License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

Print | Bookmark | Font Size: + | –

September 6, 2003

4th Quarter 2003 Update - Part B Not Otherwise Classified Drug Fee Schedule

Effective 10-01-2003

Name of Drug and Exact Dosage Given in Block 19 (paper) or Narrative Field (EMC)

** = Carrier Priced
Changes In Bold

DRUG NAME	DOSAGE	Current PAR	Current NONPAR	*Price Change
**Actiq (Cephalon) Lozenge on a Stick (Non-Covered)
Acyclovir Sodium Covered if given IV for mucosal and cutaneous HSV1, HSV2, or varicella-zoster (shingles) in immunocompromised patients. ICD-9 Code(s) 052.0 - 054.9.	500 mg	48.64	46.21
** Adenosine (Adenoscan) for 90 mg see J0151	60mg/20ml	155.24	147.48
** Alefacept (Amevive) Covered DX = 696.0	7.5 mg	665.00	631.75
** Alefacept (Amevive) Covered DX = 696.0	15 mg	945.25	897.99
**Alfentanil HCL (Alfenta)	500 mcg/5 ml	2.29	2.18
Allopurinol Sodium (Aloprim) ICD-9's 274.9 or 790.6 plus the ICD-9 for the neoplasm. Need name of chemotherapy agent causing the elevation of uric acid and a statement as to why patient can not tolerate oral form of the drug.	500 mg/SDV	475.00	451.25
Amikacin Sulfate (Amikin)	500 mg	5.70	5.42	L
Amino Acid	500 ml	23.60	22.42
Amino Acid	1000 ml	39.33	37.36
**Arginine HCL (R-Gene 10) A4641 Diagnostic Agent		Invoice	Invoice
**Argyrol (Considered Part of Procedure)
**Ascorbic Acid (Non Covered)
**Atenolol (Tenormin) ICD-9's = 401.0 - 429.9	0.5 mg/ml	0.80	0.76
Aztreonam (Azactam)	500 mg	11.06	10.51	H
** Bacitracin	50,000 U	10.39	9.87
** Bortezomib (Velcade) Covered for patients with relapsed Multiple Myeloma (203.00)	3.5mg/ SDV	1,039.68	987.70	L
Bretylium Tosylate (Bretylol)	500 mg	21.32	20.25	L
** Brevibloc (See Esmolol HCL)
** Brevital (Methohexilate) Considered Part of Procedure
** Bromptons Cocktail (Non-Covered)
Bumetanide (Bumex)	1 mg	1.60	1.52	H
Bupivacaine Hcl, 0..25%, 2 ml (Considered Part of Procedure)	2 ml	0.15	0.14
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of Procedure)	2 ml	0.23	0.22
** Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.25%/10ml	1.95	1.85
** Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.50%/10ml	2.21	2.10
** Bupivacaine, Sterile, 0.75%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400-64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	0.75%/10ml	2.48	2.36
**Butorphanol Tartrate IV/IM, (Stadol IV/IM) Allowed separately when administered in the Dr.'s office and no surgical procedures are billed.	2 mg	7.11	6.75
Butorphanol Tartrate IV/IM, (Stadol IV/IM) Allowed separately when administered in the Dr.'s office and no surgical procedures are billed.	20 mg	60.52	57.49	L
** Calcium Chloride	100 mg/ml	0.14	0.13
** Cefamanadole Nafate (Mandol)	1 gm	8.61	8.18
Cefepime Hydrochloride	1 mg	0.02	0.02
** Cefoperazone Sodium (Cefobid)	1 gram	16.38	15.56
Cefotetan Disodium (Cefotan)	1 gram	11.04	10.49	H
Cimetidine Hcl.(Tagamet) Covered ICD-9's = 787.01, 787.03 or 995.2	150 mg	1.42	1.35
Cimetidine Hcl.(Tagamet) Covered ICD-9's = 787.01, 787.03 or 995.2	300 mg	2.96	2.81
Clavulanate Potassium	100 mg	14.32	13.60
Clindamycin Phosphate (Cleocin) (Dosage change from 300 mg to 150 mg)	150 mg	1.33	1.26
Cytarabine Liposome (Depocyt) J9999 Covered for ICD-9 198.4	10 mg	371.45	352.88
Dantrolene Sodium	20 mg	81.59	77.51
Denileukin Difitox, Ontak (For 300 mcg, see J9160)	150 mcg	665.48	632.21	H
Dextrose 2.5%	2.50%	8.84	8.40
**Dextrose 5%/ 5 ml	5%/ 5 ml	0.16	0.15
Dextrose 5%	5%	8.79	8.35
Dextrose 10%	500 ml	11.72	11.13
Dextrose 50%	50%	14.59	13.86
**Dextrose 50%/ 50 ml	50 %/50 ml	1.98	1.88
**Dextrose/Nitroglycerin 5%-20 mg/ 100 ml/250 ml	20 mg/100 ml/250 ml	6.32	6.00
**Dextrose 5%/ Sodium Chloride	1000 ml	11.22	10.66
Diltiazem Hcl. (Cardizem IV)	5 mg	1.94	1.84
** Dopamine Hcl. (Intropine, Dopostat)	40 mg	1.02	0.97
** Doxycycline Hyclate	100 mg	13.45	12.78	L
Edrophonium Chloride (Tensilon) (Allow for ICD9—358.0)	10 mg	0.66	0.63	H
** Enalaprilat (Vasotec IV)	1.25 mg	5.36	5.09
Ergocalciferol D2 (Calciferol) ICD-9's = 579.8 or 579.9 Allowed when administered in physician's office	500,000 IU/ 1ml	33.35	31.68	H
Ertapenem Sodium (Invanz)	1 gram	47.48	45.11
Esmolol Hcl. (Brevibloc) Covered when administered in the doctor office or ambulance. Covered ICD-9 = 427.89 (Dosage change from 10 mg to 100 mg)	100 mg	20.97	19.92
Estradiol	1 gram	13.30	12.64	H
** Estradiol Pellets	Per Pellet	Invoice	Invoice
Ethracrynate Sodium (Edecrin Sodium)	50 mg	22.61	21.48
** Etoposide Phosphate (Etopophus) J9999 covered diagnoses = 151.0-151.9, 155.0, 155.2, 160.0-160.9, 162.0-162.9, 170.0-171.9, 173.0-176.9, 182.0-183.9, 186.0-186.9, 188.0-189.9, 190.5, 191.0-191.9, 194.0-195.8, 200.00 to 207.01, 236.1.	100mg	126.19	119.88
Famotidine (Pepcid) Covered ICD-9's = 787.01, 787.03 or 995.2	10 mg	1.79	1.70	H
** Flumazenil (Mazicon, Romazicon)	0.1 mg/ml	2.39	2.27
Flumazenil (Mazicon, Romazicon)	0.5 mg/ml	47.87	45.48	H
Folic Acid	5 mg	1.26	1.20
Fulvestrant (Faslodex) J9999 Covered DX's 174.0 through 175.9.	50 mg	175.05	166.30	L
** Gatifloxacin (Tequin)	200 mg	18.15	17.24
**Glutathione (Not covered -Oral Med)
Glycopyrrolate (Robinul)	0.2mg	0.80	0.76	H
Heparin Sodium	100 units	0.07	0.07
Hetastarch Sodium Cl., 6 gm/500 ml	6 gm/500 ml	5.46	5.19
** Inamrinone Lactate	5 mg	4.05	3.85
** Isopropyl Alchol/Peginterferon Alfa-2A (Pegasys) Covered indication 070.54 when administered in the office	180 mcg/ml	331.74	315.15
Isoproterenol Hydrochloride (Considered Part of Procedure)	0.2 mg	0.73	0.69
** Ketamine Hcl. (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368, 95990, or 96530.	50 mg/ml	0.73	0.69
**Labetalol Hcl (Trandate, Normodyne) Covered if given IV in the office for control of BP in severe hypertension. Patient is normally switched to oral for maintainance doses.	20 mg	1.00	0.95
** Levobupivacaine Hydrochloride (Chirocaine) Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. Not payable separately when billed with any other procedures	2.5 mg/ml	0.31	0.29
** Levothyroxine Sodium (Synthroid) Need statemnt on claim as to why patient can't take oral form of drug.	0.5 mg	55.38	52.61
Lidocaine Hcl. (Xylocaine-MPF) Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. Not payable when billed with any other procedure.	5 ml	2.44	2.32
Meropenem IV (Merrem IV)	1 gram	50.92	48.37	H
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	0.77	0.73
Metronidazole Hcl. (Flagyl IV) IV in the office	500 mg	24.86	23.62	H
Minocycline Hydrochloride	100 mg	44.06	41.86
Morrhuate Sodium	50 mg	1.98	1.88
Nafcillin (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	2.69	2.56
Nitroglycerin IV – Allowed in the Office or Ambulance – In emergency situation. (Dosage Change from 25 mg to 5 mg)	5 mg	0.48	0.46
Normal Saline (Sterile Water)	50 ml	1.43	1.36
** Octreotide Acetate (Sandostatin) Covered when given in the doctor's office. (Effective July 1, 2003 Use Code J2352 per 1 mg) Not to be used to bill for Octreotide Acetate for Injectable Suspension/ Sandostatin LAR Depot .	50 mcg	9.10	8.65
Oxaliplatin (Eloxatin) J9999 Dx's = 153.0 - 153.9, 154.0, 154.1, or 154.8 Covered in combination therapy with 5FU and Leucovorin for colorectal cancer.	50 mg	944.57	897.34
Oxaliplatin (Eloxatin) J9999 Dx's = 153.0 - 153.9, 154.0, 154.1, or 154.8 Covered in combination therapy with 5FU and Leucovorin for colorectal cancer.	100 mg	1,889.09	1,794.64
**Oxychlorosene Sodium	1 gram	1.85	1.76
** Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	22.80	21.66
Pegfilgrastim (Neulasta) Covered Indications = 205.00, 205.01, 205.10, 205.11, 238.7, 288.0-288.9, V42.9, V58.1, V59.3, V66.2, V66.5 (Effective July 1, 2003 Use Code Q4053 per 1 mg)	6mg/0.6ml	2,802.50	2,662.38
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys) Covered indication 070.54 when administered in the office	180mcg/ml	331.74	315.15
** Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered indication 070.54 when administered in the office.	50 mcg	320.61	304.58	H
** Peginterferon Alfa-2B, 80mcg	80 mcg	336.60	319.77	H
** Peginterferon Alfa-2B, 120mcg	120 mcg	353.46	335.79	H
** Peginterferon Alfa-2B, 150mcg	150 mcg	371.12	352.56	H
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered		0.00	0.00
** Piperacillin Sodium (Pipracil)	1 gm	7.00	6.65
Potassium Acetate	2 meq	0.08	0.08
Procaine Hydrochloride	1%	2.65	2.52
Procaine Hydrochloride	2%	3.80	3.61
Propofol (Diprivan) (Carrier does not pay separately)	10 mg	0.05	0.05	L
Rifampin	600 mg	70.68	67.15
** SMZ-TMP (Sulfamethoxazole/Trimethoprim) Documentation as to why the patient needs to be on IV infusion instead of oral medication, must be in block 19 or as an attachment for paper claims or in the notepad for EMC claims.	5ml	3.05	2.90
Sincalide (Kinevac) (Use A4641/Carrier Pays Radiopharmaceuticals by Invoice)	5 mcg	33.42	31.75
Sodium Acetate	100 meq	3.82	3.63
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	2.73	2.59
Sodium Bicarbonate (NACH03)	8.4%/1ml	0.05	0.05	L
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	0.97	0.92
**Somavert (See Pegvisomant for Injection)
** Sufentanil Citrate (Sufenta) Separate payment allowed when billed with 62310, 62311, 62318, 62319, 76005, 95990, or 96530. If billed with any other procedures, it will be considered part of the procedure and separate payment will not be allowed.	50mcg/ml	9.81	9.32
** Teriparatide (Forteo) Considered Usually Self-Administered
Testosterone	37.5 mg	0.11	0.10
** Testosterone Pellets (Testopel)	Per Pellet	Invoice	Invoice
Valproate Sodium (Depacon) IV, Covered ICD9's = 345.00 - 345.91, Allowed when administered IV, in the physician's office. (Dosage change from 500 mg to 100 mg)	100 mg	2.26	2.15
Vasopressin	20 units/ml	6.60	6.27
Verapamil Hcl. (Isoptin IV) (Dosage Change from 5 mg to 2.5 mg)	2.5 mg	1.10	1.05
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3ml	0.93	0.88
Vitamin C (Ascorbic Acid) (Non-covered by Carrier)	500 mg	0.66	0.63
**Water, Sterile, 1000 ml	1000 ml	5.64	5.36

NOTE: Although this file may list a drug and an associated Medicare allowed amount, it does not necessarily follow that the drug is covered by Medicare and, if covered, whether payment may be due in a particular circumstance. Medicare contractors separately determine whether a particular drug meets the program's requirements for coverage and, if covered, whether payment may be made for the drug in the circumstance under which it was furnished.

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

4th Quarter 2003 Update - Part B Not Otherwise Classified Drug Fee Schedule

spacer