N.Y. Comp. Codes R. & Regs. tit. 11, Appendices, app 17-D

Current through Register Vol. 46, No. 45, November 2, 2024

Appendix 17-D

(cf. Part 68)

SCHEDULE OF RATES FOR OUTPATIENT HOSPITAL SERVICES

Effective 1/1/85 - 12/31/85

Room other than an operating room when used for minor surgery or emergency treatment:

For the medical service provided, whether by employed staff, attending staff or by contractual arrangement with the physician groups, the fee for this service is the fee as appears on line 90010 of the Schedule of Medical Fees.

For the hospital providing intern or resident staffing or by physician group contractual coverage, the total fee is the fee for physician services as appears on line 90010 of the Schedule of Medical Fees plus the fee for use of the Emergency Service Room as set forth below.

When the care is provided by an attending physician, the hospital fee is the Emergency Service Room fee as set forth below, with the physician billing separately.

Note: The above fees include common or ordinary medications.

Crutches, mechanical splints and appliances Rental or sale at cost Plaster cast and/or splint Cost of plaster Radium and deep therapy A & A (authorization and arrangement) E.K.G., E.E.G., X-RAY, P.T. and laboratory charges Rates in Schedule of Medical Fees promulgated by the Chairman, Workers' Compensation Board.....................

Material supplied by the emergency room (i.e., sterile trays, medications, etc.) over and above those usually included with the emergency room visit may be charged for separately. Itemize these on the bill submitted.

COMMON OR ORDINARY DRUGS COVERED BY THE EMERGENCY ROOM HOSPITAL RATES

A study was undertaken to determine the low-cost drugs which a large umber of hospitals in New York State regard as fairly common or ordinary and for which no charges are made apart from the inclusive emergency room rates. A partial list of such drugs is furnished below. It is expected that the list will be enlarged or augmented from time to time. In the meanwhile, the drugs shown below or on any future similar list, or heretofore regarded as common or ordinary, or any additional drugs so regarded, should be considered as covered by the applicable emergency room rate.

No charge should be made for any drugs, whether or not listed hereunder, in connection with hospitalized patients.

Current List of "No Charge" Drugs and Pharmaceutical Supplies

Acetaminophen 325 mg tablet

Alcohol 70 percent

Alcohol swabs

Antacid (e.g., Mylanta, Maalox, etc.)

Aspirin 325 mg tablet

Aromatic spirits of ammonia

Atropine 2 percent ophthalmic solution

Atropine 0.4 mg/ml

Bacitracin ointment

Castor oil

Calamine lotion

Collodion flexible

Cold cream

Clinitest tablets

Dibucaine 1 percent ointment (e.g., Nupercainal)

Epinephrine injection

Ethyl Chloride spray

Gelfoam

Glycerin suppository

Hematest tablets

Hydrocortisone 1 percent ointment

Hydrogen Peroxide

Iodine

Ipecac syrup

Lidocaine 2 percent viscous (e.g., Xylocaine)

Lidocaine 1 percent with/without Epinephrine

Lidocaine 2 percent with/without Epinephrine

Lidocaine 5 percent ointment

Lindane lotion (e.g., Kwell)

Lubricating jelly

Magnesium Sulfate

Meperidine injection (e.g., Demerol)

Merthiolate

Neomycin and Polymyxin B Sulfates w/ Hydrocortisone ophthalmic suspension ( e.g. Cortisporin)

Nitroglycerin 0.4 mg s.1. tablet

Nitroglycerin 0.6 mg s.1. tablet

Peppermint Spirit

Petrolatum

Providone-Iodine solution (e.g., Betadine)

Pralidoxime Chloride (e.g., Protopam)

Silver Nitrate sticks

Silver Sulfadiazine cream (e.g., Silvadene)

Sodium Chloride - injection

Sodium Chloride for irrigation

Sterile water for irrigation

Talcum powder

Tetanus Toxoid

Tuberculin PPD (1st and 2nd strength)

Witch Hazel

Zinc Oxide ointment

Hospital	Emergency service room rateNo-Fault-effective 01/01/85-12/31/85
Western New York Region
ALLEGANY:
Cuba Memorial Hospital, Inc.	$30
Memorial Hospital of Wm. F. & Gertrude F. Jones Memorial A/K/A Jones Memorial	30
CATTARAUGUS:
Olean General Hospital	37
Salamanca Hospital District Authority	28
St. Francis Hospital of Olean	30
Tri-County Memorial Hospital	30
CHAUTAUQUA:
Brooks Memorial Hospital	30
Jamestown General Hospital	48
Lake Shore Hospital, Inc.	30
Westfield Memorial Hospital, Inc.	48
Woman's Christian Association	30
ERIE:
Bertrand Chaffee Hospital	28
Buffalo Columbus Hospital	28
Buffalo General Hospital	48
Children's Hospital of Buffalo	30
Erie County Medical Center	48
Kenmore Mercy Hospital	37
Lafayette General Hospital	37
Mercy Hospital of Buffalo	28
Millard Fillmore Hospital	37
Our Lady of Victory Hospital of Lackawanna	48
Roswell Park Memorial Institute	No E.R. service
Saint Francis Hospital of Buffalo	48
Sheehan Memorial Emergency Hospital, Inc.	28
Sheridan Park Hospital, Inc.	37
Sisters of Charity Hospital	48
St. Joseph Intercommunity Hospital	37
GENESEE:
Genesee Memorial Hospital	30
St. Jerome Hospital	30
NIAGARA:
Degraff Memorial Hospital	30
Inter-Community Memorial Hospital at Newfane, Inc.	30
Lockport Memorial Hospital	48
Mount St. Mary's Hospital of Niagra Falls	37
Niagra Falls Memorial Medical Center	37
ORLEANS:
Arnold Gregory Memorial Hospital	28
Medina Memorial Hospital	30
WYOMING:
Wyoming County Community Hospital	48
CHEMUNG:
Arnot-Ogden Memorial Hospital	37
St. Joseph's Hospital of Elmira	48
LIVINGSTON:
Nicholas H. Noyes Memorial Hospital	37
MONROE:
Genesee Hospital of Rochester	48
Highland Hospital of Rochester	48
Lakeside Memorial Hospital	37
Monroe Community Hospital	No E.R. service
Park Ridge Hospital	48
Rochester General Hospital	48
St. Mary's Hospital of Rochester	48
Strong Memorial Hospital	48
ONTARIO:
Clifton Springs Hospital and Clinic	48
F.F. Thompson Hospital	30
Geneva General Hospital	37
SCHUYLER:
Schuyler Hospital	28
SENECA:
Seneca Falls Hospital	48
Waterloo Memorial Hospital, Inc. d/b/a
Taylor-Brown Memorial Hospital	48
STEUBEN:
Bethesda Hospital	28
Corning Hospital	48
Ira Davenport Memorial Hospital, Inc.	48
St. James' Mercy Hospital	30
WAYNE:
Myers Community Hospital Foundation, Inc.	37
Newark-Wayne Community Hospital, Inc.	37
YATES:
Soldiers and Sailors Memorial Hospital of Yates County, Inc.	37
Central New York Region
BROOME:
Our Lady of Lourdes Memorial Hospital	37
United Health Services, Inc.	37
CAYUGA:
Auburn Memorial Hospital	30
CHENANGO:
Chenango Memorial Hospital, Inc.	37
CORTLAND:
Cortland Memorial Hospital, Inc.	37
HERKIMER:
Little Falls Hospital	30
Mohawk Valley General Hospital	28
JEFFERSON:
Carthage Area Hospital, Inc	37
Edward John Noble Hospital of Alexandria Bay	37
House of the Good Samaritan	30
Mercy Hospital of Watertown	37
LEWIS:
Lewis County General Hospital	48
MADISON:
Community Memorial Hospital, Inc.	37
Oneida City Hospital	28
ONEIDA:
Childrens Hospital and Rehabilitation Center	No E.R. service
Faxton Hospital	28
Rome Hospital and Murphy Memorial Hospital	30
St. Elizabeth Hospital	48
St. Luke's Memorial Hospital Center	30
ONONDAGA:
Community General Hospital of Greater Syracuse	48
Crouse Irvin Memorial Hospital	48
St. Joseph's Hospital Health Center	30
State University Hospital-Upstate Medical Center	48
OSWEGO:
Albert Lindley Lee Memorial Hospital	30
Oswego Hospital	30
ST. LAWRENCE:
A. Barton Hepburn Hospital	37
Canton-Potsdam Hospital	30
Clifton-Fine Hospital	28
Edward John Noble Hospital of Gouverneur	30
Massena Memorial Hospital	37
TIOGA:
Tioga General Hospital	30
TOMPKINS:
Tompkins County Hospital	30
Northeastern New York Region
ALBANY:
Albany Medical Center Hospital	48
Child's Hospital	No E.R. service
Cohoes Memorial Hospital	37
Memorial Hospital of Albany	30
St. Peter's Hospital	48
CLINTON:
Champlain Valley Physicians Hospital Medical Center	30
COLUMBIA:
Columbia Memorial Hospital	37
DELAWARE:
A. Lindsay & Olive B. O'Connor Hospital	30
Community Hospital of Stamford	30
Delaware Valley Hospital, Inc.	28
Margaretville Memorial Hospital	30
The Hospital	30
ESSEX:
Elizabethtown Community Hospital	48
Moses Ludington Hospital	48
Placid Memorial Hospital, Inc.	48
FRANKLIN:
Alice Hyde Memorial Hospital	28
General Hospital of Saranac Lake	30
FULTON
Johnstown Hospital	37
Nathan Littauer Hospital	30
GREENE:
Memorial Hospital and Nursing Home of Greene County	37
MONTGOMERY:
Amsterdam Memorial Hospital	37
St. Mary's Hospital at Amsterdam	37
OTSEGO:
Aurelia Osborn Fox Memorial Hospital	48
Mary Imogene Bassett Hospital	48
RENSSELAER:
Leonard Hospital	37
Samaritan Hospital of Troy	37
St. Mary's Hospital of Troy	37
SARATOGA:
Adirondack Regional Hospital	30
Saratoga Hospital	37
SCHENECTADY:
Bellevue Maternity Hospital, Inc.	No E.R. service
Ellis Hospital	48
St. Clare's Hospital of Schenectady	30
Sunnyview Hospital and Rehabilitation Center	No E.R. service
SCHOHARIE:
Community Hospital of Schoharie County, Inc.	48
WARREN:
Glens Falls Hospital	30
WASHINGTON:
Emma Laing Stevens Hospital	48
Mary McClellan Hospital	37
Northern Metropolitan Region
DUTCHESS:
Highland Hospital of Beacon	28
Northern Dutchess Hospital	37
St. Francis Hospital of Poughkeepsie	37
Vassar Brothers Hospital	48
ORANGE:
Arden Hill Hospital	37
Cornwall Hospital	30
E.A. Horton Memorial Hospital	48
Mercy Community Hospital of Port Jervis	28
St. Anthony Community Hospital	30
St. Luke's Hospital of Newburgh	30
Tuxedo Memorial Hospital	48
PUTNAM:
Julia Butterfield Memorial Hospital	37
Putnam Community Hospital	37
ROCKLAND:
Good Samaritan Hospital of Suffern	48
Helen Hayes Hospital	No E.R. service
Nyack Hospital	48
Summit Park Hospital-Rockland County Infirmary	No E.R. service
SULLIVAN:
Community General Hospital of Sullivan County	48
Community General Hospital of Sullivan County-G. Herman Div.	37
ULSTER:
Benedictine Hospital	37
Ellenville Community Hospital	28
Kingston Hospital	30
WESTCHESTER:
Blythedale Children's Hospital	No E.R. service
Burke Rehabilitation Center	No E.R. service
Dobbs Ferry Hospital	28
Lawrence Hospital	48
Mount Vernon Hospital	37
New Rochelle Hospital Medical Center	48
New York Hospital-Cornell Medical Center Westchester Division	No E.R. service
Northern Westchester Hospital	48
Peekskill Hospital	30
Phelps Memorial Hospital Association	48
St. Agnes Hospital	48
St. John's Riverside Hospital	30
St. Joseph's Hospital, Yonkers	48
St. Vincent's Hospital and Medical Center of New York-Westchester Branch	No E.R. service
United Hospital	28
Westchester County Medical Center	48
White Plains Hospital Medical Center	48
Yonkers General Hospital	30
Long Island Region
NASSAU:
Central General Hospital	48
Community Hospital at Glen Cove	28
Franklin General Hospital	48
Hempstead General Hospital	48
Long Beach Memorial Hospital	28
Long Island Jewish-Hillside Medical Center (Manhasset Division)	48
Lydia E. Hall Hospital	48
Massapequa General Hospital	48
Mercy Hospital of Rockville Centre	37
Mid-Island Hospital	37
Nassau County Medical Center-East Meadow Division	48
Nassau Hospital (Winthrop-University Hospital)	37
North Shore University Hospital	48
South Nassau Communities Hospital	30
St. Francis Hospital of Roslyn	48
Syosset Community Hospital	48
Winthrop-University Hospital (Nassau Hospital)	37
SUFFOLK:
Brookhaven Memorial Hospital	48
Brunswick Hospital Center, Inc.	48
Central Suffolk Hospital Association	28
Eastern Long Island Hospital	28
Good Samaritan Hospital of West Islip	37
Huntington Hospital	30
John T. Mather Memorial Hospital of Port Jefferson, New York, Inc.	48
Smithtown General Hospital	48
Southampton Hospital	30
Southside Hospital	48
St. Charles' Hospital	37
St. John's Episcopal Hospital, Smithtown	37
University Hospital of Stony Brook	48
NEW YORK CITY:
Astoria General Hospital	30
Baptist Medical Center of New York	28
Bayley Seton Hospital	48
Beth Israel Medical Center	48
Booth Memorial Medical Center	48
Boulevard Hospital	28
Bronx-Lebanon Hospital Center	37
Brookdale Hospital Medical Center	48
Brooklyn/Caledonia Hospital	48
Cabrini Health Care Center	48
Calvary Hospital	No E.R. service
Catholic Medical Center	48
Community Hospital of Brooklyn, Inc.	37
Deepdale General Hospital	30
Doctors Hospital, Inc.	48
Doctors Hospital of Staten Island	37
Flatbush General Hospital	28
Flushing Hospital and Medical Center	30
Hip Hospital, Inc. (La Guardia)	48
Hospital for Joint Diseases and Medical Center Orthopedic Institute	No E.R. service
Hospital for Special Surgery	No E.R. service
Institute of Rehab Medicine NY University	No E.R. service
Interfaith Medical Center	48
Jamaica Hospital	48
Joint Diseases North General Hospital	48
Kings Highway Hospital	30
Kingsbrook Jewish Medical Center	48
Lenox Hill Hospital	48
Long Island College Hospital	48
Long Island Jewish-Hillside Medical Center	48
Lutheran Medical Center	48
Maimonides Medical Center	48
Manhattan Eye, Ear and Throat Hospital	30
Medical Arts Center Hospital	30
Memorial Hospital for Cancer and Allied Diseases	No E.R. service
Methodist Hospital of Brooklyn	48
Misericordia Hospital Medical Center (Our Lady of Mercy Medical Center)	37
Monteflore Hospital and Medical Center	48
Mount Sinai Hospital	48
New York Eye and Ear Infirmary	No E.R. service
New York Hospital and Payne Whitney Psychiatric Clinic	48
New York Infirmary-Beekman Downtown Hospital	48
New York University Medical Center	48
Osteopathic/Hillcrest Hospital (St. Joseph's Hospital Div. of CMC)	48
Our Lady of Mercy Medical Center	37
Parkway Hospital	48
Parsons Hospital	37
Pelham Bay General Hospital	48
Peninsula Hospital Center	48
Physicians Hospital	28
Presbyterian Hospital in the City of New York	48
Prospect Hospital	28
Richmond Memorial Hospital and Health Center	48
Rockefeller University Hospital	No E.R. service
St. Barnabas Hospital	48
St. Clare's Hospital and Health Center	48
St. John's Episcopal Hospital	37
St. Joseph's Hospital Division of CMC	48
St. Luke's-Roosevelt Hospital Center	48
St. Mary's Hospital of Brooklyn	48
St. Vincent's Hospital and Medical Center of New York	48
St. Vincent's Medical Center of Richmond	48
State University Hospital-Downstate Medical Center	No E.R. service
Staten Island Hospital	48
Union Hospital of The Bronx	28
Victory Memorial Hospital	37
Westchester Square Hospital	48
Wyckoff Heights Hospital	37
HEALTH AND HOSPITAL CORPORATION:
Bellevue Hospital Center	48
Bronx Municipal Hospital Center	37
City Hospital Center at Elmhurst	28
Coler Memorial Hospital and Home	No E.R. service
Coney Island Hospital	37
Cumberland Hospital	30
Goldwater Memorial Hospital	No E.R. service
Harlem Hospital Center	48
Kings County Hospital Center	30
Lincoln Medical and Mental Health Center	48
Metropolitan Hospital Center	48
North Central Bronx Hospital	48
Queens Hospital Center	37
Woodhull Medical and Mental Health Center	48

N.Y. Comp. Codes R. & Regs. tit. 11, Appendices, app 17-D