10.19.A. - Sabizabulin Codes - FY 2024													
													
Note:  The applicant provided the following codes and/or MS-DRGs that were used in performing a cost analysis for the Charges section of the new technology add-on payment application.													
													
Analysis 1 MS-DRG 1		Analysis 2 MS-DRG 1		Analysis 3 MS-DRG 1		ICD-10-PCS Procedure Codes for Mechanical Ventilation 		ICD-10-PCS Procedure Codes for High/Low Flow Oxygen 					
177		177		207		5A1935Z?		5A0935A 					
871		871		870		5A1945Z?		5A0945A 					
178		291		208		5A1955Z?		5A0955A 					
291		853		871				5A0920Z 					
189		981		004				5A09357?					
853		189		853				5A09358?					
981		064		003				5A09359?					
179		280		981				5A0935B?					
280		166		064				5A0935Z?					
682		377		166				5A09457?					
190		698		023				5A09458?					
698		682		377				5A09459?					
640		283		283				5A0945B?					
974		246		329				5A0945Z?					
064		178		100				5A09557?					
480		974		974				5A09558?					
377		308		246				5A0955B?					
193		205		270				5A0955Z?					
987		190		291									
637		193		987									
308		314		163									
175		987		296									
689		480		917									
166		640		682									
951		637		698									
602		673		025									
521		163		308									
393		175		082									
205		689		480									
		286		640									
		270		314									
		329		215									
		917		637									
		252		252									
		242		280									
		082		356									
		521		907									
		085		326									
		393		432									
		811		441									
		862		673									
		235		239									
		233		393									
		180		233									
		100		286									
		444		085									
				219									
				856									
				070									
				957									
				963									
				091									
				689									
				268									
				521									
				659									
				896									
				242									
				299									
				915									
				001									
				224									
				061									
				228									
				811									
				335									
				919									
				862									
				951									
				391									
				388									
				380									
				056									
				956									
				020									
				813									
				492									
				551									
				463									
				264									
				028									
				840									
				444									
				417									
				374									
				216									
				040									
				602									
				368									
				273									
				097									
				250									
				453									
				235									
				834									
				037									
				014									
				474									
				459									
				453									
													
													
"1 For the MS-DRG desciptions, refer to Table 5 associated with the applicable fiscal year IPPS/LTCH PPS proposed rule."													
