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 

rates for hospital outpatient services over time, beneficiary coinsurance3 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 costsharing 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 

proposed 2004 copayment methodology confirms this position.14 

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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