oversight

Medicare: Discrepancy in Hospital Outpatient Prospective Payment System Methodology Leads to Inaccurate Beneficiary Copayments and Medicate Payments

Published by the Government Accountability Office on 2003-10-06.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

United States General Accounting Office
Washington, DC 20548



          October 6, 2003 


          The Honorable Thomas A. Scully 

          Administrator 

          Centers for Medicare & Medicaid Services 


          Subject: Medicare: Discrepancy in Hospital Outpatient Prospective Payment System
                       Methodology Leads to Inaccurate Beneficiary Copayments and Medicare
                       Payments

          Dear Mr. Scully:

          Under the Medicare hospital outpatient prospective payment system (OPPS),
          beneficiaries can be responsible for paying 50 percent or more of the total payment
          for outpatient services they receive in hospitals. The Balanced Budget Act of 1997
          (BBA)1 introduced a mechanism to gradually decrease beneficiary cost sharing to 20
          percent of the payment rate for each hospital outpatient service.2 The Centers for
          Medicare & Medicaid Services (CMS) published a final rule that implemented,
          effective with the 2002 payment rates, a methodology for calculating copayment
          amounts that was designed to ensure that even as certain changes affect the payment
                                                                                   3
          rates for hospital outpatient services over time, beneficiary coinsurance for services
          would eventually be 20 percent of the total payment rate for each service.4 Under this
          2002 methodology, the copayment amount for each outpatient payment group of
          services, called an ambulatory payment classification (APC) group, could not
          increase from year to year, and the beneficiary coinsurance percentage would remain
          the same or decrease, eventually reaching 20 percent for each APC.5


          1
              Pub. L. No 105-33, § 4523(a), 111 Stat. 251, 445.
          2
            Beneficiary cost sharing will decline to 20 percent at a different time for each outpatient service depending on
          the service’s initial cost-sharing percentage. In 2000, the Medicare Payment Advisory Commission estimated
          that achieving a 20 percent cost-sharing rate for services will take an average of 30 to 40 years.
          3
           We use the term “coinsurance” to refer to the percentage of the Medicare payment amount that beneficiaries
          are responsible for paying for a service under the OPPS. We use the term “copayment” to refer to the dollar
          amount that beneficiaries are responsible for paying for a service under the OPPS.
          4
              66 Fed. Reg. 59,856, 59,888 (2001).
          5
            Under the OPPS, outpatient services with clinical and resource use similarities are grouped into APCs for
          payment purposes. Each service within an APC is paid at the same rate. The total payment rate for an APC is
          composed of two parts: an amount that the beneficiary is responsible for paying and an amount that Medicare is
          responsible for paying. As the beneficiary coinsurance proportion declines to 20 percent, the proportion that


                                                                  GAO-04-103R Medicare Hospital Outpatient Payments
When CMS published the final rule updating the OPPS payment rates for 2003, the
agency stated that it used the methodology implemented in 2002 for determining 2003
copayments.6 However, in the course of other ongoing work, we found several APCs
for which copayment amounts increased from 2002 to 2003, contrary to the
methodology implemented in 2002.7 For a federal agency to adopt a new position or
payment methodology that is inconsistent with existing rules and regulations, it must
follow Administrative Procedure Act rulemaking requirements, which generally
include publishing its intentions and allowing for public comment.8 Because of our
concerns about this methodological discrepancy, we discussed the issue with CMS
staff in May 2003. Thereafter, in its August 2003 proposed rule setting forth the 2004
OPPS payment rates, CMS stated that it would revise and clarify the copayment
methodology implemented in 2002, and that this revised methodology would be used
to calculate copayment amounts beginning in 2004.9

In this report, we present our complete analysis of the 2003 copayment methodology
and the implications its use holds for copayment amounts in 2003 and future years.
We also present the estimated financial impact this methodology has had on both
beneficiary cost sharing and Medicare payments in 2003.

To estimate the impact of the 2003 copayment methodology on beneficiary cost-
sharing obligations, we used 2001 Medicare outpatient claims data10 together with the
569 APC groups in 2003 and the 2003 payment rates. We calculated the 2003
copayment amount for each of the APCs according to the 2002 methodology and
calculated the difference between that amount and the amount published in the 2003
OPPS final rule. We compiled a list of the differences, multiplied the difference by
the respective service volume for each APC from the 2001 claims, and then summed
them across all affected APCs to estimate the total amount of inaccurate copayments.
See Enclosure I for more details on our methodology. We performed our work in
accordance with generally accepted government auditing standards from May
through October 2003.

In summary, we found that use of a copayment methodology in 2003 that differed
from the copayment methodology in 2002 has resulted in inaccurate 2003 copayment


Medicare is responsible for will increase. Once the coinsurance percentage is 20 percent of the payment rate,
the copayment amount will increase to maintain the 20 percent coinsurance rate if the payment rate increases.
6
     67 Fed. Reg. 66,718, 66,788 (2002).
7
 In this report we will refer to the methodology CMS implemented for 2002 as the 2002 copayment
methodology. We will refer to the methodology used for 2003, but not implemented through the rulemaking
process, as the 2003 copayment methodology.
8
     See, e.g., Shalala v. Guernsey Memorial Hosp., 514 U.S. 87, 100 (1995).
9
     68 Fed. Reg. 47,966, 48,006-07 (2003).
10
  The 2001 Medicare outpatient claims contain all outpatient claims for services furnished on or after April 1,
2001 and on or before March 31, 2002.


2                                                       GAO-04-103R Medicare Hospital Outpatient Payments
amounts for 75 APCs.11 For 28 APCs, this methodology has resulted in beneficiaries
being responsible for higher copayments than they would have been under the 2002
methodology. For 47 APCs, beneficiaries are responsible for lower copayments, and,
therefore, Medicare is making higher payments than it would have under the 2002
methodology. Moreover, under this methodology, copayment amounts for some
APCs may never decline to 20 percent of the APC payment rate. Although CMS is
proposing to revise the copayment methodology for 2004, the agency did not
recalculate the 2003 copayment amounts using the 2002 methodology before using
them as the basis for calculating the 2004 copayment amounts. Thus, certain
proposed 2004 copayment amounts are higher and others are lower than they would
have been if CMS had used the 2002 methodology in 2003. In addition, the time it will
take for the copayment amounts for some of these APCs to reach 20 percent of the
APC payment rate will increase. We estimate that in 2003 the methodology used by
CMS will result in about $414 million in inaccurate copayments, with a net of $192
million in Medicare program overpayments. Specifically, we estimate beneficiaries
will be overcharged by approximately $111 million for certain services, and Medicare
will overpay by approximately $303 million for other services.

We recommend that, for the purpose of calculating the 2004 OPPS beneficiary
copayment amounts, the Administrator of CMS first apply the 2002 copayment
methodology to the 2003 APCs for which beneficiaries were inaccurately charged.
The 2004 copayment amounts should then be based on these revised 2003 copayment
amounts. In written comments on a draft of this report, CMS stated that it would
take the information we provided into consideration as part of issuing its 2004 final
rule.

Background

The initial OPPS payment rates that went into effect August 1, 2000 were based on
hospitals’ median costs in 1996. The initial copayment amounts were based on
hospitals’ median charges for the same year, but were to be no lower than 20 percent
of the payment rate for each APC. Because hospitals’ median charges usually
exceeded hospitals’ median costs, the copayments for most APCs were set at levels
well above 20 percent of the payment rate.

BBA provides the methodology by which copayment amounts were to be initially
determined and specifies that a copayment amount for an APC would be held
constant as the payment rate increases for that APC with the annual inflation
adjustment until the copayment amount declines to 20 percent of the payment rate.
However, BBA does not specify how copayments are to be determined when CMS
reviews and revises the APCs, as it is required to do at least annually in accordance
with section 1833(t)(9)(A) of the Social Security Act.12 CMS takes into account
changes in medical practice and technology and the addition of new services, cost

11
     Enclosure II contains a list of these APCs.
12
     42 U.S.C. § 1395l(t)(9) (2000).


3                                                  GAO-04-103R Medicare Hospital Outpatient Payments
data, and other relevant information and makes revisions in the services assigned to a
particular APC, known as reclassification, and in the relative payment weight for an
APC, known as recalibration. Thus, although the payment rates are annually adjusted
upward for inflation, an APC’s payment rate could either increase or decrease from
one year to the next because of reclassification and recalibration or recalibration
alone.

In the final rule that established the 2002 OPPS rates, CMS set forth a methodology
for calculating copayments that was designed to take reclassification and
recalibration changes into account and ensure that the copayment amount for a
particular APC would not increase from one year to the next due to these changes,
until it represented 20 percent of the total payment rate. CMS stated that if an APC’s
payment rate increased, the copayment dollar amount would remain the same,
causing the coinsurance percentage to decrease. If an APC’s payment rate decreased,
the coinsurance percentage for the APC would remain the same, causing the
copayment amount to decrease. If two or more APCs were combined to make a new
APC, the lowest of the contributing APCs’ coinsurance percentages would apply to
the new APC.13 According to the 2002 copayment methodology, the transfer of a
service from one APC to another is not considered the creation of a new APC. The
                                                                 14
proposed 2004 copayment methodology confirms this position.

Change in 2003 Copayment Methodology Affects Beneficiary Copayment
Amounts in 2003 and Future Years

In the final rule that established the 2003 payment rates, CMS stated that it calculated
the copayment amounts using the 2002 methodology.15 However, when the 2003
copayment amounts were calculated in that final rule, CMS made unexplained
modifications that were inconsistent with its rules. As a result, the 2003 copayment
amounts for 28 APCs increased compared to the 2002 amounts, and the copayment
amounts for 47 other APCs decreased more than they would have using the 2002
methodology. In addition, under the 2003 methodology, copayment amounts for
some APCs may not have eventually declined to 20 percent of the APC payment rate.
Finally, certain proposed 2004 copayment amounts are higher and others are lower
than they would have been if CMS had consistently applied the 2002 methodology in
2003.

The fundamental difference between the 2002 and 2003 methodologies was that,
according to CMS documentation, for 2003, CMS deemed any APC that had one or
more services added to it to be a “new” APC. In 2002, an APC was not considered to




13
     66 Fed. Reg. 59,856, 59,888 (2001).
14
     68 Fed. Reg. 47,966, 48,006 (2003).
15
     67 Fed. Reg. 66,718, 66,788 (2002).


4                                          GAO-04-103R Medicare Hospital Outpatient Payments
be new if it had services added to it.16 Under the 2002 methodology, CMS calculated
the copayment amount of an APC containing reclassified services, referred to as a
“revised” APC, from its own copayment amount or coinsurance percentage from the
previous year depending on whether the payment rate increased or decreased. Under
the 2003 methodology, CMS calculated the copayment amount of an APC containing
reclassified services by adopting the lowest coinsurance percentage from the
previous year of any APC that contributed a service to that APC. This change, when
coupled with payment changes, led the copayment amounts for some APCs to
inaccurately increase or decrease between 2002 and 2003. In order to illustrate how
the methodology used in 2003 affected copayment amounts, we present two
simplified hypothetical examples below.

Example 1: Demonstration of How the 2003 CMS Copayment Methodology Led to
Inaccurately High 2003 Beneficiary Copayment Amounts

In 2002, hypothetical APC 1 had a payment rate of $50.00, a coinsurance percentage
of 50 percent, a copayment amount of $25.00, and included services A, B, and C (see
fig. 1). Hypothetical APC 2 had a payment rate of $65.00, a coinsurance percentage of
45 percent, a copayment amount of $29.25, and included services D, E, and F.

Figure 1: Hypothetical APCs in 2002




For 2003, service D was reclassified to APC 1, and the payment rate of APC 1
increased to $60.00 through recalibration and application of the annual inflation
adjustment (see fig. 2). Applying the 2002 methodology, the 2003 copayment amount
should have remained $25.00 because this APC was not considered new, and the 2003
coinsurance percentage should have decreased to 42 percent.




16
  According to the 2002 methodology, a new APC would be one that is either composed of new outpatient
services or is created from some or all of the services from two or more existing APCs. (66 Fed. Reg. 59,856,
59,888 (2001).)


5                                                    GAO-04-103R Medicare Hospital Outpatient Payments
Figure 2: Update to the Copayment Amount for a Hypothetical APC with a
Payment Rate Increase for 2003 If the 2002 Methodology Had Been Used




However, because service D was reclassified to APC 1, CMS would have considered it
a new APC under the 2003 methodology. Therefore, the 2003 coinsurance percentage
for APC 1 would have been 45 percent, the lowest 2002 coinsurance percentage of all
APCs contributing services to it, in this case, APC 1 and APC 2 (see fig. 3). However,
the payment rate for APC 1 increased enough so that 45 percent of $60.00 ($27.00) is
higher than the $25.00 the copayment should have been.

Figure 3: Update to the Copayment Amount for a Hypothetical APC with a
Payment Rate Increase for 2003 Using the 2003 Methodology




6                                        GAO-04-103R Medicare Hospital Outpatient Payments
Example 2: Demonstration of How the 2003 CMS Copayment Methodology Led to
Inaccurately Low 2003 Beneficiary Copayment Amounts

This example uses the same hypothetical APC 1 and APC 2 as presented in figure 1.
For 2003, service D was again reclassified to APC 1; however, in this example, the
payment rate of APC 1 decreased to $45.00 in 2003 (see fig. 4). Applying the 2002
methodology, the 2003 coinsurance percentage of APC 1 should have remained 50
percent, because this APC was not considered new, and the 2003 copayment amount
should have decreased to $22.50.

Figure 4: Update to the Copayment Amount for a Hypothetical APC with a
Payment Rate Decrease for 2003 If the 2002 Methodology Had Been Used




However, under the 2003 methodology, CMS would have considered APC 1 a new
APC. Because the 2002 coinsurance percentage of APC 2 (45 percent) was lower
than the 2002 coinsurance percentage of APC 1 (50 percent), CMS would have used
45 percent to calculate the copayment amount for APC 1 (see fig. 5). In this example,
because the payment rate for APC 1 decreased, the lower coinsurance percentage in
conjunction with a lower payment rate would have resulted in a copayment amount
of $20.25, instead of the $22.50 calculated using the 2002 methodology.




7                                        GAO-04-103R Medicare Hospital Outpatient Payments
Figure 5: Update to the Copayment Amount for a Hypothetical APC with a
Payment Rate Decrease for 2003 Using the 2003 Methodology




In the proposed rule updating the OPPS payment rates for 2004, CMS stated that,
effective with the 2004 payment rates, it would revise and clarify the copayment
methodology. Our review of the proposed methodology indicates that it would be
consistent with the statute because it would not allow copayment amounts to
increase from year to year, and they would eventually decline to 20 percent of the
APC payment rate. However, CMS did not recalculate the 2003 copayment amounts
using the 2002 methodology before using them as the basis for calculating the 2004
copayment amounts. Thus, certain 2004 copayment amounts are higher, and others
are lower, than they would have been if CMS had consistently applied the 2002
methodology, and the time it will take for the copayment amounts for some of these
APCs to reach 20 percent of the APC payment rate will increase.

2003 Copayment Methodology Results in Inaccurate Beneficiary Copayments
and Medicare Payments

We estimate that in 2003, the copayment methodology used by CMS will result in
about $414 million in inaccurate copayments, with a net of $192 million in Medicare
program overpayments. More specifically, we estimate that beneficiaries will be
overcharged by approximately $111 million for certain services. Beneficiaries will be
undercharged for other services, and therefore we estimate that Medicare will
overpay by approximately $303 million for these other services. The exact amounts
will depend on the actual number of services provided in the affected APCs in 2003.

For some APCs, the beneficiary is being overcharged. APC 0291, Level II Diagnostic
Nuclear Medicine Excluding Myocardial Scans, is an example of an APC for which
the beneficiary is responsible for paying a higher copayment as a result of the 2003
copayment methodology. We determined that the 2003 copayment for this APC is
more than $14 higher than it would have been had the 2002 methodology been used.
Multiplying that amount by the total number of 2001 claims for this APC results in an


8                                        GAO-04-103R Medicare Hospital Outpatient Payments
estimated $1.7 million in beneficiary overcharges for 2003. For the APCs for which
beneficiaries were overcharged, we estimate that the sum of those overcharges is
approximately $111 million.

For the majority of the miscalculated APCs, however, Medicare is overpaying. For
example, for APC 0110, Transfusion, we determined that the 2003 copayment amount
for this APC was $46 lower than it would have been had the 2002 methodology been
used and, therefore, the Medicare payment portion was that much higher.
Multiplying that amount by the total number of 2001 claims for this APC results in an
estimated $15.2 million in Medicare overpayments for 2003. Summing the Medicare
overpayments of all APCs for which beneficiaries were undercharged results in an
estimated total of approximately $303 million.

Conclusions

The methodology that CMS used to calculate beneficiary copayment amounts in 2003
is inconsistent with (1) the methodology published by CMS in its final rule setting
forth the 2002 OPPS payment rates and (2) the statutory objective of steadily
decreasing all copayment amounts until they are 20 percent of the total payment rate
for each service.

Though CMS has proposed clarifications to its methodology for 2004, there are
reasons for concern. First, some beneficiaries continue to be inaccurately charged
and Medicare continues to overpay for certain outpatient hospital services delivered
in 2003. In addition, although CMS has proposed a methodology for 2004 and later
years that would not increase copayment amounts for an APC from one year to the
next and that would eventually decrease copayment amounts to 20 percent of the
payment rate, CMS would be using the miscalculated 2003 copayment amounts as the
basis for these and future copayment amounts. Finally, the time it will take for the
copayment amounts for certain APCs to reach 20 percent of the APC payment rate
will increase.

Recommendations for Executive Action

For the purpose of calculating the 2004 OPPS beneficiary copayment amounts, we
recommend that the Administrator of CMS first apply the 2002 copayment
methodology to the 2003 APCs for which beneficiaries were inaccurately charged.
The 2004 copayment amounts should then be based on these revised 2003 copayment
amounts.

Agency Comments

In written comments on a draft of this report, CMS stated that in 2003 it treated
reconfigured APCs as if they were new APCs. CMS also stated that in the 2004 OPPS
proposed rule, it proposed to change the method of copayment calculation to treat
reconfigured APCs in the same manner as recalibrated APCs, consistent with the
methodology that we stated should have been used in 2003. However, CMS noted


9                                        GAO-04-103R Medicare Hospital Outpatient Payments
that it did not propose to recalculate the 2003 copayments, which must be used in 

part as the basis for the calculation of the 2004 OPPS copayments. In its comments, 

CMS stated that it would carefully consider the information we provided to it as part 

of issuing its final rule. 


CMS’s comments about its methodology are generally consistent with the information 

in our draft report. We believe that CMS should apply the 2002 copayment 

methodology to the 2003 copayment amounts before calculating the 2004 copayment 

amounts to ensure that they are accurate. CMS’s comments appear in Enclosure III. 


We are sending copies of this report to interested congressional committees. We will 

also make copies available to others upon request. In addition, the report will be 

available at no charge on the GAO Web site at http://www.gao.gov. 


If you or your staff have questions, please contact me at (202) 512-7119. Another 

contact and key contributors to this report appear in Enclosure IV. 


Sincerely yours, 





A. Bruce Steinwald 

Director, Heath Care—Economic 

 and Payment Issues 


Enclosures—4 





10                                       GAO-04-103R Medicare Hospital Outpatient Payments
Enclosure I                                                                                        Enclosure I


                                        Scope and Methodology

We obtained the 2001 Medicare outpatient prospective payment system (OPPS)
claims data, the latest data available, directly from the Centers for Medicare &
Medicaid Services (CMS).17 We used these claims data together with the 569
ambulatory payment classification (APC) groups in 2003 and the published 2003
OPPS copayment amounts to estimate the impact of the 2003 copayment
methodology on copayment amounts. We calculated the 2003 copayment amount for
each of the APCs using the 2002 methodology and calculated the difference between
that amount and the published 2003 copayment amount. The copayment amounts we
analyzed were those published in the final rules setting both the 2002 and 2003
payment rates. We did not take wage index adjustments into account, and thus our
estimates are based on national APC payment rates.

We determined that 75 APCs had inaccurate copayment amounts in 2003; however, 6
of these 75 APCs are not included in our financial impact estimate because, while
they existed in 2002, they did not exist in 2001 and were not in the 2001 Medicare
claims data. We multiplied the difference between the two 2003 copayment amounts
by the frequency of each APC in the 2001 Medicare hospital outpatient claims data
and summed the beneficiary overcharges for the affected APCs. We then summed
the beneficiary undercharges (Medicare overpayments) for the other affected APCs.
We applied the CMS rule that payment rates and copayment amounts for certain
APCs are discounted by a factor of 50 percent when these services are performed
more than once or with certain other procedures during a single operative session by
using the discounted rates as appropriate in our analysis when these APCs appeared
in the claims data.




17
  The 2001 outpatient claims data file contains all final action outpatient claims for services furnished on or
after April 1, 2001 and on or before March 31, 2002. As it is the file that CMS used to set the 2003 OPPS
payment rates, we consider it reliable for the purpose of our estimate, which is to count the frequency with
which outpatient services were performed.


11                                                     GAO-04-103R Medicare Hospital Outpatient Payments
Enclosure II                                                                        Enclosure II


List of APCs for Which Beneficiaries Are Overcharged or Medicare Overpays
                             for 2003 Services

Table 1: List of APCs for Which Beneficiaries Are Overcharged for 2003 Services

 APC      Title
 0010     Level I Destruction of Lesion
 0012     Level I Debridement & Destruction
 0022     Level IV Excision/Biopsy
 0025     Level II Skin Repair
 0035     Placement of Arterial or Central Venous Catheter
 0148     Level I Anal/Rectal Procedure
 0155     Level II Anal/Rectal Procedure
 0156     Level II Urinary and Anal Procedures
 0164     Level I Urinary and Anal Procedures
 0192     Level IV Female Reproductive Procedures
 0214     Electroencephalogram
 0216     Level III Nerve and Muscle Tests
 0230     Level I Eye Tests & Treatments
 0231     Level III Eye Tests & Treatments
 0232     Level I Anterior Segment Eye Procedures
 0234     Level III Anterior Segment Eye Procedures
 0247     Laser Eye Procedures Except Retinal
 0248     Laser Retinal Procedures
 0254     Level IV ENT Procedures
 0260     Level I Plain Film Except Teeth
 0265     Level I Diagnostic Ultrasound Except Vascular
 0266     Level II Diagnostic Ultrasound Except Vascular
 0286     Myocardial Scans
 0290     Level I Diagnostic Nuclear Medicine Excluding Myocardial Scans
 0291     Level II Diagnostic Nuclear Medicine Excluding Myocardial Scans
 0343     Level II Pathology
 0344     Level III Pathology
 0360     Level I Alimentary Tests

Source: CMS. 


Note: GAO analysis of 2003 OPPS copayment rates and 2002 OPPS final rule. 





12                                                GAO-04-103R Medicare Hospital Outpatient Payments
Enclosure II                                                                            Enclosure II

Table 2: List of APCs for Which Medicare Overpays for 2003 Services

 APC              Title
 0002             Fine Needle Biopsy/Aspiration
 0003             Bone Marrow Biopsy/Aspiration
 0006             Level I Incision & Drainage
 0015             Level III Debridement & Destruction
 0021             Level III Excision/Biopsy
 0041             Level I Arthroscopy
 0045             Bone/Joint Manipulation Under Anesthesia
 0049             Level I Musculoskeletal Procedures Except Hand and Foot
 0050             Level II Musculoskeletal Procedures Except Hand and Foot
 0051             Level III Musculoskeletal Procedures Except Hand and Foot
 0052             Level IV Musculoskeletal Procedures Except Hand and Foot
 0054             Level II Hand Musculoskeletal Procedures
 0058             Level I Strapping and Cast Application
 0070             Thoracentesis/Lavage Procedures
 0072             Level II Endoscopy Upper Airway
 0081             Non-coronary Angioplasty or Atherectomy
 0083             Coronary Angioplasty and Percutaneous Valvuloplasty
 0084             Level I Electrophysiologic Evaluation
 0090             Insertion/Replacement of Pacemaker Pulse Generator
 0099             Electrocardiograms
 0110             Transfusion
 0113             Excision Lymphatic System
 0114             Thyroid/Lymphadenectomy Procedures
 0115             Cannula/Access Device Procedures
 0141             Upper GI Procedures
 0147             Level II Sigmoidoscopy
 0153             Peritoneal and Abdominal Procedures
 0162             Level III Cystourethroscopy and other Genitourinary Procedures
 0163             Level IV Cystourethroscopy and other Genitourinary Procedures
 0182             Insertion of Penile Prosthesis
 0183             Testes/Epididymis Procedures
 0218             Level II Nerve and Muscle Tests
 0220             Level I Nerve Procedures
 0251             Level I ENT Procedures
 0253             Level III ENT Procedures
 0256             Level V ENT Procedures
 0261             Level II Plain Film Except Teeth Including Bone Density Measurement
 0263             Level I Miscellaneous Radiology Procedures
 0264             Level II Miscellaneous Radiology Procedures
 0288             Bone Density: Axial Skeleton
 0292             Level III Diagnostic Nuclear Medicine Excluding Myocardial Scans
 0300             Level I Radiation Therapy
 0340             Minor Ancillary Procedures
 0345             Level I Transfusion Laboratory Procedures
 0346             Level II Transfusion Laboratory Procedures
 0368             Level II Pulmonary Tests
 0689             Electronic Analysis of Cardioverter-defibrillators

Source: CMS. 


Note: GAO analysis of 2003 OPPS copayment rates and 2002 OPPS final rule. 





13                                                 GAO-04-103R Medicare Hospital Outpatient Payments
Enclosure III                                                        Enclosure III


        Comments from the Centers for Medicare & Medicaid Services




14                                 GAO-04-103R Medicare Hospital Outpatient Payments
Enclosure III                                     Enclosure III




15              GAO-04-103R Medicare Hospital Outpatient Payments
Enclosure IV                                                             Enclosure IV


                  GAO Contact and Staff Acknowledgments


GAO Contact

Nancy A. Edwards, (202) 512-3340

Acknowledgments

Beth Cameron Feldpush, Joanna L. Hiatt, Maria Martino, and Jonathan Sclarsic made
major contributions to this report.




(290326)



16                                     GAO-04-103R Medicare Hospital Outpatient Payments
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