Beginning January 1, 2021, Hospitals must post a machine-readable file of their chargemasters including negotiated charges and cash discounts to their websites, along with a consumer-friendly display of shoppable services.
Hospital means an institution in any State in which State or applicable local law provides for the licensing of hospitals, that is licensed as a hospital pursuant to such law or is approved, by the agency of such State or locality responsible for licensing hospitals, as meeting the standards established for such licensing.
Standard charges must be posted two ways:
1. Machine Readable File
Single machine-readable digital file containing the following standard charges for all items and services provided by the hospital: gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges.
For additional details on this requirement refer to 45 CFR §180.50.
2. Consumer-friendly Display of Shoppable Services
Display of at least 300 “shoppable services” (or as many as the hospital provides if less than 300) that a health care consumer can schedule in advance. Must contain plain language descriptions of the services and group them with ancillary services, and provide the discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges.
For additional details on this requirement, including the use of price estimator tools, refer to 45 CFR §180.60.
Beginning January 1, 2021, CMS will monitor and enforce these price transparency requirements. For hospitals that do not comply, CMS may issue a warning notice, request a corrective action plan, and impose a civil monetary penalty (CMP) and publicize the penalty on a CMS website. The maximum daily dollar amount for a CMP to which a hospital may be subject would be $300.
In 2010, the Affordable Care Act added a new Section 2718(e) to the Public Health Service Act requiring all hospitals to make public a list of their "standard charges." In previous rulemaking, CMS interpreted the statute to require hospitals to publish their chargemasters in a machine-readable format. That CMS Final Rule can be found here: https://www.govinfo.gov/content/pkg/FR-2018-08-17/pdf/2018-16766.pdf
On June 24th 2019, President Trump issued Executive Order 13877 entitled "Improving Price and Quality Transparency in American Healthcare to Put Patients First" that in rulemaking CMS has required hospitals to expand the machine readable file of the chargemasters and display a consumer-friendly list of shoppable services. That CMS Final Rule can be found here: https://www.govinfo.gov/content/pkg/FR-2019-11-27/pdf/2019-24931.pdf
Have a question about Hospital Price Transparency? Email the hospital price transparency team.
CMS has specified 70 mandatory shoppable services that must be included if a hospital offers them. Those are:
| Evaluation & management services | 2020 CPT/HCPCS primary code |
|---|---|
| Psychotherapy, 30 min | 90832 |
| Psychotherapy, 45 min | 90834 |
| Psychotherapy, 60 min | 90837 |
| Family psychotherapy, not including patient, 50 min | 90846 |
| Family psychotherapy, including patient, 50 min | 90847 |
| Group psychotherapy | 90853 |
| New patient office or other outpatient visit, typically 30 min | 99203 |
| New patient office of other outpatient visit, typically 45 min | 99204 |
| New patient office of other outpatient visit, typically 60 min | 99205 |
| Patient office consultation, typically 40 min | 99243 |
| Patient office consultation, typically 60 min | 99244 |
| Initial new patient preventive medicine evaluation (18-39 years) | 99385 |
| Initial new patient preventive medicine evaluation (40-64 years) | 99386 |
| Laboratory & pathology services | 2020 CPT/HCPCS primary code |
|---|---|
| Basic metabolic panel | 80048 |
| Blood test, comprehensive group of blood chemicals | 80053 |
| Obstetric blood test panel | 80055 |
| Blood test, lipids (cholesterol and triglycerides) | 80061 |
| Kidney function panel test | 80069 |
| Liver function blood test panel | 80076 |
| Manual urinalysis test with examination using microscope | 81000 or 81001 |
| Automated urinalysis test | 81002 or 81003 |
| PSA (prostate specific antigen) | 84153-84154 |
| Blood test, thyroid stimulating hormone (TSH) | 84443 |
| Complete blood cell count, with differential white blood cells, automated | 85025 |
| Complete blood count, automated | 85027 |
| Blood test, clotting time | 85610 |
| Coagulation assessment blood test | 85730 |
| Radiology services | 2020 CPT/HCPCS primary code |
|---|---|
| CT scan, head or brain, without contrast | 70450 |
| MRI scan of brain before and after contrast | 70553 |
| X-Ray, lower back, minimum four views | 72110 |
| MRI scan of lower spinal canal | 72148 |
| CT scan, pelvis, with contrast | 72193 |
| MRI scan of leg joint | 73721 |
| CT scan of abdomen and pelvis with contrast | 74177 |
| Ultrasound of abdomen | 76700 |
| Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus | 76805 |
| Ultrasound pelvis through vagina | 76830 |
| Mammography of one breast | 77065 |
| Mammography of both breasts | 77066 |
| Mammography, screening, bilateral | 77067 |
| Medicine and surgery services | 2020 CPT/HCPCS primary code |
|---|---|
| Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities | 216 |
| Spinal fusion except cervical without major comorbid conditions or complications (MCC) | 460 |
| Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications (MCC) | 470 |
| Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) | 473 |
| Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid conditions or complications (MCC) | 743 |
| Removal of 1 or more breast growth, open procedure | 19120 |
| Shaving of shoulder bone using an endoscope | 29826 |
| Removal of one knee cartilage using an endoscope | 29881 |
| Removal of tonsils and adenoid glands patient younger than age 12 | 42820 |
| Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope | 43235 |
| Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope | 43239 |
| Diagnostic examination of large bowel using an endoscope | 45378 |
| Biopsy of large bowel using an endoscope | 45380 |
| Removal of polyps or growths of large bowel using an endoscope | 45385 |
| Ultrasound examination of lower large bowel using an endoscope | 45391 |
| Removal of gallbladder using an endoscope | 47562 |
| Repair of groin hernia patient age 5 years or older | 49505 |
| Biopsy of prostate gland | 55700 |
| Surgical removal of prostate and surrounding lymph nodes using an endoscope | 55866 |
| Routine obstetric care for vaginal delivery, including pre-and post-delivery care | 59400 |
| Routine obstetric care for cesarean delivery, including pre-and post-delivery care | 59510 |
| Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care | 59610 |
| Injection of substance into spinal canal of lower back or sacrum using imaging guidance | 62322-62323 |
| Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance | 64483 |
| Removal of recurring cataract in lens capsule using laser | 66821 |
| Removal of cataract with insertion of lens | 66984 |
| Electrocardiogram, routine, with interpretation and report | 93000 |
| Insertion of catheter into left heart for diagnosis | 93452 |
| Sleep study | 95810 |
| Physical therapy, therapeutic exercise | 97110 |
