[Federal Register Volume 69, Number 3 (Tuesday, January 6, 2004)]
[Rules and Regulations]
[Pages 820-844]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-32322]



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Part IV





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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42 CFR Part 419



Medicare Program; Hospital Outpatient Prospective Payment System; 
Payment Reform for Calendar Year 2004; Interim Final Rule

  Federal Register / Vol. 69, No. 3 / Tuesday, January 6, 2004 / Rules 
and Regulations  

[[Page 820]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 419

[CMS-1371-IFC]
RIN 0938-AM96


Medicare Program; Hospital Outpatient Prospective Payment System; 
Payment Reform for Calendar Year 2004

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Interim final rule with comment period.

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SUMMARY: This interim final rule with comment period implements 
provisions of the Medicare Prescription Drug, Improvement, and 
Modernization Act (DIMA) of 2003 that affect the Medicare outpatient 
prospective payment system (OPPS) that become effective January 1, 
2004. Sections 303 and 621 of the DIMA include provisions that alter 
the methods for drug payment in hospital outpatient departments, some 
of which become effective January 1, 2004. These provisions affect the 
methodology for paying for pass-through and non-pass-through drugs 
under the OPPS. Further, the new law includes a requirement that all 
brachytherapy sources be paid separately. Section 411 of the DIMA 
reinstates the hold-harmless protection for small rural hospitals with 
fewer than 100 beds and extends that protection to sole community 
hospitals in rural areas.

DATES: Effective date: January 1, 2004.
    Comment date: We will consider comments if we receive them at the 
appropriate address, as provided below, no later than 5 p.m. on March 
8, 2004.

ADDRESSES: In commenting, please refer to file code CMS-1371-IFC. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission or e-mail.
    Mail written comments (one original and two copies) to the 
following address ONLY: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-1371-IFC, P.O. 
Box 8018, Baltimore, MD 21244-8018.
    Please allow sufficient time for mailed comments to be timely 
received in the event of delivery delays.
    If you prefer, you may deliver (by hand or courier) your written 
comments (one original and two copies) to one of the following 
addresses: Room 445-G, Hubert H. Humphrey Building, 200 Independence 
Avenue, SW., Washington, DC 20201, or Room C5-14-03, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    (Because access to the interior of the HHH Building is not readily 
available to persons without Federal Government identification, 
commenters are encouraged to leave their comments in the CMS drop slots 
located in the main lobby of the building. A stamp-in clock is 
available for persons wishing to retain a proof of filing by stamping 
in and retaining an extra copy of the comments being filed.)
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and could be considered late.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Dana Burley, (410) 786-0378.

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: Comments 
received timely will be available for public inspection as they are 
received, generally beginning approximately 3 weeks after publication 
of a document, at the headquarters of the Centers for Medicare & 
Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, 
Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule 
an appointment to view public comments, call (410) 786-7195.

Availability of Copies and Electronic Access

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I. Background

A. Authority for the Outpatient Prospective Payment System

    When the Medicare statute was originally enacted, Medicare payment 
for hospital outpatient services was based on hospital-specific costs. 
In an effort to ensure that Medicare and its beneficiaries pay 
appropriately for services and to encourage more efficient delivery of 
care, the Congress mandated replacement of the cost-based payment 
methodology with a prospective payment system (PPS). The Balanced 
Budget Act of 1997 (BBA) (Pub. L. 105-33), enacted on August 5, 1997, 
added section 1833(t) to the Social Security Act (the Act) authorizing 
implementation of a PPS for hospital outpatient services. The Balanced 
Budget Refinement Act of 1999 (BBRA) (Pub. L. 106-113), enacted on 
November 29, 1999, made major changes that affected the hospital 
outpatient PPS (OPPS). The Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106-554), 
enacted on December 21, 2000, made further changes in the OPPS. The 
OPPS was first implemented for services furnished on or after August 1, 
2000.
    The Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003 (DIMA) (Pub. L. 108-173), enacted on December 8, 2003, made 
additional changes to the Act relating to the OPPS and calendar year 
2004 payment rates to be implemented January 1, 2004.
    We would ordinarily publish a notice of proposed rulemaking in the 
Federal Register and invite public comment on the proposed rule. This 
procedure can be waived, however, if an agency finds good cause that a 
notice-and-comment procedure is impracticable, unnecessary, or contrary 
to the public interest and incorporates a statement of the finding and 
its reasons in the rule issued. We find good cause to waive notice and 
comment procedures for this correction notice as set forth in section 
IV, ``Waiver of Proposed Rulemaking and Waiver of 30-Day Delay in the 
Effective Date,'' below.

B. Summary of Relevant Provisions of the DIMA

    The DIMA, enacted December 8, 2003, made the following changes to 
the Act that relate to the OPPS:
1. Transitional Corridor Payments Extended
    Section 411 of the DIMA amends section 1833(t)(7)(D)(i) of the Act 
and extends the hold-harmless provision for small rural hospitals. The 
hold harmless

[[Page 821]]

transitional corridor payments will continue through December 31, 2005 
for small rural hospitals having 100 or fewer beds. Section 411 of the 
DIMA further amends section 1833(t)(7) of the Act to provide that hold-
harmless transitional corridor payments shall apply to sole community 
hospitals as defined in section 1886(d)(5)(D)(iii) of the Act and will 
continue through December 31, 2005.
2. Payment for ``Specified Covered Outpatient Drugs''
    Section 621(a)(1) of the DIMA amends the Act by adding section 
1833(t)(14) that requires classification of separately paid 
radiopharmaceutical agents and drugs or biologicals that had 
transitional pass-through status on or before December 31, 2002, into 3 
categories: innovator multiple source drugs; noninnovator multiple 
source drugs; and sole source drugs. Payment levels based on the 
reference average wholesale price are specified for each category.
3. Payment for Drug or Biological Before HCPCS Code Assigned
    Section 621(a)(1) of the DIMA amends the Act by adding section 
1833(t)(15), which requires that payment be made at 95 percent of the 
average wholesale price (AWP) for new drugs and biologicals until a 
HCPCS code is assigned.
4. Payment for Pass-Through Drugs
    Section 303(b) of the DIMA amends section 1842(o) of the Act. As a 
result, certain pass-through drugs are to be paid at 95 percent, and 
others at 85 percent, of the AWP. Drugs and biologicals furnished 
during 2004 for which pass-through payment was first made on or after 
January 1, 2003 (which removes them from application of section 621 of 
the DIMA) and were approved by the FDA for marketing as of April 1, 
2003, will be paid 85 percent of AWP pursuant to section 1842(o)(1)(B) 
and 1842(o)(4)(A), unless sections 1842(o)(4)(B), (C) or (D) apply. 
Blood clotting factors furnished during 2004, drugs or biologicals 
furnished during 2004 that were not available for payment as of April 
1, 2003, vaccines furnished on or after January 1, 2004, and drugs or 
biologicals furnished during 2004 in connection with the renal dialysis 
services if billed by renal dialysis facilities, are paid at 95 percent 
of the reference AWP. Drugs or biologicals that were paid on a pass-
through basis under the OPPS on or after January 1, 2003 and that were 
available for payment as of April 1, 2003 are paid at 85 percent of the 
reference AWP rather than 95 percent as was previously the policy under 
section 1842(o) of the Act.
5. Exclude Separately Payable Drugs and Biologicals From Outlier 
Payments
    Section 621(a)(3) amends section 1833(t)(5) of the Act to require 
that separately paid drugs and biologicals be excluded from outlier 
payments.
6. Brachytherapy Sources Are To Be Paid Separately
    Section 621(b) amends the Act by adding section 1833(t)(16)(C) 
which requires that all devices of brachytherapy consisting of a seed 
or seeds (or radioactive source) be paid based on the hospital's charge 
for each device adjusted to cost. Also included in the new provision is 
a requirement that all such brachytherapy sources be excluded from 
outlier payments.

Payment Methodology That Applied Prior To Enactment

    In the hospital outpatient prospective payment update final rule 
published in the Federal Register on November 7, 2003, CMS announced 
payments for 2004 under the Medicare hospital outpatient prospective 
payment system (68 FR 63398). The provisions of that final rule with 
regard to payment for brachytherapy sources, for separately payable 
drugs, biologicals and radiopharmaceutical agents and for pass-through 
drugs and biologicals is superceded in part with enactment of the DIMA, 
effective for services furnished on or after January 1, 2004. This 
interim final rule with comment presents the payment amounts that apply 
in 2004 that result from the changes made by DIMA.
    The following is a summarization of the payment policies that we 
published for the 2004 OPPS before enactment of the new law.
    Drugs and biologicals that were within the 2-3 year pass-through 
payment period were paid amounts as specified in section 1842(o) of the 
Act. Under the November 7 final rule, that payment was 95 percent of 
AWP.
    Under the provisions of the November 7 OPPS final rule, payment for 
non-pass-through drugs, biologicals and radiopharmaceutical agents with 
per day median costs greater than $50 was based on data compiled from 
hospital claims submitted on or after April 1, 2002 through December 
31, 2002. Those data were used to set median costs which were converted 
to relative weights, scaled for budget neutrality, and multiplied by 
the 2004 conversion factor, the same methodology used to set relative 
weights for procedural ambulatory payment classifications (APCs) under 
the OPPS. A detailed discussion of the rate setting methodology for the 
2004 OPPS update is provided in the November 7, 2003 final rule (68 FR 
63416).
    Payment for drugs, biologicals and radiopharmaceutical agents that 
had per day median costs less than $50 and drugs, biologicals and 
radiopharmaceutical agents for which there was no HCPCS code, was 
included in the rate for the service in which the item was used. There 
were no separate payments for these drugs, biologicals and 
radiopharmaceutical agents.

Changes Required Under the DIMA

    a. Changes in Payment for ``specified covered outpatient drugs'': 
radiopharmaceutical agents and drugs or biologicals that were paid as 
pass-throughs under the OPPS on or before December 31, 2002. The DIMA 
amends the Act by adding section 1833(t)(14) which states that payment 
for specified covered outpatient drugs is to be based on its 
``reference average wholesale price,'' that is, the average wholesale 
price for the drug as determined under section 1842(o) of the Act as of 
May 1, 2003 (1833(t)(14)(G)).
    Under new section 1833(t)(14)(B)(i) a ``specified covered 
outpatient drug'' is a covered outpatient drug as defined in 1927(k)(2) 
of the Act, for which a separate ambulatory payment classification 
group (APC) exists and that is a radiopharmaceutical agent or a drug or 
biological for which payment was made on a pass-through basis on or 
before December 31, 2002.
    Under section 1833(t)(14)(B)(ii) of the Act, certain drugs and 
biologicals are designated as exceptions, which are not included in the 
definition of ``specified covered outpatient drugs.'' These exceptions 
are the following:
    [sbull] A drug or biological for which payment is first made on or 
after January 1, 2003 under the transitional pass-through payment 
provision in section 1833(t)(6) of the Act.
    [sbull] A drug or biological for which a temporary HCPCS code has 
not been assigned.
    [sbull] During 2004 and 2005, an orphan drug (as designated by the 
Secretary).
    Section 1833(t)(14)(A)(i) specifies payment limits for 3 categories 
of ``specified covered outpatient drugs'' in 2004. Section 
1833(t)(14)(F) defines the 3 categories of ``specified covered 
outpatient drugs'' based on sections 1861(t)(1) and 1927(k)(7)(A)(ii), 
(iii) and (iv) of the Act. The categories of drugs are ``sole source 
drugs'', ``innovator multiple source drugs'' and ``noninnovator 
multiple source drugs.''

[[Page 822]]

    b. Definitions and payment rates for DIMA-specified categories for 
drugs, biologicals, and radiopharmaceutical agents. Section 1927(k) of 
the Act pertains to the Medicaid drug rebate program. In order to 
administer the Medicaid drug rebate program, CMS gathers information 
from manufacturers and classifies drugs into categories that are 
defined in sections 1927(k)(7)(A)(ii), (iii) and (iv) of the Act. We 
are using these category designations to guide our classification of 
covered OPPS drugs in order to implement the changes in payment under 
the OPPS that are required by DIMA in section 1833(t)(14) of the Act. 
The classifications are listed in the Medicaid average manufacturer 
price (AMP) database, which can be found at http://www.cms.gov/medicaid/drugs/drug6.asp. In cases when the AMP database does not 
provide a classification for an affected drug or biological, we relied 
on our clinical and pharmaceutical experts to determine the appropriate 
classification. Further, when there are conflicting or incomplete 
designations in the AMP, we assigned drugs to the noninnovator 
multiple-source category for payment effective January 1, 2004, until 
we can resolve the conflicts and make a definitive classification. 
Classification changes will be implemented April 1, 2004 effective for 
services furnished on or after January 1, 2004. We invite comments 
regarding the appropriate classification of the drugs listed in Table 
2.
    The Medicaid AMP database is updated on a quarterly basis. However, 
we believe that midyear changes in the classification of drugs could be 
confusing and burdensome for providers to administer. Therefore, the 
final category designations used to determine 2004 OPPS drug payments 
for the ``specified covered outpatient drugs'' to which section 
1833(t)(14)(A)(i) of the Act applies, will remain in effect through 
December 31, 2004. We will update the category designations through 
rulemaking as part of the annual OPPS update for 2005.
    The sole source category is defined in section 1833(t)(14)(F)(i) of 
the Act as a biological product (as defined under section 1861(t)(1) of 
the Act) or a single source drug (as defined in section 
1927(k)(7)(A)(iv)) of the Act). Section 1927(k)(7)(A)(iv) of the Act 
defines the term ``single source drug'' to mean a covered outpatient 
drug which is produced or distributed under an original new drug 
application (NDA) approved by the Food and Drug Administration (FDA), 
including a drug product marketed by any cross-licensed producers or 
distributors operating under the NDA. Based on this definition, in 
effect, single source drugs are brand name drugs for which there is no 
FDA generic approval, and the term is used interchangeably with ``sole 
source drug'' in this preamble.
    Section 621(a) of the DIMA, amends the Act by adding section 
1833(t)(14)(A)(i)(I), which provides that a sole source drug shall, in 
2004, be paid no less than 88 percent and no more than 95 percent of 
the reference AWP.
    Innovator multiple source drugs are defined in section 
1833(t)(14)(F)(ii) of the Act according to the definition provided in 
section 1927(k)(7)(A)(ii) of the Act. Section 1927(k)(7)(A)(ii) of the 
Act defines an innovator multiple source drug as a multiple source drug 
that was originally marketed under an original NDA approved by the FDA. 
Under this definition, these drugs were originally sole source drugs 
for which FDA subsequently approved a generic alternative(s). An 
innovator multiple source drug first must be a sole source drug.
    Section 621(a) of the DIMA, amends the Act by adding section 
1833(t)(14)(A)(i)(II), which provides that an innovator multiple source 
drug shall, in 2004, be paid no more than 68 percent of the reference 
AWP.
    Section 1833(t)(14)(F)(III) defines a noninnovator multiple source 
drug according to the definition of the term in 1927(k)(7)(A)(iii). 
Section 1927(k)(7)(A)(iii) defines noninnovator multiple source drug as 
a multiple source drug that is not an innovator multiple source drug. 
Under this definition, noninnovator multiple source drugs are, in 
effect, generic drugs approved by the FDA.
    Section 621(a) of the DIMA, amends the Act by adding section 
1833(t)(14)(A)(i)(III), which provides that a noninnovator multiple 
source drug shall, in 2004, be paid no more than 46 percent of the 
reference AWP.
    There are several drugs that are classified in the AMP database as 
qualifying for all three categories. A drug that meets the criteria for 
all 3 categories has FDA approval as an innovator drug. A generic 
version of the drug, the noninnovator, also has received FDA approval. 
In addition, there is an FDA approval for a different indication for 
use under a different NDA for which the drug is the sole source. When a 
single drug, biological or radiopharmaceutical agent that meets the 
definition of a single HCPCS code qualifies for all of the 3 categories 
in the AMP file, we are recognizing the product only as an innovator 
multiple source and noninnovator multiple source drug. That is, once a 
drug qualifies as a multiple source drug, we will not recognize it as a 
sole source drug for payment under the OPPS. We believe that it would 
be impossible to operationalize a system in which the same drug would 
be paid differently according to the clinical indication for its use. 
Medicare makes payment for a drug or biological that is reasonable and 
necessary to treat an illness or disease. Medicare does not base 
payment for drugs and biologicals according to their indicated uses, 
except when required by a national coverage decision. Further, to do so 
would circumvent the payment limitation that the law requires for 
drugs, biologicals and radiopharmaceutical agents that have generic 
competition by allowing payment for a drug that has generic competition 
at the sole source rate (88 to 95 percent of AWP) rather than at the 
limit for innovator multiple source (68 percent of AWP) or noninnovator 
multiple source (46 percent of AWP) drugs.
    c. Definition of ``reference AWP'' and determination of payment 
amounts. Section 1833(t)(14)(G) of the Act defines reference AWP as the 
AWP determined under section 1842(o) as of May 1, 2003. We interpret 
this to mean the AWP set under the CMS single drug pricer (SDP) based 
on prices published in the Red Book on May 1, 2003.
    We determined the payment amount for specified covered outpatient 
drugs under the provisions of the DIMA by comparing the payment amount 
calculated under the median cost methodology in effect prior to 
enactment of the DIMA to the percentages specified in new section 
1833(t)(14)(A) of the Act.
    Specifically, for sole source drugs, we compared the payments 
established in the November 7, 2003 final rule for the HCPCS code for 
the drug to its reference AWP. When the payment fell below 88 percent 
of the reference AWP, we increased the payment to 88 percent of the 
reference AWP. When the payment exceeded 95 percent of the reference 
AWP, we reduced the payment to 95 percent of the reference AWP. When 
the payment was no lower than 88 percent and no higher than 95 percent 
of reference AWP, we made no change. To receive payment for sole source 
drugs on or after January 1, 2004, hospitals should continue to bill 
the appropriate HCPCS code for the drug. Table 1 lists the payment 
amounts for sole source drugs, biologicals and radiopharmaceutical 
agents effective January 1, 2004 through December 31, 2004.

[[Page 823]]

    There are a few drugs for which we cannot find an AWP rate. We are 
working to resolve this on a case-by-case basis for each of the drugs. 
The drugs are: Technetium TC 99M Sodium Glucoheptonate (C1200), Cobalt 
Co 57 cobaltous chloride (C9013), I-131 tositumomab, diagnostic (C1080) 
and I-131 tositumomab, therapeutic (C1081).
    With regard to C1080 and C1081, there is no AWP available because 
this drug did not receive FDA approval until June, 2003 and so could 
not be in the May 1, 2003 Red Book (AWP) that we have identified as the 
source of the reference AWP. We presented an in-depth discussion of our 
policy for payment of this drug, Bexxar, in our November 7 final rule. 
In that rule we explain our rationale for making payment for Bexxar 
parallel to that for another radiopharmaceutical called Zevalin. In 
order to set the payment rate for Bexxar in accordance with DIMA, we 
also have adhered to the policy regarding the pricing of Bexxar 
established in the November 7 final rule.
    For the remaining drugs for which we could not identify a May 1, 
2003 AWP amount, we will continue our research to find an AWP. If we 
are able to identify the AWP established on dates other than May 1, 
2003, we will use whichever is closest to May 2003. In the interim, we 
will implement the payment rates published in the November 7 final rule 
to make payments for these drugs for January 1, 2004 through March 31, 
2004. We will address our findings regarding development of payment 
rates for these drugs in our April update.
    APC 9024 is made up of 3 sole source drugs: Amphotericin B lipid 
complex (J0287); Amphotericin B cholesteryl sulfate (J0288); and 
Amphotericin B liposome injection (J0289). To comply with the statute, 
these 3 drugs must all be paid separately under the OPPS and that will 
require that we create an APC for each of the drugs. Due to the limited 
time available to implement the changes required for January 1, 2004, 
we will not be able to implement the new APCs until April 1, 2004. We 
will continue to pay for these drugs in APC 9024 at the rate published 
in the November 7 final rule. The new APCs will be implemented April 1, 
2004 and will be effective for services furnished on or after January 
1, 2004.

                                           Table 1.--Sole Source Drugs
----------------------------------------------------------------------------------------------------------------
                                                                                   OPPS CY 2004
          HCPCS              Status indicator         Description          APC      November 7,     DIMA final
                                                                                     2003 rate         rate
----------------------------------------------------------------------------------------------------------------
A4642....................  K                    Satumomab pendetide per     0704         $124.46       $1,474.00
                                                 dose.
A9500....................  K                    Technetium TC 99m           1600           64.28          112.73
                                                 sestamibi.
A9502....................  K                    Technetium TC99M            0705           58.06          665.28
                                                 tetrofosmin.
A9507....................  K                    Indium/111 capromab         1604          687.71        2,030.60
                                                 pendetid.
A9511....................  K                    Technetium TC 99m           1095           37.87          704.00
                                                 depreotide.
A9521....................  K                    Technetiumtc-99m            1096          210.65          825.00
                                                 exametazine.
A9524....................  K                    Iodinated I-131             9100            0.36           48.58
                                                 serumalbumin, per 5uci.
A9600....................  K                    Strontium-89 chloride..     0701          402.85          892.43
C1079....................  K                    CO 57/58 per 0.5 uCi...     1079           68.51          235.14
C1080....................  K                    I-131 tositumomab, dx..     1080        2,260.00        2,565.55
C1081....................  K                    I-131 tositumomab, tx..     1081       19,565.00       22,210.19
C1082....................  K                    In-111 ibritumomab          9118        2,260.00        2,565.55
                                                 tiuxetan.
C1083....................  K                    Yttrium 90 ibritumomab      9117       19,565.00       22,210.19
                                                 tiuxetan.
C1092....................  K                    IN 111 pentetate per        1092          217.45          237.60
                                                 0.5 mCi.
C1122....................  K                    Tc 99M ARCITUMOMAB PER      1122          534.77        1,144.00
                                                 VIAL.
C1166....................  K                    CYTARABINE LIPOSOMAL,       1166          278.99          344.08
                                                 10 mg.
C1167....................  K                    EPIRUBICIN HCL, 2 mg...     1167           20.43           25.60
C1178....................  K                    BUSULFAN IV, 6 Mg......     1178          299.70           27.87
C1200....................  K                    TC 99M Sodium               1200           30.28           30.28
                                                 Glucoheptonat.
C1201....................  K                    TC 99M SUCCIMER, PER        1201           80.24          125.66
                                                 Vial.
C1305....................  K                    Apligraf...............     1305          822.19        1,199.00
C9003....................  K                    Palivizumab, per 50 mg.     9003          344.15          611.24
C9008....................  K                    Baclofen Refill Kit-        9008            6.90           73.92
                                                 500mcg.
C9009....................  K                    Baclofen Refill Kit-        9009           40.92           40.92
                                                 2000mcg.
C9010....................  K                    Baclofen Refill Kit--       9010           42.22           79.82
                                                 4000mcg.
C9109....................  K                    Tirofiban hcl, 6.25 mg.     9109          118.60          218.33
C9202....................  K                    Octafluoropropane......     9202          118.60          137.28
J0130....................  K                    Abciximab injection....     1605          289.44          475.22
J0207....................  K                    Amifostine.............     7000          289.40          419.59
J0287....................  K                    Amphotericin b lipid        9024           20.86           20.86
                                                 complex.
J0288....................  K                    Ampho b cholesteryl         9024           20.86           20.86
                                                 sulfate.
J0289....................  K                    Amphotericin b liposome     9024           20.86           20.86
                                                 inj.
J0350....................  K                    Injection anistreplase      1606        1,516.46        2,495.31
                                                 30 u.
J0585....................  K                    Botulinum toxin a per       0902            3.21            4.58
                                                 unit.
J0587....................  K                    Botulinum toxin type B.     9018            6.98            8.14
J0637....................  K                    Caspofungin acetate....     9019           29.64           30.52
J0850....................  K                    Cytomegalovirus imm IV /    0903          291.18          659.60
                                                 vial.
J1327....................  K                    Eptifibatide injection.     1607            7.99           11.88
J1438....................  K                    Etanercept injection...     1608          102.37          143.73
J1440....................  K                    Filgrastim 300 mcg          0728          123.48          172.20
                                                 injection.
J1441....................  K                    Filgrastim 480 mcg          7049          175.96          290.93
                                                 injection.
J1565....................  K                    RSV-ivig...............     0906           48.61           16.55
J1626....................  K                    Granisetron HCl             0764            5.70           17.18
                                                 injection.
J1830....................  K                    Interferon beta-1b /        0910          100.51           67.22
                                                 .25 MG.
J1950....................  K                    Leuprolide acetate /        0800          182.92          479.20
                                                 3.75 MG.

[[Page 824]]

 
J2020....................  K                    Linezolid injection....     9001           15.12           34.09
J2353....................  K                    Octreotide injection,       1207           65.74           73.62
                                                 depot.
J2354....................  K                    Octreotide inj, non-        7031            1.44            3.94
                                                 depot.
J2788....................  K                    Rho d immune globulin       9023            1.69           32.21
                                                 50 mcg.
J2790....................  K                    Rho d immune globulin       0884           10.16           92.93
                                                 inj.
J2792....................  K                    Rho(D) immune globulin      1609            9.76           19.03
                                                 h, sd.
J2820....................  K                    Sargramostim injection.     0731           16.32           26.92
J2941....................  K                    Somatropin injection...     7034           41.18          297.79
J2993....................  K                    Reteplase injection....     9005          568.33        1,263.90
J3100....................  K                    Tenecteplase injection.     9002        1,296.75        2,492.60
J3245....................  K                    Tirofiban hydrochloride     7041          227.85          436.66
J3305....................  K                    Inj trimetrexate            7045           61.36          132.00
                                                 glucoronate.
J3395....................  K                    Verteporfin injection..     1203          897.20        1,350.80
J7191....................  K                    Factor VIII (porcine)..     0926            1.52            1.89
J7195....................  K                    Factor IX recombinant..     0932            1.01            1.04
J7320....................  K                    Hylan G-F 20 injection.     1611          123.46          215.97
J7504....................  K                    Lymphocyte immune           0890          127.89          258.17
                                                 globulin.
J7505....................  K                    Monoclonal antibodies..     7038          320.84          792.33
J7507....................  K                    Tacrolimus oral per 1       0891            1.34            3.24
                                                 MG.
J7511....................  K                    Antithymocyte globuln       9104          163.56          331.23
                                                 rabbit.
J7520....................  K                    Sirolimus, oral........     9020            2.89            6.60
J7525....................  K                    Tacrolimus injection...     9006            5.72          110.04
J8510....................  K                    Oral busulfan..........     7015            1.57            1.93
J8520....................  K                    Capecitabine, oral, 150     7042            1.65            3.14
                                                 mg.
J8700....................  K                    Temozolmide............     1086            3.76            6.81
J9001....................  K                    Doxorubicin hcl             7046          256.34          364.49
                                                 liposome inj.
J9010....................  K                    Alemtuzumab injection..     9110          424.88          541.46
J9017....................  K                    Arsenic trioxide.......     9012           26.91           34.32
J9020....................  K                    Asparaginase injection.     0814           16.13           58.00
J9045....................  K                    Carboplatin injection..     0811           86.47          137.79
J9098....................  K                    Cytarabine liposome....     1166          278.99          344.08
J9151....................  K                    Daunorubicin citrate        0821          163.55           64.60
                                                 liposom.
J9170....................  K                    Docetaxel..............     0823          220.97          331.53
J9178....................  K                    Inj, epirubicin hcl, 2      1167           20.43           25.60
                                                 mg.
J9185....................  K                    Fludarabine phosphate       0842          205.74          329.83
                                                 inj.
J9201....................  K                    Gemcitabine HCl........     0828           80.43          112.09
J9202....................  K                    Goserelin acetate           0810          285.16          413.59
                                                 implant.
J9206....................  K                    Irinotecan injection...     0830          100.55          135.00
J9213....................  K                    Interferon alfa-2a inj.     0834           20.61           32.31
J9214....................  K                    Interferon alfa-2b inj.     0836           10.93           13.78
J9215....................  K                    Interferon alfa-n3 inj.     0865           79.65            8.17
J9216....................  K                    Interferon gamma 1-b        0838          180.15          290.70
                                                 inj.
J9217....................  K                    Leuprolide acetate          9217          312.37          576.47
                                                 suspnsion.
J9219....................  K                    Leuprolide acetate          7051        3,666.71        5,001.92
                                                 implant.
J9245....................  K                    Inj melphalan hydrochl      0840          254.90          389.14
                                                 50 MG.
J9268....................  K                    Pentostatin injection..     0844          965.98        1,784.64
J9270....................  K                    Plicamycin                  0860           15.42           86.89
                                                 (mithramycin) inj.
J9293....................  K                    Mitoxantrone hydrochl /     0864          173.68          332.87
                                                 5 MG.
J9310....................  K                    Rituximab cancer            0849          306.40          464.20
                                                 treatment.
J9320....................  K                    Streptozocin injection.     0850           65.19          131.05
J9350....................  K                    Topotecan..............     0852          433.41          739.80
J9355....................  K                    Trastuzumab............     1613           40.56           53.85
J9357....................  K                    Valrubicin, 200 mg.....     1614          461.78          487.87
J9390....................  K                    Vinorelbine tartrate/10     0855           64.79          100.97
                                                 mg.
J9600....................  K                    Porfimer sodium........     0856        1,594.30        2,411.82
Q0136....................  K                    Non esrd epoetin alpha      0733            9.83           11.76
                                                 inj.
Q0137....................  K                    Darbepoetin alfa, non       0734            3.24            3.88
                                                 esrd.
Q0166....................  K                    Granisetron HCl 1 mg        0765           34.49          171.78
                                                 oral.
Q0180....................  K                    Dolasetron mesylate         0763           41.00          152.38
                                                 oral.
Q0187....................  K                    Factor viia recombinant     1409        1,083.93        1,495.30
Q2003....................  K                    Aprotinin, 10,000 kiu..     7019            1.17           13.26
Q2005....................  K                    Corticorelin ovine          7024          224.91          375.00
                                                 triflutat.
Q2006....................  K                    Digoxin immune fab          7025          271.14            1.79
                                                 (ovine).
Q2007....................  K                    Ethanolamine oleate 100     7026           27.82           67.10
                                                 mg.
Q2008....................  K                    Fomepizole, 15 mg......     7027            7.23           10.65
Q2009....................  K                    Fosphenytoin, 50 mg....     7028            4.88            5.63
Q2011....................  K                    Hemin, per 1 mg........     7030            0.64            6.86
Q2013....................  K                    Pentastarch 10%             7040           26.40          139.94
                                                 solution.
Q2017....................  K                    Teniposide, 50 mg......     7035          137.41          238.49

[[Page 825]]

 
Q2018....................  K                    Urofollitropin, 75 iu..     7037           63.48           63.48
Q3000....................  K                    Rubidium-Rb-82.........     9025          143.89          162.63
Q3003....................  K                    Technetium tc99m            1620          183.69          392.93
                                                 bicisate.
Q3005....................  K                    Technetium tc99m            1622           20.63        1,650.00
                                                 mertiatide.
Q3008....................  K                    Indium 111-in               1625          449.84        1,144.00
                                                 pentetreotide.
Q4052....................  K                    Octreotide injection,       1207           65.74           73.62
                                                 depot.
----------------------------------------------------------------------------------------------------------------


                                           Table 2.--Multisource Drugs
----------------------------------------------------------------------------------------------------------------
                                                                                   OPPS CY 2004
          HCPCS              Status indicator         Description          APC      November 7,     DIMA final
                                                                                     2003 rate         rate
----------------------------------------------------------------------------------------------------------------
A9505....................  K                    Thallous chloride TL        1603          $19.89          $18.29
                                                 201/mci.
A9508....................  K                    Iobenguane sulfate I-       1045          165.82          165.82
                                                 131, per 0.5 mCi.
A9517....................  K                    Th I131 so iodide cap       1064            5.48            5.48
                                                 millic.
A9528....................  K                    Dx I131 so iodide cap       1064            5.48            5.48
                                                 millic.
A9529....................  K                    Dx I131 so iodide sol       1065            6.49            6.49
                                                 millic.
A9530....................  K                    Th I131 so iodide sol       1065            6.49            6.49
                                                 millic.
A9605....................  K                    Samarium sm153              0702          874.44          493.89
                                                 lexidronamm.
C1091....................  K                    IN111 oxyquinoline,         1091          224.52          224.52
                                                 per0.5mCi.
C1775....................  K                    FDG, per dose (4-40 mCi/    1775          324.48          324.48
                                                 ml).
C9013....................  K                    Co 57 cobaltous             9013           56.67           56.67
                                                 chloride.
C9105....................  K                    Hep B imm glob, per 1       9105           71.33           65.58
                                                 ml.
J1190....................  K                    Dexrazoxane HCl             0726          112.48          112.48
                                                 injection.
J1563....................  K                    Immune globulin, 1 g...     0905           43.96           37.95
J1564....................  K                    Immune globulin 10 mg..     9021            0.44            0.41
J1745....................  K                    Infliximab injection...     7043           38.86           31.81
J1825....................  K                    Interferon beta-1a.....     0909          184.79          123.77
J2430....................  K                    Pamidronate disodium /      0730          174.32          128.74
                                                 30 MG.
J7190....................  K                    Factor viii............     0925            0.51            0.42
J7192....................  K                    Factor viii recombinant     0927            1.01            0.61
J7193....................  K                    Factor IX non-              0931            0.51            0.51
                                                 recombinant.
J7194....................  K                    Factor ix complex......     0928            0.51            0.18
J7198....................  K                    Anti-inhibitor.........     0929            1.01            0.69
J7310....................  K                    Ganciclovir long act        0913           86.54           86.54
                                                 implant.
J7317....................  K                    Sodium hyaluronate          7316          138.78           67.16
                                                 injection.
J7502....................  K                    Cyclosporine oral 100       0888            2.56            2.41
                                                 mg.
J7517....................  K                    Mycophenolate mofetil       9015            2.04            1.36
                                                 oral.
J8560....................  K                    Etoposide oral 50 MG...     0802           27.37           21.91
J9000....................  K                    Doxorubic hcl 10 MG vl      0847            6.61            4.69
                                                 chemo.
J9031....................  K                    Bcg live intravesical       0809          103.75           77.54
                                                 vac.
J9040....................  K                    Bleomycin sulfate           0857          160.56           88.32
                                                 injection.
J9060....................  K                    Cisplatin 10 MG             0813           21.74            7.73
                                                 injection.
J9065....................  K                    Inj cladribine per 1 MG     0858           37.82           24.84
J9070....................  K                    Cyclophosphamide 100 MG     0815            4.74            2.77
                                                 inj.
J9093....................  K                    Cyclophosphamide            0816            4.50            2.36
                                                 lyophilized.
J9100....................  K                    Cytarabine hcl 100 MG       0817            5.07            1.55
                                                 inj.
J9130....................  K                    Dacarbazine 100 mg inj.     0819            5.31            5.31
J9150....................  K                    Daunorubicin...........     0820           73.97           35.94
J9181....................  K                    Etoposide 10 MG inj....     0824            4.56            0.83
J9200....................  K                    Floxuridine injection..     0827          114.19           66.24
J9208....................  K                    Ifosfomide injection...     0831          106.04           72.81
J9209....................  K                    Mesna injection........     0732           28.43           17.66
J9211....................  K                    Idarubicin hcl              0832          178.21          178.21
                                                 injection.
J9218....................  K                    Leuprolide acetate          0861           43.60           14.48
                                                 injection.
J9265....................  K                    Paclitaxel injection...     0863          112.14           79.04
J9280....................  K                    Mitomycin 5 MG inj.....     0862           53.03           30.91
J9340....................  K                    Thiotepa injection.....     0851           59.93           45.31
Q2022....................  K                    VonWillebrandFactr          1618            1.01            0.46
                                                 CmplxperIU.
Q3002....................  K                    Gallium ga 67..........     1619           11.22           11.22
Q3007....................  K                    Sodium phosphate p32...     1624           70.61           66.44
Q3011....................  K                    Chromic phosphate p32..     1628           98.52           81.27
Q3012....................  K                    Cyanocobalamin cobalt       1089           57.07           47.38
                                                 co57.
Q3025....................  K                    IM inj interferon beta      9022           61.60           13.36
                                                 1-a.
----------------------------------------------------------------------------------------------------------------


[[Page 826]]

Coding for Specified Outpatient Drugs

    In order to implement these provisions timely on January 1, 2004, 
we are instructing hospitals to use the existing HCPCS code that 
describes the drug for services furnished on or after January 1, 2004. 
For sole source drugs, the existing HCPCS code is priced in accordance 
with the provisions of section 1833(t)(14)(A)(i) of the Act as 
indicated in Table 1. However, existing HCPCS codes do not allow us to 
differentiate payment amounts for innovator multiple source and 
noninnovator multiple source forms of the drug.
    Therefore, for implementation January 1, 2004, we set payment rates 
for all multiple source innovator and noninnovator drugs, biologicals 
and radiopharmaceutical agents at the lower of the payment rate in the 
November 7, 2003 final rule or 46 percent of the reference AWP. These 
rates are shown in Table 2.
    Initially, we will implement sections 1833(t)(14)(A)(i)(II) and 
(III) of the Act in this manner because we are unable to compile a 
definitive list of the innovator multiple source drugs in time for 
January 1, 2004 implementation. On April 1, 2004, CMS will implement 
new HCPCS codes that providers may use to bill for innovator multiple 
source drugs in order to receive appropriate payment in accordance with 
section 1833(t)(14)(A)(i)(II) of the Act, that is, the payment amount 
established in the November 7, 2003 final rule or 68 percent of the 
reference AWP, whichever is lower. The new codes will be effective 
January 1, 2004 so that providers may submit adjustment bills after 
April 1, 2004 to receive appropriate payment for multiple source 
innovator drugs furnished on or after January 1, 2004 through March 31, 
2004.
    Beginning April 1, 2004, innovator multiple source drugs will be 
paid at the statutory rate as long as the new codes are used. The 
multiple source noninnovator rate will be the default payment rate for 
the existing HCPCS code assigned to the drug, and providers will 
continue to use the current HCPCS codes to bill for noninnovator 
multiple source drugs after March 31, 2004. The new HCPCS codes will be 
very similar to the current codes with only the distinction that the 
drug being billed is an innovator multiple source drug eligible for 
payment of as much as 68 percent of the AWP.
    We recognize that creation and use of a new code to designate a 
drug to be an innovator multiple source drug creates burden for 
hospitals. However, the law provides different payment rules based on 
the category into which the drug falls and therefore, to ensure correct 
payment, hospitals must report a code for the drug that identifies the 
category into which it falls. We request comments on ways that we can 
reduce the reporting burden on hospitals that results from the law's 
imposing different payment limitations on brand name and generic 
versions of the same drug.
    Table 2 lists the drugs for which the new HCPCS codes will be 
implemented April 1, 2004 to distinguish innovator multiple source from 
noninnovator multiple source drugs.

Other changes in payment methodology effective January 1, 2004 as a 
result of enactment of the Medicare Prescription Drug, Improvement and 
Modernization Act of 2003

Payment for Pass-Through Drugs, Biologicals, and Radiopharmaceuticals

    Drugs and biologicals that are within the 2-3 year pass-through 
payment period in 2004 continue to be paid pursuant to section 1842(o) 
of the Act. However, section 1842(o) of the Act has been revised by 
section 303(b) of the DIMA and those revisions change the way that 
these drugs are paid.
    Drugs and biologicals furnished during 2004 that are approved for 
pass-through payment under the OPPS and that were not approved by the 
FDA for marketing as of April 1, 2003 will be paid 95 percent of AWP 
pursuant to section 1842(o)(1)(A)(iii). See Table 3b for a list of 
these pass-through drugs.
    Drugs and biologicals furnished during 2004 for which pass-through 
payment was first made on or after January 1, 2003 (which removes them 
from application of section 621 of the DIMA) and were approved by the 
FDA for marketing as of April 1, 2003, will be paid 85 percent of AWP 
pursuant to section 1842(o)(1)(B) and 1842(o)(4)(A), unless sections 
1842(o)(4)(B), (C) or (D) apply. See Table 3a for a list of these pass-
through drugs.
    Table 3c lists 10 drugs and biologicals with pass-through status in 
2004 that also meet the criteria for ``specified covered outpatient 
drugs'' under section 1833(t)(14). That is, the drugs in Table 3c are 
pass-through drugs in 2004 that were available for payment before April 
1, 2003 and would therefore be paid 85 percent of AWP (determined as of 
April 1, 2003) under the cross reference in section 1833(t)(6)(D)(i) to 
section 1842(o). Separate APCs have been established for these drugs 
and they were paid as pass-through drugs on or before December 31, 
2002. Therefore, these pass-through drugs qualify under section 
1833(t)(14)(B) as ``specified covered outpatient drugs.'' As specified 
covered outpatient drugs, the ten drugs would be categorized as ``sole 
source'' drugs.
    Sole source drugs, under section 1833(t)(14)(A)(i)(I) are paid no 
less than 88 percent nor more than 95 percent of the reference AWP. To 
the extent that the ten drugs listed in Table 3c qualify as both pass-
through drugs and sole source drugs under the DIMA, it appears that 
they are subject to two different payment provisions. We have 
reconciled the two apparently conflicting payment provisions in a way 
that we believe results in the fewest anomalies. The drugs will retain 
their pass-through status, and therefore, the rules and policies that 
otherwise apply to pass-through drugs continue to apply to them. They 
will also be considered sole source drugs for purposes of section 
1833(t)(14). We will pay for the drugs as follows.
    First, because the drugs are pass-through drugs, we will give them 
pass-through payments. The pass-through payments will equal 85 percent 
of AWP (determined as of April 1, 2003) under section 1833(t)(6)(D)(i). 
However, because the drugs are also sole source drugs, we will also 
apply the payment methodology set forth in section 
1833(t)(14)(A)(i)(I), and raise the payment to 88 percent of the 
reference AWP (the AWP determined as of May 1, 2003).
    Under the payment methodology that we are applying to sole source 
drugs, we look at the payment that would otherwise be made and if it is 
less than 88 percent or greater than 95 percent of reference AWP, we 
adjust it as minimally as necessary to ensure that it is within the 
required range. In the case of these drugs, absent the provisions of 
1833(t)(14)(i)(I), we would pay 85 percent of AWP (determined as of 
April 1, 2003). Therefore adjusting the payment that would otherwise be 
made results in payment at 88 percent of reference AWP.
    In light of the total revamping of the methodology for payment for 
drugs and biologicals under OPPS, we revisited the adjustment that we 
made under our authority in section 1833(t)(2)(E) of the Act to ensure 
equitable payments in 2003 and in the November 7 final rule for the 
2004 update of the OPPS. After considering the nature of the DIMA 
payment changes, we have concluded that it is still appropriate to 
apply this adjustment to the methodology discussed in the previous two 
paragraphs for the reasons we stated in the OPPS rulemaking during the 
past two years. Therefore, for darbepoetin alpha (Q0137 and C1774), we 
are

[[Page 827]]

making an adjustment in accordance with section 1833(t)(2)(E) of the 
Act (which was unaffected by DIMA) to the combined pass-through amount 
and 3 percent additional payment provided under section 
1833(t)(14)(A)(i)(I) of DIMA, resulting in a payment rate of $3.88 per 
unit. This payment rate is budget neutral.

                             Table 3a.--Pass-Through Drugs Reimbursed at 85% of AWP
----------------------------------------------------------------------------------------------------------------
                                                                                   2004 Payment      2004 Co-
               HCPCS                   APC             Long description               amount      payment amount
----------------------------------------------------------------------------------------------------------------
J9395..............................     9120  Injection, Fulvestrant, per 25 mg.          $78.36          $13.09
C9121..............................     9121  Injection, Argotroban, per 5 mg...           14.63            2.44
C9123..............................     9123  TransCyte, per 247 sq cm..........          689.78          115.23
C9205..............................     9205  Injection, Oxaliplatin, per 5 mg..            8.45            1.41
C9203..............................     9203  Injection, Perflexane lipid                 127.50           21.30
                                               microspheres, per single use vial.
J3315..............................     9122  Injection, Triptorelin pamoate,             356.66           59.58
                                               per 3.75 mg.
J3486..............................     9204  Injection, Ziprasidone mesylate,             18.60            3.11
                                               per 10 mg.
C9211..............................     9211  Injection, IV, Alefacept, per 7.5           595.00           99.40
                                               mg.
C9212..............................     9212  Injection, IM, Alefacept, per 7.5           422.88           70.65
                                               mg.
----------------------------------------------------------------------------------------------------------------


                                Table 3b.--Pass-Through Drugs Paid at 95% of AWP
----------------------------------------------------------------------------------------------------------------
               HCPCS                   APC             Long description               Amount          Amount
----------------------------------------------------------------------------------------------------------------
C9207..............................     9207  Injection, IV, Bortezomib, per 3.5        1,039.68          155.40
                                               mg.
C9208..............................     9208  Injection, IV, Agalsidase beta,             123.78           18.50
                                               per 1 mg.
C9209..............................     9209  Injection, IV, Laronidase, per 2.9          644.10           96.28
                                               mg.
C9210..............................     9210  Injection, IV, Palonosetron HCI,            307.80           46.01
                                               per 0.25 mg (250 micrograms).
----------------------------------------------------------------------------------------------------------------


                      Table 3c.--Pass-Through Drugs Paid as Sole Source Drugs at 88% of AWP
----------------------------------------------------------------------------------------------------------------
                                                                                    OPPS CY2004
               HCPCS                   APC             Long description             November 7      DIMA final
                                                                                       rate            rate
----------------------------------------------------------------------------------------------------------------
J0583..............................     9111  Injection, Bivalirudin, per 1 mg..           $1.43           $1.61
C9112..............................     9112  Injection, Perflutren lipid                 132.60          137.28
                                               microsphere, per 2 ml.
C9113..............................     9113  Injection, Pantoprazole sodium,              22.44           23.23
                                               per vial.
J1335..............................     9116  Injection, Ertapenem sodium, per             21.24           21.99
                                               500 mg.
J2505..............................     9119  Injection, Pegfilgrastim, per 6 mg        2,507.50        2,596.00
                                               single dose vial.
C9200..............................     9200  Orcel, per 36 sqare centimeters...        1,015.75        1,051.60
C9201..............................     9201  Dermagraft, per 37.5 square                 516.80          535.04
                                               centimeters.
J2324..............................     9114  Injection, Nesiritide, per 0.5 mg.          135.66          140.45
J3487..............................     9115  Injection, Zoledronic acid, per 1           194.52          211.07
                                               mg.
----------------------------------------------------------------------------------------------------------------

Payment for New Drugs and Biologicals Before a HCPCS Code Is Assigned

    Under new section 1833(t)(15) of the Act, as added by section 
621(a)(1) of the DIMA a drug or biological that is furnished as part of 
covered outpatient department services for which a HCPCS codes has not 
been established, is to be paid at 95 percent of the AWP for the drug 
or biological.
    We are in the process of determining how hospitals would bill 
Medicare for a drug prior to assignment of a HCPCS code. We will issue 
instructions once we have determined how to make this requirement 
operational.

Payment for Orphan Drugs as Designated by the Secretary

    Section 1833(t)(14)(C) as added by section 621(a)(1) of the DIMA, 
provides that the amount of payment for orphan drugs designated by the 
Secretary shall, for 2004 and 2005, equal the amount the Secretary 
shall specify. We have determined that single indication orphan drugs 
as designated by the Secretary will be paid at the rates published in 
the November 7, 2003 Federal Register (68 FR 63398). Neither the 
definition nor the 2004 payment amounts for single indication orphan 
drugs under the OPPS have changed from what was published in the 
November 7 final rule.

Brachytherapy

    Section 621(b)(1) of the DIMA of 2003 amends the Act by adding 
section 1833(t)(16)(C) and section 1833(t)(2)(H) which establish 
separate payment for devices of brachytherapy consisting of a seed or 
seeds (or radioactive source) based on a hospital's charges for the 
service, adjusted to cost. Further, charges for the brachytherapy 
devices shall not be used in determining any outlier payments and 
consistent with our practice under OPPS to exclude items paid at cost 
from budget neutrality consideration, these items will be excluded from 
budget neutrality as well. The period of payment under this provision 
is for brachytherapy sources furnished from January 1, 2004 through 
December 31, 2006.
    We will pay for the brachytherapy sources listed in Table 4 on a 
cost basis, as required by the statute. The status indicator for 
brachytherapy sources is changed to ``H.'' The definition of status 
indicator ``H'' is currently for pass-through payment for devices, but 
the brachytherapy sources affected by new sections 1833(t)(16)(C) and 
1833(t)(2)(H) are not pass-through device categories. Therefore, we are 
also changing, for 2004, the definition of payment status indicator 
``H'' to include non-pass-through brachytherapy sources paid for on a 
cost basis. This use of status indicator ``H'' is a pragmatic decision 
that allows us to pay for brachytherapy sources in accordance with new 
section 1833(t)(16)(C) effective January 1, 2004

[[Page 828]]

without having to modify our claims processing systems. We will revisit 
the use and definition of status indicator ``H'' for this purpose for 
the OPPS update for 2005. Table 4 provides a complete listing of the 
HCPCS codes, descriptors, APC assignments and status indicators for 
brachytherapy sources.

  Table 4.--Brachytherapy Sources To Be Paid Separately, Using Charges
                             Reduced to Cost
------------------------------------------------------------------------
                                                              New status
      HCPCS           Descriptor      APC       APC title      indicator
------------------------------------------------------------------------
C1716............  Brachytx            1716  Brachytx         H
                    source, Gold              source, Gold
                    198.                      198.
C1717............  Brachytx            1717  Brachytx         H
                    source, HDR Ir-           source, HDR Ir-
                    192.                      192.
C1718............  Brachytx            1718  Brachytx         H
                    source, Iodine            source, Iodine
                    125.                      125.
C1719............  Brachytx sour,      1719  Brachytx         H
                    Non-HDR Ir-192.           source, Non-
                                              HDR Ir-192.
C1720............  Brachytx            1720  Brachytx         H
                    source,                   source,
                    Paladium 103.             Paladium 103.
C2616............  Brachytx            2616  Brachytx         H
                    source,                   source,
                    Yttrium-90.               Yttrium-90.
C2632............  Brachytx            2632  Brachytx sol, I- H
                    solution, I-              125, per mCi.
                    125, per mCi.
C2633............  Brachytx            2633  Brachytx         H
                    source, Cesium-           source, Cesium-
                    131.                      131.
C2632............  Brachytx sol, I-    2632  Brachytx sol, I- H
                    125, per mCi.             125, per mCi.
------------------------------------------------------------------------

    As indicated in Table 4, brachytherapy source in HCPCS code C1717 
will be paid based on the hospital's charge reduced to cost beginning 
January 1, 2004. Prior to enactment of DIMA, these sources were paid as 
packaged services in APC 0313. As a result of the requirement to pay 
for C1717 separately, we are adjusting the payment rate for APC 0313 to 
reflect the unpackaging of the brachytherapy source. The new rate is 
listed in Addendum A.
    Section 1833(t)(2)(H) is added by section 621(b)(2)(C) of DIMA, 
mandating the creation of separate groups of covered OPD services that 
classify brachytherapy devices separately from other services or groups 
of services. The additional groups shall be created in a manner 
reflecting the number, isotope and radioactive intensity of the devices 
of brachytherapy furnished, including separate groups for palladium-103 
and iodine-125.
    We invite the public to submit recommendations for new codes to 
describe brachytherapy sources in a manner reflecting the number, 
radioisotope, and radioactive intensity of the sources. We request that 
commenting parties provide a detailed rationale to support recommended 
new codes. We will propose appropriate changes in codes for 
brachytherapy sources in the 2005 OPPS update.

Continuation of Transitional Corridor Payments for CY 2004

    Since the inception of the OPPS, providers have been eligible to 
receive additional transitional payments if the payments they received 
under the OPPS were less than the payments they would have received for 
the same services under the payment system in effect before the OPPS. 
Under 1833(t)(7) of the Act, most hospitals that realize lower payments 
under the OPPS received transitional corridor payments based on a 
percent of the decrease in payments. However, rural hospitals having 
100 or fewer beds, as well as cancer hospitals and children's hospitals 
described in section 1886(d)(1)(B)(iii) and (v) of the Act, were held 
harmless under this provision and paid the full amount of the decrease 
in payments under the OPPS.
    Transitional corridor payments were intended to be temporary 
payments to ease providers' transition from the prior cost-based 
payment system to the prospective payment system. In accordance with 
section 1833(t)(7) of the Act, transitional corridor payments were to 
be eliminated January 1, 2004, for all providers other than cancer 
hospitals and children's hospitals. Cancer hospitals and children's 
hospitals are held harmless permanently under the transitional corridor 
provisions of the statute.
    Section 411 of the DIMA amends section 1833(t)(7) of the Act to 
provide that hold harmless transitional corridor payments will continue 
through December 31, 2005 for rural hospitals having 100 or fewer beds.
    Section 411 of the DIMA further amends section 1833(t)(7) of the 
Act to provide that hold harmless transitional corridor payments shall 
apply to sole community hospitals, as defined in section 
1886(d)(5)(D)(iii) of the Act, which are located in rural areas, with 
respect to services furnished during cost reporting periods beginning 
on or after January 1, 2004, and continuing through December 31, 2005. 
For purposes of this provision, a sole community hospital's location in 
a rural area will be determined as it is under the inpatient PPS, in 42 
CFR 412.63(b).

II. Provisions of the Interim Final Rule With Comment Period

    The Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003 (DIMA), enacted December 8, 2003 makes changes to the Social 
Security Act (the Act) relating to calendar year 2004 payments under 
the Hospital Outpatient Prospective Payment System. This interim final 
rule with comment period implements changes resulting from enactment of 
the DIMA that are effective January 1, 2004, as follows:

Transitional Corridor Payments Extended

    Hold harmless transitional corridor payments are continued through 
December 31, 2005 for small rural hospitals having 100 or fewer beds. 
In addition, hold-harmless transitional corridor provisions shall apply 
to sole community hospitals as defined in section 1886(d)(5)(D)(iii) of 
the Act with respect to cost reporting periods beginning on or after 
January 1, 2004 and will continue through December 31, 2005.

Payment for ``Specified Covered Outpatient Drugs''

    Separately paid radiopharmaceutical agents and drugs or biologicals 
that had transitional pass-through status on or before December 31, 
2002, are classified into 3 categories: innovator multiple source 
drugs; noninnovator multiple source drugs; and sole source drugs. 
Payment levels based on the reference average wholesale price as of May 
1, 2003 are specified for each category.

Payment for Pass-Through Drugs

    Drugs and biologicals furnished during 2004 for which pass-through 
payment was first made on or after January 1, 2003 (which removes them 
from application of section 621 of the

[[Page 829]]

DIMA) and were approved by the FDA for marketing as of April 1, 2003, 
will be paid 85 percent of AWP pursuant to section 1842(o)(1)(B) and 
1842(o)(4)(A), unless sections 1842(o)(4)(B), (C) or (D) apply.
    Certain drugs, biologicals and radiopharmaceutical agents that are 
pass-through drugs in 2004 and that also meet the definition of 
``specified covered outpatient drugs'', except as otherwise specified, 
are paid 88 percent of the reference AWP. Those drugs, biologicals, and 
radiopharmaceutical agents remain pass-through drugs and all policies 
that apply to them as pass-through drugs continue to apply.

Exclude Separately Payable Drugs and Biologicals From Outlier Payments

    Separately paid drugs and biologicals are excluded from outlier 
payments.

Brachytherapy Sources Are To Be Paid Separately

    All devices of brachytherapy consisting of a seed or seeds (or 
radioactive source) are paid based on the hospital's charge for the 
device adjusted to cost. All such brachytherapy sources are excluded 
from outlier payments.

III. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995.

IV. Waiver of Notice of Proposed Rulemaking and the 30-Day Delay in the 
Effective Date

    We ordinarily publish a notice of proposed rulemaking in the 
Federal Register and invite public comment on the proposed rule in 
accordance with 5 U.S.C. section 553(b) of the Administrative Procedure 
Act (APA). The notice of proposed rulemaking includes a reference to 
the legal authority under which the rule is proposed, and the terms and 
substances of the proposed rule or a description of the subjects and 
issues involved. This procedure can be waived, however, if an agency 
finds good cause that a notice-and-comment procedure is impracticable, 
unnecessary, or contrary to the public interest and incorporates a 
statement of the finding and its reasons in the rule issued.
    In this case, we believe that it is in the public interest to 
comply with the statutory requirement to implement these changes 
effective January 1, 2004. Failure to meet this deadline would cause a 
delay in payment increases for many drugs and biologicals and 
brachytherapy sources.
    Section 1871 of the Act also provides for publication of a notice 
of proposed rulemaking and opportunity for public comment before CMS 
issues a final rule. However, section 1871(b)(2)(B) provides an 
exception when a law establishes a specific deadline for implementation 
of a provision and the deadline is less than 150 days after the law's 
date of enactment. The DIMA was enacted by the Congress on November 25, 
2003 and signed into law by the President on December 8, 2003. The 
provisions of this rule that amend the Medicare hospital outpatient 
prospective payment system are required to be implemented January 1, 
2004. Therefore, these provisions are subject to waiver of proposed 
rulemaking in accordance with section 1871(b)(2)(B) of the Act.
    In addition, we ordinarily provide a 30-day delay in the effective 
date of the provisions of an interim final rule. Section 553(d) of the 
APA (5 U.S.C. section 553(d)) ordinarily requires a 30-day delay in the 
effective date of final rules after the date of their publication in 
the Federal Register. This 30-day delay in effective date can be 
waived, however, if an agency finds for good cause that the delay is 
impracticable, unnecessary, or contrary to the public interest, and the 
agency incorporates a statement of the finding and its reasons in the 
rule issued.
    In this case, we believe that it is in the public interest to 
comply with the statutory requirement to implement these changes 
effective January 1, 2004 without the 30-day delay in effective date. 
Failure to meet this deadline would cause a delay in payment increases 
for many drugs and biologicals and brachytherapy sources.
    In addition to the APA requirements, section 1871(e)(1), as amended 
by section 903(b)(1) of DIMA also requires that a substantive change in 
a regulation shall not become effective before the end of the 30-day 
period that begins on the date that the Secretary has issued or 
published the substantive change. Section 903(b)(1) provides an 
exception to the requirement of a 30-day delay in the effective date if 
the Secretary finds that the waiver of such 30-day period is necessary 
to comply with statutory requirements or that the application of such 
30-day period is contrary to the public interest.
    For purposes of DIMA, we believe that it is in the public interest 
to comply with the statutory requirement to implement these changes 
effective January 1, 2004 without the 30-day delay in effective date 
for the same reasons stated above--failure to meet this deadline would 
cause a delay in payment increases for many drugs and biologicals and 
brachytherapy sources. In addition, we find it is necessary to waive 
the 30-day delay period in order to timely comply with the statutory 
requirement that new payment rates be effective on January 1, 2004. We 
are providing a 60-day public comment period.

V. Regulatory Impact Analysis

A. Overall Impact

    We have examined the impacts of this rule as required by Executive 
Order 12866 (September 1993, Regulatory Planning and Review), the 
Regulatory Flexibility Act (RFA) (September 16, 1980, Pub. L. 96-354), 
section 1102(b) of the Social Security Act, the Unfunded Mandates 
Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.
    Executive Order 12866 (as amended by Executive Order 13258, which 
merely reassigns responsibility of duties) directs agencies to assess 
all costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distributive impacts, and equity). A 
regulatory impact analysis (RIA) must be prepared for major rules with 
economically significant effects ($100 million or more in any 1 year).
    We estimate the effects of the provisions that will be implemented 
by this final rule will result in expenditures exceeding $100 million 
in any 1 year. Our Office of the Actuary estimates that the total 
change in expenditures under the OPPS for CY 2004 as a result of the 
changes made by DIMA to be approximately $150 million. Therefore, this 
final rule with comment is an economically significant rule under 
Executive Order 12866, and a major rule under 5 U.S.C. 804(2). 
Therefore the discussion below, in combination with the rest of this 
final rule constitutes a regulatory impact analysis. The RFA requires 
agencies to analyze options for regulatory relief of small businesses. 
However a regulatory flexibility analysis is not required for an 
interim final rule because no proposed rule is being issued.
    Therefore the discussion below constitutes a regulatory impact 
analysis but no regulatory flexibility analysis is provided.

[[Page 830]]

Unfunded Mandates
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule that may result in expenditure in any 1 year by State, 
local, or tribal governments, in the aggregate, or by the private 
sector, of $110 million. This interim final rule will not mandate any 
requirements for State, local or tribal governments. This interim final 
rule will not impose unfunded mandates on the private sector of more 
than $110 million dollars.
Federalism
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications.
    We have examined this interim final rule in accordance with 
Executive Order 13132, Federalism, and have determined that it will not 
have an impact on the rights, roles, and responsibilities of State, 
local or tribal governments.

B. Anticipated Effects of Changes in This Interim Final Rule and 
Alternatives Considered for Each Change

    All of the changes made in this interim final rule with comment are 
required by DIMA. We are required under section 621 of the DIMA to 
revise payments for certain drugs and biologicals and for 
radiopharmaceuticals. We are also required under section 621 of the 
DIMA to pay for brachytherapy sources on the basis of application of a 
cost to charge ratio to the charges for the sources. In addition, we 
are required under section 621 of the DIMA to continue transitional 
outpatient payment for certain hospitals.
Impact on Drugs and Biologicals That Will Be Paid Under Pass-Through 
Provisions in 2004
    Four of the drugs and biologicals that will be paid under pass-
through provisions in 2004 will be paid at 95 percent of AWP. Nine of 
the drugs and biologicals that will be paid under pass-through 
provisions in 2004 will be paid at 85 percent of AWP in 2004. This is a 
reduction of 10 percent of AWP compared to the payment that would have 
been made for these drugs and biologicals before passage of the DIMA.
    As discussed previously in this rule, some pass-through drugs and 
biologicals also meet the criteria for ``specified covered outpatient 
drugs'' under 1833(t)(14) and, except as specified in this rule, will 
be paid 88 percent of the reference AWP. Notwithstanding the payment 
amount, however, they remain pass-through drugs.
    Hospitals that provide drugs paid at 85 percent of AWP will be paid 
less than they would have been paid absent passage of the new law.
    It is unclear whether the reduction in payments for these drugs 
will have any effect on beneficiary access to them. Hospitals consider 
many factors when they determine whether they choose to provide the 
drugs and it is unclear whether the reduction in payment for Medicare 
will result in impaired access. However, reduction in the payment 
amounts for some drugs means that beneficiaries will have lower 
copayments for those drugs and that they, and complementary insurers 
who pay beneficiary cost sharing, will have reduced expenses. 
Hospitals, however, will clearly be paid reduced amounts by Medicare 
for these drugs compared to the amounts that would be paid had the 
statute not imposed these changes. Manufacturers and distributors of 
the pass-through drugs that will be paid at 85 percent of AWP will be 
under increased pressure to reduce the price of the drugs since the 
hospitals to which they sell the items will be paid lower amounts by 
Medicare for them when used in hospital outpatient departments.
    We considered setting payment at 85 percent for pass-through drugs 
that also meet the definition of ``specified covered outpatient drugs'' 
as allowed in the cross reference from 1833(t)(6) to 1842(o). However, 
given that the drugs are eligible for payment under both sets of 
criteria, we chose to increase their payment to 88 percent of reference 
AWP, except as otherwise specified. We believe that this choice will 
result in the least possible disruption to beneficiary access to these 
drugs.
    We considered no alternatives with regard to payment for pass-
through drugs that did not meet the definition of ``specified covered 
outpatient drugs'' because the law provides only one payment 
methodology for these drugs.
Impact of Changes for ``Specified Covered Outpatient Drugs''
    Radiopharmaceutical agents and drugs or biologicals for which 
payment was made on a pass-through basis on or before December 31, 
2002, are now to be paid under section 1833(t)(14) of the Act as added 
by DIMA. Under these provisions, radiopharmaceuticals and drugs and 
biologicals that meet the criteria, are paid amounts that must be 
limited as specified in the law. Specifically, items that meet the 
definition of sole source drugs must be paid no less than 88 percent of 
reference AWP nor more than 95 percent of reference AWP. Items that 
meet the definition of innovator multiple source drugs must be paid no 
more than 68 percent of AWP and items that meet the definition of 
noninnovator multiple source drugs must be paid no more than 46 percent 
of AWP.
    As described previously, these categories are defined in section 
1927(k)(7) of the Act. That section classifies drugs, biologicals and 
radiopharmaceuticals for purposes of the Medicaid drug rebate program. 
CMS has a database in which these items are categorized to which we 
looked to seek the classification of each drug, biological and 
radiopharmaceutical paid under pass-through provisions before December 
31, 2002. Table 1 shows those items that we believe meet the definition 
of sole source drug. Table 2 shows those items for which it is not 
clear to us whether the item should be classified as a sole source drug 
or as both an innovator multiple source and a noninnovator multiple 
source drug and which we will pay as noninnovator multiple source drugs 
until we receive comments and determine the classification into which 
the drug falls. Paying for those drugs with questionable classification 
as noninnovator multiple source drugs allows payment to be made to 
hospitals for these drugs when they are furnished and also protects 
hospitals from incurring overpayments. Once we review the public 
comments and establish the correct classification and codes for the 
billing of innovator multiple source drugs, hospitals may subject 
adjustment bills to be paid the additional amounts due.
    We will pay the 121 drugs in Table 1 at the amounts shown, as 
previously discussed. Six of these drugs will have no payment change 
from the payment announced in the November 7, 2003 final rule. Six of 
these drugs will receive decreases in payment compared to the final 
rule because the payment established in the November 7, 2003 final rule 
exceeded 95 percent of the reference AWP. The payment amounts for these 
drugs are now set at 95 percent of the reference AWP in accordance with 
the law. One hundred nine of these drugs will receive increases in 
payment compared to the final rule because the payment established in 
the November 7, 2003 final rule was less than 88 percent of reference 
AWP. The payment amounts for these drugs, biologicals and 
radiopharmaceuticals is now set at 88 percent of the reference AWP.

[[Page 831]]

    We will temporarily pay the 52 drugs in Table 2 at the amounts 
shown, as previously discussed. Thirteen of these items will be paid 
the amount that was published in the November 7, 2003 final rule. 
Thirty-eight of these items will receive payment decreases. One of 
these items did not have a reference AWP under the SDP and will require 
further research to determine the correct payment amount. Until we 
determine a reference AWP for this item it will be paid at the amount 
that was published in the November 7, 2003 final rule.
    It is unclear what the final overall impact of these changes will 
be because we are, as yet, unable to determine into which categories 52 
items in dispute will fall. Moreover, once they are categorized, we do 
not anticipate that we will know the frequency with which hospitals 
will use the innovator multiple source drug versus the noninnovator 
multiple source drug in the outpatient department. Moreover, it is not 
clear to what extent hospitals may change their behavior with regard to 
which type of a drug they choose to purchase and whether their 
purchasing decisions will be affected by whether they furnish the item 
to hospital outpatient departments or inpatient departments.
    We considered whether to classify the 52 items with questionable 
category assignment as both innovator multiple source and noninnovator 
multiple source drugs and to create HCPCS codes to be used when 
innovator multiple source drugs are administered. However, we believe 
that public comment is necessary to determine the correct 
classification of these items. Similarly, we believe that, given the 
burden the law imposes on hospitals for reporting drugs by the category 
into which they fall, it was important to receive public comment 
regarding whether new codes should be created and regarding ways we can 
reduce the reporting burden on hospitals. Hence, until we receive and 
review the comments, we will not be able to assess the impact of these 
requirements of the law.
    We do acknowledge, however, that for the 52 drugs that are not sole 
source drugs, the temporary payments to hospitals at the noninnovator 
multiple source drug rate will be less than the payment that would have 
been made under the November 7, 2003 final rule. For those drugs that 
are sole source drugs, the payment will increase in most cases.
    Hospitals that provide sole source drugs will be paid more for 
these drugs under these provisions than they would have been paid 
before enactment of the DIMA. Hospitals that provide innovator multiple 
source drugs and noninnovator multiple source drugs will be paid less 
for these items than they would have been before enactment of the DIMA. 
This may encourage use of sole source drugs and discourage use of 
multiple source drugs. As a result, beneficiaries may have greater 
access to sole source drugs but will also incur greater copayments 
because those payment rates are higher than they would have been before 
enactment of DIMA. In turn, there may be increased payment by 
complementary insurers for these items. Manufacturers of sole source 
drugs may realize increased sales and manufacturers of generic drugs 
may see reduced sales.
    We considered whether to permit a drug that is classified by AMP as 
a sole source drug, an innovator multiple source drug and a 
noninnovator multiple source drug to be paid under all three 
classifications. We decided not to pay a drug as a sole source drug if 
it is also a multiple source drug for reasons described previously in 
this interim final rule. We considered no alternatives because the law 
is quite specific with regard to the classification of drugs and the 
payment rules that apply to each class of drug.
Impact of Cost-Based Payment for Sources of Brachytherapy
    The law provides that sources of brachytherapy will be paid an 
amount equal to the hospital's charge for the source adjusted by the 
applicable cost to charge ratio. It is unclear whether this will result 
in an increase or decrease in payment for brachytherapy sources. 
However, removing the brachytherapy source from packaged payment for 
the services with which it is furnished removes incentives for using 
the least number of sources needed for the therapeutic purpose. There 
is no evidence that packaged payment for brachytherapy sources resulted 
in inappropriately low utilization of brachytherapy, nor that separate 
payment will result in any change in availability of the service. We 
are unable to estimate the impact of this change on utilization and 
program payment.
    We considered no alternatives to this policy because the statute 
was specific with regard to how payment for brachytherapy sources must 
be made.
Impact of Continuation of Transitional Outpatient Payments for Certain 
Hospitals
    The law provides that transitional outpatient payments must 
continue for rural hospitals with 100 or fewer beds and be provided for 
sole community hospitals in rural areas through December 31, 2005. 
There are approximately 600 sole community hospitals and approximately 
1150 rural hospitals with 100 beds or fewer that may be affected by 
this provision. These hospitals will continue to receive transitional 
corridor payments in addition to the payments they will receive under 
OPPS. These payments should continue to strengthen the ability of these 
hospitals to furnish services to beneficiaries who reside in the areas 
served by these hospitals. Beneficiaries should be better assured of 
access to services in these hospitals. These hospitals will be assured 
of payment for the reasonable costs of providing outpatient services.
    We considered no alternatives because the statute is quite 
directive with regard to the extension of hold harmless protection to 
these hospitals.

C. Conclusion

    We have prepared the analysis above because we have determined that 
this interim final rule will have a significant economic impact. In 
accordance with the provisions of Executive Order 12866, this interim 
final rule was reviewed by the Office of Management and Budget.
Publication of Addenda
    The addenda included in this interim final rule, Addenda A and D1 
replace the addenda in the November 7, 2003 Federal Register (68 FR 
63478). The revised addenda reflect changes required by the DIMA as 
well as corrections to minor errors contained in the addenda published 
November 7, 2003.
    In addition to the addenda included here, we will post the updated 
Addenda B and C on our Web site at http://www.cms.hhs.gov/regulations/hopps/.

List of Subjects in 42 CFR Part 419

    Hospitals, Medicare, Reporting and recordkeeping requirements.

0
For the reasons set forth in the preamble, the Centers for Medicare & 
Medicaid Services amends 42 CFR chapter IV as set forth below:

PART 419--PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT 
DEPARTMENT SERVICES

0
1. The authority citation for part 419 continues to read as follows:

    Authority: Secs. 1102, 1833(t), and 1871 of the Social Security 
Act (42 U.S.C. 1302, 1395l(t), and 1395hh).

[[Page 832]]

Subpart C--Basic Methodology for Determining Prospective Payment 
Rates for Hospital Outpatient Services

0
2. Section 419.32 is amended by revising paragraph (d) to read as 
follows:


Sec.  419.32  Calculation of prospective payment rates for hospital 
outpatient services.

* * * * *
    (d) Budget neutrality. (1) CMS adjusts the conversion factor as 
needed to ensure that updates and adjustments under Sec.  419.50(a) are 
budget neutral.
    (2) In determining adjustments for 2004 and 2005, CMS will not take 
into account any additional expenditures per section 1833(t)(14) of the 
Act that would not have been made but for enactment of section 621 of 
the Medicare Prescription Drug, Improvement, and Modernization Act of 
2003.

Subpart D--Payments to Hospitals

0
3. Section Sec.  419.43 is amended as follows:
0
A. Paragraph (d)(1) introductory text is revised.
0
B. Paragraph (e) is revised.
0
C. New paragraph (f) is added.
    The revisions and additions read as follows:


Sec.  419.43  Adjustments to national program payments and beneficiary 
copayment amounts.

* * * * *
    (d) Outlier adjustment--(1) General rule. Subject to paragraph 
(d)(4) of this section, CMS provides for an additional payment for a 
hospital outpatient service (or group of services) not excluded under 
paragraph (f) of this section for which a hospital's charges, adjusted 
to cost, exceed the following:
* * * * *
    (e) Budget neutrality. CMS establishes payment under paragraph (d) 
of this section in a budget-neutral manner excluding services and 
groups specified in paragraph (f) of this section.
    (f) Excluded services and groups. Drugs and biologicals that are 
paid under a separate APC and devices of brachytherapy, consisting of a 
seed or seeds (including a radioactive source) are excluded from 
qualification for outlier payments.

Subpart G--Transitional Pass-Through Payments

0
4. Section 419.64 is amended by revising paragraph (d).


Sec.  419.64  Transitional pass-through payments: Drugs and 
biologicals.

* * * * *
    (d) Amount of pass-through payment. (1) Subject to any reduction 
determined under Sec.  419.62(b), the pass-through payment for a drug 
or biological as specified in section 1842(o)(1)(A) and (o)(1)(D)(i) of 
the Act is 95 percent of the average wholesale price of the drug or 
biological minus the portion of the APC payment CMS determines is 
associated with the drug or biological.
    (2) Subject to any reduction determined under Sec.  419.62(b), the 
pass-through payment for a drug or biological as specified in section 
1842(o)(1)(B) and (o)(1)(E)(i) of the Act is 85 percent of the average 
wholesale price, determined as of April 1, 2003, of the drug or 
biological minus the portion of the APC payment CMS determines is 
associated with the drug or biological.

Subpart H--Transitional Corridors

0
5. Section 419.70 is amended as follows:
0
A. Paragraph (d)(1) is amended by removing ``2004'' and adding ``2006'' 
in its place.
0
B. A new paragraph (d)(3) is added to read as follows:


Sec.  419.70  Transitional adjustment to limit decline and payment.

* * * * *
    (d) * * *
    (3) Temporary treatment for sole community hospitals located in 
rural areas. For covered hospital outpatient services furnished during 
cost reporting periods beginning on or after January 1, 2004, and 
continuing through December 31, 2005, for which the prospective payment 
system amount is less than the pre-BBA amount, the amount of payment 
under this part is increased by the amount of that difference if the 
hospital--
    (i) Is a sole community hospital, under Sec.  412.92 of this 
chapter; and
    (ii) Is located in a rural area as defined in Sec.  412.63(b) of 
this chapter or is treated as being located in a rural area under 
section 1886(d)(8)(E) of the Act.

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: December 23, 2003.
Dennis G. Smith,
Acting Administrator, Centers for Medicare & Medicaid Services.

    Approved: December 23, 2003.
Tommy G. Thompson,
Secretary.

    Note: The following addenda will not appear in the Code of 
Federal Regulations.


Addendum A.--List of Ambulatory Payment Classifications (APCS) With Status Indicators, Relative Weights, Payment
                                 Rates, and Copayment Amounts Calendar Year 2004
----------------------------------------------------------------------------------------------------------------
                                                                                          National     Minimum
         APC                 Group title           Status       Relative     Payment     unadjusted   unadjusted
                                                  indicator      weight        rate      copayment    copayment
----------------------------------------------------------------------------------------------------------------
0001.................  Level I                            S        0.4237       $23.12        $7.09        $4.62
                        Photochemotherapy.
0002.................  Level I Fine Needle                T        0.8083       $44.10  ...........        $8.82
                        Biopsy/Aspiration.
0003.................  Bone Marrow Biopsy/                T        2.3229      $126.74  ...........       $25.35
                        Aspiration.
0004.................  Level I Needle Biopsy/             T        1.5882       $86.65       $22.36       $17.33
                        Aspiration Except Bone
                        Marrow.
0005.................  Level II Needle Biopsy/            T        3.2698      $178.40       $71.59       $35.68
                        Aspiration Except Bone
                        Marrow.
0006.................  Level I Incision &                 T        1.6527       $90.17       $23.26       $18.03
                        Drainage.
0007.................  Level II Incision &                T       11.8633      $647.27  ...........      $129.45
                        Drainage.
0008.................  Level III Incision and             T       19.4831    $1,063.02  ...........      $212.60
                        Drainage.
0009.................  Nail Procedures........            T        0.6652       $36.29        $8.34        $7.26
0010.................  Level I Destruction of             T        0.6480       $35.36       $10.08        $7.07
                        Lesion.
0011.................  Level II Destruction of            T        2.2217      $121.22       $27.88       $24.24
                        Lesion.
0012.................  Level I Debridement &              T        0.7612       $41.53       $11.18        $8.31
                        Destruction.
0013.................  Level II Debridement &             T        1.1302       $61.66       $14.20       $12.33
                        Destruction.
0015.................  Level III Debridement &            T        1.5968       $87.12       $20.35       $17.42
                        Destruction.
0016.................  Level IV Debridement &             T        2.5724      $140.35       $57.31       $28.07
                        Destruction.
0017.................  Level VI Debridement &             T       16.3697      $893.15      $227.84      $178.63
                        Destruction.
0018.................  Biopsy of Skin/Puncture            T        0.9178       $50.08       $16.04       $10.02
                        of Lesion.

[[Page 833]]

 
0019.................  Level I Excision/                  T        3.9493      $215.48       $71.87       $43.10
                        Biopsy.
0020.................  Level II Excision/                 T        7.0842      $386.52      $113.25       $77.30
                        Biopsy.
0021.................  Level III Excision/                T       14.3594      $783.46      $219.48      $156.69
                        Biopsy.
0022.................  Level IV Excision/                 T       18.7932    $1,025.38      $354.45      $205.08
                        Biopsy.
0023.................  Exploration Penetrating            T        2.8141      $153.54       $40.37       $30.71
                        Wound.
0024.................  Level I Skin Repair....            T        1.6850       $91.94       $33.10       $18.39
0025.................  Level II Skin Repair...            T        5.1912      $283.24      $107.00       $56.65
0027.................  Level IV Skin Repair...            T       15.8990      $867.47      $329.72      $173.49
0028.................  Level I Breast Surgery.            T       17.6584      $963.46      $303.74      $192.69
0029.................  Level II Breast Surgery            T       30.1167    $1,643.20      $632.64      $328.64
0030.................  Level III Breast                   T       37.3083    $2,035.58      $763.55      $407.12
                        Surgery.
0032.................  Insertion of Central               T       11.4907      $626.94  ...........      $125.39
                        Venous/Arterial
                        Catheter.
0033.................  Partial Hospitalization            P        5.2569      $286.82  ...........       $57.36
0035.................  Placement of Arterial              T        0.1691        $9.23        $2.79        $1.85
                        or Central Venous
                        Catheter.
0036.................  Level II Fine Needle               T        1.5170       $82.77  ...........       $16.55
                        Biopsy/Aspiration.
0037.................  Level III Needle Biopsy/           T        9.8921      $539.72      $237.45      $107.94
                        Aspiration Except Bone
                        Marrow.
0039.................  Implantation of                    S      235.1866   $12,832.02  ...........    $2,566.40
                        Neurostimulator.
0040.................  Level II Implantation              S       52.1002    $2,842.64  ...........      $568.53
                        of Neurostimulator
                        Electrodes.
0041.................  Level I Arthroscopy....            T       27.3819    $1,493.98  ...........      $298.80
0042.................  Level II Arthroscopy...            T       43.0808    $2,350.53      $804.74      $470.11
0043.................  Closed Treatment                   T        1.9074      $104.07  ...........       $20.81
                        Fracture Finger/Toe/
                        Trunk.
0045.................  Bone/Joint Manipulation            T       13.5889      $741.42      $268.47      $148.28
                        Under Anesthesia.
0046.................  Open/Percutaneous                  T       32.5581    $1,776.40      $535.76      $355.28
                        Treatment Fracture or
                        Dislocation.
0047.................  Arthroplasty without               T       29.9582    $1,634.55      $537.03      $326.91
                        Prosthesis.
0048.................  Arthroplasty with                  T       51.4609    $2,807.76      $695.60      $561.55
                        Prosthesis.
0049.................  Level I Musculoskeletal            T       19.6046    $1,069.65  ...........      $213.93
                        Procedures Except Hand
                        and Foot.
0050.................  Level II                           T       24.8651    $1,356.66  ...........      $271.33
                        Musculoskeletal
                        Procedures Except Hand
                        and Foot.
0051.................  Level III                          T       34.5144    $1,883.14  ...........      $376.63
                        Musculoskeletal
                        Procedures Except Hand
                        and Foot.
0052.................  Level IV                           T       42.7126    $2,330.44  ...........      $466.09
                        Musculoskeletal
                        Procedures Except Hand
                        and Foot.
0053.................  Level I Hand                       T       14.8831      $812.04      $253.49      $162.41
                        Musculoskeletal
                        Procedures.
0054.................  Level II Hand                      T       24.2456    $1,322.86  ...........      $264.57
                        Musculoskeletal
                        Procedures.
0055.................  Level I Foot                       T       18.7205    $1,021.41      $355.34      $204.28
                        Musculoskeletal
                        Procedures.
0056.................  Level II Foot                      T       25.3930    $1,385.47      $405.81      $277.09
                        Musculoskeletal
                        Procedures.
0057.................  Bunion Procedures......            T       25.5035    $1,391.50      $475.91      $278.30
0058.................  Level I Strapping and              S        1.0931       $59.64  ...........       $11.93
                        Cast Application.
0060.................  Manipulation Therapy...            S        0.2788       $15.21  ...........        $3.04
0068.................  CPAP Initiation........            S        1.0807       $58.96       $29.48       $11.79
0069.................  Thoracoscopy...........            T       28.9392    $1,578.95      $591.64      $315.79
0070.................  Thoracentesis/Lavage               T        3.0717      $167.60  ...........       $33.52
                        Procedures.
0071.................  Level I Endoscopy Upper            T        0.8799       $48.01       $12.89        $9.60
                        Airway.
0072.................  Level II Endoscopy                 T        1.7613       $96.10       $26.68       $19.22
                        Upper Airway.
0073.................  Level III Endoscopy                T        3.4541      $188.46       $73.38       $37.69
                        Upper Airway.
0074.................  Level IV Endoscopy                 T       13.9480      $761.02      $295.70      $152.20
                        Upper Airway.
0075.................  Level V Endoscopy Upper            T       20.3815    $1,112.04      $445.92      $222.41
                        Airway.
0076.................  Level I Endoscopy Lower            T        9.2346      $503.85      $189.82      $100.77
                        Airway.
0077.................  Level I Pulmonary                  S        0.2837       $15.48        $7.74        $3.10
                        Treatment.
0078.................  Level II Pulmonary                 S        0.7917       $43.20       $14.55        $8.64
                        Treatment.
0079.................  Ventilation Initiation             S        2.1494      $117.27  ...........       $23.45
                        and Management.
0080.................  Diagnostic Cardiac                 T       36.0160    $1,965.07      $838.92      $393.01
                        Catheterization.
0081.................  Non-Coronary                       T       35.0285    $1,911.19  ...........      $382.24
                        Angioplasty or
                        Atherectomy.
0082.................  Coronary Atherectomy...            T      110.2196    $6,013.69    $1,293.59    $1,202.74
0083.................  Coronary Angioplasty               T       59.2047    $3,230.27  ...........      $646.05
                        and Percutaneous
                        Valvuloplasty.
0084.................  Level I                            S       10.5226      $574.12  ...........      $114.82
                        Electrophysiologic
                        Evaluation.
0085.................  Level II                           T       35.4126    $1,932.15      $426.25      $386.43
                        Electrophysiologic
                        Evaluation.
0086.................  Ablate Heart Dysrhythm             T       44.9389    $2,451.91      $833.33      $490.38
                        Focus.
0087.................  Cardiac                            T       39.8161    $2,172.41  ...........      $434.48
                        Electrophysiologic
                        Recording/Mapping.
0088.................  Thrombectomy...........            T       34.6942    $1,892.95      $655.22      $378.59
0089.................  Insertion/Replacement              T      117.1896    $6,393.98    $1,722.59    $1,278.80
                        of Permanent Pacemaker
                        and Electrodes.
0090.................  Insertion/Replacement              T       96.8284    $5,283.05    $1,651.45    $1,056.61
                        of Pacemaker Pulse
                        Generator.
0091.................  Level II Vascular                  T       28.8326    $1,573.14      $348.23      $314.63
                        Ligation.
0092.................  Level I Vascular                   T       25.0959    $1,369.26      $505.37      $273.85
                        Ligation.
0093.................  Vascular Reconstruction/           T       21.3104    $1,162.72      $277.34      $232.54
                        Fistula Repair without
                        Device.
0094.................  Level I Resuscitation              S        2.6345      $143.74       $48.58       $28.75
                        and Cardioversion.
0095.................  Cardiac Rehabilitation.            S        0.5994       $32.70       $16.35        $6.54

[[Page 834]]

 
0096.................  Non-Invasive Vascular              S        1.7176       $93.71       $46.85       $18.74
                        Studies.
0097.................  Cardiac and Ambulatory             X        1.0635       $58.03       $23.80       $11.61
                        Blood Pressure
                        Monitoring.
0098.................  Injection of Sclerosing            T        1.0729       $58.54       $14.06       $11.71
                        Solution.
0099.................  Electrocardiograms.....            S        0.3703       $20.20  ...........        $4.04
0100.................  Cardiac Stress Tests...            X        1.5862       $86.54       $41.44       $17.31
0101.................  Tilt Table Evaluation..            S        4.4040      $240.29      $105.27       $48.06
0103.................  Miscellaneous Vascular             T       11.6202      $634.01      $223.63      $126.80
                        Procedures.
0104.................  Transcatheter Placement            T       82.6713    $4,510.63  ...........      $902.13
                        of Intracoronary
                        Stents.
0105.................  Revision/Removal of                T       19.1898    $1,047.01      $370.40      $209.40
                        Pacemakers, AICD, or
                        Vascular.
0106.................  Insertion/Replacement/             T       58.9719    $3,217.57  ...........      $643.51
                        Repair of Pacemaker
                        and/or Electrodes.
0107.................  Insertion of                       T      337.1304   $18,394.17    $3,699.14    $3,678.83
                        Cardioverter-
                        Defibrillator.
0108.................  Insertion/Replacement/             T      452.6995   $24,699.74  ...........    $4,939.95
                        Repair of Cardioverter-
                        Defibrillator Leads.
0109.................  Removal of Implanted               T        7.4705      $407.60      $131.49       $81.52
                        Devices.
0110.................  Transfusion............            S        3.6718      $200.34  ...........       $40.07
0111.................  Blood Product Exchange.            S       13.1719      $718.67      $200.18      $143.73
0112.................  Apheresis,                         S       37.5832    $2,050.58      $612.47      $410.12
                        Photopheresis, and
                        Plasmapheresis.
0113.................  Excision Lymphatic                 T       19.9322    $1,087.52  ...........      $217.50
                        System.
0114.................  Thyroid/Lymphadenectomy            T       37.5963    $2,051.29      $485.91      $410.26
                        Procedures.
0115.................  Cannula/Access Device              T       25.6437    $1,399.15      $459.35      $279.83
                        Procedures.
0116.................  Chemotherapy                       S        0.7996       $43.63  ...........        $8.73
                        Administration by
                        Other Technique Except
                        Infusion.
0117.................  Chemotherapy                       S        3.0360      $165.65       $42.54       $33.13
                        Administration by
                        Infusion Only.
0119.................  Implantation of                    T      134.7194    $7,350.43  ...........    $1,470.09
                        Infusion Pump.
0120.................  Infusion Therapy Except            T        1.9114      $104.29       $28.21       $20.86
                        Chemotherapy.
0121.................  Level I Tube changes               T        2.1114      $115.20       $43.80       $23.04
                        and Repositioning.
0122.................  Level II Tube changes              T        8.8621      $483.53       $99.16       $96.71
                        and Repositioning.
0123.................  Bone Marrow Harvesting             S        6.1499      $335.54  ...........       $67.11
                        and Bone Marrow/Stem
                        Cell Transplant.
0124.................  Revision of Implanted              T       23.8050    $1,298.82  ...........      $259.76
                        Infusion Pump.
0125.................  Refilling of Infusion              T        2.1606      $117.88  ...........       $23.58
                        Pump.
0130.................  Level I Laparoscopy....            T       32.7724    $1,788.09      $659.53      $357.62
0131.................  Level II Laparoscopy...            T       40.8064    $2,226.44    $1,001.89      $445.29
0132.................  Level III Laparoscopy..            T       57.2045    $3,121.13    $1,239.22      $624.23
0140.................  Esophageal Dilation                T        6.4525      $352.05      $107.24       $70.41
                        without Endoscopy.
0141.................  Upper GI Procedures....            T        7.8206      $426.70      $143.38       $85.34
0142.................  Small Intestine                    T        8.7959      $479.91      $152.78       $95.98
                        Endoscopy.
0143.................  Lower GI Endoscopy.....            T        8.2957      $452.62      $186.06       $90.52
0146.................  Level I Sigmoidoscopy..            T        3.9826      $217.29       $64.40       $43.46
0147.................  Level II Sigmoidoscopy.            T        7.6808      $419.07  ...........       $83.81
0148.................  Level I Anal/Rectal                T        3.8320      $209.08       $63.38       $41.82
                        Procedure.
0149.................  Level III Anal/Rectal              T       17.1425      $935.31      $293.06      $187.06
                        Procedure.
0150.................  Level IV Anal/Rectal               T       22.1919    $1,210.81      $437.12      $242.16
                        Procedure.
0151.................  Endoscopic Retrograde              T       17.9462      $979.16      $245.46      $195.83
                        Cholangio-
                        Pancreatography (ERCP).
0152.................  Percutaneous Abdominal             T        9.1474      $499.09      $125.28       $99.82
                        and Biliary Procedures.
0153.................  Peritoneal and                     T       20.8723    $1,138.81      $410.87      $227.76
                        Abdominal Procedures.
0154.................  Hernia/Hydrocele                   T       26.9636    $1,471.16      $464.85      $294.23
                        Procedures.
0155.................  Level II Anal/Rectal               T       10.0809      $550.02      $188.89      $110.00
                        Procedure.
0156.................  Level II Urinary and               T        2.4747      $135.02       $40.52       $27.00
                        Anal Procedures.
0157.................  Colorectal Cancer                  S        2.5693      $140.18  ...........       $28.04
                        Screening: Barium
                        Enema.
0158.................  Colorectal Cancer                  T        7.4244      $405.08  ...........      $101.27
                        Screening: Colonoscopy.
0159.................  Colorectal Cancer                  S        2.7823      $151.81  ...........       $37.95
                        Screening: Flexible
                        Sigmoidoscopy.
0160.................  Level I                            T        6.8801      $375.39      $105.06       $75.08
                        Cystourethroscopy and
                        other Genitourinary
                        Procedures.
0161.................  Level II                           T       16.8407      $918.85      $249.36      $183.77
                        Cystourethroscopy and
                        other Genitourinary
                        Procedures.
0162.................  Level III                          T       21.9098    $1,195.42  ...........      $239.08
                        Cystourethroscopy and
                        other Genitourinary
                        Procedures.
0163.................  Level IV                           T       33.8805    $1,848.55  ...........      $369.71
                        Cystourethroscopy and
                        other Genitourinary
                        Procedures.
0164.................  Level I Urinary and                T        1.2021       $65.59       $17.59       $13.12
                        Anal Procedures.
0165.................  Level III Urinary and              T       14.6838      $801.16  ...........      $160.23
                        Anal Procedures.
0166.................  Level I Urethral                   T       16.7918      $916.18      $218.73      $183.24
                        Procedures.
0167.................  Level III Urethral                 T       30.0186    $1,637.84      $555.84      $327.57
                        Procedures.
0168.................  Level II Urethral                  T       30.0147    $1,637.63      $405.60      $327.53
                        Procedures.
0169.................  Lithotripsy............            T       45.1150    $2,461.52    $1,115.69      $492.30
0170.................  Dialysis...............            S        5.9678      $325.61  ...........       $65.12

[[Page 835]]

 
0180.................  Circumcision...........            T       18.6176    $1,015.79      $304.87      $203.16
0181.................  Penile Procedures......            T       29.4217    $1,605.28      $621.82      $321.06
0183.................  Testes/Epididymis                  T       21.6724    $1,182.47  ...........      $236.49
                        Procedures.
0184.................  Prostate Biopsy........            T        3.8995      $212.76       $96.27       $42.55
0187.................  Miscellaneous Placement/           X        4.4288      $241.64       $90.71       $48.33
                        Repositioning.
0188.................  Level II Female                    T        1.1365       $62.01  ...........       $12.40
                        Reproductive Proc.
0189.................  Level III Female                   T        1.4232       $77.65       $18.09       $15.53
                        Reproductive Proc.
0190.................  Level I Hysteroscopy...            T       19.6922    $1,074.43      $424.28      $214.89
0191.................  Level I Female                     T        0.1853       $10.11        $2.93        $2.02
                        Reproductive Proc.
0192.................  Level IV Female                    T        2.7121      $147.97       $39.11       $29.59
                        Reproductive Proc.
0193.................  Level V Female                     T       15.0453      $820.89      $171.13      $164.18
                        Reproductive Proc.
0194.................  Level VIII Female                  T       18.4286    $1,005.48      $397.84      $201.10
                        Reproductive Proc.
0195.................  Level IX Female                    T       25.6950    $1,401.94      $483.80      $280.39
                        Reproductive Proc.
0196.................  Dilation and Curettage.            T       16.1219      $879.63      $338.23      $175.93
0197.................  Infertility Procedures.            T        4.8280      $263.42  ...........       $52.68
0198.................  Pregnancy and Neonatal             T        1.3578       $74.08       $32.19       $14.82
                        Care Procedures.
0199.................  Obstetrical Care                   T       17.2831      $942.98  ...........      $188.60
                        Service.
0200.................  Level VII Female                   T       17.9920      $981.66      $307.83      $196.33
                        Reproductive Proc.
0201.................  Level VI Female                    T       16.8660      $920.23      $329.65      $184.05
                        Reproductive Proc.
0202.................  Level X Female                     T       38.9821    $2,126.90    $1,042.18      $425.38
                        Reproductive Proc.
0203.................  Level IV Nerve                     T       11.5969      $632.74      $276.76      $126.55
                        Injections.
0204.................  Level I Nerve                      T        2.1711      $118.46       $40.13       $23.69
                        Injections.
0206.................  Level II Nerve                     T        5.2875      $288.49       $75.55       $57.70
                        Injections.
0207.................  Level III Nerve                    T        6.4554      $352.21      $123.69       $70.44
                        Injections.
0208.................  Laminotomies and                   T       40.2830    $2,197.88  ...........      $439.58
                        Laminectomies.
0209.................  Extended EEG Studies               S       11.5435      $629.82      $280.58      $125.96
                        and Sleep Studies,
                        Level II.
0212.................  Nervous System                     T        2.9739      $162.26       $74.67       $32.45
                        Injections.
0213.................  Extended EEG Studies               S        2.9055      $158.53       $65.74       $31.71
                        and Sleep Studies,
                        Level I.
0214.................  Electroencephalogram...            S        2.2176      $120.99       $58.12       $24.20
0215.................  Level I Nerve and                  S        0.6457       $35.23       $15.76        $7.05
                        Muscle Tests.
0216.................  Level III Nerve and                S        2.8535      $155.69       $67.98       $31.14
                        Muscle Tests.
0218.................  Level II Nerve and                 S        1.1404       $62.22  ...........       $12.44
                        Muscle Tests.
0220.................  Level I Nerve                      T       16.5554      $903.28  ...........      $180.66
                        Procedures.
0221.................  Level II Nerve                     T       24.8875    $1,357.89      $463.62      $271.58
                        Procedures.
0222.................  Implantation of                    T      232.2024   $12,669.20  ...........    $2,533.84
                        Neurological Device.
0223.................  Implantation or                    T       26.7610    $1,460.11  ...........      $292.02
                        Revision of Pain
                        Management Catheter.
0224.................  Implantation of                    T       34.1770    $1,864.73      $453.41      $372.95
                        Reservoir/Pump/Shunt.
0225.................  Level I Implementation             S      206.0034   $11,239.75  ...........    $2,247.95
                        of Neurostimulator
                        Electrodes.
0226.................  Implantation of Drug               T      136.2989    $7,436.60  ...........    $1,487.32
                        Infusion Reservoir.
0227.................  Implantation of Drug               T      160.8363    $8,775.39  ...........    $1,755.08
                        Infusion Device.
0228.................  Creation of Lumbar                 T       52.2880    $2,852.89      $639.03      $570.58
                        Subarachnoid Shunt.
0229.................  Transcatherter                     T       61.9895    $3,382.21      $771.23      $676.44
                        Placement of
                        Intravascular Shunt.
0230.................  Level I Eye Tests &                S        0.7619       $41.57       $14.97        $8.31
                        Treatments.
0231.................  Level III Eye Tests &              S        2.1883      $119.40       $50.94       $23.88
                        Treatments.
0232.................  Level I Anterior                   T        4.9206      $268.47      $103.17       $53.69
                        Segment Eye Procedures.
0233.................  Level II Anterior                  T       14.4205      $786.80      $266.33      $157.36
                        Segment Eye Procedures.
0234.................  Level III Anterior                 T       21.4631    $1,171.05      $511.31      $234.21
                        Segment Eye Procedures.
0235.................  Level I Posterior                  T        5.0749      $276.89       $72.04       $55.38
                        Segment Eye Procedures.
0236.................  Level II Posterior                 T       18.6701    $1,018.66  ...........      $203.73
                        Segment Eye Procedures.
0237.................  Level III Posterior                T       34.1784    $1,864.81      $818.54      $372.96
                        Segment Eye Procedures.
0238.................  Level I Repair and                 T        3.1954      $174.34       $58.96       $34.87
                        Plastic Eye Procedures.
0239.................  Level II Repair and                T        6.1331      $334.63  ...........       $66.93
                        Plastic Eye Procedures.
0240.................  Level III Repair and               T       17.4535      $952.28      $315.31      $190.46
                        Plastic Eye Procedures.
0241.................  Level IV Repair and                T       22.1969    $1,211.09      $384.47      $242.22
                        Plastic Eye Procedures.
0242.................  Level V Repair and                 T       29.4294    $1,605.70      $597.36      $321.14
                        Plastic Eye Procedures.
0243.................  Strabismus/Muscle                  T       21.7323    $1,185.74      $431.39      $237.15
                        Procedures.
0244.................  Corneal Transplant.....            T       37.6284    $2,053.04      $803.26      $410.61
0245.................  Level I Cataract                   T       12.2973      $670.95      $222.22      $134.19
                        Procedures without IOL
                        Insert.
0246.................  Cataract Procedures                T       22.9755    $1,253.57      $495.96      $250.71
                        with IOL Insert.
0247.................  Laser Eye Procedures               T        4.9482      $269.98      $104.31       $54.00
                        Except Retinal.
0248.................  Laser Retinal                      T        4.8223      $263.11       $95.08       $52.62
                        Procedures.
0249.................  Level II Cataract                  T       27.7406    $1,513.55      $524.67      $302.71
                        Procedures without IOL
                        Insert.
0250.................  Nasal Cauterization/               T        1.4697       $80.19       $28.07       $16.04
                        Packing.
0251.................  Level I ENT Procedures.            T        1.7880       $97.56  ...........       $19.51
0252.................  Level II ENT Procedures            T        6.4469      $351.75      $113.41       $70.35
0253.................  Level III ENT                      T       15.2249      $830.69      $282.29      $166.14
                        Procedures.
0254.................  Level IV ENT Procedures            T       21.8901    $1,194.35      $321.35      $238.87
0256.................  Level V ENT Procedures.            T       35.1548    $1,918.08  ...........      $383.62
0258.................  Tonsil and Adenoid                 T       20.6265    $1,125.40      $437.25      $225.08
                        Procedures.

[[Page 836]]

 
0259.................  Level VI ENT Procedures            T      392.8622   $21,434.95    $9,394.83    $4,286.99
0260.................  Level I Plain Film                 X        0.7802       $42.57       $21.28        $8.51
                        Except Teeth.
0261.................  Level II Plain Film                X        1.3176       $71.89  ...........       $14.38
                        Except Teeth Including
                        Bone Density
                        Measurement.
0262.................  Plain Film of Teeth....            X        0.7540       $41.14        $9.82        $8.23
0263.................  Level I Miscellaneous              X        2.1883      $119.40       $43.58       $23.88
                        Radiology Procedures.
0264.................  Level II Miscellaneous             X        3.0287      $165.25       $79.41       $33.05
                        Radiology Procedures.
0265.................  Level I Diagnostic                 S        1.0289       $56.14       $28.07       $11.23
                        Ultrasound Except
                        Vascular.
0266.................  Level II Diagnostic                S        1.6117       $87.94       $43.97       $17.59
                        Ultrasound Except
                        Vascular.
0267.................  Level III Diagnostic               S        2.4586      $134.14       $65.52       $26.83
                        Ultrasound Except
                        Vascular.
0268.................  Ultrasound Guidance                S        1.3081       $71.37  ...........       $14.27
                        Procedures.
0269.................  Level III                          S        3.2309      $176.28       $87.24       $35.26
                        Echocardiogram Except
                        Transesophageal.
0270.................  Transesophageal                    S        5.8546      $319.43      $146.79       $63.89
                        Echocardiogram.
0271.................  Mammography............            S        0.6499       $35.46       $16.80        $7.09
0272.................  Level I Fluoroscopy....            X        1.4184       $77.39       $38.36       $15.48
0274.................  Myelography............            S        3.5931      $196.04       $93.63       $39.21
0275.................  Arthrography...........            S        3.2775      $178.82       $69.09       $35.76
0276.................  Level I Digestive                  S        1.5906       $86.78       $41.72       $17.36
                        Radiology.
0277.................  Level II Digestive                 S        2.4444      $133.37       $60.47       $26.67
                        Radiology.
0278.................  Diagnostic Urography...            S        2.7012      $147.38       $66.07       $29.48
0279.................  Level II Angiography               S       10.7073      $584.20      $174.57      $116.84
                        and Venography except
                        Extremity.
0280.................  Level III Angiography              S       19.1015    $1,042.20      $353.85      $208.44
                        and Venography except
                        Extremity.
0281.................  Venography of Extremity            S        6.6031      $360.27      $115.16       $72.05
0282.................  Miscellaneous                      S        1.6834       $91.85       $44.51       $18.37
                        Computerized Axial
                        Tomography.
0283.................  Computerized Axial                 S        4.6543      $253.94      $126.27       $50.79
                        Tomography with
                        Contrast Material.
0284.................  Magnetic Resonance                 S        7.1165      $388.28      $194.13       $77.66
                        Imaging and Magnetic
                        Resonance Angiography
                        with Contras.
0285.................  Myocardial Positron                S       14.1508      $772.08      $334.45      $154.42
                        Emission Tomography
                        (PET).
0287.................  Complex Venography.....            S        6.4923      $354.23      $111.33       $70.85
0288.................  Bone Density:Axial                 S        1.2726       $69.43  ...........       $13.89
                        Skeleton.
0289.................  Needle Localization for            X        3.4900      $190.42       $44.80       $38.08
                        Breast Biopsy.
0296.................  Level I Therapeutic                S        2.8635      $156.24       $69.20       $31.25
                        Radiologic Procedures.
0297.................  Level II Therapeutic               S        7.7145      $420.91      $172.51       $84.18
                        Radiologic Procedures.
0299.................  Miscellaneous Radiation            S        5.7618      $314.37  ...........       $62.87
                        Treatment.
0300.................  Level I Radiation                  S        1.4912       $81.36  ...........       $16.27
                        Therapy.
0301.................  Level II Radiation                 S        2.1340      $116.43       $23.29
                        Therapy.
0302.................  Level III Radiation                S        6.3268      $345.20      $130.77       $69.04
                        Therapy.
0303.................  Treatment Device                   X        2.8835      $157.33       $66.95       $31.47
                        Construction.
0304.................  Level I Therapeutic                X        1.6742       $91.35       $41.52       $18.27
                        Radiation Treatment
                        Preparation.
0305.................  Level II Therapeutic               X        3.6767      $200.60       $91.38       $40.12
                        Radiation Treatment
                        Preparation.
0310.................  Level III Therapeutic              X       13.7165      $748.39      $325.27      $149.68
                        Radiation Treatment
                        Preparation.
0312.................  Radioelement                       S        3.6637      $199.90  ...........       $39.98
                        Applications.
0313.................  Brachytherapy..........            S       13.8073      $753.34  ...........      $150.67
0314.................  Hyperthermic Therapies.            S        4.6041      $251.20      $101.77       $50.24
0320.................  Electroconvulsive                  S        5.3785      $293.46       $80.06       $58.69
                        Therapy.
0321.................  Biofeedback and Other              S        1.4817       $80.84       $21.78       $16.17
                        Training.
0322.................  Brief Individual                   S        1.2802       $69.85  ...........       $13.97
                        Psychotherapy.
0323.................  Extended Individual                S        1.8689      $101.97       $21.26       $20.39
                        Psychotherapy.
0324.................  Family Psychotherapy...            S        2.4473      $133.53  ...........       $26.71
0325.................  Group Psychotherapy....            S        1.4865       $81.10       $18.27       $16.22
0330.................  Dental Procedures......            S        0.5745       $31.35  ...........        $6.27
0332.................  Computerized Axial                 S        3.3936      $185.16       $91.27       $37.03
                        Tomography and
                        Computerized
                        Angiography without
                        Contras.
0333.................  Computerized Axial                 S        5.4241      $295.94      $146.98       $59.19
                        Tomography and
                        Computerized Angio w/o
                        Contrast Material.
0335.................  Magnetic Resonance                 S        6.3499      $346.46      $151.46       $69.29
                        Imaging, Miscellaneous.
0336.................  Magnetic Resonance                 S        6.3897      $348.63      $174.31       $69.73
                        Imaging and Magnetic
                        Resonance Angiography
                        without Cont.
0337.................  MRI and Magnetic                   S        9.2075      $502.37      $240.77      $100.47
                        Resonance Angiography
                        without Contrast
                        Material followed.
0339.................  Observation............            S        6.6961      $365.35  ...........       $73.07
0340.................  Minor Ancillary                    X        0.6314       $34.45  ...........        $6.89
                        Procedures.
0341.................  Skin Tests.............            X        0.1365        $7.45        $3.03        $1.49
0342.................  Level I Pathology......            X        0.2162       $11.80        $5.88        $2.36
0343.................  Level II Pathology.....            X        0.4617       $25.19       $12.55        $5.04
0344.................  Level III Pathology....            X        0.6291       $34.32       $17.16        $6.86
0345.................  Level I Transfusion                X        0.2550       $13.91        $3.10        $2.78
                        Laboratory Procedures.
0346.................  Level II Transfusion               X        0.3866       $21.09        $5.32        $4.22
                        Laboratory Procedures.
0347.................  Level III Transfusion              X        0.9610       $52.43       $13.20       $10.49
                        Laboratory Procedures.

[[Page 837]]

 
0348.................  Fertility Laboratory               X        0.8194       $44.71  ...........        $8.94
                        Procedures.
0352.................  Level I Injections.....            X        0.1230        $6.71  ...........        $1.34
0353.................  Level II Allergy                   X        0.3982       $21.73  ...........        $4.35
                        Injections.
0355.................  Level III Immunizations            K        0.2749       $15.00  ...........        $3.00
0356.................  Level IV Immunizations.            K        0.7698       $42.00  ...........        $8.40
0359.................  Level II Injections....            X        0.8000       $43.65  ...........        $8.73
0360.................  Level I Alimentary                 X        1.7313       $94.46       $42.45       $18.89
                        Tests.
0361.................  Level II Alimentary                X        3.5510      $193.75       $83.23       $38.75
                        Tests.
0362.................  Level III                          X        2.6984      $147.23  ...........       $29.45
                        Otorhinolaryngologic
                        Function Tests.
0363.................  Level I                            X        0.8641       $47.15       $17.44        $9.43
                        Otorhinolaryngologic
                        Function Tests.
0364.................  Level I Audiometry.....            X        0.4459       $24.33        $9.06        $4.87
0365.................  Level II Audiometry....            X        1.2132       $66.19       $18.95       $13.24
0367.................  Level I Pulmonary Test.            X        0.5887       $32.12       $15.16        $6.42
0368.................  Level II Pulmonary                 X        0.9319       $50.85       $25.42       $10.17
                        Tests.
0369.................  Level III Pulmonary                X        2.4984      $136.32       $44.18       $27.26
                        Tests.
0370.................  Allergy Tests..........            X        0.9185       $50.11       $11.58       $10.02
0371.................  Level I Allergy                    X        0.4105       $22.40  ...........        $4.48
                        Injections.
0372.................  Therapeutic Phlebotomy.            X        0.5607       $30.59       $10.09        $6.12
0373.................  Neuropsychological                 X        2.3288      $127.06  ...........       $25.41
                        Testing.
0374.................  Monitoring Psychiatric             X        1.1252       $61.39  ...........       $12.28
                        Drugs.
0375.................  Ancillary Outpatient               T   ...........    $1,150.00  ...........      $230.00
                        Services When Patient
                        Expires.
0376.................  Level II Cardiac                   S        4.4510      $242.85      $121.42       $48.57
                        Imaging.
0377.................  Level III Cardiac                  S        6.8830      $375.54      $187.76       $75.11
                        Imaging.
0378.................  Level II Pulmonary                 S        5.4852      $299.28      $149.63       $59.86
                        Imaging.
0379.................  Injection adenosine 6              K        0.2078       $11.34  ...........        $2.27
                        Mg.
0380.................  Dipyridamole injection.            K        0.2525       $13.78  ...........        $2.76
0384.................  GI Procedures with                 T       36.5400    $1,993.66      $433.01      $398.73
                        Stents.
0385.................  Level I Prosthetic                 S       67.1530    $3,663.93  ...........      $732.79
                        Urological Procedures.
0386.................  Level II Prosthetic                S      116.2382    $6,342.07  ...........    $1,268.41
                        Urological Procedures.
0387.................  Level II Hysteroscopy..            T       28.1480    $1,535.78      $655.55      $307.16
0388.................  Discography............            S       11.6347      $634.80      $303.19      $126.96
0389.................  Non-imaging Nuclear                S        1.6328       $89.09       $44.54       $17.82
                        Medicine.
0390.................  Level I Endocrine                  S        2.7907      $152.26       $76.13       $30.45
                        Imaging.
0391.................  Level II Endocrine                 S        3.1956      $174.36       $87.18       $34.87
                        Imaging.
0393.................  Red Cell/Plasma Studies            S        4.4354      $242.00      $121.00       $48.40
0394.................  Hepatobiliary Imaging..            S        4.3714      $238.51      $119.25       $47.70
0395.................  GI Tract Imaging.......            S        3.9536      $215.71      $107.85       $43.14
0396.................  Bone Imaging...........            S        4.1883      $228.52      $114.26       $45.70
0397.................  Vascular Imaging.......            S        2.2183      $121.03       $60.51       $24.21
0398.................  Level I Cardiac Imaging            S        4.5091      $246.02      $123.01       $49.20
0399.................  Nuclear Medicine Add-on            S        1.5273       $83.33       $41.66       $16.67
                        Imaging.
0400.................  Hematopoietic Imaging..            S        3.8242      $208.65      $104.32       $41.73
0401.................  Level I Pulmonary                  S        3.3736      $184.07       $92.03       $36.81
                        Imaging.
0402.................  Brain Imaging..........            S        5.4063      $294.97      $147.48       $58.99
0403.................  CSF Imaging............            S        3.8402      $209.53      $104.76       $41.91
0404.................  Renal and Genitourinary            S        3.7303      $203.53      $101.76       $40.71
                        Studies Level I.
0405.................  Renal and Genitourinary            S        4.3432      $236.97      $118.48       $47.39
                        Studies Level II.
0406.................  Tumor/Infection Imaging            S        4.3955      $239.82      $119.91       $47.96
0407.................  Radionuclide Therapy...            S        3.5841      $195.55       $97.77       $39.11
0409.................  Red Blood Cell Tests...            X        0.1390        $7.58        $2.32        $1.52
0410.................  Mammogram Add On.......            S        0.1523        $8.31  ...........        $1.66
0411.................  Respiratory Procedures.            S        0.4367       $23.83  ...........        $4.77
0412.................  IMRT Treatment Delivery            S        5.3904      $294.11  ...........       $58.82
0415.................  Level II Endoscopy                 T       20.7348    $1,131.31      $459.92      $226.26
                        Lower Airway.
0600.................  Low Level Clinic Visits            V        0.9278       $50.62  ...........       $10.12
0601.................  Mid Level Clinic Visits            V        0.9816       $53.56  ...........       $10.71
0602.................  High Level Clinic                  V        1.5041       $82.07  ...........       $16.41
                        Visits.
0610.................  Low Level Emergency                V        1.3691       $74.70       $19.57       $14.94
                        Visits.
0611.................  Mid Level Emergency                V        2.3967      $130.77       $36.16       $26.15
                        Visits.
0612.................  High Level Emergency               V        4.1476      $226.30       $54.12       $45.26
                        Visits.
0620.................  Critical Care..........            S        8.9992      $491.01      $142.30       $98.20
0648.................  Breast Reconstruction              T       54.0165    $2,947.19  ...........      $589.44
                        with Prosthesis.
0651.................  Complex Interstitial               S       10.2314      $558.24  ...........      $111.65
                        Radiation Source
                        Application.
0652.................  Insertion of                       T       27.0364    $1,475.13  ...........      $295.03
                        Intraperitoneal
                        Catheters.
0653.................  Vascular Reconstruction/           T       30.0334    $1,638.65  ...........      $327.73
                        Fistula Repair with
                        Device.
0654.................  Insertion/Replacement              T      112.6957    $6,148.79  ...........    $1,229.76
                        of a permanent dual
                        chamber pacemaker.
0655.................  Insertion/Replacement/             T      142.7039    $7,786.07  ...........    $1,557.21
                        Conversion of a
                        permanent dual chamber
                        pacemaker.

[[Page 838]]

 
0656.................  Transcatheter Placement            T      103.4907    $5,646.56  ...........    $1,129.31
                        of Intracoronary Drug-
                        Eluting Stents.
0657.................  Placement of Tissue                S        1.5102       $82.40  ...........       $16.48
                        Clips.
0658.................  Percutaneous Breast                T        5.5779      $304.34  ...........       $60.87
                        Biopsies.
0659.................  Hyperbaric Oxygen......            S        3.0228      $164.93  ...........       $32.99
660..................  Level II                           X        1.7353       $94.68       $30.66       $18.94
                        Otorhinolaryngologic
                        Function Tests.
0661.................  Level IV Pathology.....            X        3.2576      $177.74       $88.87       $35.55
0662.................  CT Angiography.........            S        5.8775      $320.68      $156.47       $64.14
0664.................  Proton Beam Radiation              S        9.7295      $530.85  ...........      $106.17
                        Therapy.
0665.................  Bone Density:                      S        0.7257       $39.59  ...........        $7.92
                        Appendicular Skeleton.
0668.................  Level I Angiography and            S       10.2660      $560.12      $237.76      $112.02
                        Venography except
                        Extremity.
0669.................  Digital Mammography....            S        0.9009       $49.15  ...........        $9.83
0670.................  Intravenous and                    S       27.4483    $1,497.61      $542.37      $299.52
                        Intracardiac
                        Ultrasound.
0671.................  Level II Echocardiogram            S        1.6384       $89.39       $44.69       $17.88
                        Except Transesophageal.
0672.................  Level IV Posterior                 T       38.9476    $2,125.02      $988.43      $425.00
                        Segment Procedures.
0673.................  Level IV Anterior                  T       26.8390    $1,464.36      $649.56      $292.87
                        Segment Eye Procedures.
0674.................  Prostate Cryoablation..            T      119.9733    $6,545.86  ...........    $1,309.17
0675.................  Prostatic Thermotherapy            T       49.3452    $2,692.32  ...........      $538.46
0676.................  Level II Transcatheter             T        2.7315      $149.03       $40.30       $29.81
                        Thrombolysis.
0677.................  Level I Transcatheter              T        2.1805      $118.97  ...........       $23.79
                        Thrombolysis.
0678.................  External                           T        2.0659      $112.72  ...........       $22.54
                        Counterpulsation.
0679.................  Level II Resuscitation             S        5.4887      $299.47       $95.30       $59.89
                        and Cardioversion.
0680.................  Insertion of Patient               S       62.8252    $3,427.81  ...........      $685.56
                        Activated Event
                        Recorders.
0681.................  Knee Arthroplasty......            T       98.1613    $5,355.78    $2,131.36    $1,071.16
0682.................  Level V Debridement &              T        8.0790      $440.80      $174.57       $88.16
                        Destruction.
0683.................  Level II                           S        1.5489       $84.51       $30.42       $16.90
                        Photochemotherapy.
0685.................  Level III Needle Biopsy/           T        4.8100      $262.44      $115.47       $52.49
                        Aspiration Except Bone
                        Marrow.
0686.................  Level III Skin Repair..            T        7.9247      $432.38      $198.89       $86.48
0687.................  Revision/Removal of                T       20.4416    $1,115.31      $513.05      $223.06
                        Neurostimulator
                        Electrodes.
0688.................  Revision/Removal of                T       46.7347    $2,549.89    $1,249.45      $509.98
                        Neurostimulator Pulse
                        Generator Receiver.
0689.................  Electronic Analysis of             S        0.5533       $30.19  ...........        $6.04
                        Cardioverter-
                        defibrillators.
0690.................  Electronic Analysis of             S        0.4074       $22.23       $10.63        $4.45
                        Pacemakers and other
                        Cardiac Devices.
0691.................  Electronic Analysis of             S        2.8066      $153.13       $76.56       $30.63
                        Programmable Shunts/
                        Pumps.
0692.................  Electronic Analysis of             S        1.1057       $60.33       $30.16       $12.07
                        Neurostimulator Pulse
                        Generators.
0693.................  Level II Breast                    T       39.0111    $2,128.48      $798.17      $425.70
                        Reconstruction.
0694.................  Mohs Surgery...........            T        2.9752      $162.33       $64.93       $32.47
0695.................  Level VII Debridement &            T       19.1849    $1,046.75      $266.59      $209.35
                        Destruction.
0697.................  Level I Echocardiogram             S        1.4415       $78.65       $39.32       $15.73
                        Except Transesophageal.
0698.................  Level II Eye Tests &               S        0.9599       $52.37       $18.72       $10.47
                        Treatments.
0699.................  Level IV Eye Tests &               T        2.2303      $121.69       $47.46       $24.34
                        Treatments.
0700.................  Antepartum Manipulation            T        2.4306      $132.62       $37.13       $26.52
0701.................  SR 89 chloride, per mCi            K   ...........      $892.43  ...........      $178.49
0702.................  SM 153 lexidronam, 50              K   ...........      $493.89  ...........       $98.78
                        mCi.
0704.................  IN 111 Satumomab                   K   ...........    $1,474.00  ...........      $294.80
                        pendetide per dose.
0705.................  Technetium TC99M                   K        1.0642      $665.28  ...........      $133.06
                        tetrofosmin.
0726.................  Dexrazoxane hcl                    K        2.0616      $112.48  ...........       $22.50
                        injection, 250 mg.
0728.................  Filgrastim 300 mcg                 K   ...........      $172.20  ...........       $34.44
                        injection.
0730.................  Pamidronate disodium ,             K   ...........      $128.74  ...........       $25.75
                        30 mg.
0731.................  Sargramostim injection.            K   ...........       $26.92  ...........        $5.38
0732.................  Mesna injection 200 mg.            K   ...........       $17.66  ...........        $3.53
0733.................  Non esrd epoetin alpha             K   ...........       $11.76  ...........        $2.35
                        inj, 1000 u.
0734.................  Injection, darbepoetin             K   ...........        $3.88  ...........        $0.78
                        alfa (for non-ESRD),
                        per 1 mcg.
0763.................  Dolasetron mesylate                K   ...........      $152.38  ...........       $30.48
                        oral.
0764.................  Granisetron HCl                    K   ...........       $17.18  ...........        $3.44
                        injection.
0765.................  Granisetron HCl 1 mg               K   ...........      $171.78  ...........       $34.36
                        oral.
0800.................  Leuprolide acetate,                K   ...........      $479.20  ...........       $95.84
                        3.75 mg.
0802.................  Etoposide oral 50 mg...            K   ...........       $21.91  ...........        $4.38
0807.................  Aldesleukin/single use             K   ...........      $680.35  ...........      $136.07
                        vial.
0809.................  Bcg live intravesical              K   ...........       $77.54  ...........       $15.51
                        vac.
0810.................  Goserelin acetate                  K   ...........      $413.59  ...........       $82.72
                        implant 3.6 mg.
0811.................  Carboplatin injection              K   ...........      $137.79  ...........       $27.56
                        50 mg.
0813.................  Cisplatin 10 mg                    K   ...........        $7.73  ...........        $1.55
                        injection.
0814.................  Asparaginase injection.            K   ...........       $58.00  ...........       $11.60
0815.................  Cyclophosphamide 100 MG            K   ...........        $2.77  ...........        $0.55
                        inj.
0816.................  Cyclophosphamide                   K   ...........        $2.36  ...........        $0.47
                        lyophilized.
0817.................  Cytarabine hcl 100 MG              K   ...........        $1.55  ...........        $0.31
                        inj.
0819.................  Dacarbazine 100 mg inj.            K        0.0974        $5.31  ...........        $1.06

[[Page 839]]

 
0820.................  Daunorubicin 10 mg.....            K   ...........       $35.94  ...........        $7.19
0821.................  Daunorubicin citrate               K   ...........       $64.60  ...........       $12.92
                        liposom 10 mg.
0823.................  Docetaxel, 20 mg.......            K   ...........      $331.53  ...........       $66.31
0824.................  Etoposide 10 MG inj....            K   ...........        $0.83  ...........        $0.17
0827.................  Floxuridine injection              K   ...........       $66.24  ...........       $13.25
                        500 mg.
0828.................  Gemcitabine HCL 200 mg.            K   ...........      $112.09  ...........       $22.42
0830.................  Irinotecan injection 20            K   ...........      $135.00  ...........       $27.00
                        mg.
0831.................  Ifosfomide injection 1             K   ...........       $72.81  ...........       $14.56
                        gm.
0832.................  Idarubicin hcl                     K        3.2663      $178.21  ...........       $35.64
                        injection 5 mg.
0834.................  Interferon alfa-2a inj.            K   ...........       $32.31  ...........        $6.46
0836.................  Interferon alfa-2b inj             K   ...........       $13.78  ...........        $2.76
                        recombinant, 1 million.
0838.................  Interferon gamma 1-b               K   ...........      $290.70  ...........       $58.14
                        inj, 3 million u.
0840.................  Melphalan hydrochl 50              K   ...........      $389.14  ...........       $77.83
                        mg.
0842.................  Fludarabine phosphate              K   ...........      $329.83  ...........       $65.97
                        inj 50 mg.
0844.................  Pentostatin injection,             K   ...........    $1,784.64  ...........      $356.93
                        10 mg.
0847.................  Doxorubic hcl 10 MG vl             K   ...........        $4.69  ...........        $0.94
                        chemo.
0849.................  Rituximab, 100 mg......            K   ...........      $464.20  ...........       $92.84
0850.................  Streptozocin injection,            K   ...........      $131.05  ...........       $26.21
                        1 gm.
0851.................  Thiotepa injection.....            K   ...........       $45.31  ...........        $9.06
0852.................  Topotecan, 4 mg........            K   ...........      $739.80  ...........      $147.96
0855.................  Vinorelbine tartrate,              K   ...........      $100.97  ...........       $20.19
                        10 mg.
0856.................  Porfimer sodium, 75 mg.            K   ...........    $2,411.82  ...........      $482.36
0857.................  Bleomycin sulfate                  K   ...........       $88.32  ...........       $17.66
                        injection 15 u.
0858.................  Cladribine, 1mg........            K   ...........       $24.84  ...........        $4.97
0860.................  Plicamycin                         K   ...........       $86.89  ...........       $17.38
                        (mithramycin) inj.
0861.................  Leuprolide acetate                 K   ...........       $14.48  ...........        $2.90
                        injection 1 mg.
0862.................  Mitomycin 5 mg inj.....            K   ...........       $30.91  ...........        $6.18
0863.................  Paclitaxel injection,              K   ...........       $79.04  ...........       $15.81
                        30 mg.
0864.................  Mitoxantrone hcl, 5 mg.            K   ...........      $332.87  ...........       $66.57
0865.................  Interferon alfa-n3 inj,            K   ...........        $8.17  ...........        $1.63
                        human leukocyte
                        derived, 2.
0884.................  Rho d immune globulin              K   ...........       $92.93  ...........       $18.59
                        inj, 1 dose pkg.
0888.................  Cyclosporine oral 100              K   ...........        $2.41  ...........        $0.48
                        mg.
0890.................  Lymphocyte immune                  K   ...........      $258.17  ...........       $51.63
                        globulin 250 mg.
0891.................  Tacrolimus oral per 1              K   ...........        $3.24  ...........        $0.65
                        mg.
0900.................  Alglucerase injection,             K   ...........       $37.13  ...........        $7.43
                        per 10 u.
0901.................  Alpha 1 proteinase                 K   ...........        $3.43  ...........        $0.69
                        inhibitor, 10 mg.
0902.................  Botulinum toxin a, per             K   ...........        $4.58  ...........        $0.92
                        unit.
0903.................  Cytomegalovirus imm IV/            K   ...........      $659.60  ...........      $131.92
                        vial.
0905.................  Immune globulin, 1g....            K   ...........       $37.95  ...........        $7.59
0906.................  RSV-ivig, 50 mg........            K   ...........       $16.55  ...........        $3.31
0907.................  Ganciclovir sodium                 K        0.5918       $32.29  ...........        $6.46
                        injection.
0909.................  Interferon beta-1a, 33             K   ...........      $123.77  ...........       $24.75
                        mcg.
0910.................  Interferon beta-1b /               K   ...........       $67.22  ...........       $13.44
                        0.25 mg.
0911.................  Streptokinase per                  K        1.5733       $85.84  ...........       $17.17
                        250,000 iu.
0913.................  Ganciclovir long act               K        1.5861       $86.54  ...........       $17.31
                        implant.
0916.................  Imiglucerase injection/            K   ...........        $3.71  ...........        $0.74
                        unit.
0917.................  Adenosine injection....            K        1.0393       $56.71  ...........       $11.34
0925.................  Factor viii per iu.....            K   ...........        $0.42  ...........        $0.08
0926.................  Factor VIII (porcine)              K   ...........        $1.89  ...........        $0.38
                        per iu.
0927.................  Factor viii recombinant            K   ...........        $0.61  ...........        $0.12
                        per iu.
0928.................  Factor ix complex per              K   ...........        $0.18  ...........        $0.04
                        iu.
0929.................  Anti-inhibitor per iu..            K   ...........        $0.69  ...........        $0.14
0931.................  Factor IX non-                     K   ...........        $0.51  ...........        $0.10
                        recombinant, per iu.
0932.................  Factor IX recombinant,             K   ...........        $1.04  ...........        $0.21
                        per iu.
0949.................  Plasma, Pooled Multiple            K   ...........      $124.31  ...........       $24.86
                        Donor, Solvent/
                        Detergent.
0950.................  Blood (Whole) For                  K   ...........       $87.93  ...........       $17.59
                        Transfusion.
0952.................  Cryoprecipitate........            K   ...........       $29.31  ...........        $5.86
0954.................  RBC leukocytes reduced.            K   ...........      $119.26  ...........       $23.85
0955.................  Plasma, Fresh Frozen...            K   ...........       $95.00  ...........       $19.00
0956.................  Plasma Protein Fraction            K   ...........       $92.98  ...........       $18.60
0957.................  Platelet Concentrate...            K   ...........       $41.44  ...........        $8.29
0958.................  Platelet Rich Plasma...            K   ...........       $53.56  ...........       $10.71
0959.................  Red Blood Cells........            K   ...........       $86.41  ...........       $17.28
0960.................  Washed Red Blood Cells.            K   ...........      $160.69  ...........       $32.14
0961.................  Infusion, Albumin                  K        0.2802       $15.29  ...........        $3.06
                        (Human) 5%, 50 ml.
0963.................  Albumin (human), 5%,               K        1.0901       $59.48  ...........       $11.90
                        250 ml.
0964.................  Albumin (human), 25%,              K        0.3741       $20.41  ...........        $4.08
                        20 ml.
0965.................  Albumin (human), 25%,              K        0.8869       $48.39  ...........        $9.68
                        50ml.
0966.................  Plasmaprotein                      K   ...........      $464.90  ...........       $92.98
                        fract,5%,250ml.

[[Page 840]]

 
1009.................  Cryoprecip reduced                 K   ...........       $37.39  ...........        $7.48
                        plasma.
1010.................  Blood, L/R, CMV-neg....            K   ...........      $121.78  ...........       $24.36
1011.................  Platelets, HLA-m, L/R,             K   ...........      $499.77  ...........       $99.95
                        unit.
1013.................  Platelet concentrate, L/           K   ...........       $49.52  ...........        $9.90
                        R, unit.
1016.................  Blood, L/R, froz/                  K   ...........      $301.68  ...........       $60.34
                        deglycerol/washed.
1017.................  Platelets, aph/pher, L/            K   ...........      $393.15  ...........       $78.63
                        R, CMV-neg, unit.
1018.................  Blood, L/R, irradiated.            K   ...........      $132.40  ...........       $26.48
1019.................  Platelets, aph/pher, L/            K   ...........      $406.28  ...........       $81.26
                        R, irradiated, unit.
1020.................  Pit, pher,L/R,CMV,irrad            K   ...........      $495.22  ...........       $99.04
1021.................  RBC, frz/deg/wsh, L/R,             K   ...........      $336.04  ...........       $67.21
                        irrad.
1022.................  RBC, L/R, CMV neg,                 K   ...........      $201.12  ...........       $40.22
                        irrad.
1045.................  Iobenguane sulfate I-              K        3.0392      $165.82  ...........       $33.16
                        131per 0.5 mCi.
1064.................  I-131 sodium iodide                K        0.1004        $5.48  ...........        $1.10
                        capsule.
1065.................  I-131 sodium iodide                K        0.1189        $6.49  ...........        $1.30
                        solution.
1079.................  CO 57/58 per 0.5 uCi...            K   ...........      $235.14  ...........       $47.03
1080.................  I-131 tositumomab, dx..            K   ...........    $2,565.55  ...........      $513.11
1081.................  I-131 tositumomab, tx..            K   ...........   $22,210.19  ...........    $4,442.04
1084.................  Denileukin diftitox,               K   ...........    $1,232.88  ...........      $246.58
                        300 MCG.
1086.................  Temozolomide,oral 5 mg.            K   ...........        $6.81  ...........        $1.36
1089.................  Cyanocobalamin cobalt              K   ...........       $47.38  ...........        $9.48
                        co57.
1091.................  IN 111 Oxyquinoline,               K        4.1151      $224.52  ...........       $44.90
                        per .5 mCi.
1092.................  IN 111 Pentetate, per              K   ...........      $237.60  ...........       $47.52
                        0.5 mCi.
1095.................  Technetium TC 99M                  K   ...........      $704.00  ...........      $140.80
                        Depreotide.
1096.................  TC 99M Exametazime, per            K   ...........      $825.00  ...........      $165.00
                        dose.
1122.................  TC 99M arcitumomab, per            K   ...........    $1,144.00  ...........      $228.80
                        vial.
1166.................  Cytarabine liposome....            K   ...........      $344.08  ...........       $68.82
1167.................  Epirubicin hcl, 2 mg...            K   ...........       $25.60  ...........        $5.12
1178.................  Busulfan IV, 6 mg......            K   ...........       $27.87  ...........        $5.57
1200.................  TC 99M Sodium                      K   ...........       $30.28  ...........        $6.06
                        Glucoheptonat.
1201.................  TC 99M SUCCIMER, PER               K   ...........      $125.66  ...........       $25.13
                        Vial.
1203.................  Verteporfin for                    K   ...........    $1,350.80  ...........      $270.16
                        injection.
1207.................  Octreotide injection,              K   ...........       $73.62  ...........       $14.72
                        depd.
1305.................  Apligraf...............            K   ...........    $1,199.00  ...........      $239.80
1409.................  Factor viia                        K   ...........    $1,495.30  ...........      $299.06
                        recombinant, per 1.2
                        mg.
1501.................  New Technology - Level             S   ...........       $25.00  ...........        $5.00
                        I ($0-$50).
1502.................  New Technology - Level             S   ...........       $75.00  ...........       $15.00
                        II ($50-$100).
1503.................  New Technology - Level             S   ...........      $150.00  ...........       $30.00
                        III ($100-$200).
1504.................  New Technology - Level             S   ...........      $250.00  ...........       $50.00
                        IV ($200-$300).
1505.................  New Technology - Level             S   ...........      $350.00  ...........       $70.00
                        V ($300-$400).
1506.................  New Technology - Level             S   ...........      $450.00  ...........       $90.00
                        VI ($400-$500).
1507.................  New Technology - Level             S   ...........      $550.00  ...........      $110.00
                        VII ($500-$600).
1508.................  New Technology - Level             S   ...........      $650.00  ...........      $130.00
                        VIII ($600-$700).
1509.................  New Technology - Level             S   ...........      $750.00  ...........      $150.00
                        IX ($700-$800).
1510.................  New Technology - Level             S   ...........      $850.00  ...........      $170.00
                        X ($800-$900).
1511.................  New Technology - Level             S   ...........      $950.00  ...........      $190.00
                        XI ($900-$1000).
1512.................  New Technology - Level             S   ...........    $1,050.00  ...........      $210.00
                        XII ($1000-$1100).
1513.................  New Technology - Level             S   ...........    $1,150.00  ...........      $230.00
                        XIII ($1100-$1200).
1514.................  New Technology - Level             S   ...........    $1,250.00  ...........      $250.00
                        XIV ($1200-$1300).
1515.................  New Technology - Level             S   ...........    $1,350.00  ...........      $270.00
                        XV ($1300-$1400).
1516.................  New Technology - Level             S   ...........    $1,450.00  ...........      $290.00
                        XVI ($1400-$1500).
1517.................  New Technology - Level             S   ...........    $1,550.00  ...........      $310.00
                        XVII ($1500-$1600).
1518.................  New Technology - Level             S   ...........    $1,650.00  ...........      $330.00
                        XVIII ($1600-$1700).
1519.................  New Technology - Level             S   ...........    $1,750.00  ...........      $350.00
                        IXX ($1700-$1800).
1520.................  New Technology - Level             S   ...........    $1,850.00  ...........      $370.00
                        XX ($1800-$1900).
1521.................  New Technology - Level             S   ...........    $1,950.00  ...........      $390.00
                        XXI ($1900-$2000).
1522.................  New Technology - Level             S   ...........    $2,250.00  ...........      $450.00
                        XXII ($2000-$2500).
1523.................  New Technology - Level             S   ...........    $2,750.00  ...........      $550.00
                        XXIII ($2500-$3000).
1524.................  New Technology - Level             S   ...........    $3,250.00  ...........      $650.00
                        XIV ($3000-$3500).
1525.................  New Technology - Level             S   ...........    $3,750.00  ...........      $750.00
                        XXV ($3500-$4000).
1526.................  New Technology - Level             S   ...........    $4,250.00  ...........      $850.00
                        XXVI ($4000-$4500).
1527.................  New Technology - Level             S   ...........    $4,750.00  ...........      $950.00
                        XXVII ($4500-$5000).
1528.................  New Technology - Level             S   ...........    $5,250.00  ...........    $1,050.00
                        XXVIII ($5000-$5500).
1529.................  New Technology - Level             S   ...........    $5,750.00  ...........    $1,150.00
                        XXIX ($5500-$6000).
1530.................  New Technology - Level             S   ...........    $6,250.00  ...........    $1,250.00
                        XXX ($6000-$6500).
1531.................  New Technology - Level             S   ...........    $6,750.00  ...........    $1,350.00
                        XXXI ($6500-$7000).
1532.................  New Technology - Level             S   ...........    $7,250.00  ...........    $1,450.00
                        XXXII ($7000-$7500).
1533.................  New Technology - Level             S   ...........    $7,750.00  ...........    $1,550.00
                        XXXIII ($7500-$8000).
1534.................  New Technology - Level             S   ...........    $8,250.00  ...........    $1,650.00
                        XXXIV ($8000-$8500).
1535.................  New Technology - Level             S   ...........    $8,750.00  ...........    $1,750.00
                        XXXV ($8500-$9000).

[[Page 841]]

 
1536.................  New Technology - Level             S   ...........    $9,250.00  ...........    $1,850.00
                        XXXVI ($9000-$9500).
1537.................  New Technology - Level             S   ...........    $9,750.00  ...........    $1,950.00
                        XXXVII ($9500-$10000).
1538.................  New Technology - Level             T   ...........       $25.00  ...........        $5.00
                        I ($0-$50).
1539.................  New Technology - Level             T   ...........       $75.00  ...........       $15.00
                        II ($50-$100).
1540.................  New Technology - Level             T   ...........      $150.00  ...........       $30.00
                        III ($100-$200).
1541.................  New Technology - Level             T   ...........      $250.00  ...........       $50.00
                        IV ($200-$300).
1542.................  New Technology - Level             T   ...........      $350.00  ...........       $70.00
                        V ($300-$400).
1543.................  New Technology - Level             T   ...........      $450.00  ...........       $90.00
                        VI ($400-$500).
1544.................  New Technology - Level             T   ...........      $550.00  ...........      $110.00
                        VII ($500-$600).
1545.................  New Technology - Level             T   ...........      $650.00  ...........      $130.00
                        VIII ($600-$700).
1546.................  New Technology - Level             T   ...........      $750.00  ...........      $150.00
                        IX ($700-$800).
1547.................  New Technology - Level             T   ...........      $850.00  ...........      $170.00
                        X ($800-$900).
1548.................  New Technology - Level             T   ...........      $950.00  ...........      $190.00
                        XI ($900-$1000).
1549.................  New Technology - Level             T   ...........    $1,050.00  ...........      $210.00
                        XII ($1000-$1100).
1550.................  New Technology - Level             T   ...........    $1,150.00  ...........      $230.00
                        XIII ($1100-$1200).
1551.................  New Technology - Level             T   ...........    $1,250.00  ...........      $250.00
                        XIV ($1200-$1300).
1552.................  New Technology - Level             T   ...........    $1,350.00  ...........      $270.00
                        XV ($1300-$1400).
1553.................  New Technology - Level             T   ...........    $1,450.00  ...........      $290.00
                        XVI ($1400-$1500).
1554.................  New Technology - Level             T   ...........    $1,550.00  ...........      $310.00
                        XVII ($1500-$1600).
1555.................  New Technology - Level             T   ...........    $1,650.00  ...........      $330.00
                        XVIII ($1600-$1700).
1556.................  New Technology - Level             T   ...........    $1,750.00  ...........      $350.00
                        XIX ($1700-$1800).
1557.................  New Technology - Level             T   ...........    $1,850.00  ...........      $370.00
                        XX ($1800-$1900).
1558.................  New Technology - Level             T   ...........    $1,950.00  ...........      $390.00
                        XXI ($1900-$2000).
1559.................  New Technology - Level             T   ...........    $2,250.00  ...........      $450.00
                        XXII ($2000-$2500).
1560.................  New Technology - Level             T   ...........    $2,750.00  ...........      $550.00
                        XXIII ($2500-$3000).
1561.................  New Technology - Level             T   ...........    $3,250.00  ...........      $650.00
                        XXIV ($3000-$3500).
1562.................  New Technology - Level             T   ...........    $3,750.00  ...........      $750.00
                        XXV ($3500-$4000).
1563.................  New Technology - Level             T   ...........    $4,250.00  ...........      $850.00
                        XXVI ($4000-$4500).
1564.................  New Technology - Level             T   ...........    $4,750.00  ...........      $950.00
                        XXVII ($4500-$5000).
1565.................  New Technology - Level             T   ...........    $5,250.00  ...........    $1,050.00
                        XXVIII ($5000-$5500).
1566.................  New Technology - Level             T   ...........    $5,750.00  ...........    $1,150.00
                        XXIX ($5500-$6000).
1567.................  New Technology - Level             T   ...........    $6,250.00  ...........    $1,250.00
                        XXX ($6000-$6500).
1568.................  New Technology - Level             T   ...........    $6,750.00  ...........    $1,350.00
                        XXXI ($6500-$7000).
1569.................  New Technology - Level             T   ...........    $7,250.00  ...........    $1,450.00
                        XXXII ($7000-$7500).
1570.................  New Technology - Level             T   ...........    $7,750.00  ...........    $1,550.00
                        XXXIII ($7500-$8000).
1571.................  New Technology - Level             T   ...........    $8,250.00  ...........    $1,650.00
                        XXXIV ($8000-$8500).
1572.................  New Technology - Level             T   ...........    $8,750.00  ...........    $1,750.00
                        XXXV ($8500-$9000).
1573.................  New Technology - Level             T   ...........    $9,250.00  ...........    $1,850.00
                        XXXVI ($9000-$9500).
1574.................  New Technology - Level             T   ...........    $9,750.00  ...........    $1,950.00
                        XXXVII ($9500-$10000).
1600.................  Technetium TC 99m                  K   ...........      $112.73  ...........       $22.55
                        sestamibi.
1603.................  Thallous chloride TL               K   ...........       $18.29  ...........        $3.66
                        201/mci.
1604.................  IN 111 capromab                    K   ...........    $2,030.60  ...........      $406.12
                        pendetide, per dose.
1605.................  Abciximab injection, 10            K   ...........      $475.22  ...........       $95.04
                        mg.
1606.................  Anistreplase, 30 u.....            K   ...........    $2,495.31  ...........      $499.06
1607.................  Eptifibatide injection,            K   ...........       $11.88  ...........        $2.38
                        5mg.
1608.................  Etanercept injection...            K   ...........      $143.73  ...........       $28.75
1609.................  Rho(D) immune globulin             K   ...........       $19.03  ...........        $3.81
                        h, sd, 100 iu.
1611.................  Hylan G-F 20 injection,            K   ...........      $215.97  ...........       $43.19
                        16 mg.
1612.................  Daclizumab, parenteral,            K   ...........      $393.78  ...........       $78.76
                        25 mg.
1613.................  Trastuzumab, 10 mg.....            K   ...........       $53.85  ...........       $10.77
1614.................  Valrubicin, 200 mg.....            K   ...........      $487.87  ...........       $97.57
1615.................  Basiliximab, 20 mg.....            K   ...........    $1,425.06  ...........      $285.01
1618.................  Vonwillebrandfactrcmplx            K   ...........        $0.46  ...........        $0.09
                        , per iu.
1619.................  Gallium ga 67..........            K        0.2056       $11.22  ...........        $2.24
1620.................  Technetium tc99m                   K   ...........      $392.93  ...........       $78.59
                        bicisate.
1622.................  Technetium tc99m                   K   ...........    $1,650.00  ...........      $330.00
                        mertiatide.
1624.................  Sodium phosphate p32...            K   ...........       $66.44  ...........       $13.29
1625.................  Indium 111-in                      K   ...........    $1,144.00  ...........      $228.80
                        pentetreotide.
1628.................  Chromic phosphate p32..            K   ...........       $81.27  ...........       $16.25
1716.................  Brachytx source, Gold              H   ...........  ...........  ...........  ...........
                        198.
1717.................  Brachytx source, HDR Ir-           H   ...........  ...........  ...........  ...........
                        192.
1718.................  Brachytx source, Iodine            H   ...........  ...........  ...........  ...........
                        125.
1719.................  Brachytx source,Non-HDR            H   ...........  ...........  ...........  ...........
                        Ir-192.
1720.................  Brachytx source,                   H   ...........  ...........  ...........  ...........
                        Palladium 103.
1775.................  FDG, per dose (4-40 mCi/           K        5.9471      $324.48  ...........       $64.90
                        ml).
1783.................  Ocular implant, aqueous            H   ...........  ...........  ...........           $-
                        drain device.
1814.................  Retinal Tamp, silicone             H   ...........  ...........  ...........           $-
                        oil.
1818.................  Integrated                         H   ...........  ...........  ...........           $-
                        keratoprosthesis.
1819.................  Tissue localization-               H   ...........  ...........  ...........           $-
                        excision dev.

[[Page 842]]

 
1884.................  Embolization Protect               H   ...........  ...........  ...........           $-
                        syst.
1888.................  Catheter, ablation, non-           H   ...........  ...........  ...........           $-
                        cardiac, endovascular
                        (implantable).
1900.................  Lead coronary venous...            H   ...........  ...........  ...........           $-
2614.................  Probe, percutaneous                H   ...........  ...........  ...........           $-
                        lumbar disc.
2616.................  Brachytx source,                   H   ...........  ...........  ...........  ...........
                        Yttrium-90.
2632.................  Brachytx sol, I-125,               H   ...........  ...........  ...........           $-
                        per mCi.
2633.................  Brachytx source, Cesium-           H   ...........  ...........  ...........  ...........
                        131.
7000.................  Amifostine, 500 mg.....            K   ...........      $419.59  ...........       $83.92
7007.................  Inj milrinone lactate,             K        0.2129       $11.62  ...........        $2.32
                        per 5 mg.
7011.................  Oprelvekin injection, 5            K   ...........      $248.16  ...........       $49.63
                        mg.
7015.................  Busulfan, oral, 2 mg...            K   ...........        $1.93  ...........        $0.39
7019.................  Aprotinin, 10,000 kiu..            K   ...........       $13.26  ...........        $2.65
7024.................  Corticorelin ovine                 K   ...........      $375.00  ...........       $75.00
                        triflutat.
7025.................  Digoxin immune FAB                 K   ...........        $1.79  ...........        $0.36
                        (ovine).
7026.................  Ethanolamine oleate 100            K   ...........       $67.10  ...........       $13.42
                        mg.
7027.................  Fomepizole, 15mg.......            K   ...........       $10.65  ...........        $2.13
7028.................  Fosphenytoin, 50 mg....            K   ...........        $5.63  ...........        $1.13
7030.................  Hemin, per 1 mg........            K   ...........        $6.86  ...........        $1.37
7031.................  Octreotide acetate                 K   ...........        $3.94  ...........        $0.79
                        injection.
7034.................  Somatropin injection...            K   ...........      $297.79  ...........       $59.56
7035.................  Teniposide, 50 mg......            K   ...........      $238.49  ...........       $47.70
7036.................  Urokinase 250,000 iu               K        3.7855      $206.54  ...........       $41.31
                        inj.
7037.................  Urofollitropin, 75 iu..            K        1.1634       $63.48  ...........       $12.70
7038.................  Muromonab-CD3, 5 mg....            K   ...........      $792.33  ...........      $158.47
7040.................  Pentastarch 10%                    K   ...........      $139.94  ...........       $27.99
                        solution.
7041.................  Tirofiban hydrochloride            K   ...........      $436.66  ...........       $87.33
                        12.5 mg.
7042.................  Capecitabine, oral, 150            K   ...........        $3.14  ...........        $0.63
                        mg.
7043.................  Infliximab injection 10            K   ...........       $31.81  ...........        $6.36
                        mg.
7045.................  Trimetrexate                       K   ...........      $132.00  ...........       $26.40
                        glucoronate.
7046.................  Doxorubicin hcl                    K   ...........      $364.49  ...........       $72.90
                        liposome inj 10 mg.
7048.................  Alteplase recombinant..            K        0.2856       $15.58  ...........        $3.12
7049.................  Filgrastim 480 mcg                 K   ...........      $290.93  ...........       $58.19
                        injection.
7051.................  Leuprolide acetate                 K   ...........    $5,001.92  ...........    $1,000.38
                        implant, 65 mg.
7316.................  Sodium hyaluronate                 K   ...........       $67.16  ...........       $13.43
                        injection.
9001.................  Linezolid injection....            K   ...........       $34.09  ...........        $6.82
9002.................  Tenecteplase, 50mg/vial            K   ...........    $2,492.60  ...........      $498.52
9003.................  Palivizumab, per 50mg..            K   ...........      $611.24  ...........      $122.25
9004.................  Gemtuzumab ozogamicin              K   ...........    $2,022.90  ...........      $404.58
                        inj,5mg.
9005.................  Reteplase injection....            K   ...........    $1,263.90  ...........      $252.78
9006.................  Tacrolimus injection...            K   ...........      $110.04  ...........       $22.01
9008.................  Baclofen Refill Kit-               K   ...........       $73.92  ...........       $14.78
                        500mcg.
9009.................  Baclofen refill kit -              K        0.7499       $40.92  ...........        $8.18
                        per 2000 mcg.
9010.................  Baclofen refill kit -              K   ...........       $79.82  ...........       $15.96
                        per 4000 mcg.
9012.................  Arsenic Trioxide.......            K   ...........       $34.32  ...........        $6.86
9013.................  Co 57 cobaltous                    K   ...........       $56.67  ...........       $11.33
                        chloride.
9015.................  Mycophenolate mofetil              K   ...........        $1.36  ...........        $0.27
                        oral 250 mg.
9018.................  Botulinum toxin B, per             K   ...........        $8.14  ...........        $1.63
                        100 u.
9019.................  Caspofungin acetate, 5             K   ...........       $30.52  ...........        $6.10
                        mg.
9020.................  Sirolimus tablet, 1 mg.            K   ...........        $6.60  ...........        $1.32
9021.................  Immune globulin 10 mg..            K   ...........        $0.41  ...........        $0.08
9022.................  IM inj interferon beta             K   ...........       $13.36  ...........        $2.67
                        1-a.
9023.................  Rho d immune globulin              K   ...........       $32.21  ...........        $6.44
                        50 mcg.
9024.................  Amphotericin B, lipid              K   ...........       $20.86  ...........        $4.17
                        formulation.
9025.................  Radiopharms Used to                K   ...........      $162.63  ...........       $32.53
                        Image Perfusion of
                        Heart.
9100.................  Iodinated I-131albumin,            K   ...........       $48.58  ...........        $9.72
                        per 5 uci.
9104.................  Anti-thymocycte                    K   ...........      $331.23  ...........       $66.25
                        globulin rabbit.
9105.................  Hep B imm glob, per 1              K   ...........       $65.58  ...........       $13.12
                        ml.
9108.................  Thyrotropin alfa, per              K   ...........      $572.00  ...........      $114.40
                        1.1 mg.
9109.................  Tirofliban hcl, per                K   ...........      $218.33  ...........       $43.67
                        6.25 mg.
9110.................  Alemtuzumab, per 10 mg.            K   ...........      $541.46  ...........      $108.29
9111.................  Inj, bivalirudin, per              G   ...........        $1.61  ...........        $0.32
                        250 mg vial.
9112.................  Perflutren lipid micro,            G   ...........      $137.28  ...........       $27.46
                        per 2ml.
9113.................  Inj, pantoprazole                  G   ...........       $23.23  ...........        $4.65
                        sodium, vial.
9114.................  Nesiritide, per 0.5 mg             G   ...........      $140.45  ...........       $28.09
                        vial.
9115.................  Inj, zoledronic acid,              G   ...........      $211.07  ...........       $42.21
                        per 1 mg.
9116.................  Inj, Ertapenem sodium,             G   ...........       $21.99  ...........        $4.40
                        per 500 mg.
9117.................  Yttrium 90 ibritumomab             K   ...........   $22,210.19  ...........    $4,442.04
                        tiuxetan.
9118.................  In-111 ibritumomab                 K   ...........    $2,565.55  ...........      $513.11
                        tiuxetan.

[[Page 843]]

 
9119.................  Pegfilgrastim, per 1 mg            G   ...........    $2,596.00  ...........      $519.20
9120.................  Inj, Fulvestrant, per              G   ...........       $78.36  ...........       $13.09
                        50 mg.
9121.................  Inj, Argatroban, per 5             G   ...........       $14.63  ...........        $2.44
                        mg.
9122.................  Inj, Triptorelin                   G   ...........      $356.66  ...........       $59.58
                        pamoate, per 3.75 mg.
9123.................  Transcyte, per 247 sq              G   ...........      $689.78  ...........      $115.23
                        cm.
9200.................  Orcel, per 36 cm2......            G   ...........    $1,051.60  ...........      $210.32
9201.................  Dermagraft, per 37.5 sq            G   ...........      $535.04  ...........      $107.01
                        cm.
9202.................  Octafluoropropane......            K   ...........      $137.28  ...........       $27.46
9203.................  Perflexane lipid micro.            G   ...........      $127.50  ...........       $21.30
9204.................  Ziprasidone mesylate...            G   ...........       $18.60  ...........        $3.11
9205.................  Oxaliplatin............            G   ...........        $8.45  ...........       $14.12
9207.................  Injection, bortezomib..            G   ...........    $1,039.68  ...........      $155.40
9208.................  Injection, agalsidase              G   ...........      $123.78  ...........       $18.50
                        beta.
9209.................  Injection, laronidase..            G   ...........      $644.10  ...........       $96.28
9210.................  Injection, palonosetron            G   ...........      $307.80  ...........       $46.01
                        HCL.
9211.................  Inj, alefacept, IV.....            G   ...........      $595.00  ...........       $99.40
9212.................  Inj, alefacept, IM.....            G   ...........      $422.88  ...........       $70.65
9217.................  Leuprolide acetate                 K   ...........      $576.47  ...........      $115.29
                        suspnsion, 7.5 mg.
9500.................  Platelets, irradiated..            K   ...........       $74.79  ...........       $14.96
9501.................  Platelets, pheresis....            K   ...........      $408.81  ...........       $81.76
9502.................  Platelet pheresis                  K   ...........      $443.68  ...........       $88.74
                        irradiated.
9503.................  Fresh frozen plasma, ea            K   ...........       $69.74  ...........       $13.95
                        unit.
9504.................  RBC deglycerolized.....            K   ...........      $183.44  ...........       $36.69
9505.................  RBC irradiated.........            K   ...........      $108.65  ...........       $21.73
9506.................  Granulocytes, pheresis.            K   ...........    $1,248.66  ...........      $249.73
----------------------------------------------------------------------------------------------------------------


   Addendum D1.--Payment Status Indicators for the Hospital Outpatient
                       Prospective Payment System
------------------------------------------------------------------------
     Indicator          Item/Code/Service             Explanation
------------------------------------------------------------------------
A.................  Services furnished to a    Not paid under OPPS. Paid
                     Hospital Outpatient that   by Intermediaries under
                     are paid under a Fee       a Fee Schedule/Payment
                     Schedule/Payment System    System other than OPPS.
                     other than OPPS, e.g.:
                    [sbull] Ambulance
                     Services.
                    [sbull] Clinical
                     Diagnostic Laboratory
                     Services.
                    [sbull] Non-Implantable
                     Prosthetic and Orthotic
                     Devices.
                    [sbull] EPO for ESRD
                     Patients.
                    [sbull] Physical,
                     Occupational and Speech
                     Therapy.
                    [sbull] Routine Dialysis
                     Services for ESRD
                     Patients Provided in a
                     Certified Dialysis Unit
                     of a Hospital.
                    [sbull] Screening
                     Mammography.
B.................  Codes that are not         Not paid under OPPS.
                     recognized by OPPS when   [sbull] May be paid by
                     submitted on an            Intermediaries when
                     Outpatient Hospital Part   submitted on a different
                     B bill type (12x, 13x,     bill type, e.g., 75x
                     and 14x).                  (CORF), but not paid
                                                under OPPS.
                                               [sbull] An alternate code
                                                that is recognized by
                                                OPPS when submitted on
                                                an Outpatient Hospital
                                                Part B bill type (12x,
                                                13x, and 14x) may be
                                                available.
C.................  Inpatient Procedures.....  Not paid under OPPS.
                                                Admit patient; Bill as
                                                Inpatient.
D.................  Deleted Codes............  Not paid under OPPS. Not
                                                paid under Medicare.
E.................  Items, Codes, and
                     Services:
                    [sbull] That are not
                     covered by Medicare
                     based on Statutory
                     Exclusion.
                    [sbull] That are not
                     covered by Medicare for
                     reasons other than
                     Statutory Exclusion.
                    [sbull] That are not
                     recognized by Medicare
                     but for which an
                     alternate code for the
                     same item or service may
                     be available.
                    [sbull] For which
                     separate payment is not
                     provided by Medicare Not
                     paid under OPPS.
F.................  Corneal Tissue             Not paid under OPPS. Paid
                     Acquisition; Certain       at reasonable cost.
                     CRNA Services.
G.................  Drug/Biological Pass-      Paid under OPPS; Separate
                     Through.                   APC payment includes
                                                Pass-Through amount.
H.................  Device Category Pass-      Paid under OPPS; Separate
                     Through and                cost-based
                     Brachytherapy Source.
K.................  Non Pass-Through Drugs     Paid under OPPS; Separate
                     and Biologicals;           APC payment.
                     Radiopharmaceutical
                     Agents.
L.................  Influenza Vaccine;         Not paid under OPPS. Paid
                     Pneumococcal Pneumonia     at reasonable cost; Not
                     Vaccine.                   subject to deductible or
                                                coinsurance.
N.................  Items and Services         Paid under OPPS. However,
                     packaged into APC Rates.   payment is packaged into
                                                payment for other
                                                services, including
                                                Outliers. Therefore,
                                                there is no separate APC
                                                payment.

[[Page 844]]

 
P.................  Partial Hospitalization..  Paid under OPPS; Per diem
                                                APC payment.
S.................  Significant Procedure,     Paid under OPPS; Separate
                     Not Discounted when        APC payment.
                     Multiple.
T.................  Significant Procedure,     Paid under OPPS; Separate
                     Multiple Procedure         APC payment.
                     Reduction Applies.
V.................  Clinic or Emergency        Paid under OPPS; Separate
                     Department Visit.          APC payment.
Y.................  Non-Implantable Durable    Not paid under OPPS. All
                     Medical Equipment.         institutional providers
                                                other than Home Health
                                                Agencies bill to DMERC.
X.................  Ancillary Service........  Paid under OPPS; Separate
                                                APC payment.
------------------------------------------------------------------------

[FR Doc. 03-32322 Filed 12-31-03; 12:00 pm]
BILLING CODE 4120-01-P