This information is provided free of charge by the Department of Industrial Relations from its web site at www.dir.ca.gov. These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at https://www.dir.ca.gov/od_pub/disclaimer.html.
 
Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director - Administrative Rules
Article 5.3. Official Medical Fee Schedule

New Query

§ 9789.39. Update Table by Date of Service.

(a) Federal Regulations by Date of Service--For services rendered before March 1, 2021.
The Federal Regulations can be accessed at: http://www.cms.gov/HospitalOutpatientPPS/ and the referenced sections are incorporated by reference and will be made available upon request to the Administrative Director.
Services Occurring On or After 7/15/2005
Services Occurring On or After 2/15/2006
Services Occurring On or After 3/1/2007
Services Occurring On or After 3/1/2008
Title 42, Code of Federal
Regulations, § 419.2
Title 42, Code of Federal
Regulations, § 419.32
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.43
January 1, 2006
January 1, 2007
January 1, 2008
Title 42, Code of Federal
Amended; effective
Regulations, § 419.44
January 1, 2008
Title 42, Code of Federal
Regulations, § 419.62
Title 42, Code of Federal
As amended; effective
Regulations, § 419.64
January 1, 2005
Title 42, Code of Federal
As amended; effective
Regulations, § 419.66
January 1, 2006
Services Occurring On or After 3/1/2009
Services Occurring On or After 4/15/2010
Services Occurring On or After 9/15/2011
Services Occurring On or After 3/1/2012
Title 42, Code of Federal
Regulations, § 419.2
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, § 419.32
January 1, 2011
January 1, 2012
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.43
January 1, 2009
January 1, 2011
January 1, 2012
Title 42, Code of Federal
Regulations, § 419.44
Title 42, Code of Federal
Regulations, § 419.62
Title 42, Code of Federal
As amended; effective
Regulations, § 419.64
January 1, 2010
Title 42, Code of Federal
As amended; effective
Regulations, § 419.66
January 1, 2010
Services Occurring On or After 4/1/2013
Services Occurring On or After 12/1/2014
Services Occurring On After December 15, 2016
or Services Occurring On or After June 1, 2017
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.2
January 1, 2013
January 1, 2014
January 1, 2016
January 1, 2016
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.32
January 1, 2013
January 1, 2014
January 1, 2016
January 1, 2017
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, § 419.43
January 1, 2012
January 1, 2017
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, § 419.44
January 1, 2016
January 1, 2017
Title 42, Code of Federal
Effective January 1, 2004
Effective January 1, 2004
Regulations, § 419.62
Title 42, Code of Federal
As amended; effective
As amended; effective
Regulations, § 419.64
January 1, 2015
January 1, 2015
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.66
January 1, 2014
January 1, 2016
January 1, 2017
Services Occurring On or After March 15, 2018
Services Occurring On or After February 15, 2019
Services Occuring On or After March 1, 2020
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.2
January 1, 2016
January 1, 2016
January 1, 2016
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.32
January 1, 2018
January 1, 2019
January 1, 2020
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.43
January 1, 2017
January 1, 2017
January 1, 2017
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.44
January 1, 2017
January 1, 2017
January 1, 2017
Title 42, Code of Federal
Effective January 1, 2004
Effective January 1, 2004
Effective January 1, 2004
Regulations, § 419.62
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.64
January 1, 2015
January 1, 2015
January 1, 2015
Title 42, Code of Federal
As amended; effective
As amended; effective
As amended; effective
Regulations, § 419.66
January 1, 2017
January 1, 2017
January 1, 2020
Title 42, Code of Federal
Effective January 1, 2018
Effective January 1, 2018
Effective January 1, 2018
Regulations, § 419.71
(b) Update factors and Federal Register Notices by Date of Service
The Federal Register Notices can be accessed at: https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient and the referenced sections are incorporated by reference and will be made available upon request to the Administrative Director. The Federal Regulations can be accessed at: https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient and the referenced sections are incorporated by reference and will be made available upon request to the Administrative Director.
Services Occurring On or After 1/1/2004
Services Occurring On or After 7/15/2005
Services Occurring On or After 2/15/2006
Services Occurring On or After 3/1/2007
Applicable FR Notices
(A) November 7, 2003
(A) November 15, 2004
(A) November 10, 2005
(A) November 24, 2006
(CMS-1471-FC;
(CMS-1427-FC;
(CMS-1501-FC;
(CMS-1506-FC;
68 FR 63398);
69 FR 65681);
70 FR 68515);
71 FR 67960);
(B) December 31, 2003
(B) December 30, 2004
(B) December 23, 2005
(B) August 18, 2006
(CMS-1471-CN;
(CMS-1427-CN;
(CMS-1501-CN2;
(CMS-1488-F;
68 FR 75442);
69 FR 78315;
70 FR 76176);
71 FR 47870)
(C) January 6, 2004
(C) August 11, 2004
(C) August 12, 2005
(C) October 11, 2006
(CMS-1371-IFC;
(CMS-1428-F;
(CMS-1500-F;
(CMS-1488-N;
69 FR 820);
69 FR 48916);
70 FR 47278);
71 FR 59886)
(D) August 1, 2003
(D) December 30, 2004
(D) September 30, 2005
(CMS-1470-F;
(CMS-1482-F2;
(CMS-1500-CN;
68 FR 45346);
69 FR 78526
70 FR 57161)
(E) August 11, 2003 (CMS-1470-F; 68 FR 47637)
APC Payment Rate
Addendum B
Addendum B
Addendum B
Addendum B
(A) beginning on page
(A) beginning on
(A) beginning on
(A) beginning on
63488 conformed to comply with
page 65887
page 68752
page 68283
(B) beginning on page 75442 and (C) beginning on page 820
APC Relative Weight
Addendum B
Addendum B
Addendum B
Addendum B
(A) beginning on page
(A) beginning on
(A) beginning on
(A) beginning on
63488 conformed to comply with
page 65887
page 68752
page 68283
(B) beginning on page 75442 and (C) beginning on page 820
Emergency Department
99281-99285
99281-99285
99281-99285
99281-99285
HCPCS Codes
HOPPS Addenda
Addenda A, B, D1, D2, E,
Addenda A, B, D1, D2,
Addenda A, B, D1, D2,
Addenda A, B, D1, D2,
H, I, and J (A) beginning
and E (A) beginning at
E and L (A) beginning
at E, and L (A) beginning
at page 63478; as changed by
page 65864
page 68729; and correction
at page 68231
(B) beginning at page 75442;
(B) beginning at page 76176
and (C) beginning at page 820
IPPS Tables
Tables 4A1, 4A2, 4B1, 4B2,
Tables 4A, 4B, 4C,
Tables 4A-1, 4A-2, 4B-1,
4C1, 4C2 and 4J (D)
and 4J (D) beginning at
4B-2, 4C-1, 4C-2, and 4J
beginning at page 78619
page 57163; and Tables
(C) beginning at page 59975
4A, 4B, 4C, and 4J (C) beginning on page 47580
Labor-related Share
60% ((A) page 63458)
60% ((A) beginning at
60% ((A) beginning at
60% ((A) beginning at
page 65842)
page 68551)
page 68003)
Market Basket
3.4% (D) page 45346
3.3% (C) page 49274
3.7% (C) page 47492
3.4% (B) page 48146
Inflation Factor
Outlier Threshold
$1,175 (A) at page 65846
$1,250 (A) at page 68565
$1,825(A) at page 68012
Surgical Procedure
10021-69990
10021-69990
10021-69990
10021-69990
HCPCS
Conversion Factor adjusted
$53.924 (2003 unadjusted
$55.703 (2004 unadjusted
$57.764 (2005 unadjusted
$59.728 (2006 unadjusted
for inflation factor
conversion factor of
conversion factor of
conversion factor of
conversion factor of
52.151 x estimated inflation
$53.924 x estimated
$55.703 x estimated
$57.764 x estimated
factor of 1.034)
inflation factor of 1.033)
inflation factor of 1.037)
inflation factor of 1.034)
Wage Index
Addenda H through J
Referenced in Addenda H
Referenced in (A)
Referenced in (A)
(A) beginning at page 63682
through J (B) beginning at page 78316; wage index values are specified in Tables 4A1 through 4C2 (D) beginning at page 78619
beginning at page 68551; wage index values are specified in Tables 4A through 4C (D) beginning at page 57163; and as specified in Tables 4A through 4C (C) beginning at page 47580
beginning at page 68003; wage index values are specified in Tables 4A-1 through 4C-2 (C) beginning at page 59975
Services Occurring On or After 3/1/2008
Services Occurring On or After 3/1/2009
Services Occurring On or After 4/15/2010
Services Occurring On or After 9/15/2011
Applicable FR Notices
(A) November 27, 2007
(A) November 18, 2008
(A) November 20, 2009
(A) November 24, 2010
(CMS-1392-FC;
(CMS-1404-FC;
(CMS-1414-FC;
(CMS-1504-FC;
CMS-1533-F2;
73 FR 68502);
74 FR 60316);
75 FR 71800);
72 FR 66580);
(B) August 19, 2008
(B) December 31, 2009
(B) March 11, 2011
(B) August 22, 2007
(CMS-1390-F;
(CMS-1414-CN;
(CMS-1504-CN;
(CMS-1533-FC;
73 FR 48434);
74 FR 69502);
76 FR 13292);
72 FR 47130);
(C) October 3, 2008
(C) August 27, 2009
(C) August 16, 2010
(C) October 10, 2007
(CMS-1390-CN;
(CMS-1406-F;
(CMS-1498-F;
(CMS-1533-CN2;
73 FR 57541);
74 FR 43754);
75 FR 50042);
72 FR 57634);
(D) October 3, 2008
(D) October 7, 2009
(D) October 1, 2010
(D) November 6, 2007
(CMS-1390-N;
(CMS-1406-CN;
(CMS-1498-F;
(CMS-1533-CN3;
73 FR 57888);
74 FR 51496)
75 FR 60640)
72 FR 62585);
(E) December 3, 2008
(E) November 27, 2007
(CMS-1390-N2;
(CMS-1392-FC;
73 FR 73656);
CMS-1533-F2;
(F) January 26, 2009
72 FR 66580);
(CMS-1404-CN;
(F) February 22, 2008
74 FR 4343)
(CMS-1392-CN; CMS-1533-CN)
APC Payment Rate
Addendum B
Addendum B
Addendum B
Addendum B
(A) beginning on
(A) beginning on
(A) beginning on
(A) beginning on
page 66993 conformed to
page 68934
page 60752
page 72331
comply with correction
conformed to comply with
conformed to comply with
conformed to comply with
published in
correction published in
correction published in
correction published in
(F) beginning on page 9863
(F) beginning on page 4344
(B) page 69503
(B) page 13295
APC Relative Weight
Addendum B
Addendum B
Addendum B
Addendum B
(A) beginning on
(A) beginning on
(A) beginning on
(A) beginning on
page 66993 conformed to
page 68934 conformed to
page 60752 conformed to
page 72331 conformed to
comply with correction
comply with correction
comply with correction
comply with correction
published in
published in
published in
published in
(F) beginning on page 9863
(F) beginning on page 4344
(B) page 69503
(B) page 13295
Emergency Department
99281-99285
99281-99285
99281-99285
99281-99285
HCPCS Codes
HOPPS Addenda
Addenda A, B, D1, D2,
Addenda A, B, D1, D2,
Addenda A, B, D1, D2,
Addenda A, B, D1, D2,
E, L, and M (A) beginning
E, L, and M (A) beginning
E, L, and M (A) beginning
E, L, and M (A) beginning
at page 66934; and
at page 68816; and
at page 60682; and
at page 72268; and
corrections to addenda A,
corrections to addenda
corrections to addenda B
corrections to addendum B
B, D2, and M (F) beginning at page 9862
A and B (F) beginning
and E (B) beginning
(B) on page 13295
at page 4343
at page 69503
IPPS Tables
Tables 4A, 4B, and 4C
Tables 4A, 4B, 4C, and 4J
Tables 2, 4A, 4B, 4C, and 4J
Tables 2, 4A, 4B, 4C, and 4J
(C) beginning at page 57698
(C) beginning at page 57956;
(C) beginning at page 44032;
(C) beginning at page 50451
and Table 4J (B) beginning
and Tables 2 and 4J
as changed by correction to
at page 47531 and correction
(E) beginning at page 73657
Tables 2, 4A, 4B, 4C, and 4J
(C) beginning at page 57726
(D) beginning at page 51499
Labor-related Share
60% ((A) beginning at
60% ((A) beginning at
60% ((A) beginning at
60% ((A) beginning at
page 66678)
page 68585)
page 60419)
page 71877)
+
Market Basket Inflation Factor
3.3% (B) page 47415
3.6% (B) page 48759
2.1% (C) page 44002
2.6% (C) page 50422
Outlier Threshold
$1,575 (A) at page 66686
$1,800 (A) at page 68594
$2,175 (A) at page 60428
$2,025 (A) at page 71889
Surgical Procedure
10021-69990
10021-69990
10021-69990
10021-69990
HCPCS
Conversion Factor adjusted
$61.699 (2007 unadjusted
$63.920 (2008 unadjusted
$65.262 (2009 unadjusted
$66.959 (2010 unadjusted
for inflation factor
conversion factor of
conversion factor of
conversion factor of
conversion factor of
$59.728 x estimated
$61.699 x estimated
$63.920 x estimated
$65.262 x estimated
inflation factor of 1.033)
inflation factor of 1.036)
inflation factor of 1.021)
inflation factor of 1.026)
Wage Index
Referenced in (A)
Referenced in (A)
Referenced in (A)
Referenced in (A)
beginning at page 66678;
beginning at page 68585;
beginning at page 60419;
beginning at page 71877;
wage index values are
wage index values are
wage index values are
wage index values are
specified in Tables 4A through 4C
specified in Tables 4A through 4C
specified in Tables 4A through 4C
specified in Tables 4A through 4C
(C) beginning at page 57698
(D) beginning at page 57956
(D) beginning at page 51505; and as specified in Tables 4A through 4C (C) beginning at page 44085
(C) beginning at page 50511
Services Occurring On or After 3/1/2012
Services Occurring On or After 9/1/2012
Services Occurring On or After 4/1/2013
Services Occurring On or After 9/1/2014
Applicable FR Notices
(A) November 30, 2011
(A) November 30, 2011
(A) November 15, 2012
(CMS-1525-FC;
(CMS-1525-FC;
(CMS-1589-FC;
76 FR 74122);
76 FR 74122);
77 FR 68210)
(B) January 4, 2012
(B) January 4, 2012
(CMS-1525-CN;
(CMS-1525-CN;
77 FR 217);
77 FR 217);
(C) August 18, 2011
(C) August 18, 2011
(CMS-1518-F;
(CMS-1518-F;
76 FR 51476);
76 FR 51476);
(D) September 26, 2011
(D) September 26, 2011
(CMS-1518-CN3;
(CMS-1518-CN3;
76 FR 59263)
76 FR 59263);
(E) April 24, 2012 (CMS-1525-CN2; 77 FR 24409)
APC Payment Rate
Addendum B (A) conformed to comply with correction published in (B) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
Addendum B (A) conformed to comply with corrections published in (B) and (E) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
Addendum B (A) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
APC Relative Weight
Addendum B (A) conformed to comply with correction published in (B) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
Addendum B (A) conformed to comply with corrections published in (B) and (E) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
Addendum B (A) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
Emergency Department
99281-99285
99281-99285
99281-99285
99281-99285,
HCPCS Codes
99291, 99292, G0380-G0384, G0390
Facility Only Services
Services with a “NA” in the column labeled “Non-Facility NA Indicator” of the Medicare Physician Fee Schedule Relative Value File for Calendar Year 2014 (RVU14A), located at: http://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html
HOPPS Addenda
Addenda A, B, D1, D2, E, L, and M (A) and corrections to addenda (B) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
Addenda A, B, D1, D2, E, L, and M (A and E) and corrections to addenda (A) and (B) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
Addenda A, B, D1, D2, E, L, and M (A) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
IPPS Tables
Tables 2, 4A, 4B, 4C, and 4J (C) and correction (D) found on CMS website at: http://www. cms.hhs.gov/
AcuteInpatientPPS/.
Tables 2, 4A, 4B, 4C, and 4J (C) and correction (D) found on CMS website at: http://www. cms.hhs.gov/
AcuteInpatientPPS/.
Labor-related Share
60% ((A) beginning at page 74191)
60% (A) beginning at page 68285
Market Basket Inflation Factor
3.0% (A) page 74189
2.6% (A) page 68215
Medicare Physician Fee
Calendar Year 2014
Schedule Relative Value File
(RVU14A), located at: http://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html
Outlier Threshold
$2,025 (B) at page 222
$2,025 (A) page 68297
Surgical Procedure HCPCS
10021-69990
10021-69990
10021-69990
10021-69990, G0413
Conversion Factor adjusted
$68.968 (2011 unadjusted
$70.761 (2012 unadjusted
for inflation factor
conversion factor of
conversion factor of
$66.959 x estimated inflation factor of 1.03)
$68.968 x estimated inflation factor of 1.026)
Wage Index
Referenced in (A) beginning at page 74191; wage index values are specified in Tables 4A through 4C (C) found on the CMS web site at: http://www. cms.
gov/AcuteInpatientPPS/
Referenced in (A) beginning at page 68285; wage index values are specified in Tables 4A through 4C found on the CMS web site at: http://www. cms.gov/
AcuteInpatientPPS/
Services Occurring On or After 12/1/2014
Services Occurring On or After December 15, 2016 and Mid-year Updates
Services Occurring On or After June 1, 2017 and Mid-year Updates
Services Occurring On or After March 15, 2018 and Mid-year Updates
Applicable FR Notices
(A) December 10, 2013
(CMS-1601-FC; 78 FR 74826)
(A) November 13, 2015
(CMS-1633-FC; 80 FR 70298)
(A) November 14, 2016
(CMS-1656-FC; 81 FR 79562)
(A) December 14, 2017
(CMS-1678-FC; 82 FR 59216, Republication)
(B) August 19, 2013
(CMS-1599-F; 78 FR 50496)
(B) August 17, 2015
(CMS-1632-F; 80 FR 49326)
(B) January 3, 2017
(CMS-1656-CN; 82 FR 24)
(B) December 27, 2017
(CMS-1678-CN; 82 FR 61184)
(C) October 3, 2013
(CMS-1599-CN2; 78 FR 61197)
(C) October 5, 2015
(CMS 1632-CN; 80 FR 60055)
(C) August 22, 2016
(CMS-1655-F; 81 FR 56762)
(C) August 14, 2017
(CMS-1677-F; 82 FR 37990)
(D) October 3, 2013
(CMS-1599-IFC; 78 FR 61191)
(D) October 5, 2016
(CMS-1655-F Correction; 81 FR 68947)
(D) October 4, 2017
(CMS-1677-CN;82 FR 46138; Final rule; correction)
(E) January 2, 2014 (CMS-1599-CN3; 79 FR 61)
(F) January 10, 2014 (CMS-1599-CN4; 79 FR 1741)
(G) March 14, 2014 (CMS-1599-IFC2; 79 FR 15022)
(H) June 17, 2014; (CMS-1599-N; 79 FR 34444)
Ambulatory Surgical
For services rendered on
For services occurring on
For services occurring on
Centers Payment System
or after December 15,
or after June 1, 2017,
or after March 15 2018,
Addenda
2016, Column A, of
Column A, of
Column A, of
Addendum AA, entitled,
Addendum AA, entitled,
Addendum AA, entitled,
“HCPCS Code” and
“HCPCS Code” and
“HCPCS Code” and
Column A, of
Column A, of
Column A, of
Addendum EE entitled,
Addendum EE entitled,
Addendum EE entitled,
“HCPCS Code” located in
“HCPCS Code” located in
“HCPCS Code” located in
“July 2016 ASC Approved
“April 2017 ASC
“Correction Notice
HCPCS Code and
Approved HCPCS Code
Addendum AA, BB, DD1,
Payment Rates” found
and Payment Rates”
DD2, EE” (CMS-1678-
on CMS website at:
(april_2017_asc_addenda_
CN-ASC-Addendum-
https://www. cms.gov/
rev_20170329)
AA-BB-DD1-DD2-
Medicare/Medicare-
Fee-for-Service-Payment/
EE.zip)
ASCPayment/index.htm
For services occurring on
For services occurring on
or after July 1 2017,
or after April 1 2018,
Column A, of
Column A, of
Addendum AA, entitled,
Addendum AA, entitled,
“HCPCS Code” and
“HCPCS Code” and
Column A, of
Column A, of
Addendum EE, entitled,
Addendum EE, entitled,
“HCPCS Code” located in
“HCPCS Code” located in
“July 2017 ASC Approved
“April 2018 ASC
HCPCS Code and
Approved HCPCS Code
Payment Rates”
and Payment Rates--
(july_2017_asc_addenda1)
Updated 03/21/2018” (april_2018_asc_
addenda_updated_04
_01_2018b.xlsx)
For services occurring on
For services occurring on
or after October 1 2017,
or after July 1, 2018,
Column A, of
Column A, of Addendum
Addendum AA, entitled,
AA, entitled, “HCPCS
“HCPCS Code” and
Code” and Column A, of
Column A, of
Addendum EE, entitled,
Addendum EE, entitled,
“HCPCS Code” located in
“HCPCS Code” located in
“July 2018 ASC
“October 2017 ASC
Approved HCPCS Code
Approved HCPCS Code
and Payment Rates --
and Payment Rates”
Updated 06/28/2018” (july_
(october_2017_asc_addenda)
2018_asc_addenda_updated
_06_28_2018.xlsx)
Access the files on
CMS website at:
For services occurring on
https://www. cms.gov/
or after October 1, 2018,
Medicare/Medicare-Fee-
Column A, of Addendum
for-Service-Payment
AA, entitled, “HCPCS
/ASCPayment/index.html
Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “October 2018 ASC Approved HCPCS Code and Payment Rates” (oct_2018_asc_addenda_updated_09_19
_2018.09212018cb.xlsx)
Access the files on CMS website at: https://www. cms.gov/
Medicare/Medicare-Fee-
for-Service-Payment/
ASCPayment/index.html
APC Payment Rate
Addendum B (A) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
For services rendered on or after December 15, 2016, Addendum B, dated July 2016, (A) found on CMS website at: http://www. cms. gov/
HospitalOutpatientPPS
For services occurring on or after June 1, 2017, Addendum B, dated April 2017 (-- updated: 03/28/2017; april_2017_
web_addendum_
b.03.28.17)
For services occurring on or after March 15, 2018, Addendum B (CMS-1678-
CN-2018-OPPS-
Addendum-B.zip; 2018 CN Addendum B.11.29.17)
For services occurring on
For services occurring on
or after July 1, 2017,
or after April 1, 2018,
Addendum B, dated
Addendum B, dated
July 2017
April 2018
(july_2017__
(2018_april_
web_addendum_
web_addendum_
b.06.13.17)
b.03.19.18final.xlsx)
For services occurring on
For services occurring on
or after October 1, 2017,
or after July 1, 2018,
Addendum B, dated
Addendum B -- Updated
October 2017
6/27/2018 (july_
(october_2017__
addendum_b.07.01.18
web_addendum_
revised06272018.xlsx)
a.09.14.17)
For services occurring on
-- found on CMS website
or after October 1, 2018,
at: http://www. cms.gov/
Addendum B (2018_
HospitalOutpatientPPS
october_web_addendum_b.10.01.18
no340brem.xlsx)
Access the files on the CMS website at:
https://www. cms.gov/Medicare/Medicare-
Fee-for-Service-Payment/HospitalOutpatientPPS/
index.html?redirect=/HospitalOutpatientPPS/
APC Relative Weight
Addendum B (A) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
For services rendered on or after December 15, 2016, Addendum B, dated July 2016, (A) found on CMS website at: http://www. cms. gov/
HospitalOutpatientPPS
For services occurring on or after June 1, 2017, Addendum B, dated April 2017 (-- updated: 03/28/2017; april_2017_
web_addendum_
b.03.28.17)
For services occurring on or after March 15, 2018, Addendum B (CMS-1678-
CN-2018-OPPS-
Addendum-B.zip; 2018 CN Addendum B.11.29.17)
For services occurring on
For services occurring on
or after July 1, 2017,
or after April 1, 2018,
Addendum B, dated
Addendum B, dated
July 2017
April 2018
(july_2017__
(2018_april_
web_addendum_
web_addendum_
b.06.13.17)
b.03.19.18final.xlsx)
For services occurring on
For services occurring on
or after October 1, 2017,
or after July 1, 2018,
Addendum B, dated
Addendum B -- Updated
October 2017
6/27/2018 (july_
(october_2017__
addendum_b.07.01.18
web_addendum_
revised06272018.xlsx)
a.09.14.17)
For services occurring on
-- found on CMS website
or after October 1, 2018,
at: http://www. cms.gov/
Addendum B (2018_
HospitalOutpatientPPS
october_web_addendum_b.10.01.18
no340brem.xlsx)
Access the files on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/Hospital
OutpatientPPS/index.html?
redirect=/HospitalOutpatientPPS/
Composite APCs (codes
For services occurring on
assigned status indicator
or after March 15, 2018,
“Q1,” “Q2,” “Q3,” or “Q4”)
payment rules payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2018 OPPS Addendum D1
• CMS 2018 OPPS Addendum M (corrected 12/4/2017)
• Integrated OCE (IOCE) CMS Specifications V19.0 (effective 01/01/2018), sections 10-12, 20
For services occurring on or after April 1, 2018, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2018 OPPS Addendum D1
• CMS 2018 OPPS Addendum M (corrected 12/4/2017)
• IOCE Quarterly Data Files V19.1 [ZIP, 46MB] (IntegOCEspecs V19.1.pdf), sections 6.4.1, 6.4.3, 6.4.5, and 6.5
For services occurring on or after July 1, 2018, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2018 OPPS Addendum D1
• CMS 2018 OPPS Addendum M (corrected 12/4/2017)
• Revised IOCE Quarterly Data Files V19.2.R1 [ZIP, 9MB], sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after October 1, 2018, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2018 OPPS Addendum D1
• CMS 2018 OPPS Addendum M (corrected 12/4/2017)
• IOCE Quarterly Data Files V19.3 [ZIP, 55MB], sections 5.4.1, 5.4.3, 5.4.5, and 5.5
A copy of the IOCE is posted on the DWC website: http://www. dir.ca.gov/dwc/OMFS9904.htm#6
Access documents on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/index.
html?redirect=/HospitalOutpatientPPS/ and https://www. cms.gov/Regulations-
and-Guidance/Guidance/Manuals/Internet-
Only-Manuals-IOMs-Items/CMS018912.html
Comprehensive APCs
For services occurring on
(codes assigned status
or after March 15, 2018,
indicator “J1” or “J2”) payment rules
payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2018 OPPS Addendum D1
• CMS 2018 OPPS Addendum J (Revised 1/25/2018)
• Integrated OCE (IOCE) CMS Specifications V19.0 (effective 01/01/2018), sections 7, 21, and Appendix L
For services occurring on or after April 1, 2018, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2018 OPPS Addendum D1
• CMS 2018 OPPS Addendum J (Revised 1/25/2018)
• IOCE Quarterly Data Files V19.1 [ZIP, 46MB] (IntegOCE-specsV19.1.pdf), sections 6.6.1, 6.6.1.1, 6.6.2, 6.6.3, 6.6.4, 6.6.4.1, and 6.6.4.2
For services occurring on or after July 1, 2018, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2018 OPPS Addendum D1
• CMS 2018 OPPS Addendum J (Revised 1/25/2018)
• Revised IOCE Quarterly Data Files V19.2.R1 [ZIP, 9MB], sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after October 1, 2018, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2018 OPPS Addendum D1
• CMS 2018 OPPS Addendum J (Revised 1/25/2018)
• IOCE Quarterly Data Files V19.3 [ZIP, 55MB], sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
A copy of the IOCE is posted on the DWC website: http://www. dir.ca.gov/dwc/OMFS9904.htm#6
Access documents on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/HospitalOutpatientPPS/
index.html?redirect=/HospitalOutpatient
PPS/ and https://www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
Emergency Department
99281-99285, 99291, 99292,
99281-99285, 99291,
99281-99285, 99291,
99281-99285, 99291,
HCP CS Codes
G0380-G0384, G0390
99292, G0380-G0384,
99292, G0380-G0384,
99292, G0380-G0384,
G0390
G0390
G0390
Facility Only Services
Services with a “NA” in
Not applicable for services
Not applicable for services
Not applicable for
the column labeled
rendered on or after
rendered on or after
services srendered on or
“Non-Facility NA
December 15, 2016
December 15, 2016
after December 15, 2016
Indicator” of the Medicare Physician Fee Schedule Relative Value File, by date of service, as adopted and incorporated by reference in the Official Medical Fee Schedule (OMFS) Physician Fee Schedule (Title 8 CCR sections 9789.12.1, et seq.). The (OMFS) Physician Fee Schedule is located at: http://www. dir.ca.gov/dwc/OMFS9904.htm and the Medicare Physician Fee Schedule Relative Value File is located at: http://www. cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/PhysicianFeeSched/PFS-
Relative-Value-Files.html
Film X-ray services and X
For services occurring on
-rays taken using computed
or after March 15, 2018,
radiography technology/
use modifier “FX” to
cassette-based imaging
report X-rays taken
payment reductions
using film, which requires a 20 percent payment reduction for such service. Use modifier “FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent payment reduction for such service. Apply payment rules set forth in:
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 01/01/2018)
• CFR section 419.71
For services occurring on or after April 1, 2018, use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for such service. Use modifier “FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent payment reduction for such service. Apply payment rules set forth in:
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 01/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515 Revised March 22, 2018, Transmittal R4005CP, section 6
For services occurring on or after July 1, 2018, use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for such service. Use modifier “FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent payment reduction for such service. Apply payment rules set forth in:
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 01/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515 Revised March 22, 2018, Transmittal R4005CP, section 6
For services occurring on or after October 1, 2018, use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for such service. Use modifier “FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent payment reduction for such service. Apply payment rules set forth in:
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 01/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515 Revised March 22, 2018, Transmittal R4005CP, section 6
Access the Medicare Claims Processing Manual on the CMS website at: https://www. cms.gov/Regulations-and-Guidance/
Guidance/Manuals/Internet-Only-Manuals-IOMs-
Items/CMS018912.html
HOPPS Addenda
Addenda A, B, D1, D2, E, L, M, and P (A) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
Addenda A, B, D1, D2, E, J, L, and M (A) found on CMS website at: http://www. cms.gov/
HospitalOutpatientPPS
For services occurring on or after June 1, 2017, addenda:
For services occurring on or after March 15, 2018 addenda:
• A (April 2017 (-- updated 3/20/2017; april_2017_web_addendum
_a_03202017)
• A (2018 CN Addendum A.11.29.17)
• B (2018 CN Addendum B.11.29.17)
• B (April 2017 (-- updated 3/28/2017; april_2017_web_addendum
_b.03.28.17)
• D1 (2018 Final Addendum 2018, NFRM Addendum D1.10.18.17)
• D1 (2017 Final Addendum D1.10.11.16)
• D2 (2018 Final Addendum, 2018
• D2 (2017 Final Addendum D2.10.11.16)
NFRM Addendum D2.10.18.17)
• E (2017 Final Addendum E.10.20.16)
• E (2018 Final Addendum, 2018 NFRM Addendum E.10.18.17)
• J (2017 NFRM Addendum J 2016 12.05.16)
• L (2017 Final OPPS Addendum L)
• J (2018 NFRM Addendum J Revised 01-25-2018)
• M (2017 Final Addendum M.10.20.16)
• L (2018 Final Addendum, 2018 NFRM Addendum L_ final)
• P (2017 Final Addendum P)
• M (2018 CN Addendum M.12.04.17)
• P (2018 NFRM CN Addendum P 11 20 17)
For services occurring on
For services occurring
or after July 1, 2017, addenda:
on or after April 1, 2018 addenda:
• A (July 2017; july_2017_web_addendum
_a.06.13.17)
• A (April 2018; 2018_april_web_addendum
_a.03.19.18final.xlsx)
• B (July 2017; july_2017_web_addendum
_b.06.13.17)
• B (April 2018; 2018_april_web_addendum
_b.03.19.18final.xlsx)
• D1 (2017 Final Addendum D1.10.11.16)
• D1 (2018 Final Addendum 2018, NFRM Addendum D1.10.18.17)
• D2 (2017 Final Addendum D2.10.11.16)
• E (2017 Final Addendum E.10.20.16)
• D2 (2018 Final Addendum, 2018 NFRM Addendum D2.10.18.17)
• J (2017 NFRM Addendum J 2016 12.05.16)
• E (2018 Final Addendum, 2018 NFRM Addendum E.10.18.17)
• L (2017 Final OPPS Addendum L)
• M (2017 Final Addendum M.10.20.16)
• J (2018 NFRM Addendum J Revised 01-25-2018)
• P (2017 Final Addendum P)
• L (2018 Final Addendum, 2018 NFRM Addendum L_ final)
For services occurring on or
after October 1, 2017, M.12.04.17)
• M (2018 CN Addendum addenda:
• A (October 2017; october_2017 _web_
addendum_a.09.14.17)
• P (2018 NFRM CN Addendum P 11 20 17)
• B (October 2017; october_ 2017 _web_
addendum_b.09.14.17)
For services occurring on or after July 1, 2018 addenda:
• A (July 2018 -- Updated 6/27/2018; july_
addendum_a.07.01.18 revised06272018.xlsx)
• D1 (2017 Final Addendum D1.10.11.16)
• D2 (2017 Final Addendum D2.10.11.16)
• B (July 2018 -- Updated 6/27/2018; july_addendum_
b.07.01.18 revised06272018.xlsx)
• E (2017 Final Addendum E.10.20.16)
• J (2017 NFRM Addendum J 2016 12.05.16)
• D1 (2018 Final Addendum 2018, NFRM Addendum D1.10.18.17)
• L (2017 Final OPPS Addendum L)
• M (2017 Final Addendum M.10.20.16)
• D2 (2018 Final Addendum, 2018 NFRM Addendum D2.10.18.17)
• P (2017 Final Addendum P)
• E (2018 Final Addendum, 2018 NFRM Addendum E.10.18.17)
Access the files on the CMS
website at: http://www. cms.gov/Hospital
• J (2018 NFRM Addendum J Revised 01-25-2018)
OutpatientPPS
• L (2018 Final Addendum, 2018 NFRM Addendum L_final)
• M (2018 CN Addendum M.12.04.17)
• P (2018 NFRM CN Addendum P 11 20 17)
For services occurring on or after October 1, 2018 addenda:
• A (October 2018; 2018_october_web_
addendum_a.10.01.18 no_340brem.xlsx)
• B (October 2018; 2018_october_web_
addendum_b.10.01.18 no340brem.xlsx)
• D1 (2018 Final Addendum 2018, NFRM Addendum D1.10.18.17)
• D2 (2018 Final Addendum, 2018 NFRM Addendum D2.10.18.17)
• E (2018 Final Addendum, 2018 NFRM Addendum E.10.18.17)
• J (2018 NFRM Addendum J Revised 01-25-2018)
• L (2018 Final Addendum, 2018 NFRM Addendum L_final)
• M (2018 CN Addendum M.12.04.17)
• P (2018 NFRM CN Addendum P 11 20 17)
Access the files on the CMS website at:
https://www. cms.gov/Medicare/Medicare-
Fee-for-Service-
Payment/HospitalOut
patientPPS/index.html
IPPS Tables
Tables 2, 4A, 4B, 4C, and
Tables 2 and 3 found on
Tables 2 and 3 (CMS 1655-
Tables 2 and 3 (CMS-
4J (B) found on CMS
CMS website at:
F and CN FY 2017
1677-F; CMS-1677-CN)
website at: http://www. cms.hhs.gov/
AcuteInpatientPPS/.
http://www. cms.hhs.gov/
AcuteInpatientPPS/.
Tables 2 and 3) found on CMS website at: http://www. cms.hhs.gov/
AcuteInpatientPPS/
found at: https://www. cms. gov/Medicare/Medicare-
Fee-for-Service-Payment/
AcuteInpatientPPS/FY
2018-IPPS-Final-Rule-
Home-Page.html?
DLSort=0&DLEntries
=10&DLPage=1&DL
SortDir=ascending
Labor-related Share
60% ((A) beginning at
60% ((A) beginning at
60% ((A) beginning at
60% ((A) beginning at
page 74950)
page 70359)
page 79597)
page 59258)
Market Basket Inflation Factor
2.5% (A) page 74949
2.4% (A) page 70351
2.7% (A) page 79595
2.7% (A) page 59222)
Medicare Physician Fee
Schedule Relative Value File
Medicare Physician Fee Schedule Relative Value File, by date of service, as adopted and incorporated by reference in the Official Medical Fee Schedule (OMFS) Physician Fee Schedule (Title 8 CCR sections 9789.12.1, et seq.). The (OMFS) Physician Fee Schedule is located at: http://www. dir.ca.
gov/dwc/OMFS9904.htm and the Medicare Physician Fee Schedule Relative Value File is located at: http://www. cms.gov/
Medicare/Medicare-Fee-for-
Service-Payment/
PhysicianFeeSched/PFS
-Relative-Value-Files.html
Not applicable for services rendered on or after December 15, 2016
Not applicable for services rendered on or after December 15, 2016
Not applicable for services rendered on or after December 15, 2016
Surgical Procedure HCPCS
10021-69990, G0413
HCPCS codes listed in column A of July 2016 CMS' Ambulatory Surgical Center Payment System (ASC) Addendum AA, column A of July2016 CMS' ASC Addendum EE, and CPT codes 21811-21813, but, excluding HCPCS codes listed on CMS' HOPPS Addendum E as an inpatient only procedure.
For services rendered on
For services rendered on
or after June 1, 2017,
or after March 15, 2018,
HCPCS codes listed in
HCPCS codes listed in
column A of April 2017
column A of January 2018
CMS'Ambulatory Surgical
CMS' Ambulatory Surgical
Center Payment System
Center Payment
(ASC)Addendum AA,
System (ASC) corrected
column A of April 2017
Addendum AA, column
CMS' ASC Addendum
A of January 2018 CMS'
EE, and CPT codes
ASC corrected Addendum
21811-21813, and 36415,
EE, and CPT codes 21811-
but excluding HCPCS
21813, and 36415, but,
codes listed on CMS' 2017
excluding HCPCS codes
HOPPS Addendum E
listed on CMS' 2018
as an inpatient only
HOPPS Addendum E
procedure. ASC Addenda AA
as an inpatient only
may be found in: and EE
procedure.
April 2017 --
ASC Addenda AA
april_2017_asc_
addenda_rev_
and EE may
be found in:
20170329, at: (https://www.
“Correction Notice
cms.gov/Medicare/
Addendum AA, BB, DD1,
Medicare-Fee-for-Service
DD2, EE” (CMS-1678-
-Payment/ASCPayment/
CN-ASC-Addendum-
11_Addenda_Updates.
AA-BB-DD1-DD2-
html) EE.zip) at:
https://www.
2017 HOPPS Addendum E
cms.gov/Medicare/
(2017 Final Addendum
Medicare-Fee-for-
E.10.20.16) is found at:
Service-Payment/
https://www. cms.gov/
ASCPayment/
Medicare/Medicare-Fee-
11_Addenda_
for-Service-Payment/
Updates.html
HospitalOutpatientPPS/
2018 HOPPS Addendum E
Hospital-Outpatient-
(2018 NFRM Addendum
Regulations-and-Notices-
E.10.18.17) is found at:
Items/CMS-1656-FC.html?
https://www. cms.gov/
DLPage=1&DLEntries
Medicare/Medicare-Fee-
=10&DLSort=2&
for-Service-Payment/
DLSortDir=descending
HospitalOutpatientPPS/
For services rendered on
Hospital-Outpatient-
or after July 1, 2017,
Regulations-and-Notices-
HCPCS codes listed in
Items/CMS-1678-
column A of July 2017 CMS' Ambulatory Surgical Center Payment System (ASC) Addendum AA, column A of July 2017 CMS' ASC Addendum EE, and CPT codes 21811- 21813, and 36415, but, excluding HCPCS codes listed on CMS' 2017 HOPPS Addendum E as an inpatient only procedure.
FC.html?DLPage=1&
DLEntries=10 &DLSort=2&DLSort Dir=descending For services rendered on or after April 1, 2018, HCPCS codes listed in column A, of April 2018 CMS'
Ambulatory Surgical
Center Payment System
(ASC) Addendum
AA, Column
ASC Addenda AA and EE
A, of April 2018 CMS'
may be found in: July
ASC Addendum EE,
2017 - July_2017_asc_
and CPT codes 21811-
addenda1: (https://www.
21813, and 36415, but,
cms.gov/Medicare/
excluding HCPCS codes
Medicare-Fee-for-Service
listed on CMS' 2018
-Payment/ASCPayment
HOPPS Addendum E as
/11_Addenda_Updates.
an inpatient only
html) 2017 HOPPS
procedure. ASC Addenda
Addendum E (2017 Final
AA and EE may be
ddendum E.10.20.16)
found in: “April 2018
is found at: https://
www. cms.gov/
ASC Approved
HCPCS Code
Medicare/Medicare-Fee
and Payment Rates --
-for-Service-Payment/
Updated 03/21/2018”
HospitalOutpatientPPS/
(april_2018_asc_addenda_
Hospital-Outpatient-
updated_04_01_
Regulations-and-
2018b.xlsx) at:
Notices-Items/CMS-1656-
https://www. cms.gov/
FC.html?DLPage=1&
Medicare/Medicare-Fee-
DLEntries=10&
for-Service-Payment/
DLSort=2&DLSort
ASCPayment/11_
Dir=descending
Addenda_Updates.html
For services rendered on
2018 HOPPS Addendum
or after October 1, 2017,
E (2018 NFRM Adden-
HCPCS codes listed in
dum E.10.18.17) is found
column A of October 2017
at: https://www. cms.gov/
CMS' Ambulatory Surgical
Medicare/Medicare-Fee-
Center Payment System
for-Service-Payment/
(ASC) Adendum AA,
HospitalOutpatientPPS/
column A of October
Hospital-Outpatient-
2017 CMS' ASC
Regulations-and-Notices-
Addendum EE, and
Items/CMS-1678-
CPT codes 21811-21813,
FC.html?DLPage=1
and 36415, but, excluding
&DLEntries=10
HCPCS codes listed on
&DLSort=2&DL
CMS' 2017 HOPPS Addendum E as an inpatient only procedure.
SortDir=descending
ASC Addenda AA and EE
For services rendered on
may be found in: October
or after July 1, 2018,
2017 -- october_2017_asc_
HCPCS codes listed in
addenda: (https://www.
column A, of July 2018
cms.gov/Medicare/
CMS'Ambulatory Surgical
Medicare-Fee-for-
Center Payment
Service-Payment/
System (ASC) Addendum
ASCPayment/11_
AA, Column A, of
Addenda_Updates.html)
July 2018 CMS' ASC
2017 HOPPS Addendum E
Addendum EE, and CPT
(2017 Final Addendum
codes 21811-21813, and
E.10.20.16) is found at:
36415, but, excluding
https://www. cms.gov/
HCPCS codes listed on
Medicare/Medicare-Fee
CMS' 2018 HOPPS
-for-Service-Payment/
Addendum E as an
HospitalOutpatientPPS/
inpatient only procedure.
Hospital-Outpatient-
ASC Addenda AA and EE
Regulations-and-Notices
may be found in: “July
-Items/CMS-1656-FC.
2018 ASC Approved
html?DLPage=1&
HCPCS Code and
DLEntries=10&DL
Sort=2&DLSortDir
=descending
Payment Rates-- Updated 06/28/2018” (july_2018_asc_
addenda_updated_
06_28_2018.
xlsx) at: https://www. cms.
gov/Medicare/Medicare
-Fee-for-Service
-Payment/ASCPayment/
11_Addenda_Updates.
html 2018 HOPPS Addendum E (2018 NFRM Addendum E.10.18.17) is found at: https://www. cms.
gov/Medicare/Medicare
-Fee-for-Service-Payment/
HospitalOutpatientPPS/
Hospital-Outpatient-
Regulations-and-
Notices-Items/CMS-1678-FC.html?
DLPage=1&DL
Entries=10&DLSort=
2&DLSortDir=
descending
For services rendered on or after October 1, 2018, HCPCS codes listed in column A, of October 2018 CMS' Ambulatory Surgical Center Payment System (ASC) Addendum AA, Column A, of October 2018 CMS' ASC Addendum EE, and CPT codes 21811-21813, and 36415, but, excluding HCPCS codes listed on CMS' 2018 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “October 2018 ASC Approved HCPCS Code and Payment Rates” (oct_2018_asc_addenda
_updated_09_19_
2018.09212018cb.xlsx) at: https://www. cms.gov/
Medicare/Medicare-Fee-
for-Service-Payment/
ASCPayment/11_
Addenda_Updates.html
2018 HOPPS Addendum E (2018 NFRM Addendum E.10.18.17) is found at: https://www. cms.gov/
Medicare/Medicare-Fee-
for-Service-Payment/
HospitalOutpatientPPS/
Hospital-Outpatient-
Regulations-and-
Notices-Items/CMS-1678-
FC.html?DLPage=
1&DLEntries=10&DLSort
=2&DLSortDir=descending
Conversion Factor adjusted
$72.530 (2013 unadjusted
$76.424 (2015 unadjusted
$78.488 (2016 unadjusted
$80.607 (2017 unadjusted
for inflation factor
conversion factor of $70.761 x estimated inflation factor of 1.025)
conversion factor of $74.633 x estimated inflation factor of 1.024)
conversion factor of $76.424 x estimated inflation factor of 1.027)
conversion factor of $78.488 x estimated inflation factor of 1.027)
Wage Index
Referenced in (A) beginning at page 74952; wage index values are specified in Tables 4A through 4C
Referenced in (A) beginning at page 70359; wage index values are specified
Referenced in (A) beginning at page 79597; wage index values are specified
Referenced in (A) beginning at page 59261; wage index values are
(B) found on the CMS website at: http://www. cms.gov/
AcuteInpatientPPS/
InpatientPPS/
in Table 2 (B) found on the CMS website at http://www. cms.gov/
AcuteInpatientPPS/
InpatientPPS/
in Table 2 (D) found on the CMS website at http://www. cms.gov/
AcuteInpatientPPS/
InpatientPPS/
Medicare/Medicare-Fee-for-Service-
Payment/AcuteInpatientPPS/FY2018-
IPPS-Final-Rule-Home-
Page.html?DLSort=
0&DLEntries=10&
DLPage=1&DLSortDir=ascending
Services Occurring On or After February 15, 2019 and Mid-year Updates
Applicable FR Notices
(A) November 21, 2018 (CMS-1695-FC; 83 FR 58818)
(B) December 28, 2018 (CMS-1695-CN2; 83 FR 67083)
(C) August 17, 2018 (CMS-1694-F; 83 FR 41144)
(D) October 3, 2018 (CMS-1694-CN2; 83 FR 49836)
Ambulatory Surgical Centers
For services occurring on or after February 15, 2019, Column A, of Addendum AA, entitled, “HCPCS
Payment System Addenda
Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “January 2019 ASC Approved HCPCS Code and Payment Rates - Updated 01/29/2019” (jan_2019_asc_addenda_1_28_19.xlsx)
For services occurring on or after April 1, 2019, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “April 2019 ASC Approved HCPCS Code and Payment Rates - Updated 3/28/2019” (Apr_2019_ASC_Addenda_3_27_2019)
For services occurring on or after July 1, 2019, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “July 2019 ASC Approved HCPCS Code and Payment Rates - Updated 06/27/2019” (July_2019_ASC_Addenda.06262019.xlsx)
For services occurring on or after October 1, 2019, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “October 2019 ASC Approved HCPCS Code and Payment Rates CORRECTIONS - Updated 10/15/2019” (October_2019_ASC_Addenda.CORRECTED.10152019.xlsx)
Note:
Access the files on CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ ASCPayment/index.html
APC Payment Rate
For services occurring on or after February 15, 2019, Addendum B, dated January 2019 (january_2019_opps_web_addendum_b.12312018.xlsx)
For services occurring on or after April 1, 2019, Addendum B, dated April 2019 (2019_April_Web_ Addendum_B.03222019.xlsx)
For services occurring on or after July 1, 2019, Addendum B, dated July 2019 (July_2019_Web_Addendum_B.06212019.xlsx)
For services occurring on or after October 1, 2019, Addendum B - Correction, dated October 2019 (2019_October_Web_ Addendum_B.CORRECTED.09292019.xlsx)
APC Relative Weight
For services occurring on or after February 15, 2019, Addendum B, dated January 2019 (january_2019_opps_web_ addendum_b.12312018.xlsx)
For services occurring on or after April 1, 2019, Addendum B, dated April 2019 (2019_April_Web_ Addendum_B.03222019.xlsx)
For services occurring on or after July 1, 2019, Addendum B, dated July 2019 (July_2019_Web_Addendum_B.06212019.xlsx)
For services occurring on or after October 1, 2019, Addendum B - Correction, dated October 2019 (2019_October_Web_ Addendum_B.CORRECTED.09292019.xlsx)
Composite APCs (codes
For services occurring on or after February 15, 2019, payment rules are:
assigned status indicator “Q1,”
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
“Q2,” “Q3,” or “Q4”) payment
• CMS 2019 OPPS Addendum D1
rules
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.0 [ZIP, 52MB], IntegOCEspecsV20.0.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after April 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.1 [ZIP, 50MB], IntegOCEspecsV20.1.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after July 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.2 [ZIP, 50MB], IntegOCEspecsV20.2.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after October 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.3 [ZIP, 50 MB] IntegOCEspecsV20.3.pdf, sections 4.4.1, 4.4.3, 4.4.5, and 4.5
Note:
A copy of the IOCE is posted on the DWC website: http://www. dir.ca.gov/dwc/OMFS9904.htm#6
Access documents on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html?redirect=/HospitalOutpatientPPS/ and CMS Claims Processing Manual at: https://www. cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
Comprehensive APCs (codes
For services occurring on or after February 15, 2019, payment rules are:
assigned status indicator “J1”
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
or“J2”) payment rules
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum J
• IOCE Quarterly Data Files V20.0 [ZIP, 52MB], IntegOCEspecsV20.0.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after April 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.1 [ZIP, 50MB], IntegOCEspecsV20.1.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after July 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.2 [ZIP, 50MB], IntegOCEspecsV20.2.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after October 1, 2019, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2019 OPPS Addendum D1
• CMS 2019 OPPS Addendum M
• IOCE Quarterly Data Files V20.3 [ZIP, 50 MB] IntegOCEspecsV20.3.pdf, sections 4.4.1, 4.4.3, 4.4.5, and 4.5
Note:
A copy of the IOCE is posted on the DWC website: http://www. dir.ca.gov/dwc/OMFS9904.htm#6
Access documents on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOut patientPPS/index.html
And CMS Claims Processing Manual at: https://www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending
Emergency Department HCPCS Codes
99281-99285, 99291, 99292, G0380-G0384, G0390
Facility Only Services
Not applicable for services rendered on or after December 15, 2016
Film X-ray services and
Use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for
X-rays taken using computed radiography technology/cassette-based imaging payment reductions
such service. Use modifier “FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent pay ment reduction for such service. Apply payment rules set forth in:
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 1/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515 Revised March 22, 2018, Transmittal R4005CP, section 6
Access the Medicare Claims Processing Manual on the CMS website at: https://www. cms. gov/Regulations-and-Guidance/Guid ance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
HOPPS Addenda
For services occurring on or after February 15, 2019 addenda:
• A (January 2019; january_2019_opps_web_addendum_a.12312018.xlsx)
• B (January 2019; january_2019_opps_web_addendum_b.12312018.xlsx)
• D1 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D1.11012018.xlsx)
• D2 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D2.11012018.xlsm)
• E (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum E.11012018.xlsx)
• J (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum J.11012018.xls)
• L (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum L.11012018.xlsx)
• M (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum M.11012018.xlsx)
• P (2019 CN2 OPPS Addenda; 2019 CN2 Addendum P.12212018.xlsx)
For services occurring on or after April 1, 2019 addenda:
• A (April 2019; 2019_April_Web_Addendum_A.03222019.xlsx)
• B (April 2019; 2019_April_Web_Addendum_B.03222019.xlsx)
• D1 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D1.11012018.xlsx)
• D2 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D2.11012018.xlsm)
• E (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum E.11012018.xlsx)
• J (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum J.11012018.xls)
• L (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum L.11012018.xlsx)
• M (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum M.11012018.xlsx)
• P (2019 CN2 OPPS Addenda; 2019 CN2 Addendum P.12212018.xlsx)
For services occurring on or after July 1, 2019 addenda:
• A (July 2019; July_2019_Web_Addendum_A.06212019.xlsx)
• B (July 2019; July_2019_Web_Addendum_B.06212019.xlsx)
• D1 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D1.11012018.xlsx)
• D2 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D2.11012018.xlsm)
• E (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum E.11012018.xlsx)
• J (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum J.11012018.xls)
• L (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum L.11012018.xlsx)
• M (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum M.11012018.xlsx)
• P (2019 CN2 OPPS Addenda; 2019 CN2 Addendum P.12212018.xlsx)
For services occurring on or after October 1, 2019 addenda:
• A (October 2019; 2019_October_Web_Addendum_A.CORRECTED.09292019.xlsx)
• B (October 2019; 2019_October_Web_Addendum_B.CORRECTED.09292019.xlsx)
• D1 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D1.11012018.xlsx)
• D2 (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum D2.11012018.xlsm)
• E (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum E.11012018.xlsx)
• J (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum J.11012018.xls)
• L (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum L.11012018.xlsx)
• M (CY2019 NFRM OPPS Addenda; CY2019 NFRM Addendum M.11012018.xlsx)
• P (2019 CN2 OPPS Addenda; 2019 CN2 Addendum P.12212018.xlsx)
Note:
Access the files on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html
IPPS Tables
FY 2019 Tables 2, 3 and 4 (Wage Index Tables) (Final Rule and Correction Notice) [ZIP, 1MB] found at: https://www. cms.gov/Medicare/Medicare-Fee-for- Service-Payment/AcutelnpatientPPS/FY2019-IPPS-Final-Rule-Home-Page-Items/FY2019-IPPS-Final-Rule-Tables.html?DLPage=1&DLEntries=10&DLSort=0&DLSort Dir=ascending
Labor-related Share
60% (A) beginning at page 58863
Market Basket Inflation Factor
2.9% (A) page 58822
Medicare Physician Fee Schedule Relative Value File
Not applicable for services rendered on or after December 15, 2016
Surgical Procedure HCPCS
For services rendered on or after February 15, 2019, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Jan 2019 ASC AA,” Column A, of CMS' ASC “Jan 2019 ASC EE, and CPT codes 21811-21813, 33289, and 36415, but, excluding HCPCS codes listed on CMS' 2019 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “January 2019 ASC Approved HCPCS Code and Payment Rates - Updated-01/29/2019” (jan_2019_asc_addenda_1_28_19.xlsx) at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html
2019 HOPPS Addendum E (CY2019 NFRM Addendum E.11012018.xlsx) is found at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
For services rendered on or after April 1, 2019, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Apr 2019 ASC AA,” Column A, of CMS' ASC “Apr 2019 ASC EE,” and CPT codes 21811-21813, 33289, and 36415, but, excluding HCPCS codes listed on CMS' 2019 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “April 2019 ASC Approved HCPCS Code and Payment Rates - Updated 3/28/19” (Apr_2019_ASC_Addenda_3_27_2019) at: https://www. cms.gov/Medicare/Medicare-Fee- for-Service-Payment/ASCPayment/11_Addenda_Updates.html
2019 HOPPS Addendum E (CY2019 NFRM Addendum E.11012018.xlsx) is found at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
For services rendered on or after July 1, 2019, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Jul 2019 ASC AA,” Column A, of CMS' ASC “Jul 2019 ASC EE,” and CPT codes 21811-21813, 33289, and 36415, but, excluding HCPCS codes listed on CMS' 2019 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “July 2019 ASC Approved HCPCS Code and Payment Rates - Updated 06/27/2019” (July_2019_ASC_Addenda.06262019.xlsx) at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html
2019 HOPPS Addendum E (CY2019 NFRM Addendum E.11012018.xlsx) is found at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
For services rendered on or after October 1, 2019, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Oct 2019 ASC AA,” Column A, of CMS' ASC “Oct 2019 ASC EE,” and CPT codes 21811-21813, 3289, and 36415, but, excluding HCPCS codes listed on CMS' 2019 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “October 2019 ASC Approved HCPCS Code and Payment Rates CORRECTIONS - Updated 10/15/2019” (October_2019_ASC_Addenda.CORRECTED.10152019.xlsx) at: https://www. cms. gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html
2019 HOPPS Addendum E (CY2019 NFRM Addendum E.11012018.xlsx) is found at: https://www. cms. gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
Conversion Factor adjusted for inflation factor
$82.945 (2018 unadjusted conversion factor of $80.607 x estimated inflation factor of 1.029)
Wage Index
Referenced in (A) beginning at page 58876; wage index values are specified in Table 2 (C) and (D) found on the CMS website at https://www. cms. gov/Medicare/Medicare-Fee-for-Service-Payment/AcutelnpatientPPS/FY2019-IPPS-Final-Rule-Home-Page-Items/FY2019-IPPS-Final-Rule-Tables.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending
Services Occurring On or After March 1, 2020 and Mid-year Updates
Applicable FR Notices
(A) November 12, 2019 (CMS-1717-FC; 84 FR 61142)
(B) January 3, 2020 (CMS-1717-CN; 85 FR 224)
(C) August 16, 2019 (CMS-1716-F; 84 FR 42044)
(D) October 8, 2019 (CMS-1716-CN2; 84 FR 53603)
Ambulatory Surgical Centers Payment System Addenda
For services occurring on or after March 1, 2020, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “CY 2020 CN ASC Addenda.12122019” (CY 2020 CN ASC Addenda.12122019.xlsx)
For services occurring on or after April 1, 2020, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “April 2020 ASC Approved HCPCS Code and Payment Rates - Updated 04/09/2020 (cy2020 april asc addenda.04092020.xlsx)
For services occurring on or after July 1, 2020, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “July 2020 ASC Approved HCPCS Code and Payment Rates - Updated 06/29/2020” (cy2020 july asc addenda.06292020.xlsx)
For services occurring on or after October 1, 2020, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “October 2020 ASC Approved HCPCS Code and Payment Rates” (CY2020 October ASC Addenda.09282020.xlsx)
Note:
Access the files on CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html
APC Payment Rate
For services occurring on or after March 1, 2020, Addendum B, dated February 4, 2020 (2020 CN Addendum B CORRECTION.02042020.xlsx
For services on or after March 1, 2020, for HCPCS code C9803, Addendum B, April 2020 Correction (ZIP) dated May 4, 2020 (2020_april_web_addendum_b.05042020.xlsx)
For services occurring on or after April 1, 2020, Addendum B, April 2020 CORRECTION (ZIP) dated May 4, 2020 (2020_april_web_addendum_b.05042020.xlsx)
For services occurring on or after July 1, 2020, Addendum B, July 2020 dated June 26, 2020 (2020_july_web_ addendum_b.06262020.xlsx)
For services occurring on or after October 1, 2020, Addendum B, October 2020 CORRECTION dated October 21, 2020 (2020_October_Web_Addendum_B.10212020.xlsx)
APC Relative Weight
For services occurring on or after March 1, 2020, Addendum B, dated February 4, 2020 (2020 Addendum B CORRRECTION.02042020.xlsx)
For services on or after March 1, 2020, for HCPCS code C9803, Addendum B, April 2020 Correction (ZIP) dated May 4, 2020 (2020_april_web_addendum_b.05042020.xlsx)
For services occurring on or after April 1, 2020, Addendum B, April 2020 CORRECTION (ZIP) dated May 4, 2020 (2020_april_web_addendum_b.05042020.xlsx)
For services occurring on or after July 1, 2020, Addendum B, July 2020 dated June 26, 2020 (2020_july_web_ addendum_b.06262020.xlsx)
For services occurring on or after October 1, 2020, Addendum B, October 2020 CORRECTION dated October 21, 2020 (2020_October_Web_Addendum_B.10212020.xlsx)
Composite APCs (codes
For services occurring on or after March 1, 2020, payment rules are:
assigned status indicator
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
“Q1,” “Q2,” “Q3,” or “Q4”)
• CMS 2020 OPPS Addendum D1
payment rules
• CMS 2020 OPPS Addendum M
• IOCE Quarterly Data Files V21.0 [ZIP, 1.17MB], IntegOCEspecsV21.0.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after April 1, 2020, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2020 OPPS Addendum D1
• CMS 2020 OPPS Addendum M
• IOCE Quarterly Data Files V21.1 R2 Apr 2020 [ZIP, 1.53MB], IntegOCEspecsV21.1 R2 Apr 2020.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after July 1, 2020, payment rules are:
Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2020 OPPS Addendum D1
• CMS 2020 OPPS Addendum M
• IOCE Quarterly Data Files V212.R0 July 2020 [ZIP, 25.5MB], IntegOCEspecsV21.2 July 2020.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after October 1, 2020, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2020 OPPS Addendum D1
• CMS 2020 OPPS Addendum M
• October 2020 IOCE Quarterly Data Files V213.R1 Re-Release (posted 10/05/2020) [ZIP, 27.5MB], IntegOCE specsV21.3 R1_Oct 20.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
Note:
Access the IOCE on the CMS website at: https://www. cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs Access documents on the CMS website at: https://www. cms. gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index and CMS Claims Processing Manual at: https://www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
Comprehensive APCs (codes
For services occurring on or after March 1, 2020, payment rules are:
assigned status indicator “J1”
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
or “J2”) payment rules
• CMS 2020 OPPS Addendum D1
• CMS 2020 OPPS Addendum J
• IOCE Quarterly Data Files V21.0 [ZIP, 1.17MB], IntegOCEspecsV21.0.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after April 1, 2020, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2020 OPPS Addendum D1
• CMS 2020 OPPS Addendum J
• IOCE Quarterly Data Files V21.1 R2 Apr 2020 [ZIP, 1.53MB], IntegOCEspecsV21.1 R2 Apr 2020.pdf sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after July 1, 2020, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2020 OPPS Addendum D1
• CMS 2020 OPPS Addendum J
• IOCE Quarterly Data Files V212.R0 July 2020 [ZIP, 25.5MB], IntegOCEspecsV21.2 July 2020.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after October 1, 2020, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2020 OPPS Addendum D1
• CMS 2020 OPPS Addendum J
• October 2020 IOCE Quarterly Data Files V213.R1 Re-Release (posted 10/05/2020) [ZIP, 27.5MB], IntegOCE specsV21.3 R1_Oct 20.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
Note:
Access the IOCE on the CMS website: https://www. cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs
Access documents on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospital OutpatientPPS/index and CMS Claims Processing Manual at: https://www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir= ascending
Emergency Department HCPCS Codes
99281-99285, 99291, 99292, G0380-G0384, G0390
Facility Only Services
Not applicable for services rendered on or after December 15, 2016
Film X-ray services and
Use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for
X-rays taken using computed radiography technology/cassette- based imaging payment reductions
such service. Use modifier “FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent payment reduction for such service. Apply payment rules set forth in:
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 01/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515 Revised March 22, 2018, Transmittal R4005CP, section 6
Access the Medicare Claims Processing Manual on the CMS website at: https://www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
HOPPS Addenda
For services occurring on or after March 1, 2020 addenda:
• A (January 2020 Addendum A CORRECTION; 2020 Addendum A CORRECTION.02042020.xlsx)
• B (January 2020 Addendum B CORRECTION; 2020 Addendum B CORRECTION.02042020.xlsx)
• D1 (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum D1.11012019.xlsx)
• D2 (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum D2.11012019.xlsm)
• E (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum E.11012019.xlsx)
• J (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum J.11012019.xls)
• L (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum L.11012019.xlsx)
• M (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum M.11012019.xlsx)
• P (CY2020 CN Addendum P; CY2020 CN Addendum P.12202019.xlsx)
For services on or after March 1, 2020, for HCPCS code C9803:
• B (April 2020 CORRECTION (ZIP); 2020_april_web_addendum_b.05042020.xlsx)
For services occurring on or after April 1, 2020 addenda:
• A (April 2020 Addendum A; 2020_april_web_addendum_a.03262020.xlsx)
• B (April 2020 CORRECTION (ZIP); 2020_april_web_addendum_b.05042020.xlsx)
• D1 (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum D1.11012019.xlsx)
• D2 (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum D2.11012019.xlsm)
• E (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum E.11012019.xlsx)
• J (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum J.1101201.xls)
• L (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum L.11012019.xlsx)
• M (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum M.11012019.xlsx)
• P (CY2020 CN Addendum P; CY2020 CN Addendum P.12202019.xlsx)
For services occurring on or after July 1, 2020 addenda:
• A (July 2020 Addendum A; 2020_july_web_addendum_a.06262020.xlsx)
• B (July 2020 Addendum B; 2020_july_web_addendum_b.06262020.xlxs)
• D1 (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum D1.11012019.xlsx)
• D2 (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum D2.11012019.xlsm)
• E (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum E.11012019.xlsx)
• J (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum J.1101201.xls)
• L (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum L.11012019.xlsx)
• M (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum M.11012019.xlsx)
• P (CY2020 CN Addendum P; CY2020 CN Addendum P.12202019.xlsx)
For services occurring on or after October 1, 2020 addenda:
• A (October 2020 CORRECTION Addendum A; 2020_October_Web_Addendum_A.10212020.xlsx)
• B (October 2020 CORRECTION Addendum B; 2020_October_Web_Addendum_B.10212020.xlsx)
• D1 (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum D1.11012019.xlsx)
• D2 (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum D2.11012019.xlsm)
• E (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum E.11012019.xlsx)
• J (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum J.1101201.xls)
• L (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum L.11012019.xlsx)
• M (CY2020 NFRM OPPS Addenda; CY2020 NFRM Addendum M.11012019.xlsx)
• P (CY2020 CN Addendum P; CY2020 CN Addendum P.12202019.xlsx)
Note:
Access the files on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospital OutpatientPPS/index.html
IPPS Tables
FY 2020 Tables 2, 3 and 4 (Wage Index Tables) (Final Rule and Correction Notice) [ZIP, 1MB] found at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcutelnpatientPPS/FY2020-IPPS-Final-Rule-Home-Page-Items/FY2020-IPPS-Final-Rule-Tables
Labor-related Share
60% (A) beginning at page 61184
Market Basket Inflation Factor
3% (A) page 61145
Medicare Physician Fee Schedule Relative Value File
Not applicable for services rendered on or after December 15, 2016
Surgical Procedure HCPCS
For services rendered on or after March 1, 2020, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Jan 2020 ASC AA,” Column A, of CMS' ASC “Jan 2020 ASC EE, and CPT codes 21811-21813, 33289, and 36415, but, excluding HCPCS codes listed on CMS' 2020 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “January 2020 ASC Approved HCPCS Code and Payment Rates - Updated 01/01/2020” (cy2020_january_asc_addenda.01022020.xlsx) at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service -Payment/ASCPayment/11_Addenda_Updates
2020 HOPPS Addendum E (2020 NFRM Addendum E.11012019.xlsx) is found at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
For services rendered on or after April 1, 2020, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Apr 2020 ASC AA,” Column A, of CMS' ASC “Apr 2020 ASC EE, and CPT codes 21811-21813, 33289, and 36415, but, excluding HCPCS codes listed on CMS' 2020 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “April 2020 ASC Approved HCPCS Code and Payment Rates - Updated 04/09/2020” (cy2020_april_asc_addenda.04092020.xlsx on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
2020 HOPPS Addendum E (2020 NFRM Addendum E.11012019.xlsx) is found at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
For services rendered on or after July 1, 2020, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “CY 2020 Jul ASC AA,” Column A, of CMS' ASC “CY 2020 Jul ASC EE”, and CPT codes 21811-21813, 33289, and 36415, but, excluding HCPCS codes listed on CMS' 2020 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “July 2020 ASC Approved HCPCS Code and Payment Rates - Updated 06/29/2020” (cy2020_july_asc_adenda_06292020.xlsx) on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
2020 HOPPS Addendum E (2020 NFRM Addendum E.11012019.xlsx) is found at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DL SortDir=descending
For services rendered on or after October 1, 2020, HCPCS codes listed in column A of CMS' Ambulatory Surgical Center Payment System (ASC) “CY 2020 Oct ASC AA,” column A of CMS' ASC “CY 2020 Oct ASC EE”, CPT codes 21811-21813, 33289, and 36415, but, excluding HCPCS codes listed on CMS' 2020 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “October 2020 ASC Approved HCPCS Code and Payment Rates” (CY2020_October_ASC_Addenda.09282020.xlsx) on the CMS website at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
2020 HOPPS Addendum E (2020 NFRM Addendum E.11012019.xlsx) is found at: https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DL SortDir=descending
Conversion Factor adjusted for inflation factor
$ 85.433 (2019 unadjusted conversion factor of $82.945 x estimated inflation factor of 1.03)
Wage Index
Referenced in (A) beginning at page 61184; wage index values are specified in Table 2 (C) and (D) found on the CMS website at https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcutelnpatientPPS/FY2020-IPPS-Final-Rule-Home-Page-Items/FY2020-IPPS-Final-Rule-Tables
Services Occurring On or After March 1, 2021 and Mid-year Updates
Applicable FR Notices
(A) December 29, 2020 (CMS-1736-FC; 85 FR 85866)
(B) February 25, 2021 (CMS-1736-CN; 86 FR 11428)
(C) September 18, 2020 (CMS-1735-F; 85 FR 58432)
(D) December 7, 2020 (CMS 1735-CN; 85 FR 78748)
Applicable sections of
§ 419.2 (As amended; effective January 1, 2016)
Title 42, Code of
§ 419.32 (As amended; effective January 1, 2021)
Federal Regulations
§ 419.43 (As amended; effective January 1, 2017)
§ 419.44 (As amended; effective January 1, 2017)
§ 419.62 (Effective January 1, 2004)
§ 419.64 (As amended; effective January 1, 2015)
§ 419.66 (As mended; effective January 1, 2021)
§ 419.71 (Effective January 1, 2018)
Ambulatory Surgical Centers Payment System Addenda
For services occurring on or after March 1, 2021, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “Correction Notice Addendum AA, BB, DD1, DD2, EE,” (2021 CN ASC Addenda.022221.xlsx)
For services occurring on or after April 1, 2021, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “April 2021 ASC Approved HCPCS Code and Payment Rates-Updated 03/25/2021,” (April 2021 ASC Addenda.03242021.xlsx)
For services occurring on or after July 1, 2021, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “July 2021 ASC Approved HCPCS Code and Payment Rates,” (July 2021 ASC Addenda.06252021.xlsx)
For services occurring on or after October 1, 2021, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “October 2021 ASC Approved HCPCS Code and Payment Rates,” (Oct 2021 ASC Addenda.09222021.xlsx)
Note:
Access the files on CMS website at:
https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html
APC Payment Rate
For services occurring on or after March 1, 2021, Addendum B-Correction, dated February 22, 2021 (2021 CN Addendum B.022221.xlsx)
For services occurring on or after April 1, 2021, Addendum B April 2021 (April 2021 OPPS Web Addendum B.03222021.xlsx)
For services occurring on or after July 1, 2021, Addendum B July 2021 (July 2021 Web Addendum B.06212021.xlsx)
For services occurring on or after October 1, 2021, Addendum B October 2021 (2021 October Web Addendum B.09212021.xlsx)
APC Relative Weight
For services occurring on or after March 1, 2021, Addendum B-Correction, dated February 22, 2021 (2021 CN Addendum B.022221.xlsx)
For services occurring on or after April 1, 2021, Addendum B April 2021 (April 2021 OPPS Web Addendum B.03222021.xlsx)
For services occurring on or after July 1, 2021, Addendum B July 2021 (July 2021 Web Addendum B.06212021.xlsx)
For services occurring on or after October 1, 2021, Addendum B October 2021 (2021 October Web Addendum B.09212021.xlsx)
Composite APCs
For services occurring on or after March 1, 2021, payment rules are:
(codes assigned
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
status indicator
• CMS 2021 OPPS Addendum D1-Updated 01/12/2021 (2021 NFRM OPPS Addendum D1.01122021.xlsx)
“Q1,” “Q2,” “Q3,”
• CMS 2021 OPPS Addendum M
or “Q4”) payment
• IOCE Quarterly Data Files V220.R0[ZIP, 28MB] IntegOCEspecsV22.0. Jan.21.pdf, sections 5.4.1, 5.4.3,
rules
5.4.5, and 5.5
For services occurring on or after April 1, 2021, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2021 OPPS Addendum D1-Updated 01/12/2021 (2021 NFRM OPPS Addendum D1.01122021.xlsx)
• CMS 2021 OPPS Addendum M
• IOCE Quarterly Data Files V212.R0 April 2021 [ZIP, 28.1MB], IntegOCEspecs V22.1 Apr21.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after July 1, 2021, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2021 OPPS Addendum D1-Updated 01/12/2021 (2021 NFRM OPPS Addendum D1.01122021.xlsx)
• CMS 2021 OPPS Addendum M
• IOCE Quarterly Data Files V222.R0 July 2021 [ZIP. 28.1MB], IntegOCEspecs V22.2 Jul21.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after October 1, 2021, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2021 OPPS Addendum D1-Updated 01/12/2021 (2021 NFRM OPPS Addendum D1.01122021.xlsx)
• CMS 2021 OPPS Addendum M
• IOCE Quarterly Data Files V223.R1 October 2021 [ZIP, 25.6MB], IntegOCEspecs V22.3.R1 Oct 21.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
Note:
Access the IOCE on the CMS website at: https://www. cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs
Access documents on the CMS website at:
https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index and CMS
Claims Processing Manual at:
https://www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CM S018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending
Comprehensive
For services occurring on or after March 1, 2021, payment rules are:
APCs (codes
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.2.4, 10.4, 290.5.2, and 290.5.3
assigned status
• CMS 2021 OPPS Addendum D1-Updated 01/12/2021 (2021 NFRM OPPS Addendum D1.01122021.xlsx)
indicator “J1” or
• CMS 2021 OPPS Addendum J
“J2”) payment
• IOCE Quarterly Data Files V220.R0[ZIP, 28MB] IntegOCEspecsV22.0._Jan.21.pdf, sections 5.6.1, 5.6.1.1,
rules
5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after April 1, 2021, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.2.4, 10.4, 290.5.2, and 290.5.3
• CMS 2021 OPPS Addendum D1-Updated 01/12/2021 (2021 NFRM OPPS Addendum D1.01122021.xlsx)
• CMS 2021 OPPS Addendum J
• IOCE Quarterly Data Files V212.R0 April 2021 [ZIP, 28.1MB], IntegOCEspecs V22.1 Apr21.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after July 1, 2021, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.2.4, 10.4, 290.5.2, and 290.5.3
• CMS 2021 OPPS Addendum D1-Updated 01/12/2021 (2021 NFRM OPPS Addendum D1.01122021.xlsx)
• CMS 2021 OPPS Addendum J
• IOCE Quarterly Data Files V222.R0 July 2021 [ZIP, 28.1MB], IntegOCEspecs V22.2 Jul21.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after October 1, 2021, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.2.4, 10.4, 290.5.2, and 290.5.3
• CMS 2021 OPPS Addendum D1-Updated 01/12/2021 (2021 NFRM OPPS Addendum D1.01122021.xlsx)
• CMS 2021 OPPS Addendum J
• IOCE Quarterly Data Files V223.R1 Oct 2021 [ZIP, 28.1MB], IntegOCEspecs V22.3.R1 Oct21.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
Note:
Access the IOCE on the CMS website at:
https://www. cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs
Access documents on the CMS website at:
https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index and CMS
Claims Processing Manual at:
https://www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CM S018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending
Emergency Department HCPCS Codes
99281-99285, 99291, 99292, G0380-G0384, G0390
Facility Only Services
Not applicable for services rendered on or after December 15, 2016
Film X-ray services and X-rays taken using computed radiography technology/cassette-based imaging payment reductions
Use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for such service. Use modifier “FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent payment reduction for such service. Apply payment rules set forth in:
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15
(effective 01/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515
Revised March 22, 2018, Transmittal R4005CP, section 6
Access the Medicare Claims Processing Manual on the CMS website at:
https://www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CM S018912.html
HOPPS
For services occurring on or after March 1, 2021 addenda:
Addenda
• A (2021 Correction Notice OPPS Addendum A; 2021 CN Addendum A.022221.xlsx)
• B (2021 Correction Notice OPPS Addendum B; 2021 CN Addendum B.022221.xlsx)
• D1 (2021 NFRM OPPS Addenda; 2021 NFRM Addendum D1-Updated 01/12/2021)
• D2 (2021 NFRM OPPS Addenda; 2021 NFRM Addendum D2.11302020.xlsm)
• E (2021 NFRM OPPS Addenda; 2021 NFRM Addendum E.11302020.xlsx)
• J (2021 NFRM OPPS Addenda; 2021 NFRM Addendum J.11302020.xls)
• L (2021 NFRM OPPS Addenda; 2021 NFRM Addendum L.11302020.xlsx)
• M (2021 NFRM OPPS Addenda; 2021 NFRM Addendum M.11302020.xlsx)
• P (2021 Correction Notice OPPS Addendum P; 2021_CN_Addendum P.022221.xlsx)
For services occurring on or after April 1, 2021 addenda:
• A (Addendum A April 2021; April 2021 OPPS Web Addendum A.03222021.xlsx
• B (Addendum B April 2021; April 2021 OPPS Web Addendum B.03222021.xlsx
• D1 (2021 NFRM OPPS Addenda; 2021 NFRM Addendum D1-Updated 01/12/2021)
• D2 (2021 NFRM OPPS Addenda; 2021 NFRM Addendum D2.11302020.xlsm)
• E (2021 NFRM OPPS Addenda; 2021 NFRM Addendum E.11302020.xlsx)
• J (2021 NFRM OPPS Addenda; 2021 NFRM Addendum J.11302020.xls)
• L (2021 NFRM OPPS Addenda; 2021 NFRM Addendum L.11302020.xlsx)
• M (2021 NFRM OPPS Addenda; 2021 NFRM Addendum M. 11302020.xlsx)
• P (2021 Correction Notice OPPS Addendum P; 2021 CN Addendum P.022221.xlsx)
For services occurring on or after July 1, 2021 addenda:
• A (Addendum A July 2021; July 2021 Web Addendum A.06212021)
• B (Addendum B July 2021; July 2021 OPPS Web Addendum B. 06212021.xlsx)
• D1 (2021 NFRM OPPS Addenda; 2021 NFRM Addendum D1-Updated 01/12/2021)
• D2 (2021 NFRM OPPS Addenda; 2021 NFRM Addendum D2.11302020.xlsm)
• E (2021 NFRM OPPS Addenda: 2021 NFRM Addendum E.11302020.xlsx)
• J (2021 NFRM OPPS Addenda; 2021 NFRM Addendum J.11302020.xls)
• L (2021 NFRM OPPS Addenda; 2021 NFRM Addendum L. 11302020.xlsx)
• M (2021 NFRM OPPS Addenda; 2021 NFRM Addendum M.11302020.xlsx)
• P (2021 Correction Notice OPPS Addendum P; 2021 CN Addendum P.022221.xlsx)
For services occurring on or after October 1, 2021 addenda:
• A (Addendum A October 2021; 2021 Oct Web Addendum A.09212021.xlsx)
• B (Addendum B October 2021; 2021 Oct Web Addenda B.09212021.xlsx)
• D1 (2021 NFRM OPPS Addenda; 2021 NFRM Addendum D1-Updated 01/12/2021)
• D2 (2021 NFRM OPPS Addenda; 2021 NFRM Addendum D2.11302020.xlsm)
• E (2021 NFRM OPPS Addenda; 2021 NFRM Addendum E.11302020.xlsx)
• J (2021 NFRM OPPS Addenda; 2021 NFRM Addendum J.11302020.xls)
• L (2021 NFRM OPPS Addenda; 2021 NFRM Addendum L. 11302020.xlsx)
• M (2021 NFRM OPPS Addenda; 2021 NFRM Addendum M. 11302020.xlsx)
• P (2021 Correction Notice OPPS Addendum P; 2021 CN Addendum P.022221.xlsx)
Note:
Access the files on the CMS website at:
https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html
IPPS Tables
FY 2021 Tables 2, 3 and 4A and 4B (Wage Index Tables) (Final Rule and Correction Notice) [ZIP, 1.29MB] found at: https://www. cms.gov/medicare/acute-inpatient-pps/fy-2021-ipps-final-rule-home-page
Labor-related Share
60% (A) beginning at page 85906
Market Basket Inflation Factor
2.4% (A) at page 85869
Medicare Physician Fee Schedule Relative Value File
Not applicable for services rendered on or after December 15, 2016
Surgical Procedure
For services rendered on or after March 1, 2021, HCPCS codes listed in column A, of CMS' Ambulatory
HCPCS
Surgical Center Payment System (ASC) “CY 2021 CN ASC AA,” Column A, of CMS' ASC “CY 2021 CN ASC EE, and CPT codes 20560, 20561, 21811-21813, 33289, 36415, and 36456, but, excluding HCPCS codes listed on CMS' 2021 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “Correction Notice Addendum AA, BB, DD1, DD2, EE” (2021 CN ASC Addenda.022221.xlsx) at:
https://www. cms.gov/medicaremedicare-fee-service-paymentascpay-mentasc-regulations-and-notices/cms-1736-cn
2021 HOPPS Addendum E (2021 NFRM Addendum E.11302020) is found at:
https://www. cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1736-fc
For services rendered on or after April 1, 2021, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Apr 2021 ASC AA,” Column A. of CMS' ASC “Apr 2021 ASC EE,” and CPT codes 20560, 20561, 21811-21813, 33289, 36415, and 36456, but, excluding HCPCS codes listed on CMS' 2021 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “April 2021 ASC Approved HCPCS Code and Payment Rates-Updated 03/25/21” (April 2021 ASC Addenda.03242021.xlsx) at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html
2021 HOPPS Addendum E (2021 NFRM Addendum E.11302020) is found at: https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms1736-fc
For services rendered on or after July 1, 2021, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Jul 2021 ASC AA,” Column A. of CMS' ASC “Jul 2021 ASC EE,” and CPT codes 20560, 20561, 21811-21813, 33289, 36415, and 36456, but, excluding HCPCS codes listed on CMS' 2021 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “July 2021 ASC Approved HCPCS Code and Payment Rates” (July 2021 ASC Addenda.06252021.xlsx) at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html
2021 HOPPS Addendum E (2021 NFRM Addendum E.11302020) is found at: https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1736-fc
For services rendered on or after October 1, 2021, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Oct 2021 ASC AA,” Column A, of CMS' ASC “Oct 2021 ASC EE,” and CPT codes 20560, 20561, 21811-21813, 33289, 36415, and 36456, but, excluding HCPCS codes listed on CMS' 2021 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “October 2021 ASC Approved HCPCS Code and Payment Rates” (October 2021 ASC Addenda.09222021.xlsx) at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html
2021 HOPPS Addendum E (2021 NFRM Addendum E.11302020) is found at:
https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientopshospital-outpatient-regulations-and-notices/cms-1736-fc
Conversion Factor adjusted for inflation factor
$ 87.483 (2020 unadjusted conversion factor of $85.433 x estimated inflation factor of 1.024)
Wage Index
Referenced in (A) beginning at page 85916; wage index values are specified in CN Table 2 (C) and (D) found on the CMS website at https://www. cms.gov/medicare/acute-inpatient-pps/fy-2021-ipps-final-rule-home-page#1735
Services Occurring On or After March 1, 2022 and Mid-year Updates
Applicable FR Notices
(A) November 16, 2021 (CMS-1753-FC; 86 FR 63458)
(B) January 13, 2022 (CMS-1753-CN; 87 FR 2058)
(C) August 13, 2021 (CMS-1752-F; 86 FR 44774)
(D) October 20, 2021 (CMS-1752-F2; 86 FR 58019)
Applicable sections of Title 42, Code of Federal Regulations
§ 419.2 (As amended; effective January 1, 2016)
§ 419.32 (As amended; effective January 1, 2021)
§ 419.43 (As amended; effective January 1, 2017)
§ 419.44 (As amended; effective January 1, 2017)
§ 419.62 (Effective January 1, 2004)
§ 419.64 (As amended; effective January 1, 2015)
§ 419.66 (As amended; effective January 1, 2021)
§ 419.71 (Effective January 1, 2018)
Ambulatory Surgical Centers Payment System Addenda
For services occurring on or after March 1, 2022, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “January 2022 ASC Approved HCPCS Code and Payment Rates -- Updated 02/10/22” (January_2022_ASC_Addenda_revised_2.10.22.xlsx)
For services occurring on or after April 1, 2022, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “April 2022 ASC Approved HCPCS Code and Payment Rates-Updated 04/6/2022” (April_2022_ASC_Addenda_revised.04062022.xlsx)
For services occurring on or after July 1, 2022 Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “July 2022 ASC Approved HCPCS Code and Payment Rates” (July_2022_ASC_Addenda.063022.xlsx)
For services occurring on or after October 1, 2022, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “October 2022 ASC Approved HCPCS Code and Payment Rates-Updated 10/18/2022” (October_2022_ASC_Addenda.10172022.xlsx)
Note:
Access the files on CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
APC Payment Rate
For services occurring on or after March 1, 2022, Addendum B-Correction dated January 10, 2022, (January_2022_OPPS_Web_Addendum_B.01.10.22.xlsx)
For services occurring on or after April 1, 2022, Addendum B April 2022-updated 4/6/2022, (April_2022_Web_Addendum_B.04052022.xlsx)
For services occurring on or after July 1, 2022, Addendum B dated June 22, 2022, (July_2022_Web_Addendum_B.062222.xlsx)
For services occurring on or after October 1, 2022, Addendum B October 2022-updated 11/14/2022, (October_2022_Web_Addendum_B.11142022.xlsx)
APC Relative Weight
For services occurring on or after March 1, 2022, Addendum B-Correction dated January 10, 2022 (January_2022_OPPS_Web_Addendum_B.01.10.22.xlsx)
For services occurring on or after April 1, 2022, Addendum B April 2022-updated 4/6/2022, (April_2022_Web_Addendum_B.04052022.xlsx)
For services occurring on or after July 1, 2022, Addendum B dated June 22, 2022, (July_2022_Web_Addendum_B.062222.xlsx)
For services occurring on or after October 1, 2022, Addendum B October 2022-updated 11/14/2022, (October_2022_Web_Addendum_B.11142022.xlsx)
Composite APCs (codes assigned status indicator “Q1,” “Q2,” “Q3,” or “Q4”) payment rules
For services occurring on or after March 1, 2022, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2022 OPPS Addendum D1 (2021 NFRM OPPS Addendum D1.11012021.xlsx)
• CMS 2022 OPPS Addendum M
• IOCE Quarterly Data Files V23.R0 [ZIP, 27.3MB] IntegOCEspecs_V23.0_Jan.22.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after April 1, 2022, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2022 OPPS Addendum D1 (2022 NFRM OPPS Addendum D1.11012021.xlsx)
• CMS 2022 OPPS Addendum M
• IOCE Quarterly Data IOCE Quarterly Data Files V231.R0 April 2022 [ZIP, 26.9MB], IntegOCEspecs_V23.1_Apr22.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after July 1, 2022, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2022 OPPS Addendum D1 (2022 NFRM OPPS Addendum D1.11012021.xlsx)
• CMS 2022 OPPS Addendum M
• IOCE Quarterly Data IOCE Quarterly Data Files V232.R0 July 2022 [ZIP, 25.7MB], IntegOCEspecs_V23.2_Jul22.pdf, sections 5.4.1, 5.4.3, 5.4.5, and 5.5
For services occurring on or after October 1, 2022, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2022 OPPS Addendum D1 (2022 NFRM OPPS Addendum D1.11012021.xlsx)
• CMS 2022 OPPS Addendum M
• IOCE Quarterly Data IOCE Quarterly Data Files V233.R0 October 2022 [ZIP, 25.9MB], IntegOCEspecs_V23.3_Oct22.pdf, sections 5.3.1, 5.3.3, 5.3.5, and 5.4
Access documents on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html?redirect=/HospitalOutpatientPPS/ and CMS Claims Processing Manual at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
Comprehensive APCs (codes assigned status indicator “J1” or “J2”) payment rules
For services occurring on or after March 1, 2022, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2022 OPPS Addendum D1
• CMS 2022 OPPS Addendum J
• IOCE Quarterly Data Files V23.R0 [ZIP, 27.3MB] IntegOCEspecs_V23.0_Jan.22.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after April 1, 2022, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.2.4, 10.4, 290.5.2, and 290.5.3
• CMS 2022 OPPS Addendum D1 (2022 NFRM OPPS Addendum D1.11012021.xlsx)
• CMS 2022 OPPS Addendum J
• IOCE Quarterly Data IOCE Quarterly Data Files V231.R0 April 2022 [ZIP, 26.9MB], IntegOCEspecs_V23.1_Apr22.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after July 1, 2022, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.2.4, 10.4, 290.5.2, and 290.5.3
• CMS 2022 OPPS Addendum D1 (2022 NFRM OPPS Addendum D1.11012021.xlsx)
• CMS 2022 OPPS Addendum J
• IOCE Quarterly Data IOCE Quarterly Data Files V232.R0 July 2022 [ZIP, 25.7MB], IntegOCEspecs_V23.2_Jul22.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after October 1, 2022, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.2.4, 10.4, 290.5.2, and 290.5.3
• CMS 2022 OPPS Addendum D1 (2022 NFRM OPPS Addendum D1.11012021.xlsx)
• CMS 2022 OPPS Addendum J
• IOCE Quarterly Data IOCE Quarterly Data Files V233.R0 October 2022 [ZIP, 25.9MB], IntegOCEspecs_V23.3_Oct22.pdf, sections 5.5.1, 5.5.1.1, 5.5.2, 5.5.3.1, 5.5.4, 5.5.4.1, and 5.5.4.2
Access documents on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html
And CMS Claims Processing Manual at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending
Emergency Department HCPCS Codes
99281-99285, 99291, 99292, G0380-G0384, G0390
Facility Only Services
Not applicable for services rendered on or after December 15, 2016
Film X-ray services and X-rays taken using computed radiography technology/cassette-based imaging payment reductions
Use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for such service. Use modifier “FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent payment reduction for such service. Apply payment rules set forth in:
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 01/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515 Revised March 22, 2018, Transmittal R4005CP, section 6
Access the Medicare Claims Processing Manual on the CMS website at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-ltems/CMS018912.html
HOPPS Addenda
For services occurring on or after March 1, 2022 addenda:
• A (January 2022-Correction; January_2022_OPPS_Web_Addendum_A.01.10.22.xlsx)
• B (January 2022-Correction; January_2022_OPPS_Web_Addendum_B.01.10.22.xlsx)
• D1 (2022 NFRM OPPS Addenda; 2022 NFRM Addendum D1.11012022.xlsx)
• D2 (2022 NFRM OPPS Addenda; 2022 NFRM Addendum D2.11012022.xlsm)
• E (2022 NFRM OPPS Addenda; 2022 NFRM Addendum E.11012022.xlsx)
• J (2022 NFRM OPPS Addenda; 2022 NFRM Addendum J.11012022.xls)
• L (2022 NFRM OPPS Addenda; 2022 NFRM Addendum L.11012022.xlsx)
• M (2022 NFRM OPPS Addenda; 2022 NFRM Addendum M.11012022.xlsx)
• P (2022 CN Addendum P; 2022 CN Addendum P.01142022.xlsx)
For services rendered on or after April 1, 2022:
• A (April 2022-Correction; April_2022_Web_Addendum_A.04062022.xlsx)
• B (April 2022-Correction; April_2022_Web_Addendum_B.04062022.xlsx)
• D1 (2022 NFRM OPPS Addenda; 2022 NFRM Addendum D1.11012022.xlsx)
• D2 (2022 NFRM OPPS Addenda; 2022 NFRM Addendum D2.11012022.xlsm)
• E (2022 NFRM OPPS Addenda; 2022 NFRM Addendum E.11012022.xlsx)
• J (2022 NFRM OPPS Addenda; 2022 NFRM Addendum J.11012022.xls)
• L (2022 NFRM OPPS Addenda; 2022 NFRM Addendum L.11012022.xlsx)
• M (2022 NFRM OPPS Addenda; 2022 NFRM Addendum M.11012022.xlsx)
• P (2022 CN Addendum P; 2022 CN Addendum P.01142022.xlsx)
For services occurring on or July 1, 2022 addenda:
• A (July 2022; July 2022 Web Addendum_A.062222.xlsx)
• B (July 2022; July 2022 Web Addendum_B.062222.xlsx)
• D1 (2022 NFRM OPPS Addenda; 2022 NFRM Addendum D1.11012021.xlsx)
• D2 (2022 NFRM OPPS Addenda; 2022 NFRM Addendum D2.11012021.xlsm)
• E (2022 NFRM OPPS Addenda; 2022 NFRM Addendum E.11012021.xlsx)
• J (2022 NFRM OPPS Addenda; 2022 NFRM Addendum J.11012021.xls)
• L (2022 NFRM OPPS Addenda; 2022 NFRM Addendum L.11012021.xlsx)
• M (2022 NFRM OPPS Addenda; 2022 NFRM Addendum M.11012021.xlsx)
• P (2022 CN Addendum P; 2022 CN Addendum P.01142022.xlsx)
For services occurring on or after October 1, 2022 addenda:
• A (October 2022-updated; October_2022_Web_Addendum_A.11142022.xlsx)
• B (October 2022-updated; October_2022_Web_Addendum_B.11142022.xlsx)
• D1 (2022 NFRM OPPS Addenda; 2022 NFRM Addendum D1.11012021.xlsx)
• D2 (2022 NFRM OPPS Addenda; 2022 NFRM Addendum D2.11012021.xlsm)
• E (2022 NFRM OPPS Addenda; 2022 NFRM Addendum E.11012021.xlsx)
• J (2022 NFRM OPPS Addenda; 2022 NFRM Addendum J.11012021.xls)
• L (2022 NFRM OPPS Addenda; 2022 NFRM Addendum L.1101201.xlsx)
• M (2022 NFRM OPPS Addenda; 2022 NFRM Addendum M.11012021.xlsx)
• P (2022 CN Addendum P; 2022 CN Addendum P.01142022.xlsx)
Note:
Access the files on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html
IPPS Tables
FY 2022 Tables 2, 3, and 4A and 4B (Wage Index Tables) (Final Rule, Correction and Correcting Amendment,) [ZIP, 1.2MB] found at https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page
Labor-related Share
60% (A) at page 63,500
Market Basket Inflation Factor
2.7% (A) at page 63,500
Medicare Physician Fee Schedule Relative Value File
Not applicable for services rendered on or after December 15, 2016
Surgical Procedure HCPCS
For services rendered on or after March 1, 2022, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “CY 2022 CN ASC AA,” Column A, of CMS' ASC “CY 2022 CN ASC EE, and CPT codes 15772, 15774, 15999, 17999, 19499, 20560, 20561, 20700-20705, 20999, 21089, 21299, 21499, 21811-21813, 21899, 22634, 22899, 22999, 23929, 24999, 25999, 26989, 27299, 27599, 27899, 28899, 29799, 29999, 30999, 31299, 31599, 31899, 32999, 33289, 33370, 33999, 35500, 35685, 35686, 36299, 36415, 36456, 37501, 37799, 38129, 38589, 38999, 40799, 40899, 41599, 41899, 42299, 42699, 42999, 43289, 43499, 43659, 43999, 44238, 44799, 44979, 45399, 45499, 45999, 46999, 47379, 47399, 47579, 47999, 48999, 49329, 49659, 49999, 50549, 50949, 51999, 53899, 54699, 55559, 55899, 57465, 58578, 58579, 58679, 58999, 60659, 60699, 63502, 63503, 64629, 64999, 66999, 67299, 67399, 67599, 67999, 68399, 68841, 68899, 69399, 69799, 69949, and 69979 but, excluding HCPCS codes listed on CMS' 2022 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “January 2022 ASC Approved HCPCS Code and Payment Rates -- Updated 02/10/2022” (January_2022_ASC_Addenda_revised_2.10.22.xlsx)
Access the files on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
2022 HOPPS Addendum E (2022 NFRM Addendum E.11012022.xlsx) is found at: https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientpps/cms-1753-fc
For services rendered on or after April 1, 2022, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Apr 2022 ASC AA,” Column A, of CMS' ASC “Apr 2022 ASC EE,” and CPT codes 15772, 15774, 15999, 17999, 19499, 20560, 20561, 20700-20705, 20999, 21089, 21299, 21499, 21811-21813, 21899, 22634, 22899, 22999, 23929, 24999, 25999, 26989, 27299, 27599, 27899, 28899, 29799, 29999, 30999, 31299, 31599, 31899, 32999, 33289, 33370, 33999, 35500, 35685, 35686, 36299, 36415, 36456, 37501, 37799, 38129, 38589, 38999, 40799, 40899, 41599, 41899, 42299, 42699, 42999, 43289, 43499, 43659, 43999, 44238, 44799, 44979, 45399, 45499, 45999, 46999, 47379, 47399, 47579, 47999, 48999, 49329, 49659, 49999, 50549, 50949, 51999, 53899, 54699, 55559, 55899, 57465, 58578, 58579, 58679, 58999, 60659, 60699, 63502, 63503, 64629, 64999, 66999, 67299, 67399, 67599, 67999, 68399, 68841, 68899, 69399, 69799, 69949, and 69979 but, excluding HCPCS codes listed on CMS' 2022 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “April 2022 ASC Approved HCPCS Code and Payment Rates-Updated 04/06/22” (April_2022_ASC_Addenda.04062022.xlsx)
2022 HOPPS Addendum E (2022 NFRM Addendum E.11012021.xlsx) is found at: https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientpps/cms-1753-fc
For services rendered on or after July 1, 2022, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “July 2022 ASC AA,” Column A, of CMS' ASC “July 2022 ASC EE”, and CPT codes 15772, 15774, 15999, 17999, 19499, 20560, 20561, 20700-20705, 20999, 21089, 21299, 21499, 21811-21813, 21899, 22634, 22899, 22999, 23929, 24999, 25999, 26989, 27299, 27599, 27899, 28899, 29799, 29999, 30999, 31299, 31599, 31899, 32999, 33289, 33370, 33999, 35500, 35685, 35686, 36299, 36415, 36456, 37501, 37799, 38129, 38589, 38999, 40799, 40899, 41599, 41899, 42299, 42699, 42999, 43289, 43499, 43659, 43999, 44238, 44799, 44979, 45399, 45499, 45999, 46999, 47379, 47399, 47579, 47999, 48999, 49329, 49659, 49999, 50549, 50949, 51999, 53899, 54699, 55559, 55899, 57465, 58578, 58579, 58679, 58999, 60659, 60699, 63502, 63503, 64629, 64999, 66999, 67299, 67399, 67599, 67999, 68399, 68841, 68899, 69399, 69799, 69949, and 69979 but, excluding HCPCS codes listed on CMS' 2022 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “July 2022 ASC Approved HCPCS Code and Payment Rates” (July_2022_ASC_Addenda.063022.xlsx)
Access the files on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
2022 HOPPS Addendum E (2022 NFRM Addendum E.11012021.xlsx) is found at: https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientpps/cms-1753-fc
For services rendered on or after October 1, 2022, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Oct 2022 ASC AA,” Column A, of CMS' ASC “Oct 2022 ASC EE”, and CPT codes 15772, 15774, 15999, 17999, 19499, 20560, 20561, 20700-20705, 20999, 21089, 21299, 21499, 21811-21813, 21899, 22634, 22899, 22999, 23929, 24999, 25999, 26989, 27299, 27599, 27899, 28899, 29799, 29999, 30999, 31299, 31599, 31899, 32999, 33289, 33370, 33999, 35500, 35685, 35686, 36299, 36415, 36456, 37501, 37799, 38129, 38589, 38999, 40799, 40899, 41599, 41899, 42299, 42699, 42999, 43289, 43499, 43659, 43999, 44238, 44799, 44979, 45399, 45499, 45999, 46999, 47379, 47399, 47579, 47999, 48999, 49329, 49659, 49999, 50549, 50949, 51999, 53899, 54699, 55559, 55899, 57465, 58578, 58579, 58679, 58999, 60659, 60699, 63502, 63503, 64629, 64999, 66999, 67299, 67399, 67599, 67999, 68399, 68841, 68899, 69399, 69799, 69949, and 69979 but, excluding HCPCS codes listed on CMS' 2022 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “October 2022 ASC Approved HCPCS Code and Payment Rates-Updated 10/18/2022” (October_2022_ASC_Addenda.10172022.xlsx)
Access the files on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
Conversion Factor adjusted for inflation factor
$ 89.845 (2021 unadjusted conversion factor of $87.483 x estimated inflation factor of 1.027)
Wage Index
Referenced in (A) beginning at page 63503; wage index values are specified in Table 2 (C) and (D) found on the CMS website at: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page
Services Occurring On or After March 1, 2023 and Mid-year Updates
Applicable FR Notices
(A) November 23, 2022 (CMS-1772-FC; 87 FR 71748);
(B) August 10, 2022 (CMS-1771-F; 87 FR 48780 final rule)
(C) November 4, 2022 (CMS-1771-F2; 87 FR 66558; correcting amendment)
(D) December 13, 2022 (CMS-1771-CN; 87 FR 76109)
Applicable sections of Title 42, Code of Federal Regulations
§ 419.2 (As amended; effective January 1, 2016)
§ 419.32 (As amended; effective January 1, 2021)
§ 419.43 (As amended; effective January 1, 2023)
§ 419.44 (As amended; effective January 1, 2017)
§ 419.62 (Effective January 1, 2004)
§ 419.64 (As amended; effective January 1, 2015)
§ 419.66 (As amended; effective January 1, 2021)
§ 419.71 (Effective January 1, 2018)
Ambulatory Surgical Centers Payment System Addenda
For services occurring on or after March 1, 2023, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “January 2023 ASC Approved HCPCS Code and Payment Rates -- Updated 01/09/2023” (2023_January_ASC_Addenda_revised_01092023.xlsx)
For services occurring on or after May 1, 2023 Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “April 2023 ASC Approved HCPCS Code and Payment Rates -- Updated 04/03/2023” (April_2023_ASC_Addenda_04032023.xlsx)
For services occurring on or after July 1, 2023 Column A, of Addendum AA entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “July 2023 ASC Approved HCPCS Code and Payment Rates -- Updated 06/29/2023” (July_2023_ASC_Addenda_06292023.xlsx)
For services occurring on or after October 1, 2023 Column A, of Addendum AA entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “October 2023 ASC Approved HCPCS Code and Payment Rates -- Updated 09/22/2023” (October_2023_ASC_Addenda.09212023rev.xlsx)
Note:
Access the files on CMS website at: https://www.cms.gov/medicare/payment/prospective-payment-systems/ambulatory-surgical-center-asc/asc-payment-rates-addenda
APC Payment Rate
For services occurring on or after March 1, 2023, January 2023 Addendum B (2023_Web_Addendum_B.01202023a.xlsx)
For services occurring on or after May 1, 2023, Addendum B April 2023 -- updated 05/10/2023, (2023_April_Web_Addendum_B.05102023.xlsx)
For services occurring on or after July 1, 2023, Addendum B July 2023 -- updated 08/01/2023, (2023_July_Web_Addendum_B.08012023.xlsx)
For services occurring on or after October 1, 2023, Addendum B October 2023, (2023_Web_October_Addendum_B.09192023.xlsx)
APC Relative Weight
For services occurring on or after March 1, 2023, January 2023 Addendum B (2023_Web_Addendum_B.01202023a.xlsx)
For services occurring on or after May 1, 2023, Addendum B April 20223 -- updated 05/10/2023, (2023_April_Web_Addendum_B.05102023.xlsx)
For services occurring on or after July 1, 2023, Addendum B July 2023 -- updated 08/01/2023, (2023_July_Web_Addendum_B.08012023.xlsx)
For services occurring on or after October 1, 2023, Addendum B October 2023 (2023_Web_October_Addendum_B.09192023.xlsx)
Composite APCs (codes assigned status indicator “Q1,” “Q2,” “Q3,” or “Q4”) payment rules
For services occurring on or after March 1, 2023, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2023 OPPS Addendum D1 (2023 NFRM OPPS Addendum D1.11012022.xlsx)
• CMS 2023 OPPS Addendum M
• IOCE Quarterly Data Files V240.R1 [ZIP, 27.6MB] IntegOCEspecs_V24.0_Jan.23.pdf, sections 5.3.1, 5.3.3, 5.3.5, and 5.4
For services occurring on or after May 1, 2023, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2023 OPPS Addendum D1 (2023 NFRM OPPS Addendum D1.11012022.xlsx)
• CMS 2023 OPPS Addendum M
• IOCE Quarterly Data IOCE Quarterly Data Files V241.R0 April 2023 [ZIP, 26.2MB], IntegOCEspecs_V24.1_Apr23.pdf, sections 5.3.1, 5.3.3, 5.3.5 and 5.4
For services occurring on or after July 1, 2023, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2023 OPPS Addendum D1 (2023 NFRM OPPS Addendum D1.11012022.xlsx)
• CMS 2023 OPPS Addendum M
• IOCE Quarterly Data IOCE Quarterly Data Files V242.R0 July 2023 [ZIP, 27.1MB], IntegOCEspecs_V24.2_Jul23.pdf, sections 5.4.1, 5.4.3, 5.4.5 and 5.5
For services occurring on or after October 1, 2023, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2023 OPPS Addendum D1 (2023 NFRM OPPS Addendum D1.11012022.xlsx)
• CMS 2023 OPPS Addendum M
• IOCE Quarterly Data IOCE Quarterly Data Files V243.R0 October 2023 [ZIP, 24.9MB], IntegOCEspecs_V24.3_Oct23.pdf, sections 5.4.1, 5.4.3, 5.4.5 and 5.5
Note:
A link to the IOCE is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#6
Access documents on the CMS website at: https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1772-fc and CMS Claims Processing Manual at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
Comprehensive APCs (codes assigned status indicator “J1” or “J2”) payment rules
For services occurring on or after March 1, 2023, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2023 OPPS Addendum D1
• CMS 2023 OPPS Addendum J
• IOCE Quarterly Data Files V240.R1 [ZIP, 27.6MB] IntegOCEspecs_V24.0_Jan.23.pdf, sections 5.5.1, 5.5.1.1, 5.5.2, 5.5.3, 5.5.4, 5.5.4.1, and 5.5.4.2
For services occurring on or after May 1, 2023, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2023 OPPS Addendum D1
• CMS 2023 OPPS Addendum J
• IOCE Quarterly Data IOCE Quarterly Data Files V241.R0 April 2023 [ZIP, 26.2MB], IntegOCEspecs_V24.1_Apr23.pdf, sections 5.5.1, 5.5.1.1, 5.5.2, 5.5.3, 5.5.4, 5.5.4.1, and 5.5.4.2
For services occurring on or after July 1, 2023, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2023 OPPS Addendum D1
• CMS 2023 OPPS Addendum J
• IOCE Quarterly Data IOCE Quarterly Data Files V242.R0 July 2023 [ZIP, 27.1MB], IntegOCEspecs_V24.2_Jul23.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
For services occurring on or after October 1, 2023, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2023 OPPS Addendum D1
• CMS 2023 OPPS Addendum J
• IOCE Quarterly Data IOCE Quarterly Data Files V243.R0 October 2023 [ZIP, 24.9MB], IntegOCEspecs_V24.3_Oct23.pdf, sections 5.6.1, 5.6.1.1, 5.6.2, 5.6.3, 5.6.4, 5.6.4.1, and 5.6.4.2
Note:
A link to the IOCE is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#6
Access documents on the CMS website at: https://www.cms.gov/medicaremedicare-fee-service-paymen-thospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1772-fc
And CMS Claims Processing Manual at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
Emergency Department HCPCS Codes
99281-99285, 99291, 99292, G0380-G0384, G0390
Facility Only Services
Not applicable for services rendered on or after December 15, 2016
Film X-ray services and X-rays taken using computed radiography technology/cassette-based imaging payment reductions
Use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for such service. Use modifier “FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent payment reduction for such service. Apply payment rules set forth in:
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 01/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515 Revised March 22, 2018, Transmittal R4005CP, section 6
Access the Medicare Claims Processing Manual on the CMS website at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-ltems/CMS018912.html
HOPPS Addenda
For services occurring on or after March 1, 2023 addenda:
• A (January 2023 -- Correction; 2023_January_Web_Addendum_A.01202023a.xlsx)
• B (January 2023 -- Correction; 2023_January_Web_Addendum_B.01202023a.xlsx)
• D1 (2023 NFRM OPPS Addenda; 2023 NFRM Addendum D1.11012022.xlsx)
• D2 (2023 NFRM OPPS Addenda; 2023 NFRM Addendum D2.11012022.xlsm)
• E (2023 NFRM OPPS Addenda; 2023 NFRM Addendum E.11012022.xlsx)
• J (2023 NFRM OPPS Addenda; 2023 NFRM Addendum J.11012022.xls)
• L (2023 NFRM OPPS Addenda; 2023 NFRM Addendum L.11012022.xlsx)
• M (2023 NFRM OPPS Addenda; 2023 NFRM Addendum M.11012022.xlsx)
• P (2023 NFRM OPPS Addenda; 2023 NFRM Addendum P.11012022.xlsx)
For services occurring on or after May 1, 2023 addenda:
•
A (April 2023 -- updated 05/10/2023; 2023_April_Web_Addendum_A.05102023.xlsx)
•
B (April 2023 -- updated 05/10/2023; 2023_April_Web_Addendum_B.05102023.xlsx)
•
D1 (2023 NFRM OPPS Addenda; 2023 NFRM Addendum D1.11012022.xlsx)
•
D2 (2023 NFRM OPPS Addenda; 2023 NFRM Addendum D2.11012022.xlsm)
•
E (2023 NFRM OPPS Addenda; 2023 NFRM Addendum E.11012022.xlsx)
•
J (2023 NFRM OPPS Addenda; 2023 NFRM Addendum J.11012022.xls)
•
L (2023 NFRM OPPS Addenda; 2023 NFRM Addendum L.11012022.xlsx)
•
M (2023 NFRM OPPS Addenda; 2023 NFRM Addendum M.11012022.xlsx)
•
P (2023 NFRM OPPS Addenda; 2023 NFRM Addendum P.11012022.xlsx)
For services occurring on or after July 1, 2023 addenda:
•
A (July 2023 -- updated 08/01/2023; 2023_July_Web_Adddendum_A.08012023.xlsx)
•
B (July 2023 -- updated 08/01/2023; 2023_July_Web_Addendum_B.08012023.xlsx)
•
D1 (2023 NFRM OPPS Addenda; 2023 NFRM Addendum D1.11012022.xlsx)
•
D2 (2023 NFRM OPPS Addenda; 2023 NFRM Addendum D2.11012022.xlsm)
•
E (2023 NFRM OPPS Addenda; 2023 NFRM Addendum E.11012022.xlsx)
•
J (2023 NFRM OPPS Addenda; 2023 NFRM Addendum J.11012022.xls)
•
L (2023 NFRM OPPS Addenda; 2023 NFRM Addendum L.11012022.xlsx)
•
M (2023 NFRM OPPS Addenda; 2023 NFRM Addendum M.11012022.xlsx)
•
P (2023 NFRM OPPS Addenda; 2023 NFRM Addendum P.11012022.xlsx)
For services occurring on or after October 1, 2023 addenda:
•
A (October 2023; 2023_October_Web_Adddendum_A.09192023.xlsx)
•
B (October 2023; 2023_October_Web_Addendum_B.09192023.xlsx)
•
D1 (2023 NFRM OPPS Addenda; 2023 NFRM Addendum D1.11012022.xlsx)
•
D2 (2023 NFRM OPPS Addenda; 2023 NFRM Addendum D2.11012022.xlsm)
•
E (2023 NFRM OPPS Addenda; 2023 NFRM Addendum E.11012022.xlsx)
•
J (2023 NFRM OPPS Addenda; 2023 NFRM Addendum J.11012022.xls)
•
L (2023 NFRM OPPS Addenda; 2023 NFRM Addendum L11012022.xlsx)
•
M (2023 NFRM OPPS Addenda; 2023 NFRM Addendum M.11012022.xlsx)
•
P (2023 NFRM OPPS Addenda; 2023 NFRM Addendum P.11012022.xlsx)
Note:
Access the files on the CMS website at: https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/addendum-a-b-updates
IPPS Tables
FY 2023 Tables 2, 3 and 4A and 4B (Wage Index Tables) (Final Rule) [ZIP, 700KB] found at https://www.cms.gov/medicare/acute-inpatient-pps/fy-2023-ipps-final-rule-home-page
Labor-related Share
60% (A) at page 71782
Market Basket Inflation Factor
4.1% (A) at page 71782
Medicare Physician Fee Schedule Relative Value File
Not applicable for services rendered on or after December 15, 2016
Surgical Procedure HCPCS
For services rendered on or after March 1, 2023, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Jan 2023 ASC AA,” Column A, of CMS' ASC “Jan 2023 ASC EE”, and CPT codes 15772, 15774, 15853, 15854, 20560, 20561, 20701-20705, 21811-21813, 22634, 33289, 33370, 33904, 35500, 35685, 35686, 36415, 36456, 49623, 57465, 63052, 63053, 64629, and 68841, but, excluding HCPCS codes listed on CMS' 2023 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: January 2023 ASC Approved HCPS Code and Payment Rates -- Updated 01/09/2023 (2023_January_ASC_Addenda_updated_01092023.xlsx) on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
Access the files on the CMS website at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/ascpayment/11_addenda_updates
2023 HOPPS Addendum E (2023 NFRM Addendum E.11012022.xlsx) is found at: https://www.cms.gov/medicaremedicare-fee-service-paymentascpaymentasc-regulations-and-notices/cms-1772-fc
For services rendered on or after May 1, 2023, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “Apr 2023 ASC AA,” Column A, of CMS' ASC “Apr 2023 ASC EE”, and CPT codes 15772, 15774, 15853, 15854, 20560, 20561, 20701-20705, 21811-21813, 22634, 33289, 33370, 33904, 35500, 35685, 35686, 36415, 36456, 49623, 57465, 63052, 63053, 64629, and 68841, but, excluding HCPCS codes listed on CMS' 2023 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “April 2023 ASC Approved HCPCS Code and Payment Rates -- Updated 04/03/23” (April_2023_ASC_Addenda_04032023.xlsx)
Access the files on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
2023 HOPPS Addendum E (2023 NFRM Addendum E.11012022.xlsx) is found at: https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1772-fc
For services rendered on or after July 1, 2023, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “July 2023 ASC AA,” Column A, of CMS' ASC “July 2023 ASC EE”, and CPT codes 15772, 15774, 15853, 15854, 20560, 20561, 20701-20705, 21811-21813, 22634, 33289, 33370, 33904, 35500, 35685, 35686, 36415, 36456, 49623, 57465, 63052, 63053, 64629, and 68841, but, excluding HCPCS codes listed on CMS' 2023 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “July 2023 ASC Approved HCPCS Code and Payment Rates -- Updated 06/29/23” (July_2023_ASC_Addenda_06292023.xlsx)
Access the files on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
2023 HOPPS Addendum E (2023 NFRM Addendum E.11012022.xlsx) is found at: https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1772-fc
For services rendered on or after October 1, 2023, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center Payment System (ASC) “October 2023 ASC AA,” Column A, of CMS' ASC “October 2023 ASC EE”, and CPT codes 15772, 15774, 15853, 15854, 20560, 20561, 20701-20705, 21811-21813, 22634, 33289, 33370, 33904, 35500, 35685, 35686, 36415, 36456, 49623, 57465, 63052, 63053, 64629, and 68841, but, excluding HCPCS codes listed on CMS' 2023 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: “October 2023 ASC Approved HCPCS Code and Payment Rates -- Updated 09/22/2023” (October_2023_ASC_Addenda_09212023rev.xlsx)
Access the files on the CMS website at: https://www.cms.gov/medicare/payment/prospective-payment-systems/ambulatory-surgical-center-asc/asc-payment-rates-addenda
2023 HOPPS Addendum E (2023 NFRM Addendum E.11012022.xlsx) is found at: https://www.cms.gov/medicaremedicare-fee-service-paymentascpaymentasc-regulations-and-notices/cms-1772-fc
Conversion Factor adjusted for inflation factor
$ 93.528 (2022 unadjusted conversion factor of $89.845 x estimated inflation factor of 1.041)
Wage Index
Referenced in (A) beginning at page 71782; wage index values are specified in Table 2(C) found on the CMS website at: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2023-ipps-final-rule-home-page#FinalRule
Services Occurring On or After February 15, 2024 and Mid-year Updates
Applicable FR Notices
(A) November 22, 2023 (CMS-1786-FC; 88 FR 81540);
(B) August 28, 2023 (CMS-1785-F; 88 FR 58640 Final rule);
(C) October 4, 2023 (CMS-1785-CN; 88 FR 68482 Correction Notice)
Applicable sections of Title 42. Code of Federal Regulations
§ 419.2 (As amended; effective January 1, 2016)
§ 419.32 (As amended; effective January 1, 2021)
§ 419.43 (As amended; effective January 1, 2023)
§ 419.44 (As amended; effective January 1, 2017)
§ 419.62 (Effective January 1, 2004)
§ 419.64 (As amended; effective January 1, 2015)
§ 419.66 (As amended; effective January 1, 2021)
§ 419.71 (Effective January 1, 2018)
Ambulatory Surgical Centers Payment System Addenda
For services occurring on or after February 15, 2024, Column A, of Addendum AA, entitled, “HCPCS Code” and Column A, of Addendum EE, entitled, “HCPCS Code” located in “January 2024 ASC Approved HCPCS Code and Payment Rates -- updated 12/27/2023” “AA, BB, DD1, DD2, EE, and FF” (January_2024_ASC_Addenda.12272023.xlsx)
Note:
Access the files on CMS website at: https://www.cms.gov/medicare/medicare/payment/prospective-payment-systems/ambulatory-surgical-center-asc/asc-payment-rates-addenda
APC Payment Rate
For services occurring on or after February 15, 2024, Addendum A and B Updates -- (January 2024 OPPS Addendum B.12212023.xlsx)
APC Relative Weight
For services occurring on or after February 15, 2024, Addendum A and B Updates -- (January 2024 OPPS Addendum B.12212023.xlsx)
Composite APCs (codes assigned status indicator “Q1,” “Q2,” “Q3,” or “Q4”) payment rules
For services occurring on or after February 15, 2024, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.2, 10.4, and 10.4.1
• CMS 2024 OPPS Addenda D1 (2024 NFRM Addendum D111012023.xlsx)
• CMS 2024 OPPS Addendum M (2024 NFRM Addendum D111012023.xlsx)
• IOCE Quarterly Data Files V250.R0 [ZIP, 27.5MB] IntegOCEspecs V25.0 Jan24.pdf, sections 6.4.1, 6.4.3, 6.4.5, and 6.5
Note:
A link to the IOCE is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#6
Access documents on the CMS website at: https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/regulations-notices/cms-1786-fc and CMS Claims Processing Manual at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-ltems/CMS018912.html
Comprehensive APCs (codes assigned status indicator “J1” or “J2”) payment rules
For services occurring on or February 15, 2024, payment rules are:
• Medicare Claims Processing Manual, Chapter 4, sections 10.2.3, 10.4, 290.5.2, and 290.5.3
• CMS 2024 OPPS Addendum D1
• CMS 2024 OPPS Addendum J
• IOCE Quarterly Data Files V250.R0 [ZIP, 27.5MB] IntegOCEspecs V25.0 Jan24.pdf, sections 6.6.1, 6.6.1.1, 6.6.2, 6.6.3, 6.6.4, 6.6.4.1, and 6.6.4.2
Note:
A link to the IOCE is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#6
Access documents on the CMS website at: https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/regulatlations-notices/cms-1786-fc and CMS Claims Processing Manual at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-ltems/CMS018912.html
Emergency Department HCPCS Codes
99281-99285, 99291, 99292, G0380-G0384, G0390
Facility Only Services
Not applicable for services rendered on or after December 15, 2016
Film X-ray services and X-rays taken using computed radiography technology/cassette-based imaging payment reductions
Use modifier “FX” to report X-rays taken using film, which requires a 20 percent payment reduction for such service. Use modifier “FY” to report X-rays taken using computed radiography technology/cassette-based imaging which requires a 7 percent payment reduction for such service. Apply payment rules set forth in:
• December 14, 2017 (CMS-1678-FC; 82 FR 59216, Republished, section X.E., pages 59391 through 59393)
• Medicare Claims Processing Manual, Chapter 4, section 20.6.14 (effective 01/01/2018) and section 20.6.15 (effective 01/01/2018)
• CFR section 419.71
• CMS' April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS) CR 10515 Revised March 22, 2018, Transmittal R4005CP, section 6
Access the Medicare Claims Processing Manual on the CMS website at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-ltems/CMS018912.html
HOPPS Addenda
For services occurring on or February 15, 2024 addenda:
•
A (Addendum A and B Updates; January_2024_OPPS_Addendum_A.12262023.xlsx)
•
B (Addendum A and B Updates; January_2024_OPPS_Addendum_B.12212023.xlsx)
•
D1 (2024 NFRM OPPS Addenda; 2024 NFRM Addendum D1.11012023.xlsx)
•
D2 (2024 NFRM OPPS Addenda; 2024 NFRM Addendum D2.11012023.xlsm)
•
E (2024 NFRM OPPS Addenda; 2024 NFRM Addendum E.11012023.xlsx)
•
J (2024 NFRM OPPS Addenda; 2024 NFRM Addendum J.11012023.xls)
•
L (2024 NFRM OPPS Addenda; 2024 NFRM Addendum L.11012023.xlsx)
•
M (2024 NFRM OPPS Addenda; 2024 NFRM Addendum M.11012023.xlsx)
•
P (2024 NFRM OPPS Addenda; 2024 NFRM Addendum P.11012023.xlsx)
Note:
Access the files on the CMS website at: https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/regulations-notice/cms-1786-fc
IPPS Tables
FY 2024 Tables 2, 3 and 4A and 4B (Wage Index Tables) (Final Rule and Correction Notice) [ZIP, 1.31MB] found at https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2024-ipps-final-rule-home-page#CMS1785F
Labor-related Share
60% at (A) page (81583)
Market Basket Inflation Factor
3.3% at (A) page (81543)
Medicare Physician Fee Schedule Relative Value File
Not applicable for services rendered on or after December 15, 2016
Surgical Procedure HCPCS
For services rendered on or after February 15, 2024, HCPCS codes listed in column A, of CMS' Ambulatory Surgical Center (ASC) Payment System “CY 2024 ASC AA,” Column A, of CMS' ASC “CY 2024 ASC EE”, and CPT codes 15772, 15774, 15853, 15854, 20560, 20561, 20701-20705, 21811-21813, 22634, 33370, 33904, 35500, 35685, 35686, 36415, 36456, 49623, 57465, 63052, 63053, and 64629, but excluding HCPCS codes listed on CMS' 2024 HOPPS Addendum E as an inpatient only procedure.
ASC Addenda AA and EE may be found in: January 2024 ASC Approved HCPCS Code and Payment Rates -- updated 12/27/2023 (January_2024_ASC_Addenda.12272023.xlsx) on the CMS website at: https://www.cms.gov/medicare/payment/prospective-payment-systems/ambulatory-surgical-center-asc/asc-payment-rates-addenda
2024 HOPPS Addendum E (2024 NFRM Addendum E.11012023.xlsx) is found at: https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/regulations-notices/cms-1786-fc
Conversion Factor adjusted for inflation factor
$ 96.614 (2023 unadjusted conversion factor of $93.528 x estimated inflation factor of 1.033)
Wage Index
Referenced in (A) beginning at page 81583; wage index values are specified in Table 2(B) and (C) found on the CMS website at: https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2024-ipps-final-rule-home-page
Note: Authority cited: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 4603.2 and 5307.1, Labor Code.
History
1. New section filed 12-27-2012; operative 1-1-2013 as a file and print only pursuant to Government Code section 11340.9(g) (Register 2012, No. 52).
2. Amendment filed 3-29-2013; operative 4-1-2013 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2013, No. 13).
3. Amendment of section heading and section filed 6-3-2014; operative 9-1-2014 as a file and print only pursuant to Government Code section 11340.9(g) (Register 2014, No. 23).
4. Amendment filed 12-4-2014; operative 12-1-2014 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2014, No. 49).
5. Amendment filed 12-15-2016; operative 12-15-2016 as a file and print only pursuant to Government Code section 11340.9(g) (Register 2016, No. 51).
6. Editorial correction of subsection (b) (Register 2017, No. 18).
7. Amendment filed 6-20-2017; operative 6-1-2017 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2017, No. 25).
8. Amendment filed 5-8-2018; operative 3-15-2018 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2018, No. 19).
9. Editorial correction (Register 2019, No. 5).
10. Amendment filed 2-14-2019; operative 2-15-2019 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2019, No. 7).
11. Editorial correction (Register 2019, No. 33).
12. Amendment of subsection (b) filed 3-19-2020; operative 3-1-2020 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2020, No. 12).
13. Amendment filed 4-1-2021; operative 3-1-2021 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2021, No. 14).
14. Amendment of subsection (b) filed 4-5-2022; operative 3-1-2022 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2022, No. 14).
15. Amendment of subsection (b) filed 3-1-2023; operative 3-1-2023 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2023, No. 9).
16. Amendment of subsection (b) filed 3-12-2024; operative 2-15-2024 pursuant to Labor Code section 5307.1(g)(2). Exempt from the APA pursuant to Labor Code section 5307.1(g)(2) and submitted to OAL for filing and printing only pursuant to Government Code section 11343.8 (Register, No. 11).


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