CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021 Procedure Relative Payment Payment CT FEE Code Short Descriptor SI APC Weight Rate Type SCHED Change 0001A Adm sarscov2 30mcg/0.3ml 1st S 01492 $15.50 APC-PR New 0002A Adm sarscov2 30mcg/0.3ml 2nd S 01493 $25.50 APC-PR New 0003A Fee covid-19 vac 1 booster E1 No New 0004A Fee covid-19 vac 1 res E1 No New 0010U Nfct ds strn typ whl gen seq Q4 No X 0011A Adm sarscov2 100mcg/0.5ml1st S 01492 $15.50 APC-PR New 0012A Adm sarscov2 100mcg/0.5ml2nd S 01493 $25.50 APC-PR New 0013A Fee covid-19 vac 2 booster E1 No New 0014A Fee covid-19 vac 2 res E1 No New 0016M Onc bladder mrna 209 gen alg A No X 0017M Onc dlbcl mrna 20 genes alg A No New 00192 Anesth facial bone surgery N APC X 0021A Adm sarscov2 5x1010vp/.5ml 1 E1 No New 0022A Adm sarscov2 5x1010vp/.5ml 2 E1 No New 0023A Fee covid-19 vac 3 booster E1 No New 0024A Fee covid-19 vac 3 res E1 No New 0031A Fee covid-19 vac 4 dose 1 E1 No New 0032A Fee covid-19 vac 4 dose 2 E1 No New 0033A Fee covid-19 vac 4 booster E1 No New 0034A Fee covid-19 vac 4 res E1 No New 0041A Fee covid-19 vac 5 dose 1 E1 No New 0042A Fee covid-19 vac 5 dose 2 E1 No New 0043A Fee covid-19 vac 5 booster E1 No New 0044A Fee covid-19 vac 5 res E1 No New 00474 Anesth surgery of rib N APC X 0051A Fee covid-19 vac 6 dose 1 E1 No New 0052A Fee covid-19 vac 6 dose 2 E1 No New 0053A Fee covid-19 vac 6 booster E1 No New 0054A Fee covid-19 vac 6 res E1 No New 00604 Anesth sitting procedure N APC X 0061A Fee covid-19 vac 7 dose 1 E1 No New 0062A Fee covid-19 vac 7 dose 2 E1 No New 0063A Fee covid-19 vac 7 booster E1 No New 0064A Fee covid-19 vac 7 res E1 No New 0071A Fee covid-19 vac 8 dose 1 E1 No New 0072A Fee covid-19 vac 8 dose 2 E1 No New 0073A Fee covid-19 vac 8 booster E1 No New 0074A Fee covid-19 vac 8 res E1 No New 0081A Fee covid-19 vac 9 dose 1 E1 No New 0082A Fee covid-19 vac 9 dose 2 E1 No New 0083A Fee covid-19 vac 9 booster E1 No New 0084A Fee covid-19 vac 9 res E1 No New 0086U Nfct ds bact&fng org id 6+ Q4 No X 00904 Anesth perineal surgery N APC X 0091A Fee covid-19 vac 10 dose 1 E1 No New 0092A Fee covid-19 vac 10 dose 2 E1 No New 0093A Fee covid-19 vac 10 booster E1 No New 0094A Fee covid-19 vac 10 res E1 No New 0095T Rmvl artific disc addl crvcl N no X 0098T Rev artific disc addl N No X 0101A Fee covid-19 vac 11 dose 1 E1 No New 0102A Fee covid-19 vac 11 dose 2 E1 No New as of 2/4/2021 Page 1 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021 0103A Fee covid-19 vac 11 booster E1 No New 0104A Fee covid-19 vac 11 res E1 No New 0109U Id aspergillus dna 4 species Q4 No X 01140 Anesth amputation at pelvis N APC X 01150 Anesth pelvic tumor surgery N APC X 0115U Respir iadna 18 viral&2 bact Q4 No X 01212 Anesth hip disarticulation N APC X 01232 Anesth amputation of femur N APC X 01234 Anesth radical femur surg N APC X 01274 Anesth femoral embolectomy N APC X 01404 Anesth amputation at knee N APC X 0140U Nfct ds fungi dna 15 trgt Q4 No X 0141U Nfct ds bact&fng gram pos Q4 No X 0142U Nfct ds bact&fng gram neg Q4 No X 01486 Anesth ankle replacement N APC X 0151U Nfct bct/vir resp nfctj 33 Q4 No X 0152U Nfct ds dna untrgt ngnrj seq Q4 No X 01634 Anesth shoulder joint amput N No X 01636 Anesth forequarter amput N APC X 01638 Anesth shoulder replacement N APC X 0163T Lumb artif diskectomy addl N No X 0164T Remove lumb artif disc addl N No X 0165T Revise lumb artif disc addl N No X 01756 Anesth radical humerus surg N APC X 0202T Post vert arthrplst 1 lumbar J1 05115 148.7344 $12,314.76 No X 0219T Plmt post facet implt cerv J1 05115 148.7344 $12,314.76 No X 0220T Plmt post facet implt thor J1 05115 148.7344 $12,314.76 No X 0227U Rx asy prsmv 30+rx/metablt Q4 No New 0228U Onc prst8 ma molec prfl alg Q4 No New 0229U Bcat1 promoter mthyltn alys A No New 0230U Ar full sequence analysis A No New 0231U Cacna1a full gene analysis A No New 0232U Cstb full gene analysis A No New 0233U Fxn gene analysis A No New 0234U Mecp2 full gene analysis A No New 0235U Pten full gene analysis A No New 0236U Smn1&smn2 full gene analysis A No New 0237U Car ion chnlpthy gen seq pnl A No New 0238U Onc lnch syn gen dna seq aly A No New 0239U Trgt gen seq alys pnl 311+ A No New 0240U Nfct ds vir resp rna 3 trgt A No New 0241U Nfct ds vir resp rna 4 trgt A No New 0398T Mrgfus strtctc les abltj J1 05463 135.7079 $11,236.21 No X 0524T Ev cath dir chem abltj w/img J1 05183 34.5624 $2,861.66 No X 0583T Tmpst auto tube dlvr sys J1 05163 16.3386 $1,352.79 No X 0587T Perq impltj/rplcmt isdns ptn J1 05462 74.4071 $6,160.68 No X 0588T Revision/removal isdns ptn J1 05461 39.5582 $3,275.30 No X 0609T Mrs disc pain acquisj data Q3 05523 2.7794 $230.13 No X 0610T Mrs disc pain transmis data N No X 0611T Mrs disc pain alg alys data S 05523 2.7794 $230.13 No X 0612T Mrs discogenic pain i&r M No X 0620T Evasc ven artlz tibl/prnl vn J1 05194 194.0167 $16,064.00 No New 0621T Trabeculostomy interno laser E1 No New 0622T Trabeculostomy int lsr w/scp E1 No New as of 2/4/2021 Page 2 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021 0623T Auto quantification c plaque E1 No New 0624T Auto quan c plaq data prep E1 No New 0625T Auto quan c plaq cptr alys E1 No New 0626T Auto quan c plaq i&r E1 No New 0627T Perq njx algc fluor lmbr 1st J1 05115 148.7344 $12,314.76 No New 0628T Perq njx algc fluor lmbr ea N No New 0629T Perq njx algc ct lmbr 1st J1 05115 148.7344 $12,314.76 No New 0630T Perq njx algc ct lmbr ea N No New 0631T Tc vis lit hyperspectral img Q1 05731 0.298 $24.67 No New 0632T Perq tcat us abltj nrv p-art E1 No New 0633T Ct breast w/3d uni c- Q3 05522 1.3161 $108.97 No New 0634T Ct breast w/3d uni c+ Q3 05571 2.1565 $178.55 No New 0635T Ct breast w/3d uni c-/c+ Q3 05571 2.1565 $178.55 No New 0636T Ct breast w/3d bi c- Q3 05523 2.7794 $230.13 No New 0637T Ct breast w/3d bi c+ Q3 05572 4.446 $368.12 No New 0638T Ct breast w/3d bi c-/c+ Q3 05572 4.446 $368.12 No New 0639T Wrls skn snr anisotropy meas E1 No New 20661 Application of head brace Q1 05113 34.1848 APC X 20664 Application of halo Q1 05113 34.1848 $2,830.40 APC X 20802 Replantation arm complete J1 05116 191.651 $15,868.13 APC X 20805 Replant forearm complete J1 05116 191.651 $15,868.13 APC X 20808 Replantation hand complete J1 05116 191.651 $15,868.13 APC X 20816 Replantation digit complete J1 05114 75.6664 APC X 20824 Replantation thumb complete J1 05114 75.6664 $6,264.95 APC X 20827 Replantation thumb complete J1 05114 75.6664 $6,264.95 APC X 20838 Replantation foot complete J1 05116 191.651 $15,868.13 APC X 20955 Fibula bone graft microvasc J1 05114 75.6664 $6,264.95 APC X 20956 Iliac bone graft microvasc J1 05114 75.6664 $6,264.95 APC X 20957 Mt bone graft microvasc J1 05114 75.6664 $6,264.95 APC X 20962 Other bone graft microvasc J1 05114 75.6664 $6,264.95 APC X 20969 Bone/skin graft microvasc J1 05114 75.6664 $6,264.95 APC X 20970 Bone/skin graft iliac crest J1 05114 75.6664 $6,264.95 APC X 21045 Extensive jaw surgery J1 05165 61.428 $5,086.05 APC X 21141 Lefort i-1 piece w/o graft J1 05165 61.428 APC X 21142 Lefort i-2 piece w/o graft J1 05165 61.428 APC X 21143 Lefort i-3/> piece w/o graft J1 05165 61.428 APC X 21145 Lefort i-1 piece w/ graft J1 05165 61.428 $5,086.05 APC X 21146 Lefort i-2 piece w/ graft J1 05165 61.428 APC X 21147 Lefort i-3/> piece w/ graft J1 05165 61.428 $5,086.05 APC X 21151 Lefort ii w/bone grafts J1 05165 61.428 $5,086.05 APC X 21154 Lefort iii w/o lefort i J1 05165 61.428 $5,086.05 APC X 21155 Lefort iii w/ lefort i J1 05165 61.428 $5,086.05 APC X 21159 Lefort iii w/fhdw/o lefort i J1 05165 61.428 $5,086.05 APC X 21160 Lefort iii w/fhd w/ lefort i J1 05165 61.428 $5,086.05 APC X 21179 Reconstruct entire forehead J1 05165 61.428 $5,086.05 APC X 21180 Reconstruct entire forehead J1 05165 61.428 $5,086.05 APC X 21182 Reconstruct cranial bone J1 05165 61.428 $5,086.05 APC X 21183 Reconstruct cranial bone J1 05165 61.428 $5,086.05 APC X 21184 Reconstruct cranial bone J1 05165 61.428 $5,086.05 APC X 21188 Reconstruction of midface J1 05165 61.428 $5,086.05 APC X 21194 Reconst lwr jaw w/graft J1 05165 61.428 $5,086.05 APC X 21196 Reconst lwr jaw w/fixation J1 05165 61.428 APC X 21247 Reconstruct lower jaw bone J1 05165 61.428 $5,086.05 APC X 21255 Reconstruct lower jaw bone J1 05165 61.428 $5,086.05 APC X as of 2/4/2021 Page 3 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021 21268 Revise eye sockets J1 05165 61.428 $5,086.05 APC X 21343 Open tx dprsd front sinus fx J1 05165 61.428 $5,086.05 APC X 21344 Open tx compl front sinus fx J1 05165 61.428 APC X 21347 Opn tx nasomax fx multple J1 05165 61.428 $5,086.05 APC X 21348 Opn tx nasomax fx w/graft J1 05165 61.428 $5,086.05 APC X 21366 Opn tx complx malar w/grft J1 05165 61.428 $5,086.05 APC X 21422 Treat mouth roof fracture J1 05165 61.428 APC X 21423 Treat mouth roof fracture J1 05165 61.428 $5,086.05 APC X 21431 Treat craniofacial fracture J1 05165 61.428 $5,086.05 APC X 21432 Treat craniofacial fracture J1 05165 61.428 $5,086.05 APC X 21433 Treat craniofacial fracture J1 05165 61.428 $5,086.05 APC X 21435 Treat craniofacial fracture J1 05165 61.428 $5,086.05 APC X 21436 Treat craniofacial fracture J1 05165 61.428 $5,086.05 APC X 21510 Drainage of bone lesion J1 05114 75.6664 $6,264.95 APC X 21602 Exc ch wal tum w/o lymphadec J1 05114 75.6664 $6,264.95 APC X 21603 Exc ch wal tum w/lymphadec J1 05114 75.6664 $6,264.95 APC X 21615 Removal of rib J1 05114 75.6664 $6,264.95 APC X 21616 Removal of rib and nerves J1 05114 75.6664 $6,264.95 APC