 0109 0110 0111 0112 0113 0114 0115 0119 0121 0122 0123 0124 0125 0130 0131 0132 0140 0141 0142 0143 0146 0147 0148 0149 0150 0151 0152 0153 0154 0155 0156 0157 0158 0159 0160

Colorectal Cancer Screening: Flexible Sigmoidoscopy Level I Cystourethroscopy and other Genitourinary Procedures

Page 3 of 30

$131.49 $211.96 $609.71 $485.91 $459.35 $43.80 $93.97

$298.10 $659.53 $1,001.89 $1,239.22 $107.24 $143.38 $152.78 $186.06 $64.40 $63.38 $293.06 $437.12

$5,315.19 $83.69 $40.31 $152.19 $378.20 $216.64 $405.63 $278.21 $1,410.42 $23.95 $91.64 $43.51 $298.10 $27.26 $353.92 $444.04 $614.90 $68.93 $85.28 $97.87 $90.37 $43.42 $82.38 $44.70 $183.02 $241.66

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC

Status Relative Indicator Weights

Group Title

0163 0164 0165 0166 0167 0168 0169 0170 0180 0181 0183 0184 0187 0188 0189 0190 0191 0192 0193 0194 0195 0196 0197 0198 0199 0200 0201 0202 0203 0204 0206 0207 0208

Level II Cystourethroscopy and other Genitourinary Procedures Level III Cystourethroscopy and other Genitourinary Procedures Level IV Cystourethroscopy and other Genitourinary Procedures Level I Urinary and Anal Procedures Level III Urinary and Anal Procedures Level I Urethral Procedures Level III Urethral Procedures Level II Urethral Procedures Lithotripsy Dialysis Circumcision Penile Procedures Testes/Epididymis Procedures Prostate Biopsy Miscellaneous Placement/Repositioning Level II Female Reproductive Proc Level III Female Reproductive Proc Level I Hysteroscopy Level I Female Reproductive Proc Level IV Female Reproductive Proc Level V Female Reproductive Proc Level VI Female Reproductive Proc Level VII Female Reproductive Proc Dilation and Curettage Infertility Procedures Pregnancy and Neonatal Care Procedures Obstetrical Care Service Therapeutic Abortion Spontaneous Abortion Level VIII Female Reproductive Proc Level IV Nerve Injections Level I Nerve Injections Level II Nerve Injections Level III Nerve Injections Laminotomies and Laminectomies

0209 0212 0213 0214 0215 0216 0218 0220

0161 0162

Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

T

16.5822

$900.23

T

21.8578

$1,186.64

T T T T T T T S T T T T X T T T T T T T T T T T T T T T T T T T T

33.6435 1.2115 14.0780 16.8401 30.1066 30.3485 44.5329 5.9427 18.4967 29.0094 21.7612 3.8073 4.4274 1.1079 1.3207 19.8088 0.1679 2.6966 15.7365 18.8194 25.3207 16.1823 5.1958 1.3718 16.8630 18.3633 17.2803 38.8053 11.8511 2.2209 5.2584 6.5998 40.6521

$1,826.47 $65.77 $764.28 $914.23 $1,634.46 $1,647.59 $2,417.65 $322.62 $1,004.17 $1,574.89 $1,181.39 $206.69 $240.36 $60.15 $71.70 $1,075.40 $9.12 $146.40 $854.32 $1,021.69 $1,374.64 $878.52 $282.07 $74.47 $915.48 $996.93 $938.13 $2,106.70 $643.38 $120.57 $285.47 $358.30 $2,206.96

Extended EEG Studies and Sleep Studies, Level II Nervous System Injections

S T

11.5352 2.9989

$626.23 $162.81

$280.58 $74.92

$125.25 $32.56

Extended EEG Studies and Sleep Studies, Level I Electroencephalogram Level I Nerve and Muscle Tests Level III Nerve and Muscle Tests Level II Nerve and Muscle Tests Level I Nerve Procedures

S S S S S T

3.2422 2.2459 0.6390 2.8332 1.1296 16.5293

$176.02 $121.93 $34.69 $153.81 $61.32 $897.36

$70.41 $58.12 $15.76 $67.98

$35.20 $24.39 $6.94 $30.76 $12.26 $179.47

Page 4 of 30

$249.36

$180.05 $237.33

$17.59 $218.73 $555.84 $405.60 $1,115.69 $304.87 $621.82 $96.27 $90.71 $16.70 $424.28 $2.65 $39.11 $171.13 $397.84 $483.80 $338.23 $32.19 $307.83 $329.65 $1,032.28 $276.76 $40.13 $75.55 $123.69

$365.29 $13.15 $152.86 $182.85 $326.89 $329.52 $483.53 $64.52 $200.83 $314.98 $236.28 $41.34 $48.07 $12.03 $14.34 $215.08 $1.82 $29.28 $170.86 $204.34 $274.93 $175.70 $56.41 $14.89 $183.10 $199.39 $187.63 $421.34 $128.68 $24.11 $57.09 $71.66 $441.39

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC 0221 0222 0223 0224 0225 0226 0227 0228 0229 0230 0231 0232 0233 0234 0235 0236 0237 0238 0239 0240 0241 0242 0243 0244 0245 0246 0247 0248 0249 0250 0251 0252 0253 0254 0256 0258 0259 0260 0261 0262 0263 0264 0265 0266 0267

Status Relative Indicator Weights

Group Title Level II Nerve Procedures Implantation of Neurological Device Implantation or Revision of Pain Management Catheter Implantation of Reservoir/Pump/Shunt Implantation of Neurostimulator Electrodes Implantation of Drug Infusion Reservoir Implantation of Drug Infusion Device Creation of Lumbar Subarachnoid Shunt Transcatherter Placement of Intravascular Shunts Level I Eye Tests & Treatments Level III Eye Tests & Treatments Level I Anterior Segment Eye Procedures Level II Anterior Segment Eye Procedures Level III Anterior Segment Eye Procedures Level I Posterior Segment Eye Procedures Level II Posterior Segment Eye Procedures Level III Posterior Segment Eye Procedures Level I Repair and Plastic Eye Procedures Level II Repair and Plastic Eye Procedures Level III Repair and Plastic Eye Procedures Level IV Repair and Plastic Eye Procedures Level V Repair and Plastic Eye Procedures Strabismus/Muscle Procedures Corneal Transplant Level I Cataract Procedures without IOL Insert Cataract Procedures with IOL Insert Laser Eye Procedures Except Retinal Laser Retinal Procedures Level II Cataract Procedures without IOL Insert Nasal Cauterization/Packing Level I ENT Procedures Level II ENT Procedures Level III ENT Procedures Level IV ENT Procedures Level V ENT Procedures Tonsil and Adenoid Procedures Level VI ENT Procedures Level I Plain Film Except Teeth Level II Plain Film Except Teeth Including Bone Density Measurement Plain Film of Teeth Level I Miscellaneous Radiology Procedures Level II Miscellaneous Radiology Procedures Level I Diagnostic Ultrasound Except Vascular Level II Diagnostic Ultrasound Except Vascular Level III Diagnostic Ultrasound Except Vascular

Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

T T

25.8194 188.7735

$1,401.71 $10,248.32

T T S T T T

26.0352 34.0161 56.0375 159.6795 163.6124 51.1329

$1,413.42 $1,846.70 $3,042.22 $8,668.84 $8,882.35 $2,775.95

T S S T T T T T T T T T T T T T T T T T T T T T T T T T T X

59.4977 0.7379 2.0880 4.9739 14.5435 21.5482 4.9900 19.6866 34.0324 3.2016 6.2432 17.3397 21.9830 29.2193 21.1035 37.4885 12.5751 22.8428 5.0192 4.7544 28.3307 1.5381 1.8643 6.5416 15.1698 21.4368 35.0866 21.0273 389.1764 0.7845

$3,230.07 $40.06 $113.36 $270.03 $789.55 $1,169.83 $270.90 $1,068.77 $1,847.58 $173.81 $338.94 $941.35 $1,193.44 $1,586.29 $1,145.69 $2,035.21 $682.69 $1,240.11 $272.49 $258.11 $1,538.05 $83.50 $101.21 $355.14 $823.55 $1,163.78 $1,904.82 $1,141.55 $21,128.00 $42.59

$437.25 $9,394.83 $21.29

$646.01 $8.01 $22.67 $54.01 $157.91 $233.97 $54.18 $213.75 $369.52 $34.76 $67.79 $188.27 $238.69 $317.26 $229.14 $407.04 $136.54 $248.02 $54.50 $51.62 $307.61 $16.70 $20.24 $71.03 $164.71 $232.76 $380.96 $228.31 $4,225.60 $8.52

X X X X S S S

1.3238 0.7851 2.1875 3.0022 1.0245 1.6234 2.4805

$71.87 $42.62 $118.76 $162.99 $55.62 $88.13 $134.66

$9.82 $43.58 $79.41 $27.81 $44.07 $65.52

$14.37 $8.52 $23.75 $32.60 $11.12 $17.63 $26.93

Page 5 of 30

$463.62

$453.41

$621.80 $771.23 $14.97 $50.94 $103.17 $266.33 $511.31 $72.04 $818.54 $58.96 $110.62 $315.31 $384.47 $597.36 $431.39 $803.26 $226.11 $495.96 $104.31 $95.08 $524.67 $29.23 $113.41 $282.29 $321.35

$280.34 $2,049.66 $282.68 $369.34 $608.44 $1,733.77 $1,776.47 $555.19

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC

Status Relative Indicator Weights

Group Title

Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

0268

Ultrasound Guidance Procedures

S

1.2640

$68.62

0269 0270 0271 0272 0274 0275 0276 0277 0278

S S S X S S S S S

3.2517 5.9057 0.6548 1.4086 3.5837 3.2967 1.6025 2.4462 2.7365

$176.53 $320.61 $35.55 $76.47 $194.56 $178.97 $87.00 $132.80 $148.56

$87.24 $146.79 $16.80 $38.24 $92.92 $69.09 $41.72 $60.47 $66.07

$35.31 $64.12 $7.11 $15.29 $38.91 $35.79 $17.40 $26.56 $29.71

S

11.0678

$600.86

$174.57

$120.17

S S S

19.0237 6.6888 1.6813

$1,032.78 $363.13 $91.28

$353.85 $115.16 $44.51

$206.56 $72.63 $18.26

S

4.6121

$250.39

$125.19

$50.08

0284

Level III Echocardiogram Except Transesophageal Transesophageal Echocardiogram Mammography Level I Fluoroscopy Myelography Arthrography Level I Digestive Radiology Level II Digestive Radiology Diagnostic Urography Level II Angiography and Venography except Extremity Level III Angiography and Venography except Extremity Venography of Extremity Miscellaneous Computerized Axial Tomography Computerized Axial Tomography with Contrast Material Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contras

S

7.0207

$381.15

$190.57

$76.23

0285 0287 0288 0289 0296 0297 0299 0300 0301 0302 0303

Myocardial Positron Emission Tomography (PET) Complex Venography Bone Density:Axial Skeleton Needle Localization for Breast Biopsy Level I Therapeutic Radiologic Procedures Level II Therapeutic Radiologic Procedures Miscellaneous Radiation Treatment Level I Radiation Therapy Level II Radiation Therapy Level III Radiation Therapy Treatment Device Construction

S S S X S S S S S S X

19.5044 6.2829 1.2854 3.6386 3.1381 8.1532 5.7427 1.5112 2.1337 6.1992 2.8636

$1,058.87 $341.09 $69.78 $197.54 $170.36 $442.63 $311.77 $82.04 $115.84 $336.55 $155.46

$409.56 $107.20

$23.17 $127.49 $66.95

$211.77 $68.22 $13.96 $39.51 $34.07 $88.53 $62.35 $16.41 $23.17 $67.31 $31.09

0304

Level I Therapeutic Radiation Treatment Preparation

X

1.6599

$90.11

$41.52

$18.02

0305

Level II Therapeutic Radiation Treatment Preparation

X

3.6649

$198.96

$91.38

$39.79

0310 0312 0313 0314 0320 0321 0322 0323 0324 0325

Level III Therapeutic Radiation Treatment Preparation Radioelement Applications Brachytherapy Hyperthermic Therapies Electroconvulsive Therapy Biofeedback and Other Training Brief Individual Psychotherapy Extended Individual Psychotherapy Family Psychotherapy Group Psychotherapy

X S S S S S S S S S

13.7085 3.6892 13.1258 5.0930 5.4480 1.2462 1.3091 1.7955 2.8219 1.5820

$744.22 $200.28 $712.59 $276.49 $295.77 $67.65 $71.07 $97.48 $153.20 $85.89

$325.27 $40.06

$148.84 $40.06 $142.52 $55.30 $59.15 $13.53 $14.21 $19.50 $30.64 $17.18

0279 0280 0281 0282 0283

Page 6 of 30

$13.72

$44.80 $69.20 $172.51 $62.36

$101.77 $80.06 $21.78 $21.26 $18.27

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC 0330

Status Relative Indicator Weights

Group Title

Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

S

0.5609

$30.45

$6.09

$6.09

S

3.3916

$184.13

$91.27

$36.83

S S

5.4299 6.4453

$294.78 $349.91

$146.98 $151.46

$58.96 $69.98

S

6.4817

$351.89

$175.94

$70.38

0337 0339 0340 0341 0342 0343 0344 0345 0346 0347 0348 0352 0353 0355 0356 0359 0360 0361 0362 0363 0364 0365 0367 0368 0369 0370 0371 0372 0373 0374

Dental Procedures Computerized Axial Tomography and Computerized Angiography without Contras Computerized Axial Tomography and Computerized Angio w/o Contrast Material Magnetic Resonance Imaging, Miscellaneous Magnetic Resonance Imaging and Magnetic Resonance Angiography without Cont MRI and Magnetic Resonance Angiography without Contrast Material followed Observation Minor Ancillary Procedures Skin Tests Level I Pathology Level II Pathology Level III Pathology Level I Transfusion Laboratory Procedures Level II Transfusion Laboratory Procedures Level III Transfusion Laboratory Procedures Fertility Laboratory Procedures Level I Injections Level II Allergy Injections Level III Immunizations Level IV Immunizations Level II Injections Level I Alimentary Tests Level II Alimentary Tests Level III Otorhinolaryngologic Function Tests Level I Otorhinolaryngologic Function Tests Level I Audiometry Level II Audiometry Level I Pulmonary Test Level II Pulmonary Tests Level III Pulmonary Tests Allergy Tests Level I Allergy Injections Therapeutic Phlebotomy Neuropsychological Testing Monitoring Psychiatric Drugs

S S X X X X X X X X X X X K K X X X X X X X X X X X X X X X

9.3215 7.2016 0.6232 0.1468 0.2169 0.4662 0.6278 0.2589 0.3877 0.9646 1.2207 0.1076 0.4106 0.2667 0.4353 0.8794 1.7088 3.5574 2.5384 0.8536 0.4415 1.1915 0.5828 0.9321 2.5282 0.8858 0.4084 0.5529 2.1165 1.1062

$506.05 $390.97 $33.83 $7.97 $11.78 $25.31 $34.08 $14.06 $21.05 $52.37 $66.27 $5.84 $22.29 $14.48 $23.63 $47.74 $92.77 $193.13 $137.81 $46.34 $23.97 $64.69 $31.64 $50.60 $137.25 $48.09 $22.17 $30.02 $114.90 $60.05

$240.77

$101.21 $78.19 $6.77 $1.59 $2.36 $5.06 $6.82 $2.81 $4.21 $10.47 $13.25 $1.17 $4.46 $2.90 $4.73 $9.55 $18.55 $38.63 $27.56 $9.27 $4.79 $12.94 $6.33 $10.12 $27.45 $9.62 $4.43 $6.00 $22.98 $12.01

0375 0376 0377 0378 0379 0380 0381 0382

Ancillary Outpatient Services when Patient Expires Pkgd cancer chemo, other Sep cancer chemo, other Infusion of pkgd cancer Infusion, separate cancer Pkgd cancer chemo, both Sep cancer chemo, both Infusion, pkgd noncancer

T S S S S S S S

2.1479 0.6673 4.3955 2.4298 5.1857 2.1596 4.6839

$1,150.00 $116.61 $36.23 $238.63 $131.91 $281.53 $117.24 $254.28

0332 0333 0335 0336

Page 7 of 30

$3.08 $5.88 $12.55 $17.04 $3.10 $5.31 $13.19

$42.45 $83.23 $17.15 $9.06 $18.95 $15.16 $25.30 $44.18 $11.58 $4.44 $10.09 $22.98

$230.00 $23.32 $7.25 $47.73 $26.38 $56.31 $23.45 $50.86

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC

Status Relative Indicator Weights

Group Title

Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

0383 0384 0385 0386 0387 0388 0389 0390 0391 0392 0393 0394 0395 0396 0397 0398 0399 0400 0401 0402 0403 0404 0405 0406 0407 0408 0409 0410 0411 0412 0413 0414 0415 0600 0601 0602 0610 0611 0612 0620 0648 0649 0651 0652

Infusion, separate noncancer GI Procedures with Stents Level I Prosthetic Urological Procedures Level II Prosthetic Urological Procedures Level II Hysteroscopy Discography Non-imaging Nuclear Medicine Level I Thyroid Imaging Level II Thyroid Imaging Adrenal Imaging Red Cell/Plasma Studies Hepatobiliary Imaging GI Tract and B12 Studies Bone Imaging Vascular Imaging Cardiac Imaging Cardiac Add-on Imaging Hematopoietic Imaging Pulmonary Imaging Brain Imaging CSF Imaging Renal Imaging Non-renal GU Studies Tumor/Infection Imaging Thyroid Radionucliide treatment Non-thyroid Radionucliide treatment Red Blood Cell Tests Mammogram Add On Respiratory Procedures IMRT Treatment Delivery IMRT Treatment Plan Reconstruction CT Angiography of Aorta Level II Endoscopy Lower Airway Low Level Clinic Visits Mid Level Clinic Visits High Level Clinic Visits Low Level Emergency Visits Mid Level Emergency Visits High Level Emergency Visits Critical Care Breast Reconstruction with Prosthesis Prostate Brachytherapy Palladium Seeds Complex Interstitial Radiation Source Application Insertion of Intraperitoneal Catheters

S T T T T S S S S S S S S S S S S S S S S S S S S S X S S S S S T V V V V V V S T T S T

1.8419 36.0040 66.4829 118.8122 28.5174 11.7450 1.6475 2.8434 3.7174 6.7081 4.0720 4.4370 3.9372 4.2445 2.4737 6.6521 1.6033 3.8691 4.9130 5.4818 3.9265 5.1538 0.7739 4.7542 4.2797 4.0000 0.1385 0.1473 0.4207 5.2832 6.0369 4.8012 20.9920 0.9376 1.0031 1.5603 1.4146 2.4881 4.3235 9.2657 55.5345 119.0281 10.0459 28.0692

$99.99 $1,954.62 $3,609.29 $6,450.20 $1,548.18 $637.62 $89.44 $154.37 $201.81 $364.18 $221.06 $240.88 $213.75 $230.43 $134.29 $361.14 $87.04 $210.05 $266.72 $297.60 $213.17 $279.79 $42.01 $258.10 $232.34 $217.16 $7.52 $8.00 $22.84 $286.82 $327.74 $260.65 $1,139.63 $50.90 $54.46 $84.71 $76.80 $135.08 $234.72 $503.03 $3,014.91 $6,461.92 $545.38 $1,523.85

0653

Vascular Reconstruction/Fistula Repair with Device Insertion/Replacement of a permanent dual chamber pacemaker

T

32.4880

$1,763.74

$352.75

T

103.8544

$5,638.15

$1,127.63

0654

Page 8 of 30

$20.00 $0.00

$660.84 $304.54 $44.72 $77.18 $100.91 $182.09 $110.53 $120.44 $106.87 $115.21 $67.15 $180.57 $43.52 $105.02 $133.36 $148.80 $106.58 $139.90 $21.01 $116.17 $2.31

$463.30

$19.57 $36.47 $54.14 $145.78

$109.08

$390.92

$721.86 $1,290.04 $309.64 $127.52 $17.89 $30.87 $40.36 $72.84 $44.21 $48.18 $42.75 $46.09 $26.86 $72.23 $17.41 $42.01 $53.34 $59.52 $42.63 $55.96 $8.40 $51.62 $46.47 $43.43 $1.50 $1.60 $4.57 $57.36 $65.55 $52.13 $227.93 $10.18 $10.89 $16.94 $15.36 $27.02 $46.94 $100.61 $602.98 $1,292.38 $109.08 $304.77

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC

Status Relative Indicator Weights

Group Title

Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

T

142.2244

$7,721.22

$1,544.24

0656 0657 0658 0659 0660 0661 0662 0664 0665

Insertion/Replacement/Conversion of a permanent dual chamber pacemaker Transcatheter Placement of Intracoronary DrugEluting Stents Placement of Tissue Clips Percutaneous Breast Biopsies Hyperbaric Oxygen Level II Otorhinolaryngologic Function Tests Level IV Pathology CT Angiography Proton Beam Radiation Therapy Bone Density:AppendicularSkeleton

T S T S X X S S S

101.3662 1.5630 5.6035 3.2220 1.7330 3.3215 5.8751 9.6828 0.7225

$5,503.07 $84.85 $304.21 $174.92 $94.08 $180.32 $318.95 $525.67 $39.22

$1,100.61 $16.97 $60.84 $34.98 $18.82 $36.06 $63.79 $105.13 $7.84

0668 0669 0670

Level I Angiography and Venography except Extremity Digital Mammography Intravenous and Intracardiac Ultrasound

S S S

10.4896 0.9111 26.5472

$569.47 $49.46 $1,441.22

0671 0672 0673 0674 0675 0676 0677 0678 0679 0680 0681 0682 0683 0684

Level II Echocardiogram Except Transesophageal Level IV Posterior Segment Procedures Level IV Anterior Segment Eye Procedures Prostate Cryoablation Prostatic Thermotherapy Level II Transcatheter Thrombolysis Level I Transcatheter Thrombolysis External Counterpulsation Level II Resuscitation and Cardioversion Insertion of Patient Activated Event Recorders Knee Arthroplasty Level V Debridement & Destruction Level II Photochemotherapy Prostate Brachytherapy Iodine Seeds Level III Needle Biopsy/Aspiration Except Bone Marrow Level III Skin Repair

S T T T T T T T S S T T S T

1.6392 39.1363 26.7626 101.1198 49.3613 3.7505 3.0769 2.0622 5.4862 61.4222 96.7483 7.6815 1.7915 104.7194

$88.99 $2,124.67 $1,452.91 $5,489.69 $2,679.78 $203.61 $167.04 $111.95 $297.84 $3,334.55 $5,252.37 $417.02 $97.26 $5,685.11

T T

4.8912 17.0868

$265.54 $927.63

$116.83 $341.70

$53.11 $185.53

Revision/Removal of Neurostimulator Electrodes Revision/Removal of Neurostimulator Pulse Generator Receiver Electronic Analysis of Cardioverter-defibrillators Electronic Analysis of Pacemakers and other Cardiac Devices

T

19.9913

$1,085.31

$499.24

$217.06

T S

42.5880 0.5427

$2,312.06 $29.46

$1,132.91

$462.41 $5.89

S

0.3986

$21.64

$10.35

$4.33

S

2.9894

$162.29

$81.15

$32.46

S T T T

0.9625 38.6469 3.3272 19.1377

$52.25 $2,098.10 $180.63 $1,038.97

$26.13 $798.17 $72.25 $266.59

$10.45 $419.62 $36.13 $207.79

0655

0685 0686 0687 0688 0689 0690 0691 0692 0693 0694 0695

Electronic Analysis of Programmable Shunts/Pumps Electronic Analysis of Neurostimulator Pulse Generators Level II Breast Reconstruction Mohs Surgery Level VII Debridement & Destruction

Page 9 of 30

$30.66 $90.16 $156.47

$237.76 $521.95 $44.50 $988.43 $649.56

$55.06

$95.30 $2,090.21 $174.57 $35.01

$113.89 $9.89 $288.24 $17.80 $424.93 $290.58 $1,097.94 $535.96 $40.72 $33.41 $22.39 $59.57 $666.91 $1,050.47 $83.40 $19.45 $1,137.02

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC 0697 0698 0699 0700 0701 0702 0704 0726 0728 0730 0732 0733 0734 0800 0802 0807 0810 0811 0812 0813 0820 0821 0822 0823 0827 0828 0830 0831 0832 0836 0838 0840 0842 0843 0844 0849 0850 0852 0855 0856 0857 0858 0861 0862 0863 0864

Status Relative Indicator Weights

Group Title Level I Echocardiogram Except Transesophageal Level II Eye Tests & Treatments Level IV Eye Tests & Treatments Antepartum Manipulation SR 89 chloride, per mCi SM 153 lexidronam, 50 mCi IN 111 Satumomab pendetide per dose Dexrazoxane hcl injection, 250 mg Filgrastim 300 mcg injection Pamidronate disodium , 30 mg Mesna injection 200 mg Non esrd epoetin alpha inj, 1000 u Injection, darbepoetin alfa (for non-ESRD use), per 1 mcg Leuprolide acetate, 3.75 mg Etoposide oral 50 mg Aldesleukin/single use vial Goserelin acetate implant 3.6 mg Carboplatin injection 50 mg Carmustine, 100 mg Cisplatin 10 mg injection Daunorubicin 10 mg Daunorubicin citrate liposom 10 mg Diethylstilbestrol injection 250 mg Docetaxel, 20 mg Floxuridine injection 500 mg Gemcitabine HCL 200 mg Irinotecan injection 20 mg Ifosfomide injection 1 gm Idarubicin hcl injection 5 mg Interferon alfa-2b inj recombinant, 1 million Interferon gamma 1-b inj, 3 million u Melphalan hydrochl 50 mg Fludarabine phosphate inj 50 mg Pegaspargase, single dose vial Pentostatin injection, 10 mg Rituximab, 100 mg Streptozocin injection, 1 gm Topotecan, 4 mg Vinorelbine tartrate, 10 mg Porfimer sodium, 75 mg Bleomycin sulfate injection 15 u Cladribine, 1mg Leuprolide acetate injection 1 mg Mitomycin 5 mg inj Paclitaxel injection, 30 mg Mitoxantrone hcl, 5 mg

Payment Rate

S S T T K K K K K K K K

1.4621 0.9355 2.2211 2.4359 7.4586 16.1415 2.9212 1.9860 2.2544 2.0537 0.4908 0.1782

$79.38 $50.79 $120.58 $132.24 $404.92 $876.31 $158.59 $107.82 $122.39 $111.49 $26.65 $9.67

K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K

0.0463 3.3020 0.4830 7.0936 4.9549 1.5475 0.9972 0.3594 0.6052 2.9697 1.3274 4.0041 2.1836 1.4523 1.8626 1.1616

$2.51 $179.26 $26.22 $385.10 $269.00 $84.01 $54.14 $19.51 $32.86 $161.22 $72.06 $217.38 $118.55 $78.84 $101.12 $63.06

3.2438

$176.10

0.2000 2.4742 4.4072 3.6854 5.7621 17.4201 5.5636 1.3942 7.9075 1.1683 25.3788 2.2352 0.7031 0.8223 0.9557 1.2674 3.1513

$10.86 $134.32 $239.26 $200.08 $312.82 $945.72 $302.04 $75.69 $429.29 $63.43 $1,377.79 $121.35 $38.17 $44.64 $51.88 $68.81 $171.08

Page 10 of 30

National Minimum Unadjusted Unadjusted Copayment Copayment $39.69 $18.72 $54.26 $37.03

$15.88 $10.16 $24.12 $26.45 $80.98 $175.26 $31.72 $21.56 $24.48 $22.30 $5.33 $1.93 $0.50 $35.85 $5.24 $77.02 $53.80 $16.80 $10.83 $3.90 $6.57 $32.24 $14.41 $43.48 $23.71 $15.77 $20.22 $12.61 $35.22 $2.17 $26.86 $47.85 $40.02 $62.56 $189.14 $60.41 $15.14 $85.86 $12.69 $275.56 $24.27 $7.63 $8.93 $10.38 $13.76 $34.22

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC

Status Relative Indicator Weights

Group Title

Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

0865 0884 0888 0890 0891 0900 0901 0902 0903 0905 0906 0909 0910 0911 0916 0917 0925 0926 0927 0928 0929 0930 0931 0932

Interferon alfa-n3 inj, human leukocyte derived, 2 Rho d immune globulin inj, 1 dose pkg Cyclosporine oral 100 mg Lymphocyte immune globulin 250 mg Tacrolimus oral per 1 mg Alglucerase injection, per 10 u Alpha 1 proteinase inhibitor, 10 mg Botulinum toxin a, per unit Cytomegalovirus imm IV/vial Immune globulin, 1g RSV-ivig, 50 mg Interferon beta-1a, 33 mcg Interferon beta-1b /0.25 mg Streptokinase per 250,000 iu Imiglucerase injection/unit Inj, Adenosine, 90 mg Factor viii per iu Factor VIII (porcine) per iu Factor viii recombinant per iu Factor ix complex per iu Anti-inhibitor per iu Antithrombin iii injection per iu Factor IX non-recombinant, per iu Factor IX recombinant, per iu

K K K K K K K K K K K K K K K K K K K K K K K K

1.5823 0.2312 0.0482 2.1958 0.0236 0.5473 0.0214 0.0460 5.0754 0.8103 6.0142 2.8010 1.9843 1.6055 0.0531 2.3474 0.0085 0.0253 0.0168 0.0085 0.0168 0.0117 0.0104 0.0168

$85.90 $12.55 $2.62 $119.21 $1.28 $29.71 $1.16 $2.50 $275.54 $43.99 $326.50 $152.06 $107.73 $87.16 $2.88 $127.44 $0.46 $1.37 $0.91 $0.46 $0.91 $0.64 $0.56 $0.91

$17.18 $2.51 $0.52 $23.84 $0.26 $5.94 $0.23 $0.50 $55.11 $8.80 $65.30 $30.41 $21.55 $17.43 $0.58 $25.49 $0.09 $0.27 $0.18 $0.09 $0.18 $0.13 $0.11 $0.18

0949 0950 0952 0954 0955 0956 0957 0958 0959 0960 0961 0963 0964 0965 0966 1009 1010 1011 1013 1016 1017 1018 1019

Plasma, Pooled Multiple Donor, Solvent/Detergent T Blood (Whole) For Transfusion Cryoprecipitate RBC leukocytes reduced Plasma, Fresh Frozen Plasma Protein Fraction Platelet Concentrate Platelet Rich Plasma Red Blood Cells Washed Red Blood Cells Infusion, Albumin (Human) 5%, 50 ml Albumin (human), 5%, 250 ml Albumin (human), 25%, 20 ml Albumin (human), 25%, 50ml Plasmaprotein fract,5%,250ml Cryoprecip reduced plasma Blood, L/R, CMV-neg Platelets, HLA-m, L/R, unit Platelet concentrate, L/R, unit Blood, L/R, froz/deglycerol/washed Platelets, aph/pher, L/R, CMV-neg, unit Blood, L/R, irradiated Platelets, aph/pher, L/R, irradiated, unit

K K K K K K K K K K K K K K K K K K K K K K K

2.0608 1.4575 0.4860 1.9770 1.5750 1.5414 0.6870 1.1296 1.4326 2.6638 0.7319 3.4713 0.7911 1.9432 7.7071 0.9447 2.1361 8.2851 0.9101 5.0012 6.5175 2.1950 6.7353

$111.88 $79.13 $26.38 $107.33 $85.51 $83.68 $37.30 $61.32 $77.77 $144.62 $39.73 $188.45 $42.95 $105.49 $418.41 $51.29 $115.97 $449.79 $49.41 $271.51 $353.83 $119.16 $365.65

$22.38 $15.83 $5.28 $21.47 $17.10 $16.74 $7.46 $12.26 $15.55 $28.92 $7.95 $37.69 $8.59 $21.10 $83.68 $10.26 $23.19 $89.96 $9.88 $54.30 $70.77 $23.83 $73.13

Page 11 of 30

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC 1020 1021 1022 1045 1064 1065 1084 1086 1091 1092 1095 1096 1122 1167 1178 1203 1207 1305 1409 1501 1502 1503 1504 1505 1506 1507 1508 1509 1510 1511 1512 1513 1514 1515 1516 1517 1518 1519 1520 1521 1522 1523 1524 1525 1526 1527 1528 1529

Group Title Pit, pher,L/R,CMV,irrad RBC, frz/deg/wsh, L/R, irrad RBC, L/R, CMV neg, irrad Iobenguane sulfate I-131per 0.5 mCi I-131 sodium iodide capsule I-131 sodium iodide solution Denileukin diftitox, 300 MCG Temozolomide,oral 5 mg IN 111 Oxyquinoline, per .5 mCi IN 111 Pentetate, per 0.5 mCi Technetium TC 99M Depreotide TC 99M Exametazime, per dose TC 99M arcitumomab, per vial Epirubicin hcl, 2 mg Busulfan IV, 6 mg Verteporfin for injection Octreotide injection, depot Apligraf Factor viia recombinant, per 1.2 mg New Technology - Level I ($0 - $50) New Technology - Level II ($50 - $100) New Technology - Level III ($100 - $200) New Technology - Level IV ($200 - $300) New Technology - Level V ($300 - $400) New Technology - Level VI ($400 - $500) New Technology - Level VII ($500 - $600) New Technology - Level VIII ($600 - $700) New Technology - Level IX ($700 - $800) New Technology - Level X ($800 - $900) New Technology - Level XI ($900 - $1000) New Technology - Level XII ($1000 - $1100) New Technology - Level XIII ($1100 - $1200) New Technology-Level XIV ($1200- $1300) New Technology - Level XV ($1300 - $1400) New Technology - Level XVI ($1400 - $1500) New Technology - Level XX ($1500-$1600) New Technology - Level XX ($1600-$1700) New Technology - Level XX ($1700-$1800) New Technology - Level XX ($1800-$1900) New Technology - Level XX ($1900-$2000) New Technology - Level XX ($2000-$2500) New Technology - Level XX ($2500-$3000) New Technology - Level XX ($3000-$3500) New Technology - Level XX ($3500-$4000) New Technology - Level XX ($4000-$4500) New Technology - Level XX ($4500-$5000) New Technology - Level XX ($5000-$5500) New Technology - Level XX ($5500-$6000)

Status Relative Indicator Weights K K K K K K K K K K K K K K K K K K K S S S S S S S S S S S S S S S S S S S S S S S S S S S S S

Page 12 of 30

9.6266 6.5287 3.9139 2.9293 0.1007 0.0002 15.0913 0.0643 4.0535 4.0824 3.7042 3.8103 9.6556 0.3597 6.0245 16.1946 1.1849 11.2075 17.9693

Payment Rate $522.62 $354.44 $212.48 $159.03 $5.47 $0.01 $819.29 $3.49 $220.06 $221.63 $201.10 $206.86 $524.19 $19.53 $327.06 $879.19 $64.33 $608.44 $975.54 $25.00 $75.00 $150.00 $250.00 $350.00 $450.00 $550.00 $650.00 $750.00 $850.00 $950.00 $1,050.00 $1,150.00 $1,250.00 $1,350.00 $1,450.00 $1,550.00 $1,650.00 $1,750.00 $1,850.00 $1,950.00 $2,250.00 $2,750.00 $3,250.00 $3,750.00 $4,250.00 $4,750.00 $5,250.00 $5,750.00

National Minimum Unadjusted Unadjusted Copayment Copayment $104.52 $70.89 $42.50 $31.81 $1.09 $0.00 $163.86 $0.70 $44.01 $44.33 $40.22 $41.37 $104.84 $3.91 $65.41 $175.84 $12.87 $121.69 $195.11 $5.00 $15.00 $30.00 $50.00 $70.00 $90.00 $110.00 $130.00 $150.00 $170.00 $190.00 $210.00 $230.00 $250.00 $270.00 $290.00 $310.00 $330.00 $350.00 $370.00 $390.00 $450.00 $550.00 $650.00 $750.00 $850.00 $950.00 $1,050.00 $1,150.00

8/6/2003 2:47 PM

ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC 1530 1531 1532 1533 1534 1535 1536 1537 1538 1539 1540 1541 1542 1543 1544 1545 1546 1547 1548 1549 1550 1551 1552 1553 1554 1555 1556 1557 1558 1559 1560 1561 1562 1563 1564 1565 1566 1567 1568 1569 1570 1571 1572 1573 1574 1604 1605 1606

Group Title New Technology - Level XX ($6000-$6500) New Technology - Level XX ($6500-$7000) New Technology - Level XX ($7000-$7500) New Technology - Level XX ($7500-$8000) New Technology - Level XX ($8000-$8500) New Technology - Level XX ($8500-$9000) New Technology - Level XX ($9000-$9500) New Technology - Level XX ($9500-$10000) New Technology - Level I ($0 - $50) New Technology - Level II ($50 - $100) New Technology - Level III ($100 - $200) New Technology - Level IV ($200 - $300) New Technology - Level V ($300 - $400) New Technology - Level VI ($400 - $500) New Technology - Level VII ($500 - $600) New Technology - Level VIII ($600 - $700) New Technology - Level IX ($700 - $800) New Technology - Level X ($800 - $900) New Technology - Level XI ($900 - $1000) New Technology - Level XII ($1000 - $1100) New Technology - Level XIII ($1100 - $1200) New Technology-Level XIV ($1200- $1300) New Technology - Level XV ($1300 - $1400) New Technology - Level XVI ($1400 - $1500) New Technology - Level XX ($1500-$1600) New Technology - Level XX ($1600-$1700) New Technology - Level XX ($1700-$1800) New Technology - Level XX ($1800-$1900) New Technology - Level XX ($1900-$2000) New Technology - Level XX ($2000-$2500) New Technology - Level XX ($2500-$3000) New Technology - Level XX ($3000-$3500) New Technology - Level XX ($3500-$4000) New Technology - Level XX ($4000-$4500) New Technology - Level XX ($4500-$5000) New Technology - Level XX ($5000-$5500) New Technology - Level XX ($5500-$6000) New Technology - Level XX ($6000-$6500) New Technology - Level XX ($6500-$7000) New Technology - Level XX ($7000-$7500) New Technology - Level XX ($7500-$8000) New Technology - Level XX ($8000-$8500) New Technology - Level XX ($8500-$9000) New Technology - Level XX ($9000-$9500) New Technology - Level XX ($9500-$10000) IN 111 capromab pendetide, per dose Abciximab injection, 10 mg Anistreplase, 30 u

Status Relative Indicator Weights S S S S S S S S T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T K K K

Page 13 of 30

12.4029 5.2806 25.3116

Payment Rate $6,250.00 $6,750.00 $7,250.00 $7,750.00 $8,250.00 $8,750.00 $9,250.00 $9,750.00 $25.00 $75.00 $150.00 $250.00 $350.00 $450.00 $550.00 $650.00 $750.00 $850.00 $950.00 $1,050.00 $1,150.00 $1,250.00 $1,350.00 $1,450.00 $1,550.00 $1,650.00 $1,750.00 $1,850.00 $1,950.00 $2,250.00 $2,750.00 $3,250.00 $3,750.00 $4,250.00 $4,750.00 $5,250.00 $5,750.00 $6,250.00 $6,750.00 $7,250.00 $7,750.00 $8,250.00 $8,750.00 $9,250.00 $9,750.00 $673.34 $286.68 $1,374.14

National Minimum Unadjusted Unadjusted Copayment Copayment $1,250.00 $1,350.00 $1,450.00 $1,550.00 $1,650.00 $1,750.00 $1,850.00 $1,950.00 $5.00 $15.00 $30.00 $50.00 $70.00 $90.00 $110.00 $130.00 $150.00 $170.00 $190.00 $210.00 $230.00 $250.00 $270.00 $290.00 $310.00 $330.00 $350.00 $370.00 $390.00 $450.00 $550.00 $650.00 $750.00 $850.00 $950.00 $1,050.00 $1,150.00 $1,250.00 $1,350.00 $1,450.00 $1,550.00 $1,650.00 $1,750.00 $1,850.00 $1,950.00 $134.67 $57.34 $274.83

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ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC 1607 1609 1611 1612 1613 1614 1615 1618 1620 1625 1628 1716 1718 1719 1720 1775 1783 1814 1818 1884 1888 1900 2614 2616 2632 7000 7011 7015 7024 7025 7027 7030 7031 7034 7035 7036 7037 7038 7041 7042 7043 7045 7046 7049 7051 9000 9002 9003

Group Title Eptifibatide injection, 5mg Rho(D) immune globulin h, sd, 100 iu Hylan G-F 20 injection, 16 mg Daclizumab, parenteral, 25 mg Trastuzumab, 10 mg Valrubicin, 200 mg Basiliximab, 20 mg Vonwillebrandfactrcmplx, per iu Technetium tc99m bicisate Indium 111-in pentetreotide Chromic phosphate p32 Brachytx source, Gold 198 Brachytx source, Iodine 125 Brachytx source,Non-HDR Ir-192 Brachytx source, Palladium 103 FDG, per dose (4-40 mCi/ml) Ocular implant, aqueous drain device Retinal Tamp, silicone oil Integrated keratoprosthesis Embolization protective system Endovas non-cardiac ablation catheter Lead coronary venous Probe, percutaneous lumbar disc Brachytx source, Yttrium-90 Brachytx sol, I-125, per mCi Amifostine, 500 mg Oprelvekin injection, 5 mg Busulfan, oral, 2 mg Corticorelin ovine triflutat Digoxin immune FAB (ovine) Fomepizole, 15mg Hemin, per 1 mg Octreotide acetate injection Somatropin injection Teniposide, 50 mg Urokinase 250,000 iu inj Urofollitropin, 75 iu Muromonab-CD3, 5 mg Tirofiban hydrochloride 12.5 mg Capecitabine, oral, 150 mg Infliximab injection 10 mg Trimetrexate glucoronate Doxorubicin hcl liposome inj 10 mg Filgrastim 480 mcg injection Leuprolide acetate implant, 65 mg Na chromate Cr51, per 0.25mCi Tenecteplase, 50mg/vial Palivizumab, per 50mg

Status Relative Indicator Weights K K K K K K K K K K K K K K K K H H H H H H H K H K K K K K K K K K K K K K K K K K K K K K K K

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Payment Rate

National Minimum Unadjusted Unadjusted Copayment Copayment

0.1426 0.1863 2.1566 3.7304 0.7384 9.6183 11.2007 0.0168 3.3106 6.8170 2.0103 1.3399 0.6695 0.3053 0.8104 5.8606

$7.74 $10.11 $117.08 $202.52 $40.09 $522.17 $608.07 $0.91 $179.73 $370.09 $109.14 $72.74 $36.35 $16.57 $44.00 $318.17

$1.55 $2.02 $23.42 $40.50 $8.02 $104.43 $121.61 $0.18 $35.95 $74.02 $21.83 $14.55 $7.27 $3.31 $8.80 $63.63

163.4011

$8,870.88

$1,774.18

3.9932 2.7246 0.0263 3.4880 4.4789 0.2215 0.0119 1.0339 0.9206 1.5530 5.1032 1.1321 5.8452 4.2976 0.0290 0.6841 1.2099 4.6362 3.1998 68.9392 1.2631 23.2303 6.3850

$216.79 $147.92 $1.43 $189.36 $243.16 $12.03 $0.65 $56.13 $49.98 $84.31 $277.05 $61.46 $317.33 $233.31 $1.57 $37.14 $65.68 $251.69 $173.71 $3,742.64 $68.57 $1,261.15 $346.64

$43.36 $29.58 $0.29 $37.87 $48.63 $2.41 $0.13 $11.23 $10.00 $16.86 $55.41 $12.29 $63.47 $46.66 $0.31 $7.43 $13.14 $50.34 $34.74 $748.53 $13.71 $252.23 $69.33

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ADDENDUM A.--List of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts (2004 NPRM)

APC 9004 9005 9009 9010 9012 9015 9018 9019 9020 9021 9022 9023 9024 9025 9100 9104 9105 9108 9109 9110 9111 9112 9113 9114 9115 9116 9117 9118 9119 9120 9121 9122 9200 9201 9202 9203 9204 9205 9217 9500 9501 9502 9503 9504 9505 9506

Group Title Gemtuzumab ozogamicin inj,5mg Reteplase injection Baclofen refill kit - per 2000 mcg Baclofen refill kit - per 4000 mcg Arsenic Trioxide Mycophenolate mofetil oral 250 mg Botulinum toxin B, per 100 u Caspofungin acetate, 5 mg Sirolimus tablet, oral 1 mg Immune globulin 10 mg IM inj interferon beta 1-a Rho d immune globulin 50 mcg Amphotericin b lipid complex Rubidium-Rb-82 Iodinated I-131albumin, per 5 uci Anti-thymocycte globulin rabbit Hep B imm glob, per 1 ml Thyrotropin alfa, per 1.1 mg Tirofiban hcl, per 6.25 mg Alemtuzumab, per 10 mg Inj, bivalirudin, per 250 mg vial Perflutren lipid micro, per 2ml Inj, pantoprazole sodium, vial Nesiritide, per 0.5 mg vial Inj, zoledronic acid, per 1 mg Inj, Ertapenem sodium, per 1 gm vial Y-90 ibritumomab tiuxetan IN-111 ibritumomab tiuxetan Pegfilgrastim, per 1 mg Inj, Fulvestrant, per 50 mg Inj, Argatroban, per 5 mg Inj, Triptorelin pamoate, per 3.75 mg Orcel, per 36 cm2 Dermagraft, per 37.5 sq cm Octafluoropropane Perflexane lipid micro Ziprasidone mesylate Oxaliplatin Leuprolide acetate suspnsion, 7.5 mg Platelets, irradiated Platelets, pheresis Platelet pheresis irradiated Fresh frozen plasma, ea unit RBC deglycerolized RBC irradiated Granulocytes, pheresis

Status Relative Indicator Weights K K K K K K K K K K K K K K K K K K K K G G G G G G K K G G G G G K K G G G K K K K K K K K

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17.5020 10.1332 0.7478 0.7340 0.4837 0.0373 0.1272 0.5334 0.0520 0.0080 0.9417 0.0523 0.4174 2.5939 0.0071 2.9801 1.5621 6.6059 2.2328 7.6422

332.7763 38.3972

7.9288 2.1253

5.5128 1.2398 6.7772 7.3552 1.1560 3.9764 1.8011 20.7004

Payment Rate $950.17 $550.12 $40.60 $39.85 $26.26 $2.02 $6.91 $28.96 $2.82 $0.43 $51.12 $2.84 $22.66 $140.82 $0.39 $161.79 $84.80 $358.63 $121.22 $414.89 $397.81 $148.20 $22.80 $144.40 $203.40 $45.31 $18,066.09 $2,084.55 $467.09 $175.16 $14.25 $415.24 $1,135.25 $430.45 $115.38 $142.50 $41.56 $94.46 $299.28 $67.31 $367.93 $399.31 $62.76 $215.87 $97.78 $1,123.80

National Minimum Unadjusted Unadjusted Copayment Copayment $190.03 $110.02 $8.12 $7.97 $5.25 $0.40 $1.38 $5.79 $0.56 $0.09 $10.22 $0.57 $4.53 $28.16 $0.08 $32.36 $16.96 $71.73 $24.24 $82.98 $59.46 $22.15 $3.41 $21.58 $30.40 $6.77 $3,613.22 $416.91 $69.82 $26.18 $2.13 $62.07 $169.69 $86.09 $23.08 $21.30 $6.21 $14.12 $59.86 $13.46 $73.59 $79.86 $12.55 $43.17 $19.56 $224.76

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