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2016 Table of Drugs

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2016 Table of Drugs IA - Intra-arterial administration IV - Intravenous administration IM - Intramuscular administration IT - Intrathecal SC - Subcutaneous administration INH - Administration by inhaled solution VAR - Various routes of administration OTH - Other routes of administration ORAL - Administered orally Intravenous administration includes all methods, such as gravity infusion, injections, and timed pushes. The ‘VAR’ posting denotes various routes of administration and is used for drugs that are commonly administered into joints, cavities, tissues, or topical applications, in addition to other parenteral administrations. Listings posted with ‘OTH’ indicate other administration methods, such as suppositories or catheter injections. A Abatacept 10 mg IV J0129 Abbokinase, see Urokinase Abbokinase, Open Cath, see Urokinase Abciximab 10 mg IV J0130 Abelcet, see Amphotericin B Lipid Complex ABLC, see Amphotericin B AbobotulinumtoxintypeA 5 units IM J0586 Acetaminophen 10 mg IV J0131 Acetazolamide sodium up to 500 mg IM, IV J1120 Acetylcysteine, injection 100 mg IV J0132 Acetylcysteine, unit dose form per gram INH J7604,J7608 Achromycin, see Tetracycline Actemra, see Tocilizumab ACTH, see Corticotropin 1 Acthar, see Corticotropin Actimmune, see Interferon gamma 1-B Activase, see Alteplase recombinant Acyclovir 5 mg J0133 Adalimumab 20 mg SC J0135 Adcetis, see Brentuximab Vedotin Adenocard, see Adenosine Adenoscan, see Adenosine Adenosine 1 mg IV J0153 Ado-trastuzumab Emtansine 1 mg IV J9354 Adrenalin Chloride, see Adrenalin, epinephrine Adrenalin, epinephrine 0.1 mg SC, IM J0171 Adriamycin PFS, see Doxorubicin HCl Adriamycin RDF, see Doxorubicin HCl Adrucil, see Fluorouracil Aflibercept 1 mg OTH J0178 Agalsidase beta 1 mg IV J0180 Aggrastat, see Tirofiban hydrochloride A-hydroCort, see Hydrocortisone sodium phosphate Akineton, see Biperiden Alatrofloxacin mesylate, injection 100 mg IV J0200 Albuterol 0.5 mg INH J7620 Albuterol, concentrated form 1 mg INH J7610, J7611 Albuterol, unit dose form 1 mg INH J7609, J7613 Aldesleukin per single use vial IM, IV J9015 Aldomet, see Methyldopate HCl Alefacept 0.5 mg IM, IV J0215 Alferon N, see Interferon alfa-n3 Alglucerase per 10 units IV J0205 Alglucosidase alfa 10 mg IV J0220, J0221 Alkaban-AQ, see Vinblastine sulfate Alkeran, see Melphalan, oral Alpha 1-proteinase inhibitor, human 10 mg IV J0256, J0257 Alphanate J7186 Alprostadil, injection 1.25 mcg OTH J0270 Alprostadil, urethral suppository OTH J0275 Alteplase recombinant 1 mg IV J2997 Alupent, see Metaproterenol sulfate or Metaproterenol, compounded Amcort, see Triamcinolone diacetate A-methaPred, see Methylprednisolone sodium succinate Amgen, see Interferon alphacon-1 Amifostine 500 mg IV J0207 Amikacin sulfate 100 mg J0278 Aminolevalinic acid Hcl unit dose (354 mg) OTH J7308 Aminolevulinate 1 gm OTH J7309 2 Aminophylline/Aminophyllin up to 250 mg IV J0280 Amiodarone HCl 30 mg IV J0282 Amitriptyline HCl up to 20 mg IM J1320 Amobarbital up to 125 mg IM, IV J0300 Amphocin, see Amphotericin B Amphotericin B 50 mg IV J0285 Amphotericin B, lipid complex 10 mg IV J0287-J0289 Ampicillin sodium up to 500 mg IM, IV J0290 Ampicillin sodium/sulbactam sodium per 1.5 gm IM, IV J0295 Amygdalin, see Laetrile, Amygdalin, vitamin B-17 Amytal, see Amobarbital Anabolin LA 100, see Nandrolone decanoate Anadulafungin 1 mg IV J0348 Anascorp, see Centruroides Immune F(ab) Ancef, see Cefazolin sodium Andrest 90-4, see Testosterone enanthate and estradiol valerate Andro-Cyp, see Testosterone cypionate Andro-Cyp 200, see Testosterone cypionate Andro L.A. 200, see Testosterone enanthate Andro-Estro 90-4, see Testosterone enanthate and estradiol valerate Andro/Fem, see Testosterone cypionate and estradiol cypionate Androgyn L.A., see Testosterone enanthate and estradiol valerate Androlone-50, see Nandrolone phenpropionate Androlone-D 100, see Nandrolone decanoate Andronaq-50, see Testosterone suspension Andronaq-LA, see Testosterone cypionate Andronate-200, see Testosterone cypionate Andronate-100, see Testosterone cypionate Andropository 100, see Testosterone enanthate Andryl 200, see Testosterone enanthate Anectine, see Succinylcholine chloride Anergan 25, see Promethazine HCl Anergan 50, see Promethazine HCl Anistreplase 30 units IV J0350 Anti-Inhibitor per IU IV J7198 Antispas, see Dicyclomine HCl Antithrombin III (human) per IU IV J7197 Antithrombin recombinant 50 IU IV J7196 Anzemet, see Dolasetron mesylate injection A.P.L., see Chorionic gonadotropin Apomorphine Hydrochloride 1 mg SC J0364 Apresoline, see Hydralazine HCl Aprotinin 10,000 kiu J0365 AquaMEPHYTON, see Vitamin K 3 Aralen, see Chloroquine HCl Aramine, see Metaraminol Aranesp, see Darbepoetin Alfa Arbutamine 1 mg IV J0395 Arcalyst, see Rilanocept Aredia, see Pamidronate disodium Arfonad, see Trimethaphan camsylate Arformoterol tartrate 15 mcg INH J7605 Aridol, see Mannitol Aripiprazole 0.25 mg IM J0400 Aripiprazole, extended release 1 mg INJ J0401 Aristocort Forte, see Triamcinolone diacetate Aristocort Intralesional, see Triamcinolone diacetate Aristospan Intra-Articular, see Triamcinolone hexacetonide Aristospan Intralesional, see Triamcinolone hexacetonide Arrestin, see Trimethobenzamide HCl Arsenic trioxide 1 mg IV J9017 Arzerra, see Ofatumumab Asparaginase 1,000 units IV, IM J9019 10,000 units IV, IM J9020 Astramorph PF, see Morphine sulfate Atgam, see Lymphocyte immune globulin Ativan, see Lorazepam Atropine, concentrated form per mg INH J7635 Atropine, unit dose form per mg INH J7636 Atropine sulfate 0.01 mg IV, IM, SC J0461 Atrovent, see Ipratropium bromide Atryn, see Antithrombin recombinant Aurothioglucose up to 50 mg IM J2910 Autologous cultured chondrocytes implant OTH J7330 Autoplex T, see Hemophilia clotting factors Avonex, see Interferon beta-1a Azacitidine 1 mg SC J9025 Azathioprine 50 mg ORAL J7500 Azathioprine, parenteral 100 mg IV J7501 Azithromycin, dihydrate 1 gm ORAL Q0144 Azithromycin, injection 500 mg IV J0456 B Baclofen 10 mg IT J0475 Baclofen for intrathecal trial 50 mcg OTH J0476 Bactocill, see Oxacillin sodium BAL in oil, see Dimercaprol Banflex, see Orphenadrine citrate 4 Basiliximab 20 mg J0480 BCG (Bacillus Calmette and Guérin), live per vial IV J9031 instillation Beclomethasone inhalation solution, unit dose form per mg INH J7622 Belatacept 1 mg IV J0485 Belimumab 10 mg IV J0490 Belinostat 10 mg IV J9032 Bena-D 10, see Diphenhydramine HCl Bena-D 50, see Diphenhydramine HCl Benadryl, see Diphenhydramine HCl Benahist 10, see Diphenhydramine HCl Benahist 50, see Diphenhydramine HCl Ben-Allergin-50, see Diphenhydramine HCl Bendamustine HCl 1 mg IV J9033 Benefix, see Factor IX, recombinant Benlysta, see Belimumab Benoject-10, see Diphenhydramine HCl Benoject-50, see Diphenhydramine HCl Bentyl, see Dicyclomine Benztropine mesylate per 1 mg IM, IV J0515 Berinert, see C-1 esterase inhibitor Berubigen, see Vitamin B-12 cyanocobalamin Beta amyloid per study dose OTH A9599 Betalin 12, see Vitamin B-12 cyanocobalamin Betameth, see Betamethasone sodium phosphate Betamethasone acetate & betamethasone sodium phosphate per 3 mg IM J0702 Betamethasone inhalation solution, unit dose form per mg INH J7624 Betaseron, see Interferon beta-1b Bethanechol chloride up to 5 mg SC J0520 Bevacizumab 10 mg IV J9035 Bicillin L-A, see Penicillin G benzathine Bicillin C-R 900/300, see Penicillin G procaine and penicillin G benzathine Bicillin C-R, see Penicillin G benzathine and penicillin G procaine BiCNU, see Carmustine Biperiden lactate per 5 mg IM, IV J0190 Bitolterol mesylate,concentrated form per mg INH J7628 Bitolterol mesylate,unit dose form per mg INH J7629 Bivalirudin 1 mg IV J0583 Blenoxane, see Bleomycin sulfate Bleomycin sulfate 15 units IM, IV, SC J9040 Blinatumomab 1 microgram IV J9039 Bortezomib 0.1 mg IV J9041 Botox, see OnabotulinumtoxinA 5 Brentuximab Vedotin 1 mg IV J9042 Brethine, see Terbutaline sulfate or Terbutaline, compounded Bricanyl Subcutaneous, see Terbutaline sulfate Brompheniramine maleate per 10 mg IM, SC, IV J0945 Bronkephrine, see Ethylnorepinephrine HCl Bronkosol, see Isoetharine HCl Budesonide inhalation solution, concentrated form 0.25 mg INH J7633, J7634 Budesonide inhalation solution, unit dose form 0.5 mg INH J7626, J7627 Buprenorphine Hydrochloride 0.1 mg IM J0592 Buprenorphine/Naloxone 1 mg ORAL J0571 <=3 mg ORAL J0572 >3 mg but <=6 mg ORAL J0573 >6 mg but <=10 mg ORAL J0574 >10 mg ORAL J0575 Busulfan 1 mg IV J0594 Busulfan 2 mg ORAL J8510 Butorphanol tartrate 1 mg J0595 C C1 Esterase Inhibitor 10 units IV J0596-J0598 Cabazitaxel 1 mg IV J9043 Cabergoline .25 mg ORAL J8515 Cafcit, see Caffeine citrate Caffeine citrate 5 mg IV J0706 Caine-1, see Lidocaine Hcl Caine-2, see Lidocaine HCl Calcijex, see Calcitriol Calcimar, see Calcitonin-salmon Calcitonin-salmon up to 400 units SC, IM J0630 Calcitriol 0.1 mcg IM J0636 Calcium Disodium Versenate, see Edetate calcium disodium Calcium gluconate per 10 ml IV J0610 Calcium glycerophosphate & calcium lactate per 10 ml IM, SC J0620 Caldolor, see Ibuprofen Calphosan, see Calcium glycerophosphate and calcium lactate Camptosar, see Irinotecan Canakinumab 1 mg SC J0638 Capecitabine 150 mg ORAL J8520 500 mg ORAL J8521 Capsaicin patch per sq cm OTH J7336 Carbidopa 5 mg/levodopa 20 mg enteral suspension IV J7340 Carbocaine with Neo-Cobefrin, see Mepivacaine Carbocaine, see Mepivacaine Carboplatin 50 mg IV J9045 6 Carfilzomib 1 mg IV J9047 Carmustine 100 mg IV J9050 Carnitor, see Levocarnitine Carticel, see Autologous cultured chondrocytes Caspofungin acetate 5 mg IV J0637 Cayston, see Aztreonam Cefadyl,
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    Exhibit #4 Outpatient Surgery Facility Codes and Fees source: 2019 CN2 Addendum A.12212018 Effective 1/1/2020 APC Short Descriptor Outpatient ASC Rate Additional Hospital Rate (85% of Instructions (180% of Hospital Rate) Medicare $) 0701 Sr89 strontium $ 2,704.24 $ 2,298.60 0726 Dexrazoxane HCl injection $ 413.87 $ 351.79 0731 Sargramostim injection $ 67.69 $ 57.54 0736 Amphotericin b liposome inj $ 86.52 $ 73.54 0738 Rasburicase $ 500.66 $ 425.56 0751 Mechlorethamine hcl inj $ 579.10 $ 492.24 0752 Dactinomycin injection $ 2,569.80 $ 2,184.33 0759 Naltrexone, depot form $ 5.86 $ 4.98 0800 Leuprolide acetate $ 2,148.60 $ 1,826.31 0802 Etoposide oral $ 136.01 $ 115.61 0807 Aldesleukin injection $ 7,448.66 $ 6,331.36 0809 Bcg live intravesical vac $ 253.11 $ 215.14 0810 Goserelin acetate implant $ 916.24 $ 778.80 0812 Carmustine injection $ 7,292.71 $ 6,198.80 0820 Daunorubicin injection $ 91.19 $ 77.51 0823 Docetaxel injection $ 2.72 $ 2.31 0825 Nelarabine injection $ 273.99 $ 232.89 0836 Interferon alfa-2b inj $ 61.46 $ 52.24 0840 Inj melphalan hydrochl $ 1,466.65 $ 1,246.65 0843 Pegaspargase injection $ 27,051.68 $ 22,993.93 0844 Pentostatin injection $ 3,773.31 $ 3,207.31 0850 Streptozocin injection $ 627.67 $ 533.52 0851 Thiotepa injection $ 1,334.84 $ 1,134.61 0856 Porfimer sodium injection $ 38,195.22 $ 32,465.94 0858 Inj cladribine $ 40.75 $ 34.64 0864 Mitoxantrone hydrochl $ 49.25 $ 41.86 0873 Hyalgan supartz visco-3 dose $ 153.55 $ 130.52 0874 Synvisc or synvisc-one $ 21.29 $ 18.10 0875 Euflexxa inj per dose $ 254.65 $ 216.45 0877
  • Oregon Health Authority Division of Medical Assistance Programs Addendum a - Final OPPS Apcs for CY 2012 Effective October 1, 2012

    Oregon Health Authority Division of Medical Assistance Programs Addendum a - Final OPPS Apcs for CY 2012 Effective October 1, 2012

    Oregon Health Authority Division of Medical Assistance Programs Addendum A - Final OPPS APCs for CY 2012 Effective October 1, 2012 Relative APC Group Title SI Weight 0001 Level I Photochemotherapy S 0.5042 0002 Fine Needle Biopsy/Aspiration T 1.6115 0003 Bone Marrow Biopsy/Aspiration T 3.5702 0004 Level I Needle Biopsy/ Aspiration Except Bone Marrow T 4.5746 0005 Level II Needle Biopsy/Aspiration Except Bone Marrow T 8.1566 0006 Level I Incision & Drainage T 1.4206 0007 Level II Incision & Drainage T 13.1250 0008 Level III Incision and Drainage T 20.5648 0012 Level I Debridement & Destruction T 0.3878 0013 Level II Debridement & Destruction T 0.8785 0015 Level III Debridement & Destruction T 1.4989 0016 Level IV Debridement & Destruction T 2.7592 0017 Level V Debridement & Destruction T 21.6661 0019 Level I Excision/ Biopsy T 4.4238 0020 Level II Excision/ Biopsy T 8.2746 0021 Level III Excision/ Biopsy T 17.0074 0022 Level IV Excision/ Biopsy T 23.2662 0028 Level I Breast Surgery T 25.5054 0029 Level II Breast Surgery T 33.4070 0030 Level III Breast Surgery T 44.8999 0031 Smoking Cessation Services X 0.2997 0034 Mental Health Services Composite S 2.7295 0035 Vascular Puncture and Minor Diagnostic Procedures X 0.2691 0037 Level IV Needle Biopsy/Aspiration Except Bone Marrow T 15.3499 0039 Level I Implantation of Neurostimulator Generator S 216.7598 0040 Level I Implantation/Revision/Replacement of Neurostimulator Electrodes S 63.7616 0041 Level I Arthroscopy T 29.6568 0042 Level II Arthroscopy T 57.0137 0045 Bone/Joint Manipulation Under