Several Healthcare Common Procedure Coding System codes are not used anymore (i.e., E0472 and E0130). Under these circumstances it is very difficult or impossible to procure these items at a price that would be considered bona fide. How are the obscure items expected to be bona fide?

We encourage you to use the Lead Item Pricing Calculator, which is designed to help you determine your bid amount for the lead item in the product category and its impact on the non-lead items’ potential single payment amounts (SPAs). Also, you may want to review the Utilization Report. The report indicates the ratios relative to the lead item that will be used to calculate the SPAs for the non-lead items. The Utilization Report also provides 2017 and 2018 allowed amounts for the lead and non-lead items in each product category. Historic and anticipated utilization of the non-lead items are also factors to consider when developing your bid amount for the lead item. 

If requested to substantiate your bid amount for the lead item, you should provide an explanation that describes how you arrived at the amount, including factors such as anticipated costs (i.e., direct and indirect) for the lead and non-lead items and desired profit.

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Updated: 09/06/2019