Medicare Price Exclusion Analysis
Date: 2026-04-21
Version: v3
Pipeline: ssp_pricing/sql/claims/discover_institutional.sql, discover_professional.sql
Summary
The SSP pricing pipeline excludes line codes from the fee schedule when their Medicare rate is below $10. This filter prevents low-value codes from inflating the professional fee component.
- Facility (OPPS < $10): 4 codes excluded
- Professional (MPFS < $10): 8 codes excluded
These are codes that have association rate > 30% with at least one anchor and are not already excluded by other filters (anchor-of-another-SSP, excluded code list).
Facility Fee Exclusions (OPPS < $10)
| Code | Description | OPPS Rate | MPFS Rate | Max Assoc. | # SSPs | Assessment |
|---|---|---|---|---|---|---|
| J1885 | Injection, ketorolac tromethamine, per 15 MG | $0.34 | N/A | 100.0% | 42 | High impact. Common post-surgical analgesic with 100% association across 42 SSPs. OPPS rate is per-unit ($0.34/15mg), but actual billing involves multiple units. Excluding this removes a consistently-appearing drug code from facility pricing. May be worth reconsidering since the per-unit rate is misleading. |
| J0666 | Injection, bupivacaine liposome, 1 MG | $1.46 | N/A | 100.0% | 2 | Long-acting local anesthetic (Exparel). 100% association in colectomy and thoracoscopy. Low OPPS per-unit rate but high total cost per administration. |
| J0585 | Injection, onabotulinumtoxina, 1 unit | $6.51 | N/A | 55.3% | 1 | Botox. Per-unit rate is low but procedures use many units. Only affects EGD SSP. |
| Q9968 | Visualization adjunct (e.g., methylene blue), 1 MG | $9.81 | N/A | 37.8% | 2 | Surgical dye for lymph node mapping. Low volume, moderate impact. |
Key Finding
J1885 (ketorolac) stands out: it appears in 42 SSPs at 100% association — nearly every surgical SSP. The $0.34 OPPS rate is per-unit (per 15mg), but typical doses are 30-60mg (2-4 units). The per-unit Medicare rate is misleading for this code. This is the most impactful exclusion in the facility filter.
Professional Fee Exclusions (MPFS < $10)
| Code | Description | OPPS Rate | MPFS Rate | Max Assoc. | # SSPs | Assessment |
|---|---|---|---|---|---|---|
| 96160 | Health risk assessment instrument | $38.81 | $2.93 | 100.0% | 1 | Screening tool for genomic SSP. Low clinical value for pricing. |
| 95004 | Percutaneous allergy tests, per test | $889.45 | $3.56 | 100.0% | 1 | Per-test rate is low but billed as many units. Only affects allergy_testing SSP. OPPS rate ($889) is high, suggesting institutional setting prices this correctly. |
| 96127 | Brief emotional/behavioral assessment | $38.69 | $4.85 | 35.3% | 1 | Screening instrument for blood_test SSP. Low relevance. |
| 17003 | Destruction, premalignant lesions (2nd-14th) | N/A | $6.24 | 59.5% | 1 | Add-on code for actinic_destruction. Per-lesion rate; procedures bill many units. |
| 93005 | ECG tracing only | $61.10 | $6.81 | 100.0% | 1 | Technical component only. Excluded from cardiography but the interpretation code (93010) is separately excluded as anchor-of-another-SSP. |
| 93042 | Rhythm ECG interpretation only | N/A | $6.98 | 36.7% | 1 | Interpretation-only component for cardiography. Low rate reflects component billing. |
| 76514 | Corneal pachymetry | $29.96 | $7.67 | 100.0% | 1 | Ophthalmic ultrasound for ultrasound SSP. Technical measurement, low prof fee appropriate. |
| 93010 | ECG interpretation & report only | N/A | $8.31 | 100.0% | 158 | Highest impact. Appears in 158 SSPs at 100% association. This is the professional interpretation component of an ECG — nearly universal in surgical and medical SSPs. The $8.31 MPFS rate is technically correct (interpretation-only), but excluding it removes a ubiquitous professional service from pricing. |
Key Finding
93010 (ECG interpretation) is the most impactful exclusion: 158 SSPs at 100% association. It's the professional component of a routine ECG that's performed on virtually every hospital encounter. The 10 threshold may be too aggressive for codes that appear this universally.
Recommendations
-
Consider per-unit codes separately. J-codes (J1885, J0666, J0585) and per-test codes (95004) have low per-unit Medicare rates but high total-per-procedure costs. The $10 filter was designed for genuinely low-value services, not per-unit drug codes. Consider either:
- Exempting J-codes from the Medicare rate filter
- Using total-per-encounter charge instead of per-unit Medicare rate
-
Review 93010 exclusion. At 158 SSPs and 100% association, this is a significant exclusion. The ECG interpretation is a real professional service that affects pricing. Options:
- Lower the threshold to $5 (would keep 93010 excluded but is worth discussing)
- Exempt codes with >50 SSP coverage from the filter
- Accept the exclusion if the $8.31 fee genuinely doesn't move the needle on total SSP price
-
J1885 (ketorolac) warrants a targeted exception. 42 SSPs, 100% association, and the per-unit rate is misleading. This is a standard-of-care post-surgical drug.