	Addendum J for CY2015 services excluded from comprehensive APC packaging			
Exclusion Type	HCPCS Code	Descriptor	SI	APC
Ambulance	A0420	Ambulance waiting 1/2 hr	A	
Ambulance	A0422	Ambulance 02 life sustaining	A	
Ambulance	A0424	Extra ambulance attendant	A	
Ambulance	A0425	Ground mileage	A	
Ambulance	A0426	ALS 1	A	
Ambulance	A0427	ALS 1-emergency	A	
Ambulance	A0428	bls	A	
Ambulance	A0429	BLS-emergency	A	
Ambulance	A0430	Fixed wing air transport	A	
Ambulance	A0431	Rotary wing air transport	A	
Ambulance	A0432	PI volunteer ambulance co	A	
Ambulance	A0433	als 2	A	
Ambulance	A0434	Specialty care transport	A	
Ambulance	A0435	Fixed wing air mileage	A	
Ambulance	A0436	Rotary wing air mileage	A	
Ambulance	A0999	Unlisted ambulance service	A	
Brachytherapy	A9527	Iodine I-125 sodium iodide	U	2632
Brachytherapy	C1716	"Brachytx, non-str, Gold-198"	U	1716
Brachytherapy	C1717	"Brachytx, non-str,HDR Ir-192"	U	1717
Brachytherapy	C1719	"Brachytx, NS, Non-HDRIr-192"	U	1719
Brachytherapy	C2616	"Brachytx, non-str,Yttrium-90"	U	2616
Brachytherapy	C2634	"Brachytx, non-str, HA, I-125"	U	2634
Brachytherapy	C2635	"Brachytx, non-str, HA, P-103"	U	2635
Brachytherapy	C2636	"Brachy linear, non-str,P-103"	U	2636
Brachytherapy	C2638	"Brachytx, stranded, I-125"	U	2638
Brachytherapy	C2639	"Brachytx, non-stranded,I-125"	U	2639
Brachytherapy	C2640	"Brachytx, stranded, P-103"	U	2640
Brachytherapy	C2641	"Brachytx, non-stranded,P-103"	U	2641
Brachytherapy	C2642	"Brachytx, stranded, C-131"	U	2642
Brachytherapy	C2643	"Brachytx, non-stranded,C-131"	U	2643
Brachytherapy	C2698	"Brachytx, stranded, NOS"	U	2698
Brachytherapy	C2699	"Brachytx, non-stranded, NOS"	U	2699
"Corneal, CRNA, and Hep B Vaccine"	V2785	"	Corneal tissue processing"	F	
Mammography	77051	Computer dx mammogram add-on	A	
Mammography	77052	Comp screen mammogram add-on	A	
Mammography	77055	Mammogram one breast	A	
Mammography	77056	Mammogram both breasts	A	
Mammography	77057	Mammogram screening	A	
Mammography	G0202	Screeningmammographydigital	A	
Mammography	G0204	Diagnosticmammographydigital	A	
Mammography	G0206	Diagnosticmammographydigital	A	
Pass-through Drugs and Devices	A9520	Tc99 tilmanocept diag 0.5mci	G	1463
Pass-through Drugs and Devices	C1841	Retinal prosth int/ext comp	H	1841
Pass-through Drugs and Devices	C9021	"Injection, obinutuzumab"	G	1476
Pass-through Drugs and Devices	C9132	"	Kcentra, per i.u."	G	9132
Pass-through Drugs and Devices	C9133	Factor ix recombinant	G	1467
Pass-through Drugs and Devices	C9441	"	Inj, ferric carboxymaltose"	G	9441
Pass-through Drugs and Devices	C9497	"Loxapine, inhalation powder"	G	9497
Pass-through Drugs and Devices	J1556	"Inj, imm glob bivigam, 500mg"	G	9130
Pass-through Drugs and Devices	J3060	"Inj, taliglucerace alfa 10 u"	G	9294
Pass-through Drugs and Devices	J7315	Ophthalmic mitomycin	G	1448
Pass-through Drugs and Devices	J7316	"Inj, ocriplasmin, 0.125 mg"	G	9298
Pass-through Drugs and Devices	J7508	"	Tacrolimus ex rel oral 0.1mg"	G	1465
Pass-through Drugs and Devices	J9047	"Injection, carfilzomib, 1 mg"	G	9295
Pass-through Drugs and Devices	J9262	"Inj, omacetaxine mep, 0.01mg"	G	9297
Pass-through Drugs and Devices	J9354	"Inj, ado-trastuzumab emt 1mg"	G	9131
Pass-through Drugs and Devices	J9371	"	Inj, vincristine sul lip 1mg"	G	1466
Pass-through Drugs and Devices	J9400	"	Inj, ziv-aflibercept, 1mg"	G	9296
Pass-through Drugs and Devices	Q4121	"	Theraskin"	G	1479
Pass-through Drugs and Devices	Q4122	"	Dermacell"	G	1419
Pass-through Drugs and Devices	Q4127	"	Talymed"	G	1449
Preventive Care	76977	"Ultrasound bone density measurement and interpretation, peripheral site(s), any method"	Q1	0340
Preventive Care	77078	"Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)"	Q1	0260
Preventive Care	77080	"Dual-energy x-ray absorptiometry (dxa), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)"	Q1	0261
Preventive Care	77081	"Dual-energy x-ray absorptiometry (dxa), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)"	Q1	0260
Preventive Care	80061	Lipid panel	Q4	
Preventive Care	82270	"Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection)"	Q4	
Preventive Care	82465	"Cholesterol, serum or whole blood, total"	Q4	
Preventive Care	82947	"Glucose; quantitative, blood (except reagent strip)"	Q4	
Preventive Care	82950	Glucose; post glucose dose (includes glucose)	Q4	
Preventive Care	82951	"Glucose; tolerance test (gtt), 3 specimens (includes glucose)"	Q4	
Preventive Care	83718	"Lipoprotein, direct measurement; high density cholesterol (hdl cholesterol)"	Q4	
Preventive Care	84478	Triglycerides	Q4	
Preventive Care	86592	"Syphilis test, non-treponemal antibody; qualitative (eg, vdrl, rpr, art)"	Q4	
Preventive Care	86593	"Syphilis test, non-treponemal antibody; quantitative"	Q4	
Preventive Care	86631	Antibody; chlamydia	Q4	
Preventive Care	86632	"Antibody; chlamydia, igm"	Q4	
Preventive Care	86780	Antibody; treponema pallidum	Q4	
Preventive Care	87110	"Culture, chlamydia, any source"	Q4	
Preventive Care	87270	Infectious agent antigen detection by immunofluorescent technique; chlamydia trachomatis	Q4	
Preventive Care	87320	"Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; chlamydia trachomatis"	Q4	
Preventive Care	87341	"Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis b surface antigen (hbsag) neutralization"	Q4	
Preventive Care	87490	"Infectious agent detection by nucleic acid (dna or rna); chlamydia trachomatis, direct probe technique"	Q4	
Preventive Care	87491	"Infectious agent detection by nucleic acid (dna or rna); chlamydia trachomatis, amplified probe technique"	Q4	
Preventive Care	87590	"Infectious agent detection by nucleic acid (dna or rna); neisseria gonorrhoeae, direct probe technique"	Q4	
Preventive Care	87591	"Infectious agent detection by nucleic acid (dna or rna); neisseria gonorrhoeae, amplified probe technique"	Q4	
Preventive Care	87800	"Infectious agent detection by nucleic acid (dna or rna), multiple organisms; direct probe(s) technique"	Q4	
Preventive Care	87810	Infectious agent antigen detection by immunoassay with direct optical observation; chlamydia trachomatis	Q4	
Preventive Care	87850	Infectious agent antigen detection by immunoassay with direct optical observation; neisseria gonorrhoeae	Q4	
Preventive Care	90653	"Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use"	E	
Preventive Care	90654	"Influenza virus vaccine, split virus, preservative-free, for intradermal use"	L	
Preventive Care	90655	"Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use"	L	
Preventive Care	90656	"Influenza virus vaccine, trivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use"	L	
Preventive Care	90657	"Influenza virus vaccine, trivalent, split virus, when administered to children 6-35 months of age, for intramuscular use"	L	
Preventive Care	90660	"Influenza virus vaccine, trivalent, live, for intranasal use"	L	
Preventive Care	90661	"Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use"	L	
Preventive Care	90662	"Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use"	L	
Preventive Care	90669	"Pneumococcal conjugate vaccine, 7 valent, for intramuscular use"	L	
Preventive Care	90670	"Pneumococcal conjugate vaccine, 13 valent, for intramuscular use"	L	
Preventive Care	90672	"Influenza virus vaccine, quadrivalent, live, for intranasal use"	L	
Preventive Care	90673	"Influenza virus vaccine Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use"	L	
Preventive Care	90685	"Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use"	L	
Preventive Care	90686	"Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use"	L	
Preventive Care	90687	"Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for intramuscular use"	E	
Preventive Care	90688	"Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use"	L	
Preventive Care	90732	"Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use"	L	
Preventive Care	90739	"Hepatitis b vaccine, adult dosage (2 dose schedule), for intramuscular use"	E	
Preventive Care	90740	"Hepatitis b vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use"	F	
Preventive Care	90743	"Hepatitis b vaccine, adolescent (2 dose schedule), for intramuscular use"	F	
Preventive Care	90744	"Hepatitis b vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use"	F	
Preventive Care	90746	"Hepatitis b vaccine, adult dosage (3 dose schedule), for intramuscular use"	F	
Preventive Care	90747	"Hepatitis b vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use"	F	
Preventive Care	97802	"Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes"	A	
Preventive Care	97803	"Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes"	A	
Preventive Care	97804	"Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes"	A	
Preventive Care	G0008	Administration of influenza virus vaccine	S	0436
Preventive Care	G0009	Administration of pneumococcal vaccine	S	0437
Preventive Care	G0010	Administration of hepatitis b vaccine	S	0437
Preventive Care	G0101 	Cervical or vaginal cancer screening; pelvic and clinical breast examination	V	0631
Preventive Care	G0103	Prostate cancer screening; prostate specific antigen test (psa)	A	
Preventive Care	G0104	Colorectal cancer screening; flexible sigmoidoscopy	S	0159
Preventive Care	G0105	Colorectal cancer screening; colonoscopy on individual at high risk	T	0158
Preventive Care	G0106	"Colorectal cancer screening; alternative to g0104, screening sigmoidoscopy, barium enema"	S	0157
Preventive Care	G0108	"Diabetes outpatient self-management training services, individual, per 30 minutes"	A	
Preventive Care	G0109	"Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes"	A	
Preventive Care	G0117 	Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist	Q1	0230
Preventive Care	G0118	Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalomologist	Q1	0230
Preventive Care	G0120	"Colorectal cancer screening; alternative to g0105, screening colonoscopy, barium enema."	S	0157
Preventive Care	G0121	Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk	T	0158
Preventive Care	G0123	"Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision"	A	
Preventive Care	G0124	"Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician"	B	
Preventive Care	G0130	"Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)"	Q1	0260
Preventive Care	G0141	"Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician"	B	
Preventive Care	G0143	"Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision"	A	
Preventive Care	G0144	"Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with  screening by automated system, under physician supervision"	A	
Preventive Care	G0145	"Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with  screening by automated system and manual rescreening under physician supervision"	A	
Preventive Care	G0147	"Screening cytopathology smears,  cervical or vaginal, performed by automated system under physician supervision"	A	
Preventive Care	G0148	"Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening"	A	
Preventive Care	G0270	"Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes"	A	
Preventive Care	G0271	"Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes"	A	
Preventive Care	G0328	"Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous"	A	
Preventive Care	G0389 	Ultrasound b-scan and/or real time with image documentation; for abdominal aortic aneurysm (aaa) screening	Q1	0265
Preventive Care	G0402	"Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment"	V	0632
Preventive Care	G0403	"Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report"	M	
Preventive Care	G0404	"Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination"	Q1	0450
Preventive Care	G0405	"Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination"	B	
Preventive Care	G0432 	"Infectious agent antibody detection by enzyme immunoassay (eia) technique, hiv-1 and/or hiv-2, screening"	A	
Preventive Care	G0433	"Infectious agent antibody detection by enzyme-linked immunosorbent assay (elisa) technique, hiv-1 and/or hiv-2, screening"	A	
Preventive Care	G0435	"Infectious agent antibody detection by rapid antibody test, hiv-1 and/or hiv-2, screening"	A	
Preventive Care	G0436	"Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes"	S	0031
Preventive Care	G0437	"Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes"	S	0432
Preventive Care	G0438	"Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit"	A	
Preventive Care	G0439	"Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit"	A	
Preventive Care	G0442	"Annual alcohol misuse screening, 15 minutes"	S	0432
Preventive Care	G0443	"Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes"	S	0432
Preventive Care	G0444 	"Annual depression screening, 15 minutes"	S	0031
Preventive Care	G0445	"High intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes"	S	0031
Preventive Care	G0446 	"Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes"	S	0031
Preventive Care	G0447	"Face-to-face behavioral counseling for obesity, 15 minutes"	S	0432
Preventive Care	P3000	"Screening papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision"	A	
Preventive Care	P3001	"Screening papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician"	B	
Preventive Care	Q0091	"Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory"	Q1	0450
Preventive Care	Q2034	"Influenza virus vaccine, split virus, for intramuscular use (agriflu)"	L	
Preventive Care	Q2035	"Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (afluria)"	L	
Preventive Care	Q2036	"Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (flulaval)"	L	
Preventive Care	Q2037	"Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluvirin)"	L	
Preventive Care	Q2038	"Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluzone)"	L	
Preventive Care	Q2039	"Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified)"	L	
