Skip to Content
Proposed Rule

Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016

Action

Proposed Rule.

Summary

This major proposed rule addresses changes to the physician fee schedule, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.

Unified Agenda

 

Table of Contents Back to Top

Tables Back to Top

DATES: Back to Top

Comment date: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on September 8, 2015.

ADDRESSES: Back to Top

In commenting, please refer to file code CMS-1631-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (please choose only one of the ways listed):

1. Electronically. You may submit electronic comments on this regulation to www.regulations.gov. Follow the instructions for “submitting a comment.”

2. By regular mail. You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1631-P, P.O. Box 8013, Baltimore, MD 21244-8013.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1631-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments before the close of the comment period to either of the following addresses:

a. For delivery in Washington, DC—Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201.

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

b. For delivery in Baltimore, MD—Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members.

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

FOR FURTHER INFORMATION CONTACT: Back to Top

Donta Henson, (410) 786-1947 for any physician payment issues not identified below.

Gail Addis, (410) 786-4522, for issues related to the refinement panel.

Chava Sheffield, (410) 786-2298, for issues related to practice expense methodology, impacts, conversion factors, target, and phase-in provisions.

Jessica Bruton, (410) 786-5991, for issues related to potentially misvalued code lists.

Geri Mondowney, (410) 786-4584, for issues related to geographic practice cost indices and malpractice RVUs.

Ken Marsalek, (410) 786-4502, for issues related to telehealth services.

Ann Marshall, (410) 786-3059, for issues related to advance care planning, and for primary care and care management services.

Michael Soracoe, (410) 786-6312, for issues related to the valuation and coding of the global surgical packages.

Roberta Epps, (410) 786-4503, for issues related to PAMA section 218(a) policy.

Regina Walker-Wren, (410) 786-9160, for issues related to the “incident to” proposals.

Lindsey Baldwin, (410) 786-1694, for issues related to valuation of moderate sedation and colonoscopy services and portable x-ray transportation fees.

Emily Yoder, (410) 786-1804, for issues related to valuation of radiation treatment services.

Amy Gruber, (410) 786-1542, for issues related to ambulance payment policy.

Corinne Axelrod, (410) 786-5620, for issues related to rural health clinics or federally qualified health centers and payment to grandfathered tribal FQHCs.

Simone Dennis, (410) 786-8409, for issues related to rural health clinics HCPCS reporting.

Edmund Kasaitis (410) 786-0477, for issues related to Part B drugs, biologicals, and biosimilars.

Alesia Hovatter, (410) 786-6861, for issues related to Physician Compare.

Christine Estella, (410) 786-0485, for issues related to the physician quality reporting system and the merit-based incentive payment system.

Alexandra Mugge (410) 786-4457, for issues related to EHR Incentive Program.

Sarah Arceo, (410) 786-2356) or Patrice Holtz, (410-786-5663) for issues related to EHR Incentive Program-CPC initiative and meaningful use aligned reporting.

Christiane LaBonte, (410) 786-7237, for issues related to comprehensive primary care initiative.

Rabia Khan, (410) 786-9328 or Terri Postma, (410) 786-4169, for issues related to Medicare Shared Savings Program.

Kimberly Spalding Bush, (410) 786-3232, or Sabrina Ahmed (410) 786-7499, for issues related to value-based Payment Modifier and Physician Feedback Program.

Frederick Grabau, (410) 786-0206, for issues related to changes to opt-out regulations.

Lisa Ohrin Wilson (410) 786-8852, for issues related to physician self-referral updates.

SUPPLEMENTARY INFORMATION: Back to Top

Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to view public comments.

Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

Table of Contents Back to Top

I. Executive Summary and Background

A. Executive Summary

B. Background

II. Provisions of the Proposed Rule for PFS

A. Determination of Practice Expense (PE) Relative Value Units (RVUs)

B. Determination of Malpractice Relative Value Units (RVUs)

C. Potentially Misvalued Services Under the Physician Fee Schedule

D. Refinement Panel

E. Improving Payment Accuracy for Primary Care and Care Management Services

F. Target for Relative Value Adjustments for Misvalued Services

G. Phase-In of Significant RVU Reductions

H. Changes for Computed Tomography (CT) Under the Protecting Access to Medicare Act of 2014 (PAMA)

I. Valuation of Specific Codes

J. Medicare Telehealth Services

K. Incident to Proposals: Billing Physician as the Supervising Physician and Ancillary Personnel Requirements

L. Portable X-Ray: Billing of the Transportation Fee

M. Technical Correction: Waiver of Deductible for Anesthesia Services Furnished on the Same Date as a Planned Screening Colorectal Cancer Test

III. Other Provisions of the Proposed Regulations

A. Proposed Provisions Associated With the Ambulance Fee Schedule

B. Chronic Care Management (CCM) Services for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

C. Healthcare Common Procedure Coding System (HCPCS) Coding for Rural Health Clinics (RHCs)

D. Payment to Grandfathered Tribal FQHCs That Were Provider-Based Clinics on or Before April 7, 2000

E. Part B Drugs—Biosimilars

F. Productivity Adjustment for the Ambulance, Clinical Laboratory, and DMEPOS Fee Schedules

G. Appropriate Use Criteria for Advanced Diagnostic Imaging Services

H. Physician Compare Web site

I. Physician Payment, Efficiency, and Quality Improvements—Physician Quality Reporting System

J. Electronic Clinical Quality Measures (eCQM) and Certification Criteria and Electronic Health Record (EHR) Incentive Program—Comprehensive Primary Care (CPC) Initiative and Medicare Meaningful Use Aligned Reporting

K. Potential Expansion of the Comprehensive Primary Care (CPC) Initiative

L. Medicare Shared Savings Program

M. Value-Based Payment Modifier and Physician Feedback Program

N. Physician Self-Referral Updates

O. Private Contracting/Opt-Out

IV. Collection of Information Requirements

V. Response to Comments

VI. Regulatory Impact Analysis

Regulations Text

Acronyms Back to Top

In addition, because of the many organizations and terms to which we refer by acronym in this proposed rule, we are listing these acronyms and their corresponding terms in alphabetical order below:

AAAAbdominal aortic aneurysms

ACOAccountable care organization

AMAAmerican Medical Association

ASCAmbulatory surgical center

ATAAmerican Telehealth Association

ATRAAmerican Taxpayer Relief Act (Pub. L. 112-240)

BBABalanced Budget Act of 1997 (Pub. L. 105-33)

BBRA[Medicare, Medicaid and State Child Health Insurance Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106-113)

CADCoronary artery disease

CAHCritical access hospital

CBSACore-Based Statistical Area

CCMChronic care management

CEHRTCertified EHR technology

CFConversion factor

CG-CAHPSClinician and Group Consumer Assessment of Healthcare Providers and Systems

CLFSClinical Laboratory Fee Schedule

CNMCertified nurse-midwife

CPClinical psychologist

CPCComprehensive Primary Care

CPEPClinical Practice Expert Panel

CPT[Physicians] Current Procedural Terminology (CPT codes, descriptions and other data only are copyright 2014 American Medical Association. All rights reserved.)

CQMClinical quality measure

CSWClinical social worker

CTComputed tomography

CYCalendar year

DFARDefense Federal Acquisition Regulations

DHSDesignated health services

DMDiabetes mellitus

DSMTDiabetes self-management training

eCQMElectronic clinical quality measures

EHRElectronic health record

E/MEvaluation and management

EPEligible professional

eRxElectronic prescribing

ESRDEnd-stage renal disease

FARFederal Acquisition Regulations

FFSFee-for-service

FQHCFederally qualified health center

FRFederal Register

GAFGeographic adjustment factor

GAOGovernment Accountability Office

GPCIGeographic practice cost index

GPOGroup purchasing organization

GPROGroup practice reporting option

GTRGenetic Testing Registry

HCPCSHealthcare Common Procedure Coding System

HHS[Department of] Health and Human Services

HOPDHospital outpatient department

HPSAHealth professional shortage area

IDTFIndependent diagnostic testing facility

IPPSInpatient Prospective Payment System

IQRInpatient Quality Reporting

ISOInsurance service office

IWPUTIntensity of work per unit of time

LCDLocal coverage determination

MAMedicare Advantage

MACMedicare Administrative Contractor

MAPMeasure Applications Partnership

MAPCPMulti-payer Advanced Primary Care Practice

MAVMeasure application validity [process]

MCPMonthly capitation payment

MedPACMedicare Payment Advisory Commission

MEIMedicare Economic Index

MFPMulti-Factor Productivity

MIPPAMedicare Improvements for Patients and Providers Act (Pub. L. 110-275)

MMAMedicare Prescription Drug, Improvement and Modernization Act of 2003 (Pub. L. 108-173, enacted on December 8, 2003)

MPMalpractice

MPPRMultiple procedure payment reduction

MRAMagnetic resonance angiography

MRIMagnetic resonance imaging

MSAMetropolitan Statistical Areas

MSPBMedicare Spending per Beneficiary

MSSPMedicare Shared Savings Program

MUMeaningful use

NCDNational coverage determination

NCQDISNational Coalition of Quality Diagnostic Imaging Services

NPNurse practitioner

NPINational Provider Identifier

NPPNonphysician practitioner

NQSNational Quality Strategy

OACTCMS's Office of the Actuary

OBRA '89Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239)

OBRA '90Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508)

OESOccupational Employment Statistics

OMBOffice of Management and Budget

OPPSOutpatient prospective payment system

OTOccupational therapy

PAPhysician assistant

PAMAProtecting Access to Medicare Act of 2014 (Pub. L. 113-93)

PCProfessional component

PCIPPrimary Care Incentive Payment

PEPractice expense

PE/HRPractice expense per hour

PEACPractice Expense Advisory Committee

PECOSProvider Enrollment, Chain, and Ownership System

PFSPhysician Fee Schedule

PLIProfessional Liability Insurance

PMAPremarket approval

PQRSPhysician Quality Reporting System

PPISPhysician Practice Expense Information Survey

PTPhysical therapy

PYPerformance year

QCDRQualified clinical data registry

QRURQuality and Resources Use Report

RBRVSResource-based relative value scale

RFARegulatory Flexibility Act

RHCRural health clinic

RIARegulatory impact analysis

RUCAmerican Medical Association/Specialty Society Relative (Value) Update Committee

RUCARural Urban Commuting Area

RVURelative value unit

SBASmall Business Administration

SGRSustainable growth rate

SIMState Innovation Model

SLPSpeech-language pathology

SMSSocioeconomic Monitoring System

SNFSkilled nursing facility

TAPTechnical Advisory Panel

TCTechnical component

TINTax identification number

UAFUpdate adjustment factor

UPINUnique Physician Identification Number

USPSTFUnited States Preventive Services Task Force

VBPValue-based purchasing

VMValue-Based Payment Modifier

Addenda Available Only Through the Internet on the CMS Web Site Back to Top

The PFS Addenda along with other supporting documents and tables referenced in this proposed rule are available through the Internet on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. Click on the link on the left side of the screen titled, “PFS Federal Regulations Notices” for a chronological list of PFS Federal Register and other related documents. For the CY 2016 PFS proposed rule, refer to item CMS-1631-P. Readers who experience any problems accessing any of the Addenda or other documents referenced in this rule and posted on the CMS Web site identified above should contact Donta Henson at (410) 786-1947.

CPT (Current Procedural Terminology) Copyright Notice Back to Top

Throughout this proposed rule, we use CPT codes and descriptions to refer to a variety of services. We note that CPT codes and descriptions are copyright 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association (AMA). Applicable Federal Acquisition Regulations (FAR) and Defense Federal Acquisition Regulations (DFAR) apply.

I. Executive Summary and Background Back to Top

A. Executive Summary

1. Purpose

This major proposed rule proposes to revise payment polices under the Medicare Physician Fee Schedule (PFS) and make other policy changes related to Medicare Part B payment. These proposed changes would be applicable to services furnished in CY 2016.

2. Summary of the Major Provisions

The Social Security Act (the Act) requires us to establish payments under the PFS based on national uniform relative value units (RVUs) that account for the relative resources used in furnishing a service. The Act requires that RVUs be established for three categories of resources: Work, practice expense (PE); and malpractice (MP) expense; and, that we establish by regulation each year's payment amounts for all physicians' services paid under the PFS, incorporating geographic adjustments to reflect the variations in the costs of furnishing services in different geographic areas. In this major proposed rule, we establish RVUs for CY 2016 for the PFS, and other Medicare Part B payment policies, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this proposed rule includes discussions and proposals regarding:

  • Potentially Misvalued PFS Codes.
  • Telehealth Services.
  • Advance Care Planning Services.
  • Establishing Values for New, Revised, and Misvalued Codes.
  • Target for Relative Value Adjustments for Misvalued Services.
  • Phase-in of Significant RVU Reductions.
  • “Incident to” policy.
  • Portable X-Ray Transportation Fee.
  • Updating the Ambulance Fee Schedule regulations.
  • Changes in Geographic Area Delineations for Ambulance Payment.
  • Chronic Care Management Services for RHCs and FQHCs.
  • HCPCS Coding for RHCs.
  • Payment to Grandfathered Tribal FQHCs that were Provider-Based Clinics on or before April 7, 2000.
  • Payment for Biosimilars under Medicare Part B.
  • Physician Compare Web site.
  • Physician Quality Reporting System.
  • Medicare Shared Savings Program.
  • Electronic Health Record (EHR) Incentive Program.
  • Value-Based Payment Modifier and the Physician Feedback Program.

3. Summary of Costs and Benefits

The Act requires that annual adjustments to PFS RVUs may not cause annual estimated expenditures to differ by more than $20 million from what they would have been had the adjustments not been made. If adjustments to RVUs would cause expenditures to change by more than $20 million, we must make adjustments to preserve budget neutrality. These adjustments can affect the distribution of Medicare expenditures across specialties. In addition, several proposed changes would affect the specialty distribution of Medicare expenditures. When considering the combined impact of work, PE, and MP RVU changes, the projected payment impacts are small for most specialties; however, the impact would be larger for a few specialties.

We have determined that this major proposed rule is economically significant. For a detailed discussion of the economic impacts, see section VII. of this proposed rule.

B. Background

Since January 1, 1992, Medicare has paid for physicians' services under section 1848 of the Act, “Payment for Physicians' Services.” The system relies on national relative values that are established for work, PE, and MP, which are adjusted for geographic cost variations. These values are multiplied by a conversion factor (CF) to convert the RVUs into payment rates. The concepts and methodology underlying the PFS were enacted as part of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239, enacted on December 19, 1989) (OBRA '89), and the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508, enacted on November 5, 1990) (OBRA '90). The final rule published on November 25, 1991 (56 FR 59502) set forth the first fee schedule used for payment for physicians' services.

We note that throughout this major proposed rule, unless otherwise noted, the term “practitioner” is used to describe both physicians and nonphysician practitioners (NPPs) who are permitted to bill Medicare under the PFS for services furnished to Medicare beneficiaries.

1. Development of the Relative Values

a. Work RVUs

The work RVUs established for the initial fee schedule, which was implemented on January 1, 1992, were developed with extensive input from the physician community. A research team at the Harvard School of Public Health developed the original work RVUs for most codes under a cooperative agreement with the Department of Health and Human Services (HHS). In constructing the code-specific vignettes used in determining the original physician work RVUs, Harvard worked with panels of experts, both inside and outside the federal government, and obtained input from numerous physician specialty groups.

As specified in section 1848(c)(1)(A) of the Act, the work component of physicians' services means the portion of the resources used in furnishing the service that reflects physician time and intensity. We establish work RVUs for new, revised and potentially misvalued codes based on our review of information that generally includes, but is not limited to, recommendations received from the American Medical Association/Specialty Society Relative Value Update Committee (RUC), the Health Care Professionals Advisory Committee (HCPAC), the Medicare Payment Advisory Commission (MedPAC), and other public commenters; medical literature and comparative databases; as well as a comparison of the work for other codes within the Medicare PFS, and consultation with other physicians and health care professionals within CMS and the federal government. We also assess the methodology and data used to develop the recommendations submitted to us by the RUC and other public commenters, and the rationale for their recommendations.

b. Practice Expense RVUs

Initially, only the work RVUs were resource-based, and the PE and MP RVUs were based on average allowable charges. Section 121 of the Social Security Act Amendments of 1994 (Pub. L. 103-432, enacted on October 31, 1994), amended section 1848(c)(2)(C)(ii) of the Act and required us to develop resource-based PE RVUs for each physicians' service beginning in 1998. We were required to consider general categories of expenses (such as office rent and wages of personnel, but excluding malpractice expenses) comprising PEs. The PE RVUs continue to represent the portion of these resources involved in furnishing PFS services.

Originally, the resource-based method was to be used beginning in 1998, but section 4505(a) of the Balanced Budget Act of 1997 (Pub. L. 105-33, enacted on August 5, 1997) (BBA) delayed implementation of the resource-based PE RVU system until January 1, 1999. In addition, section 4505(b) of the BBA provided for a 4-year transition period from the charge-based PE RVUs to the resource-based PE RVUs.

We established the resource-based PE RVUs for each physicians' service in a final rule, published on November 2, 1998 (63 FR 58814), effective for services furnished in CY 1999. Based on the requirement to transition to a resource-based system for PE over a 4-year period, payment rates were not fully based upon resource-based PE RVUs until CY 2002. This resource-based system was based on two significant sources of actual PE data: the Clinical Practice Expert Panel (CPEP) data and the AMA's Socioeconomic Monitoring System (SMS) data. (These data sources are described in greater detail in the CY 2012 final rule with comment period (76 FR 73033).)

Separate PE RVUs are established for services furnished in facility settings, such as a hospital outpatient department (HOPD) or an ambulatory surgical center (ASC), and in nonfacility settings, such as a physician's office. The nonfacility RVUs reflect all of the direct and indirect PEs involved in furnishing a service described by a particular HCPCS code. The difference, if any, in these PE RVUs generally results in a higher payment in the nonfacility setting because in the facility settings some costs are borne by the facility. Medicare's payment to the facility (such as the outpatient prospective payment system (OPPS) payment to the HOPD) would reflect costs typically incurred by the facility. Thus, payment associated with those facility resources is not made under the PFS.

Section 212 of the Balanced Budget Refinement Act of 1999 (Pub. L. 106-113, enacted on November 29, 1999) (BBRA) directed the Secretary of Health and Human Services (the Secretary) to establish a process under which we accept and use, to the maximum extent practicable and consistent with sound data practices, data collected or developed by entities and organizations to supplement the data we normally collect in determining the PE component. On May 3, 2000, we published the interim final rule (65 FR 25664) that set forth the criteria for the submission of these supplemental PE survey data. The criteria were modified in response to comments received, and published in the Federal Register (65 FR 65376) as part of a November 1, 2000 final rule. The PFS final rules published in 2001 and 2003, respectively, (66 FR 55246 and 68 FR 63196) extended the period during which we would accept these supplemental data through March 1, 2005.

In the CY 2007 PFS final rule with comment period (71 FR 69624), we revised the methodology for calculating direct PE RVUs from the top-down to the bottom-up methodology beginning in CY 2007. We adopted a 4-year transition to the new PE RVUs. This transition was completed for CY 2010. In the CY 2010 PFS final rule with comment period, we updated the practice expense per hour (PE/HR) data that are used in the calculation of PE RVUs for most specialties (74 FR 61749). In CY 2010, we began a 4-year transition to the new PE RVUs using the updated PE/HR data, which was completed for CY 2013.

c. Malpractice RVUs

Section 4505(f) of the BBA amended section 1848(c) of the Act to require that we implement resource-based MP RVUs for services furnished on or after CY 2000. The resource-based MP RVUs were implemented in the PFS final rule with comment period published November 2, 1999 (64 FR 59380). The MP RVUs are based on commercial and physician-owned insurers' malpractice insurance premium data from all the states, the District of Columbia, and Puerto Rico. For more information on MP RVUs, see section II.C. of this proposed rule.

d. Refinements to the RVUs

Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no less often than every 5 years. Prior to CY 2013, we conducted periodic reviews of work RVUs and PE RVUs independently. We completed five-year reviews of work RVUs that were effective for calendar years 1997, 2002, 2007, and 2012.

Although refinements to the direct PE inputs initially relied heavily on input from the RUC Practice Expense Advisory Committee (PEAC), the shifts to the bottom-up PE methodology in CY 2007 and to the use of the updated PE/HR data in CY 2010 have resulted in significant refinements to the PE RVUs in recent years.

In the CY 2012 PFS final rule with comment period (76 FR 73057), we finalized a proposal to consolidate reviews of work and PE RVUs under section 1848(c)(2)(B) of the Act and reviews of potentially misvalued codes under section 1848(c)(2)(K) of the Act into one annual process.

In addition to the five-year reviews, beginning for CY 2009, CMS, and the RUC have identified and reviewed a number of potentially misvalued codes on an annual basis based on various identification screens. This annual review of work and PE RVUs for potentially misvalued codes was supplemented by the amendments to section 1848 of the Act, as enacted by section 3134 of the Affordable Care Act, which requires the agency to periodically identify, review and adjust values for potentially misvalued codes.

e. Application of Budget Neutrality to Adjustments of RVUs

As described in section VI.C. of this proposed rule, in accordance with section 1848(c)(2)(B)(ii)(II) of the Act, if revisions to the RVUs caused expenditures for the year to change by more than $20 million, we make adjustments to ensure that expenditures did not increase or decrease by more than $20 million.

2. Calculation of Payments Based on RVUs

To calculate the payment for each service, the components of the fee schedule (work, PE, and MP RVUs) are adjusted by geographic practice cost indices (GPCIs) to reflect the variations in the costs of furnishing the services. The GPCIs reflect the relative costs of work, PE, and MP in an area compared to the national average costs for each component. (See section II.D. of this proposed rule for more information about GPCIs.)

RVUs are converted to dollar amounts through the application of a CF, which is calculated based on a statutory formula by CMS's Office of the Actuary (OACT). The formula for calculating the Medicare fee schedule payment amount for a given service and fee schedule area can be expressed as:

Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI MP)] x CF.

3. Separate Fee Schedule Methodology for Anesthesia Services

Section 1848(b)(2)(B) of the Act specifies that the fee schedule amounts for anesthesia services are to be based on a uniform relative value guide, with appropriate adjustment of an anesthesia conversion factor, in a manner to assure that fee schedule amounts for anesthesia services are consistent with those for other services of comparable value. Therefore, there is a separate fee schedule methodology for anesthesia services. Specifically, we establish a separate conversion factor for anesthesia services and we utilize the uniform relative value guide, or base units, as well as time units, to calculate the fee schedule amounts for anesthesia services. Since anesthesia services are not valued using RVUs, a separate methodology for locality adjustments is also necessary. This involves an adjustment to the national anesthesia CF for each payment locality.

4. Most Recent Changes to the Fee Schedule

Section 220(d) of the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. 113-93, enacted on April 1, 2014) added a new subparagraph (O) to section 1848(c)(2) of the Act to establish an annual target for reductions in PFS expenditures resulting from adjustments to relative values of misvalued codes. If the estimated net reduction in expenditures for a year is equal to or greater than the target for that year, the provision specifies that reduced expenditures attributable to such adjustments shall be redistributed in a budget-neutral manner within the PFS. The provision also specifies that the amount by which such reduced expenditures exceed the target for a given year shall be treated as a reduction in expenditures for the subsequent year for purposes of determining whether the target for the subsequent year has been met. The provision also specifies that an amount equal to the difference between the target and the estimated net reduction, called the target recapture amount shall not be taken into account when applying the budget neutrality requirements specified in section 1848(c)(2)(B)(ii)(II) of the Act. The PAMA originally applied the target to CYs 2017 through 2020 and set the target amount to 0.5 percent of the estimated amount of expenditures under the PFS for each of those 4 years.

More recently, section 202 of the Achieving a Better Life Experience Act of 2014 (ABLE) (Division B of Pub. L. 113-295, enacted December 19, 2014) accelerated the application of the target, amending section 1848(c)(2)(O) of the Act to specify that targets would apply for CYs 2016, 2017, and 2018 and set a 1 percent target for CY 2016 and 0.5 percent for CYs 2017 and 2018. The implementation of the target legislation is discussed in section II.F. of this proposed rule.

Section 1848(c)(7) of the Act, as added by section 220(e) of the PAMA, specifies that for services that are not new or revised codes, if the total RVUs for a service for a year would otherwise be decreased by an estimated 20 percent or more as compared to the total RVUs for the previous year, the applicable adjustments in work, PE, and MP RVUs shall be phased-in over a 2-year period. Although section 220(e) of the PAMA required the phase-in of RVU reductions of 20 percent or more to begin for 2017, section 202 of the ABLE Act now requires the phase-in to begin in CY 2016. The implementation of the phase-in legislation is discussed in section II.G. of this proposed rule.

Section 218(a) of the PAMA adds a new section 1834(p) to the statute. Section 1834(p) requires reductions in payment for the technical component (TC) (and the TC of the global fee) of the PFS service and in the hospital OPPS payment (5 percent in 2016, and 15 percent in 2017 and subsequent years) for computed tomography (CT) services (identified as of January 1, 2014 by HCPCS codes 70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178, 74261-74263, and 75571-75574, and succeeding codes) furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013, entitled “Standard Attributes on CT Equipment Related to Dose Optimization and Management.” The implementation of section 218(a) of the PAMA is discussed in section II.H. of this proposed rule.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted on April 16, 2015) makes several changes to the statute, including but not limited to:

(1) Repealing the sustainable growth rate (SGR) update methodology for physicians' services.

(2) Revising the PFS update for 2015 and subsequent years.

(3) Establishing a Merit-based Incentive Payment System (MIPS) under which eligible professionals (initially including physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists) receive annual payment increases or decreases based on their performance in a prior period. These and other MACRA provisions are discussions in various sections of this proposed rule. Please refer to the table of contents for the location of the various MACRA provision discussions.

II. Provisions of the Proposed Rule for PFS Back to Top

A. Determination of Practice Expense (PE) Relative Value Units (RVUs)

1. Overview

Practice expense (PE) is the portion of the resources used in furnishing a service that reflects the general categories of physician and practitioner expenses, such as office rent and personnel wages, but excluding malpractice expenses, as specified in section 1848(c)(1)(B) of the Act. As required by section 1848(c)(2)(C)(ii) of the Act, we use a resource-based system for determining PE RVUs for each physicians' service. We develop PE RVUs by considering the direct and indirect practice resources involved in furnishing each service. Direct expense categories include clinical labor, medical supplies, and medical equipment. Indirect expenses include administrative labor, office expense, and all other expenses. The sections that follow provide more detailed information about the methodology for translating the resources involved in furnishing each service into service-specific PE RVUs. We refer readers to the CY 2010 PFS final rule with comment period (74 FR 61743 through 61748) for a more detailed explanation of the PE methodology.

2. Practice Expense Methodology

a. Direct Practice Expense

We determine the direct PE for a specific service by adding the costs of the direct resources (that is, the clinical staff, medical supplies, and medical equipment) typically involved with furnishing that service. The costs of the resources are calculated using the refined direct PE inputs assigned to each CPT code in our PE database, which are generally based on our review of recommendations received from the RUC and those provided in response to public comment periods. For a detailed explanation of the direct PE methodology, including examples, we refer readers to the Five-Year Review of Work Relative Value Units under the PFS and Proposed Changes to the Practice Expense Methodology proposed notice (71 FR 37242) and the CY 2007 PFS final rule with comment period (71 FR 69629).

b. Indirect Practice Expense per Hour Data

We use survey data on indirect PEs incurred per hour worked in developing the indirect portion of the PE RVUs. Prior to CY 2010, we primarily used the practice expense per hour (PE/HR) by specialty that was obtained from the AMA's Socioeconomic Monitoring Surveys (SMS). The AMA administered a new survey in CY 2007 and CY 2008, the Physician Practice Expense Information Survey (PPIS). The PPIS is a multispecialty, nationally representative, PE survey of both physicians and nonphysician practitioners (NPPs) paid under the PFS using a survey instrument and methods highly consistent with those used for the SMS and the supplemental surveys. The PPIS gathered information from 3,656 respondents across 51 physician specialty and health care professional groups. We believe the PPIS is the most comprehensive source of PE survey information available. We used the PPIS data to update the PE/HR data for the CY 2010 PFS for almost all of the Medicare-recognized specialties that participated in the survey.

When we began using the PPIS data in CY 2010, we did not change the PE RVU methodology itself or the manner in which the PE/HR data are used in that methodology. We only updated the PE/HR data based on the new survey. Furthermore, as we explained in the CY 2010 PFS final rule with comment period (74 FR 61751), because of the magnitude of payment reductions for some specialties resulting from the use of the PPIS data, we transitioned its use over a 4-year period from the previous PE RVUs to the PE RVUs developed using the new PPIS data. As provided in the CY 2010 PFS final rule with comment period (74 FR 61751), the transition to the PPIS data was complete for CY 2013. Therefore, PE RVUs from CY 2013 forward are developed based entirely on the PPIS data, except as noted in this section.

Section 1848(c)(2)(H)(i) of the Act requires us to use the medical oncology supplemental survey data submitted in 2003 for oncology drug administration services. Therefore, the PE/HR for medical oncology, hematology, and hematology/oncology reflects the continued use of these supplemental survey data.

Supplemental survey data on independent labs from the College of American Pathologists were implemented for payments beginning in CY 2005. Supplemental survey data from the National Coalition of Quality Diagnostic Imaging Services (NCQDIS), representing independent diagnostic testing facilities (IDTFs), were blended with supplementary survey data from the American College of Radiology (ACR) and implemented for payments beginning in CY 2007. Neither IDTFs, nor independent labs, participated in the PPIS. Therefore, we continue to use the PE/HR that was developed from their supplemental survey data.

Consistent with our past practice, the previous indirect PE/HR values from the supplemental surveys for these specialties were updated to CY 2006 using the MEI to put them on a comparable basis with the PPIS data.

We also do not use the PPIS data for reproductive endocrinology and spine surgery since these specialties currently are not separately recognized by Medicare, nor do we have a method to blend the PPIS data with Medicare-recognized specialty data.

Previously, we established PE/HR values for various specialties without SMS or supplemental survey data by crosswalking them to other similar specialties to estimate a proxy PE/HR. For specialties that were part of the PPIS for which we previously used a crosswalked PE/HR, we instead used the PPIS-based PE/HR. We continue previous crosswalks for specialties that did not participate in the PPIS. However, beginning in CY 2010 we changed the PE/HR crosswalk for portable x-ray suppliers from radiology to IDTF, a more appropriate crosswalk because these specialties are more similar to each other for work time.

For registered dietician services, the resource-based PE RVUs have been calculated in accordance with the final policy that crosswalks the specialty to the “All Physicians” PE/HR data, as adopted in the CY 2010 PFS final rule with comment period (74 FR 61752) and discussed in more detail in the CY 2011 PFS final rule with comment period (75 FR 73183).

For CY 2016, we have incorporated the available utilization data for interventional cardiology, which became a recognized Medicare specialty during 2014. We are proposing to use a proxy PE/HR value for interventional cardiology, as there are no PPIS data for this specialty, by crosswalking the PE/HR for from Cardiology, since the specialties furnish similar services in the Medicare claims data. The proposed change is reflected in the “PE/HR” file available on the CMS Web site under the supporting data files for the CY 2016 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.

c. Allocation of PE to Services

To establish PE RVUs for specific services, it is necessary to establish the direct and indirect PE associated with each service.

(1) Direct Costs

The relative relationship between the direct cost portions of the PE RVUs for any two services is determined by the relative relationship between the sum of the direct cost resources (that is, the clinical staff, medical supplies, and medical equipment) typically involved with furnishing each of the services. The costs of these resources are calculated from the refined direct PE inputs in our PE database. For example, if one service has a direct cost sum of $400 from our PE database and another service has a direct cost sum of $200, the direct portion of the PE RVUs of the first service would be twice as much as the direct portion of the PE RVUs for the second service.

(2) Indirect Costs

Section II.A.2.b. of this proposed rule describes the current data sources for specialty-specific indirect costs used in our PE calculations. We allocated the indirect costs to the code level on the basis of the direct costs specifically associated with a code and the greater of either the clinical labor costs or the work RVUs. We also incorporated the survey data described earlier in the PE/HR discussion. The general approach to developing the indirect portion of the PE RVUs is as follows:

  • For a given service, we use the direct portion of the PE RVUs calculated as previously described and the average percentage that direct costs represent of total costs (based on survey data) across the specialties that furnish the service to determine an initial indirect allocator. In other words, the initial indirect allocator is calculated so that the direct costs equal the average percentage of direct costs of those specialties furnishing the service. For example, if the direct portion of the PE RVUs for a given service is 2.00 and direct costs, on average, represented 25 percent of total costs for the specialties that furnished the service, the initial indirect allocator would be calculated so that it equals 75 percent of the total PE RVUs. Thus, in this example, the initial indirect allocator would equal 6.00, resulting in a total PE RVUs of 8.00 (2.00 is 25 percent of 8.00 and 6.00 is 75 percent of 8.00).
  • Next, we add the greater of the work RVUs or clinical labor portion of the direct portion of the PE RVUs to this initial indirect allocator. In our example, if this service had work RVUs of 4.00 and the clinical labor portion of the direct PE RVUs was 1.50, we would add 4.00 (since the 4.00 work RVUs are greater than the 1.50 clinical labor portion) to the initial indirect allocator of 6.00 to get an indirect allocator of 10.00. In the absence of any further use of the survey data, the relative relationship between the indirect cost portions of the PE RVUs for any two services would be determined by the relative relationship between these indirect cost allocators. For example, if one service had an indirect cost allocator of 10.00 and another service had an indirect cost allocator of 5.00, the indirect portion of the PE RVUs of the first service would be twice as great as the indirect portion of the PE RVUs for the second service.
  • Next, we incorporate the specialty-specific indirect PE/HR data into the calculation. In our example, if, based on the survey data, the average indirect cost of the specialties furnishing the first service with an allocator of 10.00 was half of the average indirect cost of the specialties furnishing the second service with an indirect allocator of 5.00, the indirect portion of the PE RVUs of the first service would be equal to that of the second service.

(4) Facility and Nonfacility Costs

For procedures that can be furnished in a physician's office, as well as in a hospital or other facility setting, we establish two PE RVUs: facility and nonfacility. The methodology for calculating PE RVUs is the same for both the facility and nonfacility RVUs, but is applied independently to yield two separate PE RVUs. Because in calculating the PE RVUs for services furnished in a facility, we do not include resources that would generally not be provided by physicians when furnishing the service in a facility, the facility PE RVUs are generally lower than the nonfacility PE RVUs. Medicare makes a separate payment to the facility for its costs of furnishing a service.

(5) Services With Technical Components (TCs) and Professional Components (PCs)

Diagnostic services are generally comprised of two components: A professional component (PC); and a technical component (TC). The PC and TC may be furnished independently or by different providers, or they may be furnished together as a “global” service. When services have separately billable PC and TC components, the payment for the global service equals the sum of the payment for the TC and PC. To achieve this we use a weighted average of the ratio of indirect to direct costs across all the specialties that furnish the global service, TCs, and PCs; that is, we apply the same weighted average indirect percentage factor to allocate indirect expenses to the global service, PCs, and TCs for a service. (The direct PE RVUs for the TC and PC sum to the global.)

(6) PE RVU Methodology

For a more detailed description of the PE RVU methodology, we refer readers to the CY 2010 PFS final rule with comment period (74 FR 61745 through 61746).

(a) Setup File

First, we create a setup file for the PE methodology. The setup file contains the direct cost inputs, the utilization for each procedure code at the specialty and facility/nonfacility place of service level, and the specialty-specific PE/HR data calculated from the surveys.

(b) Calculate the Direct Cost PE RVUs

Sum the costs of each direct input.

Step 1: Sum the direct costs of the inputs for each service. Apply a scaling adjustment to the direct inputs.

Step 2: Calculate the aggregate pool of direct PE costs for the current year. Under our current methodology, we first multiply the current year's conversion factor by the product of the current year's PE RVUs and utilization for each service to arrive at the aggregate pool of total PE costs (Step 2a). We then calculate the average direct percentage of the current pool of PE RVUs (using a weighted average of the survey data for the specialties that furnish each service (Step 2b).) We then multiply the result of 2a by the result of 2b to arrive at the aggregate pool of direct PE costs for the current year. For CY 2016, we are proposing a technical improvement to step 2a of this calculation. In place of the step 2a calculation described above, we propose to set the aggregate pool of PE costs equal to the product of the ratio of the current aggregate PE RVUs to current aggregate work RVUs and the proposed aggregate work RVUs. Historically, in allowing the current PE RVUs to determine the size of the base PE pool in the PE methodology, we have assumed that the relationship of PE RVUs to work RVUs is constant from year to year. Since this is not ordinarily the case, by not considering the proposed aggregate work RVUs in determining the size of the base PE pool, we have introduced some minor instability from year to year in the relative shares of work, PE, and MP RVUs. While this proposed modification would result in greater stability in the relationship among the work and PE RVU components in the aggregate, we do not anticipate it will affect the distribution of PE RVUs across specialties. The PE RVUs in addendum B of this proposed rule with comment period reflect this proposed refinement to the PE methodology.

Step 3: Calculate the aggregate pool of direct PE costs for use in ratesetting. This is the product of the aggregate direct costs for all services from Step 1 and the utilization data for that service.

Step 4: Using the results of Step 2 and Step 3, calculate a direct PE scaling adjustment to ensure that the aggregate pool of direct PE costs calculated in Step 3 does not vary from the aggregate pool of direct PE costs for the current year. Apply the scaling factor to the direct costs for each service (as calculated in Step 1).

Step 5: Convert the results of Step 4 to an RVU scale for each service. To do this, divide the results of Step 4 by the CF. Note that the actual value of the CF used in this calculation does not influence the final direct cost PE RVUs, as long as the same CF is used in Step 2 and Step 5. Different CFs will result in different direct PE scaling factors, but this has no effect on the final direct cost PE RVUs since changes in the CFs and changes in the associated direct scaling factors offset one another.

(c) Create the Indirect Cost PE RVUs

Create indirect allocators.

Step 6: Based on the survey data, calculate direct and indirect PE percentages for each physician specialty.

Step 7: Calculate direct and indirect PE percentages at the service level by taking a weighted average of the results of Step 6 for the specialties that furnish the service. Note that for services with TCs and PCs, the direct and indirect percentages for a given service do not vary by the PC, TC, and global service.

Historically, we have used the specialties that furnish the service in the most recent full year of Medicare claims data (crosswalked to the current year set of codes) to determine which specialties furnish individual procedures. For example, for CY 2015 ratesetting, we used the mix of specialties that furnished the services in the CY 2013 claims data to determine the specialty mix assigned to each code. While we believe that there are clear advantages to using the most recent available data in making these determinations, we have also found that using a single year of data contributes to greater year-to-year instability in PE RVUs for individual codes and often creates extreme, annual fluctuations for low-volume services, as well as delayed fluctuations for some services described by new codes once claims data for those codes becomes available.

We believe that using an average of the three most recent years of available data may increase stability of PE RVUs and mitigate code-level fluctuations for both the full range of PFS codes, and for new and low-volume codes in particular. Therefore, we are proposing to refine this step of the PE methodology to use an average of the 3 most recent years of available Medicare claims data to determine the specialty mix assigned to each code. The PE RVUs in Addendum B of the CMS Web site reflect this proposed refinement to the PE methodology.

Step 8: Calculate the service level allocators for the indirect PEs based on the percentages calculated in Step 7. The indirect PEs are allocated based on the three components: The direct PE RVUs; the clinical PE RVUs; and the work RVUs. For most services the indirect allocator is: Indirect PE percentage * (direct PE RVUs/direct percentage) + work RVUs.

There are two situations where this formula is modified:

  • If the service is a global service (that is, a service with global, professional, and technical components), then the indirect PE allocator is: Indirect percentage (direct PE RVUs/direct percentage) + clinical labor PE RVUs + work RVUs.
  • If the clinical labor PE RVUs exceed the work RVUs (and the service is not a global service), then the indirect allocator is: Indirect PE percentage (direct PE RVUs/direct percentage) + clinical labor PE RVUs.

(Note: For global services, the indirect PE allocator is based on both the work RVUs and the clinical labor PE RVUs. We do this to recognize that, for the PC service, indirect PEs will be allocated using the work RVUs, and for the TC service, indirect PEs will be allocated using the direct PE RVUs and the clinical labor PE RVUs. This also allows the global component RVUs to equal the sum of the PC and TC RVUs.)

For presentation purposes in the examples in Table 1, the formulas were divided into two parts for each service.

  • The first part does not vary by service and is the indirect percentage (direct PE RVUs/direct percentage).
  • The second part is either the work RVU, clinical labor PE RVU, or both depending on whether the service is a global service and whether the clinical PE RVUs exceed the work RVUs (as described earlier in this step).

Apply a scaling adjustment to the indirect allocators.

Step 9: Calculate the current aggregate pool of indirect PE RVUs by multiplying the result of step 2a (as calculated with the proposed change) by the average indirect PE percentage from the survey data.

Step 10: Calculate an aggregate pool of indirect PE RVUs for all PFS services by adding the product of the indirect PE allocators for a service from Step 8 and the utilization data for that service.

Step 11: Using the results of Step 9 and Step 10, calculate an indirect PE adjustment so that the aggregate indirect allocation does not exceed the available aggregate indirect PE RVUs and apply it to indirect allocators calculated in Step 8.

Calculate the indirect practice cost index.

Step 12: Using the results of Step 11, calculate aggregate pools of specialty-specific adjusted indirect PE allocators for all PFS services for a specialty by adding the product of the adjusted indirect PE allocator for each service and the utilization data for that service.

Step 13: Using the specialty-specific indirect PE/HR data, calculate specialty-specific aggregate pools of indirect PE for all PFS services for that specialty by adding the product of the indirect PE/HR for the specialty, the work time for the service, and the specialty's utilization for the service across all services furnished by the specialty.

Step 14: Using the results of Step 12 and Step 13, calculate the specialty-specific indirect PE scaling factors.

Step 15: Using the results of Step 14, calculate an indirect practice cost index at the specialty level by dividing each specialty-specific indirect scaling factor by the average indirect scaling factor for the entire PFS.

Step 16: Calculate the indirect practice cost index at the service level to ensure the capture of all indirect costs. Calculate a weighted average of the practice cost index values for the specialties that furnish the service. (Note: For services with TCs and PCs, we calculate the indirect practice cost index across the global service, PCs, and TCs. Under this method, the indirect practice cost index for a given service (for example, echocardiogram) does not vary by the PC, TC, and global service.)

Step 17: Apply the service level indirect practice cost index calculated in Step 16 to the service level adjusted indirect allocators calculated in Step 11 to get the indirect PE RVUs.

(d) Calculate the Final PE RVUs

Step 18: Add the direct PE RVUs from Step 6 to the indirect PE RVUs from Step 17 and apply the final PE budget neutrality (BN) adjustment. The final PE BN adjustment is calculated by comparing the results of Step 18 to the proposed aggregate work RVUs scaled by the ratio of current aggregate PE and work RVUs, consistent with the proposed changes in Steps 2 and 9. This final BN adjustment is required to redistribute RVUs from step 18 to all PE RVUs in the PFS, and because certain specialties are excluded from the PE RVU calculation for ratesetting purposes, but we note that all specialties are included for purposes of calculating the final BN adjustment. (See “Specialties excluded from ratesetting calculation” later in this section.)

(e) Setup File Information

  • Specialties excluded from ratesetting calculation: For the purposes of calculating the PE RVUs, we exclude certain specialties, such as certain nonphysician practitioners paid at a percentage of the PFS and low-volume specialties, from the calculation. These specialties are included for the purposes of calculating the BN adjustment. They are displayed in Table 1.
Table 1—Specialties Excluded from Ratesetting Calculation Back to Top
Specialty code Specialty description
49 Ambulatory surgical center.
50 Nurse practitioner.
51 Medical supply company with certified orthotist.
52 Medical supply company with certified prosthetist.
53 Medical supply company with certified prosthetist-orthotist.
54 Medical supply company not included in 51, 52, or 53.
55 Individual certified orthotist.
56 Individual certified prosthetist.
57 Individual certified prosthetist-orthotist.
58 Medical supply company with registered pharmacist.
59 Ambulance service supplier, e.g., private ambulance companies, funeral homes, etc.
60 Public health or welfare agencies.
61 Voluntary health or charitable agencies.
73 Mass immunization roster biller.
74 Radiation therapy centers.
87 All other suppliers (e.g., drug and department stores).
88 Unknown supplier/provider specialty.
89 Certified clinical nurse specialist.
96 Optician.
97 Physician assistant.
A0 Hospital.
A1 SNF.
A2 Intermediate care nursing facility.
A3 Nursing facility, other.
A4 HHA.
A5 Pharmacy.
A6 Medical supply company with respiratory therapist.
A7 Department store.
B2 Pedorthic personnel.
B3 Medical supply company with pedorthic personnel.
  • Crosswalk certain low volume physician specialties: Crosswalk the utilization of certain specialties with relatively low PFS utilization to the associated specialties.
  • Physical therapy utilization: Crosswalk the utilization associated with all physical therapy services to the specialty of physical therapy.
  • Identify professional and technical services not identified under the usual TC and 26 modifiers: Flag the services that are PC and TC services but do not use TC and 26 modifiers (for example, electrocardiograms). This flag associates the PC and TC with the associated global code for use in creating the indirect PE RVUs. For example, the professional service, CPT code 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), is associated with the global service, CPT code 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report).
  • Payment modifiers: Payment modifiers are accounted for in the creation of the file consistent with current payment policy as implemented in claims processing. For example, services billed with the assistant at surgery modifier are paid 16 percent of the PFS amount for that service; therefore, the utilization file is modified to only account for 16 percent of any service that contains the assistant at surgery modifier. Similarly, for those services to which volume adjustments are made to account for the payment modifiers, time adjustments are applied as well. For time adjustments to surgical services, the intraoperative portion in the work time file is used; where it is not present, the intraoperative percentage from the payment files used by contractors to process Medicare claims is used instead. Where neither is available, we use the payment adjustment ratio to adjust the time accordingly. Table 2 details the manner in which the modifiers are applied.
Table 2—Application of Payment Modifiers to Utilization Files Back to Top
Modifier Description Volume adjustment Time adjustment
80,81,82 Assistant at Surgery 16% Intraoperative portion.
AS Assistant at Surgery—Physician Assistant 14% (85% * 16%) Intraoperative portion.
50 or LT and RT Bilateral Surgery 150% 150% of work time.
51 Multiple Procedure 50% Intraoperative portion.
52 Reduced Services 50% 50%.
53 Discontinued Procedure 50% 50%.
54 Intraoperative Care only Preoperative + Intraoperative Percentages on the payment files used by Medicare contractors to process Medicare claims Preoperative + Intraoperative portion.
55 Postoperative Care only Postoperative Percentage on the payment files used by Medicare contractors to process Medicare claims Postoperative portion.
62 Co-surgeons 62.5% 50%.
66 Team Surgeons 33% 33%.

We also make adjustments to volume and time that correspond to other payment rules, including special multiple procedure endoscopy rules and multiple procedure payment reductions (MPPRs). We note that section 1848(c)(2)(B)(v) of the Act exempts certain reduced payments for multiple imaging procedures and multiple therapy services from the BN calculation under section 1848(c)(2)(B)(ii)(II) of the Act. These MPPRs are not included in the development of the RVUs.

For anesthesia services, we do not apply adjustments to volume since we use the average allowed charge when simulating RVUs; therefore, the RVUs as calculated already reflect the payments as adjusted by modifiers, and no volume adjustments are necessary. However, a time adjustment of 33 percent is made only for medical direction of two to four cases since that is the only situation where a single practitioner is involved with multiple beneficiaries concurrently, so that counting each service without regard to the overlap with other services would overstate the amount of time spent by the practitioner furnishing these services.

  • Work RVUs: The setup file contains the work RVUs from this proposed rule with comment period.

(7) Equipment Cost Per Minute

The equipment cost per minute is calculated as:

(1/(minutes per year * usage)) * price * ((interest rate/(1-(1/((1 + interest rate)^ life of equipment)))) + maintenance)

Where:

minutes per year = maximum minutes per year if usage were continuous (that is, usage = 1); generally 150,000 minutes.

usage = variable, see discussion below.

price = price of the particular piece of equipment.

life of equipment = useful life of the particular piece of equipment.

maintenance = factor for maintenance; 0.05.

interest rate = variable, see discussion below.

Usage: We currently use an equipment utilization rate assumption of 50 percent for most equipment, with the exception of expensive diagnostic imaging equipment, for which we use a 90 percent assumption as required by section 1848(b)(4)(C) of the Act. We also direct the reader to section II.5.b of this proposed rule for a discussion of our proposed change in the utilization rate assumption for the linear accelerator used in furnishing radiation treatment services.

Maintenance: This factor for maintenance was proposed and finalized during rulemaking for CY 1998 PFS (62 FR 33164). Several stakeholders have suggested that this maintenance factor assumption should be variable, similar to other assumptions in the equipment cost per minute calculation. In CY 2015 rulemaking, we solicited comments regarding the availability of reliable data on maintenance costs that vary for particular equipment items. We received several comments about variable maintenance costs, and in reviewing the information offered in those comments, it is clear that the relationship between maintenance costs and the price of equipment is not necessarily uniform across equipment. However, based on our review of comments, we have been unable to identify a systematic way of varying the maintenance cost assumption relative to the price or useful life of equipment. Therefore, in order to accommodate a variable, as opposed to a standard, maintenance rate within the equipment cost per minute calculation, we believe we would have to gather and maintain valid data on the maintenance costs for each equipment item in the direct PE input database, much like we do for price and useful life.

Given our longstanding difficulties in acquiring accurate pricing information for equipment items, we are seeking comment on whether adding another item-specific financial variable for equipment costs will be likely to increase the accuracy of PE RVUs across the PFS. We note that most of the information for maintenance costs we have received is for capital equipment, and for the most part, this information has been limited to single invoices. Like the invoices for the equipment items themselves, we do not believe that very small numbers of voluntarily submitted invoices are likely to reflect typical costs for all of the same reasons we have discussed in previous rulemaking. We note that some commenters submitted high-level summary data from informal surveys but we currently have no means to validate that data. Therefore, we continue to seek a source of publicly available data on actual maintenance costs for medical equipment to improve the accuracy of the equipment costs used in developing PE RVUs.

Interest Rate: In the CY 2013 final rule with comment period (77 FR 68902), we updated the interest rates used in developing an equipment cost per minute calculation. The interest rate was based on the Small Business Administration (SBA) maximum interest rates for different categories of loan size (equipment cost) and maturity (useful life). The interest rates are listed in Table 3. (See 77 FR 68902 for a thorough discussion of this issue.)

Table 3—SBA Maximum Interest Rates Back to Top
Price Useful life Interest rate (%)
<$25K <7 Years 7.50
$25K to $50K <7 Years 6.50
>$50K <7 Years 5.50
<$25K 7+ Years 8.00
$25K to $50K 7+ Years 7.00
>$50K 7+ Years 6.00
Table 4—Calculation of PE RVUS Under Methodology for Selected Codes Back to Top
Step Source Formula 99213 Office visit, est nonfacility 33533 CABG, arterial, single facility 71020 chest x-ray nonfacility 71020-TC chest x-ray, nonfacility 71020-26 chest x-ray, nonfacility 93000 ECG, complete, nonfacility 93005 ECG, tracing nonfacility 93010 ECG, report nonfacility
CPT codes and descriptions are copyright 2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.
Notes: PE RVUs above (row 27), may not match Addendum B due to rounding.
The use of any particular conversion factor (CF) in the table to illustrate the PE Calculation has no effect on the resulting RVUs.
*The direct adj = [current pe rvus * CF * avg dir pct]/[sum direct inputs] = [step2]/[step3]; **The indirect adj =[current pe rvus * avg ind pct]/[sum of ind allocators]=[step9]/[step10]
(1) Labor cost (Lab) Step 1 AMA 13.32 77.52 5.74 5.74 0 5.1 5.1 0
(2) Supply cost (Sup) Step 1 AMA 2.98 7.34 0.53 0.53 0 1.19 1.19 0
(3) Equipment cost (Eqp) Step 1 AMA 0.17 0.58 7.08 7.08 0 0.09 0.09 0
(4) Direct cost (Dir) Step 1 =(1)+(2)+(3) 16.48 85.45 13.36 13.36 0 6.38 6.38 0
(5) Direct adjustment (Dir. Adj.) Steps 2-4 See footnote* 0.6003 0.6003 0.6003 0.6003 0.6003 0.6003 0.6003 0.6003
(6) Adjusted Labor Steps 2-4 =Labor * Dir Adj =(1)*(5) 8 46.53 3.45 3.45 0 3.06 3.06 0
(7) Adjusted Supplies Steps 2-4 =Eqp * Dir Adj =(2)*(5) 1.79 4.41 0.32 0.32 0 0.72 0.72 0
(8) Adjusted Equipment Steps 2-4 =Sup * Dir Adj =(3)*(5) 0.10 0.35 4.25 4.25 0 0.05 0.05 0
(9) Adjusted Direct Steps 2-4 =(6)+(7)+(8) 9.89 51.29 8.02 8.02 0 3.83 3.83 0
(10) Conversion Factor (CF) Step 5 PFS 35.9335 35.9335 35.9335 35.9335 35.9335 35.9335 35.9335 35.9335
(11) Adj. labor cost converted Step 5 =(Lab * Dir Adj)/CF =(6)/(10) 0.22 1.3 0.1 0.1 0 0.09 0.09 0
(12) Adj. supply cost converted Step 5 =(Sup * Dir Adj)/CF =(7)/(10) 0.05 0.12 0.01 0.01 0 0.02 0.02 0
(13) Adj. equipment cost converted Step 5 =(Eqp * Dir Adj)/CF =(8)/(10) 0 0.01 0.12 0.12 0 0 0 0
(14) Adj. direct cost converted Step 5 =(11)+(12)+(13) 0.28 1.43 0.22 0.22 0 0.11 0.11 0
(15) Work RVU Setup File PFS 0.97 33.75 0.22 0 0.22 0.17 0 0.17
(16) Dir_pct Steps 6,7 Surveys 0.25 0.17 0.29 0.29 0.29 0.29 0.29 0.29
(17) Ind_pct Steps 6,7 Surveys 0.75 0.83 0.71 0.71 0.71 0.71 0.71 0.71
(18) Ind. Alloc. Formula (1st part) Step 8 See Step 8 (14)/(16)*(17) (14)/(16)*(17) (14)/(16)*(17) (14)/(16)*(17) (14)/(16)*(17) (14)/(16)*(17) (14)/(16)*(17) (14)/(16)*(17)
(19) Ind. Alloc.(1st part) Step 8 See 18 0.83 6.75 0.54 0.54 0 0.26 0.26 0
(20) Ind. Alloc. Formula (2nd part) Step 8 See Step 8 (15) (15) (15+11) (11) (15) (15+11) (11) (15)
(21) Ind. Alloc.(2nd part) Step 8 See 20 0.97 33.75 0.32 0.1 0.22 0.26 0.09 0.17
(22) Indirect Allocator (1st + 2nd) Step 8 =(19)+(21) 1.8 40.50 0.86 0.64 0.22 0.52 0.35 0.17
(23) Indirect Adjustment (Ind. Adj.) Steps 9-11 See Footnote** 0.3811 0.3811 0.3811 0.3811 0.3811 0.3811 0.3811 0.3811
(24) Adjusted Indirect Allocator Steps 9-11 =Ind Alloc * Ind Adj 0.69 15.43 0.33 0.24 0.08 0.2 0.13 0.06
(25) Ind. Practice Cost Index (IPCI) Steps 12-16 1.07 0.76 0.98 0.98 0.98 0.9 0.9 0.9
(26) Adjusted Indirect Step 17 = Adj.Ind Alloc * PCI =(24)*(25) 0.73 11.68 0.32 0.24 0.08 0.18 0.12 0.06
(27) Final PE RVU Step 18 =(Adj Dir + Adj Ind) * Other Adj =((14)+(26)) * Other Adj) 1.01 13.15 0.54 0.46 0.08 0.28 0.23 0.06

c. Changes to Direct PE Inputs for Specific Services

In this section, we discuss other CY 2016 proposals related to particular PE inputs. The proposed direct PE inputs are included in the proposed CY 2016 direct PE input database, which is available on the CMS Web site under downloads for the CY 2016 PFS proposed rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.

(1) PE Inputs for Digital Imaging Services

Prior to CY 2015 rulemaking, the RUC provided a recommendation regarding the PE inputs for digital imaging services. Specifically, the RUC recommended that we remove supply and equipment items associated with film technology from a list of codes since these items are no longer typical resource inputs. The RUC also recommended that the Picture Archiving and Communication System (PACS) equipment be included for these imaging services since these items are now typically used in furnishing imaging services. However, since we did not receive any invoices for the PACS system, we were unable to determine the appropriate pricing to use for the inputs. For CY 2015, we proposed, and finalized our proposal, to remove the film supply and equipment items, and to create a new equipment item as a proxy for the PACS workstation as a direct expense. We used the current price associated with ED021 (computer, desktop, w-monitor) to price the new item, ED050 (PACS Workstation Proxy), pending receipt of invoices to facilitate pricing specific to the PACS workstation.

Subsequent to establishing payment rates for CY 2015, we received information from several stakeholders regarding pricing for items related to the digital acquisition and storage of images. Some of these stakeholders submitted information that included prices for items clearly categorized as indirect costs within the established PE methodology and equivalent to the storage mechanisms for film. Additionally, some of the invoices we received included other products (like training and maintenance costs) in addition to the equipment items, and there was no distinction on these invoices between the prices for the equipment items themselves and the related services. However, we did receive invoices from one stakeholder that facilitated a proposed price update for the PACS workstation. Therefore, we are proposing to update the price for the PACS workstation to $5,557 from the current price of $2,501 since the latter price was based on the proxy item and the former based on submitted invoices. The PE RVUs in Addendum B on the CMS Web site reflect the updated price.

In addition to the workstation used by the clinical staff acquiring the images and furnishing the technical component of the services, a stakeholder also submitted more detailed information regarding a workstation used by the practitioner interpreting the image in furnishing the professional component of many of these services. As we stated in the CY 2015 final rule with comment period (79 FR 67563), we generally believe that workstations used by these practitioners are more accurately considered indirect costs associated with the professional component of the service. However, we understand that the professional workstations for interpretation of digital images are similar in principle to some of the previous film inputs incorporated into the global and technical components of the codes. Given that many of these services are reported globally in the nonfacility setting, we believe it may be appropriate to include these costs as direct inputs for the associated HCPCS codes. Based on our established methodology, these costs would be incorporated into the PE RVUs of the global and technical component of the HCPCS code. We are seeking comment on whether including the professional workstation as a direct PE input for these codes would be appropriate, given that the resulting PE RVUs would be assigned to the global and technical components of the codes.

Another stakeholder expressed concern about the changes in direct PE inputs for CPT code 76377, (3D radiographic procedure with computerized image post-processing), that were proposed and finalized in CY 2015 rulemaking as part of the film to digital change. Based on a recommendation from the RUC, we removed the input called “computer workstation, 3D reconstruction CT-MR” from the direct PE input database and assigned the associated minutes to the proxy for the PACS workstation. We are seeking comment from stakeholders, including the RUC, about whether or not the PACS workstation used in in imaging codes is the same workstation that is used in the postprocessing described by CPT code 76377, or if more specific workstation should be incorporated in the direct PE input database . . .

(2) Standardization of Clinical Labor Tasks

As we noted in PFS rulemaking for CY 2015, we continue to work on revisions to the direct PE input database to provide the number of clinical labor minutes assigned for each task for every code in the database instead of only including the number of clinical labor minutes for the pre-service, service, and post-service periods for each code. In addition to increasing the transparency of the information used to set PE RVUs, this improvement would allow us to compare clinical labor times for activities associated with services across the PFS, which we believe is important to maintaining the relativity of the direct PE inputs. This information will facilitate the identification of the usual numbers of minutes for clinical labor tasks and the identification of exceptions to the usual values. It will also allow for greater transparency and consistency in the assignment of equipment minutes based on clinical labor times. Finally, we believe that the information can be useful in maintaining standard times for particular clinical labor tasks that can be applied consistently to many codes as they are valued over several years, similar in principle to the use of physician pre-service time packages. We believe such standards will provide greater consistency among codes that share the same clinical labor tasks and could improve relativity of values among codes. For example, as medical practice and technologies change over time, changes in the standards could be updated at once for all codes with the applicable clinical labor tasks, instead of waiting for individual codes to be reviewed.

While this work is not yet complete, we anticipate completing it in the near future. In the following paragraphs, we address a series of issues related to clinical labor tasks, particularly relevant to services currently being reviewed under the misvalued code initiative

(a) Clinical Labor Tasks Associated With Digital Imaging

In PFS rulemaking for CY 2015, we noted that the RUC recommendation regarding inputs for digital imaging services indicated that, as each code is reviewed under the misvalued code initiative, the clinical labor tasks associated with digital technology (instead of film) would need to be addressed. When we reviewed that recommendation, we did not have the capability of assigning standard clinical labor times for the hundreds of individual codes since the direct PE input database did not previously allow for comprehensive adjustments for clinical labor times based on particular clinical labor tasks. Therefore, consistent with the recommendation, we proposed to remove film-based supply and equipment items but maintain clinical labor minutes that were assigned based on film technology.

As noted in the paragraphs above, we continue to improve the direct PE input database by specifying the minutes for each code associated with each clinical labor task. Once completed, this work would allow adjustments to be made to minutes assigned to particular clinical labor tasks related to digital technology, consistent with the changes that were made to individual supply and equipment items. In the meantime, we believe it would be appropriate to establish standard times for clinical labor tasks associated with all digital imaging for purposes of reviewing individual services at present, and for possible broad-based standardization once the changes to the database facilitate our ability to adjust time for existing services. Therefore, we are seeking comment on the appropriate standard minutes for the clinical labor tasks associated with services that use digital technology, which are listed in Table 5. We note that the application of any standardized times we adopt for clinical labor tasks to codes that are not being reviewed in this proposed rule would be considered for possible inclusion in future notice and comment rulemaking.

Table 5—Clinical Labor Tasks Associated With Digital Technology Back to Top
Clinical labor task Typical minutes
* This clinical labor task is listed as it appears on the “PE worksheets.” QC refers to quality control, which we understand to mean the verification of the image using the PACS workstation.
Availability of prior images confirmed 2
Patient clinical information and questionnaire reviewed by technologist, order from physician confirmed and exam protocoled by radiologist 2
Technologist QC's * images in PACS, checking for all images, reformats, and dose page 2
Review examination with interpreting MD 2
Exam documents scanned into PACS. Exam completed in RIS system to generate billing process and to populate images into Radiologist work queue 1

(b) Pathology Clinical Labor Tasks

As with the clinical labor tasks associated with digital imaging, many of the specialized clinical labor tasks associated with pathology services do not have consistent times across those codes. In reviewing the recommendations for pathology services, we have not identified information that suggests that the inconsistencies reflect the judgment that the same tasks take significantly more or less time depending on the individual service for which they are performed, especially given the specificity with which they are described.

We have therefore developed proposed standard times that we have used in proposing direct PE inputs. These times are based on our review and assessment of the current times included for these clinical labor tasks in the direct PE input database. We have listed these proposed standard times in Table 6. For services reviewed for CY 2016, in cases where the RUC-recommended times differed from these standards, we have refined the time for those tasks to align with the values in Table 6. We seek comment on whether these standard times accurately reflect the typical time it takes to perform these clinical labor tasks when furnishing pathology services.

Table 6—Standard Times for Clinical Labor Tasks Associated With Pathology Services Back to Top
Clinical Labor Task Standard clinical labor time
Accession specimen/prepare for examination 4
Assemble and deliver slides with paperwork to pathologists 0.5
Assemble other light microscopy slides, open nerve biopsy slides, and clinical history, and present to pathologist to prepare clinical pathologic interpretation 0.5
Assist pathologist with gross specimen examination 3
Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 1
Dispose of remaining specimens, spent chemicals/other consumables, and hazardous waste 1
Enter patient data, computational prep for antibody testing, generate and apply bar codes to slides, and enter data for automated slide stainer 1
Instrument start-up, quality control functions, calibration, centrifugation, maintaining specimen tracking, logs and labeling 13
Load specimen into flow cytometer, run specimen, monitor data acquisition and data modeling, and unload flow cytometer 7
Preparation: labeling of blocks and containers and document location and processor used 0.5
Prepare automated stainer with solutions and load microscopic slides 4
Prepare specimen containers/preload fixative/label containers/distribute requisition form(s) to physician 0.5
Prepare, pack and transport specimens and records for in-house storage and external storage (where applicable) 1
Print out histograms, assemble materials with paperwork to pathologists. Review histograms and gating with pathologist. 2
Receive phone call from referring laboratory/facility with scheduled procedure to arrange special delivery of specimen procurement kit, including muscle biopsy clamp as needed. Review with sender instructions for preservation of specimen integrity and return arrangements. Contact courier and arrange delivery to referring laboratory/facility 5
Register the patient in the information system, including all demographic and billing information. 4
Stain air dried slides with modified Wright stain. Review slides for malignancy/high cellularity (cross contamination) 3

(c) Clinical Labor Task: “Complete Botox Log”

In the process of improving the level of detail in the direct PE input database by including the minutes assigned for each clinical labor task, we noticed that there are several codes with minutes assigned for the clinical labor task called “complete botox log.” We do not believe the completion of such a log is a direct resource cost of furnishing a medically reasonable and necessary physician's service for a Medicare beneficiary. Therefore, we are proposing to eliminate the minutes assigned for the task “complete botox log” from the direct PE input database. The PE RVUs displayed in Addendum B on the CMS Web site were calculated with the modified inputs displayed in the CY 2016 direct PE input database.

(3) Clinical Labor Input Inconsistencies

Subsequent to the publication of the CY 2015 PFS final rule with comment period, stakeholders alerted us to several clerical inconsistencies in the clinical labor nonfacility intraservice time for several vertebroplasty codes with interim final values for CY 2015, based on our understanding of RUC recommended values. We are proposing to correct these inconsistencies in the CY 2016 proposed direct PE input database to reflect the RUC recommended values, without refinement, as stated in the CY 2015 PFS final rule with comment period. The CY 2015 interim final direct PE inputs for these codes are displayed on the CMS Web site under downloads for the CY 2015 PFS final rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. For CY 2016, we are proposing the following adjustments. For CPT codes 22510 (percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic) and 22511 (percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral), a value of 45 minutes for labor code L041B (“Radiologic Technologist”) were are proposing to assign for the “assist physician” task and a value of 5 minutes for labor code L037D (“RN/LPN/MTA”) for the “Check dressings & wound/home care instructions/coordinate office visits/prescriptions” task. For CPT code 22514 (percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar), we are proposing to adjust the nonfacility intraservice time to 50 minutes for L041B, 50 minutes for L051A (“RN”), 38 minutes for a second L041B, and 12 minutes for L037D. The PE RVUs displayed in Addendum B on the CMS Web site were calculated with the inputs displayed in the CY 2016 direct PE input database.

(4) Freezer

We identified several pathology codes for which equipment minutes are assigned to the item EP110 “Freezer.” Minutes are only allocated to particular equipment items when those items cannot be used in conjunction with furnishing services to another patient at the same time. We do not believe that minutes should be allocated to items such as freezers since the storage of any particular specimen or item in a freezer for any given period of time would be unlikely to make the freezer unavailable for storing other specimens or items. Instead, we propose to classify the freezer as an indirect cost because we believe that would be most consistent with the principles underlying the PE methodology since freezers can be used for many specimens at once. The PE RVUs displayed in Addendum B on the CMS Web site were calculated with the modified inputs displayed in the CY 2016 direct PE input database.

(5) Updates to Price for Existing Direct Inputs

In the CY 2011 PFS final rule with comment period (75 FR 73205), we finalized a process to act on public requests to update equipment and supply price and equipment useful life inputs through annual rulemaking beginning with the CY 2012 PFS proposed rule. During 2014, we received a request to update the price of supply item “antigen, mite” (SH006) from $4.10 per test to $59. In reviewing the request, it is evident that the requested price update does not apply to the SH006 item but instead represents a different item than the one currently included as an input in CPT code 86490 (skin test, coccidioidomycosis). Therefore, rather than changing the price for SH006 that is included in several codes, we are proposing to create a new supply code for Spherusol, valued at $590 per 1 ml vial and $59 per test, and to include this new item as a supply for 86490 instead of the current input, SH006. We also received a request to update the price for EQ340 (Patient Worn Telemetry System) used only in CPT code 93229 (External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care.) The requestor noted that we had previously proposed and finalized a policy to remove wireless communication and delivery costs related to the equipment item that had previously been included in the direct PE input database as supply items. The requestor asked that we alter the price of the equipment from $21,575 to $23,537 to account for the equipment costs specific to the patient-worn telemetry system.

We have considered this request in the context of the unique nature of this particular equipment item. This equipment item is unique in several ways, including that it is used continuously 24 hours per day and 7 days per week for an individual patient over several weeks. It is also unique in that the equipment is primarily used outside of a healthcare setting. Within our current methodology, we currently account for these unique properties by calculating the per minute costs with different assumptions than those used for most other equipment by increasing the number of hours the equipment is available for use. Therefore, we also believe it would be appropriate to incorporate other unique aspects of the operating costs of this item in our calculation of the equipment cost per minute. We believe the requestor's suggestion to do so by increasing the price of the equipment is practicable and appropriate. Therefore, we are proposing to change the price for EQ340 (Patient Worn Telemetry System) to $23,537. The PE RVUs displayed in Addendum B on the CMS Web site were calculated with the modified inputs displayed in the CY 2016 direct PE input database.

For CY 2015, we received a request to update the price for supply item “kit, HER-2/neu DNA Probe” (SL196) from $105 to $144.50. Accordingly, we proposed to update the price to $144.50. In the CY 2015 final rule with comment period, we indicated that we obtained new information suggesting that further study of the price of this item was necessary before proceeding to update the input price. We obtained pricing information readily available on the Internet that indicated a price of $94 for this item for a particular hospital. Subsequent to the CY 2015 final rule with comment period, stakeholders requested that we use the updated price of $144.50. One stakeholder suggested that the price of $94 likely reflected discounts for volume purchases not received by the typical laboratory. We are seeking comment on how to consider the higher-priced invoice, which is 53 percent higher than the price listed, relative to the price currently in the direct PE database. Specifically, we are seeking information on the price of the disposable supply in the typical case of the service furnished to a Medicare beneficiary, including, based on data, whether the typical Medicare case is furnished by an entity likely to receive a volume discount.

(6) Typical Supply and Equipment Inputs for Pathology Services

In reviewing public comments in response to the CY 2015 PFS final rule with comment period, we re-examined issues around the typical number of pathology tests furnished at once. In the CY 2013 final rule with comment period (77 FR 69074), we noted that the number of blocks assumed for a particular code significantly impacts the assumed clinical labor, supplies, and equipment for that service. We indicated that we had concerns that the assumed number of blocks was inaccurate, and that we sought corroborating, independent evidence that the number of blocks assumed in the current direct PE input recommendations is typical. We note that, given the high volume of many pathology services, these assumptions have a significant impact on the PE RVUs for all other PFS services. We refer readers to section II.I.5.d where we detail our concerns about the lack of information regarding typical batch size and typical block size for many pathology services and solicit stakeholder input on approaches to obtaining accurate information that can facilitate our establishing payment rates that best reflect the relative resources involved in furnishing the typical service, for both pathology services in particular and more broadly for services across the PFS.

d. Developing Nonfacility Rates

We note that not all PFS services are priced in the nonfacility setting, but as medical practice changes, we routinely develop nonfacility prices for particular services when they can be furnished outside of a facility setting. We note that the valuation of a service under the PFS in particular settings does not address whether those services are medically reasonable and necessary in the case of individual patients, including being furnished in a setting appropriate to the patient's medical needs and condition.

(1) Request for Information on Nonfacility Cataract Surgery

Cataract surgery generally has been performed in an ambulatory surgery center (ASC) or a hospital outpatient department (HOPD). Therefore, CMS has not assigned nonfacility PE RVUs under the PFS for cataract surgery. According to Medicare claims data, there are a relatively small number of these services furnished in nonfacility settings. Except in unusual circumstances, anesthesia for cataract surgery is either local or topical/intracameral. Advancements in technology have significantly reduced operating time and improved both the safety of the procedure and patient outcomes. We believe that it is now possible for cataract surgery to be furnished in an in-office surgical suite, especially for routine cases. Cataract surgery patients require a sterile surgical suite with certain equipment and supplies that we believe could be a part of a nonfacility-based setting that is properly constructed and maintained for appropriate infection prevention and control.

We believe that there are potential advantages for all parties to furnishing appropriate cataract surgery cases in the nonfacility setting. Cataract surgery has been for many years the highest volume surgical procedure performed on Medicare beneficiaries. For beneficiaries, cataract surgery in the office setting might provide the additional convenience of receiving the preoperative, operative, and post-operative care in one location. It might also reduce delays associated with registration, processing, and discharge protocols associated with some facilities. Similarly, it might provide surgeons with greater flexibility in scheduling patients at an appropriate site of service depending on the individual patient's needs. For example, routine cases in patients with no comorbidities could be performed in the nonfacility surgical suite, while more complicated cases (for example, pseudoexfoliation) could be scheduled in the ASC or HOPD. In addition, furnishing cataract surgery in the nonfacility setting could result in lower Medicare expenditures for cataract surgery if the nonfacility payment rate were lower than the sum of the PFS facility payment rate and the payment to either the ASC or HOPD.

We are seeking comments from ophthalmologists and other stakeholders on office-based surgical suite cataract surgery. In addition, we are soliciting comments from the RUC and other stakeholders on the direct practice expense inputs involved in furnishing cataract surgery in the nonfacility setting in conjunction with our consideration of information regarding the possibility of developing nonfacility PE RVUs for cataract surgery. We understand that cataract surgery generally requires some standard equipment and supplies (for example; phacoemulsification machine, surgical pack, intraocular lenses (IOL), etc.) that would be incorporated as direct PE inputs in calculating nonfacility PE RVUs.

(2) Direct PE Inputs for Functional Endoscopic Sinus Surgery Services

A stakeholder indicated that due to changes in technology and technique, several codes that describe endoscopic sinus surgeries can now be furnished in the nonfacility setting. According to Medicare claims data, there are a relatively small number of these services furnished in nonfacility settings. These CPT codes are 31254 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)), 31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)), 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy;), 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus), 31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus), 31287 (Nasal/sinus endoscopy, surgical, with sphenoidotomy;), and 31288 (Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus). We are seeking input from stakeholders, including the RUC, about the appropriate direct PE inputs for these services.

B. Determination of Malpractice Relative Value Units (RVUs)

1. Overview

Section 1848(c) of the Act requires that each service paid under the PFS be comprised of three components: work, PE, and malpractice (MP) expense. As required by section 1848(c)(2)(C)(iii) of the Act, beginning in CY 2000, MP RVUs are resource based. Malpractice RVUs for new codes after 1991 were extrapolated from similar existing codes or as a percentage of the corresponding work RVU. Section 1848(c)(2)(B)(i) of the Act also requires that we review, and if necessary adjust, RVUs no less often than every 5 years. In the CY 2015 PFS final rule with comment period, we implemented the third review and update of MP RVUs. For a discussion of the third review and update of MP RVUs see the CY 2015 proposed rule (79 FR 40349 through 40355) and final rule with comment period (79 FR 67591 through 67596).

As explained in the CY 2011 PFS final rule with comment period (75 FR 73208), MP RVUs for new and revised codes effective before the next five-year review of MP RVUs (for example, effective CY 2016 through CY 2019, assuming that the next review of MP RVUs occurs for CY 2020) are determined either by a direct crosswalk from a similar source code or by a modified crosswalk to account for differences in work RVUs between the new/revised code and the source code. For the modified crosswalk approach, we adjust (or “scale”) the MP RVU for the new/revised code to reflect the difference in work RVU between the source code and the new/revised work value (or, if greater, the clinical labor portion of the fully implemented PE RVU) for the new code. For example, if the proposed work RVU for a revised code is 10 percent higher than the work RVU for its source code, the MP RVU for the revised code would be increased by 10 percent over the source code MP RVU. Under this approach the same risk factor is applied for the new/revised code and source code, but the work RVU for the new/revised code is used to adjust the MP RVUs for risk.

For CY 2016, we propose to continue our current approach for determining MP RVUs for new/revised codes. For the new and revised codes for which we include proposed work values and PE inputs in the proposed rule, we will also publish the proposed MP crosswalks used to determine their MP RVUs in the proposed rule. The MP crosswalks for those new and revised codes will be subject to public comment and finalized in the CY 2016 PFS final rule. The MP crosswalks for new and revised codes with interim final values established in the CY 2016 final rule will be implemented for CY 2016 and subject to public comment. They will then be finalized in the CY 2017 PFS final rule with comment period.

2. Proposed Annual Update of MP RVUs

In the CY 2012 PFS final rule with comment period (76 FR 73057), we finalized a process to consolidate the five-year reviews of physician work and PE RVUs with our annual review of potentially misvalued codes. We discussed the exclusion of MP RVUs from this process at the time, and we stated that, since it is not feasible to obtain updated specialty level MP insurance premium data on an annual basis, we believe the comprehensive review of MP RVUs should continue to occur at 5-year intervals. In the CY 2015 PFS proposed rule (79 FR 40349 through 40355), we stated that there are two main aspects to the update of MP RVUs: (1) Recalculation of specialty risk factors based upon updated premium data; and (2) recalculation of service level RVUs based upon the mix of practitioners providing the service. In the CY 2015 PFS final rule with comment period (79 FR 67596), in response to several stakeholders' comments, we stated that we would address potential changes regarding the frequency of MP RVU updates in a future proposed rule. For CY 2016, we are proposing to begin conducting annual MP RVU updates to reflect changes in the mix of practitioners providing services, and to adjust MP RVUs for risk. Under this approach, the specialty-specific risk factors would continue to be updated every five years using updated premium data, but would remain unchanged between the 5-year reviews. However, in an effort to ensure that MP RVUs are as current as possible, our proposal would involve recalibrating all MP RVUs on an annual basis to reflect the specialty mix based on updated Medicare claims data. Since under this proposal, we would be recalculating the MP RVUs annually, we are also proposing to maintain the relative pool of MP RVUs from year to year; this will preserve the relative weight of MP RVUs to work and PE RVUs. We are proposing to calculate the current pool of MP RVUs by using a process parallel to the one we use in calculating the pool of PE RVUs. (We direct the reader to section II.2.b.(6) for detailed description of that process, including a proposed technical revision for 2016.) To determine the specialty mix assigned to each code, we are also proposing to use the same process used in the PE methodology, described in section II.2.b.(6) of this proposed rule. We note that for CY 2016, we are proposing to modify the specialty mix assignment methodology to use an average of the 3 most recent years of available data instead of a single year of data as is our current policy. We anticipate that this change will increase the stability of PE and MP RVUs and mitigate code-level fluctuations for all services paid under the PFS, and for new and low-volume codes in particular. We are also proposing to no longer apply the dominant specialty for low volume services, because the primary rationale for the policy has been mitigated by this proposed change in methodology. However, we are not proposing to adjust the code-specific overrides established in prior rulemaking for codes where the claims data are inconsistent with a specialty that could be reasonably expected to furnish the service. We believe that these proposed changes will serve to balance the advantages of using annually updated information with the need for year-to-year stability in values. We seek comment on both aspects of the proposal: updating the specialty mix for MP RVUs annually (while continuing to update specialty-specific risk factors every 5 years using updated premium data); and using the same process to determine the specialty mix assigned to each code as is used in the PE methodology, including the proposed modification to use the most recent 3 years of claims data. We also seek comment on whether this approach will be helpful in addressing some of the concerns regarding the calculation of MP RVUs for services with low volume in the Medicare population, including the possibility of limiting our use of code-specific overrides of the claims data.

We are also proposing an additional refinement in our process for assigning MP RVUs to individual codes. Historically, we have used a floor of 0.01 MP RVUs for all nationally-priced PFS codes. This means that even when the code-level calculation for the MP RVU falls below 0.005, we have rounded to 0.01. In general, we believe this approach accounts for the minimum MP costs associated with each service furnished to a Medicare beneficiary. However, in examining the calculation of MP RVUs, we do not believe that this floor should apply to add-on codes. Since add-on codes must be reported with another code, there is already an MP floor of 0.01 that applies to the base code, and therefore, to each individual service. By applying the floor to add-on codes, the current methodology practically creates a 0.02 floor for any service reported with one add-on code, and 0.03 for those with 2 add-on codes, etc. Therefore, we are proposing to maintain the 0.01 MP RVU floor for all nationally-priced PFS services that are described by base codes, but not for add-on codes. We will continue to calculate, display, and make payments that include MP RVUs for add-on codes that are calculated to 0.01 or greater, including those that round to 0.01. We are only proposing to allow the MP RVUs for add-on codes to round to 0.00 where the calculated MP RVU is less than 0.005.

We will continue to study the appropriate frequency for collecting and updating premium data and will address any further proposed changes in future rulemaking.

3. MP RVU Update for Anesthesia Services

In the CY 2015 PFS proposed rule (79 FR 40354 through 40355), we did not include an adjustment under the anesthesia fee schedule to reflect updated MP premium information, and stated that we intended to propose an anesthesia adjustment for MP in the CY 2016 PFS proposed rule. We also solicited comments regarding how to best reflect updated MP premium amounts under the anesthesiology fee schedule.

As we previously explained, anesthesia services under the PFS are paid based upon a separate fee schedule, so routine updates must be calculated in a different way than those for services for which payment is calculated based upon work, PE, and MP RVUs. To apply budget neutrality and relativity updates to the anesthesiology fee schedule, we typically develop proxy RVUs for individual anesthesia services that are derived from the total portion of PFS payments made through the anesthesia fee schedule. We then update the proxy RVUs as we would the RVUs for other PFS services and adjust the anesthesia fee schedule conversion factor based on the differences between the original proxy RVUs and those adjusted for relativity and budget neutrality.

We believe that taking the same approach to update the anesthesia fee schedule based on new MP premium data is appropriate. However, because work RVUs are integral to the MP RVU methodology and anesthesia services do not have work RVUs, we decided to seek potential alternatives prior to implementing our approach in conjunction with the proposed CY 2015 MP RVUs based on updated premium data. One commenter supported the delay in proposing to update the MP for anesthesia at the same time as updating the rest of the PFS, and another commenter suggested using mean anesthesia MP premiums per provider over a 4 or 5 year period prorated by Medicare utilization to yield the MP expense for anesthesia services; no commenters offered alternatives to calculating updated MP for anesthesia services. The latter suggestion might apply more broadly to the MP methodology for the PFS and does not address the methodology as much as the data source.

We continue to believe that payment rates for anesthesia should reflect MP resource costs relative to the rest of the PFS, including updates to reflect changes over time. Therefore, for CY 2016, in order to appropriately update the MP resource costs for anesthesia, we are proposing to make adjustments to the anesthesia conversion factor to reflect the updated premium information collected for the five year review. To determine the appropriate adjustment, we calculated imputed work RVUs and MP RVUs for the anesthesiology fee schedule services using the work, PE, and MP shares of the anesthesia fee schedule. Again, this is consistent with our longstanding approach to making annual adjustments to the PE and work RVU portions of the anesthesiology fee schedule. To reflect differences in the complexity and risk among the anesthesia fee schedule services, we multiplied the service-specific risk factor for each anesthesia fee schedule service by the CY 2016 imputed proxy work RVUs and used the product as the updated raw proxy MP RVUs for each anesthesia service for CY 2016. We then applied the same scaling adjustments to these raw proxy MP RVUs that we apply to the remainder of the PFS MP RVUs. Finally, we calculated the aggregate difference between the 2015 proxy MP RVUs and the proxy MP RVUs calculated for CY 2016. We then adjusted the portion of the anesthesia conversion factor attributable to MP proportionately; we refer the reader to section VI.C. of this proposed rule for the Anesthesia Fee Schedule Conversion Factors for CY 2016. We are inviting public comments regarding this proposal.

4. MP RVU Methodology Refinements

In the CY 2015 PFS final rule with comment period (79 FR 67591 through 67596), we finalized updated MP RVUs that were calculated based on updated MP premium data obtained from state insurance rate filings. The methodology used in calculating the finalized CY 2015 review and update of resource-based MP RVUs largely paralleled the process used in the CY 2010 update. We posted our contractor's report, “Final Report on the CY 2015 Update of Malpractice RVUs” on the CMS Web site. It is also located under the supporting documents section of the CY 2015 PFS final rule with comment period located at http://www.cms.gov/PhysicianFeeSched/. A more detailed explanation of the 2015 MP RVU update can be found in the CY 2015 PFS proposed rule (79 FR 40349 through 40355).

In the CY 2015 PFS proposed rule, we outlined the steps for calculating MP RVUs. In the process of calculating MP RVUs for purposes of this proposed rule, we have identified a necessary refinement to way we have calculated Step 1, which involves computing a preliminary national average premium for each specialty, to align the calculations within the methodology to the calculations described within the aforementioned contractor's report. Specifically, in the calculation of the national premium for each specialty (refer to equations 2.3, 2.4, 2.5 in the aforementioned contractor's report), we calculate a weighted sum of premiums across areas and divide it by a weighted sum of MP GPCIs across areas. The calculation currently takes the ratio of sums, rather than the weighted average of the local premiums to the MP GPCI in that area. Instead, we are proposing to update the calculation to use a price-adjusted premium (that is, the premium divided by the GPCI) in each area, and then taking a weighted average of those adjusted premiums. The CY 2016 PFS proposed rule MP RVUs were calculated in this manner.

Additionally, in the calculation of the national average premium for each specialty as discussed above, our current methodology used the total RVUs in each area as the weight in the numerator (that is, for premiums), and total MP RVUs as the weights in the denominator (that is, for the MP GPCIs). After further consideration, we believe that the use of these RVU weights is problematic. Use of weights that are central to the process at hand presents potential circularity since both weights incorporate MP RVUs as part of the computation to calculate MP RVUs. The use of different weights for the numerator and denominator introduces potential inconsistency. Instead, we believe that it would be better to use a different measure that is independent of MP RVUs and better represents the reason for weighting. Specifically, we are proposing to use area population as a share of total U.S. population as the weight. The premium data are for all MP premium costs, not just those associated with Medicare patients, so we believe that the distribution of the population does a better job of capturing the role of each area's premium in the “national” premium for each specialty than our previous Medicare-specific measure. Use of population weights also avoids the potential problems of circularity and inconsistency.

The CY 2016 PFS proposed MP RVUs, as displayed in Addendum B of this proposed rule, reflect MP RVUs calculated following our established methodology, with the inclusion of the proposals and refinements described above.

C. Potentially Misvalued Services Under the Physician Fee Schedule

1. Background

Section 1848(c)(2)(B) of the Act directs the Secretary to conduct a periodic review, not less often than every 5 years, of the RVUs established under the PFS. Section 1848(c)(2)(K) of the Act requires the Secretary to periodically identify potentially misvalued services using certain criteria and to review and make appropriate adjustments to the relative values for those services. Section 1848(c)(2)(L) to the Act also requires the Secretary to develop a process to validate the RVUs of certain potentially misvalued codes under the PFS, using the same criteria used to identify potentially misvalued codes, and to make appropriate adjustments.

As discussed in section I.B. of this proposed rule, each year we develop appropriate adjustments to the RVUs taking into account recommendations provided by the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), the Medicare Payment Advisory Commission (MedPAC), and others. For many years, the RUC has provided us with recommendations on the appropriate relative values for new, revised, and potentially misvalued PFS services. We review these recommendations on a code-by-code basis and consider these recommendations in conjunction with analyses of other data, such as claims data, to inform the decision-making process to establish relative values for these codes. We may also consider analyses of work time, work RVUs, or direct practice expense (PE) inputs using other data sources, such as Department of Veteran Affairs (VA), National Surgical Quality Improvement Program (NSQIP), the Society for Thoracic Surgeons (STS), and the Physician Quality Reporting System (PQRS) databases. In addition to considering the most recently available data, we also assess the results of physician surveys and specialty recommendations submitted to us by the RUC. We also consider information provided by other stakeholders. We conduct a review to assess the appropriate RVUs in the context of contemporary medical practice. We note that section 1848(c)(2)(A)(ii) of the Act authorizes the use of extrapolation and other techniques to determine the RVUs for physicians' services for which specific data are not available, in addition to requiring us to take into account the results of consultations with organizations representing physicians who furnish the services. In accordance with section 1848(c) of the Act, we determine and make appropriate adjustments to the RVUs. We discuss these methodologies as applied to particular codes in section I.B. of this proposed rule.

Section 1848(c)(2)(K)(ii) of the Act augments our efforts by directing the Secretary to specifically examine, as determined appropriate, potentially misvalued services in the following categories:

  • Codes that have experienced the fastest growth.
  • Codes that have experienced substantial changes in practice expenses.
  • Codes that describe new technologies or services within an appropriate time period (such as 3 years) after the relative values are initially established for such codes.
  • Codes which are multiple codes that are frequently billed in conjunction with furnishing a single service.
  • Codes with low relative values, particularly those that are often billed multiple times for a single treatment.
  • Codes that have not been subject to review since implementation of the fee schedule.
  • Codes that account for the majority of spending under the PFS.
  • Codes for services that have experienced a substantial change in the hospital length of stay or procedure time.
  • Codes for which there may be a change in the typical site of service since the code was last valued.
  • Codes for which there is a significant difference in payment for the same service between different sites of service.
  • Codes for which there may be anomalies in relative values within a family of codes.
  • Codes for services where there may be efficiencies when a service is furnished at the same time as other services.
  • Codes with high intra-service work per unit of time.
  • Codes with high practice expense relative value units.
  • Codes with high cost supplies.
  • Codes as determined appropriate by the Secretary.

Section 1848(c)(2)(K)(iii) of the Act also specifies that the Secretary may use existing processes to receive recommendations on the review and appropriate adjustment of potentially misvalued services. In addition, the Secretary may conduct surveys, other data collection activities, studies, or other analyses, as the Secretary determines to be appropriate, to facilitate the review and appropriate adjustment of potentially misvalued services. This section also authorizes the use of analytic contractors to identify and analyze potentially misvalued codes, conduct surveys or collect data, and make recommendations on the review and appropriate adjustment of potentially misvalued services. Additionally, this section provides that the Secretary may coordinate the review and adjustment of any RVU with the periodic review described in section 1848(c)(2)(B) of the Act. Section 1848(c)(2)(K)(iii)(V) of the Act specifies that the Secretary may make appropriate coding revisions (including using existing processes for consideration of coding changes) that may include consolidation of individual services into bundled codes for payment under the PFS.

2. Progress in Identifying and Reviewing Potentially Misvalued Codes

To fulfill our statutory mandate, we have identified and reviewed numerous potentially misvalued codes as specified in section 1848(c)(2)(K)(ii) of the Act, and we plan to continue our work examining potentially misvalued codes in these areas over the upcoming years. As part of our current process, we identify potentially misvalued codes for review, and request recommendations from the RUC and other public commenters on revised work RVUs and direct PE inputs for those codes. The RUC, through its own processes, also identifies potentially misvalued codes for review. Through our public nomination process for potentially misvalued codes established in the CY 2012 PFS final rule with comment period, other individuals and stakeholder groups submit nominations for review of potentially misvalued codes as well.

Since CY 2009, as a part of the annual potentially misvalued code review and Five-Year Review process, we have reviewed over 1,560 potentially misvalued codes to refine work RVUs and direct PE inputs. We have assigned appropriate work RVUs and direct PE inputs for these services as a result of these reviews. A more detailed discussion of the extensive prior reviews of potentially misvalued codes is included in the CY 2012 PFS final rule with comment period (76 FR 73052 through 73055). In the CY 2012 final rule with comment period, we finalized our policy to consolidate the review of physician work and PE at the same time (76 FR 73055 through 73958), and established a process for the annual public nomination of potentially misvalued services.

In the CY 2013 final rule with comment period, we built upon the work we began in CY 2009 to review potentially misvalued codes that have not been reviewed since the implementation of the PFS (so-called “Harvard-valued codes”). In CY 2009, we requested recommendations from the RUC to aid in our review of Harvard-valued codes that had not yet been reviewed, focusing first on high-volume, low intensity codes (73 FR 38589). In the Fourth Five-Year Review, we requested recommendations from the RUC to aid in our review of Harvard-valued codes with annual utilization of greater than 30,000 (76 FR 32410). In the CY 2013 final rule with comment period, we identified as potentially misvalued Harvard-valued services with annual allowed charges that total at least $10,000,000. In addition to the Harvard-valued codes, in the CY 2013 final rule with comment period we finalized for review a list of potentially misvalued codes that have stand-alone PE (codes with physician work and no listed work time, and codes with no physician work and listed work time).

In the CY 2014 final rule with comment period, we finalized for review a list of potentially misvalued services. We included on the list for review ultrasound guidance codes that had longer procedure times than the typical procedure with which the code is billed to Medicare. We also finalized our proposal to replace missing post-operative hospital E/M visit information and work time for approximately 100 global surgery codes. In CY 2014, we also considered a proposal to limit Medicare PFS payments for services furnished in a non-facility setting when the PFS payment would exceed the combined Medicare payment made to the practitioner under the PFS and facility payment made to either the ASC or hospital outpatient. Based upon extensive public comment we did not finalize this proposal.

In the CY 2015 final rule with comment period, we finalized a list of potentially misvalued services. The potentially misvalued codes list included the publicly nominated CPT code 41530; two neurostimulator implantation codes, CPT 64553 and 64555; four epidural injection codes, CPT 62310, 62311, 62318 and 62319; three breast mammography codes, CPT 77055, 77056 and 77057; an abdominal aortic aneurysm ultrasound screening code, HCPCS G0389; a prostate biopsy code, G0416; and an obesity behavioral group counseling code, HCPCS G0473. We also finalized our “high expenditure services across specialty” screen as a tool to identify potentially misvalued codes though we did not finalize the particular list of codes identified in that rule as potentially misvalued. In CY 2015, we also considered and finalized a proposal addressing the valuation and coding of global surgical packages, which would revalue and transition 10 and 90-day global codes to 0-day codes. We also sought comment on approaches to revalue services that included moderate sedation as an inherent part of furnishing the procedure.

3. Validating RVUs of Potentially Misvalued Codes

Section 1848(c)(2)(L) of the Act requires the Secretary to establish a formal process to validate RVUs under the PFS. The Act specifies that the validation process may include validation of work elements (such as time, mental effort and professional judgment, technical skill and physical effort, and stress due to risk) involved with furnishing a service and may include validation of the pre-, post-, and intra-service components of work. The Secretary is directed, as part of the validation, to validate a sampling of the work RVUs of codes identified through any of the 16 categories of potentially misvalued codes specified in section 1848(c)(2)(K)(ii) of the Act. Furthermore, the Secretary may conduct the validation using methods similar to those used to review potentially misvalued codes, including conducting surveys, other data collection activities, studies, or other analyses as the Secretary determines to be appropriate to facilitate the validation of RVUs of services.

In the CY 2011 PFS proposed rule (75 FR 40068) and CY 2012 PFS proposed rule (76 FR 42790), we solicited public comments on possible approaches, methodologies, and data sources that we should consider for a validation process. A summary of the comments along with our responses is included in the CY 2011 PFS final rule with comment period (75 FR 73217) and the CY 2012 PFS final rule with comment period (73054 through 73055).

We contracted with two outside entities to develop validation models for RVUs. Given the central role of time in establishing work RVUs and the concerns that have been raised about the current time values used in rate setting, we contracted with the Urban Institute to collect time data from several practices for services selected by the contractor in consultation with CMS. Urban Institute has used a variety of approaches to develop objective time estimates, depending on the type of service. Objective time estimates will be compared to the current time values used in the fee schedule. The project team will then convene groups of physicians from a range of specialties to review the new time data and the potential implications for work and the ratio of work to time. Urban Institute has prepared an interim report, “Development of a Model for the Valuation of Work Relative Value Units,” which discusses the challenges encountered in collecting objective time data and offers some thoughts on how these can be overcome. This interim report is posted on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/RVUs-Validation-UrbanInterimReport.pdf. A final report will be available once the project is complete.

The second contract is with the RAND Corporation, which is using available data to build a validation model to predict work RVUs and the individual components of work RVUs, time and intensity. The model design was informed by the statistical methodologies and approach used to develop the initial work RVUs and to identify potentially misvalued procedures under current CMS and RUC processes. RAND consulted with a technical expert panel on model design issues and the test results. The RAND report is available on the CMS Web site under downloads for the CY 2015 PFS Final Rule with Comment Period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html.

4. CY 2016 Identification of Potentially Misvalued Services for Review

a. Public Nomination of Potentially Misvalued Codes

In the CY 2012 PFS final rule with comment period, we finalized a process for the public to nominate potentially misvalued codes (76 FR 73058). The public and stakeholders may nominate potentially misvalued codes for review by submitting the code with supporting documentation during the 60-day public comment period following the release of the annual PFS final rule with comment period. Supporting documentation for codes nominated for the annual review of potentially misvalued codes may include, but are not limited to, the following:

  • Documentation in the peer reviewed medical literature or other reliable data that there have been changes in physician work due to one or more of the following: technique; knowledge and technology; patient population; site-of-service; length of hospital stay; and work time.
  • An anomalous relationship between the code being proposed for review and other codes.
  • Evidence that technology has changed physician work, that is, diffusion of technology.
  • Analysis of other data on time and effort measures, such as operating room logs or national and other representative databases.
  • Evidence that incorrect assumptions were made in the previous valuation of the service, such as a misleading vignette, survey, or flawed crosswalk assumptions in a previous evaluation.
  • Prices for certain high cost supplies or other direct PE inputs that are used to determine PE RVUs are inaccurate and do not reflect current information.
  • Analyses of work time, work RVU, or direct PE inputs using other data sources (for example, Department of Veteran Affairs (VA) National Surgical Quality Improvement Program (NSQIP), the Society for Thoracic Surgeons (STS) National Database, and the Physician Quality Reporting System (PQRS) databases).
  • National surveys of work time and intensity from professional and management societies and organizations, such as hospital associations.

After we receive the nominated codes during the 60-day comment period following the release of the annual PFS final rule with comment period, we evaluate the supporting documentation and assess whether the nominated codes appear to be potentially misvalued codes appropriate for review under the annual process. In the following year's PFS proposed rule, we publish the list of nominated codes and indicate whether we are proposing each nominated code as a potentially misvalued code.

During the comment period on the CY 2015 proposed rule and final rule with comment period, we received nominations and supporting documentation for three codes to be considered as potentially misvalued codes. We evaluated the supporting documentation for each nominated code to ascertain whether the submitted information demonstrated that the code should be proposed as potentially misvalued.

CPT Code 36516 (Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion) was nominated for review as potentially misvalued. The nominator stated that CPT code 36516 is misvalued because of incorrect direct and indirect PE inputs and an incorrect work RVU. Specifically, the nominator stated that the direct supply costs failed to include an $18 disposable bag and the $37 cost for biohazard waste disposal of the post-treatment bag, and the labor costs associated with nursing being inaccurate. The nominator also stated that the overhead expenses associated with this service were unrealistic and that the current work RVU undervalues a physician's time and expertise. We are proposing this code as a potentially misvalued code. We note that we established a policy in CY 2011 to consider biohazard bags as an indirect expense, and not as a direct PE input (75 FR 73192).

CPT Codes 52441 (Cystourethroscopy with insertion of permanent adjustable transprostatic implant; single implant) and 52442 (Cystourethroscopy with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant) were nominated for review as potentially misvalued. The nominator stated that the costs of the direct practice expense inputs were inaccurate, including the cost of the implant. We are proposing these codes as potentially misvalued codes.

b. Electronic Analysis of Implanted Neurostimulator (CPT Codes 95970-95982)

All of the inputs for CPT codes 95971 (Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming), 95972 (Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, up to one hour) and 95973 (Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)) were reviewed and valued in the CY 2015 final rule with comment period (79 FR 67670). Due to significant time changes in the base codes, we believe the entire family detailed in Table 7 should be considered as potentially misvalued and reviewed in a manner consistent with our review of CPT codes 95971, 95972 and 95973.

Table 7—Proposed Potentially Misvalued Codes Identified in the Electronic Analysis of Implanted Neurostimulator Family Back to Top
HCPCS Short descriptor
95970 Analyze neurostim no prog.
95974 Cranial neurostim complex.
95975 Cranial neurostim complex.
95978 Analyze neurostim brain/1h.
95979 Analyz neurostim brain addon.
95980 Io anal gast n-stim init.
95981 Io anal gast n-stim subsq.
95982 Io ga n-stim subsq w/reprog.

c. Review of High Expenditure Services across Specialties with Medicare Allowed Charges of $10,000,000 or More

In the CY 2015 PFS rule, we proposed and finalized the high expenditure screen as a tool to identify potentially misvalued codes in the statutory category of “codes that account for the majority of spending under the PFS.” We also identified codes through this screen and proposed them as potentially misvalued in the CY 2015 PFS proposed rule (79 FR 40337-40338). However, given the resources required for the revaluation of codes with 10- and 90-day global periods, we did not finalize those codes as potentially misvalued codes in the CY 2015 PFS final rule with comment period. We stated that we would re-run the high expenditure screen at a future date, and subsequently propose the specific set of codes that meet the high expenditure criteria as potentially misvalued codes (79 FR 67578).

We believe that our current resources will not necessitate further delay in proceeding with the high expenditure screen for CY 2016. We have re-run the screen with the same criteria finalized in last year's rule. However, in developing this year's proposed list, we excluded all codes with 10- and 90-day global periods since we believe these codes should be reviewed as part of the global surgery revaluation. We are proposing the 118 codes listed in Table 8 as potentially misvalued codes, identified using the high expenditure screen under the statutory category, “codes that account for the majority of spending under the PFS.”

To develop this list, we followed the same approach taken last year except we excluded 10 and 90- day global periods. Specifically, we identified the top 20 codes by specialty (using the specialties used in Table 45) in terms of allowed charges. As we did last year, we excluded codes that we have reviewed since CY 2010, those with fewer than $10 million in allowed charges, and those that describe anesthesia or E/M services. We excluded E/M services from the list of proposed potentially misvalued codes for the same reasons that we excluded them in a similar review in CY 2012. These reasons were explained in the CY 2012 final rule with comment period (76 FR 73062 through 73065).

Table 8—Proposed Potentially Misvalued Codes Identified Through High Expenditure by Specialty Screen Back to Top
HCPCS Short descriptor
10022 Fna w/image
11100 Biopsy skin lesion
11101 Biopsy skin add-on
11730 Removal of nail plate
20550 Inj tendon sheath/ligament
20552 Inj trigger point 1/2 muscl
20553 Inject trigger points 3/>
22614 Spine fusion extra segment
22840 Insert spine fixation device
22842 Insert spine fixation device
22845 Insert spine fixation device
27370 Injection for knee x-ray
29580 Application of paste boot
31500 Insert emergency airway
31575 Diagnostic laryngoscopy
31579 Diagnostic laryngoscopy
31600 Incision of windpipe
33518 Cabg artery-vein two
36215 Place catheter in artery
36556 Insert non-tunnel cv cath
36569 Insert picc cath
36620 Insertion catheter artery
38221 Bone marrow biopsy
51700 Irrigation of bladder
51702 Insert temp bladder cath
51720 Treatment of bladder lesion
51728 Cystometrogram w/vp
51729 Cystometrogram w/vp&up
51784 Anal/urinary muscle study
51797 Intraabdominal pressure test
51798 Us urine capacity measure
52000 Cystoscopy
55700 Biopsy of prostate
58558 Hysteroscopy biopsy
67820 Revise eyelashes
70491 Ct soft tissue neck w/dye
70543 Mri orbt/fac/nck w/o &w/dye
70544 Mr angiography head w/o dye
70549 Mr angiograph neck w/o&w/dye
71010 Chest x-ray 1 view frontal
71020 Chest x-ray 2vw frontal&latl
71260 Ct thorax w/dye
71270 Ct thorax w/o & w/dye
72195 Mri pelvis w/o dye
72197 Mri pelvis w/o & w/dye
73110 X-ray exam of wrist
73130 X-ray exam of hand
73718 Mri lower extremity w/o dye
73720 Mri lwr extremity w/o&w/dye
74000 X-ray exam of abdomen
74022 X-ray exam series abdomen
74181 Mri abdomen w/o dye
74183 Mri abdomen w/o & w/dye
75635 Ct angio abdominal arteries
75710 Artery x-rays arm/leg
75978 Repair venous blockage
76512 Ophth us b w/non-quant a
76519 Echo exam of eye
76536 Us exam of head and neck
77059 Mri both breasts
77263 Radiation therapy planning
77334 Radiation treatment aid(s)
77470 Special radiation treatment
78306 Bone imaging whole body
78452 Ht muscle image spect mult
88185 Flowcytometry/tc add-on
88189 Flowcytometry/read 16 & >
88321 Microslide consultation
88360 Tumor immunohistochem/manual
88361 Tumor immunohistochem/comput
91110 Gi tract capsule endoscopy
92002 Eye exam new patient
92136 Ophthalmic biometry
92240 Icg angiography
92250 Eye exam with photos
92275 Electroretinography
92557 Comprehensive hearing test
92567 Tympanometry
93280 Pm device progr eval dual
93288 Pm device eval in person
93293 Pm phone r-strip device eval
93294 Pm device interrogate remote
93295 Dev interrog remote 1/2/mlt
93296 Pm/icd remote tech serv
93306 Tte w/doppler complete
93350 Stress tte only
93351 Stress tte complete
93503 Insert/place heart catheter
93613 Electrophys map 3d add-on
93965 Extremity study
94010 Breathing capacity test
94620 Pulmonary stress test/simple
95004 Percut allergy skin tests
95165 Antigen therapy services
95957 Eeg digital analysis
96101 Psycho testing by psych/phys
96116 Neurobehavioral status exam
96118 Neuropsych tst by psych/phys
96360 Hydration iv infusion init
96372 Ther/proph/diag inj sc/im
96374 Ther/proph/diag inj iv push
96375 Tx/pro/dx inj new drug addon
96401 Chemo anti-neopl sq/im
96402 Chemo hormon antineopl sq/im
96409 Chemo iv push sngl drug
96411 Chemo iv push addl drug
96567 Photodynamic tx skin
96910 Photochemotherapy with uv-b
97032 Electrical stimulation
97035 Ultrasound therapy
97110 Therapeutic exercises
97112 Neuromuscular reeducation
97113 Aquatic therapy/exercises
97116 Gait training therapy
97140 Manual therapy 1/regions
97530 Therapeutic activities
97535 Self care mngment training
G0283 Elec stim other than wound

5. Valuing Services That Include Moderate Sedation as an Inherent Part of Furnishing the Procedure

The CPT manual includes more than 400 diagnostic and therapeutic procedures, listed in Appendix G, for which CPT has determined that moderate sedation is an inherent part of furnishing the procedure. Therefore, only the procedure code is reported when furnishing the service, and in developing RVUs for these services, we include the resource costs associated with moderate sedation in the valuation of these diagnostic and therapeutic procedures. To the extent that moderate sedation is inherent in the diagnostic or therapeutic service, we believe that the inclusion of moderate sedation in the valuation of the procedure is accurate. In the CY 2015 PFS proposed rule (79 FR 40349), we noted that it appeared that practice patterns for endoscopic procedures were changing, with anesthesia increasingly being separately reported for these procedures. Due to the changing nature of medical practice, we noted that we were considering establishing a uniform approach to valuation for all Appendix G services. We continue to seek an approach that is based on using the best available objective information about the provision of moderate sedation broadly, rather than merely addressing this issue on a code-by-code basis using RUC survey data when individual procedures are revalued. We sought public comment on approaches to address the appropriate valuation of these services given that moderate sedation is no longer inherent for many of these services. To the extent that Appendix G procedure values are adjusted to no longer include moderate sedation, we requested suggestions as to how moderate sedation should be reported and valued, and how to remove from existing valuations the RVUs and inputs related to moderate sedation.

To establish an approach to valuation for all Appendix G services based on the best data about the provision of moderate sedation, we need to determine the extent of the misvaluation for each code. We know that there are standard packages for the direct PE inputs associated with moderate sedation, and we began to develop approaches to estimate how much of the work is attributable to moderate sedation. However, we believe that we should seek input from the medical community prior to proposing changes in values for these services, given the different methodologies used to develop work RVUs for the hundreds of services in Appendix G. Therefore, we are seeking recommendations from the RUC and other interested stakeholders for appropriate valuation of the work associated with moderate sedation before formally proposing an approach that allows Medicare to adjust payments based on the resource costs associated with the moderate sedation or anesthesia services that are being furnished.

The anesthesia procedure codes 00740 (Anesthesia for procedure on gastrointestinal tract using an endoscope) and 00810 (Anesthesia for procedure on lower intestine using an endoscope) are used for anesthesia furnished in conjunction with lower GI procedures. In reviewing Medicare claims data, we noted that a separate anesthesia service is now reported more than 50 percent of the time that several types of colonoscopy procedures are reported. Given the significant change in the relative frequency with which anesthesia codes are reported with colonoscopy services, we believe the relative values of the anesthesia services should be re-examined. Therefore, we are proposing to identify CPT codes 00740 and 00810 as potentially misvalued. We welcome comments on both of these issues.

6. Improving the Valuation and Coding of the Global Package

a. Proposed Transition of 10-Day and 90-Day Global Packages Into 0-Day Global Packages

In the CY 2015 PFS final rule (79 FR 67582 through 67591) we finalized a policy to transition all 10-day and 90-day global codes to 0-day global codes to improve the accuracy of valuation and payment for the various components of global surgical packages, including pre- and post-operative visits and performance of the surgical procedure. Although we have marginally addressed some of the concerns noted with global packages in previous rulemaking, we believe there is still an unmet need to address some of the fundamental issues with the 10- and 90-day post-operative global packages. We believe it is critical that the RVUs used to develop PFS payment rates reflect the most accurate resource costs associated with PFS services. We believe that valuing global codes that package services together without objective, auditable data on the resource costs associated with the components of the services contained in the packages may significantly skew relativity and create unwarranted payment disparities within PFS fee-for-service payment. We also believe that the resource based valuation of individual physicians' services will continue to serve as a critical foundation for Medicare payment to physicians. Therefore, we believe it is critical that the RVUs under the PFS be based as closely and accurately as possible on the actual resources involved in furnishing the typical occurrence of specific services.

We stated our belief that transforming all 10- and 90-day global codes to 0-day global codes would:

  • Increase the accuracy of PFS payment by setting payment rates for individual services based more closely upon the typical resources used in furnishing the procedures;
  • Avoid potentially duplicative or unwarranted payments when a beneficiary receives post-operative care from a different practitioner during the global period;
  • Eliminate disparities between the payment for E/M services in global periods and those furnished individually;
  • Maintain the same-day packaging of pre- and post-operative physicians' services in the 0-day global; and
  • Facilitate availability of more accurate data for new payment models and quality research.

b. Impact of the Medicare Access and CHIP Reauthorization Act of 2015

The Medicare Access and CHIP Reauthorization Act (MACRA) was enacted into law on April 16, 2015. Section 523 of the MACRA addresses payment for global surgical packages. Section 523(a) adds a new paragraph at section 1848(c)(8) of the Act. Section 1848(c)(8)(A)(i) of the Act prohibits the Secretary from implementing the policy established in the CY 2015 PFS final rule with comment period that would have transitioned all 10-day and 90-day global surgery packages to 0-day global periods. Section 1848(c)(8)(A)(ii) of the Act provides that nothing in the previous clause shall be construed to prevent the Secretary from revaluing misvalued codes for specific surgical services or assigning values to new or revised codes for surgical services.

Section 1848(c)(8)(B)(i) of the Act requires CMS to develop through rulemaking a process to gather information needed to value surgical services from a representative sample of physicians, and requires that the data collection shall begin no later than January 1, 2017. The collected information must include the number and level of medical visits furnished during the global period and other items and services related to the surgery, as appropriate. This information must be reported on claims at the end of the global period or in another manner specified by the Secretary. Section 1848(c)(8)(B)(ii) of the Act requires that, every 4 years, we must reassess the value of this collected information, and allows us to discontinue the collection if the Secretary determines that we have adequate information from other sources in order to accurately value global surgical services. Section 1848(c)(8)(B)(iii) of the Act specifies that the Inspector General will audit a sample of the collected information to verify its accuracy. Section 1848(c)(8)(C) of the Act requires that, beginning in CY 2019, we must use the information collected as appropriate, along with other available data, to improve the accuracy of valuation of surgical services under the PFS. Section 523(b) of the MACRA adds a new paragraph at section 1848(c)(9) of the Act which authorizes the Secretary, through rulemaking, to delay up to 5 percent of the PFS payment for services for which a physician is required to report information under section 1848(c)(8)(B)(i) of the Act until the required information is reported.

Since section 1848(c)(8)(B)(i) of the Act, as added by section 523(a) of the MACRA, requires us to use rulemaking to develop and implement the process to gather information needed to value surgical services no later than January 1, 2017, we are seeking input from stakeholders on various aspects of this task. We are soliciting comments from the public regarding the kinds of auditable, objective data (including the number and type of visits and other services furnished by the practitioner reporting the procedure code during the current post-operative periods) needed to increase the accuracy of the values for surgical services. We are also seeking comment on the most efficient means of acquiring these data as accurately and efficiently as possible. For example, we seek information on the extent to which individual practitioners or practices may currently maintain their own data on services, including those furnished during the post-operative period, and how we might collect and objectively evaluate those data for use in increasing the accuracy of the values beginning in CY 2019. We will use the information from the public comments to help develop a proposed approach for the collection of this information in future rulemaking.

Section 1848(c)(8)(C) of the Act mandates that we use the collected data to improve the accuracy of valuation of surgery services beginning in 2019. We described in previous rulemaking (79 FR 67582 through 67591) the limitations and difficulties involved in the appropriate valuation of the global packages, especially when the values of the component services are not clear. We are seeking public comment on potential methods of valuing the individual components of the global surgical package, including the procedure itself, and the pre- and post-operative care, including the follow-up care during post-operative days. We are particularly interested in stakeholder input regarding the overall accuracy of the values and descriptions of the component services within the global packages. For example, we seek information from stakeholders on whether (both qualitatively and quantitatively) postoperative visits differ from other E/M services. We are also interested in stakeholder input on what other items and services related to the surgery, aside from postoperative visits, are furnished to beneficiaries during post-operative care. We believe that stakeholder input regarding these questions will help determine what data should be collected, as well as how to improve the accuracy of the valuations. We welcome the full range of public feedback from stakeholders to assist us in this process.

We intend to provide further opportunities for public feedback prior to developing a proposal for CY 2017 to collect this required data. We also seek comments regarding stakeholder interest in the potential for an open door forum, town hall meetings with the public, or other avenues for direct communication regarding implementation of these provisions of the Act.

D. Refinement Panel

1. Background

As discussed in the CY 1993 PFS final rule with comment period (57 FR 55938), we adopted a refinement panel process to assist us in reviewing the public comments on CPT codes with interim final work RVUs for a year and in developing final work values for the subsequent year. We decided the panel would be composed of a multispecialty group of physicians who would review and discuss the work involved in each procedure under review, and then each panel member would individually rate the work of the procedure. We believed establishing the panel with a multispecialty group would balance the interests of the specialty societies who commented on the work RVUs with the budgetary and redistributive effects that could occur if we accepted extensive increases in work RVUs across a broad range of services.

Following enactment of section 1848(c)(2)(K) of the Act, which required the Secretary periodically to identify and review potentially misvalued codes and make appropriate adjustments to the RVUs, we reassessed the refinement panel process. As detailed in the CY 2011 PFS final rule with comment period (75 FR 73306), we continued using the established refinement panel process with some modifications.

For CY 2015, in light of the changes we made to the process for valuing new, revised and potentially misvalued codes (79 FR 67606), we reassessed the role that the refinement panel process plays in the code valuation process. We noted that the current refinement panel process is tied to the review of interim final values. It provides an opportunity for stakeholders to provide new clinical information that was not available at the time of the RUC valuation that might affect work RVU values that are adopted in the interim final value process. For CY 2015 interim final rates, we stated in the CY 2015 PFS final rule with comment period that we will use the refinement panel process as usual for these codes (79 FR 67609).

2. CY 2016 Refinement Panel Proposal

Beginning in CY 2016, we are proposing to permanently eliminate the refinement panel and instead publish the proposed rates for all interim final codes in the PFS proposed rule for the subsequent year. For example, we will publish the proposed rates for all CY 2016 interim final codes in the CY 2017 PFS proposed rule. With the change in the process for valuing codes adopted in the CY 2015 final rule with comment period (79 FR 67606), proposed values for most codes that are being valued for CY 2016 will be published in the CY 2016 PFS proposed rule. As explained in the CY 2015 final rule with comment period, only a small number of codes being valued for CY 2016 will be published as interim final in the 2016 PFS final rule with comment period and be subject to comment. We will evaluate the comments we receive on these code values, and both respond to these comments and propose values for these codes for CY 2017 in the CY 2017 PFS proposed rule. Therefore, stakeholders will have two opportunities to comment and to provide any new clinical information that was not available at the time of the RUC valuation that might affect work RVU values that are adopted on an interim final basis. We believe that this proposed process, which includes two opportunities for public notice and comment, offers stakeholders a better mechanism and ample opportunity for providing any additional data for our consideration, and discussing any concerns with our interim final values, than the current refinement process. It also provides greater transparency because comments on our rules are made available to the public at www.regulations.gov. We welcome comments on this proposed change to eliminate the use of refinement panels in our process for establishing final values for interim final codes.

E. Improving Payment Accuracy for Primary Care and Care Management Services

We are committed to supporting primary care, and we have increasingly recognized care management as one of the critical components of primary care that contributes to better health for individuals and reduced expenditure growth (77 FR 68978). Accordingly, we have prioritized the development and implementation of a series of initiatives designed to improve the accuracy of payment for, and encourage long-term investment in, care management services.

In addition to the Medicare Shared Savings Program, various demonstration initiatives including the Pioneer Accountable Care Organization (ACO), the patient-centered medical home model in the Multi-payer Advanced Primary Care Practice (MAPCP), the Federally Qualified Health Center (FQHC) Advanced Primary Care Practice demonstration, the Comprehensive Primary Care (CPC) initiative, among others (see the CY 2015 PFS final rule (79 FR 67715) for a discussion of these), we also have continued to explore potential refinements to the PFS that would appropriately value care management within Medicare's statutory structure for fee-for-service physician payment and quality reporting. The payment for some non-face-to-face care management services is bundled into the payment for face-to-face evaluation and management (E/M) visits. However, because the current E/M office/outpatient visit CPT codes were designed with an overall orientation toward episodic treatment, we have recognized that these E/M codes may not reflect all the services and resources involved with furnishing certain kinds of care, particularly comprehensive, coordinated care management for certain categories of beneficiaries.

Over several years, we have developed proposals and sought stakeholder input regarding potential PFS refinements to improve the accuracy of payment for care management services. For example, in the CY 2013 PFS final rule with comment period, we adopted a policy to pay separately for transitional care management (TCM) involving the transition of a beneficiary from care furnished by a treating physician during an inpatient stay to care furnished by the beneficiary's primary physician in the community (77 FR 68978 through 68993). In the CY 2014 PFS final rule with comment period, we finalized a policy, beginning in CY 2015 (78 FR 74414), to pay separately for chronic care management (CCM) services furnished to Medicare beneficiaries with two or more chronic conditions. We believe that these new separately billable codes more accurately describe, recognize, and make payment for non-face-to-face care management services furnished by practitioners and clinical staff to particular patient populations.

We view ongoing refinements to payment for care management services as part of a broader strategy to incorporate input and information gathered from research, initiatives, and demonstrations conducted by CMS and other public and private stakeholders, the work of all parties involved in the potentially misvalued code initiative, and, more generally, from the public at large. Based on input and information gathered from these sources, we are considering several potential refinements that would continue our efforts to improve the accuracy of PFS payments. In this section, we discuss these potential refinements.

1. Improved Payment for the Professional Work of Care Management Services

Although both the TCM and CCM services describe certain aspects of professional work, some stakeholders have suggested that neither of these new sets of codes nor the inputs used in their valuations explicitly account for all of the services and resources associated with the more extensive cognitive work that primary care physicians and other practitioners perform in planning and thinking critically about the individual chronic care needs of particular subsets of Medicare beneficiaries. Stakeholders assert that the time and intensity of the cognitive efforts are in addition to the work typically required to supervise and manage the clinical staff associated with the current TCM and CCM codes. Similarly, we continue to receive requests from a few stakeholders for CMS to lead efforts to revise the current CPT E/M codes or construct a new set of E/M codes. The goal of such efforts would be to better describe and value the physician work (time and intensity) specific to primary care and other cognitive specialties in the context of complex care of patients relative to the time and intensity of the procedure-oriented care physicians and practitioners, who use the same codes to report E/M services. Some of these stakeholders have suggested that in current medical practice, many physicians, in addition to the time spent treating acute illnesses, spend substantial time working toward optimal outcomes for patients with chronic conditions and patients they treat episodically, which can involve additional work not reflected in the codes that describe E/M services since that work is not typical across the wide range of practitioners that report the same codes. According to these groups, this work involves medication reconciliation, the assessment and integration of numerous data points, effective coordination of care among multiple other clinicians, collaboration with team members, continuous development and modification of care plans, patient or caregiver education, and the communication of test results.

We agree with stakeholders that it is important for Medicare to use codes that accurately describe the services furnished to Medicare beneficiaries and to accurately reflect the relative resources involved with furnishing those services. Therefore, we are interested in receiving public comments on ways to recognize the different resources (particularly in cognitive work) involved in delivering broad-based, ongoing treatment, beyond those resources already incorporated in the codes that describe the broader range of E/M services. The resource costs of this work may include the time and intensity related to the management of both long-term and, in some cases, episodic conditions. In order to appropriately recognize the different resource costs for this additional cognitive work within the structure of PFS resource-based payments, we are particularly interested in codes that could be used in addition to, not instead of, the current E/M codes.

In principle, these codes could be similar to the hundreds of existing add-on codes that describe additional resource costs, such as additional blocks or slides in pathology services, additional units of repair in dermatologic procedures, or additional complexity in psychotherapy services. For example, these codes might allow for the reporting of the additional time and intensity of the cognitive work often undertaken by primary care and other cognitive specialties in conjunction with an evaluation and management service, much like add-on codes for certain procedures or diagnostic test describe the additional resources sometimes involved in furnishing those services. Similar to the CCM code, the codes might describe the increased resources used over a longer period of time than during one patient visit. For example, the add-on codes could describe the professional time in excess of 30 minutes and/or a certain set of furnished services, per one calendar month for a single patient to coordinate care, provide patient or caregiver education, reconcile and manage medications, assess and integrate data, or develop and modify care plans. Such activity may be particularly relevant for the care of patients with multiple or complicated chronic or acute conditions and should contribute to optimal patient outcomes, including more coordinated, safer care.

Like CCM, we would require that the patient have an established relationship with the billing professional; and additionally, the use of an add-on code would require the extended professional resources to be reported with another separately payable service. However, in contrast to the CCM code, the new codes might be reported based on the resources involved in professional work, instead of the resource costs in terms of clinical staff time. The codes might also apply broadly to patients in a number of different circumstances, and would not necessarily make reporting the code(s) contingent on particular business models or technologies for medical practices. We are interested in stakeholder comments on the kinds of services that involve the type of cognitive work described above and whether or not the creation of particular codes might improve the accuracy of the relative values used for such services on the PFS. Finally, we are interested in receiving information from stakeholders on the overlap between the kinds of cognitive resource costs discussed above and those already accounted for through the currently payable codes that describe CCM and other care management services.

We strongly encourage stakeholders to comment on this topic in order to assist us in developing potential proposals to address these issues through rulemaking in CY 2016 for implementation in CY 2017. We anticipate using this approach, which would parallel our multi-year approach for implementing CCM and TCM services, in order to facilitate broader input from stakeholders regarding details of implementing such codes, including their structure and description, valuation, and any requirements for reporting.

2. Establishing Separate Payment for Collaborative Care

We believe that the care and management for Medicare beneficiaries with multiple chronic conditions, a particularly complicated disease or acute condition, or common behavioral health conditions often requires extensive discussion, information-sharing and planning between a primary care physician and a specialist (for example, with a neurologist for a patient with Alzheimer's disease plus other chronic diseases). We note that for CY 2014, CPT created four codes that describe interprofessional telephone/internet consultative services (CPT codes 99446-99449). Because Medicare pays for telephone consultations with or about a beneficiary as a part of other services furnished to the beneficiary, we currently do not make separate payment for these services. We note that such interprofessional consultative services are distinct from the face-to-face visits previously reported to Medicare using the consultation codes, and we refer the reader to the CY 2010 PFS final rule for information regarding Medicare payment policies for those services (74 FR 61767).

However, in considering how to improve the accuracy of our payments for care coordination particularly for patients requiring more extensive care, we are seeking comment on how Medicare might accurately account for the resource costs of a more robust interprofessional consultation within the current structure of PFS payment. For example, we would be interested in stakeholders' perspectives regarding whether there are conditions under which it might be appropriate to make separate payment for services like those described by these CPT codes. We are interested in stakeholder input regarding the parameters of, and resources involved in these collaborations between a specialist and primary care practitioner, especially in the context of the structure and valuation of current E/M services. In particular, we are interested in comments about how these collaborations could be distinguished from the kind of services included in other E/M services, how these services could be described if stakeholders believe the current CPT codes are not adequate, and how these services should be valued on the PFS. We are also interested in comments on whether we should tie those interprofessional consultations to a beneficiary encounter and on developing appropriate beneficiary protections to ensure that beneficiaries are fully aware of the involvement of the specialist in the beneficiary's care and the associated benefits of the collaboration between the primary care physician and the specialist physician prior to being billed for such services.

Additionally, we are seeking comment on whether this kind of care might benefit from inclusion in a CMMI model that would allow Medicare to test its effectiveness with a waiver of beneficiary financial liability and/or variation of payment amounts for the consulting and the primary care practitioners. Without such protections, beneficiaries could be responsible for coinsurance for services of physicians whose role in the beneficiary's care is not necessarily understood by the beneficiary. Finally, we also are seeking comment on key technology supports needed to support collaboration between specialist and primary care practitioners in support of high quality care management services, on whether we should consider including technology requirements as part of any proposed services, and on how such requirements could be implemented in a way that minimizes burden on providers. We strongly encourage stakeholders to comment on this topic in order to assist us in developing potential proposals to address these issues through rulemaking in CY 2016 for implementation in CY 2017. We anticipate using this approach, which would parallel our multi-year approach for implementing CCM and TCM services, in order to facilitate broader input from stakeholders regarding details of implementing such codes, including their structure and description, valuation, and any requirements for reporting.

a. Collaborative Care Models for Beneficiaries With Common Behavioral Health Conditions

In recent years, many randomized controlled trials have established an evidence base for an approach to caring for patients with common behavioral health conditions called “Collaborative Care.” Collaborative care typically is provided by a primary care team, consisting of a primary care provider and a care manager, who works in collaboration with a psychiatric consultant, such as a psychiatrist. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. Several resources have been published that describe collaborative care models in greater detail and assess their impact, including pieces from the University of Washington (http://aims.uw.edu/), the Institute for Clinical and Economic Review (http://ctaf.org/reports/integration-behavioral-health-primary-care), and the Cochrane Collaboration (http://www.cochrane.org/CD006525/DEPRESSN_collaborative-care-for-people-with-depression-and-anxiety).

Because this particular kind of collaborative care model has been tested and documented in medical literature, we are particularly interested in seeking comment on how coding under the PFS might facilitate appropriate valuation of the services furnished under such a collaborative care model. As these kinds of collaborative models of care become more prevalent, we will evaluate potential refinements to the PFS to account for the provision of services through such a model. We are seeking information to assist us in considering refinements to coding and payment to address this model in particular. We also would assess application of the collaborative care model for other diagnoses and treatment modalities. For example, we seek comments on how a code similar to the CCM code applicable to multiple diagnoses and treatment plans could be used to describe collaborative care services, as well as other interprofessional services and could be appropriately valued and reported within the resource-based relative value PFS system, and how the resources involved in furnishing such services could be incorporated into the current set of PFS codes without overlap. We also request input on whether requirements similar to those used for CCM services should apply to a new collaborative care code, and whether such a code could be reported in conjunction with CCM or other E/M services. For example, we might consider whether the code should describe a minimum amount of time spent by the psychiatric consultant for a particular patient per one calendar month and be complemented by either the CCM or other care management code to support the care management and primary care elements of the collaborative care model. As with our discussion on interprofessional consultation in this section of the proposed rule, because the patient may not have direct contact with the psychiatric consultant, we seek comment on whether and, if so, how written consent for the non-face-to-face services should be required prior to practitioners reporting any new interprofessional consultation code or the care management code.

We are also seeking comment on appropriate care delivery requirements for billing, the appropriateness of CCM technology requirements or other technology requirements for these services, necessary qualifications for psychiatric consultants, and whether or not there are particular conditions for which payment would be more appropriate than others; as well as how these services may interact with quality reporting, the resource inputs we might use to value the services under the PFS (specifically, work RVUs, time, and direct PE inputs), and whether or not separate codes should be developed for the psychiatric consultant and the care management components of the service.

We are also seeking comment on whether this kind of care model should be implemented through a CMMI demonstration that would allow Medicare to test its effectiveness with a waiver of beneficiary financial liability and/or variation of payment methodology and amounts for the psychiatric consultant and the primary care physician. Again, we strongly encourage stakeholders to comment on this topic in order to assist us in developing potential proposals to address these issues through rulemaking in CY 2016 for implementation in CY 2017.

3. CCM and TCM Services

a. Reducing Administrative Burden for CCM and TCM Services

In CY 2013, we implemented separate payment for TCM services, and in CY 2015, we implemented separate payment for CCM services. Both have many service elements and billing requirements that the physician or nonphysician practitioner must satisfy in order to fully furnish these services and to report these codes (77 FR 68989, 79 FR 67728). These elements and requirements are relatively extensive and generally exceed those for otherE/M and similar services. Since the implementation of these services, some practitioners have stated that the service elements and billing requirements are too burdensome, and suggested that they interfere with their ability to provide these care management services to their patients who could benefit from them. In light of this feedback from the physician and practitioner community, we are soliciting comments on steps that we could take to further improve beneficiary access to TCM and CCM services. Our aims in implementing separate payment for these services are that Medicare practitioners are paid appropriately for the services they furnish, and that beneficiaries receive comprehensive care management that benefits their long term health outcomes. However, we understand that excessive requirements on practitioners could possibly undermine the overall goals of the payment policies. We are interested in stakeholder input in how we can best balance access to these services and practitioner burdens such that Medicare beneficiaries may obtain the full benefit of these services.

b. Payment for CPT Codes Related to CCM Services

As we stated in the CY 2015 PFS final rule (79 FR 67719), we believe that Medicare beneficiaries with two or more chronic conditions as defined under the CCM code can benefit from the care management services described by that code, and we want to make this service available to all such beneficiaries. As with most services paid under the PFS, we recognize that furnishing CCM services to some beneficiaries will require more resources and some less; but we value and make payment based upon the typical service. Because CY 2015 is the first year for which we are making separate payment for CCM services, we are seeking information regarding the circumstances under which this service is furnished. This information includes the clinical status of the beneficiaries receiving the service and the resources involved in furnishing the service, such as the number of documented non-face-to-face minutes furnished by clinical staff in the months the code is reported. We would be interested in examining such information in order to identify the range of minutes furnished over those months as well as the distribution of the number of minutes within the total volume of services. We are also seeking objective data regarding the resource costs associated with furnishing the services described by this code. As we review that information, in addition to our own claims data, we will consider any changes in payment and coding that may be warranted in the coming years, including the possibility of establishing separate payment amounts and making Medicare payment for the related CPT codes, such as the complex care coordination codes, CPT codes 99487 and 99489.

F. Target for Relative Value Adjustments for Misvalued Services

Section 220(d) of the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. 113-93, enacted on April 1, 2014) added a new subparagraph at section 1848(c)(2) of the Act to establish an annual target for reductions in PFS expenditures resulting from adjustments to relative values of misvalued codes. Under section 1848(c)(2)(O)(ii) of the Act, if the estimated net reduction in expenditures for a year is equal to or greater than the target for the year, reduced expenditures attributable to such adjustments shall be redistributed in a budget-neutral manner within the PFS in accordance with the existing budget neutrality requirement under section 1848(c)(2)(B)(ii)(II) of the Act. The provision also specifies that the amount by which such reduced expenditures exceeds the target for a given year shall be treated as a net reduction in expenditures for the succeeding year, for purposes of determining whether the target has been met for that subsequent year. Section 1848(c)(2)(O)(iv) of the Act defines a target recapture amount as the amount by which the target for the year exceeds the estimated net reduction in expenditures under the PFS resulting from adjustments to RVUs for misvalued codes. Section 1848(c)(2)(O)(iii) of the Act specifies that, if the estimated net reduction in PFS expenditures for the year is less than the target for the year, an amount equal to the target recapture amount shall not be taken into account when applying the budget neutrality requirements specified in section 1848(c)(2)(B)(ii)(II) of the Act. Section 220(d) of the PAMA applied to calendar years (CYs) 2017 through 2020 and set the target under section 1848(c)(2)(O)(v) of the Act at 0.5 percent of the estimated amount of expenditures under the PFS for each of those 4 years.

Section 202 of the Achieving a Better Life Experience Act of 2014 (ABLE) (Division B of Pub. L. 113-295, enacted December 19, 2014)) amended section 1848(c)(2)(O) of the Act to accelerate the application of the PFS expenditure reduction target to CYs 2016, 2017, and 2018, and to set a 1 percent target for CY 2016 and 0.5 percent for CYs 2017 and 2018. As a result of these provisions, if the estimated net reduction for a given year is less than the target for that year, payments under the fee schedule will be reduced.

In this section, we are proposing a methodology to implement this statutory provision in a manner consistent with the broader statutory construct of the PFS. In developing this proposed methodology, we have identified several aspects of our approach for which we are specifically seeking comment. We have organized this discussion by identifying and explaining these aspects in particular but we are seeking comment on all aspects of our proposal.

1. Distinguishing “Misvalued Code” Adjustments From Other RVU Adjustments

The potentially misvalued code initiative has resulted in changes in PFS payments in several ways. First, potentially misvalued codes have been identified, reviewed, and revalued through notice and comment rulemaking. However, in many cases, the identification of particular codes as potentially misvalued has led to the review and revaluation of related codes, and frequently, to revisions to the underlying coding for large sets of related services. Similarly, the review of individual codes has initiated reviews and proposals to make broader adjustments to values for codes across the PFS, such as when the review of a series of imaging codes prompted a RUC recommendation and CMS proposal to update the direct PE inputs for imaging services to assume digital instead of film costs. This change, originating through the misvalued code initiative, resulted in a significant reduction in RVUs for a large set of PFS services, even though the majority of affected codes were not initially identified through potentially misvalued code screens. Finally, due to both the relativity inherent in the PFS ratesetting process and the budget neutrality requirements specified in section 1848(c)(2)(B)(ii)(II) of the Act, adjustments to the RVUs for individual services necessarily result in the shifting of RVUs to broad sets of other services across the PFS.

To implement the PFS expenditure reduction target provisions under section 1848(c)(2)(O) of the Act, we must identify a subset of the adjustments in RVUs for a year to reflect an estimated “net reduction” in expenditures. Therefore, we dismissed the possibility of including all changes in RVUs for a year in calculating the estimated net reduction in PFS expenditures, even though we believe that the redistributions in RVUs to other services are an important aspect of the potentially misvalued code initiative. Conversely, we similarly considered the possibility of limiting the calculation of the estimated net reduction in expenditures to reflect RVU adjustments made to the codes formally identified as “potentially misvalued.” We do not believe that calculation would reflect the significant changes in payments that have directly resulted from the review and revaluation of misvalued codes under section 1848(c)(2) of the Act. We further considered whether to include only those codes that underwent a comprehensive review (work and PE). As we previously have stated (76 FR 73057), we believe that a comprehensive review of the work and PE for each code leads to the more accurate assignment of RVUs and appropriate payments under the PFS than do fragmentary adjustments for only one component. However, if we calculated the net reduction in expenditures using revisions to RVUs only from comprehensive reviews, the calculation would not include changes in PE RVUs that result from proposals like the film-to-digital change for imaging services, which not only originated from the review of potentially misvalued codes, but substantially improved the accuracy of PFS payments faster and more efficiently than could have been done through the multiple-year process required to complete a comprehensive review of all imaging codes.

After considering these options, we believe that the best approach is to define the reduction in expenditures as a result of adjustments to RVUs for misvalued codes to include the estimated pool of all services with revised input values. This would limit the pool of RVU adjustments used to calculate the net reduction in expenditures to those for the services for which individual, comprehensive review or broader proposed adjustments have resulted in changes to service-level inputs of work RVUs, direct PE inputs, or MP RVUs, as well as services directly affected by changes to coding for related services. For example, coding changes in certain codes can sometimes necessitate revaluations for related codes that have not been reviewed as misvalued codes, because the coding changes have also affected the scope of the related services. This definition would incorporate all reduced expenditures from revaluations for services that are deliberately addressed as potentially misvalued codes, as well as those for services with broad-based adjustments like film-to-digital and services that are redefined through coding changes as a result of the review of misvalued codes.

Because the annual target is calculated by measuring changes from one year to the next, we also considered how to account for changes in values that are best measured over 3 years, instead of 2 years. Under our current process, the overall change in valuation for many misvalued codes is measured across values for 3 years: The original value in the first year, the interim final value in the second year, and the finalized value in the third year. As we describe in section II.I.2. of this proposed rule, our misvalued code process has been to establish interim final RVUs for the potentially misvalued, new, and revised codes in the final rule with comment period for a year. Then, during the 60-day period following the publication of the final rule with comment period, we accept public comment about those valuations. For the final rule with comment period for the subsequent year, we consider and respond to public comments received on the interim final values, and make any appropriate adjustments to values based on those comments. However, the straightforward calculation of the target would only compare changes between 2 years and not among 3 years, so the contribution of a particular change towards the target for any single year would be measured against only the preceding year without regard to the overall change that takes place over 3 years.

For recent years, interim final values for misvalued codes (year 2) have generally reflected reductions relative to original values (year 1), and for most codes, the interim final values (year 2) are maintained and finalized (year 3). However, when values for particular codes have changed between the interim final (year 2) and final values (year 3) based on public comment, the general tendency has been that codes increase in the final value (year 3) relative to the interim final value (year 2), even in cases where the final value (year 3) represents a decrease from the original value (year 1). Therefore, for these codes, the year 2 changes compared to year 1 would risk over-representing the overall reduction, while the year 3 to year 2 changes would represent an increase in value. If there were similar targets in every PFS year, and a similar number of misvalued code changes made on an interim final basis, the incongruence in measuring what is really a 3-year change in 2-year increments might not be particularly problematic since each year's calculation would presumably include a similar number of codes measured between years 1 and 2 and years 2and 3.

However, including changes that take place over 3 years is particularly problematic for calculating the target for CY 2016 for two reasons. First, CY 2015 was the final full year of establishing interim final values for all new, revised, and potentially misvalued codes. Starting with this proposed rule, we are proposing and finalizing values for a significant portion of misvalued codes during one calendar year. Therefore, CY 2015 will include a disproportionate number of services that would be measured between years 2 and 3 relative to the services measured between 1 and 2 years. Second, because there was no target for CY 2015, any reductions that occurred on an interim final basis for CY 2015 were not counted toward achievement of a target. If we were to include any upward adjustments made to these codes based on public comment as “misvalued code” changes for CY 2016, we would effectively be counting the service-level increases for 2016 (year 3) relative to 2015 (year 2) against achievement of the target without any consideration to the service-level changes relative to 2014 (year 1), even in cases where the overall change in valuation was negative.

Therefore, we are proposing to exclude code-level input changes for CY 2015 interim final values from the calculation of the CY 2016 misvalued code target since the misvalued change occurred over multiple years, including years not applicable to the misvalued code target provision.

We note that the impact of interim final values in the calculation of targets for future years will be diminished as we transition to proposing values for almost all new, revised, and potentially misvalued codes in the proposed rule. We anticipate a smaller number of interim final values for CY 2016 relative to CY 2015. For calculation of the CY 2018 target, we anticipate almost no impact based on misvalued code adjustments that occur over multiple years.

The list of codes with proposed changes for CY 2016 included under this proposed definition of “adjustments to RVUs for misvalued codes” is available on the CMS Web site under downloads for the CY 2016 PFS proposed rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.

2. Calculating “Net Reduction”

Once the RVU changes attributable to misvalued codes are identified, estimated net reductions would be calculated summing the decreases and offsetting any applicable increases in valuation within the changes defined as misvalued, as described above. Because the provision only explicitly addresses reductions, and we recognize many stakeholders will want to maximize the overall magnitude of the measured reductions in order to prevent an overall reduction to the PFS conversion factor, we considered the possibility of ignoring the applicable increases in valuation in the calculation of net reduction. However, we believe that the requirement to calculate “net” reductions implies that we are to take into consideration both decreases and increases. Additionally, we believe this approach may be the only practical one due to the presence of new and deleted codes on an annual basis.

For example, a service that is described by a single code in a given year, like intensity-modulated radiation therapy (IMRT) treatment delivery, could be addressed as a misvalued service in a subsequent year through a coding revision that splits the service into two codes, “simple” and “complex.” If we counted only the reductions in RVUs, we would count only the change in value between the single code and the new code that describes the “simple” treatment delivery code. In this scenario, the change in value from the single code to the new “complex” treatment delivery code would be ignored, so that even if there were an increase in the payment for IMRT treatment delivery service(s) overall, the mere change in coding would contribute inappropriately to a “net reduction in expenditures.” Therefore, we are proposing to net the increases and decreases in values for services, including those for which there are coding revisions, in calculating the estimated net reduction in expenditures as a result of adjustments to RVUs for misvalued codes.

3. Measuring the Adjustments

The most straightforward method to estimating the net reduction in expenditures due to adjustments to RVUs for misvalued codes is to compare the total RVUs of the relevant set of codes (by volume) in the current year to the update year, and divide that by the total RVUs for all codes (by volume) for the current year. This approach is intuitive and relatively easy to replicate.

However, this method is imprecise for several reasons. First, and most significantly, the code-level PE RVUs in the update year include either increases due to the redistribution of RVUs from other services or reductions due to increases in PE for other services. Second, because relativity for work RVUs is maintained through annual adjustments to the CF, the precise value of a work RVU in any given year is adjusted based on the total number of work RVUs in that year. Finally, relativity for the MP RVUs is maintained by both redistribution of MP RVUs and adjustments to the CF, when necessary (under our proposed methodology this is true annually; based on our established methodology the redistribution of the MP RVUs only takes place once every 5 years and the CF is adjusted otherwise). Therefore, to make a more precise assessment of the net reduction in expenditures that are the result of adjustments to the RVUs for misvalued codes, we would need to compare, for the included codes, the update year's total work RVUs (by volume), direct PE RVUs (by volume), indirect PE RVUs (by volume), and MP RVUs (by volume) to the same RVUs in the current year, prior to the application of any scaling factors or adjustments. This would make for a direct comparison between years.

However, this approach would mean that the calculation of the net reduction in expenditures would occur within various steps of the PFS ratesetting methodology. While we believe that this approach would be transparent and external stakeholders could replicate this method, it may be difficult and time-consuming for stakeholders to do so. We also noted that when we modeled the interaction of the phase-in legislation and the calculation of the target using this approach during the development of this proposal, there were methodological challenges in making these calculations. When we simulated the two approaches using information from prior PFS years, we found that both approaches generally resulted in similar estimated net reductions. After considering these options, we are proposing to use the approach of comparing the total RVUs (by volume) for the relevant set of codes in the current year to the update year, and divide that result by the total RVUs (by volume) for the current year. We seek comment on whether comparing the update year's work RVUs, direct PE RVUs, indirect PE RVUs, and MP RVUs for the relevant set of codes (by volume) prior to the application of any scaling factors or adjustments to those of the current year would be a preferable methodology for determining the estimated net reduction.

4. Estimating the Target for CY 2016

CY 2016 represents a transition year in our new process of proposing values for new, revised and misvalued codes in the proposed rule, rather than establishing them as interim final in the final rule with comment period. For CY 2016, we will propose values for which we had the RUC's recommendations by our deadline of February 10th, and will establish interim final values for any codes received after the February 10th deadline but in time for us to value for the final rule. For CY 2016, there will still be a significant number of codes valued not in the proposed rule but in the final rule with comment period. In future years (with the exception of entirely new services), all codes, even those for which we do not receive RUC recommendations in time for the proposed rule, will be in the proposed rule for the subsequent year and not in the final rule with comment period. Therefore, for CY 2016, unlike for the targets for CY 2017 and CY 2018, because we will not be able to calculate a realistic estimate of the target amount at the time the proposed rule is published, we will not incorporate the impact of the target into the calculation of the proposed PFS payment rates. However, because we would apply any required budget neutrality adjustment related to this provision to the conversion factor, the proposed RVUs for individual services in this proposed rule would be the same, regardless of the estimate of the target. We also refer readers to the regulatory impact analysis section of this proposed rule for an interim estimate of the estimated net reduction in expenditures relative to the 1 percent target for CY 2016, based solely on the proposed changes in this rule.

G. Phase-in of Significant RVU Reductions

Section 1848(c)(7) of the Act, as added by section 220(e) of the PAMA, also specifies that for services that are not new or revised codes, if the total RVUs for a service for a year would otherwise be decreased by an estimated 20 percent or more as compared to the total RVUs for the previous year, the applicable adjustments in work, PE, and MP RVUs shall be phased-in over a 2-year period. Although section 220(e) of the PAMA required the phase-in to begin for 2017, section 202 of the ABLE Act amended section 1848(c)(7) of the Act to require that the phase-in begin for CY 2016.

In this section, we are proposing a methodology to implement this statutory provision. In developing this proposed methodology, we have identified several aspects of our approach for which we are specifically seeking comment, given the challenges inherent in implementing this provision in a manner consistent with the broader statutory construct of the PFS. We have organized this discussion by identifying and explaining these aspects in particular but we are seeking comment on all aspects of our proposal.

1. Identifying Services that are Not New or Revised Codes

As described in this proposed rule, the statute specifies that services described by new or revised codes are not subject to the phase-in of RVUs. We believe this exclusion recognizes the reality that there is no practical way to phase-in over 2 years changes to RVUs that occur as a result of a coding change for a particular service because there is no relevant reference code or value on which to base the transition. To determine which services are described by new or revised codes for purposes of the phase-in provision, we are proposing to apply the phase-in to all services that are described by the same, unrevised code in both the current and update year, and to exclude codes that describe different services in the current and update year. This approach would exclude services described by new codes or existing codes for which the descriptors were altered substantially for the update year to change the services that are reported using the code. We would also exclude as new and revised codes those codes that describe a different set of services in the update year when compared to the current year by virtue of changes in other, related codes, or codes that are part of a family with significant coding revisions. For example, significant coding revisions within a family of codes can change the relationships among codes to the extent that it changes the way that all services in the group are reported, even if some individual codes retain the same number or, in some cases, the same descriptor. Excluding codes from the phase-in when there are significant revisions to the code family would also help to maintain the appropriate rank order among codes in the family, avoiding years for which RVU changes for some codes in a family are in transition while others were fully implemented. This proposed application of the phase-in would also be consistent with previous RVU transitions, especially for PE RVUs, for which we only applied transition values to those codes that described the same service in both the current and the update years. We would also exclude from the phase-in as new and revised codes those codes with changes to the global period, since the code in the current year would not describe the same units of service as the code in the update year.

2. Estimating the 20 Percent Threshold

Because the phase-in of RVUs falls within the budget neutrality requirements specified in section 1848(c)(2)(B)(ii)(II) of the Act, we are proposing to estimate total RVUs for a service prior to the budget-neutrality redistributions that result from implementing phase-in values. We recognize that the result of this approach could mean that some codes may not qualify for the phase-in despite a reduction in RVUs that is ultimately slightly greater than 20 percent due to budget neutrality adjustments that are made after identifying the codes that meet the threshold in order to reflect the phase-in values for other codes. We believe the only alternative to this approach is not practicable, since it would be circular, resulting in cyclical iteration.

3. RVUs in the First Year of the Phase-In

Section 1848(c)(7) of the Act states that the applicable adjustments in work, PE, and MP RVUs shall be phased-in over a 2-year period when the RVU reduction for a code is estimated to be equal to or greater than 20 percent. We believe that there are two reasonable ways to determine the portion of the reduction to be phase-in for the first year. Most recent RVU transitions have distributed the values evenly across several years. For example, for a 2-year transition we would estimate the fully implemented value and set a rate approximately 50 percent between the value for the current year and the value for the update year. We believe that this is the most intuitive approach to the phase-in and is likely the expectation for many stakeholders. However, we believe that the 50 percent phase-in in the first year has a significant drawback. For instance, since the statute establishes a 20 percent threshold as the trigger for phasing in the change in RVUs, under the 50 percent phase-in approach, a service that is estimated to be reduced by a total of 19 percent for an update year would be reduced by a full 19 percent in that update year, while a service that is estimated to be reduced by 20 percent in an update year would only be reduced 10 percent in that update year.

The logical alternative approach is to consider a 19 percent reduction as the maximum 1-year reduction for any service not described by a new or revised code. This approach would be to reduce the service by the maximum allowed amount (that is, 19 percent) in the first year, and then phase in the remainder of the reduction in the second year. Under this approach, the code that is reduced by 19 percent in a year and the code that would otherwise have been reduced by 20 percent would both be reduced by 19 percent in the first year, and the latter code would see an additional 1 percent reduction in the second year of the phase-in. For most services, this would likely mean that the majority of the reduction would take place in the first year of the phase-in. However, for services with the most drastic reductions (greater than 40 percent), the majority of the reduction would take place in the second year of the phase-in.

After considering both of these options, we are proposing to consider the 19 percent reduction as the maximum 1-year reduction and to phase-in any remaining reduction greater than 19 percent in the second year of the phase-in. We believe that this approach is more equitable for codes with significant reductions but that are less than 20 percent. We are seeking comment on this proposal.

4. Applicable Adjustments to RVUs

The phase-in provision instructs that the applicable adjustments in work, PE, and MP RVUs be phased-in over 2 years for any service that would otherwise be decreased by an estimated amount equal to or greater than 20 percent as compared to the total RVUs for the previous year. However, for several thousand services, we develop separate RVUs for facility and nonfacility sites of service. For nearly one thousand other services, we develop separate RVUs for the professional and technical components of the service and sum those RVUs to allow for global billing. Therefore, for individual practitioners furnishing particular services to Medicare beneficiaries, the relevant changes in RVUs for a particular code are based on the total RVUs for a code for a particular setting (facility/nonfacility) or for a particular component (professional/technical). We believe the most straightforward and fair approach to addressing both the site of service differential and the codes with professional and technical components is to consider the RVUs for the different sites of service and components independently for purposes of identifying when and how the phase-in applies. We are proposing, therefore, to estimate whether a particular code meets the 20 percent threshold for change in total RVUs by taking into account the total RVUs that apply to a particular setting or to a particular component. This would mean that if the change in total facility RVUs for a code met the threshold, then that change would be phased-in over 2 years, even if the change for the total nonfacility RVUs for the same code would not be phased-in over 2 years. Similarly, if the change in the total RVUs for the technical component of a service meets the 20 percent threshold, then that change would be phased-in over 2 years, even if the change for the professional component did not meet the threshold. (Because the global is the sum of the professional and technical components, the portion of the global attributable to the technical component would then be phased-in, while the portion attributable to the professional component would not be.)

However, we note that we create the site of service differential exclusively by developing independent PE RVUs for each service in the nonfacility and facility settings. That is, for these codes, we use the same work RVUs and MP RVUs in both settings and vary only the PE RVUs to implement the difference in resources depending on the setting. Similarly, we use the work RVUs assigned to the professional component codes as the work RVUs for the service when billed globally. Like the codes with the site of service differential, the PE RVUs for each component are developed independently. The resulting PE RVUs are then summed for use as the PE RVUs for the code, billed globally. Since variation of PE RVUs is the only constant across all individual codes, codes with site of service differentials, and codes with professional and technical components, we are proposing to apply all adjustments for the phase-in to the PE RVUs.

We considered alternatives to this approach. For example, for codes with a site of service differential, we considered applying a phase-in for codes in both settings (and all components) whenever the total RVUs in either setting reached the 20 percent threshold. However, there are cases where the total RVUs for a code in one setting (or one component) may reach the 20 percent reduction threshold, while the total RVUs for the other setting (or other component) are increasing. In those cases, applying phase-in values for work or MP RVUs would mean applying an additional increase in total RVUs for particular services. We also considered basing the phase-in of the RVUs for the component codes billed globally and for the codes with site of service differentials developing an overall, blended set of overall PE RVUs using a weighted average of site of service volume in the Medicare claims data. We would then compare the global or blended value in the prior year versus the global or blended value in the current year and apply the phase-in to the value for the current year before re-allocating the new value to the respective RVUs in each setting. We did not pursue this approach for several reasons. First, the resulting phase-in amounts would not relate logically to the values paid to any individual practitioner, except those who bill the PC/TC codes globally. Second, the approach would be so administratively complicated that it would likely be difficult to replicate or predict.

Therefore, we have concluded that applying the adjustments to the PE RVUs for individual codes in order to effect the appropriate phase-in amount is the most straightforward and fair approach to mitigate the impact of significant reductions of total RVUs for services furnished by individual practitioners. The list of codes subject to the phase-in, and the RVUs that result from this proposed methodology, is available on the CMS Web site under downloads for the CY 2016 PFS proposed rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.

H. Changes for Computed Tomography (CT) Under the Protecting Access to Medicare Act of 2014 (PAMA) (CY 2016 only)

1. Section 218(a) of the Protecting Access to Medicare Act of 2014 (PAMA)

Section 218(a) of PAMA is entitled “Quality Incentives To Promote Patient Safety and Public Health in Computed Tomography Diagnostic Imaging.” It amends the statute by reducing payment for the technical component (TC) (and the TC of the global fee) of the PFS service and the hospital outpatient prospective payment system (OPPS) payment (5 percent in 2016 and 15 percent in 2017 and subsequent years) for computed tomography (CT) services identified by CPT codes 70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178, 74261-74263, and 75571-75574 furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013, entitled “Standard Attributes on CT Equipment Related to Dose Optimization and Management.”

The statutory provision requires that information be provided and attested to by a supplier and a hospital outpatient department that indicates whether an applicable CT service was furnished that was not consistent with the NEMA CT equipment standard, and that such information may be included on a claim and may be a modifier. The statutory provision also provides that such information shall be verified, as appropriate, as part of the periodic accreditation of suppliers under section 1834(e) of the Act and hospitals under section 1865(a) of the Act. Any reduced expenditures resulting from this provision are not budget neutral. To implement this provision, we will create modifier “CT” (Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013 standard). Beginning in 2016, claims for CT scans described by above-listed CPT codes (and any successor codes) that are furnished on non-NEMA Standard XR-29-2013-compliant CT scans must include modifier “CT” and that modifier will result in the applicable payment reduction for the service.

I. Valuation of Specific Codes

1. Background

Establishing valuations for newly created and revised CPT codes is a routine part of maintaining the PFS. Since inception of the PFS, it has also been a priority to revalue services regularly to assure that the payment rates reflect the changing trends in the practice of medicine and current prices for inputs used in the PE calculations. Initially, this was accomplished primarily through the five-year review process, which resulted in revised work RVUs for CY 1997, CY 2002, CY 2007, and CY 2012, and revised PE RVUs in CY 2001, CY 2006, and CY 2011. Under the five-year review process, revisions in RVUs were proposed in a proposed rule and finalized in a final rule. In addition to the five-year reviews, in each year beginning with CY 2009, CMS and the RUC have identified a number of potentially misvalued codes using various identification screens, as discussed in section II.C. of this proposed rule. Each year, when we received RUC recommendations, our process has been to establish interim final RVUs for the potentially misvalued codes, new codes, and any other codes for which there were coding changes in the final rule with comment period for a year. Then, during the 60-day period following the publication of the final rule with comment period, we accept public comment about those valuations. For services furnished during the calendar year following the publication of interim final rates, we pay for services based upon the interim final values established in the final rule with comment period. In the final rule with comment period for the subsequent year, we consider and respond to public comments received on the interim final values, and make any appropriate adjustments to values based on those comments. We then typically finalize the values for the codes.

2. Process for Valuing New, Revised, and Potentially Misvalued Codes

In the CY 2015 PFS final rule with comment period, we finalized a new process for establishing values for new, revised and potentially misvalued codes. Under the new process, we include proposed values for these services in the proposed rule, rather than establishing them as interim final in the final rule with comment period. CY 2016 represents a transition year for this new process. For CY 2016, we are proposing new values in the proposed rule for the codes for which we received complete RUC recommendations by February 10, 2015. For recommendations regarding any new or revised codes received after the February 10, 2015 deadline, including updated recommendations for codes included in this proposed rule, we will establish interim final values in the final rule with comment period, consistent with previous practice. We note that we will consider all comments received in response to proposed values for codes in this rule, including alternative recommendations to those used in developing the proposed rule. In other words, if the RUC or other interested stakeholders submit public comments that include new recommendations for codes for which we propose values as part of this proposed rule, we would consider those recommendations in developing final values for the codes in the CY 2016 PFS final rule with comment.

Beginning with valuations for CY 2017, the new process will be applicable to all codes. That is, beginning with rulemaking for CY 2017, we will propose values for the vast majority of new, revised, and potentially misvalued codes and consider public comments before establishing final values for the codes; use G-codes as necessary to facilitate continued payment for certain services for which we do not receive recommendations in time to propose values; and adopt interim final values in the case of wholly new services for which there are no predecessor codes or values and for which we do not receive recommendations in time to propose values.

For CY 2016, we received RUC recommendations prior to February 10, 2015 for many new, revised and potentially misvalued codes and have included proposed values for these codes in this proposed rule. However, the RUC recommendations included CPT tracking codes instead of the actual 2016 CPT codes that will first be made available to the public subsequent to the publication of this proposed rule. Because CPT procedure codes are 5 alpha-numeric characters but CPT tracking codes typically have 6 or 7 alpha-numeric characters and CMS systems only utilize 5-character HCPCS codes, we have developed and used alternative 5-character placeholder codes for this proposed rule. For the convenience of stakeholders and commenters with access to the CPT tracking codes, we have displayed a crosswalk from the 5-character placeholder codes to the CPT tracking codes on our Web site under downloads for the CY 2016 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/downloads/. The final CPT codes will be included in the CY 2016 final rule with comment period.

3. Methodology for Establishing Work RVUs

We conducted a review of each code identified in this section and reviewed the current work RVU (if any), RUC- recommended work RVUs, intensity, time to furnish the preservice, intraservice, and postservice activities, as well as other components of the service that contribute to the value. Our review of recommended work RVUs and time generally includes, but is not limited to, a review of information provided by the RUC, HCPAC, and other public commenters, medical literature, and comparative databases, as well as a comparison with other codes within the Medicare PFS, consultation with other physicians and health care professionals within CMS and the federal government, as well as Medicare claims data. We also assessed the methodology and data used to develop the recommendations submitted to us by the RUC and other public commenters and the rationale for the recommendations. In the CY 2011 PFS final rule with comment period (75 FR 73328 through 73329), we discussed a variety of methodologies and approaches used to develop work RVUs, including survey data, building blocks, crosswalk to key reference or similar codes, and magnitude estimation. More information on these issues is available in that rule. When referring to a survey, unless otherwise noted, we mean the surveys conducted by specialty societies as part of the formal RUC process. The building block methodology is used to construct, or deconstruct, the work RVU for a CPT code based on component pieces of the code. Components used in the building block approach may include preservice, intraservice, or postservice time and post-procedure visits. When referring to a bundled CPT code, the building block components could be the CPT codes that make up the bundled code and the inputs associated with those codes. Magnitude estimation refers to a methodology for valuing physician work that determines the appropriate work RVU for a service by gauging the total amount of physician work for that service relative to the physician work for similar service across the PFS without explicitly valuing the components of that work.

The PFS incorporates cross-specialty and cross-organ system relativity. Valuing services requires an assessment of relative value and takes into account the clinical intensity and time required to furnish a service. In selecting which methodological approach will best determine the appropriate value for a service, we consider the current and recommended work and time values, as well as the intensity of the service, all relative to other services.

Several years ago, to aid in the development of preservice time recommendations for new and revised CPT codes, the RUC created standardized preservice time packages. The packages include preservice evaluation time, preservice positioning time, and preservice scrub, dress and wait time. Currently there are six preservice time packages for services typically furnished in the facility setting, reflecting the different combinations of straightforward or difficult procedure, straightforward or difficult patient, and without or with sedation/anesthesia. Currently, there are three preservice time packages for services typically furnished in the nonfacility setting, reflecting procedures without and with sedation/anesthesia care.

We have developed several standard building block methodologies to value services appropriately when they have common billing patterns. In cases where a service is typically furnished to a beneficiary on the same day as an evaluation and management (E/M) service, we believe that there is overlap between the two services in some of the activities furnished during the preservice evaluation and postservice time. We believe that at least one-third of the work time in both the preservice evaluation and postservice period is duplicative of work furnished during the E/M visit. Accordingly, in cases where we believe that the RUC has not adequately accounted for the overlapping activities in the recommended work RVU and/or times, we adjust the work RVU and/or times to account for the overlap. The work RVU for a service is the product of the time involved in furnishing the service times the intensity of the work. Preservice evaluation time and postservice time both have a long-established intensity of work per unit of time (IWPUT) of 0.0224, which means that 1 minute of preservice evaluation or postservice time equates to 0.0224 of a work RVU. Therefore, in many cases when we remove 2 minutes of preservice time and 2 minutes of postservice time from a procedure to account for the overlap with the same day E/M service, we also remove a work RVU of 0.09 (4 minutes × 0.0224 IWPUT) if we do not believe the overlap in time has already been accounted for in the work RVU. The RUC has recognized this valuation policy and, in many cases, addresses the overlap in time and work when a service is typically provided on the same day as an E/M service.

Table 11 contains a list of proposed work RVUs for all codes with RUC recommendations received by February 10, 2015. Proposed work RVUs that vary from those recommended by the RUC or for which we do not have RUC recommendations are addressed in the portions of this section that are dedicated to particular codes.

The work RVUs and other payment information for all CY 2016 payable codes are available in Addendum B, including codes for which we have proposed changes in this proposed rule subject to public comment. Addendum B is available on the CMS Web site under downloads for the CY 2016 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/downloads/. The proposed time values for all CY 2016 codes are listed in a file called “CY 2016 PFS Work Time,” available on the CMS Web site under downloads for the CY 2016 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/downloads/.

4. Methodology for Establishing the Direct PE Inputs Used to Develop PE RVUs

a. Background

On an annual basis, the RUC provides CMS with recommendations regarding PE inputs for new, revised, and potentially misvalued codes. We review the RUC-recommended direct PE inputs on a code-by-code basis. Like our review of recommended work RVUs, our review of recommended direct PE inputs generally includes, but is not limited to, a review of information provided by the RUC, HCPAC, and other public commenters, medical literature, and comparative databases, as well as a comparison with other codes within the Medicare PFS, consultation with other physicians and health care professionals within CMS and the federal government, as well as Medicare claims data. We also assess the methodology and data used to develop the recommendations submitted to us by the RUC and other public commenters and the rationale for the recommendations. When we determine that the RUC recommendations appropriately estimate the direct PE inputs (clinical labor, disposable supplies, and medical equipment) required for the typical service, consistent with the principles of relativity, and reflect our payment policies, we use those direct PE inputs to value a service. If not, we refine the recommended PE inputs to better reflect our estimate of the PE resources required for the service. We also confirm whether CPT codes should have facility and/or nonfacility direct PE inputs and refine the inputs accordingly.

Our review and refinement of RUC-recommended direct PE input includes many refinements that are common across codes as well as refinements that are specific to particular services. Table 13 details our refinements of the RUC's direct PE recommendations at the code-specific level. In this proposed rule, we address several refinements that are common across codes, and refinements to particular codes are addressed in the portions of this section that are dedicated to particular codes. We note that for each refinement, we indicate the impact on direct costs for that service. We point out that, on average, in any case where the impact on the direct cost for a particular refinement is $0.32 or less, the refinement has no impact on the final PE RVUs. This calculation considers both the impact on the direct portion of the PE RVU as well as the impact on the indirect allocator for the average service. We also note that nearly half of the refinements listed in Table 13 result in changes under the $0.32 threshold and are unlikely to result in a change to the final RVUs.

We also note that the proposed direct PE inputs for CY 2016 are displayed in the proposed CY 2016 direct PE input database, available on the CMS Web site under the downloads for the CY 2016 proposed rule at www.cms.gov/PhysicianFeeSched/. The inputs displayed there have also been used in developing the CY 2016 PE RVUs as displayed in Addendum B of this proposed rule.

b. Common Refinements

(1) Changes in Work Time

Some direct PE inputs are directly affected by revisions in work time. Specifically, changes in the intraservice portions of the work time and changes in the number or level of postoperative visits associated with the global periods result in corresponding changes to direct PE inputs. Although the direct PE input recommendations generally correspond to the work time values associated with services, we believe that in some cases inadvertent discrepancies between work time values and direct PE inputs should be refined in the establishment of proposed direct PE inputs. In other cases, CMS refinement of recommended proposed work times prompts necessary adjustments in the direct PE inputs.

(2) Equipment Time

Prior to CY 2010, the RUC did not generally provide CMS with recommendations regarding equipment time inputs. In CY 2010, in the interest of ensuring the greatest possible degree of accuracy in allocating equipment minutes, we requested that the RUC provide equipment times along with the other direct PE recommendations, and we provided the RUC with general guidelines regarding appropriate equipment time inputs. We continue to appreciate the RUC's willingness to provide us with these additional inputs as part of its PE recommendations.

In general, the equipment time inputs correspond to the service period portion of the clinical labor times. We have clarified this principle, indicating that we consider equipment time as the time within the intraservice period when a clinician is using the piece of equipment plus any additional time that the piece of equipment is not available for use for another patient due to its use during the designated procedure. For those services for which we allocate cleaning time to portable equipment items, because the portable equipment does not need to be cleaned in the room where the service is furnished, we do not include that cleaning time for the remaining equipment items as those items and the room are both available for use for other patients during that time. In addition, when a piece of equipment is typically used during follow-up post-operative visits included in the global period for a service, the equipment time would also reflect that use.

We believe that certain highly technical pieces of equipment and equipment rooms are less likely to be used during all of the pre-service or post-service tasks performed by clinical labor staff on the day of the procedure (the clinical labor service period) and are typically available for other patients even when one member of clinical staff may be occupied with a pre-service or post-service task related to the procedure. We also note that we believe these same assumptions would apply to inexpensive equipment items that are used in conjunction with and located in a room with non-portable highly technical equipment items. Some stakeholders have objected to this rationale for our refinement of equipment minutes on this basis. We refer readers to our extensive discussion in response to those objections in the CY 2012 PFS final rule with comment period (76 FR 73182) and the CY 2015 PFS final rule with comment period (79 FR 67639).

(3) Standard Tasks and Minutes for Clinical Labor Tasks

In general, the preservice, intraservice period, and postservice clinical labor minutes associated with clinical labor inputs in the direct PE input database reflect the sum of particular tasks described in the information that accompanies the RUC-recommended direct PE inputs, commonly called the “PE worksheets.” For most of these described tasks, there are a standardized number of minutes, depending on the type of procedure, its typical setting, its global period, and the other procedures with which it is typically reported. The RUC sometimes recommends a number of minutes either greater than or less than the time typically allotted for certain tasks. In those cases, CMS staff reviews the deviations from the standards and any rationale provided for the deviations. When we do not accept the RUC-recommended exceptions, we refine the proposed direct PE inputs to match the standard times for those tasks. In addition, in cases when a service is typically billed with an E/M service, we remove the pre-service clinical labor tasks to avoid duplicative inputs and to reflect the resource costs of furnishing the typical service.

In general, clinical labor tasks fall into one of the categories on the PE worksheets. In cases where tasks cannot be attributed to an existing category, the tasks are labeled “other clinical activity.” We believe that continual addition of new and distinct clinical labor tasks each time a code is reviewed under the misvalued code initiative is likely to degrade relativity between newly reviewed services and those with already existing inputs. To mitigate the potential negative impact of these additions, our staff reviews these tasks to determine whether they are fully distinct from existing clinical labor tasks, typically included for other clinically similar services under the PFS, and thoroughly explained in the recommendation. For those tasks that do not meet these criteria, we do not accept these newly recommended clinical labor tasks; two examples of such tasks encountered during our review of the recommendations include “Enter data into laboratory information system, multiparameter analyses and field data entry, complete quality assurance documentation” and “Consult with pathologist regarding representation needed, block selection and appropriate technique.”

In conducting our review of the RUC recommendations for CY 2016, we noted that several of the recommended times for clinical labor tasks associated with pathology services differed across codes, both within the CY 2016 recommendations and in comparison to codes currently in the direct PE database. We refer readers to Table 6 in section II.A.3. of this proposed rule where we outline our proposed standard times for clinical labor tasks associated with pathology services.

(4) Recommended Items That Are Not Direct PE Inputs

In some cases, the PE worksheets included with the RUC recommendations include items that are not clinical labor, disposable supplies, or medical equipment that cannot be allocated to individual services or patients. Two examples of such items are “emergency service container/safety kit” and “service contract.” We have addressed these kinds of recommendations in previous rulemaking (78 FR 74242), and we do not use these recommended items as direct PE inputs in the calculation of PE RVUs.

(5) Moderate Sedation Inputs

In the CY 2012 PFS final rule (76 FR 73043 through 73049), we finalized a standard package of direct PE inputs for services where moderate sedation is considered inherent in the procedure. In the CY 2015 final rule with comment period, we finalized a refinement to the standard package to include a stretcher for the same length of time as the other equipment items in the standard package. We are proposing to refine the RUC's direct PE recommendations to conform to these policies. This includes the removal of a power table where it was included during the intraservice period, as the stretcher takes the place of the table. These refinements are reflected in the final CY 2016 PFS direct PE input database and detailed in Table 13.

(6) New Supply and Equipment Items

The RUC generally recommends the use of supply and equipment items that already exist in the direct PE input database for new, revised, and potentially misvalued codes. Some recommendations include supply or equipment items that are not currently in the direct PE input database. In these cases, the RUC has historically recommended a new item be created and has facilitated our pricing of that item by working with the specialty societies to provide copies of sales invoices to us. We received invoices for several new supply and equipment items for CY 2016. We have accepted the majority of these items and added them to the direct PE input database. Tables 9 and 10 detail the invoices received for new and existing items in the direct PE database. As discussed in section II.A. of this proposed rule, we encourage stakeholders to review the prices associated with these new and existing items to determine whether these prices appear to be accurate. Where prices appear inaccurate, we encourage stakeholders to provide invoices or other information to improve the accuracy of pricing for these items in the direct PE database. We remind stakeholders that due to the relativity inherent in the development of RVUs, reductions in existing prices for any items in the direct PE database increase the pool of direct PE RVUs available to all other PFS services. Tables 9 and 10 also include the number of invoices received as well as the number of nonfacility allowed services for procedures that use these equipment items. We provide the nonfacility allowed services so that stakeholders will note the impact the particular price might have on PE relativity, as well as to identify items that are used frequently, since we believe that stakeholders are more likely to have better pricing information for items used more frequently. We are concerned that a single invoice may not be reflective of typical costs and encourage stakeholders to provide additional invoices so that we might identify and use accurate prices in the development of PE RVUs.

In some cases, we do not accept the price listed on the invoice that accompanies the recommendation because we identify publicly available alternative prices or information that suggests a different price is more accurate. In these cases, we include this in the discussion of these codes. In other cases, we cannot adequately price a newly recommended item due to inadequate information. Sometimes, no supporting information regarding the price of the item has been included in the recommendation. In other cases, the supporting information does not demonstrate that the item has been purchased at the listed price (for example, vendor price quotes instead of paid invoices). In cases where the information provided on the item allows us to identify clinically appropriate proxy items, we might use existing items as proxies for the newly recommended items. In other cases, we have included the item in the direct PE input database without any associated price. Although including the item without an associated price means that the item does not contribute to the calculation of the proposed PE RVU for particular services, it facilitates our ability to incorporate a price once we obtain information and are able to do so.

(7) Service Period Clinical Labor Time in the Facility Setting

Several of the PE worksheets included in the RUC recommendations contained clinical labor minutes assigned to the service period in the facility setting. Our proposed inputs do not include these minutes because the cost of clinical labor during the service period for a procedure in the facility setting is not considered a resource cost to the practitioner since Medicare makes separate payment to the facility for these costs.

(8) Duplicative Inputs

Several of the PE worksheets included in the RUC recommendations contained time for the equipment item “xenon light source” (EQ167). Because there appear to be two special light sources already present (the fiberoptic headlight and the endoscope itself) in the services for which this equipment item was recommended, we are not proposing to include the time for this equipment item from these services, and are seeking comment on whether there is a rationale for including this additional light source as a direct PE input for these procedures.

5. Methodology for Establishing Malpractice RVUs

As discussed in section II.B. of this proposed rule, our malpractice methodology uses a crosswalk to establish risk factors for new services until utilization data becomes available. Table 15 lists the CY 2016 HCPCS codes and their respective source codes used to set the proposed CY 2016 MP RVUs. The MP RVUs for these services are reflected in Addendum B on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.

Table 9—Invoices Received for New Direct PE Inputs Back to Top
CPT/HCPCS Codes Item name CMS Code Average price Number of invoices Estimated non-facility allowed services for HCPCS codes using this item
31626 Gold Fiducial Marker SB053 135 1 6
3160A, 3160B, 3160C endoscope, ultrasound radial probe ES045 0 0 212
3725A IVUS catheter SD304 1025 3 795
3725A IVUS Catheter Sterile Cover SD305 120 3 795
3725A, 3725B IVUS system ES047 134,025 3 2,948
44385, 44386, 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45340, 45346 Video Sigmoidoscope ES043 215,00 1 18,058
44401, 45346, 45388 catheter, RF ablation, endoscopic SC103 1,780 1 3,543
44401, 45346 radiofrequency generator, endoscopy EQ369 108,291.67 1 174
45350, 45398 hemorrhoidal banding system SA115 223.50 4 3
5039D, 5039M Nephroureteral Catheter SD306 117.90 1 70
657XG suture, nylon, 10-0 SC104 12.17 2  
657XG intrastromal corneal ring SA120 1,145 7  
657XG patient/laser interface (single—use, disposable) SD307 172.50 1  
657XG femtosecond laser ES048 293,000 2  
657XG incision programming software ES049 10,012.50 1  
692XX earwash bottle disposable tips SD308 1.72 1  
77385, 77386, 77402, 77407, 77412 Power Conditioner ER102 26,400 2 2,198,441
7778A, 7778B, 7778C, 7778D, 7778E brachytherapy treatment vault ES052 175,000 1 24,936
88104, 88106, 88108 fixative spray for cytospin SL503 1.53 1 62,552
88108 Shannon cyto funnel, cytospin SD298 2.27 1 48,740
88108 slide, microscope coated cytospin (single circle) SL504 0.39 1 48,740
88182 Protease SL506 0.43 1 568
88346, 8835X Immunofluorescent mounting media SD309 3.50 1 114,211
88346, 8835X Zeus medium SL518 0.85 2 114,211
88346, 8835X Hydrophobic PAP Pen SK120 1.76 (100 uses) 1 114,211
88360, 88361 Antibody Estrogen Receptor monoclonal SL493 13.89 3 116,718
Table 10—Invoices Received for Existing Direct PE Inputs Back to Top
CPT/HCPCS Codes Item name CMS Code Current price Updated price Percent change Number of invoices Estimated non-facility allowed services for HCPCS codes using this item
31300, 31320, 31360, 31365, 31367, 31368, 31370, 31375, 31380, 31382, 31390, 31395, 31628, 31632, 31750, 31755, 31800, 41120, 41130, 41135, 41140, 41145, 41150, 41153, 41155, 41500, 41510, 41512, 41530, 42120, 42842, 42844, 42845, 42870, 42890, 42892, 42894, 42950, 42953, 42955, 43215, 43247, 58555, 58558, 58562, 58563, 60605, 92511, 92612 endosheath SD070 9.50 17.25 82 1 65,318
41530, 43228, 43229, 43270, 64633, 64634, 64635, 64636 radiofrequency generator (NEURO) EQ214 32,900 10,000 −70 1 265,270
88341, 88342, 88343, 88344, 88360, 88361 Benchmark ULTRA automated slide preparation system EP112 134,000 150,000 12 1 3,279,993
8835X antibody IgA FITC SL012 71.40 41.18 −42 1 93,520
95018 benzylpenicilloyl polylysine (eg, PrePen) 0.25ml uou SH103 72.45 83.00 15 1 60,683
95923 kit, electrode, iontophoresis SA014 11.99 4.01 −67 3 96,189

6. CY 2016 Valuation of Specific Codes

Table 11—CY 2016 Proposed Work RVUs for New, Revised and Potentially Misvalued Codes Back to Top
HCPCS Descriptor Current work RVU RUC work RVU CMS work RVU CMS time refinement
11750 Removal of nail 2.5 1.99 1.58 No.
20240 Biopsy of bone, open procedure 3.28 3.73 2.61 No.
27280 Arthrodesis, open, sacroiliac joint including obtaining bone graft 14.64 20 20 No.
3160A Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stat NEW 5 4.71 No.
3160B Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stati NEW 5.5 5.21 No.
3160C Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to NEW 1.7 1.4 No.
31622 Diagnostic examination of lung airways using an endoscope 2.78 2.78 2.78 No.
31625 Biopsy of lung airways using an endoscope 3.36 3.36 3.36 No.
31626 Insertion of radiation therapy markers into lung airways using an endoscope 4.16 4.16 4.16 No.
31628 Biopsy of one lobe of lung using an endoscope 3.8 3.8 3.8 No.
31629 Needle biopsy of windpipe cartilage, airway, and/or lung using an endoscope 4.09 4 4 No.
31632 Biopsy of lung using an endoscope 1.03 1.03 1.03 No.
31633 Needle biopsy of lung using an endoscope 1.32 1.32 1.32 No.
3347A Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed NEW 25 25 No.
37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection 19.68 18 18 No.
3725A Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial non-coronary vessel (List separately in addition to code for primary procedure) NEW 1.8 1.8 No.
3725B Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure NEW 1.44 1.44 No.
38570 Removal of abdominal cavity lymph nodes using an endoscope 9.34 9.34 8.49 No.
38571 Removal of total lymph nodes of both sides of pelvis using an endoscope 14.76 12 12 No.
38572 Removal of total lymph nodes of both sides of pelvis and abdominal lymph node biopsy using an endoscope 16.94 15.6 15.6 No.
3940A Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed NEW 5.44 5.44 No.
3940B Mediastinoscopy; with lymph node biopsy(ies) (eg, lung cancer staging) NEW 7.5 7.25 No.
43775 Stomach reduction procedure with partial removal of stomach using an endoscope C 21.4 20.38 No.
44380 Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed 1.05 0.97 0.9 No.
44381 Ileoscopy, through stoma; with transendoscopic balloon dilation N/A 1.48 1.48 Yes
44382 Ileoscopy, through stoma; with biopsy, single or multiple 1.27 1.27 1.2 No.
44384 Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) N/A 3.11 2.88 No.
44385 Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); diagnostic, including collection of specimen(s) by brushing or washing, when performed 1.82 1.3 1.23 No.
44386 Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple 2.12 1.6 1.53 No.
44388 Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 2.82 2.82 2.75 No.
44389 Colonoscopy through stoma; with biopsy, single or multiple 3.13 3.12 3.05 No.
44390 Colonoscopy through stoma; with removal of foreign body 3.82 3.82 3.77 No.
44391 Colonoscopy through stoma; with control of bleeding, any method 4.31 4.22 4.22 No.
44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 3.81 3.63 3.63 No.
44394 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 4.42 4.13 4.13 No.
44401 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion (includes pre-and post-dilation and guide wire passage, when performed) N/A 4.44 4.44 No.
44402 Colonoscopy through stoma; with endoscopic stent placement (including pre- and post-dilation and guidewire passage, when performed) N/A 4.96 4.73 No.
44403 Colonoscopy through stoma; with endoscopic mucosal resection N/A 5.81 5.53 No.
44404 Colonoscopy through stoma; with directed submucosal injection(s), any substance N/A 3.13 3.05 No.
44405 Colonoscopy through stoma; with transendoscopic balloon dilation N/A 3.33 3.33 No.
44406 Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures N/A 4.41 4.13 No.
44407 Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjace N/A 5.06 5.06 No.
44408 Colonoscopy through stoma; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed N/A 4.24 4.24 No.
45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing when performed 0.96 0.84 0.77 No.
45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 1.15 1.14 1.07 No.
45332 Sigmoidoscopy, flexible; with removal of foreign body 1.79 1.85 1.79 No.
45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 1.79 1.65 1.65 No.
45334 Sigmoidoscopy, flexible; with control of bleeding, any method 2.73 2.1 2.1 No.
45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 1.46 1.15 1.07 No.
45337 Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed 2.36 2.2 2.2 No.
45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 2.34 2.15 2.15 No.
45340 Sigmoidoscopy, flexible; with transendoscopic balloon dilation 1.89 1.35 1.35 No.
45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 2.6 2.43 2.15 No.
45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) 4.05 3.08 3.08 No.
45346 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) N/A 2.97 2.84 No.
45347 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) N/A 2.98 2.75 No.
45349 Sigmoidoscopy, flexible; with endoscopic mucosal resection N/A 3.83 3.55 No.
45350 Sigmoidoscopy, flexible;with banding (eg, hemorrhoids) N/A 1.78 1.78 No.
45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, (separate procedure) 3.69 3.36 3.29 No.
45379 Colonoscopy, flexible; with removal of foreign body 4.68 4.37 4.31 No.
45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple 4.43 3.66 3.59 No.
45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 4.19 3.67 3.59 No.
45382 Colonoscopy, flexible; with control of bleeding, any method 5.68 4.76 4.76 No.
45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 4.69 4.17 4.17 No.
45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 5.3 4.67 4.67 No.
45386 Colonoscopy, flexible; with transendoscopic balloon dilation 4.57 3.87 3.87 No.
45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) N/A 4.98 4.98 No.
45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) N/A 5.5 5.27 No.
45390 Colonoscopy, flexible; with endoscopic mucosal resection N/A 6.35 6.07 No.
45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 5.09 4.95 4.67 No.
45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and a 6.54 5.6 5.6 No.
45393 Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed N/A 4.78 4.78 No.
45398 Colonoscopy, flexible; with banding, (eg, hemorrhoids) N/A 4.3 4.3 No.
46500 Injection of hemorrhoids 1.69 1.69 1.42 No.
46601 Anoscopy; diagnostic, with high-resolution magnification N/A 1.6 1.6 No.
46607 Anoscopy; with high-resolution magnification (hra), with biopsy, single or multiple N/A 2.2 2.2 No.
47135 Transplantation of donor liver to anatomic position 83.64 91.78 90 No.
50390 Aspiration and/or injection kidney cyst, accessed through the skin 1.96 1.96 1.96 No.
5039A Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; new access NEW 3.15 3.15 No.
5039B Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; existing access NEW 1.42 1.1 No.
5039C Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation NEW 4.7 4.25 No.
5039D Placement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, new access NEW 5.75 5.3 No.
5039E Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation NEW 2 1.82 No.
5039M Convert nephrostomy catheter to nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation NEW 4.2 4 No.
5069G Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; pre-existing nephrostomy NEW 4.6 4.21 No.
5069H Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; new access, without separate NEW 6 5.5 No.
5069I Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; new access, with separate NEW 7.55 7.05 No.
5443A Repair of traumatic corporeal tear(s) NEW 11.5 11.5 No.
5443B Replantation, penis, complete amputation including urethral repair NEW 24.5 22.1 No.
63045 Laminectomy, facetectomy and foraminotomy; cervical 17.95 17.95 17.95 No.
63046 Laminectomy, facetectomy and foraminotomy; thoracic 17.25 17.25 17.25 No.
657XG Implantation of intrastromal corneal ring segments NEW 5.93 5.39 No.
68801 Dilation of tear-drainage opening 1 1 0.82 No.
68810 Insertion of probe into the tear duct 2.15 1.54 1.54 No.
68811 Insertion of probe into the tear duct under anesthesia 2.45 2.03 1.74 No.
68815 Probing of nasal-tear duct with insertion of tube or stent 3.3 3 2.7 No.
68816 Probing of nasal-tear duct with balloon catheter dilation 3.06 2.35 2.1 No.
71100 Radiologic examination, ribs, unilateral; 2 views 0.22 0.22 0.22 No.
72070 Radiologic examination, spine; thoracic, 2 views 0.22 0.22 0.22 No.
7208A Entire spine x ray, one view NEW 0.3 0.26 No.
7208B Entire spine x-ray; 2 or 3 views NEW 0.35 0.31 No.
7208C Entire spine x-ray; 4 or 5 views NEW 0.39 0.35 No.
7208D Entire spine x-ray; min 6 views NEW 0.45 0.41 No.
73060 Radiologic examination; humerus, minimum of 2 views 0.17 0.16 0.16 No.
73560 Radiologic examination, knee; 1 or 2 views 0.17 0.16 0.16 No.
73562 Radiologic examination, knee; 3 views 0.18 0.18 0.18 No.
73564 Radiologic examination, knee; complete, 4 or more views 0.22 0.22 0.22 No.
73565 Radiologic examination, knee; both knees, standing, anteroposterior 0.17 0.16 0.16 No.
73590 Radiologic examination; tibia and fibula, 2 views 0.17 0.16 0.16 No.
73600 Radiologic examination, ankle; 2 views 0.16 0.16 0.16 No.
76999 Ultrasound procedure C C C N/A
77387 Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking when performed N/A 0.58 0.58 No.
7778B Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions NEW 1.4 1.4 No.
7778C Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel NEW 1.95 1.95 No.
7778D Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels NEW 3.8 3.8 No.
7778E Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels NEW 5.4 5.4 No.
88346 Antibody evaluation 0.86 0.74 0.56 No.
8835X Immunofluorescence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) NEW 0.7 0.53 No.
88367 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen: initial single probe stain procedure 0.73 0.86 0.73 No.
88368 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative) manual, per specimen; initial single probe stain procedure 0.88 0.88 0.88 No.
91299 Procedure for gastrointestinal diagnosis C C C N/A
9254A Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations) NEW 0.8 0.6 No.
9254B Caloric vestibular test with recording, bilateral; monothermal (ie, one irrigation in each ear for a total of two irrigations) NEW 0.55 0.3 No.
99174 Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral N 0 N No.
9917X Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis NEW 0 N No.
G0104 Colorectal cancer screening; flexible sigmoidoscopy 0.96 0.84 0.77 No.
G0105 Colorectal cancer screening; colonoscopy on individual at high risk 3.36 3.36 3.29 No.
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk 3.36 3.36 3.29 No.
Table 12—CY 2016 Proposed Codes With Direct PE Input Recommendations Accepted Without Refinement Back to Top
HCPCS Descriptor
20245 Bone biopsy excisional.
20697 Comp ext fixate strut change.
27280 Fusion of sacroiliac joint.
3160A Bronch ebus 141 gmt. 141 ng 1/2 node.
3160B Bronch ebus 141 gmt. 141 ng 3/> node.
3160C Bronch ebus ivntj perph les.
31622 Dx bronchoscope/wash.
31625 Bronchoscopy w/biopsy(s).
31626 Bronchoscopy w/markers.
31628 Bronchoscopy/lung bx each.
31629 Bronchoscopy/needle bx each.
31632 Bronchoscopy/lung bx addl.
31633 Bronchoscopy/needle bx addl.
3347A Implant tcat pulm vlv perq.
37215 Transcath stent cca w/eps.
3725A Intrvasc us noncoronary 1st.
3725B Intrvasc us noncoronary addl.
38570 Laparoscopy lymph node biop.
38571 Laparoscopy lymphadenectomy.
3940A Mediastinoscpy w/medstnl bx.
3940B Mediastinoscpy w/lmph nod bx.
44384 Small bowel endoscopy.
44402 Colonoscopy w/stent plcmt.
44403 Colonoscopy w/resection.
44406 Colonoscopy w/ultrasound.
44407 Colonoscopy w/ndl aspir/bx.
44408 Colonoscopy w/decompression.
45337 Sigmoidoscopy & decompress.
45341 Sigmoidoscopy w/ultrasound.
45342 Sigmoidoscopy w/us guide bx.
45347 Sigmoidoscopy w/plcmt stent.
45349 Sigmoidoscopy w/resection.
45389 Colonoscopy w/stent plcmt.
45390 Colonoscopy w/resection.
45391 Colonoscopy w/endoscope us.
45392 Colonoscopy w/endoscopic fnb.
45393 Colonoscopy w/decompression.
47135 Transplantation of liver.
5443B Replantation of penis.
63045 Remove spine lamina 1 crvl.
63046 Remove spine lamina 1 thrc.
68811 Probe nasolacrimal duct.
68815 Probe nasolacrimal duct.
692XX Remove impacted ear wax uni.
76948 Echo guide ova aspiration.
7778A Hdr rdncl skn surf brachytx.
7778B Hdr rdncl skn surf brachytx.
7778C Hdr rdncl ntrstl/icav brchtx.
7778D Hdr rdncl ntrstl/icav brchtx.
7778E Hdr rdncl ntrstl/icav brchtx.
88346 Immunofluorescent study.
8835X Immunofluor antb addl stain.
9254A Caloric vstblr test w/rec.
9254B Caloric vstblr test w/rec.
9935A Prolong clincl staff svc.
9935B Prolong clincl staff svc add.
Table 13—CY 2016 Proposed Codes With Direct PE Input Recommendations Accepted With Refinements Back to Top
HCPCS code HCPCS code description Input code Input code description NF/F Labor activity (where applicable) RUC recommendation or current value (min or qty) CMS refinement (min or qty) Comment Direct costs change ($)
10021 Fna w/o image EF015 mayo stand NF 24 28 Refined equipment time to conform to established policies for non-highly technical equipment
EF023 table, exam NF 29 28 Refined equipment time to conform to established policies for non-highly technical equipment
L037D RN/LPN/MTA NF Greet patient, provide gowning, ensure appropriate medical records are available 1 0 Typically billed with an E/M or other evaluation service (0.37)
11750 Removal of nail bed EF015 mayo stand NF 27 45 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EF031 table, power NF 54 62 Refined equipment time to conform to established policies for non-highly technical equipment 0.13
EQ137 instrument pack, basic ($500-$1,499) NF 34 45 Refined equipment time to conform to established policies for non-highly technical equipment 0.03
EQ168 light, exam NF 54 62 Refined equipment time to conform to established policies for non-highly technical equipment 0.03
L037D RN/LPN/MTA NF Provide pre-service education/obtain consent 0 2 Refined time to standard time for this clinical labor task 0.74
SG067 penrose drain (0.25in x 4in) NF 1 0 Removed supply not typically used in this service (0.50)
11760 Repair of nail bed EF014 light, surgical NF 45 43 Refined equipment time to conform to established policies for non-highly technical equipment (0.02)
EF015 mayo stand NF 45 43 Refined equipment time to conform to established policies for non-highly technical equipment
EF031 table, power NF 72 70 Refined equipment time to conform to established policies for non-highly technical equipment (0.03)
EQ137 instrument pack, basic ($500-$1,499) NF 52 47 Refined equipment time to conform to established policies for instrument packs (0.01)
EQ168 light, exam NF 72 70 Refined equipment time to conform to established policies for non-highly technical equipment (0.01)
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Complete pre-service diagnostic & referral forms 5 0 Emergency procedure, input would not typically be used (1.85)
L037D RN/LPN/MTA NF Coordinate pre-surgery services 3 0 Emergency procedure, input would not typically be used (1.11)
L037D RN/LPN/MTA NF Provide pre-service education/obtain consent 5 0 Duplication with other clinical labor task (1.85)
12005 Rpr s/n/a/gen/trk12.6-20.0cm EF023 table, exam NF 40 44 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ110 electrocautery-hyfrecator, up to 45 watts NF 40 44 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ168 light, exam NF 40 44 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Check dressings & wound/home care instructions/coordinate office visits/prescriptions 7 3 Refined time to standard time for this clinical labor task (1.48)
12006 Rpr s/n/a/gen/trk20.1-30.0cm EF031 table, power NF 45 49 Refined equipment time to conform to established policies for non-highly technical equipment 0.07
EQ110 electrocautery-hyfrecator, up to 45 watts NF 45 49 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ168 light, exam NF 45 49 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Check dressings & wound/home care instructions/coordinate office visits/prescriptions 7 3 Refined time to standard time for this clinical labor task (1.48)
12007 Rpr s/n/ax/gen/trnk >30.0 cm EF031 table, power NF 50 54 Refined equipment time to conform to established policies for non-highly technical equipment 0.07
EQ110 electrocautery-hyfrecator, up to 45 watts NF 50 54 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ168 light, exam NF 50 54 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Check dressings & wound/home care instructions/coordinate office visits/prescriptions 7 3 Refined time to standard time for this clinical labor task (1.48)
12013 Rpr f/e/e/n/l/m 2.6-5.0 cm EF031 table, power NF 27 33 Refined equipment time to conform to established policies for non-highly technical equipment 0.10
EQ110 electrocautery-hyfrecator, up to 45 watts NF 27 33 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EQ168 light, exam NF 27 33 Refined equipment time to conform to established policies for non-highly technical equipment 0.03
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Check dressings & wound/home care instructions/coordinate office visits/prescriptions 5 3 Refined time to standard time for this clinical labor task (0.74)
12014 Rpr f/e/e/n/l/m 5.1-7.5 cm EF031 table, power NF 32 38 Refined equipment time to conform to established policies for non-highly technical equipment 0.10
EQ110 electrocautery-hyfrecator, up to 45 watts NF 32 38 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EQ168 light, exam NF 32 38 Refined equipment time to conform to established policies for non-highly technical equipment 0.03
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Check dressings & wound/home care instructions/coordinate office visits/prescriptions 5 3 Refined time to standard time for this clinical labor task (0.74)
12015 Rpr f/e/e/n/l/m 7.6-12.5 cm EF031 table, power NF 37 43 Refined equipment time to conform to established policies for non-highly technical equipment 0.10
EQ110 electrocautery-hyfrecator, up to 45 watts NF 37 43 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EQ168 light, exam NF 37 43 Refined equipment time to conform to established policies for non-highly technical equipment 0.03
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Check dressings & wound/home care instructions/coordinate office visits/prescriptions 5 3 Refined time to standard time for this clinical labor task (0.74)
12016 Rpr fe/e/en/l/m 12.6-20.0 cm EF031 table, power NF 42 48 Refined equipment time to conform to established policies for non-highly technical equipment 0.10
EQ110 electrocautery-hyfrecator, up to 45 watts NF 42 48 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EQ168 light, exam NF 42 48 Refined equipment time to conform to established policies for non-highly technical equipment 0.03
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Check dressings & wound/home care instructions/coordinate office visits/prescriptions 5 3 Refined time to standard time for this clinical labor task (0.74)
12041 Intmd rpr n-hf/genit 2.5cm/< ED004 camera, digital (6 mexapixel) F 0 27 Input added to maintain consistency with all other codes within family 0.10
ED004 camera, digital (6 mexapixel) NF 60 27 Refined equipment time to conform to office visit duration (0.12)
EF014 light, surgical NF 33 42 Refined equipment time to conform to established policies for non-highly technical equipment 0.09
EF015 mayo stand NF 33 42 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EF023 table, exam NF 60 27 Refined equipment time to conform to office visit duration (0.10)
EF031 table, power NF 33 42 Refined equipment time to conform to established policies for non-highly technical equipment 0.15
EQ110 electrocautery-hyfrecator, up to 45 watts NF 33 42 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EQ137 instrument pack, basic ($500-$1,499) NF 0 46 Equipment item replaces another item (EQ138); see preamble 0.11
EQ138 instrument pack, medium ($1,500 and up) NF 40 0 Equipment item replaced by another item (EQ137); see preamble (0.28)
EQ168 light, exam NF 60 27 Refined equipment time to conform to office visit duration (0.14)
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA F Provide pre-service education/obtain consent 2 0 Intraservice direct PE inputs are not included in the facility setting; See preamble text (0.74)
L037D RN/LPN/MTA NF Complete pre-service diagnostic & referral forms 5 0 Emergency procedure, input would not typically be used (1.85)
L037D RN/LPN/MTA NF Coordinate pre-surgery services 3 0 Emergency procedure, input would not typically be used (1.11)
L037D RN/LPN/MTA NF Follow-up phone calls and prescriptions 3 0 Emergency procedure, input would not typically be used (1.11)
12054 Intmd rpr face/mm 7.6-12.5cm ED004 camera, digital (6 mexapixel) NF 90 27 Refined equipment time to conform to office visit duration (0.24)
EF014 light, surgical NF 63 71 Refined equipment time to conform to established policies for non-highly technical equipment 0.08
EF015 mayo stand NF 63 71 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EF023 table, exam NF 90 27 Refined equipment time to conform to office visit duration (0.19)
EF031 table, power NF 63 71 Refined equipment time to conform to established policies for non-highly technical equipment 0.13
EQ110 electrocautery-hyfrecator, up to 45 watts NF 63 71 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EQ138 instrument pack, medium ($1,500 and up) NF 75 80 Refined equipment time to conform to established policies for instrument packs 0.03
EQ168 light, exam NF 90 27 Refined equipment time to conform to office visit duration (0.27)
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA F Provide pre-service education/obtain consent 2 0 Intraservice direct PE inputs are not included in the facility setting; See preamble text (0.74)
L037D RN/LPN/MTA NF Complete pre-service diagnostic & referral forms 5 0 Emergency procedure, input would not typically be used (1.85)
L037D RN/LPN/MTA NF Coordinate pre-surgery services 3 0 Emergency procedure, input would not typically be used (1.11)
L037D RN/LPN/MTA NF Follow-up phone calls and prescriptions 3 0 Emergency procedure, input would not typically be used (1.11)
12055 Intmd rpr face/mm 12.6-20 cm ED004 camera, digital (6 mexapixel) NF 136 63 Refined equipment time to conform to office visit duration (0.27)
EF014 light, surgical NF 73 81 Refined equipment time to conform to established policies for non-highly technical equipment 0.08
EF015 mayo stand NF 73 81 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EF023 table, exam NF 136 63 Refined equipment time to conform to office visit duration (0.22)
EF031 table, power NF 73 81 Refined equipment time to conform to established policies for non-highly technical equipment 0.13
EQ110 electrocautery-hyfrecator, up to 45 watts NF 73 81 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EQ138 instrument pack, medium ($1,500 and up) NF 85 90 Refined equipment time to conform to established policies for instrument packs 0.03
EQ168 light, exam NF 136 63 Refined equipment time to conform to office visit duration (0.32)
L037D RN/LPN/MTA F Provide pre-service education/obtain consent 2 0 Intraservice direct PE inputs are not included in the facility setting; See preamble text (0.74)
L037D RN/LPN/MTA NF Complete pre-service diagnostic & referral forms 5 0 Emergency procedure, input would not typically be used (1.85)
L037D RN/LPN/MTA NF Coordinate pre-surgery services 3 0 Emergency procedure, input would not typically be used (1.11)
L037D RN/LPN/MTA NF Follow-up phone calls and prescriptions 3 0 Emergency procedure, input would not typically be used (1.11)
SA054 pack, post-op incision care (suture) F 2 1 No rationale was provided for quantity change relative to current value; maintaining current value (4.91)
12057 Intmd rpr face/mm >30.0 cm ED004 camera, digital (6 mexapixel) NF 166 63 Refined equipment time to conform to office visit duration (0.39)
EF014 light, surgical NF 103 111 Refined equipment time to conform to established policies for non-highly technical equipment 0.08
EF015 mayo stand NF 103 111 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EF023 table, exam NF 166 63 Refined equipment time to conform to office visit duration (0.31)
EF031 table, power NF 103 111 Refined equipment time to conform to established policies for non-highly technical equipment 0.13
EQ110 electrocautery-hyfrecator, up to 45 watts NF 103 111 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EQ138 instrument pack, medium ($1,500 and up) NF 115 120 Refined equipment time to conform to established policies for instrument packs 0.03
EQ168 light, exam NF 166 63 Refined equipment time to conform to office visit duration (0.45)
L037D RN/LPN/MTA F Provide pre-service education/obtain consent 2 0 Intraservice direct PE inputs are not included in the facility setting; See preamble text (0.74)
L037D RN/LPN/MTA NF Complete pre-service diagnostic & referral forms 5 0 Emergency procedure, input would not typically be used (1.85)
L037D RN/LPN/MTA NF Coordinate pre-surgery services 3 0 Emergency procedure, input would not typically be used (1.11)
L037D RN/LPN/MTA NF Follow-up phone calls and prescriptions 3 0 Emergency procedure, input would not typically be used (1.11)
SA054 pack, post-op incision care (suture) F 2 1 No rationale was provided for quantity change relative to current value; maintaining current value (4.91)
SA054 pack, post-op incision care (suture) NF 2 1 No rationale was provided for quantity change relative to current value; maintaining current value (4.91)
20240 Bone biopsy excisional L037D RN/LPN/MTA F Dischrg gmt. same day (0.5 x 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
30300 Remove nasal foreign body EF008 chair with headrest, exam, reclining NF 59 67 Refined equipment time to conform to established policies for non-highly technical equipment 0.09
EF015 mayo stand NF 22 40 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EQ137 instrument pack, basic ($500-$1,499) NF 29 47 Refined equipment time to conform to established policies for instrument packs 0.04
EQ167 light source, xenon F 27 0 Redundant when used together with EQ170; see preamble (0.72)
EQ167 light source, xenon NF 59 0 Redundant when used together with EQ170; see preamble (1.57)
EQ170 light, fiberoptic headlight w-source NF 59 67 Refined equipment time to conform to established policies for non-highly technical equipment 0.06
EQ234 suction and pressure cabinet, ENT (SMR) NF 59 67 Refined equipment time to conform to established policies for non-highly technical equipment 0.07
ES013 endoscope, rigid, sinoscopy NF 71 74 Refined equipment time to conform to established policies for scopes 0.02
ES031 video system, endoscopy (processor, digital capture, monitor, printer, cart) NF 59 67 Refined equipment time to conform to established policies for non-highly technical equipment 1.03
L037D RN/LPN/MTA F Discharge day management 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
SA041 pack, basic injection NF 1 0 Supply item replaced by another item (component parts); see preamble (11.67)
SB001 cap, surgical NF 0 1 Supply item replaces another item (SA041); see preamble 0.21
SB012 drape, sterile, for Mayo stand NF 0 1 Supply item replaces another item (SA041); see preamble 1.69
SB024 gloves, sterile NF 0 2 Supply item replaces another item (SA041); see preamble 1.68
SB027 gown, staff, impervious NF 0 2 Supply item replaces another item (SA041); see preamble 2.37
SB033 mask, surgical NF 0 1 Supply item replaces another item (SA041); see preamble 0.20
SB044 underpad 2ft x 3ft (Chux) NF 0 1 Supply item replaces another item (SA041); see preamble 0.23
SG009 applicator, sponge-tipped NF 0 3 Supply item replaces another item (SA041); see preamble 0.42
SG055 gauze, sterile 4in x 4in NF 0 2 Supply item replaces another item (SA041); see preamble 0.32
SM010 cleaning brush, endoscope F 2 1 Refined supply quantity to what is typical for the procedure (4.99)
SM010 cleaning brush, endoscope NF 4 2 Refined supply quantity to what is typical for the procedure (9.98)
30903 Control of nosebleed EF008 chair with headrest, exam, reclining NF 54 110 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.60
EQ110 electrocautery-hyfrecator, up to 45 watts NF 54 50 Refined equipment time to conform to established policies for non-highly technical equipment (0.01)
EQ137 instrument pack, basic ($500-$1,499) NF 61 54 Refined equipment time to conform to established policies for instrument packs (0.02)
EQ170 light, fiberoptic headlight w-source NF 54 50 Refined equipment time to conform to established policies for non-highly technical equipment (0.03)
EQ234 suction and pressure cabinet, ENT (SMR) NF 54 110 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.52
L037D RN/LPN/MTA F Dischrg gmt. same day (0.5 x 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
30905 Control of nosebleed EF008 chair with headrest, exam, reclining NF 72 128 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.60
EQ110 electrocautery-hyfrecator, up to 45 watts NF 72 68 Refined equipment time to conform to established policies for non-highly technical equipment (0.01)
EQ137 instrument pack, basic ($500-$1,499) NF 79 72 Refined equipment time to conform to established policies for instrument packs (0.02)
EQ170 light, fiberoptic headlight w-source NF 72 68 Refined equipment time to conform to established policies for non-highly technical equipment (0.03)
EQ234 suction and pressure cabinet, ENT (SMR) NF 72 128 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.52
L037D RN/LPN/MTA F Dischrg gmt. same day (0.5 x 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
30906 Repeat control of nosebleed EF008 chair with headrest, exam, reclining NF 84 140 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.60
EQ110 electrocautery-hyfrecator, up to 45 watts NF 84 80 Refined equipment time to conform to established policies for non-highly technical equipment (0.01)
EQ137 instrument pack, basic ($500-$1,499) NF 91 84 Refined equipment time to conform to established policies for instrument packs (0.02)
EQ170 light, fiberoptic headlight w-source NF 84 80 Refined equipment time to conform to established policies for non-highly technical equipment (0.03)
EQ234 suction and pressure cabinet, ENT (SMR) NF 84 140 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.52
31295 Sinus endo w/balloon dil EF008 chair with headrest, exam, reclining NF 50 103 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.57
EF015 mayo stand NF 32 43 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ137 instrument pack, basic ($500-$1,499) NF 42 47 Refined equipment time to conform to established policies for instrument packs 0.01
EQ167 light source, xenon NF 50 0 Redundant when used together with EQ170; see preamble (1.33)
EQ170 light, fiberoptic headlight w-source NF 50 43 Refined equipment time to conform to established policies for non-highly technical equipment (0.06)
EQ234 suction and pressure cabinet, ENT (SMR) NF 50 103 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.49
ES013 endoscope, rigid, sinoscopy NF 44 47 Refined equipment time to conform to established policies for scopes 0.02
ES031 video system, endoscopy (processor, digital capture, monitor, printer, cart) NF 50 43 Refined equipment time to conform to established policies for non-highly technical equipment (0.90)
L037D RN/LPN/MTA F Dischrg gmt. same day (0.5 × 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Complete pre-service diagnostic & referral forms 5 0 See preamble text (1.85)
L037D RN/LPN/MTA NF Provide pre-service education/obtain consent 7 3 Refined time to standard time for this clinical labor task (1.48)
L037D RN/LPN/MTA NF Sedate/Apply anesthesia 5 2 Refined time to standard time for this clinical labor task (1.11)
SJ037 oxymetazoline nasal spray (Afrin) (15ml uou) NF 3 1 Refined supply quantity to what is typical for the procedure (3.66)
31296 Sinus endo w/balloon dil EF008 chair with headrest, exam, reclining NF 60 113 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.57
EF015 mayo stand NF 60 53 Refined equipment time to conform to established policies for non-highly technical equipment (0.01)
EQ137 instrument pack, basic ($500-$1,499) NF 52 57 Refined equipment time to conform to established policies for instrument packs 0.01
EQ167 light source, xenon NF 60 0 Redundant when used together with EQ170; see preamble (1.60)
EQ170 light, fiberoptic headlight w-source NF 60 53 Refined equipment time to conform to established policies for non-highly technical equipment (0.06)
EQ234 suction and pressure cabinet, ENT (SMR) NF 60 113 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.49
ES013 endoscope, rigid, sinoscopy NF 54 57 Refined equipment time to conform to established policies for scopes 0.02
ES031 video system, endoscopy (processor, digital capture, monitor, printer, cart) NF 60 53 Refined equipment time to conform to established policies for non-highly technical equipment (0.90)
L037D RN/LPN/MTA F Dischrg gmt. same day (0.5 × 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Complete pre-service diagnostic & referral forms 5 0 See preamble text (1.85)
L037D RN/LPN/MTA NF Provide pre-service education/obtain consent 7 3 Refined time to standard time for this clinical labor task (1.48)
L037D RN/LPN/MTA NF Sedate/Apply anesthesia 5 2 Refined time to standard time for this clinical labor task (1.11)
SJ037 oxymetazoline nasal spray (Afrin) (15ml uou) NF 3 1 Refined supply quantity to what is typical for the procedure (3.66)
31297 Sinus endo w/balloon dil EF008 chair with headrest, exam, reclining NF 58 111 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.57
EF015 mayo stand NF 40 51 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ137 instrument pack, basic ($500-$1,499) NF 47 55 Refined equipment time to conform to established policies for instrument packs 0.02
EQ167 light source, xenon NF 58 0 Redundant when used together with EQ170; see preamble (1.55)
EQ170 light, fiberoptic headlight w-source NF 58 51 Refined equipment time to conform to established policies for non-highly technical equipment (0.06)
EQ234 suction and pressure cabinet, ENT (SMR) NF 58 111 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.49
ES013 endoscope, rigid, sinoscopy NF 52 55 Refined equipment time to conform to established policies for scopes 0.02
ES031 video system, endoscopy (processor, digital capture, monitor, printer, cart) NF 58 51 Refined equipment time to conform to established policies for non-highly technical equipment (0.90)
L037D RN/LPN/MTA F Dischrg gmt. same day (0.5 × 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Complete pre-service diagnostic & referral forms 5 0 See preamble text (1.85)
L037D RN/LPN/MTA NF Provide pre-service education/obtain consent 7 3 Refined time to standard time for this clinical labor task (1.48)
L037D RN/LPN/MTA NF Sedate/Apply anesthesia 5 2 Refined time to standard time for this clinical labor task (1.11)
SJ037 oxymetazoline nasal spray (Afrin) (15ml uou) NF 3 1 Refined supply quantity to what is typical for the procedure (3.66)
38572 Laparoscopy lymphadenectomy SA051 pack, pelvic exam F 1 0 Removed supply not typically used in this service (1.17)
40804 Removal foreign body mouth EF008 chair with headrest, exam, reclining NF 74 82 Refined equipment time to conform to established policies for non-highly technical equipment 0.09
EQ110 electrocautery-hyfrecator, up to 45 watts NF 29 39 Refined equipment time to conform to established policies for non-highly technical equipment 0.03
EQ137 instrument pack, basic ($500-$1,499) NF 36 38 Refined equipment time to conform to established policies for instrument packs
EQ170 light, fiberoptic headlight w-source NF 74 82 Refined equipment time to conform to established policies for non-highly technical equipment 0.06
EQ234 suction and pressure cabinet, ENT (SMR) F 27 0 Equipment usage not typical for a follow-up office visit (0.25)
EQ234 suction and pressure cabinet, ENT (SMR) NF 61 39 Refined equipment time to conform to established policies for non-highly technical equipment (0.20)
L037D RN/LPN/MTA F Dischrg gmt. same day (0.5 × 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
SD009 canister, suction NF 2 1 Refined supply quantity to what is typical for the procedure (3.91)
42809 Remove pharynx foreign body EF008 chair with headrest, exam, reclining NF 58 74 Refined equipment time to conform to established policies for non-highly technical equipment 0.17
EF015 mayo stand NF 26 47 Refined equipment time to conform to established policies for non-highly technical equipment 0.02
EQ137 instrument pack, basic ($500-$1,499) NF 60 51 Refined equipment time to conform to established policies for instrument packs (0.02)
EQ170 light, fiberoptic headlight w-source NF 58 74 Refined equipment time to conform to established policies for non-highly technical equipment 0.13
EQ234 suction and pressure cabinet, ENT (SMR) F 27 0 Equipment usage not typical for a follow-up office visit (0.25)
EQ234 suction and pressure cabinet, ENT (SMR) NF 58 47 Refined equipment time to conform to established policies for non-highly technical equipment (0.10)
ES020 fiberscope, flexible, rhinolaryngoscopy NF 115 128 Refined equipment time to conform to established policies for scopes 0.47
L037D RN/LPN/MTA F Dischrg gmt. same day (0.5 × 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
SA048 pack, minimum multi-specialty visit F 2 1 Refined supply quantity to what is typical for the procedure (1.14)
44380 Small bowel endoscopy br/wa EF018 stretcher NF 73 77 Standard time for moderate sedation equipment 0.02
EF027 table, instrument, mobile NF 29 77 Standard time for moderate sedation equipment 0.07
EF031 table, power NF 29 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.47)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 52 77 Standard time for moderate sedation equipment 0.35
EQ032 IV infusion pump NF 52 77 Standard time for moderate sedation equipment 0.16
44381 Small bowel endoscopy br/wa EF018 stretcher NF 83 87 Standard equipment and time for moderate sedation 0.02
EF027 table, instrument, mobile NF 39 87 Standard equipment and time for moderate sedation 0.07
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 62 87 Standard equipment and time for moderate sedation 0.35
EQ032 IV infusion pump NF 62 87 Standard equipment and time for moderate sedation 0.16
44382 Small bowel endoscopy EF018 stretcher NF 78 82 Standard time for moderate sedation equipment 0.02
EF027 table, instrument, mobile NF 34 82 Standard time for moderate sedation equipment 0.07
EF031 table, power NF 34 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.56)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 57 82 Standard time for moderate sedation equipment 0.35
EQ032 IV infusion pump NF 57 82 Standard time for moderate sedation equipment 0.16
44385 Endoscopy of bowel pouch EF027 table, instrument, mobile NF 29 77 Standard time for moderate sedation equipment 0.07
EF031 table, power NF 29 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.47)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 52 77 Refined equipment time to conform to established policies for equipment with 4× monitoring time 0.35
EQ032 IV infusion pump NF 52 77 Standard time for moderate sedation equipment 0.16
44386 Endoscopy bowel pouch/biop EF027 table, instrument, mobile NF 31 79 Standard time for moderate sedation equipment 0.07
EF031 table, power NF 31 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.51)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 54 79 Standard time for moderate sedation equipment 0.35
EQ032 IV infusion pump NF 54 79 Standard time for moderate sedation equipment 0.16
44388 Colonoscopy thru stoma spx EF027 table, instrument, mobile NF 57 87 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 39 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.64)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 57 87 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 57 87 Standard time for moderate sedation equipment 0.19
44389 Colonoscopy with biopsy EF027 table, instrument, mobile NF 62 92 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 44 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.72)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 62 92 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 62 92 Standard time for moderate sedation equipment 0.19
44390 Colonoscopy for foreign body EF027 table, instrument, mobile NF 67 97 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 49 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.80)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 67 97 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 67 97 Standard time for moderate sedation equipment 0.19
44391 Colonoscopy for bleeding EF027 table, instrument, mobile NF 72 102 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 54 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.88)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 72 102 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 72 102 Standard time for moderate sedation equipment 0.19
44392 Colonoscopy & polypectomy EF027 table, instrument, mobile NF 62 92 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 44 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.72)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 62 92 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 62 92 Standard time for moderate sedation equipment 0.19
44394 Colonoscopy w/snare EF027 table, instrument, mobile NF 62 92 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 44 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.72)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 62 92 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 62 92 Standard time for moderate sedation equipment 0.19
44401 Colonoscopy with ablation EF027 table, instrument, mobile NF 62 92 Standard equipment and time for moderate sedation 0.04
EF031 table, power NF 44 0 Refined equipment time to conform to established policies for non-highly technical equipment (0.72)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 62 92 Standard equipment and time for moderate sedation 0.42
EQ032 IV infusion pump NF 62 92 Standard equipment and time for moderate sedation 0.19
44404 Colonoscopy w/injection EF027 table, instrument, mobile NF 62 92 Standard equipment and time for moderate sedation 0.04
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 62 92 Standard equipment and time for moderate sedation 0.42
EQ032 IV infusion pump NF 62 92 Standard equipment and time for moderate sedation 0.19
44405 Colonoscopy w/dilation EF027 table, instrument, mobile NF 40 100 Standard equipment and time for moderate sedation 0.08
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 50 100 Standard equipment and time for moderate sedation 0.70
EQ032 IV infusion pump NF 50 100 Standard equipment and time for moderate sedation 0.32
45330 Diagnostic sigmoidoscopy EF027 table, instrument, mobile NF 12 0 No moderate sedation (0.02)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 18 0 No moderate sedation (0.25)
EQ235 suction machine (Gomco) NF 12 22 Increased to reflect Intra-Service clinical labor tasks 0.02
ES031 video system, endoscopy (processor, digital capture, monitor, printer, cart) NF 12 22 Increased to reflect Intra-Service clinical labor tasks 1.29
ES043 Video Sigmoid- oscope NF 42 49 Refined equipment time to conform to established policies for scopes 0.49
45331 Sigmoidoscopy and biopsy EF027 table, instrument, mobile NF 12 0 No moderate sedation (0.02)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 33 0 No moderate sedation (0.46)
EQ235 suction machine (Gomco) NF 12 27 Matches time spent using endoscope system 0.03
ES031 video system, endoscopy (processor, digital capture, monitor, printer, cart) NF 12 27 Increased to reflect Intra-Service clinical labor tasks 1.93
ES043 Video Sigmoid- oscope NF 42 54 Refined equipment time to conform to established policies for scopes 0.83
45332 Sigmoidoscopy w/fb removal EF027 table, instrument, mobile NF 34 82 Standard time for moderate sedation equipment 0.07
EF031 table, power NF 34 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.56)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 57 82 Standard time for moderate sedation equipment 0.35
EQ032 IV infusion pump NF 57 82 Standard time for moderate sedation equipment 0.16
45333 Sigmoidoscopy & polypectomy EF027 table, instrument, mobile NF 29 77 Standard time for moderate sedation equipment 0.07
EF031 table, power NF 29 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.47)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 52 77 Standard time for moderate sedation equipment 0.35
EQ032 IV infusion pump NF 52 77 Standard time for moderate sedation equipment 0.16
45334 Sigmoidoscopy for bleeding EF027 table, instrument, mobile NF 34 82 Standard time for moderate sedation equipment 0.07
EF031 table, power NF 34 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.56)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 57 82 Standard time for moderate sedation equipment 0.35
EQ032 IV infusion pump NF 57 82 Standard time for moderate sedation equipment 0.16
45335 Sigmoidoscopy w/submuc inj EF027 table, instrument, mobile NF 29 77 Standard time for moderate sedation equipment 0.07
EF031 table, power NF 29 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.47)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 52 77 Standard time for moderate sedation equipment 0.35
EQ032 IV infusion pump NF 52 77 Standard time for moderate sedation equipment 0.16
45338 Sigmoidoscopy w/tumr remove EF027 table, instrument, mobile NF 29 77 Standard time for moderate sedation equipment 0.07
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 52 77 Standard time for moderate sedation equipment 0.35
EQ032 IV infusion pump NF 52 77 Standard time for moderate sedation equipment 0.16
45340 Sig w/tndsc balloon dilation EF027 table, instrument, mobile NF 34 82 Standard time for moderate sedation equipment 0.07
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 57 82 Standard time for moderate sedation equipment 0.35
EQ032 IV infusion pump NF 57 82 Standard time for moderate sedation equipment 0.16
45346 Sigmoidoscopy w/ablation EF027 table, instrument, mobile NF 34 82 Standard equipment and time for moderate sedation 0.07
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 57 82 Standard equipment and time for moderate sedation 0.35
EQ032 IV infusion pump NF 57 82 Standard equipment and time for moderate sedation 0.16
45350 Sgmdsc w/band ligation EF027 table, instrument, mobile NF 94 82 Standard equipment and time for moderate sedation (0.02)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 94 82 Standard equipment and time for moderate sedation (0.17)
EQ032 IV infusion pump NF 94 82 Standard equipment and time for moderate sedation (0.08)
SH074 water, sterile for irrigation (250-1000ml uou) NF 1 0 This input is not contained within any other code in this family; maintaining consistency with all other codes within family (2.09)
SK087 water, distilled NF 0 5 This input is not contained within any other code in this family; maintaining consistency with all other codes within family 0.07
45378 Diagnostic colonoscopy EF027 table, instrument, mobile NF 57 87 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 39 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.64)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 57 87 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 57 87 Standard time for moderate sedation equipment 0.19
EQ235 suction machine (Gomco) NF 72 39 Matches time spent using endoscope system (0.07)
45379 Colonoscopy w/fb removal EF027 table, instrument, mobile NF 67 97 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 49 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.80)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 67 97 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 67 97 Standard time for moderate sedation equipment 0.19
EQ235 suction machine (Gomco) NF 92 49 Matches time spent using endoscope system (0.08)
45380 Colonoscopy and biopsy EF027 table, instrument, mobile NF 60 90 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 42 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.69)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 60 90 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 60 90 Standard time for moderate sedation equipment 0.19
EQ235 suction machine (Gomco) NF 78 42 Matches time spent using endoscope system (0.07)
45381 Colonoscopy submucous njx EF027 table, instrument, mobile NF 60 90 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 42 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.69)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 60 90 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 60 90 Standard time for moderate sedation equipment 0.19
EQ235 suction machine (Gomco) NF 78 42 Matches time spent using endoscope system (0.07)
45382 Colonoscopy w/control bleed EF027 table, instrument, mobile NF 72 102 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 54 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.88)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 72 102 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 72 102 Standard time for moderate sedation equipment 0.19
EQ235 suction machine (Gomco) NF 102 54 Matches time spent using endoscope system (0.09)
45384 Colonoscopy w/lesion removal EF027 table, instrument, mobile NF 60 90 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 42 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.69)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 60 90 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 60 90 Standard time for moderate sedation equipment 0.19
EQ235 suction machine (Gomco) NF 78 42 Matches time spent using endoscope system (0.07)
45385 Colonoscopy w/lesion removal EF027 table, instrument, mobile NF 62 92 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 44 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.72)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 62 92 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 62 92 Standard time for moderate sedation equipment 0.19
EQ235 suction machine (Gomco) NF 82 44 Matches time spent using endoscope system (0.07)
45386 Colonoscopy w/balloon dilat EF027 table, instrument, mobile NF 67 97 Standard time for moderate sedation equipment 0.04
EF031 table, power NF 49 0 Equipment removed due to redundancy when used together with equipment item EF018, stretcher (0.80)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 67 97 Standard time for moderate sedation equipment 0.42
EQ032 IV infusion pump NF 67 97 Standard time for moderate sedation equipment 0.19
EQ235 suction machine (Gomco) NF 92 49 Matches time spent using endoscope system (0.08)
45388 Colonoscopy w/ablation EF027 table, instrument, mobile NF 67 97 Standard equipment and time for moderate sedation 0.04
EF031 table, power NF 49 0 Refined equipment time to conform to established policies for non-highly technical equipment (0.80)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 67 97 Standard equipment and time for moderate sedation 0.42
EQ032 IV infusion pump NF 67 97 Standard equipment and time for moderate sedation 0.19
EQ235 suction machine (Gomco) NF 92 49 Matches time spent using endoscope system (0.08)
45398 Colonoscopy w/band ligation EF027 table, instrument, mobile NF 52 82 Standard equipment and time for moderate sedation 0.04
EF031 table, power NF 34 0 Refined equipment time to conform to established policies for non-highly technical equipment (0.56)
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 52 82 Standard equipment and time for moderate sedation 0.42
EQ032 IV infusion pump NF 52 82 Standard equipment and time for moderate sedation 0.19
EQ235 suction machine (Gomco) NF 62 34 Matches time spent using endoscope system (0.06)
46500 Injection into hemorrhoid(s) EF014 light, surgical NF 73 60 Refined equipment time to conform to established policies for non-highly technical equipment (0.13)
EF031 table, power NF 73 60 Refined equipment time to conform to established policies for non-highly technical equipment (0.21)
EQ235 suction machine (Gomco) NF 73 60 Refined equipment time to conform to established policies for non-highly technical equipment (0.03)
ES002 anoscope with light source NF 78 60 Refined equipment time to conform to established policies for non-highly technical equipment (0.07)
L037D RN/LPN/MTA F Cleaning scope at POV 5 0 Included in clinical labor task “Clean room, equipment, and supplies” included in post-operative visit (1.85)
L037D RN/LPN/MTA F Complete pre-service diagnostic and referral forms 3 0 Standard 0 day global pre-service times; exception not accepted as service is rarely furnished in the facility (1.11)
L037D RN/LPN/MTA F Coordinate pre-surgery services 3 0 Standard 0 day global pre-service times; exception not accepted as service is rarely furnished in the facility (1.11)
L037D RN/LPN/MTA F Follow-up phone calls and prescriptions 3 0 Standard 0 day global pre-service times; exception not accepted as service is rarely furnished in the facility (1.11)
L037D RN/LPN/MTA F Schedule space and equipment in facility 3 0 Standard 0 day global pre-service times; exception not accepted as service is rarely furnished in the facility (1.11)
L037D RN/LPN/MTA F Setup scope at POV 5 0 Included in clinical labor task “Prepare room, equipment, supplies” included in post-operative visit (1.85)
L037D RN/LPN/MTA NF Clean scope 5 0 Included in clinical labor task “Clean room, equipment, and supplies” (1.85)
L037D RN/LPN/MTA NF Cleaning scope at POV 5 0 Included in clinical labor task “Clean room, equipment, and supplies” included in post-operative visit (1.85)
L037D RN/LPN/MTA NF Follow-up phone calls and prescriptions 3 0 Typically billed with an E/M or other evaluation service (1.11)
L037D RN/LPN/MTA NF Setup scope (non facility setting only) 5 0 Included in clinical labor task “Prepare room, equipment, supplies” (1.85)
L037D RN/LPN/MTA NF Setup scope at POV 5 0 Included in clinical labor task “Clean room, equipment, and supplies” included in post-operative visit (1.85)
SA042 pack, cleaning and disinfecting, endoscope NF 2 0 Removed supply associated with equipment item not typically used in this service (34.12)
46601 Diagnostic anoscopy EF031 table, power NF 41 33 Refined equipment time to conform to established policies for non-highly technical equipment (0.13)
46607 Diagnostic anoscopy & biopsy EF031 table, power NF 49 38 Refined equipment time to conform to established policies for non-highly technical equipment (0.18)
5039A Njx px nfrosgrm &/urtrgrm ED050 PACS Workstation Proxy NF 58 67 Refined equipment time to conform to clinical labor time 0.20
EF027 table, instrument, mobile NF 284 277 Standard equipment and time for moderate sedation (0.01)
EL011 room, angiography NF 44 0 Equipment item replaced by another item; see preamble (231.21)
EL014 room, radiographic-fluoroscopic NF 0 44 Equipment item replaces another item; see preamble 61.30
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 284 277 Standard equipment and time for moderate sedation (0.10)
EQ032 IV infusion pump NF 284 277 Standard equipment and time for moderate sedation (0.04)
EQ168 light, exam NF 44 62 Refined equipment time to conform to established policies for non-highly technical equipment 0.08
L037D RN/LPN/MTA NF Monitor pt following service/check tubes, monitors, drains (not related to moderate sedation) 0 45 Clinical labor type replaces another clinical labor type; see preamble 16.65
L051A RN NF Monitor pt following service/check tubes, monitors, drains (not related to moderate sedation) 45 0 Clinical labor type replaced by another labor type; see preamble (22.95)
SA019 kit, iv starter NF 1 0 Duplicative; a similar item is already included in this service (1.60)
SA042 pack, cleaning and disinfecting, endoscope NF 1 0 Removed supply associated with equipment item not typically used in this service (17.06)
SB022 gloves, non-sterile NF 2 0 Duplicative; items included in pack, minimum multi-specialty visit (SA048) (0.17)
SB024 gloves, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (0.84)
SB028 gown, surgical, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (4.67)
SC049 stop cock, 3-way NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.18)
5039B Njx px nfrosgrm &/urtrgrm ED050 PACS Workstation Proxy NF 21 45 Refined equipment time to conform to clinical labor time (Full intraservice period minus monitoring time) 0.53
EF027 table, instrument, mobile NF 22 40 Refined equipment time to conform to established policies for non-highly technical equipment 0.03
EL011 room, angiography NF 22 0 Equipment item replaced by another item; see preamble (115.60)
EL014 room, radiographic-fluoroscopic NF 0 22 Equipment item replaces another item; see preamble 30.65
EQ168 light, exam NF 22 40 Refined equipment time to conform to established policies for non-highly technical equipment 0.08
L037D RN/LPN/MTA NF Assist physician in performing procedure 15 0 Removed clinical labor associated with moderate sedation; moderate sedation not typical for this procedure (5.55)
SA042 pack, cleaning and disinfecting, endoscope NF 1 0 Removed supply associated with equipment item not typically used in this service (17.06)
SB001 cap, surgical NF 4 3 Aligned supply quantities with changes to number of clinical labor staff (0.21)
SB022 gloves, non-sterile NF 2 0 Duplicative; items included in pack, minimum multi-specialty visit (SA048) (0.17)
SB033 mask, surgical NF 2 1 Aligned supply quantities with changes to number of clinical labor staff (0.20)
SB039 shoe covers, surgical NF 4 3 Aligned supply quantities with changes to number of clinical labor staff (0.34)
5039C Plmt nephrostomy catheter ED050 PACS Workstation Proxy NF 71 80 Refined equipment time to conform to clinical labor time 0.20
EF027 table, instrument, mobile NF 300 290 Standard equipment and time for moderate sedation (0.01)
EL011 room, angiography NF 60 0 Equipment item replaced by another item; see preamble (315.28)
EL014 room, radiographic-fluoroscopic NF 0 60 Equipment item replaces another item; see preamble 83.59
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 300 290 Standard equipment and time for moderate sedation (0.14)
EQ032 IV infusion pump NF 300 290 Standard equipment and time for moderate sedation (0.06)
EQ168 light, exam NF 60 75 Refined equipment time to conform to established policies for non-highly technical equipment 0.06
L037D RN/LPN/MTA NF Monitor pt following service/check tubes, monitors, drains (not related to moderate sedation) 0 45 Clinical labor type replaces another clinical labor type; see preamble 16.65
L041B Radiologic Technologist NF Clean room/equipment by physician staff 6 3 Refined time to standard time for this clinical labor task (1.23)
L051A RN NF Monitor pt. following service/check tubes, monitors, drains (not related to moderate sedation) 45 0 Clinical labor type replaced by another labor type; see preamble (22.95)
SA019 kit, iv starter NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.60)
SA042 pack, cleaning and disinfecting, endoscope NF 1 0 Removed supply associated with equipment item not typically used in this service (17.06)
SB022 gloves, non-sterile NF 2 0 Duplicative; items included in pack, minimum multi-specialty visit (SA048) (0.17)
SB024 gloves, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (0.84)
SB028 gown, surgical, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (4.67)
SC049 stop cock, 3-way NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.18)
5039D Plmt nephroureteral catheter ED050 PACS Workstation Proxy NF 83 92 Refined equipment time to conform to clinical labor time 0.20
EF027 table, instrument, mobile NF 312 302 Standard equipment and time for moderate sedation (0.01)
EL011 room, angiography NF 72 0 Equipment item replaced by another item; see preamble (378.34)
EL014 room, radiographic-fluoroscopic NF 0 72 Equipment item replaces another item; see preamble 100.30
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 312 302 Standard equipment and time for moderate sedation (0.14)
EQ032 IV infusion pump NF 312 302 Standard equipment and time for moderate sedation (0.06)
EQ168 light, exam NF 72 87 Refined equipment time to conform to established policies for non-highly technical equipment 0.06
L037D RN/LPN/MTA NF Monitor pt. following service/check tubes, monitors, drains (not related to moderate sedation) 0 45 Clinical labor type replaces another clinical labor type; see preamble 16.65
L041B Radiologic Technologist NF Clean room/equipment by physician staff 6 3 Refined time to standard time for this clinical labor task (1.23)
L051A RN NF Monitor pt. following service/check tubes, monitors, drains (not related to moderate sedation) 45 0 Clinical labor type replaced by another labor type; see preamble (22.95)
SA019 kit, iv starter NF 1 0 Duplicative; a similar item is already included in this service (1.60)
SA042 pack, cleaning and disinfecting, endoscope NF 1 0 Removed supply associated with equipment item not typically used in this service (17.06)
SB022 gloves, non-sterile NF 2 0 Duplicative; items included in pack, minimum multi-specialty visit (SA048) (0.17)
SB024 gloves, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (0.84)
SB028 gown, surgical, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (4.67)
SC049 stop cock, 3-way NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.18)
SD306 Nephroureteral Catheter NF 1 0 Supply not mentioned in SOR work description (117.90)
5039E Exchange nephrostomy cath ED050 PACS Workstation Proxy NF 21 50 Refined equipment time to conform to clinical labor time 0.64
EF027 table, instrument, mobile NF 90 45 Refined equipment time to conform to established policies for non-highly technical equipment (0.06)
EL011 room, angiography NF 30 0 Equipment item replaced by another item; see preamble (157.64)
EL014 room, radiographic-fluoroscopic NF 0 30 Equipment item replaces another item; see preamble 41.79
EQ168 light, exam NF 30 45 Refined equipment time to conform to established policies for non-highly technical equipment 0.06
L037D RN/LPN/MTA NF Assist physician in performing procedure 20 0 Clinical labor type replaced by another labor type; see preamble (7.40)
L041B Radiologic Technologist NF Clean room/equipment by physician staff 6 3 Refined time to standard time for this clinical labor task (1.23)
SA031 kit, suture removal NF 1 0 Redundant when used together with supply catheter percutaneous fastener (Percu—Stay) (SD146) (1.05)
SA042 pack, cleaning and disinfecting, endoscope NF 1 0 Removed supply associated with equipment item not typically used in this service (17.06)
SB001 cap, surgical NF 4 3 Aligned supply quantities with changes to number of clinical labor staff (0.21)
SB022 gloves, non-sterile NF 2 0 Duplicative; items included in pack, minimum multi-specialty visit (SA048) (0.17)
SB033 mask, surgical NF 2 1 Aligned supply quantities with changes to number of clinical labor staff (0.20)
SB039 shoe covers, surgical NF 4 3 Aligned supply quantities with changes to number of clinical labor staff (0.34)
5039M Convert nephrostomy catheter ED050 PACS Workstation Proxy NF 68 77 Refined equipment time to conform to clinical labor time 0.20
EF027 table, instrument, mobile NF 297 287 Standard equipment and time for moderate sedation (0.01)
EL011 room, angiography NF 57 0 Equipment item replaced by another item; see preamble (299.52)
EL014 room, radiographic-fluoroscopic NF 0 57 Equipment item replaces another item; see preamble 79.41
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 297 287 Standard equipment and time for moderate sedation (0.14)
EQ032 IV infusion pump NF 297 287 Standard equipment and time for moderate sedation (0.06)
EQ168 light, exam NF 57 72 Refined equipment time to conform to established policies for non-highly technical equipment 0.06
L037D RN/LPN/MTA NF Monitor pt following service/check tubes, monitors, drains (not related to moderate sedation) 0 45 Clinical labor type replaces another clinical labor type; see preamble 16.65
L041B Radiologic Technologist NF Clean room/equipment by physician staff 6 3 Refined time to standard time for this clinical labor task (1.23)
L051A RN NF Monitor pt following service/check tubes, monitors, drains (not related to moderate sedation) 45 0 Clinical labor type replaced by another labor type; see preamble (22.95)
SA019 kit, iv starter NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.60)
SA031 kit, suture removal NF 1 0 Redundant when used together with supply catheter percutaneous fastener (Percu—Stay) (SD146) (1.05)
SA042 pack, cleaning and disinfecting, endoscope NF 1 0 Removed supply associated with equipment item not typically used in this service (17.06)
SB022 gloves, non-sterile NF 2 0 Duplicative; items included in pack, minimum multi-specialty visit (SA048) (0.17)
SB024 gloves, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (0.84)
SB028 gown, surgical, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (4.67)
SC049 stop cock, 3-way NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.18)
5069G Plmt ureteral stent prq ED050 PACS Workstation Proxy NF 68 77 Refined equipment time to conform to clinical labor time 0.20
EF027 table, instrument, mobile NF 297 287 Standard equipment and time for moderate sedation (0.01)
EL011 room, angiography NF 57 0 Equipment item replaced by another item; see preamble (299.52)
EL014 room, radiographic-fluoroscopic NF 0 57 Equipment item replaces another item; see preamble 79.41
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 297 287 Standard equipment and time for moderate sedation (0.14)
EQ032 IV infusion pump NF 297 287 Standard equipment and time for moderate sedation (0.06)
EQ168 light, exam NF 57 72 Refined equipment time to conform to established policies for non-highly technical equipment 0.06
L037D RN/LPN/MTA NF Monitor pt. following service/check tubes, monitors, drains (not related to moderate sedation) 0 45 Clinical labor type replaces another clinical labor type; see preamble 16.65
L041B Radiologic Technologist NF Clean room/equipment by physician staff 6 3 Refined time to standard time for this clinical labor task (1.23)
L051A RN NF Monitor pt. following service/check tubes, monitors, drains (not related to moderate sedation) 45 0 Clinical labor type replaced by another labor type; see preamble (22.95)
SA019 kit, iv starter NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.60)
SA031 kit, suture removal NF 1 0 Redundant when used together with supply catheter percutaneous fastener (Percu—Stay) (SD146) (1.05)
SA042 pack, cleaning and disinfecting, endoscope NF 1 0 Removed supply associated with equipment item not typically used in this service (17.06)
SB022 gloves, non-sterile NF 2 0 Duplicative; items included in pack, minimum multi-specialty visit (SA048) (0.17)
SB024 gloves, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (0.84)
SB028 gown, surgical, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (4.67)
SC049 stop cock, 3-way NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.18)
5069H Plmt ureteral stent prq ED050 PACS Workstation Proxy NF 85 94 Refined equipment time to conform to clinical labor time 0.20
EF027 table, instrument, mobile NF 314 304 Standard equipment and time for moderate sedation (0.01)
EL011 room, angiography NF 74 0 Equipment item replaced by another item; see preamble (388.85)
EL014 room, radiographic-fluoroscopic NF 0 74 Equipment item replaces another item; see preamble 103.09
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 314 304 Standard equipment and time for moderate sedation (0.14)
EQ032 IV infusion pump NF 314 304 Standard equipment and time for moderate sedation (0.06)
EQ168 light, exam NF 74 89 Refined equipment time to conform to established policies for non-highly technical equipment 0.06
L037D RN/LPN/MTA NF Monitor pt. following service/check tubes, monitors, drains (not related to moderate sedation) 0 45 Clinical labor type replaces another clinical labor type; see preamble 16.65
L041B Radiologic Technologist NF Acquire images (75%) 47 46 Rounding error in CL time calculation (0.41)
L041B Radiologic Technologist NF Clean room/equipment by physician staff 6 3 Refined time to standard time for this clinical labor task (1.23)
L051A RN NF Monitor pt. following service/check tubes, monitors, drains (not related to moderate sedation) 45 0 Clinical labor type replaced by another labor type; see preamble (22.95)
SA019 kit, iv starter NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.60)
SA042 pack, cleaning and disinfecting, endoscope NF 1 0 Removed supply associated with equipment item not typically used in this service (17.06)
SB022 gloves, non-sterile NF 2 0 Duplicative; items included in pack, minimum multi-specialty visit (SA048) (0.17)
SB024 gloves, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (0.84)
SB028 gown, surgical, sterile NF 2 1 Duplicative; a similar item is already included in this service (4.67)
SC049 stop cock, 3-way NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.18)
5069I Plmt ureteral stent prq ED050 PACS Workstation Proxy NF 98 107 Refined equipment time to conform to clinical labor time 0.20
EF027 table, instrument, mobile NF 327 317 Standard equipment and time for moderate sedation (0.01)
EL011 room, angiography NF 87 0 Equipment item replaced by another item; see preamble (457.16)
EL014 room, radiographic-fluoroscopic NF 0 87 Equipment item replaces another item; see preamble 121.20
EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) NF 327 317 Standard equipment and time for moderate sedation (0.14)
EQ032 IV infusion pump NF 327 317 Standard equipment and time for moderate sedation (0.06)
EQ168 light, exam NF 87 102 Refined equipment time to conform to established policies for non-highly technical equipment 0.06
L037D RN/LPN/MTA NF Monitor pt. following service/check tubes, monitors, drains (not related to moderate sedation) 0 45 Clinical labor type replaces another clinical labor type; see preamble 16.65
L041B Radiologic Technologist NF Clean room/equipment by physician staff 6 3 Refined time to standard time for this clinical labor task (1.23)
L051A RN NF Monitor pt. following service/check tubes, monitors, drains (not related to moderate sedation) 45 0 Clinical labor type replaced by another labor type; see preamble (22.95)
SA019 kit, iv starter NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.60)
SA042 pack, cleaning and disinfecting, endoscope NF 1 0 Removed supply associated with equipment item not typically used in this service (17.06)
SB022 gloves, non-sterile NF 2 0 Duplicative; items included in pack, minimum multi-specialty visit (SA048) (0.17)
SB024 gloves, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (0.84)
SB028 gown, surgical, sterile NF 2 1 Duplicative; items included in pack, moderate sedation (SA044) (4.67)
SC049 stop cock, 3-way NF 1 0 Duplicative; items included in pack, moderate sedation (SA044) (1.18)
5443A Repair corporeal tear EF031 table, power F 144 135 Refined equipment time to conform to clinical labor time (0.15)
EF031 table, power NF 144 135 Refined equipment time to conform to clinical labor time (0.15)
EQ168 light, exam F 144 135 Refined equipment time to conform to clinical labor time (0.04)
EQ168 light, exam NF 144 135 Refined equipment time to conform to clinical labor time (0.04)
657XG Impltj ntrstrml crnl rng seg L038A COMT/COT/RN/CST F Discharge day management same day 99238 -6 minutes 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.28)
68801 Dilate tear duct opening L038A COMT/COT/RN/CST F Discharge day management same day 99238 -6 minutes 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.28)
68810 Probe nasolacrimal duct L038A COMT/COT/RN/CST F Discharge day management same day 99238 -6 minutes 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.28)
68816 Probe nl duct w/balloon EL006 lane, screening (oph) NF 16 47 Refined equipment time to conform to clinical labor time 2.77
69200 Clear outer ear canal EF008 chair with headrest, exam, reclining NF 22 27 Refined equipment time to conform to established policies for non-highly technical equipment 0.05
EF015 mayo stand NF 19 27 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ137 instrument pack, basic ($500-$1,499) NF 26 31 Refined equipment time to conform to established policies for instrument packs 0.01
EQ170 light, fiberoptic headlight w-source NF 22 27 Refined equipment time to conform to established policies for non-highly technical equipment 0.04
EQ183 microscope, operating NF 22 27 Refined equipment time to conform to established policies for non-highly technical equipment 0.14
EQ234 suction and pressure cabinet, ENT (SMR) NF 22 27 Refined equipment time to conform to established policies for non-highly technical equipment 0.05
L037D RN/LPN/MTA F Dischrg gmt. same day (0.5 × 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
SH047 lidocaine 1%-2% inj (Xylocaine) NF 5 0 Supply item replaced by another item (SH050); see preamble (0.18)
SH050 lidocaine 4% soln, topical (Xylocaine) NF 0 3 Supply item replaces another item (SH047); see preamble 0.46
69220 Clean out mastoid cavity EF008 chair with headrest, exam, reclining NF 20 25 Refined equipment time to conform to established policies for non-highly technical equipment 0.05
EF015 mayo stand NF 17 25 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ137 instrument pack, basic ($500-$1,499) NF 0 29 Equipment item replaces another item (EQ138); see preamble 0.07
EQ138 instrument pack, medium ($1,500 and up) NF 29 0 Equipment item replaced by another item (EQ137); see preamble (0.20)
EQ183 microscope, operating NF 20 25 Refined equipment time to conform to established policies for non-highly technical equipment 0.14
EQ234 suction and pressure cabinet, ENT (SMR) NF 20 25 Refined equipment time to conform to established policies for non-highly technical equipment 0.05
L037D RN/LPN/MTA F Dischrg day gmt. (0.5 × 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
L037D RN/LPN/MTA NF Clean surgical instrument package 15 10 Refined time to standard time for this clinical labor task (1.85)
L037D RN/LPN/MTA NF Provide pre-service education/obtain consent 0 2 Refined time to standard time for this clinical labor task 0.74
7208A X-ray exam entire spi 1 vw ED050 PACS Workstation Proxy NF 21 25 Refined equipment time to conform to clinical labor time 0.09
7208B X-ray exam entire spi 2/3 vw ED050 PACS Workstation Proxy NF 36 40 Refined equipment time to conform to clinical labor time 0.09
7208C X-ray exam entire spi 4/5 vw ED050 PACS Workstation Proxy NF 44 48 Refined equipment time to conform to clinical labor time 0.09
7208D X-ray exam entire spi 6/ vw ED050 PACS Workstation Proxy NF 53 57 Refined equipment time to conform to clinical labor time 0.09
73565 X-ray exam of knees L041B Radiologic Technologist NF Greet patient and provide gowning 0 3 Input added to maintain consistency with all other codes within family 1.23
77385 Ntsty modul rad tx dlvr smpl EQ139 intercom (incl. master, pt substation, power, wiring) NF 27 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (0.10)
ER040 laser, diode, for patient positioning (Probe) NF 29 27 Refined equipment time to conform to established policies for highly technical equipment (0.12)
ER056 radiation treatment vault NF 29 27 Refined equipment time to conform to established policies for highly technical equipment (3.15)
ER065 water chiller (radiation treatment) NF 29 27 Refined equipment time to conform to established policies for highly technical equipment (0.13)
ER089 IMRT accelerator NF 29 27 Refined equipment time to conform to established policies for highly technical equipment (16.14)
ER102 Power conditioner NF 29 27 Refined equipment time to conform to established policies for highly technical equipment (0.17)
77386 Ntsty modul rad tx dlvr cplx EQ139 intercom (incl. master, pt substation, power, wiring) NF 42 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (0.15)
ER040 laser, diode, for patient positioning (Probe) NF 44 42 Refined equipment time to conform to established policies for highly technical equipment (0.12)
ER056 radiation treatment vault NF 44 42 Refined equipment time to conform to established policies for highly technical equipment (3.15)
ER065 water chiller (radiation treatment) NF 44 42 Refined equipment time to conform to established policies for highly technical equipment (0.13)
ER089 IMRT accelerator NF 44 42 Refined equipment time to conform to established policies for highly technical equipment (16.14)
ER102 Power conditioner NF 44 42 Refined equipment time to conform to established policies for highly technical equipment (0.17)
L050C Radiation Therapist NF Check dressings & wound/home care instructions/coordinate office visits/prescriptions 2 1 Refined to conform with identical labor activity in other codes in the family (0.50)
77402 Radiation treatment delivery EQ139 intercom (incl. master, pt substation, power, wiring) NF 12 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (0.04)
ER040 laser, diode, for patient positioning (Probe) NF 14 12 Refined equipment time to conform to established policies for highly technical equipment (0.12)
ER056 radiation treatment vault NF 14 12 Refined equipment time to conform to established policies for highly technical equipment (3.15)
ER065 water chiller (radiation treatment) NF 14 12 Refined equipment time to conform to established policies for highly technical equipment (0.13)
ER089 IMRT accelerator NF 14 12 Refined equipment time to conform to established policies for highly technical equipment (16.14)
ER102 Power conditioner NF 14 12 Refined equipment time to conform to established policies for highly technical equipment (0.17)
77407 Radiation treatment delivery EQ139 intercom (incl. master, pt substation, power, wiring) NF 17 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (0.06)
ER040 laser, diode, for patient positioning (Probe) NF 19 17 Refined equipment time to conform to established policies for highly technical equipment (0.12)
ER056 radiation treatment vault NF 19 17 Refined equipment time to conform to established policies for highly technical equipment (3.15)
ER065 water chiller (radiation treatment) NF 19 17 Refined equipment time to conform to established policies for highly technical equipment (0.13)
ER089 IMRT accelerator NF 19 17 Refined equipment time to conform to established policies for highly technical equipment (16.14)
ER102 Power conditioner NF 19 17 Refined equipment time to conform to established policies for highly technical equipment (0.17)
77412 Radiation treatment delivery EQ139 intercom (incl. master, pt substation, power, wiring) NF 21 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (0.08)
ER040 laser, diode, for patient positioning (Probe) NF 23 21 Refined equipment time to conform to established policies for highly technical equipment (0.12)
ER056 radiation treatment vault NF 23 21 Refined equipment time to conform to established policies for highly technical equipment (3.15)
ER065 water chiller (radiation treatment) NF 23 21 Refined equipment time to conform to established policies for highly technical equipment (0.13)
ER089 IMRT accelerator NF 23 21 Refined equipment time to conform to established policies for highly technical equipment (16.14)
ER102 Power conditioner NF 23 21 Refined equipment time to conform to established policies for highly technical equipment (0.17)
88104 Cytopath fl nongyn smears EP024 microscope, compound NF 60 56 Refined to conform with identical labor activity in other codes in the family (0.15)
L033A Lab Technician NF Order, restock, and distribute specimen containers with requisition forms. 0.5 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (0.17)
88106 Cytopath fl nongyn filter L033A Lab Technician NF Order, restock, and distribute specimen containers with requisition forms. 0.5 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (0.17)
88108 Cytopath concentrate tech L033A Lab Technician NF Order, restock, and distribute specimen containers with requisition forms. 0.5 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (0.17)
88160 Cytopath smear other source EP038 solvent recycling system NF 1 0 Refined equipment time to conform to clinical labor time (0.05)
L035A Lab Tech/Histotechnologist NF Prepare automated stainer with solutions and load microscopic slides. Set and confirm stainer program. Set and confirm stainer program 6 4 Refined time to standard time for this clinical labor task (0.70)
L035A Lab Tech/Histotechnologist NF Stain air dried slides with modified Wright stain. Review slides for malignancy/high cellularity (cross contamination) 5 0 See preamble text (1.75)
88161 Cytopath smear other source EP038 solvent recycling system NF 1 0 Refined equipment time to conform to clinical labor time (0.05)
Cytopath smear other source L035A Lab Tech/Histotechnologist NF Prepare automated stainer with solutions and load microscopic slides. Set and confirm stainer program. Set and confirm stainer program 6 4 Refined time to standard time for this clinical labor task (0.70)
Cytopath smear other source L035A Lab Tech/Histotechnologist NF Stain air dried slides with modified Wright stain. Review slides for malignancy/high cellularity (cross contamination) 5 3 Refined time to standard time for this clinical labor task (0.70)
88162 Cytopath smear other source EP038 solvent recycling system NF 1 0 Refined equipment time to conform to clinical labor time (0.05)
Cytopath smear other source L035A Lab Tech/Histotechnologist NF Other Clinical Activity (please specify): Prepare automated stainer with solutions and load microscopic slides 6 4 Refined time to standard time for this clinical labor task (0.70)
88182 Cell marker study L033A Lab Technician NF Accession specimen/prepare for examination 6 4 Refined time to standard time for this clinical labor task (0.66)
Cell marker study L033A Lab Technician NF Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 2 1 Refined time to standard time for this clinical labor task (0.33)
L033A Lab Technician NF Dispose of remaining specimens, spent chemicals/other consumables, and hazardous waste 2 1 Refined time to standard time for this clinical labor task (0.33)
L033A Lab Technician NF Prepare, pack and transport specimens and records for in-house storage and external storage (where applicable) 2 1 Refined time to standard time for this clinical labor task (0.33)
L045A Cytotechnologist NF Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 2 1 Refined time to standard time for this clinical labor task (0.45)
L045A Cytotechnologist NF Enter data into laboratory information system, multiparameter analyses and field data en 2 0 Refined time to standard time for this clinical labor task (0.90)
L045A Cytotechnologist NF Print out histograms, assemble materials with paperwork to pathologists Review histograms and gating with pathologist 5 2 Refined time to standard time for this clinical labor task (1.35)
88184 Flowcytometry/tc 1 marker ED031 printer, dye sublimation (photo, color) NF 5 1 Refined equipment time to conform to clinical labor time (0.04)
L033A Lab Technician NF Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 2 1 Refined time to standard time for this clinical labor task (0.33)
L033A Lab Technician NF Enter data into laboratory information system, multiparameter analyses and field data en 4 0 Refined time to standard time for this clinical labor task (1.32)
L045A Cytotechnologist NF Instrument start-up, quality control functions, calibration, centrifugation, maintaining specimen tracking, logs and labeling 15 13 Refined to conform with identical labor activity in other codes in the family (0.90)
L045A Cytotechnologist NF Other Clinical Activity (please specify) Load specimen into flow cytometer, run specimen, monitor data acquisition, and 10 7 Refined to conform with identical labor activity in other codes in the family (1.35)
L045A Cytotechnologist NF Print out histograms, assemble materials with paperwork to pathologists Review histograms and gating with pathologist 5 2 Refined time to standard time for this clinical labor task (1.35)
88185 Flowcytometry/tc add-on ED031 printer, dye sublimation (photo, color) NF 2 1 Refined equipment time to conform to clinical labor time (0.01)
L033A Lab Technician NF Enter data into laboratory information system, multiparameter analyses and field data en 1 0 Refined time to standard time for this clinical labor task (0.33)
88321 Microslide consultation L033A Lab Technician NF Accession specimen/prepare for examination 4 0 Duplication with other clinical labor task (1.32)
L033A Lab Technician NF Register the patient in the information system, including all demographic and billing information. In addition to stand 13 5 See preamble text (2.64)
L037B Histotechnologist NF Phone calls for clarifications and/or additional materials 0 3 Input added to maintain consistency with all other codes within family 1.11
88323 Microslide consultation L033A Lab Technician NF Register the patient in the information system, including all demographic and billing information. In addition to stand 13 5 Non-standard refinement, see preamble text (2.64)
L037B Histotechnologist NF Assemble and deliver slides with paperwork to pathologists 1 0 Duplication with other clinical labor task (0.37)
L037B Histotechnologist NF Clean equipment while performing service 1 0 Duplication with other clinical labor task (0.37)
SL063 eosin y NF 8 0 Redundant when used together with SL135 (6.41)
SL135 stain, hematoxylin NF 32 8 Refined supply quantity to what is typical for the procedure (1.06)
88325 EP019 hood, ventilator with blower NF 1 0 See preamble text
EP033 slide coverslipper, robotic NF 6 0 See preamble text (0.57)
EP034 slide dryer NF 1 0 See preamble text
EP035 slide etcher-labeler NF 1 0 See preamble text (0.05)
EP036 slide stainer, automated, high-volume throughput NF 12 0 See preamble text (0.55)
EP038 solvent recycling system NF 4 0 See preamble text (0.18)
EP043 water bath, general purpose (lab) NF 6 0 See preamble text (0.01)
ER041 microtome NF 6 0 See preamble text (0.26)
L033A Lab Technician NF Prepare room. Filter and replenish stains and supplies. (including OCT blocks, set up grossing station with colored stain 10 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (3.30)
L033A Lab Technician NF Accession specimen/prepare for examination 4 0 Duplication with other clinical labor task (1.32)
L033A Lab Technician NF Dispose of remaining specimens, spent chemicals/other consumables, and hazardous waste 1 0 See preamble text (0.33)
L033A Lab Technician NF Register the patient in the information system, including all demographic and billing information. In addition to stand 13 5 See preamble text (2.64)
L033A Lab Technician NF prepare, pack and transport specimens and records for in-house storage and external storage 2 0 See preamble text (0.66)
L037B Histotechnologist NF Clean equipment while performing service 1 0 Duplication with other clinical labor task (0.37)
L037B Histotechnologist NF Complete workload recording logs. Collate slides and paperwork. Deliver to pathologist 1 0 See preamble text (0.37)
L037B Histotechnologist NF Prepare automated coverslipper, remove slides from stainer and place on coverslipper 1 0 See preamble text (0.37)
L037B Histotechnologist NF Prepare automated stainer with solutions and load microscopic slides. Set and confirm stainer program. Set and confirm stainer program 1 0 See preamble text (0.37)
L037B Histotechnologist NF Slide preparation sectioning and recuts, quality control function, maintaining specimen tracking, logs and labeling 4 0 See preamble text (1.48)
SB023 gloves, non-sterile, nitrile NF 2 0 See preamble text (0.38)
SB027 gown, staff, impervious NF 0.1 0 See preamble text (0.12)
SF004 blade, microtome NF 0.2 0 See preamble text (0.34)
SL020 bleach NF 10 0 See preamble text (0.01)
SL030 cover slip, glass NF 2 0 See preamble text (0.16)
SL063 eosin y NF 8 0 See preamble text (6.41)
SL078 histology freezing spray (Freeze-It) NF 0.2 0 See preamble text (0.29)
SL085 label for microscope slides NF 20 10 See preamble text (0.26)
SL095 mounting media (Histomount) NF 2 0 See preamble text (0.07)
SL122 slide, microscope NF 2 0 See preamble text (0.11)
SL135 stain, hematoxylin NF 32 0 See preamble text (1.41)
SL151 xylenes solvent NF 60 0 See preamble text (0.72)
SL189 ethanol, 100% NF 60 0 See preamble text (0.20)
SL190 ethanol, 70% NF 8 0 See preamble text (0.03)
SL248 ethanol, 95% NF 36 0 See preamble text (0.12)
SM027 wipes, lens cleaning (per wipe) (Kimwipe) NF 2 0 See preamble text (0.03)
88329 Path consult introp L037B Histotechnologist NF Assist pathologist with gross specimen examination 10 3 Refined time to standard time for this clinical labor task (2.59)
L037B Histotechnologist NF Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 5 1 Refined time to standard time for this clinical labor task (1.48)
88331 Path consult intraop 1 bloc L033A Lab Technician NF Prepare room. Filter and replenish stains and supplies. (including OCT blocks, set up grossing station with colored stai 10 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service 1.48
L037B Histotechnologist NF Accession specimen/prepare for examination 0 4 Input added to maintain consistency with all other codes within family 1.48
L037B Histotechnologist NF Assemble and deliver slides with paperwork to pathologists 2 0.5 Refined time to standard time for this clinical labor task (0.56)
L037B Histotechnologist NF Assist pathologist with gross specimen examination 10 3 Refined time to standard time for this clinical labor task (2.59)
L037B Histotechnologist NF Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 10 1 Refined time to standard time for this clinical labor task (3.33)
SL134 stain, frozen section, H&E (1ml per slide) NF 0 1 Supply item replaces another item (SL231); see preamble 0.57
SL231 kit, stain, H&E NF 0.1 0 Supply item replaced by another item (SL134); see preamble (9.80)
88332 Path consult intraop addl L037B Histotechnologist NF Assemble and deliver slides with paperwork to pathologists 2 0.5 Refined time to standard time for this clinical labor task (0.56)
L037B Histotechnologist NF Assist pathologist with gross specimen examination 2 3 Refined time to standard time for this clinical labor task 0.37
L037B Histotechnologist NF Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 0 1 Input added to maintain consistency with all other codes within family 0.37
SF047 scalpel, safety, surgical, with blade (#10-20) NF 0 1 Input added to maintain consistency with all other codes within family 2.14
SL134 stain, frozen section, H&E (1ml per slide) NF 0 1 Supply item replaces another item (SL231); see preamble 0.57
SL231 kit, stain, H&E NF 0.1 0 Supply item replaced by another item (SL134); see preamble (9.80)
88333 Intraop cyto path consult 1 L033A Lab Technician NF Prepare room. Filter and replenish stains and supplies. (including OCT blocks, set up grossing station with colored stai 10 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (3.30)
L037B Histotechnologist NF Accession specimen/prepare for examination 0 4 Input added to maintain consistency with all other codes within family 1.48
L037B Histotechnologist NF Assemble and deliver slides with paperwork to pathologists 2 0.5 Refined time to standard time for this clinical labor task (1.48)
L037B Histotechnologist NF Assist pathologist with gross specimen examination (including performance of intraoperative frozen sections) 7 3 Refined time to standard time for this clinical labor task (1.48)
L037B Histotechnologist NF Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 5 1 Refined time to standard time for this clinical labor task (1.48)
SL122 slide, microscope NF 10 4 Refined supply quantity to what is typical for the procedure (0.33)
SL231 kit, stain, H&E NF 0.1 0 Removed supply not typically used in this service (9.80)
88334 Intraop cyto path consult 2 L037B Histotechnologist NF Assemble and deliver slides with paperwork to pathologists 2 0.5 Refined time to standard time for this clinical labor task (0.56)
L037B Histotechnologist NF Assist pathologist with gross specimen examination (including performance of intraoperative frozen sections) 5 3 Refined time to standard time for this clinical labor task (0.74)
L037B Histotechnologist NF Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure) 0 1 Input added to maintain consistency with all other codes within family 0.37
SL122 slide, microscope NF 10 4 Refined supply quantity to what is typical for the procedure (0.33)
SL231 kit, stain, H&E NF 0.1 0 Removed supply not typically used in this service (9.80)
88355 Analysis skeletal muscle EP046 freezer, ultradeep (−70 degrees) NF 30 0 Indirect Practice Expense; not individually allocable to a particular patient for a particular service (1.32)
L033A Lab Technician NF Accession specimen/prepare for examination 6 4 Refined time to standard time for this clinical labor task (0.66)
L033A Lab Technician NF Assemble and deliver slides with paperwork to pathologists 2 0.5 Refined time to standard time for this clinical labor task (0.50)
L033A Lab Technician NF Clean room, equipment following procedure including any equipment maintenance that must be done after the procedure 2 1 Refined time to standard time for this clinical labor task (0.33)
L033A Lab Technician NF Dispose of remaining specimens, spent chemicals/other consumables, and hazardous waste 2 1 Refined time to standard time for this clinical labor task (0.33)
L033A Lab Technician NF Prepare specimen containers/preload fixative/label containers/distribute requisition form(s) to physician 9 0.5 Refined time to standard time for this clinical labor task (2.81)
L033A Lab Technician NF Prepare specimen for −70 degree storage, log specimen and place in freezer for retrieval and performance of quantitative 5 0 Refined time to standard time for this clinical labor task (1.65)
L033A Lab Technician NF Prepare, pack and transport specimens and records for storage 4 1 Refined time to standard time for this clinical labor task (0.99)
L033A Lab Technician NF Receive phone call from referring laboratory/facility with scheduled procedure to arrange special delivery of specimen p 7 5 See preamble text (0.66)
L037B Histotechnologist NF Assist pathologist with gross examination 7 3 Refined time to standard time for this clinical labor task (1.48)
88360 Tumor immunohistochem/manual EP024 microscope, compound NF 36 25 See preamble text (0.41)
L033A Lab Technician NF Recycle xylene from tissue processor and stainer 1 0 Non-standard clinical labor task (0.33)
L037B Histotechnologist NF Enter patient data, computational prep for antibody testing, generate and apply bar codes to slides, and enter data for 5 1 Refined time to standard time for this clinical labor task (1.48)
L037B Histotechnologist NF Verify results and complete work load recording logs 1 0 Refined time to standard time for this clinical labor task (0.37)
88361 Tumor immunohistochem/comput L033A Lab Technician NF Recycle xylene from tissue processor and stainer 1 0 Non-standard clinical labor task (0.33)
L037B Histotechnologist NF Enter patient data, computational prep for antibody testing, generate and apply bar codes to slides, and enter data for 5 1 Refined time to standard time for this clinical labor task (1.48)
L037B Histotechnologist NF Verify results and complete work load recording logs 1 0 Refined time to standard time for this clinical labor task (0.37)
88362 Nerve teasing preparations L033A Lab Technician NF Assemble and deliver cedar mounted slides with paperwork to pathologists 2 0.5 Refined time to standard time for this clinical labor task (0.50)
L033A Lab Technician NF Assemble other light microscopy slides, epon nerve biopsy slides, and clinical history, and present to pathologist to pr 5 0.5 Refined time to standard time for this clinical labor task (1.49)
L033A Lab Technician NF Clean room/equipment following procedure (including dissecting microscope and dissection work area. Cedar oil specific c 7 1 Refined time to standard time for this clinical labor task (1.98)
L033A Electrodiagnostic Technologist NF Preparation: labeling of blocks and containers and document location and processor used 2 0.5 Refined time to standard time for this clinical labor task (0.50)
L037B Histotechnologist NF Accession specimen and prepare for examination 10 4 Refined time to standard time for this clinical labor task (2.22)
L037B Histotechnologist NF Assist pathologist with gross specimen examination including the following; A ; Selection of fresh unfixed tissue samp 10 5 Non-standard refinement, see preamble text (1.85)
L037B Histotechnologist NF Consult with pathologist regarding representation needed, block selection and appropriate technique 7 0 Task would not be required for the typical procedure (2.59)
L037B Histotechnologist NF Dispose of remaining specimens, spent chemicals/other consumables, and hazardous waste 2 1 Refined time to standard time for this clinical labor task (0.37)
L037B Histotechnologist NF Manage any relevant utilization review/quality assurance activities and regulatory compliance documentation 2 0 Refined time to standard time for this clinical labor task (0.74)
L037B Histotechnologist NF Prepare specimen containers preload fixative label containers distribute requisition form(s) to physician 12 0.5 Refined time to standard time for this clinical labor task (4.26)
L037B Histotechnologist NF Prepare, pack and transport cedar oiled glass slides and records for in-house special storage (need to be stored flat) 10 0 Refined time to standard time for this clinical labor task (3.70)
L037B Histotechnologist NF Prepare, pack and transport specimens and records for in-house storage and external storage (where applicable) 2 1 Refined time to standard time for this clinical labor task (0.37)
L037B Histotechnologist NF Storage remaining specimen. (Osmicated nerve strands, potential for additional teased specimens) 5 0 Refined time to standard time for this clinical labor task (1.85)
92511 Nasopharyngoscopy EF008 chair with headrest, exam, reclining NF 19 26 Refined equipment time to conform to established policies for non-highly technical equipment 0.08
EQ167 light source, xenon NF 19 0 Redundant when used together with EQ170; see preamble (0.51)
EQ170 light, fiberoptic headlight w-source NF 19 26 Refined equipment time to conform to established policies for non-highly technical equipment 0.06
ES020 fiberscope, flexible, rhinolaryngoscopy NF 46 53 Refined equipment time to conform to established policies for scopes 0.26
ES031 video system, endoscopy (processor, digital capture, monitor, printer, cart) NF 19 26 Refined equipment time to conform to established policies for non-highly technical equipment 0.90
L037D RN/LPN/MTA F Dischrge Day mgmt. (0.5 × 99238) (enter 6 min) 6 0 Aligned clinical labor discharge day management time with the work time discharge day code (2.22)
SB006 drape, non-sterile, sheet 40in x 60in NF 1 0 Removed supply not typically used in this service (0.22)
SB027 gown, staff, impervious NF 2 0 Removed supply not typically used in this service (2.37)
SB033 mask, surgical NF 2 0 Removed supply not typically used in this service (0.39)
SD070 endosheath NF 1 0 Removed supply not typically used in this service (17.25)
95812 Eeg 41-60 minutes EF003 bedroom furniture (hospital bed, table, reclining chair) NF 124 99 Refined equipment time to conform to established policies for non-highly technical equipment (0.15)
EQ017 EEG, digital, prolonged testing system (computer w-remote camera) NF 133 99 Refined equipment time to conform to established policies for non-highly technical equipment (4.99)
L047B REEGT NF Assist physician in performing procedure 79 50 Refined clinical labor time to match physician intraservice time (13.63)
L047B REEGT NF Enter patient information into laboratory log book 2 0 Refined to conform with identical labor activity in other codes in the family (0.94)
L047B REEGT NF Provide pre-service education/obtain consent 2 0 Duplication with other clinical labor task (0.94)
L047B REEGT NF Transfer data to reading station & archive data 4 2 Refined time to standard time for this clinical labor task (0.94)
95813 Eeg over 1 hour EF003 bedroom furniture (hospital bed, table, reclining chair) NF 147 129 Refined equipment time to conform to established policies for non-highly technical equipment (0.11)
EQ017 EEG, digital, prolonged testing system (computer w-remote camera) NF 156 129 Refined equipment time to conform to established policies for non-highly technical equipment (3.96)
L047B REEGT NF Assist physician in performing procedure 102 80 Refined clinical labor time to match physician intraservice time (10.34)
L047B REEGT NF Enter patient information into laboratory log book 2 0 Refined to conform with identical labor activity in other codes in the family (0.94)
L047B REEGT NF Provide pre-service education/obtain consent 2 0 Duplication with other clinical labor task (0.94)
L047B REEGT NF Transfer data to reading station & archive data 4 2 Refined time to standard time for this clinical labor task (0.94)
95863 Muscle test 3 limbs EF023 table, exam NF 52 55 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ024 EMG-NCV-EP system, 8 channel NF 52 55 Refined equipment time to conform to established policies for non-highly technical equipment 0.44
L037A Electrodiagnostic Technologist NF Clean room/equipment by physician staff 0 3 Refined to conform with identical labor activity in other codes in the family 1.11
95864 Muscle test 4 limbs EF023 table, exam NF 62 65 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ024 EMG-NCV-EP system, 8 channel NF 62 65 Refined equipment time to conform to established policies for non-highly technical equipment 0.44
L037A Electrodiagnostic Technologist NF Other Clinical Activity—specify:Prepare technician report, summarize clinical and electrodiagnostic data, and interpre 6 0 Refined to conform with identical labor activity in other codes in the family (2.22)
95869 Muscle test thor paraspinal EF023 table, exam NF 27 30 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ024 EMG-NCV-EP system, 8 channel NF 27 30 Refined equipment time to conform to established policies for non-highly technical equipment 0.44
L037A Electrodiagnostic Technologist NF Clean room/equipment by physician staff 0 3 Refined to conform with identical labor activity in other codes in the family 1.11
95870 Muscle test nonparaspinal EF023 table, exam NF 27 30 Refined equipment time to conform to established policies for non-highly technical equipment 0.01
EQ024 EMG-NCV-EP system, 8 channel NF 27 30 Refined equipment time to conform to established policies for non-highly technical equipment 0.44
L037A Electrodiagnostic Technologist NF Clean room/equipment by physician staff 0 3 Refined to conform with identical labor activity in other codes in the family 1.11
SD275 Disposable electrode pack NF 6 1 Refined supply quantity to what is typical for the procedure (13.75)
95923 Autonomic nrv syst funj test EF023 table, exam NF 51 43 Refined equipment time to conform to established policies for non-highly technical equipment (0.02)
EQ035 QSART acquisition system (Q-Sweat) NF 46 43 Refined equipment time to conform to established policies for non-highly technical equipment (0.33)
EQ124 stimulator, constant current, w-stimulating and grounding electrodes (Grass Telefactor) NF 46 43 Refined equipment time to conform to established policies for non-highly technical equipment (0.01)
EQ171 light, infra-red, ceiling mount NF 46 43 Refined equipment time to conform to established policies for non-highly technical equipment
L037A Electrodiagnostic Technologist NF Clean room/equipment by physician staff 5 0 Typically billed with an E/M or other evaluation service (1.85)
L037A Electrodiagnostic Technologist NF Complete diagnostic forms, lab & X-ray requisitions 5 0 Typically billed with an E/M or other evaluation service (1.85)
L037A Electrodiagnostic Technologist NF Complete pre-service diagnostic & referral forms 5 2 Refined to conform with identical labor activity in other codes in the family (1.11)
L037A Electrodiagnostic Technologist NF Prepare room, equipment, supplies 0 2 Refined time to standard time for this clinical labor task 0.74
SA014 kit, electrode, iontophoresis NF 4 3 See preamble text (4.01)
SA048 pack, minimum multi-specialty visit NF 1 0 Typically billed with an E/M or other evaluation service (1.14)
95928 C motor evoked uppr limbs EF023 table, exam NF 65 45 Refined equipment time to conform to established policies for non-highly technical equipment (0.06)
EQ024 EMG-NCV-EP system, 8 channel NF 65 45 Refined equipment time to conform to established policies for non-highly technical equipment (2.95)
EQ178 magnetic stimulator hand coil (70-90mm) NF 65 45 Refined equipment time to conform to established policies for non-highly technical equipment (0.16)
EQ180 magnetic stimulator system (BiStim) NF 65 45 Refined equipment time to conform to established policies for non-highly technical equipment (1.43)
L047B REEGT NF Assist physician in performing procedure 60 40 Refined clinical labor time to match physician intraservice time (9.40)
L047B REEGT NF Other Clinical Activity—specify: Review requisition. Assess for special needs. Give patient instructions for test prepa 3 0 Duplication with other clinical labor task (1.41)
SA048 pack, minimum multi-specialty visit NF 1 0 Typically billed with an E/M or other evaluation service (1.14)
95929 C motor evoked lwr limbs EF023 table, exam NF 65 45 Refined equipment time to conform to established policies for non-highly technical equipment (0.06)
EQ024 EMG-NCV-EP system, 8 channel NF 65 45 Refined equipment time to conform to established policies for non-highly technical equipment (2.95)
EQ179 magnetic stimulator leg coil (110mm) NF 65 45 Refined equipment time to conform to established policies for non-highly technical equipment (0.24)
EQ180 magnetic stimulator system (BiStim) NF 65 45 Refined equipment time to conform to established policies for non-highly technical equipment (1.43)
L047B REEGT NF Assist physician in performing procedure 60 40 Refined clinical labor time to match physician intraservice time (9.40)
L047B REEGT NF Other Clinical Activity—specify:Review requisition. Assess for special needs. Give patient instructions for test prepa 3 0 Duplication with other clinical labor task (1.41)
95933 Blink reflex test L037A Electrodiagnostic Technologist NF Clean room/equipment by physician staff 5 3 Refined time to standard time for this clinical labor task (0.74)
L037A Electrodiagnostic Technologist NF Prepare room, equipment, supplies 0 2 Refined time to standard time for this clinical labor task 0.74
95956 Eeg monitor technol attended EF003 bedroom furniture (hospital bed, table, reclining chair) NF 772 769 Refined equipment time to conform to established policies for non-highly technical equipment (0.02)
EQ017 EEG, digital, prolonged testing system (computer w-remote camera) NF 772 769 Refined equipment time to conform to established policies for non-highly technical equipment (0.44)
EQ047 air compressor, safety NF 52 49 Refined equipment time to conform to established policies for non-highly technical equipment
L047B REEGT NF Other Clinical Activity—specify: Coordinate pretesting services/review test/exam results 3 0 Duplication with other clinical labor task (1.41)
L047B REEGT NF Provide pre-service education/obtain consent 2 0 Duplication with other clinical labor task (0.94)
Table 14—Crosswalk for Establishing CY 2016 New, Revised, and Potentially Misvalued Codes Malpractice RVUs Back to Top
Note: For any codes not included in Table 14, we are proposing to use the utilization crosswalk, when a crosswalk exists, in order to calculate the malpractice risk factor for these services, as discussed in the preamble text.
CY 2016 New, Revised or Potentially Misvalued Code Malpractice Risk Factor Crosswalk Code  
11750 Removal of nail bed 11750 Removal of nail bed.
20240 Bone biopsy excisional 20240 Bone biopsy excisional.
27280 Fusion of sacroiliac joint 27280 Fusion of sacroiliac joint.
31622 Dx bronchoscope/wash 31622 Dx bronchoscope/wash.
3160A Bronch ebus sampling 1/2 node 31620 Endobronchial us add-on.
3160B Bronch ebus samplng 3/>node 31620 Endobronchial us add-on.
31625 Bronchoscopy w/biopsy(s) 31625 Bronchoscopy w/biopsy(s).
31626 Bronchoscopy w/markers 31626 Bronchoscopy w/markers.
31628 Bronchoscopy/lung bx each 31628 Bronchoscopy/lung bx each.
31629 Bronchoscopy/needle bx each 31629 Bronchoscopy/needle bx each.
3160C Bronch ebus ivntj perph les 31620 Endobronchial us add-on.
31632 Bronchoscopy/lung bx addl 31632 Bronchoscopy/lung bx addl.
31633 Bronchoscopy/needle bx addl 31633 Bronchoscopy/needle bx addl.
3347A Implant tcat pulm vlv perq 93581 Transcath closure of vsd.
3725A Intrvasc us noncoronary 1st 37250 Iv us first vessel add-on.
3725B Intrvasc us noncoronary addl 37251 Iv us each add vessel add-on.
38570 Laparoscopy lymph node biop 38570 Laparoscopy lymph node biop.
38571 Laparoscopy lymphadenectomy 38571 Laparoscopy lymphadenectomy.
38572 Laparoscopy lymphadenectomy 38572 Laparoscopy lymphadenectomy.
3940A Mediastinoscpy w/medstnl bx 33924 Remove pulmonary shunt.
3940B Mediastinoscpy w/lmph nod bx 32606 Thoracoscopy w/bx med space.
44380 Small bowel endoscopy br/wa 44380 Small bowel endoscopy br/wa.
44381 Small bowel endoscopy br/wa 45340 Sig w/tndsc balloon dilation.
44382 Small bowel endoscopy 44382 Small bowel endoscopy.
44384 Small bowel endoscopy 44383 Ileoscopy w/stent.
44385 Endoscopy of bowel pouch 44385 Endoscopy of bowel pouch.
44386 Endoscopy bowel pouch/biop 44386 Endoscopy bowel pouch/biop.
44388 Colonoscopy thru stoma spx 44388 Colonoscopy thru stoma spx.
44389 Colonoscopy with biopsy 44389 Colonoscopy with biopsy.
44390 Colonoscopy for foreign body 44390 Colonoscopy for foreign body.
44391 Colonoscopy for bleeding 44391 Colonoscopy for bleeding.
44392 Colonoscopy & polypectomy 44392 Colonoscopy & polypectomy.
44394 Colonoscopy w/snare 44394 Colonoscopy w/snare.
44401 Colonoscopy with ablation 44393 Colonoscopy lesion removal.
44402 Colonoscopy w/stent plcmt 44397 Colonoscopy w/stent.
44403 Colonoscopy w/resection 44392 Colonoscopy & polypectomy.
44404 Colonoscopy w/injection 44389 Colonoscopy with biopsy.
44405 Colonoscopy w/dilation 44390 Colonoscopy for foreign body.
44406 Colonoscopy w/ultrasound 44394 Colonoscopy w/snare.
45330 Diagnostic sigmoidoscopy 45330 Diagnostic sigmoidoscopy.
45331 Sigmoidoscopy and biopsy 45331 Sigmoidoscopy and biopsy.
45332 Sigmoidoscopy w/fb removal 45332 Sigmoidoscopy w/fb removal.
45333 Sigmoidoscopy & polypectomy 45333 Sigmoidoscopy & polypectomy.
45334 Sigmoidoscopy for bleeding 45334 Sigmoidoscopy for bleeding.
45335 Sigmoidoscopy w/submuc inj 45335 Sigmoidoscopy w/submuc inj.
45337 Sigmoidoscopy & decompress 45337 Sigmoidoscopy & decompress.
45338 Sigmoidoscopy w/tumr remove 45338 Sigmoidoscopy w/tumr remove.
45340 Sig w/tndsc balloon dilation 45340 Sig w/tndsc balloon dilation.
45341 Sigmoidoscopy w/ultrasound 45341 Sigmoidoscopy w/ultrasound.
45342 Sigmoidoscopy w/us guide bx 45342 Sigmoidoscopy w/us guide bx.
45346 Sigmoidoscopy w/ablation 45339 Sigmoidoscopy w/ablate tumr.
45347 Sigmoidoscopy w/plcmt stent 45345 Sigmoidoscopy w/stent.
45349 Sigmoidoscopy w/resection 45338 Sigmoidoscopy w/tumr remove.
45350 Sgmdsc w/band ligation 45334 Sigmoidoscopy for bleeding.
45378 Diagnostic colonoscopy 45378 Diagnostic colonoscopy.
45379 Colonoscopy w/fb removal 45379 Colonoscopy w/fb removal.
45380 Colonoscopy and biopsy 45380 Colonoscopy and biopsy.
45381 Colonoscopy submucous njx 45381 Colonoscopy submucous njx.
45382 Colonoscopy w/control bleed 45382 Colonoscopy w/control bleed.
45384 Colonoscopy w/lesion removal 45384 Colonoscopy w/lesion removal.
45385 Colonoscopy w/lesion removal 45385 Colonoscopy w/lesion removal.
45386 Colonoscopy w/balloon dilat 45386 Colonoscopy w/balloon dilat.
45388 Colonoscopy w/ablation 45383 Lesion removal colonoscopy.
45389 Colonoscopy w/stent plcmt 45387 Colonoscopy w/stent.
45390 Colonoscopy w/resection 45385 Colonoscopy w/lesion removal.
45391 Colonoscopy w/endoscope us 45391 Colonoscopy w/endoscope us.
45392 Colonoscopy w/endoscopic fnb 45392 Colonoscopy w/endoscopic fnb.
45393 Colonoscopy w/decompression 45382 Colonoscopy w/control bleed.
45398 Colonoscopy w/band ligation 45382 Colonoscopy w/control bleed.
46500 Injection into hemorrhoid(s) 46500 Injection into hemorrhoid(s).
47135 Transplantation of liver 47135 Transplantation of liver.
5039A Njx px nfrosgrm &/urtrgrm 50390 Drainage of kidney lesion.
5039B Njx px nfrosgrm &/urtrgrm 50394 Injection for kidney x-ray.
5039C Plmt nephrostomy catheter 50392 Insert kidney drain.
5039D Plmt nephroureteral catheter 50393 Insert ureteral tube.
5039M Convert nephrostomy catheter 50393 Insert ureteral tube.
5039E Exchange nephrostomy cath 50398 Change kidney tube.
5069G Plmt ureteral stent prq 50398 Change kidney tube.
5069H Plmt ureteral stent prq 50393 Insert ureteral tube.
5069I Plmt ureteral stent prq 50393 Insert ureteral tube.
5443A Repair corporeal tear 54406 Remove muti-comp penis pros.
5443B Replantation of penis 53448 Remov/replc ur sphinctr comp.
657XG Impltj ntrstrml crnl rng seg 65426 Removal of eye lesion.
7208A X-ray exam entire spi 1 vw 72050 X-ray exam neck spine 4/5vws.
7208B X-ray exam entire spi 2/3 vw 72052 X-ray exam neck spine 6/>vws.
7208C X-ray exam entire spi 4/5 vw 72052 X-ray exam neck spine 6/> vws.
7208D X-ray exam entire spi 6/> vw 72052 X-ray exam neck spine 6/> vws.
73560 X-ray exam of knee 1 or 2 73560 X-ray exam of knee 1 or 2.
73562 X-ray exam of knee 3 73562 X-ray exam of knee 3.
73564 X-ray exam knee 4 or more 73564 X-ray exam knee 4 or more.
73565 X-ray exam of knees 73565 X-ray exam of knees.
73590 X-ray exam of lower leg 73590 X-ray exam of lower leg.
73600 X-ray exam of ankle 73600 X-ray exam of ankle.
77402 Radiation treatment delivery G6003 Radiation treatment delivery.
77407 Radiation treatment delivery G6007 Radiation treatment delivery.
77412 Radiation treatment delivery G6011 Radiation treatment delivery.
77385 Ntsty modul rad tx dlvr smpl G6015 Radiation tx delivery imrt.
77386 Ntsty modul rad tx dlvr cplx G6015 Radiation treatment delivery.
77387 Guidance for radiaj tx dlvr 77014 Ct scan for therapy guide.
76948 Echo guide ova aspiration 76948 Echo guide ova aspiration.
7778A Hdr rdncl skn surf brachytx 77785 Hdr brachytx 1 channel.
7778B Hdr rdncl skn surf brachytx 77786 Hdr brachytx 2-12 channel.
7778C Hdr rdncl ntrstl/icav brchtx 77785 Hdr brachytx 1 channel.
7778D Hdr rdncl ntrstl/icav brchtx 77786 Hdr brachytx 2-12 channel.
7778E Hdr rdncl ntrstl/icav brchtx 77787 Hdr brachytx over 12 chan.
88346 Immunofluorescent study 88346 Immunofluorescent study.
8835X Immunofluor antb addl stain 88346 Immunofluorescent study.
88367 Insitu hybridization auto 88367 Insitu hybridization auto.
88368 Insitu hybridization manual 88368 Insitu hybridization manual.
91200 Liver elastography 91200 Liver elastography.
9254A Caloric vestibular test with recording 92540 Basic vestibular evaluation.
9254B Caloric vestibular test with recording 92540 Basic vestibular evaluation.
99497 Advncd care plan 30 min 99214 Office/outpatient visit est.
99498 Advncd care plan addl 30 min 99214 Office/outpatient visit est.

a. Lower GI Endoscopy Services

CPT revised the lower gastrointestinal endoscopy code set for CY 2015 following identification of some of the codes as potentially misvalued and the affected specialty society's contention that this code set did not allow for accurate reporting of services based upon current medical practice. The RUC subsequently provided recommendations to us for valuing these services. In the CY 2015 PFS final rule with comment period, we delayed valuing the lower GI codes and indicated that we would propose values for these codes in the CY 2016 proposed rule, citing the new process for including proposed values for new, revised and potentially misvalued codes in the proposed rule as one of the reasons for the delay.

(1) Gastrointestinal (GI) Endoscopy (CPT Codes 43775, 44380-46607 and HCPCS Codes G0104, G0105, and G0121)

In the CY 2014 PFS final rule with comment period, we indicated that we used what we called an “incremental difference methodology” in valuing the upper GI codes for that year. We explained that the RUC made extensive use of a methodology that uses the incremental difference in codes to determine values for many of these services. This methodology uses a base code or other comparable code and considers what the difference should be between that code and another code by comparing the differentials to those for other sets of similar codes. As with the esophagoscopy subfamily, many of the procedures described within the colonoscopy subfamily have identical counterparts in the esophagogastroduodenoscopy (EGD) subfamily. For instance, the base colonoscopy CPT code 45378 is described as “Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing when performed, (separate procedure).” The base EGD CPT code 43235 is described as “Esophagogastroduodenoscopy, flexible, transoral; diagnostic, with collection of specimen(s) by brushing or washing, when performed.” In valuing other codes within both subfamilies, the RUC frequently used the difference between these two base codes as an increment for measuring the difference in work involved in doing a similar procedure utilizing colonoscopy versus utilizing EGD. For example, the EGD CPT code 43239 includes a biopsy in addition to the base diagnostic EGD CPT code 43235. The RUC valued this by adding the incremental difference in the base colonoscopy code over the base EGD CPT code to the value it recommended for the esophagoscopy biopsy, CPT code 43202. With some variations, the RUC used this incremental difference methodology extensively in valuing subfamilies of codes. We have made use of similar methodologies in establishing work RVUs for codes in this family.

We agreed with several of the RUC recommendations for codes in this family. Where we did not agree, we consistently applied the incremental difference methodology. Table I7 reflects how we applied this methodology and the values we are proposing. To calculate the base RVU for the colonoscopy subfamily, we looked at the current intraservice time for CPT code 45378, which is 30 minutes, and the current work RVU, which is 3.69. The RUC recommended an intraservice time of 25 minutes and 3.36 RVUs. We then compared that service to the base EGD CPT code 43235 for which the RUC recommended a work RVU of 2.26, giving an increment between EGD and colonoscopy of 1.10 RVUs. We added that increment to our proposed work RVU for CPT 43235 of 2.19 to arrive at our proposed work RVU for the base colonoscopy CPT code 45378 of 3.29. We use this value as the base code in the incremental methodology for establishing the work value for the other base codes in the colonoscopy subfamilies which were then used to value the other codes in that subfamily.

Table 15—Application of the Incremental Difference Methodology Back to Top
HCPCS Descriptor Current WRVU RUC WRVU Base procedure Base RVU Increment Increment value Calculated WRVU
44380 Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed 1.05 0.97 Colonoscopy 3.29 Colonoscopy to Ileoscopy −2.39 0.9
44382 Ileoscopy, through stoma; with biopsy, single or multiple 1.27 1.27 Ileoscopy 0.9 Biopsy 0.3 1.2
44384 Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) NA 3.11 Ileoscopy 0.9 Stent 1.98 2.88
44385 Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); diagnostic, including collection of specimen(s) by brushing or washing, when performed 1.82 1.3 Colonoscopy 3.29 Colonoscopy to endo. eval −2.06 1.23
44386 Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple 2.12 1.6 Endo. Eval. 1.23 Biopsy 0.3 1.53
44388 Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 2.82 2.82 Colonoscopy 3.29 Colonoscopy to Colonoscopy through stoma −0.54 2.75
44389 Colonoscopy through stoma; with biopsy, single or multiple 3.13 3.12 Colonoscopy through stoma 2.75 Biopsy 0.3 3.05
44390 Colonoscopy through stoma; with removal of foreign body 3.82 3.82 Colonoscopy through stoma 2.75 Foreign body 1.02 3.77
44402 Colonoscopy through stoma; with endoscopic stent placement (including pre- and post-dilation and guidewire passage, when performed) 4.7 4.96 Colonoscopy through stoma 2.75 Stent 1.98 4.73
44403 Colonoscopy through stoma; with endoscopic mucosal resection NA 5.81 Colonoscopy through stoma 2.75 Endoscopic mucosal resection 2.78 5.53
44404 Colonoscopy through stoma; with directed submucosal injection(s), any substance NA 3.13 Colonoscopy through stoma 2.75 Submucosal injection 0.3 3.05
45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing when performed 0.96 0.84 Colonoscopy 3.29 Colonoscopy to Sigmoidoscopy −2.52 0.77
45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 1.15 1.14 Sigmoidoscopy 0.77 Biopsy 0.3 1.07
45332 Sigmoidoscopy, flexible; with removal of foreign body 1.79 1.85 Sigmoidoscopy 0.77 Foreign body 1.02 1.79
45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 1.46 1.15 Sigmoidoscopy 0.77 Submucosal injection 0.3 1.07
45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 2.6 2.43 Sigmoidoscopy 0.77 Endoscopic ultrasound 1.38 2.15
45346 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) NA 2.97 Sigmoidoscopy 0.77 Ablation 2.07 2.84
45347 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) NA 2.98 Sigmoidoscopy 0.77 Stent 1.98 2.75
45349 Sigmoidoscopy, flexible; with endoscopic mucosal resection NA 3.83 Sigmoidoscopy 0.77 Endoscopic mucosal resection 2.78 3.55
45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, (separate procedure) 3.69 3.36 Colonoscopy 3.29      
45379 Colonoscopy, flexible; with removal of foreign body 4.68 4.37 Colonoscopy 3.29 Foreign body 1.02 4.31
45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple 4.43 3.66 Colonoscopy 3.29 Biopsy 0.3 3.59
45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 4.19 3.67 Colonoscopy 3.29 Submucosal injection 0.3 3.59
45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) NA 5.5 Colonoscopy 3.29 Stent 1.98 5.27
45390 Colonoscopy, flexible; with endoscopic mucosal resection NA 6.35 Colonoscopy 3.29 Endoscopic mucosal resection 2.78 6.07
45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 5.09 4.95 Colonoscopy 3.29 Endoscopic ultrasound 1.38 4.67

(2) Laparoscopic Sleeve Gastrectomy (CPT Code 43775)

Prior to CY 2013, CPT code 43775 described a non-covered service. For CY 2013, this service was covered as part of the bariatric surgery National Coverage Determination (NCD) and has been contractor-priced since 2013. We are now proposing to establish national pricing for CPT code 43775. To establish a work RVU, we are crosswalking this code to CPT code 37217 (Transcatheter placement of an intravascular stent(s), intrathoracic common carotid artery or innominate artery by retrograde treatment, via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation), due to their identical intraservice times, similar total times, and similar levels of intensity. Therefore, we are proposing a work RVU of 20.38 for CPT code 43775.

(3) Incomplete Colonoscopy (CPT codes 44388, 45378, G0105, and G0121)

Prior to CY 2015, according to CPT instruction, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). In accordance with that definition, the Medicare Claims Processing Manual (pub. 100-04, chapter 12, section 30.1.B., available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items) states that physicians should report an incomplete colonoscopy with 45378 and append modifier -53, which is paid at the same rate as a sigmoidoscopy.

In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states, “When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier -53 and provide appropriate documentation.”

Given that the new definition of an incomplete colonoscopy also includes colonoscopies where the colonoscope is advanced past the splenic flexure but not to the cecum, we are proposing to establish new values for the incomplete colonoscopies, reported with the -53 modifier. At present, we crosswalk the RVUs for the incomplete colonoscopies from the values of the corresponding sigmoidoscopy. Given that the new CPT instructions will reduce the number of reported complete colonoscopies and increase the number of colonoscopies that proceeded further toward completion reported with the -53 modifier, we believe CPT code 45378 reported with the -53 modifier will now describe a more resource-intensive group of services than were previously reported. Therefore, we are proposing to develop RVUs for these codes reported with the -53 modifier by using one-half the value of the inputs for the corresponding codes reported without the -53 modifier.

In addition to this proposed change in input values, we are also seeking comment on how to address the disparity of resource costs among the broader range of services now described by the colonoscopy codes billed with the -53 modifier. We believe that it may be appropriate for practitioners to report the sigmoidoscopy CPT code 45330 under circumstances when a beneficiary is scheduled and prepared for a total colonoscopy (diagnostic colonoscopy, screening colonoscopy or colonoscopy through stoma), but the practitioner is unable to advance the colonoscope beyond the splenic flexure. We are seeking comment and recommendations on that possibility, as well as more generally, the typical resource costs of these incomplete colonoscopy services under CPT's new definition. Finally, we are seeking information regarding the number of colonoscopies that will be considered incomplete under CPT's new definition relative to the old definition, as well as the number of incomplete colonoscopies where the practitioner is unable to advance the colonoscope beyond the splenicflexure. This information will help us determine whether or not differential payment is required, and if it is, how to make the appropriate utilization assumptions within our ratesetting process.

(4) Malpractice (MP) Crosswalk

We examined the RUC's recommended MP crosswalk for this family of codes. The MP crosswalks are used to identify the presumed mix of specialties that furnish particular services until there is Medicare claims data for the new codes. We direct the reader to section II.B.1. of this proposed rule for further explanation regarding these crosswalks. In reviewing the recommended MP crosswalks for CPT codes 43775, 44407, 44408, 46601, and 46607, we noted that the RUC-recommended MP crosswalk codes are inconsistent with our analysis of the specialties likely to furnish the service based on the description of the services and our review of the RUC-recommended utilization crosswalk. The inconsistency between the RUC's recommended MP and utilization crosswalks is not altogether unusual. However when there are discrepancies between the MP and utilization crosswalk recommendations, they generally reflect the RUC's expectation that due to changes in coding, there will be a different mix of specialties reporting a new code than might be reflected in the claims data for the code previously used to report that service. This often occurs when the new coding structure for a particular family of services is either more or less specific than the old set of codes. In most of these cases, we could identify a rationale for why the RUC's recommended MP crosswalks for these codes were likely to be more accurate than the RUC's recommended utilization crosswalk. But in the case of these codes, the reason for the discrepancies were neither apparent nor explained as part of the recommendation. Since the specialty mix in the claims data is used to determine the specialty mix for each HCPCS code for the purposes of calculating MP RVUs, and that data will be used to set the MP RVUs once it is available, we believe using a specialty mix derived from the claims data of the predecessor codes is more likely to be accurate than the RUC-recommended MP crosswalk as well as more likely to result in stable MP RVUs for these services over several years. Therefore, until claims data under the new set of codes is available, we are proposing to use the specialty mix of the source code(s) in the RUC-recommended utilization crosswalk in order to calculate the malpractice risk factor for these services instead of the RUC-recommended MP crosswalk. Once claims data are available, those data will be incorporated into the calculation of MP RVUs for these services under the MP RVU methodology.

b. Radiation Treatment and Related Image Guidance Services

For CY 2015, the CPT Editorial Panel revised the set of codes that describe radiation treatment delivery services based in part on the CMS identification of these services as potentially misvalued in CY 2012. We identified these codes as potentially misvalued under a screen called “Services with Stand-Alone PE Procedure Time.” We proposed this screen following our discovery of significant discrepancies between the RUC-recommended 60 minute procedure time assumptions for intensity modulated radiation therapy (IMRT) and information available to the public suggesting that the procedure typically took between 5 and 30 minutes per treatment.

The CPT Editorial Panel's revisions included the addition and deletion of several codes and the development of new guidelines and coding instructions. Four treatment delivery codes (77402, 77403, 77404, and 77406) were condensed into 77402 (Radiation Treatment Delivery, Simple), three treatment delivery codes (77407, 77408, 77409) were condensed into 77407 (Radiation treatment delivery, intermediate), and four treatment codes (77412, 77413, 77414, 77416) were condensed into 77412 (Radiation treatment delivery, complex). Intensity Modulated Radiation Therapy (IMRT) treatment delivery, previously reported under a single code, was split into two codes, 77385 (IMRT treatment delivery, simple) and 77386 (IMRT treatment delivery, complex). The CPT Editorial Panel also created a new image guidance code, 77387 (Guidance for localization of target volume for delivery of treatment, includes intrafraction tracking when performed) to replace 77014 (computed tomography guidance for placement of radiation therapy fields), 77421 (stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy,) and 76950 (ultrasonic guidance for placement of radiation therapy fields) when any of these services were furnished in conjunction with radiation treatment delivery.

In response to stakeholder concerns regarding the magnitude of the coding changes and in light of the process changes we adopted for valuing new and revised codes, we did not implement interim final values for the new codes and delayed implementing the new code set until 2016. To address the valuation of the new code set through proposed rulemaking, and continue making payment based the previous valuations even though CPT deleted the prior radiation treatment delivery codes for CY 2015, we created G-codes that mimic the predecessor CPT codes (79 FR 67667).

We propose to establish values for the new codes based on RUC recommendations, subject to standard CMS refinements that appear in Table 15 in section II.B.4. of this proposed rule. We also note that because the invoices used to price the capital equipment included “on-board imaging,” the cost of that equipment is already reflected in the price per minute associated with the capital equipment. Therefore, we have not included it as a separate item in the proposed direct PE inputs for these codes, even though it appeared as a separate item on the PE worksheet included with the RUC recommendations for these codes. The direct PE inputs for these codes are reflected in the proposed direct PE input database available on the CMS Web site under the supporting data files for the CY 2016 PFS proposed rule with comment period at http://www.cms.gov/PhysicianFeeSched/. The RVUs that result from the use of these proposed direct PE inputs (and work RVUs and work time, as applicable) are displayed in Addendum B on the CMS Web site.

In addition to the refinements addressed above, there are three additional issues for which we are seeking comment and/or making specific proposals related to these services: image guidance, equipment utilization rate assumptions for linear accelerators, and superficial radiation treatment services.

(1) Image Guidance Services

Under the previous CPT coding structure, image guidance was separately billable when furnished in conjunction with the radiation treatment delivery services. The image guidance was reported using different CPT codes, depending on which image guidance modality was used. These codes were split into professional and/or technical components that allowed practitioners to report a single component or the global service. The professional component of each of these codes included the work of the physician furnishing the image guidance. CPT code 77014, used to report CT guidance, had a work RVU of 0.85; CPT code 77421, used to report stereotactic guidance, had a work RVU of 0.39, and CPT code 76950, used to report ultrasonic guidance, had a work RVU of 0.58. The technical component of these codes incorporated the resource costs of the image guidance capital equipment (such as CT, ultrasound, or stereotactic) and the clinical staff involved in furnishing the image guidance associated with the radiation treatment. When billed globally, the RVUs reflected the sum of the professional and technical components. In the revised coding structure, one new image guidance code is to be reported regardless of the modality used, and in developing its recommended values, the RUC assumed that CT guidance would be typical.

However, the 2013 Medicare claims data for separately reported image guidance indicates that stereotactic guidance for radiation treatment services was furnished more frequently than CT guidance. The RUC has recommended a work RVU of 0.58 and associated work times of 3 pre-service minutes, 10 intraservice minutes, and 3 post-service minutes for image guidance CPT code 77387. We reviewed this recommendation considering the discrepancy between the modality the RUC assumed to be typical in the vignette and the modality typically reported in the Medicare claims data. Given that the recommended work RVU for the new single code is similar to the work RVUs of the predecessor codes, roughly prorated based on their distribution in Medicare claims data, we agree with the RUC-recommended work RVU for the service. However, the RUC also recommended an increase in overall work time associated with image guidance consistent with the survey data used to value the new services. If accurate, this increase in time and maintenance of total work would suggest a decrease in the overall intensity for image guidance relative to the current codes. Given this implication, we are seeking comment as to the appropriate work time associated with CPT code 77387.

Although 77421 (stereotactic guidance) and 76950 (ultrasonic guidance) have been deleted, we note that CPT maintained CPT code 77014 (Computed tomography guidance for placement of radiation therapy fields) and the RUC recommendation states that CPT did so based on concerns that without this option, some practitioners might have no valid CPT alternative than to use higher valued diagnostic CT codes when they used this CT guidance. The RUC recommendation also includes a statement that utilization of this code is expected to drop to negligible levels by 2015, assuming that practitioners would use the new codes that are not differentiated based on imaging modality. Once all the new codes are implemented for Medicare, we anticipate that CPT and/or the RUC will address the continued use of 77014 and, if it continues to be part of the code set, provide recommendations as to the appropriate values given changes in utilization.

Regarding the reporting of the new image guidance codes, CPT guidance instructs that the technical portion of image guidance is now bundled into the IMRT and Stereotactic Radiation Treatment delivery codes, but it is not bundled into the simple, intermediate, and complex radiation treatment delivery codes. CPT guidance states that the technical component of the image guidance code can be reported with codes 77402, 77407, and 77412 (simple, intermediate, and complex radiation treatment) when furnished, which means that the technical component of the image guidance code should not be reported with the IMRT or Stereotactic Radiation Treatment delivery codes. The RUC recommendation, however, incorporates the same capital cost of image guidance equipment (a linear accelerator, or linac), for all these radiation treatment delivery codes, including the codes that describe IMRT and Stereotactic Radiation Treatment delivery services. The RUC explains that the recommendations were done this way because the older lower-dose external beam radiation machines are no longer manufactured and the image guidance technology is integrated into the single kind of linear accelerator used for all the radiation treatment services. In reviewing the new code structure and the RUC recommendations, we assume that the CPT editorial panel did not foresee that the RUC would recommend that we develop PE RVUs for all the radiation treatment delivery codes based on the assumption that the same capital equipment is typically used in furnishing the entire range of external beam radiation treatments. Because the RUC recommendations incorporate the more extensive capital equipment in the lower dose treatment codes as well, a portion of the resource costs of the technical portion of imaging guidance are already allocated into the PE RVUs for all of the treatment delivery codes, not just the IMRT and Stereotactic Radiation Treatment delivery codes as CPT guidance would suggest.

In order to avoid incorporating the cost of this equipment into both the treatment delivery codes (77402, 77407, and 77412) and the technical component of the new imaging guidance code (77387-TC), we considered valuing 77387 as a professional service only and not creating the professional/technical component splits envisioned by CPT. In the context of the budget neutral PFS, incorporating a duplicative direct input with a cost of more than six dollars per minute has significant impacts on the PE RVUs for all other services. However, we also noted that the RUC did not address this apparent contradiction in its recommendation and not all of the recommended direct PE inputs for the technical component of 77387 are capital equipment costs. Therefore, we are proposing to allow for professional and technical component billing for these services, as reflected in CPT guidance, and we are proposing to use the RUC recommended direct PE inputs for these services (refined as described in Table 15). However, we are also seeking comment on the apparent contradiction between technical component billing for image guidance in the context of the inclusion of a single linac with integrated imaging guidance technology being included for all external beam treatment codes.

(2) Equipment Utilization Rate for Linear Accelerators

The cost of the capital equipment is the primary determining factor in the payment rates for these services. For each CPT code, the equipment costs are estimated based on multiplying the assumed number of minutes the equipment is used for that procedure by the per minute cost of the particular equipment item. Under our PE methodology, we currently use two default equipment usage assumptions in allocating capital equipment costs to calculate PE RVUs. The first is that each equipment item is only available to be used during what are assumed to be regular business hours for a physician's office: 10 hours per day, 5 days per week (50 hours per week) and 50 weeks per year. The second assumption is that the equipment is in use only 50 percent of the time that it is available for use. The current default 50 percent utilization rate assumption translates into 25 hours per week out of a 50-hour work week.

We have previously addressed the accuracy of these default assumptions as they apply to particular equipment resources and particular services. In the CY 2008 PFS proposed rule (72 FR 38132) we discussed the 50 percent utilization assumption and acknowledged that the default 50 percent usage assumption is unlikely to capture the actual usage rates for all equipment. However, we stated that we did not believe that we had strong empirical evidence to justify any alternative approaches. We indicated that we would continue to monitor the appropriateness of the equipment utilization assumption, and evaluate whether changes should be proposed in light of the data available.

Subsequently, a 2009 report on equipment utilization by MedPAC included studies that suggested a higher utilization rate for diagnostic imaging equipment costing more than $1 million. These studies cited by MedPAC suggested that for Magnetic Resonance Imaging equipment, a utilization rate of 92 percent on a 50-hour week would be most accurate. Similarly, another MedPAC cited study suggested that for Computed Tomography scanners, 45 hours was more accurate and that is equivalent to a 90 percent utilization rate on a 50-hour work week. For the CY 2010 PFS proposed rule, we proposed to increase the equipment usage rate to 90 percent for all services containing equipment that cost in excess of $1 million dollars. We stated that the studies cited by MedPAC suggested that physicians and suppliers would not typically make huge capital investments in equipment that would only be utilized 50 percent of the time (74 FR 33532).

In response to comments to that proposal, we finalized a 90 percent utilization rate assumption for MRI and CT to be transitioned over a 4-year period. Regarding the utilization assumptions for other equipment priced over $1 million, we stated that we would continue to explore data sources regarding use of the most accurate utilization rates possible (74 FR 61755). Congress subsequently specified the utilization rate to be assumed for MRI and CT by successive amendments to Section 1848(b)(4)(C) of the Act. Section 3135(a) of the Affordable Care Act (Pub. L. 111-148) set the assumed utilization rate for expensive diagnostic imaging equipment to 75 percent, effective for 2011 and subsequent years. Section 635 of the American Taxpayer Relief Act (ATRA) (Pub. L. 112-240) set the assumed equipment utilization rate to 90%, effective for 2014 and subsequent years. Both of these changes were exempted from the budget neutrality requirements described in section 1848(c)(2)(B)(ii)(II) of the Act.

We have also made other adjustments to the default assumptions regarding the number of hours for which the equipment is available to be used. For example, some equipment used in furnishing services to Medicare beneficiaries is available to be used on a 24-hour/day, 7 days/per week basis. For these items, we develop the rate per minute by amortizing the cost over the extended period of time the equipment is in use.

Based on the RUC recommendations for the new codes that describe radiation treatment services, we do not believe our default assumptions regarding equipment usage are accurate for the capital equipment used in radiation treatment services. As we noted above, the RUC recommendations assume that the same type of linear accelerator is now typically used to furnish all levels and types of external beam radiation treatment services because the machines previously used to furnish these services are no longer manufactured. In valuing the previous code set and making procedure time assumptions, different equipment items were assumed to be used to furnish the different levels and types of radiation treatment. With the current RUC-recommended inputs, we can then assume that the same equipment item is used to furnish more services. If we assume the RUC recommendation to include the same kind of capital equipment for all of these codes is accurate, we believe that it is illogical to continue to assume that the equipment is only used for 25 out of a possible 50 hours per week. In order to estimate the difference between the previous number of minutes the linear accelerator was assumed to be in use under the previous valuation and the number of minutes now being recommended, we applied the change in assumptions to the services reported in the most recent year of Medicare claims data. Under the assumptions reflected in the previous direct PE inputs, the kind of linear accelerator used for IMRT made up a total of 44.8 million out of 65 million minutes of external beam treatments furnished to Medicare beneficiaries. Under the new code set, however, a single kind of linear accelerator would be used for all of the 65 million minutes furnished to Medicare beneficiaries. This represents a 45 percent increase in the aggregate amount of time that this kind of linac is in use. Of course, the utilization rate that corresponds with that increase in minutes is not necessarily precise since the current utilization rate only reflects the default assumption and is not itself rooted in empirical data. Additionally, in some cases, individual practices that already use linear accelerators for IMRT may have replaced the now-obsolete capital equipment with new, additional linear accelerators instead of increasing the use of capital equipment already owned. However, we do not believe that the latter scenario is likely to be common in cases where the linear accelerators had previously been used only 25 hours per week.

Therefore, we are proposing to adjust the equipment utilization rate assumption for the linear accelerator to account for the significant increase in usage. Instead of applying our default 50 percent assumption, we are proposing to use a 70 percent assumption based on the recognition that the item is now being typically used in a significantly broader range of services, and that would increase its overall usage in comparison to the previous assumption. We note that we developed the 70 percent rate based on a rough reconciliation between the number of minutes the equipment is being used according to the new recommendations versus the current number of minutes based on an analysis of claims data. We continue to seek evidence to ensure that the usage assumptions, both the utilization rate and number of available hours, used to calculate equipment costs are as accurate as possible. We believe that comparing the changes in direct PE input recommendations and using the Medicare claims data indicates that the utilization assumption to 70 percent is more accurate than the default utilization assumption of 50 percent. However, we have reviewed other information that suggests this utilization rate may be higher than 70 percent and that the number of available hours per week is greater than 50.

For example, as part of the 2014 RUC recommendations for the Radiation Treatment Delivery codes, the RUC submitted a 2011 staffing survey conducted by the American Society for Radiology Technicians (ASRT). Using the 2014 version of the same study, we noted that there are an average of 2.3 linacs per radiation treatment facility and 52.7 patients per day treated per radiation treatment facility. These data suggest that an average of 22.9 patients is treated on each linac per day. Using an average of the RUC-recommended procedure times for CPT codes 77385, 77386, 77402, 77407, and 77412 weighted by the annual volume of procedures derived from Medicare claims data yielded a total of 670.39 minutes or 11.2 hours that a single linac is in use per day. This is in contrast to both the number of hours of use reflected in our default assumptions (5 of the 10 available business hours per day) and in our proposed revision to the equipment utilization rate assumption (7 hours out of 10 available business hours per day).

For advanced diagnostic imaging services, we finalized a policy to change the equipment utilization assumption only by 10 percent per year, in response to suggestions from commenters. Because capital equipment costs are amortized over several years, we believe it is reasonable to transition changes to the default assumptions for particular items over several years. We note that the change from one kind of capital equipment to another is likely to occur over a number of years, roughly equivalent to the useful life of particular items as they become obsolete. In the case of most of these items, we have assumed a 7-year useful life, and therefore, we assume that the transition to use of the single kind of capital equipment would likely take place over 7 years as individual pieces of equipment age into obsolescence. However, in the case of this transition in capital equipment, we have reasons to believe that the transition to the new capital equipment has already occurred. First, we note that the specialty societies concluded that the single linear accelerator was typical for these services at the time that the current recommendations were developed in 2013. Therefore, we believe it is logical to assume that, at a minimum, the first several years of the transition to new capital equipment had already taken place by 2013. This would account for the linear accelerator being typically used at that time. This would not be surprising, given that prior to the 2013 review by the RUC, the codes describing the non-IMRT external beam radiation treatments had last been reviewed in 2002. Second, because we are proposing to use the 2013 recommendations for 2016 PFS payment rates, we believe it would be reasonable to assume that in the years between 2013 and 2016, the majority of the rest of the obsolete machines would have been replaced with the single linear accelerator.

Nonetheless, we recognize that there would be value in following precedent to transition changes in utilization assumptions over several years.

Given the fact that it is likely that the transition to the linear accelerator began prior to the 2013 revaluation of the radiation treatment delivery codes by CPT and that the useful life of the newest generation of linear accelerator is 7 years, we believe a 2-year transition to the 70 percent utilization rate assumption would account for any remaining time to transition to the new equipment. Therefore, in developing PE RVUs for these services, we are proposing to use a 60 percent utilization rate assumption for CY 2016 and a 70 percent utilization rate assumption for CY 2017. The PE RVUs displayed in addendum B on the CMS Web site were calculated using the proposed 60 percent equipment utilization rate for the linac as displayed in the CY 2016 direct PE input database.

Additionally, we continue to seek empirical data on the capital equipment costs, including equipment utilization rates, for the linac and other capital-intensive machines, and seek comment on how to most accurately address issues surrounding those costs within the PE methodology.

(3) Superficial Radiation Treatment Delivery

In the CY 2015 PFS final rule with comment period, we noted that changes to the CPT prefatory language modify the services that are appropriately billed with CPT code 77401 (radiation treatment delivery, superficial and/or ortho voltage, per day). The changes effectively meant that many other procedures supporting superficial radiation therapy were bundled with 77401. The RUC, however, did not review the inputs for superficial radiation therapy procedures, and therefore, did not assess whether changes in its valuation were appropriate in light of this bundling. Some stakeholders suggested that the change in the prefatory language precluded them from billing for codes that were previously frequently billed in addition to this code and expressed concern that as a result there would be significant reduction in their overall payments. In the CY 2015 PFS final rule with comment period, we requested information on whether the new radiation therapy code set combined with modifications in prefatory text allowed for appropriate reporting of the services associated with superficial radiation and whether the payment continued to reflect the relative resources required to furnish superficial radiation therapy services.

In response to our request, we received a recommendation from a stakeholder to make adjustments to both the physician work and PE components for code 77401. The stakeholder suggested that since crucial aspects of the service, such as treatment planning and device design and construction, were not currently reflected in 77401, and practitioners were precluded from reporting these activities separately, that physician work should be included for CPT code 77401. Additionally, the stakeholders suggested that the current inputs used to value the code are not accurate because the inputs include zero physician work and minutes for a radiation therapist to provide the service directly to the patient. The stakeholders suggested, alternatively, that physicians, not radiation therapists, typically provide superficial radiation services directly. Therefore, we are seeking recommendations from other stakeholders, including the RUC, regarding whether or not it would be appropriate to add physician work for this service and remove minutes for the radiation therapists, even though physician work is not included in other radiation treatment services.

The stakeholder also suggested that we amend the direct PE inputs by including nurse time and updating the price of the capital equipment used in furnishing the service. We believe it would be most appropriate to address the clinical labor assigned to the code in the context of the information regarding the physician work that might be associated with the service. Therefore, we seek information on the possible inclusion of nurse time for this service as part of the comments and/or recommendations regarding physician work for the service. However, we reviewed the submitted invoices for the request to update the capital equipment for the service. We are proposing to update the equipment item ER045 “orthovoltage radiotherapy system” by renaming it “SRT-100 superficial radiation therapy system” and updating the price from $140,000 to $216,000, on the basis of the submitted invoices. The PE RVUs displayed in Addendum B on the CMS Web site were calculated with this proposed modification that is displayed in the CY 2016 direct PE input database.

c. Advance Care Planning Services

For CY 2015, the CPT Editorial Panel created two new codes describing advance care planning (ACP) services: CPT code 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate); and an add-on CPT code 99498 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; each additional 30 minutes (List separately in addition to code for primary procedure)). In the CY 2015 PFS final rule with comment period (79 FR 67670-71), we assigned a PFS interim final status indicator of “I” (Not valid for Medicare purposes. Medicare uses another code for the reporting and payment of these services) to CPT codes 99497 and 99498 for CY 2015. We said that we would consider whether to pay for CPT codes 99497 and 99498 after we had the opportunity to go through notice and comment rulemaking.

We received many public comments to the final rule recommending that we recognize these two CPT codes and make separate payment for ACP services, in view of the time required to furnish the services and their importance for the quality of care and treatment of the patient. For CY 2016, we are proposing to assign CPT codes 99497 and 99498 PFS status indicator “A,” which is defined as: “Active code. These codes are separately payable under the PFS. There will be RVUs for codes with this status.” The presence of an “A” indicator does not mean that Medicare has made a national coverage determination regarding the service. Contractors remain responsible for local coverage decisions in the absence of a national Medicare policy. We are proposing to adopt the RUC-recommended values (work RVUs, time, and direct PE inputs) for CPT codes 99497 and 99498 beginning in CY 2016 and will consider all public comments that we receive on this proposal.

Physicians' services are covered and paid by Medicare in accordance with section 1862(a)(1)(A) of the Act. Therefore, CPT code 99497 (and CPT code 99498 when applicable) should be reported when the described service is reasonable and necessary for the diagnosis or treatment of illness or injury. For example, this could occur in conjunction with the management or treatment of a patient's current condition, such as a 68 year old male with heart failure and diabetes on multiple medications seen by his physician for the evaluation and management of these two diseases, including adjusting medications as appropriate. In addition to discussing the patient's short-term treatment options, the patient expresses interest in discussing long-term treatment options and planning, such as the possibility of a heart transplant if his congestive heart failure worsens and advance care planning including the patient's desire for care and treatment if he suffers a health event that adversely affects his decision-making capacity. In this case the physician would report a standard E/M code for the E/M service and one or both of the ACP codes depending upon the duration of the ACP service. However, the ACP service as described in this example would not necessarily have to occur on the same day as the E/M service.

We seek comment on this proposal, including whether payment is needed and what type of incentives this proposal creates. In addition, we seek comment on whether payment for advance care planning is appropriate in other circumstances such as an optional element, at the beneficiary's discretion, of the annual wellness visit (AWV) under section 1861(hhh)(2)(G) of the Act.

d. Proposed Valuation of Other Codes for CY 2016

(1) Excision of Nail Bed (CPT Code 11750)

The RUC's review of 10-day global services identified 18 services currently valued with greater than 1.5 office visits and 2012 Medicare utilization data over 1,000, including CPT code 11750. As a result, the RUC requested this service be surveyed for work and reviewed for CY 2016.

The RUC recommended a work RVU of 1.99 for CPT code 11750, despite a decrease in the associated post-operative visits. We believe the recommendation for this service overstates the work involved in performing this procedure specifically given the decrease in post-operative visits. Due to similarity in service and time, we believe a direct crosswalk of the work RVUs for CPT code 10140 (Drainage of blood or fluid accumulation), which is also a 10 day global service with one post-operative visit, to CPT code 11750 more accurately reflects the time and intensity of furnishing the service. Therefore, for CY 2016 we are proposing a work RVU of 1.58 for CPT code 11750.

(2) Bone Biopsy Excisional (CPT Code 20240)

In the same review of 10-day global services, the RUC identified CPT code 20240 as potentially misvalued. As a result, the RUC requested this service be surveyed and reviewed for CY 2016. Subsequent to this identification, the RUC also requested and we approved a global period change from a 10-day to a 0-day global period for this procedure. Based on the survey data, the RUC recommended a decrease in the intraservice time from 39 to 30 minutes, removal of two postoperative visits (one 99238 and one 99212), and an increase in the work RVUs for CPT code 20240 from 3.28 to 3.73. We do not believe this recommendation accurately reflects the work involved in this procedure, especially given the decrease in intraservice time and post-operative visits. Therefore, for CY 2016, we are proposing a work RVU of 2.61 for CPT code 20240 based on the reductions in time for the service.

(3) Endobronchial Ultrasound (CPT Codes 31622, 3160A, 3160B, 31625, 31626, 31628, 31629, 3160C, 31632 and 31633)

For CY 2016, the CPT Editorial Panel deleted one code, CPT 31620 (Ultrasound of lung airways using an endoscope), and created three new codes, CPT 3160A-3160C, to describe bronchoscopic procedures that are inherently performed with endobronchial ultrasound (EBUS).

In their review of the newly revised EBUS family, the RUC recommended a change in the work RVU for CPT code 31629 from 4.09 to 4.00. The RUC also recommended maintaining the current work RVUs for CPT codes 31622, 31625, 31626, 31628, 31632 and 31633. We are proposing to use those values for CY 2016.

For the newly created codes, the RUC recommended a work RVU of 5.00 for CPT code 3160A, 5.50 for CPT code 3160B and 1.70 for CPT code 3160C. We believe the recommended work RVUs for these services overstate the work involved in furnishing the procedures. In order to develop proposed work RVUs for CPT code 3160A, we compared the service described by the new code to deleted CPT codes 31620 and 31629, because this new code describes a service that combines services described by 31620 and 31629. Specifically, we took the sum of the current work RVU of CPT code 31629 (WRVU=4.09) and the CY 2015 work RVU of CPT code 31620 (WRVU=1.40) and multiplied it by the quotient of CPT code 3160A's RUC-recommended intraservice time (INTRA=60 min) and the sum of CPT codes 31620 and 31629's current and CY 2015 intraservice times (INTRA=70 min), respectively. This resulted in a work RVU of 4.71 and we are proposing that value. To value CPT code 3160B, we used the RUC-recommended increment of 0.5 work RVU between this service and CPT code 3160A to calculate for CPT code 3160B our proposed work RVUs of 5.21. Lastly, because the service described by new CPT code 3160C is very similar to deleted CPT code 31620, we believe a direct crosswalk of the previous values for 31620 accurately reflects the time and intensity of furnishing the service described by 3160C. Therefore, we are proposing a work RVUs of 1.40 for CPT code 3160C.

(4) Laparoscopic Lymphadenectomy (CPT Codes 38570, 38571 and 38572)

The RUC identified three laparoscopic lymphadenectomy codes as potentially misvalued: CPT code 38570 (Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple); CPT code 38571 (Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple with bilateral total pelvic lymphadenectomy); and CPT code 38572 (Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple with bilateral total pelvic lymphadenectomy and periaortic lymph node sampling (biopsy), single or multiple). Accordingly, the specialty society resurveyed these 10-day global codes, and the survey results indicated decreases in intraservice and total work times. After reviewing the survey responses, the RUC recommended that CMS maintain the current work RVU for CPT code 38570 of 9.34; reduce the work RVU for CPT code 38571 from 14.76 to 12.00; and reduce the work RVU for CPT code 38572 from 16.94 to 15.60. We propose to accept the RUC recommendations for CPT codes 38571 and 38572, as the RUC is recommending reductions in the work RVUs that correspond with marked decreases in intraservice time and decreases in total time. However, we do not agree with the RUC's recommendation to maintain the current work RVU for CPT code 38570 in spite of similar changes in intraservice and total times as were shown in the RUC recommendations for CPT codes 38571 and 38572. Therefore, we propose to reduce the work RVU for CPT code 38570 to 8.49, which reflects the ratio of the reduction in total time for this code and would maintain rank order among the three codes.

(5) Mediastinoscopy With Biopsy (CPT Codes 3940A and 3940B)

The RUC identified CPT code 39400 (Mediastinoscopy, including biopsy(ies) when performed) as a potentially misvalued code due to an unusually high preservice time and Medicare utilization over 10,000. In reviewing the code's history, it became apparent that the code has been used to report two distinct procedural variations although the code was valued using a vignette for only one of them. As a result, CPT code 39400 is being deleted and replaced with CPT codes 3940A and 3940B to describe each of the two mediastinoscopy procedures.

We are proposing to accept the RUC-recommended work RVU of 5.44 for code 3940A. We agree with the RUC that the crosswalk from CPT code 52235 (Cystourethroscopy, with fulguration) appropriately estimates the overall work for CPT code 3940A. For CPT code 3940B, we disagree with the RUC recommended work RVU of 7.50. We believe that the work value for CPT code 3940A establishes an accurate baseline for this family of codes, so we are scaling the work RVU of CPT code 3940B in accordance with the change in the intraservice times between CPT codes 3940A and 3940B. Applying this ratio in the intraservice time to the work value of CPT code 3940A yields a total work RVU of 7.25 for CPT code 3940B. We also note that the RUC recommendation for CPT code 3940A represents a decrease in value by 0.64 work RVUs, which is roughly proportionate to the reduction from a full hospital discharge visit (99238) to a half discharge visit assumed to be typical in the post-operative period. The RUC recommendation for CPT code 3940B had the same reduction in the post-operative work without a corresponding decrease in its recommended work RVU. In order to reflect the reduction in post-operative work and to maintain relativity between the two codes in the family, we are proposing 7.25 as the work RVU for CPT code 3940B.

(6) Hemorrhoid(s) Injection (CPT Code 46500)

The RUC also identified CPT code 46500 (Injection of sclerosing solution, hemorrhoids) as potentially misvalued, and the specialty society resurveyed this 10-day global code. The survey showed a significant decrease in the reported intraservice and total work times. After reviewing the survey responses, the RUC recommended that CMS should maintain the current work RVU of 1.69 in spite of these drops in intraservice and total times. We propose to instead reduce the work RVU to 1.42, which reduces the work RVU by the same ratio as the reduction in total time.

We are also proposing to refine the recommended PE inputs by removing the inputs associated with cleaning the scope. As recommended by the RUC, we are proposing to include a scope as a direct PE input that is disposable, and therefore, does not require cleaning.

(7) Liver Allotransplantation (CPT Code 47135)

The RUC also identified CPT code 47135 (Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age) as potentially misvalued, and the specialty society resurveyed this 90-day global code. The survey showed a significant decrease in reported intraservice work time, but a significant increase in total work time (the number of post-operative visits significantly declined while the level of visits increased). After reviewing the survey responses, the RUC recommended an increase in the work RVU from 83.64 to 91.78, which is the median of the survey, as well as the exact value for CPT code 33935 (Heart-lung transplant with recipient cardiectomy-pneumonectomy). However, we do not believe this crosswalk is the most accurate from among the group of transplant codes. CPT code 32854 (Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass) has intraservice and total times that are closer to those the RUC recommended for CPT code 47135, and CPT code 32854 has a work RVU of 90.00 which is the 25th percentile of the survey for CPT code 47135. Therefore, we propose to increase the work RVU of CPT code 47135 to 90.00.

(8) Genitourinary Catheter Procedures (CPT Codes 5039A, 5039B, 5039C, 5039D, 5039M, 5039E, 5069G, 5069H, 5069I)

For CY 2016, the CPT Editorial Panel is deleting six codes (50392, 50393, 50394, 50398, 74475, and 74480) that were commonly reported together, and are creating 12 new codes both to describe these genitourinary catheter procedures more accurately and to bundle inherent imaging services. Three of these codes (506XF, 507XK, and 507XL) were referred back to CPT to be resurveyed as add-on codes. The other nine codes were reviewed at the January 2015 RUC meeting and assigned recommended work RVUs and direct PE inputs.

We are proposing to use the RUC-recommended work RVU of 3.15 for CPT code 5039A. We agree that this is an appropriate value, and that the code should be used as a basis for establishing relativity with the rest of the family. As a result, we began by making comparisons between the service times of CPT code 5039A and the other codes in the family in order to determine the appropriate proposed work value of each procedure.

For CPT code 5039B, we disagree with the RUC recommended work RVU of 1.42, and we are instead proposing a work RVU of 1.10, based on three separate data points. First, the RUC summary of recommendations stated that CPT code 5039B describes work previously described by a combination of CPT codes 50394 and 74425. These two codes have work RVUs of 0.76 and 0.36, respectively, which sum together to 1.12. Second, we noted that the work of CPT code 49460 (Mechanical removal of obstructive material from gastrostomy) is similar, with the same intraservice time of 15 minutes and same total time of 55 minutes but a work RVU of 0.96. Finally, we observed that the minimum survey result had a work RVU of 1.10, and we believe this value appropriately reflects the total work for the service. Accordingly, we are proposing 1.10 as the work RVU for CPT code 5039B.

We employed a similar methodology to develop a proposed work RVU of 4.25 for CPT code 5039C. The three previously established codes are being combined in CPT code 5039C; these had respective work values of 3.37 (CPT code 50392), 0.54 (CPT code 74475), and 0.36 (CPT code 74425); together these sum to 4.27 work RVUs. We also looked at valuing CPT code 5039C based on relativity with other codes in the family. The ratio of the intraservice time of 35 minutes for CPT code 5039A and the intraservice time of 48 minutes for CPT code 5039C; applied to the work RVU of base code 5039A (3.15) results in a potential work RVU of 4.32. The total time compared to CPT code 5039A also went from 91 minutes to 107 minutes and this ratio applied to the base work RVU results in a work RVU of 3.70. We utilized these data to inform our choice of an appropriate crosswalk. We believe CPT code 31660 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance) is an appropriate reference crosswalk for CPT code 5039C. CPT code 31660 has an intraservice time of 50 minutes, total time of 105 minutes, and a work RVU of 4.25. Therefore, we propose to establish the work RVU for CPT code 5039C at the crosswalked value of 4.25 work RVUs.

According to the RUC recommendations, CPT codes 5039C and 5039D are very similar procedures, with CPT code 5039D making use of a nephroureteral catheter instead of a nephrostomy catheter. The RUC valued the added difficulty of CPT code 5039D at 1.05 work RVUs compared to code CPT code 5039C. We are maintaining the relative difference in work between these two codes by proposing a value of 5.30 for CPT code 5039D. (This is the work RVU of 4.25 for CPT code 5039C plus 1.05 RVUs.) Additionally, we are using CPT code 57155 (Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy) as our reference crosswalk. CPT code 57155 has a work RVU of 5.40 and an identical intraservice time of 60 minutes, but it also has fourteen additional minutes of total time, 133 minutes compared to 119 minutes for CPT code 5039D, which supports the difference of 0.10 RVUs. For these reasons, we are proposing the value of CPT code 5039D at 5.30 work RVUs.

As with the other genitourinary codes, we developed the proposed work value of CPT code 5039M in order to preserve relativity within the family. CPT code 5039M has 15 fewer minutes of intraservice time compared to CPT code 5039D (45 minutes compared to 60 minutes). This is a ratio of 0.75, applied to the based work RVU of CPT code 5039D (5.30) resulted in a potential work RVU of 3.98. CPT code 5039C was another close match within the family, with 3 more minutes of intraservice time compared to 5039M, 48 minutes of intraservice time instead of 45 minutes. This ratio (0.94) applied to the base work RVU of CPT code 5039C (4.25) also resulted in a potential work RVU of 3.98. Based on this information, we identified CPT code 31634 (Bronchoscopy, rigid or flexible, with balloon occlusion) as an appropriate crosswalk, and propose a work RVU of 4.00 for CPT code 5039M. The two codes share an identical intraservice time of 45 minutes, though the latter possesses a lower total time of 90 minutes.

For CPT code 5039E, we considered how the code and work RVU would fit within the family in comparison to our proposed values for CPT codes 5039A and 5039C. CPT code 5039A serves as the base code for this group; it has 35 minutes of intraservice time in comparison to 20 minutes for CPT code 5039E. This intraservice time ratio of 0.57 resulted in a potential work RVU of 1.80 for CPT code 5039E when applied to the work RVU of CPT code 5039A (3.15). Similarly, CPT code 5039C is the most clinically similar procedure to CPT code 5039E. CPT code 5039C has 48 minutes of intraservice time compared to 20 minutes of intraservice time for CPT code 5039E. This ratio of 0.42 applied to the base work RVU of CPT code 5039C (4.25) results in a potential work RVU of 1.77. We also made use of two crosswalks to help determine a proposed value for CPT code 5039E. CPT code 64416 (Injection, anesthetic agent; brachial plexus) also includes 20 minutes of intraservice time and has a work RVU of 1.81. CPT code 36569 (Insertion of peripherally inserted central venous catheter) has the same intraservice and total time as CPT code 5039E, with a work RVU of 1.82. Accordingly, we are crosswalking the work RVU for CPT code 5039E to CPT code 36569 and proposing a work RVU of 1.82 for CY 2016.

The remaining three codes all utilize ureteral stents and form their own small subfamily within the larger group of genitourinary catheter procedures. For CPT code 5069G, we are proposing a work RVU of 4.21, which is the 25th percentile result from the survey information. We believe that the 25th percentile provides a more accurate value for CPT code 5069G based on the work involved in the procedure and within the context of other codes in the family. We are also referencing CPT code 31648 (Bronchoscopy, rigid or flexible, with removal of bronchial valve), which shares 45 minutes of intraservice time and has a work RVU of 4.20, as an appropriate crosswalk for CPT code 5069G.

For CPT code 5069H, we compared its intraservice time to the code within the family that had the most similar duration, CPT code 5039D. This code has 60 minutes of intraservice time compared to 62 minutes for CPT code 5069H. This is a ratio of 1.03 applied to the base work RVU of CPT code 5039D (5.30) resulted in a potential work RVU of 5.48. We also looked to crosswalks with similar numbers, in particular CPT code 50382 (Removal and replacement of internally dwelling ureteral stent). This code has 60 minutes of intraservice time, 125 minutes of total time, and a work RVU of 5.50. For these reasons, we are crosswalking CPT code 5069H to CPT code 50382 and proposing a work RVU of 5.50.

Finally, we developed the proposed value for CPT code 5069I using three related methods. CPT codes 5069H and 5069I describe very similar procedures, with 5069I adding the use of a nephrostomy tube. The RUC addressed the additional difficulty of this procedure by recommending 1.55 more work RVUs for CPT code 5069I than for CPT code 5069H. Adding the 1.55 work RVUs to the proposed work RVU for CPT code 5069H (5.50) would produce a work RVU of 7.05 for CPT code 5069I. We also looked at the ratio of intraservice times for CPT code 5069I (75 minutes) and the base code in the subfamily, CPT code 5069G (45 minutes). The intraservice time ratio between these two codes is 1.67 when applied to the base work RVU of CPT code 5069G (4.21) resulted in a potential work RVU of 7.02. We also identified an appropriate crosswalk reference in CPT code 36481 (Percutaneous portal vein catheterization by any method) which shares the same intraservice time as CPT code 5069I and has a work RVU of 6.98. Accordingly, to maintain relativity among this subfamily of codes, we are proposing a work RVU of 7.05 for CPT code 5069I based on an incremental increase of 1.55 RVUs from CPT code 5069H.

In reviewing the direct PE inputs for this family of codes, we refined a series of the RUC- recommended inputs in order to maintain relativity with current standards. All of the following refinements refer to the non-facility setting for this family of codes. Under the clinical labor inputs, we are proposing to remove the RN/LPN/MTA (L037D) (intraservice time for assisting physician in performing procedure) for CPT codes 5039B and 5039E. This amounts to 15 minutes for CPT code 5039B and 20 minutes for CPT code 5039E. Moderate sedation is not inherent in these procedures and, therefore, we do not believe that this clinical labor task would typically be completed in the course of this procedure. We are also reducing the RadTech (L041B) intraservice time for acquiring images from 47 minutes to 46 minutes for CPT code 5069H. This procedure contains 62 minutes of intraservice time, with clinical labor assigned for acquiring images (75 percent) and a circulator (25 percent). The exact time for these clinical labor tasks multiplies out to 46.5 minutes and 15.5 minutes, respectively. The RUC recommendation for CPT code 5069H rounded both of these values upwards, assigning 47 minutes for acquiring images and 16 minutes for the circulator, which together sum to 63 minutes. We are reducing the clinical labor time for acquiring images to 46 minutes to preserve the 62 minutes of total intraservice time for CPT code 5069H.

During the post-service portion of the clinical labor service period, we are proposing to change the labor type for the “patient monitoring following service/check tubes, monitors, drains (not related to moderate sedation)” input. There are 45 minutes of clinical labor time assigned under this category to CPT codes 5039A, 5039C, 5039D, 5039M, 5069G, 5069H, and 5069I. Although we agree that the 45 minutes are appropriate for these procedures as part of moderate sedation, we are changing the clinical labor type from the recommended RN (L051A) to RN/LPN/MTA (L037D) to reflect the staff that will typically be doing the monitoring for these procedures. Even though the CPT Editorial Committee's description of post-service work for CPT code 5039E includes a recovery period for sedation, we recognize that according to the recommendation, CPT codes 5039B and 5039E do not use moderate sedation, so we did not propose to include moderate sedation inputs for these codes.

The RUC recommendation for CPT code 5039D includes a nephroureteral catheter as a new supply input with an included invoice. However, in the RUC summary of recommendations for this code, there is no mention of a nephroureteral catheter in the intraservice work description. CPT code 5039D does mention the use of a nephroureteral stent in this description, but there is no request for a nephroureteral stent supply item on the PE worksheet for this code. We are therefore seeking clarification from stakeholders regarding the use of the nephroureteral catheter for CPT code 5039D. We have not proposed to add the nephroureteral catheter as a supply item for CPT code 5039D pending this information. We are also requesting a clarification to the intraservice work description in the summary of recommendations for this code to explain the use, if any, of the nephroureteral catheter in this procedure.

The RUC recommended the inclusion of “room, angiography” (EL011) for this family of codes. We do not agree with the RUC that an angiography room would be used in the typical case for these procedures, as there are other rooms available which can provide fluoroscopic guidance. Most of the codes that make use of an angiography room are cardiovascular codes, and much of the equipment listed for this room would not be used for non-cardiovascular procedures. We are therefore proposing to replace equipment item “room, angiography” (EL011) with equipment item “room, radiographic-fluoroscopic” (EL014) for the same number of minutes. We are requesting public comment regarding the typical room type used to furnish the services described by these CPT codes, as well as the more general question of the typical room type used for GU and GI procedures. In the past, the RUC has developed broad recommendations regarding the typical uses of rooms for particular procedures, including the radiographic-fluoroscopy room. We believe that such a recommendation from the RUC concerning all of these codes could be useful in ensuring relativity across the PFS.

(9) Penile Trauma Repair (CPT Codes 5443A and 5443B)

CPT created these two new codes because there are no existing codes to capture penile traumatic injury that includes penile fracture, also known as traumatic corporal tear, and complete penile amputation. CPT code 5443A will describe a repair of traumatic corporeal tear(s) while CPT code 5443B will describe a replantation, penis, complete amputation. For CPT code 5443B, we disagree with the RUC recommendation of a work RVU of 24.50. We believe that the 25th percentile work RVU of 22.10 provides a more accurate value based on the work involved in the procedure and within the context of other codes in the same family, since CPT code 5443A was also valued using the 25th percentile. We find further support for this valuation through a crosswalk to CPT code 43334 (Repair, paraesophageal hiatal hernia via thoracotomy, except neonatal) which has an identical intraservice time and a work RVU of 22.12. Therefore we are proposing a work RVU of 22.10 for CPT code 5443B.

Because CPT codes 5443A and 5443B are typically performed on an emergency basis, we question the appropriateness of the standard 60 minutes of preservice clinical labor in the facility setting, as the typical procedure would not make use of office-based clinical labor. For example, we do not believe that the typical case would require 8 minutes to schedule space in the facility for an emergency procedure, or 20 minutes to obtain consent. We are seeking further public comment on this issue from the RUC and other stakeholders.

(10) Intrastromal Corneal Ring Implantation (CPT Code 657XG)

CPT code 657XG is a new code describing insertion of prosthetic ring segments into the corneal stroma for treatment of keratoconus in patients whose disease has progressed to a degree that they no longer tolerate contact lens wear for visual rehabilitation.

We disagree with the RUC recommendation of a work RVU of 5.93 for CPT code 657XG. Although we appreciated the extensive list of other codes the RUC provided as references, we are concerned that the recommended value for CPT code 657XG overestimates the work involved in furnishing this service relative to other PFS services. We did not find a single code with comparable intraservice and total time that had a higher work RVU. The recommended crosswalk, CPT code 67917 (Repair of ectropion; extensive), appears to have the highest work RVU of any 90-day global surgery service in this range of work time values. It also has longer intraservice time and total time than the code in question, making a direct crosswalk inappropriate.

As a result, we are proposing a new value for CPT code 657XG based on the intraservice time ratio in relation to the recommended crosswalk. We compared the 33 minutes of intraservice time in CPT code 67917 to the 30 minutes of intraservice time in CPT code 657XG. The intraservice time ratio between these two codes is 0.91, and when multiplied by the work RVU of CPT code 67917 (5.93) resulted in a potential work RVU of 5.39. We also considered CPT code 58605 (Ligation or transection of fallopian tube(s)), which has the same intraservice time, seven additional minutes of total time, and a work RVU of 5.28. We believe that CPT 58605 is a closer fit for a direct crosswalk because it shares the same intraservice time of 30 minutes with CPT code 657XG. Accordingly, we are proposing a work RVU of 5.39 for CPT code 657XG.

The RUC recommendation for CPT code 657XG includes a series of invoices for several new supplies and equipment items. One of these was the 10-0 nylon suture with two submitted invoice prices of $245.62 per box of 12, or $20.47 per suture, and another was priced at $350.62 per box of 12, or $29.22 per suture. Given the range of prices between these two invoices, we sought publicly available information and identified numerous sutures that appear to be consistent with those recommended by the specialty society, at lower prices, which we believe are more likely to be typical since we assume that the typical practitioner would seek the best price. One example is “Surgical Suture, Black Monofilament, Nylon, Size: 10-0, 12”/30cm, Needle: DSL6, 12/bx” for $146. Therefore, we are proposing to establish a new supply code for “suture, nylon 10-0” and price that item at $12.17 each. We welcome comments from stakeholders regarding this supply item.

(11) Dilation and Probing of Lacrimal and Nasolacrimal Duct (CPT Codes 66801, 68810, 68811, 68815 and 68816)

The RUC's review of 10-day global services identified 18 services with greater than 1.5 office visits and 2012 Medicare utilization data over 1,000, including CPT codes 66801, 68810, 68811, 68815, and 68816. As a result, the RUC requested these services be surveyed reviewed for CY 2016.

The RUC recommended a work RVU of 1.00 for CPT code 68801 and a work RVU of 1.54 for CPT code 68810. While we are proposing to use the RUC-recommended work RVU for CPT code 68810, we do not believe the recommendation for CPT code 68801 best reflects the work involved in the procedure because of a discrepancy between the post-operative work time and work RVU. Specifically, the RUC recommendation for the procedure included the removal of a 99211 visit, but the RUC-recommended work RVU did not reflect any corresponding adjustment. As a result, we are proposing to accept the RUC's recommendation to remove the 99211 visit from the service but are proposing to further reduce the work RVU for CPT code 68801 by removing the RVUs associated with CPT code 99211. Therefore, for CY 2016, we are proposing a work RVUs of 0.82 to CPT code 68801 and 1.54 to CPT code 68810.

The RUC recommended a work RVU of 2.03, 3.00, and 2.35 for CPT codes 68811, 68815 and 68816, respectively. We do not believe the RUC recommendations for these services best reflect the work involved in performing these procedures. To value these services, we calculated a total time ratio by dividing the code's current total time by the RUC-recommended total time, and then applying that ratio to the current work RVU. This produces our CY 2016 proposed work RVUs of 1.74, 2.70, and 2.10 for CPT codes 68811, 68815, and 68816, respectively.

(12) Spinal Instability (CPT Code 7208A, 7208B, 7208C, and 7208D)

For CY 2015, the CPT Editorial Panel deleted codes 72010 (radiologic examination, spine, entire, survey study, anteroposterior and lateral), 72069 (radiologic examination, spine, thorocolumbar, standing (scoliosis)), and 72090 (radiological examination, spine; scoliosis study, including supine and erect studies), revised one code, 72080 (Radiologic examination, spine; thoracolumbar junction, minimum of 2 views) and created four new codes which cover radiologic examination of the entire thoracic and lumbar spine, including the skull, cervical and sacral spine if performed. The new codes were organized by number of views, ranging from one view in 7208A, two to three views in 7208B, four to five views in 7208C, and minimum of 6 views in 7208D.

We disagree with the RUC's work RVU recommendations for these four codes. For 7208A, we noted that the one minute increase in time resulted in a larger work RVU than would be expected when taking the ratio between time and RVU in the source code and comparing that to the time and work RVU ratio in the new code. Using the relationship between time and RVU from deleted code 72069, we are proposing a work RVU of 0.26 for 7208A, which differs from the RUC-recommended value of 0.30. Using an incremental methodology based on the relationship between work and time in the first code we are proposing to adjust the RUC-recommended work RVUs for CPT codes 7208B, 7208C and 7208D to, respectively, 0.31, 0.35, and 0.41.

(13) Echo Guidance for Ova Aspiration (CPT Code 76948)

In the CY 2014 PFS final rule with comment period, we requested additional information to assist us in the valuation of ultrasound guidance codes. We nominated these codes as potentially misvalued based on the extent to which standalone ultrasound guidance codes were billed separately from services where ultrasound guidance was an integral part of the procedure. CPT code 76948 was among the codes considered potentially misvalued. CPT code 76948 was surveyed by the specialty societies and the RUC issued a recommendation for CY 2016. We have concerns about valuation this code, considering that it is a guidance code used only for a single procedure: 58970 (aspiration of ova), and we believe that these two codes are almost always billed concurrently. We believe codes 76948 and 58970 should be bundled to accurately reflect how the service is furnished.

We are proposing to use work times based on refinements of the RUC-recommended values by removing the 3 minutes of pre and post service time since these times are reflected in the 58970 procedure code. We are proposing work and time values for 76948 based on a crosswalk from 76945 (Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation) which has a physician work time of 30 minutes and an RVU of 0.56. Therefore we are proposing to maintain 25 minutes of intraservice time for 76948 and proposing a work RVU of 0.56.

(14) Immunohistochemistry (CPT Codes 88341, 88342, and 88344)

In establishing interim final direct PE inputs for CY 2015 for CPT codes 88341, 88342, and 88344, we replaced the RUC-recommended supply item “UltraView Universal DAB Detection Kit” (SL488) with “Universal Detection Kit” (SA117), since the RUC did not provide an explanation for the required use of a more expensive kit. We also adjusted the equipment time for equipment item “microscope, compound” (EP024). We re-examined these codes when valuing the immunofluorescence family of codes for CY 2016, and reviewed information received by commenters that explained the need for these supply items. Specifically, commenters explained that the universal detection kit that CMS included in place of the RUC-recommended kit was not typically used in these services as it was not clinically appropriate. We are proposing to include the RUC-recommended supply item, SL488, for CPT codes 88341, 88342, and 88344, as well as the RUC-recommended equipment time for “microscope, compound” for CY 2016.

(15) Immunofluorescent Studies (CPT Codes 88346 and 8835X)

For CY 2016, the CPT Editorial Panel deleted one code, CPT 88347 (Antibody evaluation), created a new add-on service, CPT 8835X, and revised CPT code 88346 to describe immunofluorescent studies. The RUC recommended a work RVU of 0.74 for CPT code 88346 and 0.70 for CPT code 8835X. While we are accepting the RUC recommendation for CPT code 88346, we do not believe the recommendation for CPT code 8835X best reflects the work involved in the procedure due to our concerns with the relationship between the RUC-recommended intraservice times for the base code and the newly created add-on code. We examined intraservice time relationships between other base codes and add-on codes and found that two codes in the Intravascular ultrasound family, CPT 37250 (Ultrasound evaluation of blood vessel during diagnosis or treatment) and 37251(Ultrasound evaluation of blood vessel during diagnosis or treatment), share a similar base code/add-on code intraservice time relationship, and are also diagnostic in nature, as are CPT codes 88346 and 8835X. Due to these similarities, we believe it is appropriate to apply the relationship, which is a 24 percent difference, between CPT codes 37250 and 37251 in calculating work RVUs for CPT codes 88346 and 8835X. Multiplying the RVU of CPT code 88346, 0.74, by 24 percent, and then subtracted the product from 0.74 results in a work RVU of 0.56 for CPT code 8835X. Therefore, for CY 2016, we are proposing a work RVU of 0.74 for CPT code 88346 and 0.56 for CPT code 8835X.

(16) Morphometric Analysis (CPT Codes 88364, 88365, 88366, 88367, 88373, 88374, 88377, 88368, and 88369)

CPT codes 88367 and 88368 were reviewed and valued in the CY 2015 PFS final rule with comment period (79 FR 67668 through 67669). Since then, the RUC has re-reviewed these services for CY 2016 due to the specialty society's initially low survey response rate. In our review of these codes, we noticed that the latest RUC recommendation is identical to the RUC recommendation provided for CY 2015 rulemaking. As a result, we do not believe there is any reason to modify our CY 2015 work RVUs or work time for these procedures. Therefore, we are proposing to retain the CY 2015 work RVUs and work time for CPT codes 88367 and 88368 for CY 2016.

In establishing interim final direct PE inputs for CY 2015 for CPT codes 88364, 88365, 88366, 88367, 88373, 88374, 88377, 88368, and 88369, we refined the RUC-recommended direct PE inputs as follows. We refined the units of several supply items, including “ethanol, 100%” (SL189), “ethanol, 70%” (SL190), “ethanol, 85%” (SL191), “ethanol, 95%” (SL248), “kit, FISH paraffin pretreatment” (SL195), “kit, HER-2/neu DNA Probe” (SL196), positive and negative control slides (SL112, SL118, SL119, SL184, SL185, SL508, SL509, SL510, SL511), “(EBER) DNA Probe Cocktail” (SL497),”Kappa probe cocktails” (SL498) and “Lambda probe cocktails” (SL499), to maintain consistency within the codes in the family, and adjusted the quantities included in these codes to align with the code descriptors and better reflect the typical resources used in furnishing these services. We also adjusted the equipment time for equipment items “water bath, FISH procedures (lab)” (EP054), “chamber, Hybridization” (EP045), “microscope, compound” (EP024), “instrument, microdissection (Veritas)” (EP087), and “ThermoBrite” (EP088), to reflect the typical time the equipment is used, among other common refinements.

We re-examined these codes when valuing the immunofluorescence family of codes for CY 2016, and reviewed information received from commenters that described the typical batch size for each of these services, thereby explaining the apparent inconsistencies and discrepancies in the quantity of units among the codes in the family. We are proposing to include the RUC-recommended quantities for each of these supply items for the CPT codes 88364, 88365, 88366, 88367, 88373, 88374, 88377, 88368, and 88369 for CY 2016. With regard to the equipment items, we received information explaining that the recommended equipment times already accounted for the typical batch size, and thus, the recommended times were already reflective of the typical case. Therefore, we are proposing to adjust the equipment time for equipment items EP054, EP045, and EP087 to align with the RUC-recommended times. We also received comments explaining the need for equipment item EP088. Based on that information, we are proposing to include this equipment item consistent with the RUC recommendations for CPT code 88366.

We note that the information we received regarding the typical batch size was critical in determining the appropriate direct PE inputs for these pathology services. We also note that we usually do not have information regarding the typical batch size or block size when we are reviewing the direct PE inputs for pathology services. The supply quantity and equipment minutes are often a direct function of the number of tests processed at once. Given the importance of the typical number of tests being processed by a laboratory in determining the direct PE inputs, which often include expensive supplies, we are very concerned that the direct PE inputs included in many pathology services may not reflect the typical resource costs involved in furnishing the typical service.

In particular, we note that since laboratories of various sizes furnish pathology tests and that, depending on the test, a large laboratory may be at least as likely to have furnished a test to a Medicare beneficiary compared to a small laboratory, we believe that an equipment item included in a recommendation that is commercially available to a small laboratory may not be the same equipment item that is used in the typical case. If the majority of services billed under the PFS for a particular CPT code are furnished by laboratories that run many of these tests each day, then assumptions informed by commercially available products may significantly underestimate the typical number of tests processed together, and thus the assumptions underlying current valuations for per-test cost of supplies and equipment may be much higher than the typical resources used in furnishing the service. We invite stakeholders to provide us with information about the equipment and supply inputs used in the typical case for particular pathology services.

(17) Vestibular Caloric Irrigation (CPT Codes 9254A and 9254B)

For CY 2016, the CPT Editorial Panel deleted CPT code 92543 (Assessment and recording of balance system during irrigation of both ears) and created two new CPT codes, 9254A and 9254B, to report caloric vestibular testing for bithermal and monothermal testing procedures, respectively. The RUC recommended a work RVU of 0.80 for CPT code 9254A and a work RVU of 0.55 for CPT code 9254B. We believe the recommendations for these services overstate the work involved in performing these procedures. Due to similarity in service and time, we believe a direct crosswalk of CPT code 97606 (Negative pressure wound therapy, surface area greater than 50 square centimeters, per session) to CPT code 9254A is appropriate. To value CPT code 9254B, we divided the proposed work RVU for 9254A in half since the code descriptor for this procedure describes the service as having two irrigations as opposed to the four involved in 9254A. Therefore, for CY 2016, we are proposing a work RVUs of 0.60 to 9254A and 0.30 to 9254B.

(18) Instrument-Based Ocular Screening (CPT Codes 99174 and 9917X)

For CY 2015, the CPT Editorial Panel created a new code, CPT code 9917X, to describe instrument-based ocular screening with on-site analysis and also revised existing CPT code 99174, which describes instrument-based ocular screening with remote analysis and report. Currently, CPT code 99174 is assigned a status indicator of N (non-covered service) which we believe should be maintained due to its nature as a screening service. After review of CPT code 9917X, we believe this service is also a screening service and should be assigned a status indicator of N (non-covered service). Therefore, for CY 2016, we are proposing to assign a PFS status indicator of N (non-covered service) for CPT codes 99174 and 9917X.

(19) Low-Dose Computer Tomography, Lung, Screening (GXXX1) and Lung Cancer Screening Counseling and Shared Decision Making Visit (GXXX2)

We have issued national coverage determination (NCD) for the coverage of a lung cancer screening counseling and shared decision making visit and, for appropriate beneficiaries, annual screening with low dose computed tomography (LDCT) as an additional preventive benefit. The American College of Radiology (ACR) submitted recommendations for work and direct PE inputs. The ACR recommended that we crosswalk GXXX1 to 71250 (computed tomography, thorax; without contrast material) with additional physician work added to account for the added intensity of the service. After reviewing this recommendation, we believe that the physician work (time and intensity) is identical in both GXXX1 and 71250, and therefore, we are proposing a work RVU of 1.02 for GXXX1.

We are proposing to value the lung cancer screening counseling and shared decision making visit (GXXX2) using a crosswalk from the work value for G0443 (Brief face-to-face counseling for alcohol misuse, 15 minutes) which has a work RVU of 0.45. We added 2 minutes of pre-service time, and 1 minute post-service time which we valued at 0.0224 RVU per minute yielding a total of 0.062 additional RVUs which we then added to 0.45, bringing the total proposed work RVUs for GXXX2 to 0.52. The direct PE input recommendations from the ACR were refined according to CMS standard refinements and appear in the CY 2016 proposed direct PE input database.

7. Direct PE Input-Only Recommendations

In CY 2014, we proposed to limit the nonfacility PE RVUs for individual codes so that the total nonfacility PFS payment amount would not exceed the total combined amount that Medicare would pay for the same code in the facility setting. In developing the proposal, we sought a reliable means for Medicare to set upper payment limits for office-based procedures given our several longstanding concerns regarding the accuracy of certain aspects of the direct PE inputs, including both items and procedure time assumptions, and prices of individual supplies and equipment (78 FR 74248 through 74250). After considering the many comments we received regarding our proposal, the majority of which urged us to withdraw the proposal for a variety of reasons, we decided not to finalize the policy. However, we continue to believe that using practice expense data that are auditable, comprehensive, and regularly updated would contribute to the accuracy of practice expense calculations.

Subsequent to our decision not to finalize the proposal, the RUC forwarded direct PE input recommendations for a subset of codes with nonfacility PE RVUs that would have been limited by the policy. Some of these codes also include work values, but the RUC recommendations did not address the accuracy of those values.

We generally believe that combined reviews of work and PE for each code under the potentially misvalued codes initiative leads to more accurate and appropriate assignment of RVUs. We also believe, and have previously stated, that our standard process for evaluating potentially misvalued codes is unlikely to be the most effective means of addressing our concerns regarding the accuracy of some aspects of the direct PE inputs (79 FR 74248).

However, we also believe it is important to use the most accurate and up-to-date information available to us when developing PFS RVUs for individual services. Therefore, we have reviewed the RUC-recommended direct PE inputs for these services and are proposing to use them, with the refinements addressed in this section. However, we are also identifying these codes as potentially misvalued because their direct PE inputs were not reviewed alongside review of their work RVUs and time. We considered not addressing these recommendations until such time as comprehensive reviews could occur, but we recognized the public interest in using the updated recommendations regarding the PE inputs until such time as the work RVUs and time can be addressed. Therefore, we note that while we are proposing adjusted PE inputs for these services based on these recommendations, we would anticipate addressing any corresponding change to direct PE inputs once the work RVUs and time are addressed.

a. Repair of Nail Bed (CPT Code 11760)

This recommendation includes 22 minutes of clinical labor time assigned for “Assist physician in performing procedure.” Because CPT code 11760 has 33 minutes of work intraservice time, we believe that this clinical labor input was intended to be calculated at 67 percent of work time. However, the equipment times are also calculated based on the 22 minutes of intraservice time. We are seeking comment on whether or not it would be appropriate to include the full 33 minutes of work intraservice time for the equipment.

b. Submucosal Ablation of the Tongue Base (CPT Code 41530)

We did not review CPT code 41530 for direct PE inputs, because we noted that the RUC anticipates making recommendations regarding the work RVU and direct PE inputs for this service in the near future.

c. Cytopathology Fluids, Washings or Brushings (CPT Codes 88104, 88106, 88108)

We are proposing to update the Millipore filter supply (SL502) based on stakeholder submission of new information following the RUC's original recommendation. As requested, we are proposing to crosswalk the price of the Millipore filter to the cytology specimen filter (Transcyst) supply (SL041) and assign a value of $4.15. This change is reflected in the proposed direct PE input database.

d. Cytopathology Smears, Screening and Interpretation (CPT Codes 88160, 88161, 88162)

We are concerned that there is a lack of clarity and the possibility for confusion contained in the CPT descriptors of CPT codes 88160 and 88161. The CPT descriptor for the first code refers to the “screening and interpretation” of Cytopathology smears, while the descriptor for the second code refers to the “preparation, screening and interpretation” of Cytopathology smears. We believe that there is currently the potential for duplicative counting of direct PE inputs due to the overlapping nature of these two codes. We are concerned that the same procedure may be billed multiple times under both CPT code 88160 and 88161. We believe that these codes are potentially misvalued, and we are seeking a full review of this family of codes for both work and PE, given the potential for overlap. We recognize that the ideal solution may involve revisions by the CPT Editorial Panel.

With regard to the current direct PE input recommendations, we are proposing to remove the clinical labor minutes recommended for “Stain air dried slides with modified Wright stain” for CPT code 88160 since staining slides would not be a typical clinical labor task if there is no slide preparation taking place, as the descriptor for this code suggests.

We are proposing to update the protease solution supply (SL506) based on stakeholder submission of new information following the RUC's original recommendation. As requested, we are proposing to change the name of the supply to “Protease”, alter the unit of measurement from milliliters to milligrams, change the quantity assigned to CPT code 88182 from 1 to 1.12, and update the price from $0.47 to $0.4267. These changes are reflected in the proposed direct PE input database.

We are requesting additional information regarding the use of the desktop computer with monitor (ED021) for CPT code 88182. We have made no change to the current equipment time value pending the submission of additional information.

e. Flow Cytometry, Cytoplasmic Cell Surface (CPT Code 88184, 88185)

We are requesting additional information regarding the specific use of the desktop computer with monitor (ED021) for CPT codes 88184 and 88185 since the recommendation does not specify how it is used.

f. Consultation on Referred Slides and Materials (CPT Codes 88321, 88323, 88325)

We are proposing to remove the clinical labor time for “Accession specimen/prepare for examination” for CPT codes 88321 and 88325. These codes do not involve the preparation of slides, so this clinical labor task is duplicative with the labor carried out under “Open shipping package, remove and sort slides based on outside number.” We are proposing to maintain the recommended 4 minutes for this clinical labor task for CPT code 88323, since it does require slide preparation.

We are proposing to refine the clinical labor time for “Register the patient in the information system, including all demographic and billing information” from 13 minutes to 5 minutes for all three codes. As indicated in Table 6, our proposed standard clinical labor time for entering patient data is 4 minutes for pathology codes, and we believe that the extra tasks involving label preparation described in this clinical labor task would typically require an additional 1 minute to complete. We also believe that the additional recommended time likely reflects administrative tasks that are appropriately accounted for in the indirect PE methodology.

We are proposing to refine the clinical labor time from 7 minutes to 5 minutes for the new task “Receive phone call from referring laboratory/facility with scheduled procedure to arrange special delivery of specimen procurement kit, including muscle biopsy clamp as needed. Review with sender instructions for preservation of specimen integrity and return arrangements. Contact courier and arrange delivery to referring laboratory/facility.” Based on the description of this task, we believe that this task would typically take 5 minutes to be performed by the Lab Technician.

We are proposing to remove the eosin solution supply (SL063) from CPT code 88323. We do not agree that this supply would be typically used in this procedure, and the eosin solution is redundant when used together with the hematoxylin stain supply (SL135). We are also refining the quantity of the hematoxylin stain from 32 to 8 for CPT code 88323, to be consistent with its use in other related Pathology codes.

We are proposing to remove many of the inputs for clinical labor, supplies, and equipment for CPT code 88325. The descriptor for this code indicates that it does not involve slide preparation, and therefore we are proposing labor, supplies, and equipment inputs to match the inputs recommended for CPT code 88321, which also does not include the preparation of slides.

g. Morphometric Analysis, Tumor Immunohistochemistry (CPT Codes 88360, 88361)

We are proposing to update the pricing for the Benchmark ULTRA automated slide preparation system (EP112) and the E-Bar II Barcode Slide Label System (EP113). Based on stakeholder submission of information subsequent to the original RUC recommendation, we are reclassifying these two pieces of equipment as a single item with a price of $150,000. CPT codes 88360 and 88361 have been valued using this new price. The equipment time values remain unchanged.

The RUC recommendation for CPT codes 88360 and 88361 included an invoice for the Antibody Estrogen Receptor monoclonal supply (SL493). The submitted invoice has a price of $694.70 per box of 50, or $13.89 per test. We sought publically available information regarding this supply and identified numerous monoclonal antibody estrogen receptors that appear to be consistent with those recommended by the specialty society, at publicly available lower prices, which we believe are more likely to be typical since we assume that the typical practitioner would seek the best price available to the public. One example is Estrogen Receptor Antibody (h-151) [DyLight 405], priced at 100 tests per box for $319. Therefore, we are proposing to establish a new supply code for “Antibody Estrogen Receptor monoclonal” and price that item at $3.19 each. We welcome comments from stakeholders regarding this supply item.

h. Nerve Teasing Preparations (CPT Code 88362)

We are proposing to refine the recommended clinical labor time for “Assist pathologist with gross specimen examination including the following; Selection of fresh unfixed tissue sample; selection of tissue for formulant fixation for paraffin blocking and epon blocking. Reserve some specimen for additional analysis” from 10 minutes to 5 minutes. We note that the 5 minutes includes 3 minutes for assisting the pathologist with the gross specimen examination (as listed in Table 6) and an additional 2 minutes for the additional tasks due to the work taking place on a fresh specimen.

i. Nasopharyngoscopy With Endoscope (CPT Code 92511)

We are proposing to remove the endosheath (SD070) from this procedure, because we do not believe it would be typically used and it was not included in the recommendations for any of the other related codes in the same tab. If the endosheath were included as a supply with the presentation of additional clinical information, then we believe it would be appropriate to remove all of the clinical labor and equipment time currently assigned to cleaning the scope.

j. Needle Electromyography (CPT Codes 95863, 95864, 95869, 95870)

We are proposing to reduce the quantity of the iontophoresis electrode kit (SA014) supply from 4 to 3. According to the description of this code, the procedure typically uses 2-4 electrodes, and therefore we believe that a supply quantity of 3 would better reflect the typical case. We are requesting further information regarding the typical number of electrodes used in this procedure; if the maximum of 4 electrodes is in fact typical for the procedure, then we recommend that the code descriptor be referred to CPT for further clarification.

J. Medicare Telehealth Services

1. Billing and Payment for Telehealth Services

Several conditions must be met for Medicare to make payments for telehealth services under the PFS. The service must be on the list of Medicare telehealth services and meet all of the following additional requirements:

  • The service must be furnished via an interactive telecommunications system.
  • The service must be furnished by a physician or authorized practitioner.
  • The service must be furnished to an eligible telehealth individual.
  • The individual receiving the service must be located in a telehealth originating site.

When all of these conditions are met, Medicare pays a facility fee to the originating site and makes a separate payment to the distant site practitioner furnishing the service.

Section 1834(m)(4)(F)(i) of the Act defines Medicare telehealth services to include consultations, office visits, office psychiatry services, and any additional service specified by the Secretary, when furnished via a telecommunications system. We first implemented this statutory provision, which was effective October 1, 2001, in the CY 2002 PFS final rule with comment period (66 FR 55246). We established a process for annual updates to the list of Medicare telehealth services as required by section 1834(m)(4)(F)(ii) of the Act in the CY 2003 PFS final rule with comment period (67 FR 79988).

As specified at § 410.78(b), we generally require that a telehealth service be furnished via an interactive telecommunications system. Under § 410.78(a)(3), an interactive telecommunications system is defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.

Telephones, facsimile machines, and stand-alone electronic mail systems that are not integrated into an electronic health record system do not meet the definition of an interactive telecommunications system. An interactive telecommunications system is generally required as a condition of payment; however, section 1834(m)(1) of the Act allows the use of asynchronous “store-and-forward” technology when the originating site is part of a federal telemedicine demonstration program in Alaska or Hawaii. As specified in § 410.78(a)(1), asynchronous store-and-forward is the transmission of medical information from an originating site for review by the distant site physician or practitioner at a later time.

Medicare telehealth services may be furnished to an eligible telehealth individual notwithstanding the fact that the practitioner furnishing the telehealth service is not at the same location as the beneficiary. An eligible telehealth individual is an individual enrolled under Part B who receives a telehealth service furnished at an originating site.

Practitioners furnishing Medicare telehealth services are reminded that these services are subject to the same non-discrimination laws as other services, including the effective communication requirements for persons with disabilities of section 504 of the Rehabilitation Act and language access for persons with limited English proficiency, as required under Title VI of the Civil Rights Act of 1964. For more information, see http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication.

Practitioners furnishing Medicare telehealth services submit claims for telehealth services to the Medicare Administrative Contractors that process claims for the service area where their distant site is located. Section 1834(m)(2)(A) of the Act requires that a practitioner who furnishes a telehealth service to an eligible telehealth individual be paid an amount equal to the amount that the practitioner would have been paid if the service had been furnished without the use of a telecommunications system.

Originating sites, which can be one of several types of sites specified in the statute where an eligible telehealth individual is located at the time the service is being furnished via a telecommunications system, are paid a fee under the PFS a facility fee for each Medicare telehealth service. The statute specifies both the types of entities that can serve as originating sites and the geographic qualifications for originating sites. With regard to geographic qualifications, § 410.78(b)(4) limits originating sites to those located in rural health professional shortage areas (HPSAs) or in a county that is not included in a metropolitan statistical areas (MSAs).

Historically, we have defined rural HPSAs to be those located outside of MSAs. Effective January 1, 2014, we modified the regulations regarding originating sites to define rural HPSAs as those located in rural census tracts as determined by the Office of Rural Health Policy (ORHP) of the Health Resources and Services Administration (HRSA) (78 FR 74811). Defining “rural” to include geographic areas located in rural census tracts within MSAs allows for broader inclusion of sites within HPSAs as telehealth originating sites. Adopting the more precise definition of “rural” for this purpose expands access to health care services for Medicare beneficiaries located in rural areas. HRSA has developed a Web site tool to provide assistance to potential originating sites to determine their geographic status. To access this tool, see the CMS Web site at www.cms.gov/teleheath/.

An entity participating in a federal telemedicine demonstration project that has been approved by, or received funding from, the Secretary as of December 31, 2000 is eligible to be an originating site regardless of its geographic location.

Effective January 1, 2014, we also changed our policy so that geographic status for an originating site would be established and maintained on an annual basis, consistent with other telehealth payment policies (78 FR 74400). Geographic status for Medicare telehealth originating sites for each calendar year is now based upon the status of the area as of December 31 of the prior calendar year.

For a detailed history of telehealth payment policy, see 78 FR 74399.

2. Adding Services to the List of Medicare Telehealth Services

As noted previously, in the December 31, 2002 Federal Register (67 FR 79988), we established a process for adding services to or deleting services from the list of Medicare telehealth services. This process provides the public with an ongoing opportunity to submit requests for adding services. Under this process, we assign any qualifying request to make additions to the list of telehealth services to one of two categories. Revisions to criteria that we use to review requests in the second category were finalized in the November 28, 2011 Federal Register (76 FR 73102). The two categories are:

  • Category 1: Services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the list of telehealth services. In reviewing these requests, we look for similarities between the requested and existing telehealth services for the roles of, and interactions among, the beneficiary, the physician (or other practitioner) at the distant site and, if necessary, the telepresenter, a practitioner who is present with the beneficiary in the originating site. We also look for similarities in the telecommunications system used to deliver the proposed service; for example, the use of interactive audio and video equipment.
  • Category 2: Services that are not similar to the current list of telehealth services. Our review of these requests includes an assessment of whether the service is accurately described by the corresponding code when furnished via telehealth and whether the use of a telecommunications system to deliver the service produces demonstrated clinical benefit to the patient. In reviewing these requests, we look for evidence indicating that the use of a telecommunications system in furnishing the candidate telehealth service produces clinical benefit to the patient. Submitted evidence should include both a description of relevant clinical studies that demonstrate the service furnished by telehealth to a Medicare beneficiary improves the diagnosis or treatment of an illness or injury or improves the functioning of a malformed body part, including dates and findings, and a list and copies of published peer reviewed articles relevant to the service when furnished via telehealth. Our evidentiary standard of clinical benefit does not include minor or incidental benefits.

Some examples of clinical benefit include the following:

  • Ability to diagnose a medical condition in a patient population without access to clinically appropriate in-person diagnostic services.
  • Treatment option for a patient population without access to clinically appropriate in-person treatment options.
  • Reduced rate of complications.
  • Decreased rate of subsequent diagnostic or therapeutic interventions (for example, due to reduced rate of recurrence of the disease process).
  • Decreased number of future hospitalizations or physician visits.
  • More rapid beneficial resolution of the disease process treatment.
  • Decreased pain, bleeding, or other quantifiable symptom.
  • Reduced recovery time.

For the list of covered telehealth services, see the CMS Web site at www.cms.gov/teleheath/. Requests to add services to the list of Medicare telehealth services must be submitted and received no later than December 31 of each calendar year to be considered for the next rulemaking cycle. For example, qualifying requests submitted before the end of CY 2015 will be considered for the CY 2017 proposed rule. Each request to add a service to the list of Medicare telehealth services must include any supporting documentation the requester wishes us to consider as we review the request. Because we use the annual PFS rulemaking process as a vehicle for making changes to the list of Medicare telehealth services, requestors should be advised that any information submitted is subject to public disclosure for this purpose. For more information on submitting a request for an addition to the list of Medicare telehealth services, including where to mail these requests, see the CMS Web site at www.cms.gov/telehealth/.

3. Submitted Requests to the List of Telehealth Services for CY 2016

Under our existing policy, we add services to the telehealth list on a category 1 basis when we determine that they are similar to services on the existing telehealth list with respect to the roles of, and interactions among, the beneficiary, physician (or other practitioner) at the distant site and, if necessary, the telepresenter. As we stated in the CY 2012 final rule with comment period (76 FR 73098), we believe that the category 1 criteria not only streamline our review process for publicly requested services that fall into this category, the criteria also expedite our ability to identify codes for the telehealth list that resemble those services already on this list.

a. Submitted Requests

We received several requests in CY 2014 to add various services as Medicare telehealth services effective for CY 2016. The following presents a discussion of these requests, and our proposals for additions to the CY 2016 telehealth list. Of the requests received, we find that the following services are sufficiently similar to psychiatric diagnostic procedures or office/outpatient visits currently on the telehealth list to qualify on a category one basis. Therefore, we propose to add the following services to the telehealth list on a category 1 basis for CY 2016:

  • CPT code 99356 (prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service); and 99357 (prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (list separately in addition to code for prolonged service).

The prolonged service codes can only be billed in conjunction with hospital inpatient and skilled nursing facility evaluation & management (E/M) codes, and of these, only subsequent hospital and subsequent nursing facility visit codes are on list of Medicare telehealth services. Therefore, CPT codes 99356 and 99357 would only be reportable with codes for which limits of one subsequent hospital visit every three days via telehealth, and one subsequent nursing facility visit every thirty days, would continue to apply.

  • CPT codes 90963 (end-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents); 90964 (end-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents); 90965 (end-stage renal disease (ESRD) related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents); and 90966 (end-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older).

Although these services are for home-based dialysis, and a patient's home is not an authorized originating site for telehealth, we recognize that many components of these services would be furnished from an authorized originating site and, therefore, can be furnished via telehealth.

The required clinical examination of the catheter access site must be furnished face-to-face “hands on” (without the use of an interactive telecommunications system) by a physician, certified nurse specialist (CNS), nurse practitioner (NP), or physician's assistant (PA). An interactive telecommunications system may be used for providing additional visits required under the 2 to 3 visit Monthly Capitation Payment (MCP) code and the 4 or more visit MCP code. See the final rule for CY 2005 (69 FR 66276) for further information on furnishing ESRD services via telehealth.

We also received requests to add services to the telehealth list that do not meet our criteria for Medicare telehealth services. We are not proposing to add the following procedures for the reasons noted:

  • All evaluation and management services, telerehabilitation services, and palliative care, pain management and patient navigation services for cancer patients.

None of these requests identified the specific codes that were being requested for addition as telehealth services, and two of the requests did not include evidence of any clinical benefit when the services are furnished via telehealth. Since we did not have information on the specific codes requested for addition or evidence of clinical benefit for these requests, we cannot evaluate whether the services are appropriate for addition to the Medicare telehealth services list.

  • CPT codes 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes); and 99292 (critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (list separately in addition to code for primary service).

We previously considered and rejected adding these codes to the list of Medicare telehealth services in the CY 2009 PFS final rule (74 FR 69744) on a category 1 basis because, due to the acuity of critically ill patients, we did not consider critical care services similar to any services on the current list of Medicare telehealth services. In that rule, we said that critical care services must be evaluated as category 2 services. Because we would consider critical care services under category 2, we needed to evaluate whether these are services for which telehealth can be an adequate substitute for a face-to-face encounter. We had no evidence suggesting that the use of telehealth could be a reasonable surrogate for the face-to-face delivery of this type of care.

The American Telemedicine Association (ATA) submitted a request, which cited several studies to support adding these services on a category 2 basis. To qualify under category 2, we would need evidence that the service produces a clinical benefit for the patient. However, in reviewing the information provided by the ATA and a study entitled, “Impact of an Intensive Care Unit Telemedicine Program on Patient Outcomes in an Integrated Health Care System,” published July 2014, in “JAMA Internal Medicine,” which found no evidence that the implementation of ICU TM significantly reduced mortality rates or hospital length of stay, we do not believe that the evidence demonstrates a clinical benefit to patients. Therefore, we are not proposing to add these services on a category 2 basis to the list of Medicare telehealth services for CY 2016.

  • CPT code 99358 (prolonged evaluation and management service before and/or after direct patient care; first hour) and 99359 (prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (list separately in addition to code for prolonged service).

As we indicated in the CY 2015 PFS final rule with comment period (79 FR 67600), these services are not separately payable by Medicare. It would be inappropriate to include a service as a telehealth service when Medicare does not otherwise make a separate payment for it. Therefore, we are not proposing to add these non-payable services to the list of Medicare telehealth services for CY 2016.

  • CPT code 99444 (online evaluation and management service provided by a physician or other qualified health care professional who may report an evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the internet or similar electronic communications network).

As we indicated in the CY 2014 PFS final rule with comment period (78 FR 74403), we assigned a status indicator of “N” (Noncovered service) to this service because: (1) this service is non-face-to-face; and (2) the code descriptor includes language that recognizes the provision of services to parties other than the beneficiary and for whom Medicare does not provide coverage (for example, a guardian). Under section 1834(m)(2)(A) of the Act, Medicare pays the physician or practitioner furnishing a telehealth service an amount equal to the amount that would have been paid if the service was furnished without the use of a telecommunications system. Because CPT code 99444 is currently noncovered, there would be no Medicare payment if this service was furnished without the use of a telecommunications system. Since this service is noncovered under Medicare, we are not proposing to add it to the list of Medicare telehealth services for CY 2016.

  • CPT code 99490 (chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored).

This service is one that can be furnished without the beneficiary's face-to-face presence, and using any number of non-face-to-face means of communication. Therefore, the service is not appropriate for consideration as a Medicare telehealth service. It is unnecessary to add this service to the list of Medicare telehealth services. Therefore, we are not proposing to add it to the list of Medicare telehealth services for CY 2016.

  • CPT codes 99605 (medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, new patient); 99606 (medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, established patient); and 99607 (medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; each additional 15 minutes (list separately in addition to code for primary service).

These codes are noncovered services for which no payment may be made under the PFS. Therefore, we are not proposing to add these services to the list of Medicare telehealth services for CY 2016.

In summary, we are proposing to add the following codes to the list of Medicare telehealth services beginning in CY 2016 on a category 1 basis: Prolonged service inpatient CPT codes 99356 and 99357 and ESRD-related services 90933 through 90936. As indicated above, the prolonged service codes can only be billed in conjunction with subsequent hospital and subsequent nursing facility codes. Limits of one subsequent hospital visit every three days, and one subsequent nursing facility visit every thirty days, would continue to apply when the services are furnished as telehealth services. For the ESRD related services, the required clinical examination of the catheter access site must be furnished face-to-face “hands on” (without the use of an interactive telecommunications system) by a physician, certified nurse specialist (CNS), nurse practitioner (NP), or physician's assistant (PA).

We remind all interested stakeholders that we are currently soliciting public requests to add services to the list of Medicare telehealth services. To be considered during PFS rulemaking for CY 2017, these requests must be submitted and received by December 31, 2015. Each request to add a service to the list of Medicare telehealth services must include any supporting documentation the requester wishes us to consider as we review the request. For more information on submitting a request for an addition to the list of Medicare telehealth services, including where to mail these requests, we refer readers to the CMS Web site at www.cms.gov/telehealth/.

4. Proposal To Amend § 410.78 To Include Certified Registered Nurse Anesthetists as Practitioners for Telehealth Services

Under section 1834(m)(1) of the Act, Medicare makes payment for telehealth services furnished by physicians and practitioners. Section 1834(m)(4)(E) of the Act specifies that, for purposes of furnishing Medicare telehealth services, the term “practitioner” has the meaning given that term in section 1842(b)(18)(C), which includes a certified registered nurse anesthetist (CRNA) as defined in section 1861 (bb)(2).

We initially omitted CRNAs from the list of distant site practitioners for telehealth services in the regulation because we did not believe these practitioners would furnish any of the service on the list of Medicare telehealth services. However, CRNAs in some states are licensed to furnish certain services on the telehealth list, including E/M services. Therefore, we propose to revise the regulation at § 410.78(b)(2) to include a CRNA, as described under § 410.69, to the list of distant site practitioners who can furnish Medicare telehealth services.

K. Incident to Proposals: Billing Physician as the Supervising Physician and Ancillary Personnel Requirements

1. Background

Section 1861(s)(2)(A) of the Act establishes the benefit category for services and supplies furnished as “incident to” the professional services of a physician. The statute specifies that services and supplies furnished as an incident to a physician's professional service (hereinafter “incident to services”) are “of kinds which are commonly furnished in physicians' offices and are commonly either rendered without charge or included in physicians' bills.” In addition to the requirements of the statute, § 410.26 sets forth specific requirements that must be met for physicians and other practitioners to bill Medicare for incident to services. Section 410.26(a)(7) limits incident to services to those included under section 1861(s)(2)(A) of the Act and that are not covered under another benefit category. Section 410.26(b) specifies (in part) that in order for services and supplies to be paid as incident to services under Medicare Part B, the services or supplies must be:

  • Furnished in a noninstitutional setting to noninstitutional patients.
  • An integral, though incidental, part of the service of a physician (or other practitioner) in the course of diagnosis or treatment of an injury or illness.
  • Furnished under direct supervision (as specified under § 410.26(a)(2)) of a physician or other practitioner eligible to bill and directly receive Medicare payment.
  • Furnished by a physician, a practitioner with an incident to benefit, or auxiliary personnel.

In addition to § 410.26, there are regulations specific to each type of practitioner who is allowed to bill for incident to services as specified in § 410.71(a)(2) (clinical psychologist services), § 410.74(b) (physician assistants' services), § 410.75(d) (nurse practitioners' services), § 410.76(d) (clinical nurse specialists' services), and § 410.77(c) (certified nurse-midwives' services). When referring to practitioners who can bill for services furnished incident to their professional services, we are referring to physicians and these practitioners.

Incident to services are treated as if they were furnished by the billing physician or other practitioner for purposes of Medicare billing and payment. Consistent with this terminology, in this discussion when referring to the physician or other practitioner furnishing the service, we are referring to the physician or other practitioner who is billing for the incident to service. When we refer to the “auxiliary personnel” or the person who provides the service, we are referring to an individual who is personally performing the service or some aspect of it as distinguished from the physician or other practitioner who bills for the incident to service.

Since we treat incident to services as services furnished by the billing physician or other practitioner for purposes of Medicare billing and payment, payment is made to the billing physician or other practitioner under the PFS, and all relevant Medicare rules apply including, but not limited to, requirements regarding medical necessity, documentation, and billing. Those practitioners who can bill Medicare for incident to services are paid at their applicable Medicare payment rate as if they personally furnished the service. For example, when incident to services are billed by a physician, they are paid at 100 percent of the fee schedule amount, and when the services are billed by a nurse practitioner or clinical nurse specialist, they are paid at 85 percent of the fee schedule amount. Payments are subject to the usual deductible and coinsurance amounts.

In the CY 2014 PFS final rule with comment period, we amended § 410.26 by adding a paragraph (b)(7) to require that, as a condition for Medicare Part B payment, all incident to services must be furnished in accordance with applicable state law. Additionally, we amended the definition of auxiliary personnel at § 410.26(a)(1) to require that the individual who provides the incident to services must meet any applicable requirements to provide such services (including licensure) imposed by the state in which the services are furnished. These requirements for compliance with applicable state laws apply to any individual providing incident to services as a means to protect the health and safety of Medicare beneficiaries in the delivery of health care services, and to provide the Medicare program with additional recourse for denying or recovering Part B payment for incident to services that are not furnished in compliance with state law (78 FR 74410). Revisions to § 410.26(a)(1) and (b)(7) were intended to clarify the longstanding payment policy of paying only for services that are furnished in compliance with any applicable state or federal requirements. The amended regulations also provide the Medicare program with additional recourse for denying or recovering Part B payment for incident to services that are not furnished in compliance with applicable requirements.

2. Billing Physician as the Supervising Physician

In addition to the CY 2014 revisions to the regulations for incident to services, we believe that additional requirements for incident to services should be explicitly and unambiguously stated in the regulations. As described in this proposed rule, incident to a physician's or other practitioner's professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician's or other practitioner's personal professional services in the course of diagnosis or treatment of an injury or illness (§ 410.26(b)(2)). Incident to services require direct supervision of the auxiliary personnel providing the service by the physician or other practitioner (§ 410.26(b)(5)).

We are proposing to revise the regulations specifying the requirements for which physicians or other practitioners can bill for incident to services. In the CY 2002 PFS final rule, in response to a comment seeking clarification regarding what physician billing number should be used on the claim form for an incident to service, at 66 FR 55267, we stated that when a claim is submitted to Medicare under the billing number of a physician or other practitioner for an `incident to' service, the physician or other practitioner is stating that he or she performed the service or directly supervised the auxiliary personnel performing the service. Accordingly, the Medicare billing number of the ordering physician or other practitioner should not be used if that person did not directly supervise the auxiliary personnel.

Section 410.26(b)(5) currently states that the physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) upon whose professional service the incident to service is based. To be certain that the incident to services furnished to a beneficiary are in fact an integral, although incidental, part of the physician's or other practitioner's personal professional service that is billed to Medicare, we believe that the physician or other practitioner who bills for the incident to service must also be the physician or other practitioner who directly supervises the service. It has been our position that billing practitioners should have a personal role in, and responsibility for, furnishing services for which they are billing and receiving payment as an incident to their own professional services. This is consistent with the requirements that all physicians and billing practitioners attest on each Medicare claim that he or she “personally furnished” the services for which he or she is billing. Without this requirement, there could be an insufficient nexus with the physician's or other practitioner's services being billed on a claim to Medicare as incident to services and the actual services being furnished to the Medicare beneficiary by the auxiliary personnel. Therefore, we are proposing to amend § 410.26(b)(5) to state that the physician or other practitioner who bills for incident to services must also be the physician or other practitioner who directly supervises the auxiliary personnel who provide the incident to services. Also, to further clarify the meaning of the proposed amendment to this regulation, we are proposing to remove the last sentence from § 410.26(b)(5) specifying that the physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) upon whose professional service the incident to service is based.

3. Auxiliary Personnel Who Have Been Excluded or Revoked From Medicare

As a condition of Medicare payment, auxiliary personnel who, under the direct supervision of a physician or other practitioner, provide incident to services to Medicare beneficiaries must comply with all applicable Federal and State laws. This includes not having been excluded from Medicare, Medicaid and all other federally funded health care programs by the Office of Inspector General. We are proposing to amend the regulation to explicitly prohibit auxiliary personnel from providing incident to services who have either been excluded from Medicare, Medicaid and all other federally funded health care programs by the Office of Inspector General or who have had their enrollment revoked for any reason. These excluded or revoked individuals are already prohibited from providing services to Medicare beneficiaries, so this proposed revision is an additional safeguard to ensure that these excluded or revoked individuals are not providing incident to services and supplies under the direct supervision of a physician or other authorized supervising practitioner. These proposed revisions to the incident to regulations will provide the Medicare program with additional recourse for denying or recovering Part B payment for incident to services and supplies that are not furnished in compliance with our program requirements.

4. Compliance and Oversight

We recognize that there are many ways in which compliance with these requirements could be consistently and fairly assured across the Medicare program. In considering implementation of these proposals, we wish to be mindful of the need to minimize or eliminate any practitioner administrative burden while at the same time ensuring that practitioners are not subjected to unnecessary audits or placed at risk of inadvertent non-compliance. Therefore, while we believe that the initial responsibility of compliance rests with the practitioner, we invite comments through this proposed rule about possible approaches we could take to improve our ability ensure that incident to services are provided to beneficiaries by qualified individuals in a manner consistent with Medicare statute and regulations. We invite commenters to consider the options we will consider, such as creating new categories of enrollment, implementing a mechanism for registration short of full enrollment, requiring the use of claim elements such as modifiers to identify the types of individuals providing services, or relying on post-payment audits, investigations and recoupments by CMS contractors such as Recovery Auditors or Program Integrity Contractors. We will consider these comments in the course of implementing the proposals we finalize in rulemaking for CY 2016, and further, if we decide in the future that additional regulations or guidance will be necessary to monitor compliance with these or other requirements surrounding incident to services.

L. Portable X-ray: Billing of the Transportation Fee

Portable X-ray suppliers receive a transportation fee for transporting portable X-ray equipment to the location where portable X-rays are taken. If more than one patient at the same location is X-rayed, the portable X-ray transportation fee is allocated among the patients. We have received feedback that some portable x-ray suppliers have been operating under the assumption that the prorated transportation payment when more than one patient is receiving portable X-ray services at the same location refers to only a subset of patients. The Medicare Claims Processing Manual (Pub. 100-4, Chapter 13, Section 90.3) currently states:

Carriers shall allow only a single transportation payment for each trip the portable X-ray supplier makes to a particular location. When more than one Medicare patient is X-rayed at the same location, e.g., a nursing home, prorate the single fee schedule transportation payment among all patients receiving the services. For example, if two patients at the same location receive X-rays, make one-half of the transportation payment for each.

In some jurisdictions, Medicare contractors have been allowing the portable X-ray transportation fee to be allocated only among Medicare Part B beneficiaries. In other jurisdictions, Medicare contractors have required the transportation fee to be allocated among all Medicare patients (Parts A and B). We believe it would be more appropriate to allocate the transportation fee among all patients who receive portable X-ray services in a single trip. Medicare should not pay for more than its share of the transportation costs for portable X-ray services.

We are proposing to revise the Medicare Claims Processing Manual (Pub. 100-4, Chapter 13, Section 90.3) to remove the word “Medicare” before “patient” in section 90.3. We are also proposing to clarify that this subregulatory guidance means that, when more than one patient is X-rayed at the same location, the single transportation payment under the PFS is to be prorated among all patients (Medicare Parts A and B, and non-Medicare) receiving portable X-ray services during that trip, regardless of their insurance status.

For example, for portable x-ray services furnished at a SNF, we believe that the transportation fee should be allocated among all patients receiving portable X-ray services at the same location in a single trip irrespective of whether the patient is in a Part A stay, a Part B patient, or not a Medicare beneficiary at all. If the patient is in a Part A SNF stay, payment for the allocated portion of the transportation fee (and the X-ray) would be the SNF's responsibility. For a privately insured patient, it would be the responsibility of that patient's insurer. For a Medicare Part B patient, payment would be made under Part B for the share of the transportation fee attributable to that patient. We welcome comments on this proposal to determine Medicare Part B's portion of the transportation payment by prorating the single fee among all patients.

M. Technical Correction: Waiver of Deductible for Anesthesia Services Furnished on the Same Date as a Planned Screening Colorectal Cancer Test

Section 1833(b)(1) of the Act waives the deductible for colorectal cancer screening tests regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as the screening test. To implement this statutory provision, we amended our regulation at § 410.160 to add to the list of services to which the deductible does not apply, beginning January 1, 2011, a surgical service furnished in connection with, as a result of, and in the same clinical encounter as a planned colorectal cancer screening test. A surgical service furnished in connection with, as a result of, and in the same clinical encounter as a colorectal cancer screening test means a surgical service furnished on the same date as a planned colorectal cancer screening test as described in § 410.37.

In the CY 2015 PFS final rule with comment period, we modified the regulatory definition of colorectal cancer screening test with regard to colonoscopies to include anesthesia services whether billed as part of the colonoscopy service or separately. (See § 410.37(a)(1)(iii) of our regulations). In the preamble to the final rule, we stated that the statutory waiver of deductible would apply to anesthesia services furnished in conjunction with a colorectal cancer screening test even when a polyp or other tissue is removed during a colonoscopy (79 FR 67731). We also indicated that practitioners should report anesthesia services with the PT modifier in such circumstances. The final policy was implemented for services furnished during CY 2015. While we modified the definition of colorectal cancer screening services in the regulation at § 410.37(a)(1)(iii) to include anesthesia furnished with a screening colonoscopy, we did not make a conforming change to our regulations to expressly reflect the inapplicability of the deductible to those anesthesia services.

To better reflect our policy in the regulations, we propose a technical correction to amend § 410.160(b)(8) to expressly recognize anesthesia services. Specifically, we propose to amend § 410.160(b)(8) to add “and beginning January 1, 2015, for an anesthesia service,” following the first use of the phrase “a surgical service” and to add “or anesthesia” following the word “surgical” each time it is used in the second sentence of § 410.160(b)(8). This amendment to our regulation will ensure that both surgical or anesthesia services furnished in connection with, as a result of, and in the same clinical encounter as a colorectal cancer screening test will be exempt from the deductible requirement when furnished on the same date as a planned colorectal cancer screening test as described in § 410.37.

III. Other Provisions of the Proposed Regulations Back to Top

A. Proposed Provisions associated with the Ambulance Fee Schedule

1. Overview of Ambulance Services

a. Ambulance Services

Under the ambulance fee schedule, the Medicare program pays for ambulance transportation services for Medicare beneficiaries when other means of transportation are contraindicated by the beneficiary's medical condition and all other coverage requirements are met. Ambulance services are classified into different levels of ground (including water) and air ambulance services based on the medically necessary treatment provided during transport.

These services include the following levels of service:

  • For Ground—

++ Basic Life Support (BLS) (emergency and non-emergency)

++ Advanced Life Support, Level 1 (ALS1) (emergency and non-emergency)

++ Advanced Life Support, Level 2 (ALS2)

++ Paramedic ALS Intercept (PI)

++ Specialty Care Transport (SCT)

  • For Air—

++ Fixed Wing Air Ambulance (FW)

++ Rotary Wing Air Ambulance (RW)

b. Statutory Coverage of Ambulance Services

Under sections 1834(l) and 1861(s)(7) of the Act, Medicare Part B (Supplemental Medical Insurance) covers and pays for ambulance services, to the extent prescribed in regulations, when the use of other methods of transportation would be contraindicated by the beneficiary's medical condition.

The House Ways and Means Committee and Senate Finance Committee Reports that accompanied the 1965 Social Security Amendments suggest that the Congress intended that—

  • The ambulance benefit cover transportation services only if other means of transportation are contraindicated by the beneficiary's medical condition; and
  • Only ambulance service to local facilities be covered unless necessary services are not available locally, in which case, transportation to the nearest facility furnishing those services is covered (H.R. Rep. No. 213, 89th Cong., 1st Sess. 37 and Rep. No. 404, 89th Cong., 1st Sess. Pt 1, 43 (1965)).

The reports indicate that transportation may also be provided from one hospital to another, to the beneficiary's home, or to an extended care facility.

c. Medicare Regulations for Ambulance Services

Our regulations relating to ambulance services are set forth at 42 CFR part 410, subpart B and 42 CFR part 414, subpart H. Section 410.10(i) lists ambulance services as one of the covered medical and other health services under Medicare Part B. Therefore, ambulance services are subject to basic conditions and limitations set forth at § 410.12 and to specific conditions and limitations included at § 410.40 and § 410.41. Part 414, subpart H, describes how payment is made for ambulance services covered by Medicare.

2. Ambulance Extender Provisions

a. Amendment to Section 1834(l)(13) of the Act

Section 146(a) of the MIPPA amended section 1834(l)(13)(A) of the Act to specify that, effective for ground ambulance services furnished on or after July 1, 2008 and before January 1, 2010, the ambulance fee schedule amounts for ground ambulance services shall be increased as follows:

  • For covered ground ambulance transports that originate in a rural area or in a rural census tract of a metropolitan statistical area, the fee schedule amounts shall be increased by 3 percent.
  • For covered ground ambulance transports that do not originate in a rural area or in a rural census tract of a metropolitan statistical area, the fee schedule amounts shall be increased by 2 percent.

The payment add-ons under section 1834(l)(13)(A) of the Act have been extended several times. Most recently, section 203(a) of the Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10, enacted on April 16, 2015) amended section 1834(l)(13)(A) of the Act to extend the payment add-ons through December 31, 2017. Thus, these payment add-ons apply to covered ground ambulance transports furnished before January 1, 2018. We are proposing to revise § 414.610(c)(1)(ii) to conform the regulations to this statutory requirement. (For a discussion of past legislation extending section 1834(l)(13) of the Act, please see the CY 2014 PFS final rule with comment period (78 FR 74438 through 74439)).

This statutory requirement is self-implementing. A plain reading of the statute requires only a ministerial application of the mandated rate increase, and does not require any substantive exercise of discretion on the part of the Secretary.

b. Amendment to Section 1834(l)(12) of the Act

Section 414(c) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Pub. L. 108-173, enacted on December 8, 2003) (MMA) added section 1834(l)(12) to the Act, which specified that, in the case of ground ambulance services furnished on or after July 1, 2004, and before January 1, 2010, for which transportation originates in a qualified rural area (as described in the statute), the Secretary shall provide for a percent increase in the base rate of the fee schedule for such transports. The statute requires this percent increase to be based on the Secretary's estimate of the average cost per trip for such services (not taking into account mileage) in the lowest quartile of all rural county populations as compared to the average cost per trip for such services (not taking into account mileage) in the highest quartile of rural county populations. Using the methodology specified in the July 1, 2004 interim final rule (69 FR 40288), we determined that this percent increase was equal to 22.6 percent. As required by the MMA, this payment increase was applied to ground ambulance transports that originated in a “qualified rural area,” that is, to transports that originated in a rural area included in those areas comprising the lowest 25th percentile of all rural populations arrayed by population density. For this purpose, rural areas included Goldsmith areas (a type of rural census tract). This rural bonus is sometimes referred to as the “Super Rural Bonus” and the qualified rural areas (also known as “super rural” areas) are identified during the claims adjudicative process via the use of a data field included in the CMS-supplied ZIP code file.

The Super Rural Bonus under section 1834(l)(12) of the Act has been extended several times. Most recently, section 203(b) of the Medicare Access and CHIP Reauthorization Act of 2015 amended section 1834(l)(12)(A) of the Act to extend this rural bonus through December 31, 2017. Therefore, we are continuing to apply the 22.6 percent rural bonus described above (in the same manner as in previous years) to ground ambulance services with dates of service before January 1, 2018 where transportation originates in a qualified rural area. Accordingly, we are proposing to revise § 414.610(c)(5)(ii) to conform the regulations to this statutory requirement. (For a discussion of past legislation extending section 1834(l)(12) of the Act, please see the CY 2014 PFS final rule with comment period (78 FR 74439 through 74440)).

This statutory provision is self-implementing. It requires an extension of this rural bonus (which was previously established by the Secretary) through December 31, 2017, and does not require any substantive exercise of discretion on the part of the Secretary.

3. Changes in Geographic Area Delineations for Ambulance Payment

a. Background

In the CY 2015 PFS final rule with comment period (79 FR 67744 through 67750) as amended by the correction issued December 31, 2014 (79 FR 78716 through 78719), we adopted, beginning in CY 2015, the revised OMB delineations as set forth in OMB's February 28, 2013 bulletin (No. 13-01) and the most recent modifications of the Rural-Urban Commuting Area (RUCA) codes for purposes of payment under the ambulance fee schedule. With respect to the updated RUCA codes, we designated any census tracts falling at or above RUCA level 4.0 as rural areas. In addition, we stated that none of the super rural areas would lose their status upon implementation of the revised OMB delineations and updated RUCA codes. After publication of the CY 2015 PFS final rule with comment period and the correction, we received feedback and comments from stakeholders expressing concerns about the implementation of the new geographic area delineations finalized in that rule (as corrected). In response to these concerns, we are clarifying our implementation of the revised OMB delineations and the updated RUCA codes in CY 2015, and reproposing the implementation of the revised OMB delineations and updated RUCA codes for CY 2016 and subsequent calendar years. We are requesting public comment on our proposals, as further discussed in section III A.3.b. of this proposed rule.

b. Provisions of the Proposed Rule

Under section 1834(l)(2)(C) of the Act, the Secretary is required to consider appropriate regional and operational differences in establishing the ambulance fee schedule. Historically, the Medicare ambulance fee schedule has used the same geographic area designations as the acute care hospital inpatient prospective payment system (IPPS) and other Medicare payment systems to take into account appropriate regional (urban and rural) differences. This use of consistent geographic standards for Medicare payment purposes provides for consistency across the Medicare program.

The geographic areas used under the ambulance fee schedule effective in CY 2007 were based on OMB standards published on December 27, 2000 (65 FR 82228 through 82238), Census 2000 data, and Census Bureau population estimates for 2007 and 2008 (OMB Bulletin No. 10-02). For a discussion of OMB's delineation of Core-Based Statistical Areas (CBSAs) and our implementation of the CBSA definitions under the ambulance fee schedule, we refer readers to the preamble of the CY 2007 Ambulance Fee Schedule proposed rule (71 FR 30358 through 30361) and the CY 2007 PFS final rule with comment period (71 FR 69712 through 69716). On February 28, 2013, OMB issued OMB Bulletin No. 13-01, which established revised delineations for Metropolitan Statistical Areas (MSAs), Micropolitan Statistical Areas, and Combined Statistical Areas, and provided guidance on the use of the delineations of these statistical areas. A copy of this bulletin may be obtained at http://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b-13-01.pdf. According to OMB, this bulletin provides the delineations of all Metropolitan Statistical Areas, Metropolitan Divisions, Micropolitan Statistical Areas, Combined Statistical Areas, and New England City and Town Areas in the United States and Puerto Rico based on the standards published on June 28, 2010, in the Federal Register (75 FR 37246-37252) and Census Bureau data. OMB defines an MSA as a CBSA associated with at least one urbanized area that has a population of at least 50,000, and a Micropolitan Statistical Area (referred to in this discussion as a Micropolitan Area) as a CBSA associated with at least one urban cluster that has a population of at least 10,000 but less than 50,000 (75 FR 37252). Counties that do not qualify for inclusion in a CBSA are deemed “Outside CBSAs.” We note that, when referencing the new OMB geographic boundaries of statistical areas, we are using the term “delineations” consistent with OMB's use of the term (75 FR 37249).

Although the revisions OMB published on February 28, 2013 were not as sweeping as the changes made when we adopted the CBSA geographic designations for CY 2007, the February 28, 2013 OMB bulletin did contain a number of significant changes. For example, there are new CBSAs, urban counties that became rural, rural counties that became urban, and existing CBSAs that were split apart. As we stated in the CY 2015 PFS final rule with comment period (79 FR 67745), we reviewed our findings and impacts relating to the new OMB delineations, and found no compelling reason to further delay implementation. We stated in the CY 2015 final rule with comment period, and we continue to believe, that it is important for the ambulance fee schedule to use the latest labor market area delineations available as soon as reasonably possible to maintain a more accurate and up-to-date payment system that reflects the reality of population shifts.

Additionally, in the FY 2015 IPPS final rule (79 FR 49952), we adopted OMB's revised delineations to identify urban areas and rural areas for purposes of the IPPS wage index. For the reasons discussed in this section above, we believe that it would be appropriate to adopt the same geographic area delineations for use under the ambulance fee schedule as are used under the IPPS and other Medicare payment systems. Thus, we are proposing to continue implementation of the new OMB delineations as described in the February 28, 2013 OMB Bulletin No. 13-01 for CY 2016 and subsequent CYs to more accurately identify urban and rural areas for ambulance fee schedule payment purposes. We continue to believe that the updated OMB delineations more realistically reflect rural and urban populations, and that the use of such delineations under the ambulance fee schedule would result in more accurate payment. Under the ambulance fee schedule, consistent with our current definitions of urban and rural areas (§ 414.605), in CY 2016 and subsequent CYs, MSAs would continue to be recognized as urban areas, while Micropolitan and other areas outside MSAs, and rural census tracts within MSAs (as discussed below in this section), would continue to be recognized as rural areas. We invite public comments on this proposal.

In addition to the OMB's statistical area delineations, the current geographic areas used in the ambulance fee schedule also are based on rural census tracts determined under the most recent version of the Goldsmith Modification. These rural census tracts within MSAs are considered rural areas under the ambulance fee schedule (see § 414.605). For certain rural add-on payments, section 1834(l) of the Act requires that we use the most recent version of the Goldsmith Modification to determine rural census tracts within MSAs. In the CY 2007 PFS final rule with comment period (71 FR 69714 through 69716), we adopted the most recent (at that time) version of the Goldsmith Modification, designated as RUCA codes. RUCA codes use urbanization, population density, and daily commuting data to categorize every census tract in the country. For a discussion about RUCA codes, we refer the reader to the CY 2007 PFS final rule with comment period (71 FR 69714 through 69716) and the CY 2015 PFS final rule with comment period (79 FR 67745 through 67746). As stated previously, on February 28, 2013, OMB issued OMB Bulletin No. 13-01, which established revised delineations for Metropolitan Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas, and provided guidance on the use of the delineations of these statistical areas. Several modifications of the RUCA codes were necessary to take into account updated commuting data and the revised OMB delineations. We refer readers to the U.S. Department of Agriculture's Economic Research Service Web site for a detailed listing of updated RUCA codes found at http://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx. The updated RUCA code definitions were introduced in late 2013 and are based on data from the 2010 decennial census and the 2006-2010 American Community Survey. Information regarding the American Community Survey can be found at http://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx. We believe that the most recent RUCA codes provide more accurate and up-to-date information regarding the rurality of census tracts throughout the country. Accordingly, we are proposing to continue to use the most recent modifications of the RUCA codes for CY 2016 and subsequent CYs, to recognize levels of rurality in census tracts located in every county across the nation, for purposes of payment under the ambulance fee schedule. If we continue to use the most recent RUCA codes, many counties that are designated as urban at the county level based on population would continue to have rural census tracts within them that would be recognized as rural areas through our use of RUCA codes.

As we stated in the CY 2015 PFS final rule with comment period (79 FR 67745), the 2010 Primary RUCA codes are as follows:

(1) Metropolitan area core: primary flow with an urbanized area (UA).

(2) Metropolitan area high commuting: primary flow 30 percent or more to a UA.

(3) Metropolitan area low commuting: primary flow 10 to 30 percent to a UA.

(4) Micropolitan area core: primary flow within an Urban Cluster of 10,000 to 49,999 (large UC).

(5) Micropolitan high commuting: primary flow 30 percent or more to a large UC.

(6) Micropolitan low commuting: primary flow 10 to 30 percent to a large UC.

(7) Small town core: primary flow within an Urban Cluster of 2,500 to 9,999 (small UC).

(8) Small town high commuting: primary flow 30 percent or more to a small UC.

(9) Small town low commuting: primary flow 10 to 30 percent to a small UC.

(10) Rural areas: primary flow to a tract outside a UA or UC.

Based on this classification, and consistent with our current policy as set forth in the CY 2015 PFS final rule with comment period (79 FR 67745), we are proposing to continue to designate any census tracts falling at or above RUCA level 4.0 as rural areas for purposes of payment for ambulance services under the ambulance fee schedule. As discussed in the CY 2007 PFS final rule with comment period (71 FR 69715) and the CY 2015 PFS final rule with comment period (79 FR 67745), the Office of Rural Health Policy within the Health Resources and Services Administration (HRSA) determines eligibility for its rural grant programs through the use of the RUCA code methodology. Under this methodology, HRSA designates any census tract that falls in RUCA level 4.0 or higher as a rural census tract. In addition to designating any census tracts falling at or above RUCA level 4.0 as rural areas, under the updated RUCA code definitions, HRSA has also designated as rural census tracts those census tracts with RUCA codes 2 or 3 that are at least 400 square miles in area with a population density of no more than 35 people. We refer readers to HRSA's Web site at ftp://ftp.hrsa.gov/ruralhealth/Eligibility2005.pdf for additional information. Consistent with the HRSA guidelines discussed above and the policy we adopted in the CY 2015 PFS final rule with comment period (79 FR 67750), we are proposing for CY 2016 and subsequent CYs, to designate as rural areas those census tracts that fall at or above RUCA level 4.0. We continue to believe that this HRSA guideline accurately identifies rural census tracts throughout the country, and thus would be appropriate to apply for ambulance fee schedule payment purposes.

Also, consistent with the policy we finalized in the CY 2015 PFS final rule with comment period (79 FR 67749), we would not designate as rural areas those census tracts that fall in RUCA levels 2 or 3 that are at least 400 square miles in area with a population density of no more than 35 people. We have determined that it is not feasible to implement this guideline due to the complexities of identifying these areas at the ZIP code level. We do not have sufficient information available to identify the ZIP codes that fall in these specific census tracts. Also, payment under the ambulance fee schedule is based on the ZIP codes; therefore, if the ZIP code is predominantly metropolitan but has some rural census tracts, we do not split the ZIP code areas to distinguish further granularity to provide different payments within the same ZIP code. We believe that payment for all ambulance transportation services at the ZIP code level provides for a more consistent and administratively feasible payment system. For example, if we were to pay based on ZIP codes for some areas and counties or census tracts for other areas, there are circumstances where ZIP codes cross county or census tract borders and where counties or census tracts cross ZIP code borders. Such overlaps in geographic designations would complicate our ability to appropriately assign ambulance transportation services to geographic areas for payment under the ambulance fee schedule. Therefore, under the ambulance fee schedule, we would not designate as rural areas those census tracts that fall in RUCA levels 2 or 3 that are at least 400 square miles in area with a population density of no more than 35 people.

We invite public comments on our proposals, as discussed in this proposed rule, to continue to use the updated RUCA codes under the ambulance fee schedule for CY 2016 and subsequent CYs.

As we stated in the CY 2015 PFS proposed rule (79 FR 40374), the adoption of the most current OMB delineations and the updated RUCA codes would affect whether certain areas are recognized as rural or urban. The distinction between urban and rural is important for ambulance payment purposes because urban and rural transports are paid differently. The determination of whether a transport is urban or rural is based on the point of pick-up for the transport; thus, a transport is paid differently depending on whether the point of pick-up is in an urban or a rural area. During claims processing, a geographic designation of urban, rural, or super rural is assigned to each claim for an ambulance transport based on the point of pick-up ZIP code that is indicated on the claim.

The continued implementation of the revised OMB delineations and the updated RUCA codes would continue to affect whether or not transports would be eligible for rural adjustments under the ambulance fee schedule statute and regulations. For ground ambulance transports where the point of pick-up is in a rural area, the mileage rate is increased by 50 percent for each of the first 17 miles (§ 414.610(c)(5)(i)). For air ambulance services where the point of pick-up is in a rural area, the total payment (base rate and mileage rate) is increased by 50 percent (§ 414.610(c)(5)(i)).

Section 1834(l)(12) of the Act (as amended most recently by section 203(b) of the Medicare Access and CHIP Reauthorization Act of 2015) specifies that, for services furnished during the period July 1, 2004 through December 31, 2017, the payment amount for the ground ambulance base rate is increased by a “percent increase” (Super Rural Bonus) where the ambulance transport originates in a “qualified rural area,” which is a rural area that we determine to be in the lowest 25th percentile of all rural populations arrayed by population density (also known as a “super rural area”). We implement this Super Rural Bonus in § 414.610(c)(5)(ii). As discussed in section III.A.2.b. of this proposed rule, we are proposing to revise § 414.610(c)(5)(ii) to conform the regulations to this statutory requirement. As we stated in the CY 2015 PFS proposed rule (79 FR 40374) and final rule with comment period (79 FR 67746), adoption of the revised OMB delineations and the updated RUCA codes would have no negative impact on ambulance transports in super rural areas, as none of the current super rural areas would lose their status due to the revised OMB delineations and the updated RUCA codes. Furthermore, under section 1834(l)(13) of the Act (as amended most recently by section 203(a) of the Medicare Access and CHIP Reauthorization Act of 2015), for ground ambulance transports furnished through December 31, 2017, transports originating in rural areas are paid based on a rate (both base rate and mileage rate) that is 3 percent higher than otherwise is applicable. (See also § 414.610(c)(1)(ii)). As discussed in section III.A.2.a. of this