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Notice: This CMS-approved document has been submitted - Philips ...

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Code<br />

<strong>CMS</strong>-1403-FC<br />

2008/9<br />

Description<br />

Snare, Nitinol<br />

(Amplatz)<br />

Unit<br />

Item<br />

NA Agent, neurolytic ml<br />

NA Strut, replacement,<br />

dynamic external<br />

NA Tube, anaerobic<br />

culture<br />

Unit<br />

Price<br />

Primary<br />

associated<br />

specialties<br />

Radiology<br />

Radiology,<br />

Interventional<br />

Radiology<br />

Associated<br />

*CPT<br />

code(s)<br />

50385,<br />

50386<br />

Prior<br />

Item<br />

Status<br />

on<br />

Table<br />

YES<br />

Commenter<br />

response<br />

and<br />

<strong>CMS</strong> action<br />

73<br />

2009 Item<br />

Status refer<br />

to note(s)<br />

New item 2008 A, D<br />

Orthopedic<br />

New item 2009 A<br />

Surgery,<br />

Podiatry<br />

64632 NO<br />

Item 1151 20697 NO New item 2009 A<br />

item 62267 Lab NO New item 2009 A, B<br />

NA Tube, jejunsostomy item 97.50 49441, 49446,<br />

49451 and<br />

49452<br />

Accessory NO Price changed/<strong>CMS</strong><br />

error. $195 price for 2<br />

J-tubes. $97.50<br />

accepted<br />

*CPT codes and descriptions only are copyright 2009 American Medical Association. All Rights Reserved. Applicable<br />

FARS/DFARS apply.<br />

Note: Acceptable <strong>document</strong>ation includes detailed description (including system, kit or product components), source (multiple<br />

sources requested), and current pricing information. For most items, there will be multiple sources of <strong>document</strong>ation available –<br />

multiple products/models that can be used as acceptable substitutes in performing a procedure. We ask that <strong>document</strong>ation from<br />

multiple sources be <strong>submitted</strong> with verified prices of the various products which represent the price range. In these instances, only<br />

one specific item/model/product is available on the market for use in a given procedure, one source of <strong>document</strong>ation is required.<br />

However, <strong>CMS</strong> expects that all <strong>document</strong>ation reflect the market price for each product reflecting the manufacturer or vendor<br />

discounts, rebates, etc. Invoices from physician purc<strong>has</strong>es are the preferred <strong>document</strong>ation. In cases where this is not possible, <strong>CMS</strong><br />

may accept other <strong>document</strong>ation such as copies of catalog pages, hard copy from specific web pages, physician invoices, and typical<br />

or average sales price “quotes” (letter format okay) from manufacturers, vendors, or distributors. Unacceptable <strong>document</strong>ation<br />

includes phone numbers and addresses of manufacturer, vendors or distributors, web site links without pricing information, etc.<br />

A. Additional <strong>document</strong>ation required. Need detailed description (including “kit”, system, or product contents and component parts),<br />

source, and current pricing information (including pricing per specified unit of measure in database).<br />

B. No/Insufficient information received. Where applicable, retained price in database on an interim basis. Forward acceptable<br />

<strong>document</strong>ation promptly.<br />

C. Submitted price accepted.<br />

D. 2008/9 price retained on an interim basis. Forward acceptable <strong>document</strong>ation promptly.<br />

C

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