Skip to Content

Proposed Rule

Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2002

Document Details

Information about this document as published in the Federal Register.

Published Document

This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

Start Preamble Start Printed Page 40372

AGENCY:

Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION:

Proposed rule.

SUMMARY:

This proposed rule would refine the resource-based practice expense relative value units and make several changes to Medicare Part B payment. The policy changes concern services and supplies incident to a physician's professional service; anesthesia base unit variations; recognition of CPT tracking codes; and nurse practitioners, physician assistants, and clinical nurse specialists performing screening sigmoidoscopies. We are proposing these refinements and changes to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. We are soliciting comments on the proposed policy changes as well as comments on the payment policy for CPT modifier 62 that is used to report the work of co-surgeons.

The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 modernizes the mammography screening benefit and authorizes payment under the physician fee schedule effective January 1, 2002; provides for biennial screening pelvic examinations for certain beneficiaries effective July 1, 2001; provides for annual glaucoma screenings for high-risk beneficiaries effective January 1, 2002; expands coverage for screening colonoscopies to all beneficiaries effective July 1, 2001; establishes coverage for medical nutrition therapy services for certain beneficiaries effective January 1, 2002; expands payment for telehealth services effective October 1, 2001; requires certain Indian Health Service providers to be paid for some services under the physician fee schedule effective July 1, 2001; and revises the payment for certain physician pathology services effective January 1, 2001. This proposed rule would conform our regulations to reflect the statutory provisions.

DATES:

We will consider comments if we receive them at the appropriate address, as provided below, no later than 5 p.m. on October 1, 2001.

ADDRESSES:

Mail written comments (1 original and 3 copies) to the following address:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1169-P, P.O. Box 8013, Baltimore, MD 21244-8013.

To insure that mailed comments are received in time for us to consider them, please allow for possible delays in delivering them. If you prefer, you may deliver your written comments (1 original and 3 copies) to one of the following addresses: Room C5-14-03, 7500 Security Boulevard, Baltimore, MD 21244-8013.

Comments mailed to the above addresses may be delayed and received too late for us to consider them.

Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. In commenting, please refer to file code CMS-1169-P.

For information on viewing public comments, please see the beginning of the Supplementary Information section.

Start Further Info

FOR FURTHER INFORMATION CONTACT:

Carolyn Mullen, (410) 786-4589 or Marc Hartstein, (410) 786-4539 (for issues related to resource-based practice expense relative value units).

Carlos Cano, (410) 786-0245 (for issues related to screenings for sigmoidoscopies).

Paul W. Kim, (410) 786-7410 (for issues related to incident to services).

Rick Ensor, (410) 786-5617 (for issues related to mammography screenings).

Bill Larson, (410) 786-4639 (for issues related to screening pelvic examinations, screenings for glaucoma, and coverage for screening colonoscopies).

Bob Ulikowski, (410) 786-5721 (for issues related to the payment for screening colonoscopies).

Mary Stojak, (410) 786-6939 (for issues related to medical nutrition therapy).

Joan Mitchell, (410) 786-4508 (for issues related to the payment for medical nutrition therapy).

Craig Dobyski, (410) 786-4584 (for issues related to telehealth).

Terri Harris, (410) 786-6830 (for issues related to Indian Health Service providers).

Jim Menas, (410) 786-4507 (for issues related to anesthesia and pathology services).

Diane Milstead, (410) 786-3355 (for all other issues).

End Further Info End Preamble Start Supplemental Information

SUPPLEMENTARY INFORMATION:

Inspection of Public Comments: Comments received timely will be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at 7500 Security Blvd, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 5 p.m. Please call (410) 786-7197 to make an appointment to view the public comments.

Copies: To order copies of the Federal Register containing this document, send your request to: New Orders, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date of the issue requested and enclose a check or money order payable to the Superintendent of Documents, or enclose your Visa or Master Card number and expiration date. Credit card orders can also be placed by calling the order desk at (202) 512-1800 or by faxing to (202) 512-2250. The cost for each copy is $9. As an alternative, you can view and photocopy the Federal Register document at most libraries designated as Federal Depository Libraries and at many other public and academic libraries throughout the country that receive the Federal Register.

This Federal Register document is also available from the Federal Register online database through GPO Access, a service of the U.S. Government Printing Office. The Website address is: http://www.access.gpo.gov/​nara/​index.html.

Information on the physician fee schedule can be found on our homepage. You can access this data by using the following directions:

1. Go to the CMS homepage (http://www.cms.hhs.gov).

2. Click on “Medicare.”

3. Click on “Professional/Technical Information.”

4. Select Medicare Payment Systems.

5. Select Physician Fee Schedule.

Or, you can go directly to the Physician Fee Schedule page by typing the following: http://www.cms.hhs.gov/​medicare/​pfsmain.htm.

To assist readers in referencing sections contained in this preamble, we are providing the following table of contents. Some of the issues discussed in this preamble affect the payment policies but do not require changes to the regulations in the Code of Federal Regulations. Information on the regulation's impact appears throughout the preamble and is not exclusively in section VI.

Table of Contents

I. Background Start Printed Page 40373

A. Legislative History

B. Published Changes to the Fee Schedule

II. Specific Proposals for Calendar Year 2002

A. Resource-Based Practice Expense Relative Value Units

B. Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists Performing Screening Sigmoidoscopies

C. Services and Supplies Incident to a Physician's Professional Services: Conditions

D. Anesthesia Services

E. Performance Measurement and Emerging Technology Codes

F. Payment Policy for CPT Modifier 62 (Co-Surgery)

III. Implementation of Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000

A. Screening Mammography

B. Screening Pelvic Examinations

C. Screening for Glaucoma

D. Screening Colonoscopy

E. Medical Nutrition Therapy

F. Telehealth Services

G. Indian Health Service

H. Pathology Services

IV. Collection of Information Requirements

V.Response to Comments

VI. Regulatory Impact Analysis

Addendum A—Explanation and Use of Addendum B

Addendum B—2002 Relative Value Units and Related Information Used in Determining Medicare Payments for 2002

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:

AMA American Medical Association

BBA Balanced Budget Act of 1997

BBRA Balanced Budget Refinement Act of 1999

CF Conversion factor

CFR Code of Federal Regulations

CPT [Physicians'] Current Procedural Terminology [4th Edition, 1997, copyrighted by the American Medical Association]

CPEP Clinical Practice Expert Panel

CRNA Certified Registered Nurse Anesthetist

E/M Evaluation and management

EB Electrical bioimpedance

FMR Fair market rental

GAF Geographic adjustment factor

GPCI Geographic practice cost index

CMS Centers for Medicare & Medicaid Services

HCPCS Healthcare Common Procedure Coding System

HHA Home health agency

HHS [Department of] Health and Human Services

IDTFs Independent Diagnostic Testing Facilities

MCM Medicare Carrier Manual

MedPAC Medicare Payment Advisory Commission

MEI Medicare Economic Index

MGMA Medical Group Management Association

MSA Metropolitan Statistical Area

NAMCS National Ambulatory Medical Care Survey

PC Professional component

PEAC Practice Expense Advisory Committee

PPAC Practicing Physicians Advisory Council

PPS Prospective payment system

RUC [AMA's Specialty Society] Relative [Value] Update Committee

RVU Relative value unit

SGR Sustainable growth rate

SMS [AMA's] Socioeconomic Monitoring System

TC Technical component

I. Background

A. Legislative History

Since January 1, 1992, Medicare has paid for physicians' services under section 1848 of the Social Security Act (the Act), “Payment for Physicians” Services.” This section provides for three major elements: (1) A fee schedule for the payment of physicians' services; (2) a sustainable growth rate for the rates of increase in Medicare expenditures for physicians' services; and (3) limits on the amounts that nonparticipating physicians can charge beneficiaries. The Act requires that payments under the fee schedule be based on national uniform relative value units (RVUs) based on the resources used in furnishing a service. Section 1848(c) of the Act requires that national RVUs be established for physician work, practice expense, and malpractice expense. Section 1848(c)(2)(B)(ii)(II) of the Act provides that adjustments in RVUs may not cause total physician fee schedule payments to differ by more than $20 million from what they would have been had the adjustments not been made. If adjustments to RVUs cause expenditures to change by more than $20 million, we must make adjustments to preserve budget neutrality.

B. Published Changes to the Fee Schedule

In the July 2000 proposed rule (65 FR 44177), we listed all of the final rules published through November 1999, relating to the updates to the RVUs and revisions to payment policies under the physician fee schedule.

In the November 2000 final rule with comment period (65 FR 65376), we revised the policy for resource-based practice expense relative value units (RVUs); the geographic practice cost indices; resource-based malpractice RVUs; critical care RVUs; care plan oversight, physician certification and recertification for home health services; observation care codes; ocular photodynamic therapy and other ophthalmologic treatments; electrical bioimpedance; antigen supply, and the implantation of ventricular assist devices. This rule also addressed the comments received on the May 3, 2000 interim final rule (65 FR 25664) on the supplemental survey criteria and made modifications to the criteria for data submitted in 2001. Based on public comments, we withdrew our proposals related to the global period for insertion, removal, and replacement of pacemakers and cardioverter defibrillators, and to the removal of RVUs for low intensity ultrasound. The November 2000 final rule also discussed or clarified the payment policy for incomplete medical direction, pulse oximetry services, outpatient therapy supervision, outpatient therapy caps, HCPCS “G” Codes, and the second 5-year refinement of work RVUs for services furnished beginning January 1, 2002. In addition, we finalized the calendar year (CY) 2000 interim physician work RVUs and issued interim RVUs for new and revised codes for CY 2001. We made these changes to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. This final rule also announced the CY 2001 Medicare physician fee schedule conversion factor under the Medicare Supplementary Medical Insurance (Part B) program as required by section 1848(d) of the Act. The 2001 Medicare physician fee schedule conversion factor was $38.2581.

II. Specific Proposals for Calendar Year 2002

This proposed rule would affect the regulations set forth at Part 405, Federal health insurance for the aged and disabled, Part 410, Supplementary medical insurance (SMI) benefits; Part 411, Exclusions from Medicare and limitations on Medicare payment; Part 414, Payment for Part B medical and other health services; and Part 415, Services furnished by physicians in providers, supervising physicians in teaching settings, and residents in certain settings.

A. Resource-Based Practice Expense Relative Value Units

1. Resource-Based Practice Expense Legislation

Section 121 of the Social Security Act Amendments of 1994 (Public Law 103-432), enacted on October 31, 1994, required us to develop a methodology for a resource-based system for determining practice expense RVUs for each physician's service beginning in Start Printed Page 403741998. In developing the methodology, we were to consider the staff, equipment, and supplies used in providing medical and surgical services in various settings. The legislation specifically required that, in implementing the new system of practice expense RVUs, we apply the same budget-neutrality provisions that we apply to other adjustments under the physician fee schedule.

Section 4505(a) of the BBA amended section 1848(c)(2)(ii) of the Act and delayed the effective date of the resource-based practice expense RVU system until January 1, 1999. In addition, section 4505(b) of the BBA provided for a 4-year transition period from charge-based practice expense RVUs to resource-based RVUs. The practice expense RVUs for CY 1999 were the product of 75 percent of charge-based RVUs and 25 percent of the resource-based RVUs. For CY 2000, the RVUs were 50 percent charge-based RVUs and 50 percent resource-based RVUs. For CY 2001, the RVUs are 25 percent charge-based and 75 percent resource-based. After CY 2001, the RVUs will be totally resource-based.

Section 4505(e) of the BBA amended section 1848(c)(2) of the Act by providing that 1998 practice expense RVUs be adjusted for certain services in anticipation of implementation of resource-based practice expenses beginning in 1999. As a result, the statute required us to increase practice expense RVUs for office visits. For other services in which practice expense RVUs exceeded 110 percent of the work RVUs and were furnished less than 75 percent of the time in an office setting, the statute required us to reduce the 1998 practice expense RVUs to a number equal to 110 percent of the work RVUs. This reduction did not apply to services that had proposed resource-based practice expense RVUs that increased from their 1997 practice expense RVUs as reflected in the June 18, 1997 proposed rule (62 FR 33196). The services affected and the final RVUs for 1998 were published in the October 1997 final rule (62 FR 59103).

Further legislation affecting resource-based practice expense RVUs was included in the Balanced Budget Refinement Act of 1999 (BBRA) (Public Law 106-113). Section 212 of the BBRA amended section 1848(c)(2)(ii) of the Act by directing us 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. These data would supplement the data we normally collect in determining the practice expense component of the physician fee schedule for payments in CY 2001 and CY 2002.

2. Current Methodology for Computing the Practice Expense Relative Value Unit System

Effective with services furnished on or after January 1, 1999, we established a new methodology for computing resource-based practice expense RVUs that used the two significant sources of actual practice expense data we have available—the Clinical Practice Expert Panel (CPEP) data and the American Medical Association's (AMA) Socioeconomic Monitoring System (SMS) data. The methodology was based on an assumption that current aggregate specialty practice costs are a reasonable way to establish initial estimates of relative resource costs for physicians' services across specialties. The methodology allocated these aggregate specialty practice costs to specific procedures and, thus, can be seen as a “top-down” approach. Discussion of the various elements of the methodology and their application follow.

a. Practice Expense Cost Pools. We used actual practice expense data by specialty, derived from the 1995 through 1998 SMS survey data, to create six cost pools—administrative labor, clinical labor, medical supplies, medical equipment, office supplies, and all other expenses. There were three steps in the creation of the cost pools. (Please note that use of the 1998 data was incorporated for CY 2001.)

  • Step (1) We used the AMA's SMS survey of actual cost data to determine practice expenses per hour by cost category. The practice expenses per hour for each physician respondent's practice was calculated as the practice expenses for the practice divided by the total number of hours spent in patient care activities. The practice expenses per hour for the specialty were an average of the practice expenses per hour for the respondent physicians in that specialty. For the CY 2000 physician fee schedule, we also used data from a survey submitted by the Society of Thoracic Surgeons (STS) in calculating thoracic and cardiac surgeons' practice expense per hour. (Please see the November 1999 final rule (64 FR 59391) for additional information concerning acceptance of these data.) For CY 2001 we used these STS data, as well as survey data submitted by the American Society of Vascular Surgery and the Society of Vascular Surgery. (Please see the November 2000 final rule (65 FR 65385) for additional information on acceptance of these data.)
  • Step (2) We determined the total number of physician hours (by specialty) spent treating Medicare patients. This was calculated from physician time data for each procedure code and from Medicare claims data.
  • Step (3) We calculated the practice expense pools by specialty and by cost category by multiplying the specialty practice expenses per hour for each category by the total physician hours.

For services with work RVUs equal to zero (including the technical component (TC) of services with a TC and professional component (PC)), we created a separate practice expense pool using the average clinical staff time from the CPEP data (since these codes by definition do not have physician time) and the “all physicians” practice expense per hour.

b. Cost Allocation Methodology. For each specialty, we divided the six practice expense pools into two groups, based on whether direct or indirect costs were involved, and used a different allocation basis for each group. The first group included clinical labor, medical supplies, and medical equipment. The second group included administrative labor, office expenses, and all other expenses.

(i) Direct Costs. For direct costs (including clinical labor, medical supplies, and medical equipment), we used the CPEP data as the allocation basis. The CPEP data for clinical labor, medical supplies, and medical equipment were used to allocate the costs for each of the respective cost pools.

For the separate practice expense pool for services with work RVUs equal to zero, we used adjusted 1998 practice expense RVUs as an interim measure to allocate the direct cost pools. (Please see the November 1998 final rule (63 FR 58891) for further information related to this adjustment.) Also, for all radiology services that are assigned work RVUs, we used the adjusted 1998 practice expense RVUs for radiology services as an interim measure to allocate the direct practice expense cost pool for radiology. For all other specialties that perform radiology services, we used the CPEP data for radiology services in the allocation of that specialty's direct practice expense cost pools.

(ii) Indirect Costs. To allocate the cost pools for indirect costs, including administrative labor, office expenses, and all other expenses, we used the total direct costs, as described above, in combination with the physician fee schedule work RVUs. We converted the work RVUs to dollars using the Medicare CF (expressed in 1995 dollars Start Printed Page 40375for consistency with the SMS survey years).

The SMS pool was divided by the CPEP pool for each specialty to produce a scaling factor that was applied to the CPEP direct cost inputs. This was intended to match costs counted as practice expenses in the SMS survey with items counted as practice expenses in the CPEP process. When the specialty-specific scaling factor exceeded the average scaling factor by more than 3 standard deviations, we used the average scaling factor. (Please see the November 1999 final rule (64 FR 59390) for further discussion of this issue.)

For procedures performed by more than one specialty, the final procedure code allocation was a weighted average of allocations for the specialties that perform the procedure, with the weights being the frequency with which each specialty performs the procedure on Medicare patients.

c. Other Methodological Issues. (i) Global Practice Expense Relative Value Units. For services with the PC and TC paid under the physician fee schedule, the global practice expense RVUs were set equal to the sum of the PC and TC.

(ii) Practice Expenses per Hour Adjustments and Specialty Crosswalks. Since many specialties identified in our claims data did not correspond exactly to the specialties included in the practice expense tables from the SMS survey data, it was necessary to crosswalk these specialties to the most appropriate SMS specialty category. We also made the following adjustments to the practice expense per hour data. (For the rationale for these adjustments to the practice expense per hour, see the November 1998 final rule (63 FR 58841).)

  • We set the medical materials and supplies practice expenses per hour for the specialty of “oncology” equal to the “all physician” medical materials and supplies practice expenses per hour.
  • We based the administrative payroll, office, and other practice expenses per hour for the specialties of “physical therapy” and “occupational therapy” on data used to develop the salary equivalency guidelines for these specialties. We set the remaining practice expense per hour categories equal to the “all physician” practice expenses per hour from the SMS survey data. (Note that in the November 2000 final rule (65 FR 65403), we increased the space allotment for therapy services to 750 square feet.)
  • Due to uncertainty concerning the appropriate crosswalk and time data for the nonphysician specialty “audiologist,” we derived the resource-based practice expense RVUs for codes performed by audiologists from the practice expenses per hour of the other specialties that perform these services.
  • For the specialty of “emergency medicine,” we used the “all physician” practice expense per hour to create practice expense cost pools for the categories “clerical payroll” and “other expenses.”
  • For the specialty of “podiatry,” we used the “all physician” practice expense per hour to create the practice expense pool.
  • For the specialty of “pathology,” we removed the supervision and autopsy hours reimbursed through Part A of the Medicare program from the practice expense per hour calculation.
  • For the specialty “maxillofacial prosthetics,” we used the “all physician” practice expense per hour to create practice expense cost pools and, as an interim measure, allocated these pools using the adjusted 1998 practice expense RVUs.
  • We split the practice expenses per hour for the specialty “radiology” into “radiation oncology” and “radiology other than radiation oncology” and used this split practice expense per hour to create practice expense cost pools for these specialties.

(iii) Time Associated with the Work RVUs. The time data resulting from the refinement of the work RVUs have been, on average, 25 percent greater than the time data obtained by the Harvard study for the same services. We increased the Harvard study's time data to ensure consistency between these data sources.

For services with no assigned physician time, such as dialysis, physical therapy, psychology, and many radiology and other diagnostic services, we calculated estimated total physician time based on work RVUs, maximum clinical staff time for each service as shown in the CPEP data, or the judgment of our clinical staff.

We calculated the time for CPT codes (hereafter referred to as “codes”) 00100 through 01996 using the base and time units from the anesthesia fee schedule and the Medicare allowed claims data.

3. Refinement

a. Background. Section 4505(d)(1)(C) of the BBA amended section 1848(c)(2)(C)(ii) of the Act by directing us to develop a refinement process to be used during each of the 4 years of the transition period. We did not propose a specific long-term refinement process in the June 1998 proposed rule (63 FR 30835). Rather, we set out the parameters for an acceptable refinement process for practice expense RVUs and solicited comments on our proposal. We received a variety of comments about broad methodology issues, practice expense per-hour data, and detailed code-level data. We made adjustments to our proposal based on comments we received. We also indicated that we would consider other comments for possible refinement and that the RVUs for all codes would be considered interim for 1999 and for future years during the transition period.

We outlined in the November 1998 final rule (63 FR 58832) the steps we were undertaking as part of the initial refinement process. These steps included the following:

  • Establishment of a mechanism to receive independent advice for dealing with broad practice expense RVU technical and methodological issues.
  • Evaluation of any additional recommendations from the General Accounting Office, the Medicare Payment Advisory Commission (MedPAC), and the Practicing Physicians Advisory Council (PPAC).
  • Consultation with physician and other groups about these issues.

We also discussed a proposal submitted by the AMA's Specialty Society Relative Value Update Committee (RUC) for development of a new advisory committee, the Practice Expense Advisory Committee (PEAC), to review comments and recommendations on the code-specific CPEP data during the refinement period. In addition, we solicited comments and suggestions about our practice expense methodology from organizations that have a broad range of interests and expertise in practice expense and survey issues.

b. Current Status of Refinement Activities. In the 1999 and 2000 proposed and final rules, we provided further information on refinement activities underway, including the AMA's formation of the PEAC and the support contract that we awarded to the Lewin Group to focus on methodologic issues. In addition, in these rules we announced actions taken and decisions made in response to the hundreds of comments received on our resource-based physician practice expense initiative. Because the transition will be completed in CY 2002 and the practice expense RVUs will then be totally resource-based, it is appropriate to recap the specific achievements reached and decisions implemented during this refinement effort to date.

(i) Use of the Top-Down Approach. Most of the physician organizations commenting agreed that this methodology was preferred for computing resource-based practice expense RVUs and that it was in accordance with the requirements of the Start Printed Page 40376BBA. KPMG Peat Marwick, under contract to us, reviewed the top-down methodology in which aggregate specialty costs are applied to specific procedures and concluded that it followed reasonable cost accounting principles. A 1999 GAO report concludes, “HCFA's new approach represents a reasonable starting point for creating resource-based practice expense RVUs. It uses the best available data for this purpose and explicitly recognizes specialty differences in practice expense.” Based on these comments and assessments, we made the decision to continue to use the top-down methodology to calculate the resource-based practice expense RVUs.

(ii) Use of the SMS Survey. The supplemental non-SMS survey data submitted by several specialties in response to the 1998 proposed rule, with the exception of the survey data from the thoracic surgeons, were not compatible with the format or methodology of the SMS. We awarded a contract to the Lewin Group to recommend criteria for the acceptance of specialty-specific practice expense data so that we could supplement the SMS data as appropriate. These recommended criteria are contained in the final report, “An Evaluation of the Health Care Financing Administration's Resource-Based Practice Expense Methodology.” This report is available on our web page under the same title. (Access to our web site is discussed under the SUPPLEMENTARY INFORMATION section above.)

The report also contains recommendations for revisions to the SMS or other surveys to efficiently meet the needs of our practice expense methodology. We augmented these recommendations and forwarded our suggestions for revisions to any future surveys to the AMA. For example, we developed supplementary survey questions that would allow us to distinguish both costs and direct patient care hours for all midlevel practitioners. We also suggested revisions that would capture the necessary information on separately billable supplies and services so that we could eliminate these costs from the specialty-specific practice expense per-hour calculations.

To obtain supplementary specialty-specific practice expense data that could be used in computing practice expense RVUs beginning January 1, 2001, we published an interim final rule on May 3, 2000 (65 FR 25664) that set forth the criteria applicable to supplemental survey data submitted to us by August 1, 2000.

We also provided a 60-day period for submission of public comments on our criteria for survey data submitted between August 2, 2000 and August 1, 2001 for use in computing the practice expense RVUs for the CY 2002 physician fee schedule.

In the November 1, 2000 final rule (65 FR 65385), we responded to comments received on the interim final rule and made modifications to the criteria for supplemental survey data that will be considered in computing practice expense RVUs for the CY 2002 physician fee schedule. These data can then be used to supplement the SMS survey data currently used to estimate each specialty's aggregate practice costs or to replace the crosswalks used for specialties not represented in the SMS.

In our November 1999 final rule, we accepted supplementary data submitted by the thoracic surgeons and, in our November 2000 rule, we accepted survey data from the vascular surgeons that replaced the previously crosswalked practice expense per hour data for that specialty. If we receive additional specialty-specific survey data before August 1, 2001 that meets the criteria outlined in the November 1, 2000 final rule, we will use this supplementary data in calculating the CY 2002 practice expense RVUs.

We accepted our contractor's recommendation to incorporate the latest SMS data into our practice-expense-per-hour calculations. For CY 2001, we incorporated the 1998 SMS data into a 4-year average and are proposing to incorporate the 1999 SMS data into a 5-year average to calculate the CY 2002 practice expense RVUs.

We also accepted the contractor's recommendation to standardize the survey practice expense data to a common year. We adjusted the data to reflect a 1995 cost year.

We received comments that urged us to use the median SMS specialty-specific data instead of the mean, as well as comments supporting our use of the mean values. We made a decision to continue to use the mean in calculating the specialty-specific practice expense per hour. We believe that, in a small sample, using the median could eliminate outlying data from the calculation that represent real costs and thus should be considered.

(iii) CPEP Data. The AMA has formed a multispecialty sub-committee of their Relative Value Update Committee (RUC), the Practice Expense Advisory Committee (PEAC), to review the CPEP clinical staff, equipment, and supply data for all physician services. This multispecialty committee, which includes representatives from all major specialty societies, would then make recommendations on suggested refinements to this data. We indicated in our November 1998 final rule (63 FR 58833) that we would work with the PEAC and RUC to refine the practice expense direct cost inputs. This refinement process was supported in comments we received from almost every major physician specialty society.

In our 1999 physician fee schedule final rule, we implemented most CPEP refinements recommended by the RUC. For the 2000 final rule, the RUC forwarded to us significant additional refinement recommendations that reflected multispecialty agreement on the typical resources for many important services, including visit codes, that account for approximately 24 percent of Medicare spending for physician services. Again we received and accepted almost all of these RUC recommendations. In addition, at its October 2000, February 2001, and April 2001 meetings, the PEAC focused on high-volume services and on standardizing inputs across wide ranges of services. We, therefore, anticipate that the pace of refinement of the CPEP inputs will continue to accelerate.

In addition to implementing most of the RUC-recommended refinements, we responded to comments on errors and anomalies in the CPEP data in both the November 1999 and November 2000 final rules. For example, we removed separately billable casting supplies and drugs from all services, we adjusted the prices of certain supplies that were clearly in error, we removed duplicated equipment from the direct inputs of the nuclear medicine codes, we added clearly essential equipment that was missing from the lithotripsy and photochemotherapy codes, we corrected anomalies in inputs within several families of codes, and we changed the crosswalks for the CPEP inputs of several codes not valued by the CPEP panels when a commenter suggested more appropriate crosswalks.

We simplified the refinement of equipment inputs by combining both the procedure-specific and overhead equipment into a single equipment category. We also deleted stand-by equipment and equipment used for multiple services at one time from the direct cost inputs because of the difficulty of allocating these costs at the code-specific level.

We are resolving issues related to averaging input costs for codes that were valued by more than one CPEP panel. While we have received comments agreeing and disagreeing with our use of mean costs, the issue is moot because we are substituting refined data for the data previously produced by multiple CPEPs. Start Printed Page 40377

(iv) Physician Time Data. In the November 1999 rule (64 FR 59404), we stated that, in general, requests for revisions for the procedure-specific physician times should be deferred to either the RUC process or the 5-year review process. However, we did adopt the newer data to correct the physician time for the pediatric surgery codes and made the requested revisions to correct anomalies in the times of certain psychotherapy codes.

In response to comments on the times associated with physical and occupational therapy services, we added preservice and postservice times to all of these codes.

(v) Crosswalk Issues. In response to concerns expressed by specialty societies representing emergency medicine that the SMS data did not capture the costs of uncompensated care, we crosswalked emergency medicine's administrative labor and other expenses cost pools to the practice expense per hour for “all physicians.”

We resolved issues related to the specialty crosswalk for nursing specialties by eliminating the separate practice expense pools for midlevel practitioners.

(vi) Calculation of Practice Expense Pools—Other Issues. We addressed concerns that potential errors in our specialty utilization data will have an effect on the calculation of practice expense RVUs. In the July 2000 proposed rule (65 FR 44178), we discussed our simulations that demonstrated that the small percentage of potential errors in our very large database have no adverse effect on specialty-specific practice expense RVUs.

We have created the zero-work pool for services with no physician work to ensure that these services are not inappropriately disadvantaged by our methodology. We have also agreed with the request of all the specialty societies that commented that their services should be moved out of the zero-work pool and into the specialty-specific pool. The specialties whose services remain in the zero-work pool have indicated that they wish their services to remain there. We plan to eliminate this separate pool for services with no physician work only when we have determined what revisions to our methodology are required so that we can value these services appropriately outside of the zero-work pool.

(vii) Calculation of Indirect Cost. We requested that our contractor evaluate various options for calculating indirect costs. The final report, referenced above, contains an analysis of the impacts of six alternative allocation methodologies. In confirming the suitability of our allocation methodology, the report concludes that “HCFA's approach is broadly consistent with most of the alternative methods. This consistency suggests that, from a broad perspective, no other allocation methodology offers a compelling reason to abandon the current HCFA approach.”

(viii) Site-of-Service. The practice expense RVUs would be expected to be higher in the non-facility setting, where the practitioner bears the costs of the necessary staff, supplies, and equipment, than in the facility setting. To prevent potential anomalies in our calculations due to the different mix of specialties performing a given service in different settings, we capped the facility practice expense RVUs at the non-facility level for each specific service.

In the November 1999 final rule (64 FR 59407), in response to a comment from the Renal Physicians Association, we agreed that the monthly capitated service codes should always be reported using the non-facility designation. The site of service designations are not meaningful for a monthly service that may be provided in different settings for the same patient during a given month.

Although we need to do additional work to complete the refinement of all practice expense RVUs, we believe that the above description of our actions to date shows that much has been accomplished. We also believe that it demonstrates that we have been responsive to comments from the medical community and have established a process that enables this community to participate fully in the refinement of both the specialty-specific practice expense per hour and the CPEP code-specific inputs.

Practice Expense Proposals for Calendar Year 2002

(1) Use of 1999 SMS Survey Data

We are currently using data from the 1995 through the 1998 SMS surveys (1994 through 1997 practice expense data) in order to calculate the specialty-specific practice expense per hour. The 1999 SMS survey data is now available. Because we want to incorporate the most recent survey data into our methodology during the transition period, we are proposing to add this 1999 data to the 4 years of data we are currently using.

We are proposing to use these 5 years of data in addition to any supplemental specialty-specific data that meet our criteria as the basis of the practice expense per hour calculations until the first 5-year review of practice expense RVUs in 2007. At that time, we anticipate that newer practice expense survey data might be available.

The proposed specialty-specific practice-expense per hour calculations are shown in Table 1. The specialty level impact of using the additional SMS data is shown in Table 5 of the regulatory impact statement. As indicated, Table 5 shows the impact of this change only relative to the current estimated fully-implemented practice expense RVUs.

Table 1.—Specialty-Specific Practice Expense Per Hour Calculations

SpecialtyClinical payroll per hourClerical payroll per hourOffice expense per hourSupplies expense per hourEquipment expense per hourOther expense per hourTotal expense per hour
ALL PHYSICIANS12.315.419.47.43.211.569
GENERAL/FAMILY PRACTICE14.814.917.77.93.18.867.1
GENERAL INTERNAL MEDICINE9.414.417.96.12.16.656.5
CARDIOVASCULAR DISEASE15.815.220.76.25.917.881.6
GASTROENTEROLOGY8.917183.62.112.361.8
ALLERGY/IMMUNOLOGY36.325.331.416215.8128.8
PULMONARY DISEASE6.912.415.72.61.66.946.1
ONCOLOGY (with supplies adjustment)27.424.126.57.44.69.399.3
GENERAL SURGERY7.215.616.83.429.954.9
OTOLARYNGOLOGY17.225.232.97.55.617.2105.7
ORTHOPEDIC SURGERY16.628.529.710.33.819.1108
OPHTHALMOLOGY25.125.834.110.88.421.1125.3
UROLOGICAL SURGERY12.418.523.225.55.311.396.2
PLASTIC SURGERY1520.332.418.55.725.2117.2
NEUROLOGICAL SURGERY8.625.628.61.81.416.182.2
CARDIAC/THORACIC SURGERY18.116.816.81.82.213.168.8
Start Printed Page 40378
PEDIATRICS12.412.918.910.21.78.664.8
OBSTETRICS/GYNECOLOGY16.418.824.77.33.211.281.7
RADIATION ONCOLOGY149.212.15.49.716.466.8
RADIOLOGY9.310.814.84.87.420.968
PSYCHIATRY1.75.110.50.40.47.225.3
ANESTHESIOLOGY11.33.75.90.40.45.927.6
PATHOLOGY (adjusted to remove Part A Hrs)11.21411.96.822166.9
DERMATOLOGY22.528.433.412.65.417.2119.4
EMERGENCY MEDICINE (adjusted for admin/other)3.315.420.70.111.533
NEUROLOGY8.32319.55.24.49.369.7
PHYS MED/RHEUMATOLOGY14.923.730.76.56.212.294.2
OTHER SPECIALTY9.31319.34.91.98.857.3
VASCULAR SURGERY (supplemental data)20.218.117.73.24.511.475.1
PHYSICAL AND OCCUPATIONAL THERAPY (see12.35.97.57.43.24.440.7
* Total expenses exclude professional liability insurance premiums and employee physician payroll.
Notes:
—Only self-employed non-federal non-resident patient care physicians who responded to all relevant expense questions are included. Self-employed physician respondents with no practice expenses for the year are excluded.
—Physicians whose typical number of hours worked in patient care activities per week is missing, less than 20, or equal to 168 are excluded. Physicians whose number of weeks worked the previous year is missing or less than 26 are excluded.
—For each respondent, total practice expense and expense components per hour are calculated as (4)/(5) below.
—Expenses adjusted for practice size = self-employed respondent expenses X # physician owners
—Hours adjusted for practice size =(respondent hours * # physician owners) + (employee physician hours (see (6) below) * # employee physicians)
—The typical number of hours worked in patient care activities for the employee physician(s) of a self-employed physician's practice is not known.
Mean hours worked in patient care activities for employee physicians of each specialty are used as an estimate of employee physician hours.
—As described earlier in this proposed rule, the practice expense per hour shown above reflect:
—the “All Physician” supplies expense per hour for Oncology
—use of supplemental SMS practice expense data for Cardiac and Thoracic Surgery in addition to regular SMS data collection.
—removal of hours spent in Part A activities for Pathology.
—Using the “All Physician” administration and other practice expense data for Emergency Medicine.
—Vascular Surgery data is based on supplemental survey not the SMS.
—Physical and occupational therapy data is based on “All Physician” for clinical, staff, supplies and equipment.
It is based on salary equivalency guidelines assuming 750 square feet of office space for clerical, office and other.

Supplemental Practice Expense Survey Data

To ensure the maximum opportunity for specialties to submit supplementary practice expense data, we are proposing to accept survey data that meets the criteria set forth in the November 2000 final rule for an additional 2 years. The deadlines for submission of such supplemental data to be considered in CY 2003 and CY 2004 are August 1, 2002 and August 1, 2003, respectively.

Repricing of CPEP Inputs

The cost of the original CPEP inputs for staff, supplies, and equipment were assigned by our contractor, Abt Associates, based primarily on 1994 and 1995 pricing data. In addition, for many items on the equipment and supply list, the associated costs were based on the recommendation of a CPEP panel member, rather than on actual catalog prices. Several equipment and supply items and clinical staff types also have been added subsequent to the CPEP panels. In general, the costs of these inputs have been provided by the relevant specialty society, with and without documentation of the costs.

We are proposing to revise the salary and cost estimates by using the most current pricing data available. We contracted with a consultant to help us in this endeavor and the contractor also solicited advice and information from the major medical specialty societies. We appreciate the time and effort given to this project by the staff of many of the specialty societies. We have at this time completed our proposals for the update of clinical staff salary data and discuss these proposals below. However, we have not yet completed the pricing update for all of the hundreds of supplies and pieces of equipment that are in our CPEP database. We have had difficulty in identifying some of these inputs because many of the original descriptions are too general to price (for example, “laser” or “antibody”) or because the item cannot be found in any supplier's catalog. In addition, several of the pieces of equipment are now obsolete and we need input regarding the appropriate equipment to price. Therefore, we need to work closely with the specialty societies in the coming months so that we can propose accurate prices for all the supply and equipment inputs in next year's proposed rule.

Staff Types and Wages

For the original CPEP wage data, Abt Associates used three primary external data sets: The Bureau of Labor Statistics' (BLS) Occupation Compensation Survey, 1993; The University of Texas Medical Branch (UTMB) Survey of Hospital and Medical School Salaries, 1994; and the Current Population Survey, 1993. Abt's report on the CPEP cost estimation stated that, “* * * the BLS data were considered to be the preferred data set. The BLS’ reputation for publishing valid estimates that are nationally representative led to the choice of the BLS data as the main source. If more than one data set provided an exact mapping for a receptionist, then the BLS wage was chosen over any other mapping.”

We agreed with this assessment and directed our current contractor to use the most current BLS survey (1999) as the main source of wage data. The two other data sets used by Abt were not useful in this pricing update. The UTMB survey has apparently not been repeated and the Current Population Survey was used mainly for administrative staff types that are no longer treated as a direct cost.

It should also be noted that the BLS discontinued the Occupational Compensation Survey used in 1995 and now conducts the National Compensation Survey that has a different breakdown of staff types than the earlier survey. This survey also does not cover all the staff types contained in the CPEP data. Therefore, it has been necessary for us to crosswalk or extrapolate the wages for several staff types using supplementary data sources for verification whenever possible.

We used three other data sources to price wages of staff types that were not referenced in the BLS data—the American Society of Clinical Start Printed Page 40379Pathologists' survey of laboratory staff salaries (found at www.ascp.org); the survey done by the American Academy of Health Physics and the American Board of Health Physics (found at www.hps1.org); and national salary data from the Salary Expert, an Internet site that develops national and local salary ranges and averages for thousands of job titles using mainly government sources. (A detailed explanation of the methodology used to determine the specific job salaries can be found at www.salaryexpert.com.)

We welcome comments and input on both our proposed wage rates and our proposed crosswalks. We are particularly seeking any additional sources of reliable national pricing for the wages of staff types not included in the BLS. Anecdotal information regarding individual pay scales will not be particularly helpful for setting national rates, though such information could help with verification of other data. For those staff types that are included in the BLS, we would require data that is equally representative and valid in order to consider revising our proposed salaries.

The table below lists the clinical staff types whose input has been priced, the source for the data, the staff type crosswalk used, the proposed annual salary in 2001 dollars (using the Medicare Economic Index to convert 1999 salaries to 2001 dollars), the proposed cost per minute (including benefits) and the current cost per minute (including benefits) for comparison purposes. The proposed cost per minute was derived by dividing the annual salary by 2080 to arrive at the hourly wage rate and then again by 60 to arrive at the per minute cost. To account for the employers' cost of providing fringe benefits, such as sick leave, we used the same benefits multiplier of 1.366 used by Abt. The last column in the table refers to the numbered notes following the table that contain proposals regarding the pricing of the staff types and additional information as needed.

Table 2.—Proposed Wage Rates for CPEP Clinical Staff Types

DescriptionSourceCrosswalkMean yrly 2001Proposed per minuteCurrent per minuteNote #
Physical Therapy AideBLSPhysical Therapist Aides21,077.360.2260.232
Medical AssistantBLSMedical Assistants23,680.670.2540.1621
Technical AideBLSMedical Assistants23,680.670.2540.2251
Medical TechnicianBLSMedical Assistants23,680.670.2540.2251
EKG TechnicianBLSMedical Assistants23,680.670.2540.2041
Anesthesia TechnicianBLSMedical Assistants23,680.670.2540.2251
TechnicianBLSMedical Assistants23,680.670.2540.2251
Cast TechnicianBLSMedical Assistants23,680.670.2540.1771
LPNBLSLicensed Practical Nurses30,340.530.3250.267
RNBLSRegistered Nurses46,493.560.4980.422
RN CardiologyBLSRegistered Nurses46,493.560.4980.5742
RN OncologyBLSRegistered Nurses plus adjustment54,862.400.5870.4972
Surgery AssistantBLSSurgical Technologists28,814.090.3080.3263
Certified Surgical TechnicianBLSSurgical Technologists28,814.090.3080.262
Lab TechnicianBLSMedical and Clinical Laboratory Technicians29,723.680.3180.288
HistotechnicianASCPHistologic Technologist33,924.510.3630.3064
Electron Microscopy TechnicianASCPHistologic Technologist33,924.510.3630.3125
CytotechnologistBLSMedical and Clinical Laboratory Technologists41,098.760.4400.415
EEG TechnicianSalary ExpertElectroencephalographic Technician29,150.740.3120.2836
Electrodiagnostic TechnologistBLSElectroneurodiagnostic Technologists33,529.310.3590.3026
Registered EEG TechnologistCurrent RateRegistered EEG Technologist37,645.000.4030.4036
Vascular TechnicianBLSCardiovascular Technologists and Technicians34,794.370.3720.3517
Cardiovascular TechnicianBLSCardiovascular Technologists and Technicians34,794.370.3720.351
Radiation TechnologistBLSRadiologic Technologists and Technicians37,125.850.3970.3198
X-Ray TechnologistBLSRadiologic Technologists and Technicians37,125.850.3970.3198
Angiographic TechnicianBLSRadiologic Technologists and Technicians37,125.850.3970.3519
CAT Scan TechnicianBLSRadiologic Technologists and Technicians37,125.850.3970.3199
MRI TechnicianBLSRadiologic Technologists and Technicians37,125.850.3970.3199
Nuclear Medicine TechnicianBLSNuclear Medicine Technologists44,360.730.4750.392
Nuclear Cardiology TechnicianBLSNuclear Medicine Technologists44,360.730.4750.39210
Ultrasound TechnicianBLSDiagnostic Medical Sonographers45,751.260.4900.38911
SonographerBLSDiagnostic Medical Sonographers45,751.260.4900.38911
Cardiac SonographerBLSDiagnostic Medical Sonographers45,751.260.4900.38911
Radiation Technical TherapistBLSRadiation Therapists45,333.050.4850.404
DosimetristBLSRadiation Therapists45,333.050.4850.500
PhysicistAAHPCertified Health Physicists84,495.540.9050.96812
COTX-WALKLab Technician29,723.680.3180.25613
COMTX-WALKHistotechnician33,924.510.3630.27813
OpticianBLSOpticians, Dispensing26,336.250.2820.278
Start Printed Page 40380
Certified Retinal AngiographerSalary ExpertOphthalmic Photographer35,453.040.3800.35114
OrthoptistX-WALKCOMT33,924.510.3630.31515
Respiratory TherapistBLSRespiratory Therapists38,537.280.4130.421
Speech PathologistBLSSpeech-Language Pathologists49,996.000.5350.419
AudiologistBLSAudiologists47,748.170.5110.411
Registered DieticianBLSDieticians and Nutritionists39,049.570.4180.365
CounselorBLSMental Health Counselors30,769.180.3290.422

(1) We are proposing to collapse the medical assistant, technical aide, medical technician, EKG technician, anesthesia technician, technician, and cast technician staff types into a new staff type called, “medical or technical assistant” that will be priced at the medical assistant proposed wage rate per minute. This will represent an increased per minute rate for all the bundled staff types.

(2) We are proposing to bundle the staff type “RN-cardiology” into the staff type “RN.” RN-cardiology is used as the staff type for the pre- and post-service time of only three percutaneous valvuloplasty services, codes 92986, 92987 and 92990. We were unable to find any national salary data for the oncology certified nurse (OCN). In the absence of other information, we are adjusting the proposed wage rate to be 18 percent higher than the RN; this is the same differential that currently exists between these two staff types.

(3) We are proposing to bundle the staff type “surgery assistant”, which is assigned to only 19 surgical services, into the staff type “certified surgical technologist (CST)”, which is assigned to 133 services. It also appears that Abt mapped the averaged costs from a first assistant and certified scrub technician to the surgery assistant staff type, which does not appear to be the most appropriate crosswalk for the office setting.

(4) We used the average hourly rate for histologic technologists from the 1998 American Society of Clinical Pathologists' survey to propose a wage for the histotechnician staff type. This survey's average hourly rate of $12.90 for laboratory technician generally corresponds to our proposed rate of $13.67 and its average hourly rate of $19.00 for cytotechnologists almost matches our proposed rate of $18.90. Therefore, we believe that the $15.60 hourly rate we are proposing for the histotechnician maintains the current relativity between these laboratory staff types.

(5) We were unable to find any national salary data for the electron microscopy technician and, in the absence of such data, are crosswalking the salary from the wage rate for the histotechnician. This does represent an increase in the per minute cost for this staff type. However, we would welcome reliable national survey data from the specialty that we could use in pricing this staff type.

(6) We were only able to find direct BLS salary data for the electroneurodiagnostic technologist staff type. This information was contained in the BLS Occupational Outlook Handbook rather than in the listing of Occupational Employment Statistics where we found all other BLS data. We are proposing to crosswalk the corresponding salary from the Handbook to the electrodiagnostic technologist staff type. Data for the EEG technician came from the Salary Expert. We were unable to find any national salary data for registered EEG technologist (REEGT) and are proposing to maintain the current rate, since the speciality society recently recommended this rate of pay. However, we would also welcome reliable national survey data from the specialty that we could use in pricing these three levels of neurodiagnostic staff.

(7) We are proposing to bundle the vascular technician in with the cardiovascular technology staff type. Currently both are priced at the same rate.

(8) We are proposing to merge the x-ray technician and radiation technologist staff types, which are currently priced at the same rate, into a staff type called “Radiologic Technologist.”

(9) Because we were unable to find any national survey data regarding the salaries for CAT scan technician, MRI technician, or angiographic technician, we are proposing to crosswalk these staff types to the BLS radiologic technologist pay scale. If there is a generally applied differential for these specialized radiologic technologists, we would welcome any reliable national survey data that would allow us to separately price these staff types.

(10) We are proposing to merge the nuclear cardiology technician in with the nuclear medicine technician staff type. Currently, both are priced at the same rate.

(11) We are proposing to merge the cardiac sonographer and the ultrasound technician into the sonographer staff type. Currently, all three are priced at the same rate.

(12) We are proposing to use the average salary data for all certified health physicists from the 1999 survey done by the American Academy of Health Physics and the American Board of Health Physics.

(13) We were unable to find representative national salary data for either the certified ophthalmic technician (COT) or the certified ophthalmic medical technologist (COMT). Until we can obtain such data, we are proposing to crosswalk the COT and COMT to the lab technician and histotechnician, respectively, since we believe that the skill and responsibility of these staff types would generally correspond. Again, we would welcome reliable and representative national salary data for these staff types.

(14) Data for our proposed salary for the certified retinal angiographer came from the Salary Expert. The position description for the ophthalmic photographer appeared to match the duties of a retinal angiographer: “Photographs medical phenomena of eye to document diseases, surgeries, treatment and congenital problems * * * Injects contrast medium into vein of patient and photographs fluorescent dye as it flows through retina or iris vessels to obtain angiogram of eye * * *”

(15) In the absence of any national salary data for the orthoptist, we crosswalked the salary from that of the COMT, the highest level of ophthalmic medical personnel.

We are also proposing to delete those clinical staff that can bill separately from the list of CPEP staff types. We believe that these staff types are used as physician extenders and thus their salaries should not be considered as Start Printed Page 40381practice expense. Therefore, we are proposing to substitute physical therapy aide for physical therapist, registered nurse for physician assistant, nurse practitioner and psychologist, and counselor for social worker. We are also proposing to delete as redundant the ophthalmic medical personnel (OMP) staff type and are substituting the COMT/COT/RN/CST blend that was suggested by the American Academy of Ophthalmology and recommended by the AMA's Relative Value Update Committee.

The CPEP clinical staff inputs also include blends of staff types that are used for those services where more than one type of clinical staff may be used in the performance of the service. We are proposing to establish the payment rates for these blends by calculating a simple average of the wage rates of the staff types included. The table below shows the blended staff types, the proposed cost per minute and the current cost per minute.

Table 3.—Proposed Wage Rates for CPEP Blended Clinical Staff Types

Current descriptionProposed descriptionProposed per minuteCurrent per minute
COMT/COT/RN/CSTSame0.3720.307
EKG Tech/MAMedical or Technical Assistant (MTA)0.2540.183
EKG Tech/Med TechMedical or Technical Assistant (MTA)0.2540.214
Lab Tech/HistotechSame0.3410.297
Lab Tech/Med TechLab Tech/MTA0.2860.257
Optician/COMTSame0.3230.278
RN/LPNSame0.4120.389
RN/LPN/MARN/LPN/MTA0.3590.317
RN/LPN/MA/TechRN/LPN/MTA0.3590.269
RN/Med Tech/MARN/LPN/MTA0.3590.269
RN/OCNSame0.5430.497
RN/PA/Cast TechRN/LPN/MTA0.3590.402
RN/Respiratory TherapistSame0.4560.421
RN/TechRN/LPN/MTA0.3590.323
RN/Ultrasound TechRN/Sonographer0.4940.405
RN//MARN/LPN/MTA0.3590.326
Note: The proposed descriptions are based on our proposals on staff types from the previous table. We have eliminated the staff types we have proposed deleting from the above blends. We are also proposing to add LPN to the blend of an RN and a medical or technical assistant because we believe that if an RN and an assistant can perform a service, it is reasonable to assume that an LPN could as well.

Revision of the Ophthalmology Visit Supply Package

In its May 2000 submission to us, the RUC recommended the use of an ophthalmology visit supply package that would contain the routine supplies typically used in each 90-day global postsurgical visit for ophthalmology services. We accepted this recommendation. However, upon further review, we noted that two of the supplies—rev eyes and post myd spectacles—were not used in many of the postsurgical office visits. Therefore, after consulting with the ophthalmology specialty society, we are proposing to remove these two items from the ophthalmology visit package. Instead, we propose to include these items as appropriate on a code-by-code basis.

Deletion of Contrast Agents From the Practice Expense Inputs

Section 430(b) of BIPA amends section 1861(t)(1) of the Act to include contrast agents in the definition of drugs and biologicals. Previously, contrast agents were defined as supplies and were included in the list of CPEP supplies for the appropriate services. Therefore, we are proposing to delete the costs of the following contrast agents from our CPEP data—hypaque, methylene blue, high density barium, polibar, telopaque tablets, barium paste contrast, effervescent sparkies (fizzies) and renographin-60 iodinated contrast.

Physician Time

RUC Time Database

The primary sources for the physician time data used in creating the specialty-specific practice expense pools are the surveys performed for the initial establishment of the work RVUs and the surveys submitted to the AMA RUC. The AMA informed us that some of the times used for the November 1998 final rule (63 FR 58823) differed from the official RUC database, and we agreed to use the RUC-verified physician time database when we received it from the AMA. Subsequently, the AMA notified us that there were gaps in its own database for certain global surgery codes and that a revised time database would be sent to us once all the times were verified. We have now received this revised database and are proposing to use it in the calculation of the specialty-specific practice expense pools. It should be noted that the RUC database reflects the proposed physician times for those codes that were surveyed as part of the 5-year review of physician work.

c. Site-of-Service: Comments on Site of Service. In the November 2, 1998 final rule (63 FR 58830) and the November 2, 1999 final rule (64 FR 59407), we indicated the circumstances under which either the facility or the non-facility RVUs are used to calculate payment for a service. Specifically, we indicated that the lower facility practice expense RVUs apply when the service is performed in an Ambulatory Service Center (ASC) and the procedure is on the ASC-approved procedures list. The higher non-facility practice expense RVUs apply to procedures performed in an ASC that are not on the ASC-approved list because there will be no separate facility payment for these services. We have recently received a number of inquiries asking about the place-of-service that should be used on the Medicare claim when a service not on the ASC-approved procedures list is provided in an ASC. In these circumstances, physicians should indicate ASC as the place-of-service on the Medicare claim. Other questions have arisen as to whether a beneficiary can be billed the ASC facility fee when Medicare does not pay a facility fee because a procedure not on the ASC list is performed in a certified ASC. In this situation, Medicare pays the higher non-facility practice expense RVUs because the ASC is effectively serving as a physician's office, and Medicare's payment for the physician's service Start Printed Page 40382includes payment for all practice expenses incurred in furnishing the service. The ASC benefit does not apply since the services do not meet the provisions of section 1833(i) of the Act. The services are covered as physicians' services and paid under the physician fee schedule. Therefore, payment to the physician reflects payment for the whole service, and the beneficiary cannot be charged in excess of the limiting charge for the physician fee schedule service.

B. Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists Performing Screening Sigmoidoscopies

On January 1, 1998, we implemented regulations at § 410.37(d) (Conditions for coverage of screening flexible sigmoidoscopies) requiring that screening flexible sigmoidoscopies be performed by a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Act). Based on our review of current medical literature, we believe that there are other practitioners whose services are covered under Medicare who have been trained and are qualified to perform these procedures safely and accurately, such as nurse practitioners, clinical nurse specialists, and physician assistants.

A growing body of literature has shown that certain non-physician health care professionals can carry out screening by flexible sigmoidoscopy as accurately and safely as physicians when properly trained. This procedure requires fewer supervised examinations to attain objective measures of technical competency than other endoscopic procedures, does not require sedation, and has a low rate of related complications. In the studies reviewed, physician and non-physician endoscopists achieved similar polyp detection rates and depth of insertion in screenings performed independently. No significant complications from sigmoidoscopy were reported in any of these studies. The level of satisfaction with the procedure was similar for all practitioners.

Therefore, we are proposing to revise § 410.37(d) to provide that, in addition to medical doctors and doctors of osteopathy, physician assistants, nurse practitioners, and clinical nurse specialists also be allowed to perform screening flexible sigmoidoscopies for beneficiaries if they meet the applicable Medicare qualification requirements in §§ 410.74, 410.75, and 410.76, and if they are authorized to perform these services under State law.

C. Services and Supplies Incident to a Physician's Professional Services: Conditions

Section 1861(s)(2)(A) of the Act authorizes coverage of services and supplies (including drugs and biologicals that cannot, as determined in accordance with regulations, be self-administered) furnished as an incident to a physician's service, of kinds which are commonly furnished in physicians' offices and are commonly either furnished without charge or included in the physician's bills. This statutory “incident to” benefit differs from the “incident to” benefit in the hospital setting as set forth in section 1861(s)(2)(B) of the Act, which authorizes coverage of hospital services (including drugs and biologicals which cannot, as determined in accordance with regulations, be self-administered) incident to a physician's service furnished to outpatients and partial hospitalization services furnished to outpatients incident to a physician's service. This proposal only addresses the “incident to” benefit set forth in section 1861(s)(2)(A) of the Act.

In addition, the statute provides Medicare coverage of services incident to practitioners other than physicians. For example, section 1861(s)(2)(K) of the Act authorizes Medicare to pay for services incident to a service of a nurse practitioner or a physician assistant.

Section 2050 of the Medicare Carriers Manual (the manual) clarifies the coverage of services “incident to” physician services as described in section 1861(s)(2)(A) of the Act. Specifically, services incident to a physician service may be furnished by an employee of the physician. Alternatively, both the physician and the individual furnishing the “incident to” service must be employed by a common employer. Furthermore, the individual furnishing the “incident to” service may be any staff member working with the physician and not just one of the non-physician practitioners listed in section 1842(b)(18)(C) of the Act. We shall refer to these staff members as auxiliary personnel, a term which includes registered nurses and medical assistants.

Currently, our manual requires that the physician be either the employer of the auxiliary personnel or be an employee of the same entity that employs the auxiliary personnel. We note that, under our manual, auxiliary personnel may be either employees, leased employees, or independent contractors. An independent contractor relationship appears to be common current practice because it affords the auxiliary personnel the flexibility to work with various physicians or practitioners on a part-time basis. We do not believe that the nature of the employment relationship is critical for purposes of payment for services incident to the services of physicians and practitioners, so long as the auxiliary personnel reports to a physician or practitioner under the required level of supervision. We see no clinical reason to exclude independent contractor physicians and practitioners from the class of practitioners who can receive Medicare payment for services incident to their own services based solely on their status as independent contractors. Accordingly, we propose to allow auxiliary personnel to provide services incident to the services of physicians or practitioners who supervise them, regardless of the employment relationship. Thus, auxiliary personnel may be employees, leased employees, or independent contractors, and may provide services incident to the services of physicians and practitioners who employ or contract with them or who are employees or independent contractors of the same entity, provided that the other requirements for payment for “incident to” services are met. We note, however, that the employment relationship remains relevant under our rules prohibiting reassignment of Medicare benefits. (§§ 424.73 and 424.80) We also propose to codify the following definitions:

  • Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician (or other practitioner) or of the same entity that employs or contracts with the physician (or other practitioner).
  • Direct supervision means the level of supervision by the physician (or other practitioner) of auxiliary personnel as defined in § 410.32(b)(3)(ii).
  • Independent contractor means an individual who performs part-time or full-time work for which the individual receives an IRS-1099 form.
  • Leased employment means an employment relationship that is recognized by applicable State law and that is established by two employers by a contract such that one employer hires the services of an employee of the other employer.
  • Noninstitutional setting means all settings other than a hospital or skilled nursing facility.
  • Practitioner means a non-physician practitioner who is authorized by the Start Printed Page 40383Act to receive payment for services incident to his or her own services.
  • Services and supplies means any service or supply (including any drug and biological that cannot be self-administered) that is included in section 1861(s)(2)(A) of the Act and is not specifically listed in the Act as a separate benefit included in the Medicare program.

We also propose to codify the provisions in section 2050 of the manual by revising § 410.26 to clarify the requirements for “incident to” services. Section 410.26 would be revised as follows:

  • Services and supplies must be furnished in a noninstitutional setting to noninstitutional patients.
  • Services and supplies must be an integral, although incidental, part of the service of a physician (or other practitioner) in the course of diagnosis or treatment of an injury or illness.
  • Services and supplies must be commonly furnished without charge or included in the bill of a physician (or other practitioner).
  • Services and supplies must be of a type that are commonly furnished in the office or clinic of a physician (or other practitioner).
  • Services and supplies must be furnished under the direct supervision of the physician (or other practitioner).
  • Services and supplies must be furnished by the physician, practitioner with an incident to benefit, or by auxiliary personnel.
  • A physician (or other practitioner) may be an employee or an independent contractor.
  • Drugs and biologicals are also subject to the limitations specified in § 410.29.

D. Anesthesia Services

Section 4048(b) of the Omnibus Budget Reconciliation Act of 1987 amended section 1842(b) of the Act and required us to establish a uniform relative value guide for use in all carrier localities in determining payment for anesthesia services furnished by physicians under Medicare Part B. In accordance with the law, the uniform relative value guide was designed so that Medicare payment for anesthesia services would not exceed the amount that would have occurred under the then-existing system of payment.

We implemented the uniform relative value guide in March 1989 and selected the 1988 American Society of Anesthesiologists' (ASA) Relative Value Guide as the basis for the uniform relative value guide. (For a discussion of this issue, please see the August 7, 1990 final rule (55 FR 32078).)

To determine base unit values, we used the 1988 ASA base unit values for each anesthesia code, except for codes 00142 (lens surgery) and 00147 (iridectomy). The base unit values for each of these codes were set at 4 units instead of the ASA values of 6 and 5 units, respectively.

The ASA has requested that we ensure that the anesthesia base units under our uniform relative value guide are the same as those listed in the ASA's most current guide. Standardization of base units between Medicare and the ASA guide will simplify billing by anesthesiologists. The ASA's base unit values for the following 8 codes are different than CMS's values:

CodeCMSASA
008165
0090245
01150810
01214108
0143256
0144058
0177086
0192178

We are proposing to use the ASA base unit values from the 1999 guide beginning in CY 2002 for the above codes. However, the base unit values for codes 00142 and 00147 would remain at 4 units. The values for these codes were established by us under the “inherent reasonableness” process in 1987.

We would make an adjustment to the anesthesia conversion factor in 2001 so that payments would not exceed payments that would have been made using the current values. We currently estimate that this adjustment will be less than 0.5 percent.

E. Performance Measurement and Emerging Technology Codes

In modernizing the CPT, the AMA has developed two new categories of codes. In addition to the traditional codes for physicians' and other practitioners' services, referred to as Category I CPT codes, which are coded by five digit numbers, the new codes describe Performance Measures and Emerging Technologies and are coded with four digits followed by a letter.

The Performance Measure codes, referred to as Category II CPT codes, are intended to facilitate data collection. These codes are designed to decrease the need for review of medical records to document when services were performed. They allow practitioners to indicate in their billing records that the visit addressed issues that need to be tracked for quality and outcome measurement. For example, there is likely to be a code to indicate that a diabetic patient received a retinal examination. The visit that contained that specific service might have been reported with an evaluation and management code or with a more general ophthalmological service code and paid for based on the code selected. Thus, the performance measurement code is used only to assist the practitioner to specify that the performance measurement service was furnished. The syntax of this code will be four digits followed by the letter “F.” We are proposing that no values are placed on the Performance Measure codes and no additional payment is made for the use of these codes. Practitioners will, however, be able to list them on their Medicare bills, to facilitate the tracking of these services.

The Emerging Technology codes, referred to as Category III CPT codes, are intended to track new and emerging technologies. These codes were developed to facilitate data collection on and assessment of new services and procedures. These data could be used to document the use of services and procedures in the Food and Drug Administration approval process or while the efficacy of a procedure is being demonstrated. The syntax of these codes is four digits followed by the letter “T.” In general, these codes represent services that are still experimental or have unverified effectiveness and would not be covered services. Although we were concerned that codes with a “T” designation might be needed for use by some Medicaid programs, we now believe that we would be able to process claims with the “T” in the fifth digit. However, we propose not to provide payment for all of the Emerging Technology Codes. Rather, we would provide payment on a case-by-case basis only in specific situations when we determine that the codes represent services that are not, in fact, experimental, but have been shown to be safe and effective. If the coverage policy is not consistent with the existing tracking codes, a Medicare-specific code may need to be developed to allow payment for the service. Thus, we propose that only specific emerging technology codes will be recognized for Medicare payment.

F. Payment Policy for CPT Modifier 62 (Co-Surgery)

The CPT modifier code 62 is used to report the work of co-surgeons. Currently, if we pay for co-surgery, we pay a total of 125 percent of the fee schedule amount to the co-surgeons who each receive half of this total payment. This policy was established at the beginning of the fee schedule and Start Printed Page 40384the level of payment reflected the predominant payment rate used by Medicare carriers at that time. Unlike other components of the fee schedule, this payment policy was not based on an analysis of the relative physician work effort for surgical services involving co-surgeons.

In addition, surgical practice has changed significantly over the past 10 years. For example, there is increasing use of noninvasive, minimally invasive, percutaneous, and endoscopic approaches to performing surgical procedures that were formerly performed as open procedures. Therefore, we are reviewing our payment policies for co-surgery to consider possible ways to ensure that they reflect current clinical practices and properly reflect the relative resources and work effort required to perform these services.

Among the issues we are considering are:

(1) Whether it would be possible to establish criteria for distinguishing the roles of a co-surgeon (when both surgeons are paid at 125 percent of the surgery amount) and assistant at surgery (when the total payment is 116 percent of the surgery amount);

(2) Whether any such criteria should vary by type of procedure (that is, open surgical, minimally invasive (including interventional procedures), and endoscopic procedures);

(3) Which procedures require a co-surgeon and under what circumstances should documentation be required for payment; and

(4) How to value the work performed by a co-surgeon.

While we are not making a specific proposal at this time, we will consider any information we receive to assist us in deciding whether to make a future proposal affecting payments for co-surgery.

III. Implementation of Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000

The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Public Law 106-554), enacted on December 21, 2000, provides for revisions to policies applicable to the physician fee schedule. These revisions are presented below.

A. Screening Mammography

Medicare has paid for screening mammography since January 1, 1991. Section 1834(c) of the Act governing these screenings did not include screening mammography under the physician fee schedule and required payment using a different methodology. As stated in § 405.534, Medicare payment for screening mammography currently equals the lesser of the following: the actual charge for the service; the applicable amount under the physician fee schedule in an area for a bilateral diagnostic mammogram; or $55, a figure specified in section 1834(c)(3) of the Act, updated since 1991 by the Medicare Economic Index (MEI). In 2001, the statutory payment limit for screening mammography is $69.23. In most cases, payment for screening mammography is made at the national limit with no differences among geographical areas.

Section 104 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amends section 1848(j)(3) of the Act to include screening mammography as a physician service for which payment is made under the physician fee schedule beginning January 1, 2002. We are proposing to amend §§ 405.534 and 405.535 to reflect the inclusion of screening mammography as a physician service which will be payable under the physician fee schedule. In addition, we are amending § 414.2 to include screening mammography under the definition for physicians' services. In accordance with part 414, payments for screening mammography will be resource-based and will have geographic adjustments that reflect cost differences among areas as do all other services under the physician fee schedule, including diagnostic mammography. The following is a discussion of our proposed RVUs for the professional and technical components (PC and TC) of a screening mammography, code 76092, under the physician fee schedule.

Professional Component

We are proposing to establish physician work RVUs=0.70. This value is equal to the proposed work RVUs from the 5-year review of physician work for code 76090, unilateral diagnostic mammogram. Due to the comparable number of views taken in both a unilateral diagnostic mammography and a screening mammography, we believe the physician work associated with the performance of screening mammography is similar to the physician work associated with unilateral diagnostic mammography.

We note that in the June 8, 2001 proposed notice on the 5-year review of work RVUs (66 FR 31028), we proposed to increase the work RVUs for unilateral diagnostic mammography from 0.58 to 0.70 RVUs, an increase of 21 percent. Additionally, we are proposing to increase the work RVUs for bilateral diagnostic mammography from 0.69 to 0.87 RVUs, an increase of 26 percent. Both of these increases would be effective for services performed on or after January 1, 2002. Our proposal to establish physician work RVUs for screening mammography equal to the physician work RVUs for unilateral diagnostic mammography, since both involve a four view film study, incorporates the increases we have proposed in the June 8, 2001 proposed notice.

We also believe that the practice expense and malpractice expense for the professional component of screening mammography is similar to the professional component of unilateral diagnostic mammography. As a result, we are proposing 0.25 practice expense RVUs and 0.03 malpractice RVUs for the PC of screening mammography. These proposed RVUs reflect changes to the practice expense RVUs for code 76090.

Technical Component

We propose valuing the technical component of screening mammography using a methodology that updates the original statutory limit for the technical component of screening mammography of $37.40, by the cumulative increase in physician fee schedule rates between 1992 and 2001. While screening mammography payments increased through application of the MEI between 1992 and 2001, resulting in a cumulative increase of 25.9 percent, physician fee schedule payments increased by 35.6 percent during this period. As a result, increasing payment for screening mammography by the statutory limit led to lower payment than if payment for the procedure had increased at the same rate as physician fee schedule services.

We propose updating the technical component of the initial screening mammography statutory limit of $37.40 by the same update factor that would have applied if screening mammography had received the same increases as physician fee schedule services. Currently, payment for the technical component of a screening mammography is equal to 68 percent of the statutory payment limit. To update the current value, we took 68 percent of the original $55 payment limit and increased it by 35.6 percent ($55 × 0.68 × 1.356 = $50.70). We divided this figure by the 2001 physician fee schedule CF of $38.2581 to determine total RVUs of 1.33. Since the TC is comprised only of practice and malpractice RVUs, we then used the Start Printed Page 40385practice expense and malpractice expense percentages for the TC of unilateral diagnostic mammography (95.3 and 4.7 percent, respectively) to determine the practice expense and malpractice RVUs for the technical component of screening mammography. We multiplied the total RVUs of 1.33 by 0.953 to determine the proposed practice expense RVUs of 1.27 and by 0.047 to determine the proposed malpractice expense RVUs of 0.06.

Overall, the proposed total RVUs associated with the combined PC and TC of code 76092 are 2.31 (0.70 work RVUs, 1.52 practice expense RVUs, and 0.09 malpractice expense RVUs). These proposed RVUs would result in a payment for CY 2002 of approximately $88.50, before application of any geographic adjustments.

New Technology Mammography

The BIPA requires us to determine whether the assignment of new HCPCS codes is appropriate for both screening and diagnostic mammography using new technologies. If new codes are appropriate, the provision requires us to provide for their use beginning January 1, 2002. The provision defines new technology mammography to be an advance in technology with respect to the test or equipment that results in: (a) A significant increase or decrease in the resources used in the test or in the manufacture of the equipment; (b) a significant improvement in the performance of the test or equipment; or (c) a significant advance in medical technology that is expected to significantly improve the treatment of Medicare beneficiaries.

Before January 1, 2002, the BIPA provides for temporary payment amounts during the period April 1, 2001 to December 31, 2001 for two types of new technology mammography used in both diagnostic and screening procedures. The BIPA specifies that payment for technologies that directly take digital images would equal 150 percent of the amount that would otherwise be paid for bilateral diagnostic mammography. The BIPA also specifies that for technologies that convert standard film to a digital form which is then analyzed, payment would be equal to the statutory screening mammography limit for CY 2001, plus an additional payment of $15.00. Moreover, the BIPA specifies that the same payment amount be used for a screening or diagnostic procedure for each of the new technologies. We have implemented the temporary payment provisions via a Program Memorandum sent to Medicare carriers on February 1, 2000.

We believe that new HCPCS codes are appropriate for new technology mammography beginning with January 1, 2002 and propose codes to be used with the associated RVUs described below. We propose to establish three separate codes for directly taking a digital image (one for screening and one each for unilateral and bilateral diagnostic). Our approach would establish a single add-on code for computer-aided diagnosis with conversion of standard film images to digital images. At the present time, the FDA has approved computer-aided diagnosis only for use in conjunction with standard film screening mammography. Thus, at the present time, our proposal would only allow Gxxx4 to be billed as an add-on to 76090 if medically necessary. In the section that follows, we discuss the proposed coding and payment methodologies for new technology mammography.

Screening mammography, direct digital image (Gxxx1). We propose to use HCPCS code Gxxx1 to report screening mammography performed using direct digital images as opposed to mammography that is performed using the standard film images associated with code 76092, or conversion of a standard film image to a digital image. (Note: Gxxx is used as a placeholder; the actual “G” code designation for payment will be included in the final rule.)

We believe that the physician work and malpractice expense associated with both the PC and TC of HCPCS code Gxxx1 are analogous to the professional and technical components of CPT code 76092. (Note: Proposed work RVUs for code 76092, discussed above, are being increased to 0.70.) However, because the equipment involved with direct digital images is different from the equipment involved with standard film images, we believe that the practice expense RVUs are different than the practice expense RVUs for code 76092. Thus, we are proposing to value the practice expense for the PC of this service using the methodology for determining resource-based practice expense RVUs. We are proposing to value the practice expense RVUs for the TC of the service using the practice expense methodology for the “zero work pool.” (For more information about the practice expense methodology for PC and TC services, see the November 2, 1998 final rule (63 FR 58817).

For the PC of HCPCS code Gxxx1, we propose 0.70 work RVUs, 0.28 practice expense RVUs, and 0.03 malpractice expense RVUs. For the TC of HCPCS code Gxxx1, for which there is no physician work associated, we propose 2.50 practice expense RVUs and 0.06 malpractice RVUs. Please see Table 4 below for a summary of all component RVUs associated with this and other mammography services.

Diagnostic mammography, unilateral, direct digital image (Gxxx2). We propose to use HCPCS code Gxxx2 to report unilateral diagnostic mammography performed using direct digital images as opposed to mammography performed using the standard film images associated with code 76090, or conversion of a standard film image to a digital image.

We believe that the physician work and malpractice expense associated with both the PC and TC of HCPCS code Gxxx2 are analogous to the PC and TC of code 76090. (Note: Proposed work RVUs for code 76090, discussed above, are being increased to 0.70). However, because the equipment involved with direct digital images is different from the equipment involved with standard film images, we believe that the practice expense RVUs are different than those for code 76090. Thus, we are proposing to value the practice expense for the PC of this service using the methodology for determining resource-based practice expense RVUs. We are proposing to value the practice expense RVUs for the TC of the service using the practice expense methodology for the “zero work pool.”

For the professional component of HCPCS code Gxxx2, we propose 0.70 work RVUs, 0.28 practice expense RVUs, and 0.03 malpractice expense RVUs. For the TC of HCPCS code Gxxx2, for which there is no physician work associated, we propose 1.99 practice expense RVUs and 0.05 malpractice expense RVUs. Please see Table 4 below for a summary of all component RVUs associated with this and other mammography services.

Diagnostic mammography, bilateral, direct digital image (Gxxx3). We propose to use HCPCS code Gxxx3 to report bilateral diagnostic mammography that is performed using direct digital images as opposed to mammography performed using the standard film images associated with code 76091, or conversion of a standard film image to a digital image.

We believe that the physician work and malpractice expenses associated with both the PC and TC of HCPCS code Gxxx3 are analogous to the PC and TC of code 76091. (Note: Proposed work RVUs for code 76091, discussed above, are being increased to 0.87). However, because the equipment involved with direct digital images is different from the equipment involved with standard Start Printed Page 40386film images, we believe that the practice expense RVUs are different than those for code 76091. Thus, we are proposing to value the practice expense for the PC of this service using the methodology for determining resource-based practice expense RVUs. The practice expense RVUs for the TC of the service are being valued using the practice expense methodology for the “zero work pool.”

For the PC of HCPCS code Gxxx3, we propose 0.87 work RVUs, 0.34 practice expense RVUs, and 0.03 malpractice expense RVUs. For the TC of HCPCS code Gxxx3, with which there is no physician work associated, we propose 2.47 practice expense RVUs and 0.06 malpractice expense RVUs. Please see Table 4 below for a summary of all component relative values associated with this and other mammography services.

Computer-aided detection, conversion of standard film images to digital images (HCPCS Code Gxxx4). We propose to use HCPCS code Gxxx4 to report conversion of standard film images to digital images when used in conjunction with computer-aided diagnosis software.

We propose establishing HCPCS code Gxxx4 as an add-on code that can be billed only in conjunction with the primary service, code 76092. At this time, we understand that the only FDA-approved use of the computer-aided diagnosis mammography software is with screening film images. If there are other FDA-approved uses of computer-aided diagnosis, we allow for use of Gxxx4 as an add-on to other mammography services. We believe that the physician work associated with CPT code 76375, Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computerized tomography, magnetic resonance imaging, or other tomographic modality, is comparable, per unit of time, to the physician work of Gxxx4. We have determined that the physician time associated with HCPCS code Gxxx4 is approximately 1/3 of the physician time associated with CPT code 76375. Using this relationship, we propose 0.06 work relative value units for HCPCS code Gxxx4. Additionally, we believe the malpractice expense RVUs for HCPCS code Gxxx4 are analogous to a level two established office visit, CPT code 99212. However, we believe that the practice expense RVUs for HCPCS code Gxxx4 are markedly different from either of the two aforementioned services; therefore, we are valuing the PC of this service using the methodology for determining resource-based practice expense RVUs. The TC of the service is being valued using the practice expense methodology for the “zero work pool.”

For the PC of code Gxxx4, we propose 0.06 work RVUs, 0.02 practice expense RVUs, and 0.01 malpractice expense RVUs. For the TC of HCPCS code Gxxx4, with which there is no physician work associated, we propose 0.41 practice expense RVUs and 0.01 malpractice expense RVUs. Table 4 below summarizes all component RVUs associated with this and other mammography services.

Table 4.—Proposed RVUs for Mammography Services

CodeModifierWorkPractice expenseMalpracticeTotal
760900.701.280.082.06
76090260.700.240.030.97
76090TC0.001.040.051.09
760910.871.590.092.55
76091260.870.300.031.20
76091TC0.001.290.061.35
760920.701.520.092.31
76092260.700.250.030.98
76092TC0.001.270.061.33
Gxxx10.702.780.093.57
Gxxx1260.700.280.031.01
Gxxx1TC0.002.500.062.56
Gxxx20.702.270.083.05
Gxxx2260.700.280.031.01
Gxxx2TC0.001.990.052.04
Gxxx30.872.810.093.77
Gxxx3260.870.340.031.24
Gxxx3TC0.002.470.062.53
Gxxx40.060.430.020.51
Gxxx4260.060.020.010.09
Gxxx4TC0.000.410.010.42

B. Screening Pelvic Examinations

Before the enactment of the BIPA, section 1861(nn)(2) of the Act authorized Medicare coverage for a screening pelvic examination (including a clinical breast examination) furnished to a woman for the purpose of early detection of cervical or vaginal cancer once every 3 years, or once every year for a woman who is at high risk for one of these conditions, or who is of childbearing age and meets certain other requirements.

Section 101 of the BIPA amends section 1861(nn)(2) of the Act (effective July 1, 2001) to provide that a woman who does not qualify for annual coverage of a screening pelvic examination under one of the statutory exceptions, qualifies for coverage of a screening pelvic examination (including a clinical breast examination) once every 2 years rather than once every 3 years.

We are conforming § 410.56 (Screening Pelvic Examinations) of the regulations to the new statutory provision that has been implemented through sections 4603, 3628.1 and 4731 of the Medicare Carrier Manual, the Medicare Intermediary Manual, and the Medicare Hospital Manual, respectively.

C. Screening for Glaucoma

Section 102 of BIPA provides for Medicare coverage under Part B for screening for glaucoma for individuals with diabetes, a family history of glaucoma, or others determined to be at “high risk” for glaucoma effective for services furnished on or after January 1, Start Printed Page 403872002. The statute provides for coverage of glaucoma screening, including (1) a dilated eye examination with an intraocular pressure measurement, and (2) a direct ophthalmoscopy or a slit-lamp biomicroscopic examination, subject to certain frequency and other limitations.

Currently, Medicare coverage policy allows for payment for examinations to diagnose glaucoma and related medically necessary services that are furnished to beneficiaries. Under this policy, diagnostic glaucoma tests are covered if they are medically necessary to evaluate a specific complaint or symptom that might indicate glaucoma or to monitor an existing medical condition of an individual who has had a history of elevated intraocular pressure or other signs of possible glaucoma. This coverage is based on sections 1861(s)(1) and (s)(3) of the Act. Section 1861(s)(1) of the Act provides for general Medicare coverage of physicians' services, including a physician's interpretation of the results of tests performed. Section 1861(s)(3) of the Act provides for general Medicare coverage of diagnostic x-ray, clinical laboratory, and other diagnostic tests. Before the enactment of the BIPA, screening for glaucoma was excluded from coverage based on § 411.15 (Particular services excluded from coverage), paragraphs (a) and (k).

To conform our regulations to the statutory requirements of the BIPA, we are specifying an exception to the list of examples of routine physical checkups excluded from coverage in §§ 411.15(a)(1) and 411.15(k)(9) for glaucoma screening examinations that meet the frequency limitation and the conditions for coverage that we are specifying under new § 410.23 (Screening for Glaucoma: Conditions for and Limitations on Coverage). Coverage of glaucoma screening is provided under Medicare Part B only. As provided in the statute, this new coverage allows payment for one glaucoma screening examination every year. We are proposing to add new § 410.23 (Screening for Glaucoma: Conditions for and Limitations on Coverage), to provide for coverage of the various types of glaucoma screening examinations specified in the statute. We are proposing several definitions of terms that would be included to implement the statutory provisions and to help the reader in understanding the provisions of the regulation. These include definitions of the following terms: (1) Screening for glaucoma, (2) eligible beneficiaries, and (3) direct supervision.

Section 102(b) of the BIPA defines the term “screening for glaucoma” to mean a dilated eye examination with an intraocular pressure measurement and a direct ophthalmoscopy or a slit-lamp biomicroscopic examination for the early detection of glaucoma. This section also provides that the screening examinations that are to be covered under Medicare are to be furnished by or under the direct supervision of an optometrist or ophthalmologist who is legally authorized to furnish these services under State law (or the State regulatory mechanism provided by State law) of the State in which the services are furnished. These are services that would otherwise be covered if furnished by a physician or as incident to a physician's professional service.

Section 102(a) of BIPA also provides that coverage of screening for glaucoma services will be available only for individuals determined to be at high risk for glaucoma, individuals with a family history of glaucoma and individuals with diabetes. Based on our review of the medical literature, and consultation with staff of the National Eye Institute and representatives of the American Academy of Ophthalmology and the American Optometric Association, we are proposing to interpret the statutory language, “individuals determined to be at high risk for glaucoma” to include Medicare beneficiaries who are African-Americans age 50 and over. While the National Eye Institute and others have provided us with information indicating that age and other factors may place a Medicare beneficiary at increased risk for glaucoma, we believe that the medical evidence available at this time is only sufficient to support inclusion of African-Americans age 50 and over in the statutory “high risk” category, in addition to individuals with diabetes and those with a family history of glaucoma who are covered separately under the new screening benefit. Studies have shown that the prevalence of glaucoma increases with age and is four to five times more likely to occur in African-Americans than in Caucasians. (Tielsch et al. JAMA 1991; Quigley. NEJM 1997) For African-Americans, the evidence indicates that the onset of the disease comes at an earlier age, and that the damage is more severe at the time of diagnosis. In view of the possibility that it may be appropriate to include other individuals in the statutory definition of those at “high risk” for glaucoma, however, we are requesting public comments on this issue. Specifically, we ask that anyone providing us with specific recommendations on this issue should provide documentation in support of them from the medical literature. In addition, we are proposing to use the term “eligible beneficiaries” to indicate who may qualify for the new screening glaucoma benefit, and we are proposing to define that term to include: (1) Individuals with diabetes mellitus, (2) individuals with a family history of glaucoma, and (3) African-Americans age 50 and over.

Section 102(b) of the BIPA also provides that the glaucoma screening examination is to be furnished by or under the direct supervision of an ophthalmologist or optometrist who is legally authorized to furnish such services under State law or regulation in which the services are furnished. We are proposing to define the term “direct supervision” as that term is defined in § 410.32(b)(3)(ii) for purposes of the oversight of covered diagnostic laboratory services as they are performed in the office setting. Specifically, we are proposing that the term “direct supervision” be defined to mean that the ophthalmologist or optometrist must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. The proposed definition states that the term “direct supervision” does not mean the physician must be present in the room when the procedure is performed.

Payment for Glaucoma Screening

We believe that services provided as part of glaucoma screening will often overlap other services a physician provides during a patient encounter as part of basic ophthalmological services and will result in no additional work or practice expense. Therefore, we propose bundling payment for glaucoma screening when it is provided on the same day as an evaluation and management (E/M) service, or when it is provided as part of any ophthalmology service. When glaucoma screening is the only service provided, or when it is provided as part of an otherwise noncovered service (for example, CPT 99397, preventive services visit), we propose to establish the following HCPCS codes and payments:

Gxxx5, Glaucoma Screening Furnished by a Physician for High Risk Patients

For physician work and for malpractice, we propose crosswalking this new HCPCS code to a level II E/M code, CPT 99212, which we believe represents a comparable level of work. The proposed work and malpractice RVUs are 0.45 and 0.02, respectively.

Start Printed Page 40388

Gxxx6, Glaucoma Screening Furnished Under the Direct Supervision of a Physician for High Risk Patients

For physician work and for malpractice, we propose crosswalking this new HCPCS code to the lowest level E/M code, CPT 99211, which we believe represents a comparable level of work. The proposed work and malpractice RVUs are 0.17 and 0.01, respectively.

For non-facility settings, we propose the following practice expense inputs for both of the above HCPCS Codes:

clinical staff time-certified ophthalmic medical technologist/certified ophthalmic technician/registered

nurse: five minutes;

equipment: screening lane; and

supplies: ophthalmology visit supply package.

D. Screening Colonoscopy

Before the enactment of the BIPA, sections 1861(pp)(1)(C) and 1834(d)(3)(E) of the Act authorized Medicare coverage of screening colonoscopies once every 2 years for individuals at high risk for colorectal cancer. Individuals not at high risk for colorectal cancer did not qualify for coverage of screening colonoscopies under the colorectal cancer screening benefit, but they did qualify for coverage of other colorectal cancer screening examinations specified in the statute. These other examinations that were covered for individuals not at high risk for colorectal cancer included screening fecal-occult blood tests, screening flexible sigmoidoscopies, and screening barium enema examinations at certain frequency intervals specified in the statute and the regulations at § 410.37 (Colorectal cancer screening tests).

Section 103 of the BIPA amended sections 1861(pp)(1)(C), 1834(d)(2)(E)(ii), and 1834(d)(3)(F) of the Act to add coverage of screening colonoscopies once every 10 years for individuals not at high risk for colorectal cancer. However, in the case of an individual who is not at high risk for colorectal cancer, but who has had a screening flexible sigmoidoscopy within the last 4 years, the statute provides that payment may be made for a screening colonoscopy only after at least 47 months have passed following the month in which the last screening flexible sigmoidoscopy was performed. In addition, the statute provides that in the case of an individual who is not at high risk for colorectal cancer but who does have a screening colonoscopy performed on or after July 1, 2001, payment may be made for a screening flexible sigmoidoscopy only after at least 119 months have passed following the month in which the last screening colonoscopy was performed.

In view of the statutory changes, we are conforming §§ 410.37(e) and 410.37(g) (related to limitations on coverage of screening colonoscopies and screening flexible sigmoidoscopies) to make them consistent with the new provisions of the statute that have been implemented through manual provisions of the Medicare Carriers Manual, the Medicare Intermediary Manual Part III, and the Medicare Hospital Manual in transmittal numbers 6097, 1824, and 7069, respectively, in February 2001.

Payment for Screening Colonoscopy

Payment for screening colonoscopy will be made under HCPCS code G0121: colorectal screening; colonoscopy for an individual not meeting criteria for high risk. As with current code G0105, screening colonoscopy for an individual at high risk, payment will be made at the level for a diagnostic colonoscopy, CPT code 45378, because the work is the same whether a procedure is screening or diagnostic. As the statute requires for both individuals who are or are not at high risk, if, during the course of the screening colonoscopy, a lesion or growth is detected that results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as colonoscopy with biopsy or removal should be billed and paid rather than HCPCS code G0105 or G0121.

E. Medical Nutrition Therapy

1. Legislation

Section 105 of the BIPA amended section 1861(s)(2) of the Act to authorize Medicare Part B coverage under Part B of medical nutrition therapy (MNT) for beneficiaries who have diabetes or renal disease, effective for services furnished on or after January 1, 2002. The legislation also:

  • Authorizes dietitians and nutritionists who meet certain qualifications to be reimbursed directly by Medicare.
  • Excludes from coverage beneficiaries who are receiving maintenance dialysis for which payment is made under section 1881 of the Act.
  • Requires coordination of medical nutrition therapy benefits with the existing benefit for diabetes outpatient self-management training services.
  • Defines a registered dietitian or other nutrition professional, and grandfathers dietitians or nutrition professionals who were licensed or certified in their States as of December 21, 2000, but would not otherwise meet the new requirements.
  • Specifies that Medicare payment for MNT services must equal 80 percent of the lesser of the actual charge for the services or 85 percent of the amount determined under the physician fee schedule for the same services if furnished by a physician.
  • Requires that we submit a report to the Congress by July 1, 2003, that contains recommendations with respect to expansion of the MNT benefit for other medical conditions.

This new benefit, while related, differs from the diabetes outpatient self-management training (DSMT) benefit, which was established by the BBA in section 1861(s)(2)(S) of the Act and described at section 1861(qq). The DSMT benefit is a comprehensive diabetes training program, of which nutrition training is only one component. Most of the available research (Diabetes Control and Complication Trial Research Group, 1993; UK Prospective Diabetes Study Group, 1995; and UK Prospective Diabetes Study Group, 1998) supports the use of a multi-disciplinary approach to diabetes, which includes nutrition training. As a result, nutrition training is considered to be an essential element of the DSMT benefit. Section 1861(qq) of the Act mandates the use of quality standards for DSMT and allows certified individuals or entities designated by the Secretary that meet such standards to receive Medicare payment for the service, provided that the physician managing the patient certified that DSMT is needed.

The approach in the BIPA with regard to MNT is different. The statute mandates specific qualifications regarding who may provide MNT services, but does not require that we establish quality standards. We are also instructed by the Congress to establish criteria for recognition of individuals in States that do not have licensure or certification requirements for registered dietitians or nutrition professionals.

We set specific duration and frequency limits for DSMT, consistent with the statutory authority granted by the BBA. In accordance with our regulations in § 410.141(c), all beneficiaries receiving the DSMT benefit may have up to 10 hours of initial training within a continuous 12-month period. For most beneficiaries, 9 of these 10 hours of training must be in a group setting. One hour of training may be on an individual basis for purposes of conducting an individual assessment and providing specialized training. Once a beneficiary has completed the 10 hours of initial Start Printed Page 40389training, the benefit provides for up to 2 hours of follow-up training each subsequent year. As with the DSMT benefit the duration and frequency of the MNT benefit was not prescribed by the Congress. However, since the Congress has indicated that beneficiaries who have received DSMT within a designated time period (to be specified by the Secretary) are not eligible for MNT, the two benefits must be coordinated.

2. Proposed Policy

Consistent with section 105(a)(3) of the BIPA, we considered the protocols of the American Dietetic Association and the National Kidney Foundation regarding nutrition training for both diabetes and renal disease. Because the protocols were inconclusive with respect to the duration and frequency issues, we are proposing to determine the duration and frequency of the benefit through the National Coverage Determination (NCD) process rather than through the rulemaking process. We will solicit the opinions of all interested parties as a part of the NCD process.

We propose to set forth the provisions regarding medical nutrition therapy at Part 410, subpart G and at § 414.64. The MNT provisions of the proposed rule are as follows:

Definitions (§ 410.130). We propose to define “renal disease” for the purpose of this benefit as only chronic renal insufficiency and post-transplant care provided after discharge from the hospital. The exclusion of patients receiving maintenance dialysis under section 1881 of the Act is consistent with section 1861(s)(2) of the Act, as amended by section 105(a)(3) of the BIPA. We propose to limit post-transplant care to care furnished within 6 months after discharge from the hospital, if the transplant is viable and effective, because under such conditions we believe the beneficiary would no longer have renal disease and would not be eligible to receive the benefit under the statutory provision. We propose a 6-month time period based on expert opinions. We specifically request comments on this proposed time period and request that commenters submit articles from clinical journals to support their comments. We do not make separate payments for MNT while the beneficiary is an inpatient in the hospital because the statute only authorizes payment for this service under Part B. We are proposing definitions of “diabetes” and “chronic renal insufficiency” for the purpose of this benefit using definitions from the Institute of Medicine report, “The Role of Nutrition in Maintaining Health in the Nation's Elderly,” published in 2000.

We propose to define “episode of care” as a time period that may not exceed 12 months, starting with the assessment (based on a referral from a physician), and including all covered interventions. The number of episodes of care covered during the lifetime of an individual beneficiary is unlimited. We chose a 12-month period to allow for the coordination of the MNT and DSMT benefits, as authorized by section 105(a)(3) of the BIPA.

Finally, in accordance with the statute, we define MNT services as nutritional diagnostic, therapy, and counseling services provided by a registered dietitian or nutrition professional for the purpose of managing disease. This definition tracks the language of the statute.

Medical Nutrition Therapy (§ 410.132).

At proposed § 410.132(a), we set forth conditions for coverage of MNT services. Specifically, we provide that Medicare Part B pays for MNT services furnished by a registered dietitian or nutrition professional as defined in § 410.134 when the beneficiary is referred for the service by the beneficiary's treating physician. We limit the definition of physician to “treating physician” to ensure that the physician establishing the need for MNT is actually treating the beneficiary for the chronic disease and the therapy is coordinated with the care being provided by the treating physician. Referrals by a non-treating physician might also be interpreted as an indication that a fraudulent situation exists.

We are proposing that the services covered will consist of nutritional assessment, interventions, reassessment, and follow-up interventions. We chose not to define the specific components of the benefit in more detail because we anticipate that registered dietitians and nutritionists will use nationally recognized protocols, such as those developed by the American Dietetic Association (ADA) as they normally would in their business practice. We also chose not to specify the number of hours of MNT that will be covered. Rather, we will develop these frequency limits using the NCD process. After we complete a literature review, we will solicit input from interested parties as part of the NCD process.

At § 410.132(b), we set forth proposed coverage limitations for MNT services. In accordance with section 1861(s)(2)(V)(ii) of the Act, we would provide that MNT services are not covered for beneficiaries on dialysis for end-stage renal disease. We do not exclude all beneficiaries who are diagnosed with end-stage renal disease because a few individuals with end-stage renal disease do not receive maintenance dialysis and the statute specifically excludes beneficiaries receiving maintenance dialysis under section 1881 of the Act. The other provisions of this section would coordinate the referrals for MNT for diabetes and renal disease, and coordinate MNT services with DSMT services as follows:

  • If a beneficiary has both diabetes and a renal disease as defined in this subpart, the beneficiary may receive both MNT and DSMT, but coverage in any 12-month period would be limited to the number of hours the beneficiary would receive under either the MNT benefit or the DSMT benefit for that period, whichever is greater.
  • MNT would only be covered if the beneficiary had not started initial training under the diabetes self-management training benefit (as described in § 410.141) within the past 12 months, unless: (1) the need for a reassessment had been documented by the referring physician; or (2) the beneficiary had been diagnosed with both diabetes and renal disease.
  • If a beneficiary diagnosed with diabetes was referred for both follow-up DSMT services and MNT, the beneficiary would only receive the total amount of hours covered under either follow-up DSMT services or MNT, whichever was greater.

If DSMT and MNT benefits overlapped, we would not allow the number of hours covered under the MNT benefit to exceed the hours Medicare would cover if the beneficiary was only receiving DSMT, except if a beneficiary receiving initial DSMT subsequently was diagnosed with renal disease or if there was a change in diagnosis or medical condition that occurred during an episode of care. We would allow additional hours of coverage for patients with renal disease and diabetes because MNT for renal disease is more complex than MNT for diabetes alone.

Eligibility for MNT services would be dependent upon diagnoses and referrals made by the treating physician. At proposed § 410.132(c), we provide that referral may only be made by the treating physician when the beneficiary has been diagnosed with diabetes or renal disease, with documentation maintained by the referring physician in the beneficiary's medical record. Referrals must be made for each episode of care. We note that the statute Start Printed Page 40390specifies that a physician, as defined in section 1861(r)(1) of the Act, must refer the beneficiary in order for the therapy to be covered. We are proposing to limit referrals to those made by the treating physician as noted earlier.

At proposed § 410.132(d), we set forth requirements regarding reassessment and follow-up interventions. Specifically, we provide that reassessments and follow-up interventions would only be covered when the referring physician determines that there was a change of diagnosis or medical condition within an episode of care that made a change in diet necessary.

Provider Qualifications (§ 410.134). BIPA specifies how we must define “registered dietitian or nutrition professional” for the purposes of this benefit and allows for the grandfathering of nutrition professionals licensed or certified by States at the time of BIPA's enactment. Pursuant to BIPA, a registered dietitian or nutrition professional means an individual who meets the following criteria:

  • Holds a bachelor's or higher degree granted by a regionally accredited ollege or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics, as accredited by an appropriate national accreditation organization we have recognized for this purpose.
  • Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
  • Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed, or, if a State does not provide for licensure or certification, meets other criteria established by the Secretary.

We propose to exercise our statutory discretion, with respect to such alternative criteria, by providing that in States that do not provide licensure or certification requirements, we would use the designation of “registered dietitian” as certified by the Commission on Dietetic Registration, the credentialing agency for the American Dietetic Association; or require compliance with the statutory educational and experience requirements alone. The Commission on Dietetic Registration is currently considered to be the recognized standard in certification programs for registered dietitians. If an individual can supply documentation to us that he/she is a “registered dietitian,” we would not require that individual to also supply documentation that he/she meets the minimum statutory educational and experience requirements, because these latter requirements are also requirements an individual must currently meet to become a “registered dietitian.” Likewise, if an individual supplies documentation to us that he/she meets the minimum statutory educational and experience requirements, that individual would not need to supply documentation to us that he/she is a “registered dietitian.”

The statute also requires that an individual who, as of December 21, 2000 (BIPA's date of enactment), is licensed or certified under the law of the State in which the services are performed as a dietitian or nutrition professional, qualifies as a “registered dietitian or nutrition professional” even if he or she does not meet the other education and experience requirements. There is no provision in the law to allow grandfathering of dietitian or nutrition professionals in States with no licensure or certification requirements, or of individuals who did not choose to be licensed or credentialed as of the date of enactment of section 1861(vv)(3) of the Act. Therefore, we only provide for “grandfathering” of individuals who do meet the specific criteria of section 1861(vv)(3) of the Act.

Payment for Medical Nutrition Therapy (§ 414.64). Section 105(c) of the BIPA requires that we pay for medical nutrition therapy services at 80 percent of the lesser of the actual charge for the services or 85 percent of the amount determined under the physician fee schedule for the same services if such services had been furnished by a physician. Section 1848 of the Act requires that payments under the physician fee schedule be established on national uniform RVUs based on the resources used in furnishing a service. We have consulted with the ADA to assess the types of resource inputs that are used to furnish a 15-minute medical nutrition therapy session by a Registered Dietitian or Professional Nutritionist.

As stated above, these services would be paid under the physician fee schedule. Malpractice RVUs for medical nutrition therapy services have been extrapolated based on analogous service procedures. The statute specifically provides that medical nutrition therapy services may only be provided by registered dietitians or nutrition professionals. We do not believe that physicians will be able to satisfy the qualification requirements and therefore will not be able to provide this service themselves. Therefore, we are not establishing physician work RVUs for this service. We interpret section 105(c)(2) of BIPA to mean that if a physician were to furnish this service, that the service was performed “incident to” the physicians treatment plan and provided by a registered dietitian or nutrition professional. Since we are not proposing work RVUs for medical nutrition therapy, we propose to determine practice expense RVUs using the practice expense methodology for the “zero work pool.” (For more information about the practice expense methodology for services that have no physician work, see the November 2, 1998 final rule (63 FR 58814)). The proposed RVUs for individuals and individuals in a group are found in Table 5 as follows:

Table 5.—RVUs for Individuals and Individuals in a Group

CodeDescriptionWork RVUsPractice expense RVUsMalpractice RVUsTotal
97802Medical nutrition, individual, initial0.000.470.010.48
97803Medical nutrition, individual, subseq0.000.340.010.35
97804Medical nutrition, group0.000.140.010.15

Much like diabetes education, the number of MNT beneficiaries attending a group session would vary. As defined in the CPT's Physical Medicine Rehabilitation codes, a group is considered to be two or more individuals.

We would refine the medical nutritional therapy services payment amounts in the future by including the services into the refinement process Start Printed Page 40391used for other Medicare services payable under the physician fee schedule.

Medicare co-payments and deductibles would apply for medical nutritional therapy services. We are proposing to pay for this service under the physician fee schedule using the following codes:

CPT 97802—Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes.

CPT 97803—reassessments and intervention, individual, face-to-face with the patient, each 15 minutes.

CPT 97804—Group, 2 or more individuals, each 30 minutes.

Since payment for MNT will be included in our payment for facility services, separate payment will not be made for hospital inpatients or skilled nursing facility patients. Section 105(c) of BIPA amends section 1833(a)(1) to add subparagraph (T), requiring Medicare payment to equal 80 percent of the of the lesser of the actual charge for the service or 85 percent of the amount determined under the physician fee schedule. Thus, we will make payment in the hospital outpatient department, Federally Qualified Health Centers and Rural Health Clinics at the lesser of 80 percent of the actual charge or 85 percent of the physician fee schedule amount. The RVUs shown above do not reflect this 85 percent adjustment. To determine payment, the RVUs shown above will need to be multiplied by the physician fee schedule conversion factor and 0.85. We expect to provide the Medicare carriers with a payment file that includes this 85 percent adjustment. That is, we expect to determine the payment amount using the RVUs shown and apply the 85 percent adjustment to the product of the geographically adjusted RVUs and conversion factor. The Medicare carriers will not need to make any additional adjustment to the payments we provide.

F. Telehealth Services

1. Background

a. History. Before January 1, 1999, payment for services delivered via a telecommunications system was limited to services that do not require a face-to-face, “hands-on” encounter under the traditional delivery of medical care. Examples of these services include interpretation of an x-ray, electrocardiogram and electroencephalogram tracings, and cardiac pacemaker analysis.

The BBA provided for coverage of and payment for consultation services delivered via a telecommunications system to Medicare beneficiaries residing in rural health professional shortage areas (HPSA) as defined by section 332(a)(1)(A) of the Public Health Services Act. Additionally, a Medicare practitioner was required to be with the patient at the time of a teleconsultation.

The BBA specified that payment for a teleconsultation had to be shared between the consulting physician or practitioner and the referring physician or practitioner and could not exceed the fee schedule payment which would have been made to the consultant for the service provided. The BBA prohibited payment for any line charges or facility fees associated with the teleconsultation and clarified that the beneficiary may not be billed for these charges or fees.

These provisions became effective January 1, 1999. The November 2, 1998 final rule on “Revisions to Payment Policies Under the Physicians Fee Schedule for Calendar Year 1999” (63 FR 58879) implemented these provisions.

b. Legislative Summary. In section 223 of the BIPA, the Congress provided for a “Revision of Medicare Reimbursement for Telehealth Services” and specified a “sunset” date for the current statutory teleconsultation provisions. The current teleconsultation provisions contained in section 4206(a) and (b) of the BBA and implemented in §§ 410.78 and 414.65 apply only to teleconsultations provided on or after January 1, 1999 and before October 1, 2001.

Beginning October 1, 2001, the BIPA amends section 1834 of the Act to provide for a new subsection (m) “Payment for Telehealth Services.” This amendment provides for an expansion of Medicare payment for telehealth services. A summary of the expansion appears below.

The BIPA specifies that we pay for telehealth services that are furnished via a telecommunications system by a physician (as defined in section 1861(r) of the Act) or a practitioner (described in section 1842(b)(18)(C) of the Act). Telehealth services may be provided only to an eligible telehealth individual enrolled under Medicare, notwithstanding the fact that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary.

The BIPA defines Medicare telehealth services as professional consultations, office or other outpatient visits, and office psychiatry services identified as of July 1, 2000, by CPT codes 99241 through 99275; 99201 through 99215, 90804 through 90809 and 90862 (and as we may subsequently modify) and any additional service we specify.

The statute requires us to establish a process that provides, on an annual basis, for the addition or deletion of services (and HCPCS codes) as appropriate, to the services specified above, for authorized payment under Medicare.

Section 1834(m)(4)(B) of the Act, as added by the BIPA, specifies that an eligible telehealth individual means an individual enrolled under Part B who receives a telehealth service furnished at an originating site. Originating sites are defined only as specified medical facilities located in specific geographic areas. Section 1834(m)(4)(C) of the Act, as added by the BIPA, limits originating sites to the following types of facilities:

  • The office of a physician or practitioner.
  • A critical access hospital (as defined in section 1861(mm)(1) of the Act).
  • A rural health clinic (as defined in section 1861(aa)(s) of the Act).
  • A Federally qualified health center (as defined in section 1861(aa)(4) of the Act).
  • A hospital (as defined in section 1861(e) of the Act).

The BIPA specifies that the originating site must be located in one of the following geographic areas:

  • In an area that is designated as a rural health professional shortage area under section 332(a)(1)(A) of the Public Health Service Act.
  • In a county that is not included in a Metropolitan Statistical Area.
  • From an entity that participates in a Federal telemedicine demonstration project that has been approved by (or receives funding from) the Secretary of Health and Human Services as of December 31, 2000.

The BIPA relaxes some of the conditions for payment imposed by the BBA. Section 1834(m)(2)(C) of the Act, as added by the BIPA, specifies that a telepresenter is not required and specifically states that nothing in section 1834(m)(2)(C) of the Act shall be construed as requiring an eligible telehealth beneficiary to be presented by a physician or practitioner at the originating site for the furnishing of a service via a telecommunications system, unless it is medically necessary (as determined by the physician or practitioner at the distant site).

Additionally, section 1834(m)(1) of the Act, as added by the BIPA, specifies that, for purposes of defining a telecommunications system, in the case of any Federal telemedicine demonstration program conducted in Alaska or Hawaii, the term “telecommunications system” includes store and forward technologies that Start Printed Page 40392provide for the asynchronous transmission of health care information in single or multimedia formats.

Section 1834(m)(2) of the Act, as added by the BIPA, states that we pay a physician or practitioner located at a distant site that furnishes a telehealth service to an eligible telehealth beneficiary an amount equal to the amount that the physician or practitioner would have been paid under Medicare had the service been furnished without the use of a telecommunications system.

This section also provides for a facility fee payment to the originating site. It specifies that for the period beginning October 1, 2001 through December 31, 2002, the originating site facility fee is equal to $20. For each subsequent year, the facility fee for the preceding year is increased by the percentage increase in the MEI as defined in section 1842(i)(3) of the Act.

The BIPA amended section 1833(a)(1) of the Act by adding subparagraph (U), specifying that with respect to the originating site facility fees, the amount paid is 80 percent of the lesser of the actual charge or the amounts specified in new section 1834(m)(2) of the Act.

Section 1834(m)(3) of the Act requires that the provisions of sections 1848(g) and 1842(b)(18)(A) and (B) of the Act apply to physicians and practitioners. The provisions of section 1842(b)(18) of the Act apply to originating sites receiving a facility payment as the provisions apply to practitioners under section 1834(m) of the Act.

Section 1848(g) of the Act provides a limitation of charges to beneficiaries and provides sanctions if a physician, supplier, or other person knowingly and willfully bills or collects for services in violation of the limitation. It also provides for sanctions if a physician, supplier, or other person fails—(1) to timely correct excess charges by reducing the actual charge billed for the service to an amount that does not exceed the limiting charge for the service, or (2) to timely refund excess collections. In addition, it requires that physicians and suppliers submit claims for services they furnished to a beneficiary to a carrier on behalf of the beneficiary using a standard Medicare claim form. The statute imposes a penalty for failure to submit the claim. In addition, section 1848(g) of the Act prohibits imposing any charge relating to completing and submitting the claim. Section 1842(b)(18) of the Act provides that services furnished by a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, anesthesiologist's assistant, certified nurse-midwife, clinical social worker, or clinical psychologist for which payment may be made on a reasonable charge or fee schedule basis may be made only on an assignment-related basis. It also limits the beneficiary's liability to any applicable deductible and coinsurance amounts. It further provides for sanctions against a practitioner who knowingly and willfully bills (or collects an amount) in violation of the limitation.

c. Implementation. Section 223 of the BIPA limits the application of the existing telehealth provision to services furnished before October 1, 2001 and mandates that the expanded benefit be effective for services furnished on or after October 1, 2001. Therefore, this benefit expansion is being implemented via program memorandum. The program memorandum is effective October 1, 2001 when the telehealth benefit supercedes the teleconsultation benefit authorized by section 4206 of the BBA and existing regulations at § 410.78 and § 414.65. Any regulatory changes resulting from this rulemaking process will be effective January 1, 2002.

d. Proposed Policies. This rule proposes to establish policies for implementing the provisions of section 1834(m) of the Act, as added by the BIPA, that change Medicare payment for telehealth services.

(i) Scope of telehealth benefit. Section 1834(m)(4)(B) of the Act, as added by the BIPA, defines an eligible telehealth individual as a Medicare beneficiary who receives a telehealth service furnished at an originating site. As discussed earlier, originating sites are limited to certain facilities within specifically identified geographic areas.

We would revise § 410.78 to specify that Medicare beneficiaries are eligible for telehealth services only if they receive services from an originating site located in either a rural HPSA as defined by section 332(a)(1)(A) of the Public Health Services Act or in a county outside of a MSA as defined by section 1886(d)(2)(D) of the Act. Additionally, we would provide for an exception if an entity participates in a Federal telemedicine demonstration project that has been approved by, or receives funding from, us as of December 31, 2000. That entity would not be required to be in a rural HPSA or non-MSA as described above.

We would also specify that, providing the geographic criteria are met, the following sites qualify as originating sites under this provision:

  • The office of a physician or practitioner.
  • A hospital as defined in section 1861(e) of the Act.
  • A critical access hospital as defined in section 1861(mm)(1).
  • A rural health clinic as defined in section 1861(aa)(2) of the Act.
  • A Federally qualified health center as defined in section 1861(aa)(4) of the Act.

Covered Services. Section 1834(m)(4)(F) of the Act, as added by the BIPA, defines telehealth services as professional consultations, office and other outpatient visits, individual psychotherapy, pharmacologic management and any additional service we specify. Additionally, this provision identifies covered services by HCPCS codes identified as of July 1, 2000. We propose to revise § 410.78 to implement this coverage expansion. The services and corresponding CPT codes are listed below:

  • Consultations (codes 99241 through 99275).
  • Office and other outpatient visits (codes 99201 through 99215).
  • Individual Psychotherapy (codes 90804 through 90809).
  • Pharmacologic management (code 90862).

The BIPA provision is effective for services beginning on October 1, 2001. Payment for the statutorily specified codes, as listed above, will be implemented beginning with that date. We propose to make any additions or deletions to the services defined as telehealth effective on a January 1st basis. We plan to use the annual physician fee schedule proposed rule published in the summer and the final rule (published by November 1) each year as the vehicle to make these changes. Since the statutory provision will be implemented on October 1, 2001, and there is limited published data on telehealth in clinical settings, we will not make any recommendations on additional services until we have had time to ensure we have a process for redefining covered services in place.

We are soliciting suggestions and comments from the public regarding the guidelines that we should use to make additions or deletions of services. We also solicit suggestions and comments about specific services that may be appropriate to be covered under the Medicare telehealth benefit. Once we complete our review of these suggestions and comments, we will propose a more detailed approach as to how we would make modifications to the existing telehealth benefit.

(ii) Conditions of Payment: Technology. The Congress defines the term “telecommunications system” with respect to demonstration projects conducted in Alaska or Hawaii; however, the BIPA does not define a Start Printed Page 40393telecommunications system in any other case. In a non-telehealth setting, Medicare pays for these codes only if there is a face-to-face encounter between the patient and attending physician or practitioner. We believe that the patient's presence and use of an interactive audio and video telecommunications system permitting the distant site practitioner to interact with the patient provides a reasonable substitute for a face-to-face encounter.

Limited exception to the interactive telecommunications requirement. For purposes of defining a telecommunications system, section 1834(m)(1) of the Act includes the use of store and forward technology in very limited circumstances. This provision specifies that, in the case of a Federal telemedicine demonstration program conducted in Alaska or Hawaii, Medicare payment is permitted when asynchronous, store and forward technologies, in single or multimedia formats is used to deliver the service.

Store and forward technology substitutes for an interactive, patient-present encounter in these limited circumstances. The patient is not present or available to interact with the distant site physician or practitioner in real-time.

We believe that when store and forward technologies are used to substitute for an interactive patient encounter, the technology must permit the distant site practitioner adequate medical information for recommending or confirming a diagnosis or treatment plan. A patient's medical information may typically include various combinations of the following items—video clips, still images, x-rays, magnetic resonance images, electrocardiogram and electroencephalogram tracings, tissue samples, laboratory results, and audio clips of heart or lungs.

We propose to specify at § 410.78 that, except for the statutory provision noted above, an interactive telecommunications system must be used and that the medical examination of the patient is at the control of the physician or practitioner at the distant site. We would define interactive telecommunications system as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and physician or practitioner at the distant site. We would also specify that telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system.

Additionally, we would provide an exception to the interactive requirements where the patient must be present for a Federal telemedicine demonstration program conducted in Alaska or Hawaii. We would specify that for Federal telemedicine demonstration programs conducted in Alaska or Hawaii, Medicare payment is permitted for telehealth when asynchronous store and forward technologies, in single or multimedia formats, are used as a substitute for an interactive telecommunications system. Additionally, we would specify that the physician or practitioner at the distant site must be affiliated with the demonstration program.

This exception would be permitted for Federal telemedicine demonstration projects conducted in Alaska or Hawaii only. Interactive telecommunications system with the real-time presence of the patient is required as a condition of payment in all other circumstances.

We would define asynchronous, store and forward technologies, as the transmission of the patient's medical information from an originating site to the physician or practitioner at the distant site. The physician or practitioner at the distant site can review the medical case without the patient being present. Asynchronous telecommunications system in single media format does not include telephone calls, images transmitted via facsimile machines, and text messages without visualization of the patient (electronic mail). Photographs must be specific to the patient's medical condition and adequate for rendering or confirming a diagnosis or treatment plan. Dermatological photographs, for example, a photograph of a skin lesion may be considered to meet the requirement of a single media format under this provision.

Additionally, we would define the originating site as the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. For asynchronous, store and forward telecommunications technologies, an originating site is a Federal telemedicine demonstration program conducted in Alaska or Hawaii.

Telepresenter. As mentioned earlier, the BIPA changed the telepresenter requirements. In accordance with section 1834(m)(2)(C) of the Act, a telepresenter is not required to be present. Therefore, we would not require a telepresenter as a condition of Medicare payment.

Practitioners eligible to receive payment for Medicare Telehealth Services. Section 1834(m)(1) of the Act requires that Medicare make payments for telehealth services furnished via a telecommunications system by a physician or a practitioner (described in section 1842(b)(18)(C) of the Act). Non-physician practitioners described in this section of the Act include nurse practitioners, physician assistants, clinical nurse specialists, certified nurse midwives, clinical psychologists, clinical social workers, and certified registered nurse anesthetists or anesthesiologists' assistants. Section 1834(m)(2) of the Act specifies that the payment amount to the physician or practitioner at the distant site who furnishes a telehealth service be equal to the amount that the physician or practitioner would have been paid under Medicare had the service been furnished without the use of a telecommunications system.

As discussed earlier in this document, covered telehealth services include office visits (codes 99201 through 99215), consultation (codes 99241 through 99275), individual psychotherapy (codes 90804 through 90809), and pharmacologic management (code 90862). If a physician, clinical nurse specialist, nurse practitioner, physician assistant, nurse midwife, clinical psychologist, or clinical social worker is licensed under State law to provide a service listed above, then these practitioners may bill for and receive payment for this service when delivered via a telecommunications system.

Clinical psychologists and clinical social workers cannot bill or receive payment for psychotherapy involving evaluation and management services under Medicare when the service is delivered face-to-face (that is, without the use of a telecommunications system). Therefore, clinical psychologists and clinical social workers cannot receive payment for these services under the telehealth benefit.

Certified registered nurse anesthetists and anesthesiologists' assistants are not eligible. Certified registered nurse anesthetists and anesthesiologists' assistants would not be permitted to bill for and receive payment for a telehealth service under this provision. Section 1861(bb) of the Act defines services provided by these practitioners as anesthesia services and related care only. Under the Medicare program, these practitioners do not receive payment for office visits, consultation, individual psychotherapy, or pharmacologic management when these services are furnished without the use of a telecommunications system. Section 1834(m)(2) of the Act specifies that the Start Printed Page 40394payment amount made to the distant site physician or practitioner must be equal to what would have been paid for the service without the use of a telecommunications system. Therefore, certified registered nurse anesthetists and anesthesiologists' assistants would not receive payment for telehealth services.

Proposed regulatory provisions. Based on the law, we would state at § 410.78 that, as a condition of Part B payment for telehealth services, the physician or practitioner at the distant site must be licensed to provide the service under State law. When the physician or practitioner at the distant site is licensed under State law to provide a covered telehealth service (that is, professional consultations, office and other outpatient visits, individual psychotherapy, and pharmacologic management), then he or she may bill for and receive payment for this service when delivered via a telecommunications system.

We would specify that the physician or practitioner at the distant site may be any of the following (provided that the physician or practitioner is licensed to bill for the service being furnished via a telecommunications system):

  • A physician as described in § 410.20.
  • A physician assistant as defined in § 410.74.
  • A nurse practitioner as defined in § 410.75.
  • A clinical nurse specialist as described in § 410.76.
  • A nurse midwife as defined in § 410.77.
  • A clinical psychologist as described in § 410.71.
  • A clinical social worker as defined in § 410.73.

However, we would further specify that a clinical psychologist and clinical social worker may bill for individual psychotherapy furnished via a telecommunications system, but may not seek payment for medical evaluation and management services.

Documentation. Documentation requirements as specified in our most recent documentation guidelines are applicable to services delivered via a telecommunications system. At this time, we will not require additional documentation under this provision beyond what is already required for medical services delivered without the use of a telecommunications system. Medicare documentation guidelines are available from our web site. You may access our documentation guidelines by using the following directions:

1. Go to the CMS Homepage (http://www.cms.gov).

2. Click on “Medicare” (Top left hand column).

3. Click on “Professional/Technical Information”

4. Click on “Documentation Guidelines for Evaluation and Management Services:”

5. You may choose the 1995 version or the 1997 version whichever best fits your needs.

(iii) Payment provisions. Professional Services: General—Section 1834(m)(2)(A) of the Act, specifies that the payment amount for the professional service is equal to the amount that would have been paid without the use of a telecommunications system. Medicare payment for physicians' services is generally based, under section 1848 of the Act, on the resource-based physician fee schedule. Payment to other health care practitioners listed earlier, authorized under section 1833 of the Act, is based on a percentage of the physician fee schedule payment amount. Therefore, we would pay for office or other outpatient visits, consultation, individual psychotherapy, and pharmacologic management services furnished by physicians at 80 percent of the lower of the actual charge or the fee schedule amount for physicians' services. We would also pay for services furnished by other practitioners at 80 percent of the lower of the actual charge or that practitioner's respective percentage of the physician fee schedule (for example, the fee schedule amount for clinical psychologists would be 100 percent of the physician fee schedule; for clinical social workers, the payment would be made at 75 percent of the clinical psychologist fee schedule; for certified nurse midwives, the payment would be made at 65 percent of the physicians fee schedule; and for all other eligible health care practitioners, payment would be made at 85 percent of the physician fee schedule). Assuming the beneficiary has met his or her Part B deductible, the beneficiary would be responsible for 20 percent of the appropriate payment amount.

Payment for Telepresenter. Section 1834(m)(2) of the Act, provides for a professional fee for the physician or practitioner at the distant site (equal to the applicable Part B fee schedule amount) and a $20 facility fee for the originating site. Telepresenters are not required, unless one is deemed medically necessary by the physician or practitioner at the distant site. BIPA does not address the issue of payment for the telepresenter. The Office of the Inspector General has advised us that permitting the physician or practitioner at the distant site to pay the telepresenter creates a significant risk under the anti-kickback statute and may also violate many State fee-splitting laws. Therefore, we would propose in § 414.65 that payments made to the distant site physician or practitioner for professional fees, including deductible and coinsurance (for the professional service), are not to be shared with the referring practitioner or telepresenter.

However, the telepresenter could bill and receive payment for services that are not telehealth services that a telepresenter would otherwise be allowed to provide under the Medicare statute, including services furnished on the same day as the telehealth service.

Facility Fee for the Originating Site. The BBA prohibited any payment for line charges or facility fees associated with a professional consultation via a telecommunications system. Section 1834(m)(2)(B) of the Act, as added by the BIPA, provides for a facility fee payment to the originating site, specifying that the amount of payment is 80 percent of the lesser of the actual charge or a facility fee of $20.00. The BIPA further specifies that, beginning January 1, 2003, the originating facility fee be increased annually by the Medicare Economic Index (MEI) as defined in section 1842(i)(3) of the Act. Additionally, we clarify that the Geographic Practice Cost Index (GPCI) would not apply to the facility fee for the originating site. This fee is statutorily set and is not subject to the geographic payment adjustments authorized under the physician's fee schedule. The beneficiary is responsible for any unmet deductible amount and Medicare coinsurance. We would revise § 414.65 to provide for payment of a facility fee to the originating site.

Coding. For office and other outpatient visits, consultation, individual psychotherapy, and pharmacologic management delivered via a telecommunications system, we would use modifiers in conjunction with existing CPT codes to indicate the use of a telecommunications system in delivering the service.

A new HCPCS code for the facility fee for the originating site will be used to identify this fee. Since this is a new occasion of payment under Medicare, a separate and distinct code for the facility fee is necessary for contractors to make the appropriate payment.

G. Indian Health Service

The Indian health care system provides primary health care to many American Indian and Alaska Native Medicare beneficiaries. This system consists of programs operated by a Start Printed Page 40395Federal agency, the Indian Health Service (IHS), and Federally funded programs operated by Indian tribes, tribal organizations, and urban Indian organizations (as those terms are defined in section 4 of the Indian Health Care Improvement Act). These programs deliver a range of clinical and preventive health services to their beneficiaries through a network of facilities including hospitals and outpatient clinics. Programs operated in IHS-owned or leased facilities, by IHS or by tribes or tribal organizations, are considered “Federal providers” by Medicare. Sections 1814(c) and 1835(d) of the Act generally prohibit payment to Federal providers, subject to exceptions contained in section 1880 of the Act for these IHS facilities. Prior to enactment of the BIPA, the exception in section 1880 of the Act was applicable only to IHS hospitals including provider-based clinics (IHS hospital outpatient clinics) and skilled nursing facilities. The exception did not permit Medicare to pay for services furnished by IHS free-standing outpatient clinics or to pay any IHS facilities for services by physicians and other practitioners paid under a fee schedule.

Effective July 1, 2001, section 432 of the BIPA extends the exception in section 1880 of the Act to permit Medicare payments to hospitals and outpatient clinics (provider-based or free-standing), operated by the IHS or by a tribe or tribal organization, for services furnished by physicians and specified non-physician practitioners in or at the direction of an IHS hospital or outpatient clinic. Payments for these services are made to the IHS or tribal hospital or outpatient clinic, not to the physician or other practitioner. These payments are subject to the same situations, terms, and conditions as would apply if the services were furnished in or at the direction of a hospital or outpatient clinic that is not operated by the IHS or by a tribe or tribal organization. The payments include incentive payments for physicians furnishing covered physicians' services in rural or urban HPSAs if the usual HPSA criteria are met. (For further information see section 1833 of the Act and § 414.42 of our regulations.) Payments will not be made under these provisions to the extent that Medicare is otherwise paying for the same services under other provisions (for example, as part of a bundled payment, or if a tribal hospital outpatient clinic continues to bill as a Federally qualified health center (FQHC)).

We are adding a new § 410.46 to our regulations to reflect this new statutory provision. Due to the statutory effective date of July 1, 2001, we will implement this BIPA provision through program memorandum instructions.

H. Pathology Services

Background

The November 2, 1999 final rule (64 FR 59380) provided that, for services furnished on or after January, 1, 2001, carriers would no longer pay claims to independent laboratories under the physician fee schedule for the technical component (TC) of physician pathology services for hospital inpatients. Before this rule, independent laboratories could bill the carrier under the physician fee schedule for the TC of a physician pathology service furnished to a hospital inpatient. Under the rule, independent labs would still have been able to bill and receive payment for TC physician pathology services furnished to patients who are not hospital inpatients. (The TC of physicians' pathology services includes the TC of cytopathology and surgical pathology physicians' services as described in the Medicare Carrier Manual, section 15020 B and C.) This change was to take effect for services furnished on or after January 1, 2001. The delay between publication and effective date was intended to allow independent laboratories and hospitals sufficient time to negotiate new arrangements, if necessary.

BIPA Provision

Section 542 of the BIPA requires the Medicare carrier to continue to pay for the TC of physician pathology services when an independent laboratory furnishes these services to an inpatient or outpatient of a covered hospital. The BIPA provisions apply to TC services furnished during the 2-year period beginning January 1, 2001 and continuing through December 31, 2002. We informed the carriers and the intermediaries of this provision through program memorandum AB-01-47 which was issued in March 2001. This program memorandum requested the carriers to notify independent laboratories of this provision in their next regularly scheduled bulletin and to place this bulletin on their Internet web site.

In the absence of further legislation, the policy of the November 1999 final rule will take effect for the TC of physician pathology services furnished to hospital patients after December 31, 2002.

Definitions

For this provision, “covered hospital” means a hospital that had an arrangement with an independent laboratory that was in effect as of July 22, 1999, under which a laboratory furnished the TC of physician pathology services to fee-for-service Medicare beneficiaries who were hospital inpatients or outpatients and submitted claims for payment for the TC to a carrier. The TC could have been submitted separately or combined with the professional component and reported as a combined service.

The term “fee-for-service Medicare beneficiary” means an individual who—(1) Is entitled to benefits under Part A or enrolled under Part B of Title XVIII or both, and; (2) Is not enrolled in any of the following:

  • A Medicare+Choice plan under Part C of that title.
  • A plan offered by an eligible organization under section 1876 of the Act.
  • A program of all-inclusive care for the elderly (PACE) under section 1894 of the Act.
  • A social health maintenance organization (SHMO) demonstration project established under section 4018(b) of the Omnibus Budget Reconciliation Act of 1987.

V. Collection of Information Requirements

Under the Paperwork Reduction Act (PRA) of 1995, we are required to provide 60-day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues:

  • The need for the information collection and its usefulness in carrying out the proper functions of our agency.
  • The accuracy of our estimate of the information collection burden.
  • The quality, utility, and clarity of the information to be collected.
  • Recommendations to minimize the information collection burden on the affected public, including automated collection techniques.

We are soliciting public comment on each of these issues for the following sections of this document that contain information collection requirements:

§ 410.132—Medical Nutrition Therapy

Paragraph (c) of this section requires a referring physician or practitioner to Start Printed Page 40396maintain referral documentation in the beneficiary's medical record for each referral. Paragraph (b)(3)(i) requires that the referring physician or qualified non-physician practitioner document a reassessment in the beneficiary's medical record. Paragraph (e) of this section requires the medical nutrition therapy care plan to be sent to the referring physician initially and each time the medical nutrition therapy care plan is updated. If the physician makes recommendations regarding the medical nutrition therapy care plan, the registered dietitian or nutrition professional must integrate the requirements into the medical nutrition therapy care plan.

We believe the burden associated with these provisions is exempt in accordance with 5 CFR 1320.3(b)(2) because the time, effort, and financial resources necessary to comply with these requirements would be incurred by certified providers in the normal course of business activities.

If you comment on these information collection and recordkeeping requirements, please mail copies directly to the following:

Health Care Financing Administration, Office of Information Services, Information Technology Investment Management Group, Attn.: John Burke, CMS-1169-P, Room N2-14-26, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503, Attn: Allison Eydt, CMS Desk Officer.

VI. Response to Comments

Because of the large number of items of correspondence we normally receive on Federal Register documents published for comment, we are not able to acknowledge or respond to them individually. We will consider all comments we receive by the date and time specified in the “DATES” section of this preamble, and, if we proceed with a subsequent document, we will respond to the major comments in the preamble to that document.

VII. Regulatory Impact Analysis

We have examined the impact of this rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act (RFA) (Public Law 96-354). Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis must be prepared for proposed rules with economically significant effects (that is, a proposed rule that would have an annual effect on the economy of $100 million or more or would adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, or tribal governments or communities). We estimate the changes to the practice expense RVUs (not including earlier proposed changes to the work RVUs) may result in a redistribution of payments among physician specialties of approximately $100 million. We estimate the benefit changes in this proposed rule resulting from the BIPA will likely result in additional Medicare expenditures of $210 to $360 million or more for any single FY through FY 2006. Therefore, this proposed rule is considered economically significant, and, thus, we have prepared a regulatory impact analysis.

The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations and government agencies. Most hospitals, and most other providers, physicians, and health care suppliers are small entities, either by nonprofit status or by having revenues of $7.5 million or less annually for physicians and $5 million or less for other practitioners. For purposes of the RFA and based on small business administration data for 1997, we estimate that there are 162,000 physician organizations that meet the definition of a small entity. There are about 700,000 physicians and other practitioners who receive Medicare payment under the physician fee schedule. Individuals and States are not included in the definition of a small entity.

Section 1102(b) of the Social Security Act requires us to prepare a regulatory impact analysis for any proposed rule that may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside a Metropolitan Statistical Area and has fewer than 100 beds.

Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in expenditure in any one year by State, local, or tribal governments, in the aggregate, or by the private sector, of $110 million. We have determined that this proposed rule will have no consequential effect on State, local, or tribal governments. We believe the private sector cost of this rule falls below the above-stated threshold as well.

Thus, we have prepared the following analysis, which together with the rest of this preamble, meets all assessment requirements. It explains the rationale for, and purposes of, the rule, details the costs and benefits of the rule, analyzes alternatives, and presents the measures we propose to use to minimize the burden on small entities.

A. Resource-Based Practice Expense Relative Value Units and 5-Year Review Changes

Under section 1848(c)(2) of the Act, adjustments to relative value units may not cause the amount of expenditures to differ by more than $20 million from the amount expenditures would have been without such adjustments. We are proposing several changes that would result in a change of expenditures exceeding $20 million without offsetting adjustments to either the conversion factor or relative value units. In the June 8, 2001 Five-Year Review of Relative Value Units Under the Physician Fee Schedule, (66 FR 31028), we described the specialty level impact on payments of proposed changes in work RVUs. We estimated that the increase in physician work RVUs would increase expenditures by more than $20 million without an offsetting adjustment to either the relative value units or conversion factor. We proposed to meet the budget neutrality requirements in the statute by reducing the physician fee schedule conversion factor by an estimated 0.3 percent. Since the changes to the physician work RVUs included in our earlier proposed notice will affect payments in 2002, we are repeating those impacts in Table 6. In addition, we are also showing the impact of proposed changes that will affect the practice expense relative value units.

With respect to practice expense, our policy has been to meet the budget neutrality requirements in the statute by incorporating a rescaling adjustment in the practice expense methodology. That is, we determined the aggregate number of practice expense relative values that will be paid under current and proposed policy in 2002. We apply a uniform adjustment factor to all proposed practice expense relative value units to make them equal to the aggregate Start Printed Page 40397number of practice expense relative values that we estimate will be paid under current policy. Table 6 shows the specialty level impact on payment of changes being proposed for 2002.

The three columns under the label “5-Year Review of Work” show the estimated change in payments that will result from our earlier notice on the 5-Year Review of Work Relative Value Units. The column labeled “Work” shows the impact on total payments that will result from increases in physician work relative value units. Since the practice expense relative value units are based, in part, on the physician work, the 5-year review will also result in a change to the practice expense relative value units. The column labeled “Practice Expense” shows this impact and includes the effect of the rescaling adjustment discussed above to make the practice expense relative value units budget neutral. The column labeled “Total” reflects the total impact on payments resulting from proposed changes in work and practice expense from the 5-year review of physician work. This column includes the effect of a 0.3 percent reduction to the physician fee schedule conversion factor to meet the budget neutrality requirements in the statute.

The column labeled “New Time” reflects the estimated specialty level impact on payments that will result from using new physician times in the practice expense methodology. As described earlier in section II.A., physician time is used in conjunction with information on practice expense per hour and Medicare utilization to create specialty practice expense pools that are used to allocate practice expenses to different services. The RUC earlier indicated to us that some of the times we were using in the practice expense methodology differed from the times included in the RUC database. We understand that the RUC has made substantial efforts to validate the time in its database with physician specialty societies and to supply us with times that were missing for some services. The RUC recently forwarded the results of this effort to us and is recommending that we use the new times in the practice expense methodology. In addition, several physician specialty societies obtained new and more recent survey times as a result of the five-year review of physician work. The RUC has reviewed and forwarded these times to us as well and is also recommending that we use them in the practice expense methodology. We believe the times supplied to us by the RUC are more likely to be reflective of the actual time it takes to perform a procedure. For this reason, we are proposing to use these new times in the practice expense methodology. As indicated in our June 8, 2001 proposed notice, our expectation was that the substitution of new times would reduce payments to cardiac and thoracic surgeons because the new times for many heart and chest procedures are shorter than those we have been using in the practice expense methodology. We estimate that substitution of new physician times will reduce payments to cardiac and thoracic surgeons by an estimated 5 and 4 percent, respectively. Combining this reduction with the change in work relative value units will result in a total estimated increase in payments from between 0 and 1 percent for cardiac and thoracic surgeons. We estimate change in payments to other specialties from using new time data will be one percent or less.

The column labeled “New SMS” refers to our proposal to recalculate the practice expense per hour data based on the 1995 through 1999 SMS. (We refer to the SMS based on its publication year. The practice expense data is actually from surveys performed the year prior to publication. For example, the 1998 SMS includes 1997 cost data.) The proposed changes in practice expense per hour from incorporating the latest SMS data are modest. Payments to pathologists are estimated to increase by 2 percent. Specialty 69—Independent Laboratory, the largest specialty included in the supplier category, bills for many of the same services as pathologists, producing our estimated 2 percent increase in Medicare payments to suppliers.

The column labeled “Clinical Labor Repricing” reflects our proposal to use 1999 information from the Bureau of Labor Statistics to update the wage rate information that is used to price clinical labor inputs in the practice expense methodology. We estimate that this proposal will result in less than a 1 percent change in payments to any physician specialty.

The column labeled “Other” refers to our proposal to make minor modifications to the specialty utilization. As discussed earlier, we are proposing to recode the specialty for several very low volume physician specialties that likely have practice expenses that are similar to other larger physician specialties. In addition, this policy reflects our proposal to drop the utilization for a number of specialties from the practice expense methodology because a very small percentage (one percent or less) of their allowed charges are from physician fee schedule services. The modifications to the utilization data that we are proposing have virtually no specialty level impact on any specialty.

Table 6.—Impact of Proposed Work and Practice Expense Changes Total Allowed Charges by Specialty

SpecialtyAllowed charges $ Billions5 year review of work practiceNew timeNew SMSClinical labor repricingOtherTotal
WorkExpenseTotal
ANESTHESIOLOGY1.51%0%1%0%0%0%0%1%
CARDIAC SURGERY0.35%1%6%5%0%0%0%0%
CARDIOLOGY4.20%0%0%0%0%0%0%0%
CHIROPRACTOR0.40%0%0%0%0%0%0%0%
CLINICS1.60%0%0%0%0%0%0%0%
DERMATOLOGY1.40%0%0%0%1%0%0%1%
EMERGENCY MEDICINE1.00%0%0%0%0%0%0%0%
FAMILY PRACTICE3.30%0%0%0%0%0%0%0%
GASTROENTEROLOGY1.20%0%0%1%0%0%0%1%
GENERAL PRACTICE1.00%0%0%0%0%0%0%0%
GENERAL SURGERY2.03%1%4%0%0%0%0%4%
HEMATOLOGY ONCOLOGY0.60%−1%−1%0%0%0%0%0%
INTERNAL MEDICINE7.10%0%0%0%0%0%0%0%
NEPHROLOGY1.00%0%0%0%0%0%0%0%
NEUROLOGY0.90%0%0%0%0%0%0%0%
NEUROSURGERY0.40%0%0%0%0%0%0%0%
NONPHYSICIAN PRACTITIONER1.20%0%0%0%0%0%0%0%
OBSTETRICS/GYNECOLOGY0.40%0%1%0%1%0%0%1%
OPHTHALMOLOGY3.90%0%0%0%−1%0%0%−1%
OPTOMETRIST0.50%0%0%0%−1%1%0%0%
Start Printed Page 40398
ORTHOPEDIC SURGERY2.30%0%0%0%0%0%0%0%
OTHER PHYSICIAN1.60%0%0%0%0%0%0%1%
OTOLARYNGOLOGY0.60%0%0%1%0%0%0%0%
PATHOLOGY0.60%0%0%0%2%0%0%3%
PLASTIC SURGERY0.20%0%0%0%0%0%0%0%
PODIATRY1.10%0%0%1%0%0%0%1%
PSYCHIATRY1.10%0%0%0%0%0%0%0%
PULMONARY1.10%0%0%0%0%0%0%0%
RADIATION ONCOLOGY0.70%−1%−1%0%0%0%0%0%
RADIOLOGY3.30%−1%0%0%0%0%0%0%
RHEUMATOLOGY0.30%0%0%0%0%0%0%0%
SUPPLIERS0.50%−1%−1%−1%2%0%1%2%
THORACIC SURGERY0.54%1%5%−4%0%0%0%1%
UROLOGY1.30%0%0%0%0%0%0%1%
VASCULAR SURGERY0.32%0%2%−1%0%0%0%2%

Table 7 shows the impact on payments for selected high volume procedures of all of the changes previously discussed. This table shows the combined impact of the change in physician work and the fully implemented practice expense relative value units on total payment for the procedure. There are separate columns that show the change in the old and new facility rates and the old and new nonfacility rates. The table does not show the actual change in payments from 2001 to 2002 for the procedures because the “old” payments do not take into account that the practice expense relative value units in 2001 are a blend of the old charge-based relative value units and the new resource-based practice expense relative value determined under current policy. We show the amounts in this way to isolate the impact of new proposals on the change in payment without including the effect of continuing to transition resource-based practice expense relative value units that will occur regardless of whether we publish this proposed rule. For an explanation of facility and non-facility practice expense refer to § 414.22(b)(5)(i).

Table 7.—Impact of 5 Year Review and Proposed Rule on Medicare Payment for Selected Procedures

HCPCSMODDescOld non-facilityNew non-facilityPercent changeOld facilityNew facilityPercent change
11721Debride nail, 6 or more$42.47$42.470%$30.61$30.610%
17000Destroy benign/premal lesion$63.89$65.803%$34.43$34.430%
27130Total hip replacementNANANA$1,499.72$1,502.400%
27236Treat thigh fractureNANANA$1,150.80$1,152.720%
27244Treat thigh fractureNANANA$1,174.91$1,177.200%
27447Total knee replacementNANANA$1,567.43$1,570.500%
33533CABG, arterial, singleNANANA$1,855.90$1,900.282%
35301Rechanneling of arteryNANANA$1,170.32$1,141.24−2%
43239Upper GI endoscopy, biopsy$298.03$318.317%$157.24$158.391%
45385Lesion removal colonoscopy$501.95$534.476%$299.56$303.001%
66821After cataract laser surgery$229.93$228.02−1%$215.01$212.72−1%
66984Cataract surg w/iol, i stageNANANA$697.83$691.71−1%
67210Treatment of retinal lesion$627.82$620.55−1%$575.40$569.66−1%
7101026Chest x-ray$9.56$9.560%$9.56$9.560%
7102026Chest x-ray$11.86$11.860%$11.86$11.860%
77427Radiation tx management, x5$176.75$177.520%$176.75$177.520%
7846526Heart image (3d), multiple$79.58$78.81−1%$79.58$78.81−1%
8830526Tissue exam by pathologist$42.08$42.852%$42.08$42.852%
90801Psy dx interview$153.80$152.65−1%$145.00$144.620%
90806Psytx, off, 45-50 min$102.15$101.38−1%$96.41$96.410%
90807Psytx, off, 45-50 min w/e&m$109.80$109.420%$104.44$104.440%
90862Medication management$53.94$53.940%$48.97$48.970%
90921ESRD related services, month$278.90$279.280%$278.90$279.280%
90935Hemodialysis, one evaluationNANANA$77.66$78.051%
92004Eye exam, new patient$131.23$130.840%$92.58$92.200%
92012Eye exam established pat$66.19$65.80−1%$37.88$37.49−1%
92014Eye exam & treatment$94.88$94.500%$62.36$61.60−1%
92980Insert intracoronary stentNANANA$845.12$832.881%
92982Coronary artery dilationNANANA$625.90$616.34−2%
93000Electrocardiogram, complete$27.55$27.16−1%NANANA
93010Electrocardiogram report$9.56$9.18−4%$9.56$9.18−4%
93015Cardiovascular stress test$108.65$107.51−1%NANANA
9330726Echo exam of heart$51.27$50.50−2%$51.27$50.50−2%
9351026Left heart catheterization$246.00$242.17−2%$246.00$242.17−2%
98941Chiropractic manipulation$37.49$37.490%$32.52$32.520%
99202Office/outpatient visit, new$63.89$63.890%$48.21$48.210%
99203Office/outpatient visit, new$95.65$95.260%$73.46$73.460%
99204Office/outpatient visit, new$137.73$136.96−1%$108.65$108.650%
99205Office/outpatient visit, new$174.46$174.460%$143.85$143.470%
99211Office/outpatient visit, est$21.04$21.040%$9.18$9.180%
99212Office/outpatient visit, est$37.49$37.490%$24.49$24.490%
Start Printed Page 40399
99213Office/outpatient visit, est$52.41$52.410%$35.96$35.960%
99214Office/outpatient visit, est$82.64$82.640%$58.92$58.920%
99215Office/outpatient visit, est$120.90$121.280%$95.26$95.260%
99221Initial hospital careNANANA$68.86$68.860%
99222Initial hospital careNANANA$114.01$114.010%
99223Initial hospital careNANANA$159.15$159.150%
99231Subsequent hospital careNANANA$34.43$34.430%
99232Subsequent hospital careNANANA$56.24$56.240%
99233Subsequent hospital careNANANA$80.34$80.340%
99236Observ/hosp same dateNANANA$225.72$225.340%
99238Hospital discharge dayNANANA$67.72$67.720%
99239Hospital discharge dayNANANA$92.58$92.580%
99241Office consultation$48.97$48.970%$34.81$34.810%
99242Office consultation$91.05$90.670%$71.54$71.540%
99243Office consultation$120.90$120.510%$95.26$94.880%
99244Office consultation$171.78$171.780%$140.79$140.790%
99245Office consultation$223.04$223.430%$186.70$186.320%
99251Initial inpatient consultNANANA$38.26$38.260%
99252Initial inpatient consultNANANA$75.37$75.370%
99253Initial inpatient consultNANANA$102.15$102.150%
99254Initial inpatient consultNANANA$146.15$146.150%
99255Initial inpatient consultNANANA$200.47$200.470%
99261Follow-up inpatient consultNANANA$24.87$24.870%
99262Follow-up inpatient consultNANANA$47.82$47.820%
99263Follow-up inpatient consultNANANA$70.01$70.010%
99282Emergency dept visitNANANA$27.93$27.930%
99283Emergency dept visitNANANA$62.74$62.740%
99284Emergency dept visitNANANA$97.94$98.320%
99285Emergency dept visitNANANA$152.65$153.030%
99291Critical care, first hour$218.45$219.220%$208.89$209.270%
99292Critical care, addl 30 min$111.71$112.100%$104.06$104.440%
99301Nursing facility careNANANA$63.51$63.510%
99302Nursing facility careNANANA$84.93$84.930%
99303Nursing facility careNANANA$105.59$105.590%
99311Nursing fac care, subseqNANANA$31.75$31.750%
99312Nursing fac care, subseqNANANA$52.41$52.410%
99313Nursing fac care, subseqNANANA$74.60$74.600%
99348Home visit, est patient$77.28$76.900%$70.01$70.010%
99350Home visit, est patient$176.37$175.600%$164.13$164.130%

B. Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists Performing Screening Sigmoidoscopies

As discussed in section II.B. of the preamble, this proposed regulation would expand the scope of who is allowed to perform screening flexible sigmoidoscopies for Medicare coverage and payment purposes to include nurse practitioners, physician assistants, and clinical nurse specialists, as long as those practitioners meet applicable Medicare qualification requirements, and they are authorized to perform those screening services under State law. At present, the Medicare condition of coverage for screening flexible sigmoidoscopies limits coverage of those services to those that are performed by either a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Act) who is authorized under State law to perform the examination.

We estimate that this expansion in the scope of who is allowed to perform screening flexible sigmoidoscopies will increase beneficiary access to these screening services and will result in an increase in the number of covered exams that are performed. At the same time, we estimate that this proposed rule will result in a decrease in payments that are made for certain screening flexible sigmoidoscopies because they will be performed by nurse practitioners, physician assistants, and clinical nurse specialists who are paid at 85 percent of the amount of payment that is made to physicians for the same screening service. Taking these factors into account, we estimate that this proposal will result in negligible additional Medicare program costs. For a more detailed discussion of this provision see section II.B. of this preamble.

C. Services and Supplies Incident to a Physician's Professional Services—Conditions

We are proposing to allow auxiliary personnel to provide services incident to the services of physicians or practitioners who supervise them, regardless of the employment relationship. There are no costs or savings to the Medicare program associated with this proposal because the same physicians and practitioners would have performed these services before publication of this proposed rule. For a more detailed discussion of this provision see section II.C. of this preamble.

D. Anesthesia Services—Anesthesia Base Units

As previously discussed in section II.D. of the preamble, with the exception of codes 00142 and 00147, we propose to use the same anesthesia base unit per anesthesia code as the ASA provides in its uniform relative value guide. There are eight codes for which the base unit values would be different under our proposed rule.

Under this proposal, the estimated total number of base units would decrease. This is due primarily to the fact that code 001214 is the dominant code in terms of allowed services and the base unit for this code would decrease from 10 to 8 units.

To maintain neutrality in the anesthesia conversion factor, we would provide for a slight increase in the Start Printed Page 40400anesthesia conversion factor, less than 0.5 percent. For a more detailed discussion of this provision see section II.D. of this preamble.

E. Performance Measurement and Emerging Technology Codes

As previously discussed in section II.E. of the preamble, the AMA has developed two new categories of codes: performance codes and emerging technology. Allowing the performance measurement code to be referenced on Medicare billing forms will have no budgetary impact since we are not proposing payment for these codes. We are proposing to allow for carrier pricing of the emerging technology codes.

We expect that the emerging technology codes will be used infrequently and may be used in place of “unlisted” procedure codes that are also carrier priced. There would be few, if any, no Medicare program costs associated with this proposal. For a more detailed discussion of this provision see section II.E. of this preamble.

F. BIPA Provisions Included in This Proposed Rule

The following provisions of the BIPA are discussed in detail in section III of this preamble. This proposed rule would conform the regulations text to the BIPA provisions. Table 8 provides the estimated costs (in millions of dollars) for the Medicare program for these provisions for the fiscal years shown:

Table 8.—Medicare Cost Estimates for BIPA 2000 Provisions

[In millions]

BIPA provisionsFY 2002FY 2003FY 2004FY 2005FY 2006
Sec. 101 Biennial Pelvic Examinations1020202020
Sec. 102 Screening Glaucoma3050506060
Sec. 103 Screening Colonoscopy4040301010
Sec. 104 Screening Mammography3040404050
Sec. 105 Medical Nutrition2050607070
Sec. 223 Telehealth Services2030405060
Sec. 432 Indian Health6070808090

1. Screening Mammography

As discussed in section III.A. of the preamble, the BIPA eliminates the statutorily prescribed payment rate for screening mammography and specifies that it will be paid under the physician fee schedule beginning January 1, 2002. To pay for the professional component of the screening mammography, we propose to use the work and malpractice RVUs that have been established for unilateral diagnostic mammography. We are establishing the practice expense RVUs for the professional component under the resource-based methodology. To establish practice expense RVUs for the technical component, we propose using the statutory payment limit and the applicable physician fee schedule update factor used each year. Currently, we pay for screening mammography under section 1834(c) of the Act. Payment for screening mammography is not subject to the budget neutrality requirements that apply to physician fee schedule services under section 1848(c)(2)(B)(ii)(II) of the Act. Effective January 1, 2002, screening mammography will be subject to the budget neutrality requirements that apply to physician fee schedule services. We will include the current payment amounts for screening mammography in aggregate physician fee schedule payments subject to the budget neutrality requirements. As a result, the BIPA requirement to pay for screening mammography under the physician fee schedule will not result in an increase in Medicare program expenditures. However, the increase in payment for screening mammography under the physician fee schedule will be included in the budget neutrality adjustments that apply to physician fee schedule services. The BIPA also establishes a methodology for determining payment for certain types of new technology that are used in providing both diagnostic and screening mammography services. The statutory provisions are in effect from April 1, 2001 to December 31, 2001. The statute gives us the authority to determine whether separate codes and payment amounts are appropriate for screening and diagnostic mammography services that involve use of a new technology on or after January 1, 2002. We are proposing several new codes and fee schedule amounts for screening and diagnostic mammography services that involve use of a new technology. The BIPA provisions related to new technology mammography will result in the Medicare program costs shown in Table 8. The BIPA makes no changes to provisions for Medicare coverage of screening mammography.

2. Screening Pelvic Examinations

As discussed in section III.B. of the preamble, section 101 of the BIPA provides for expanded coverage for screening pelvic examinations (including a clinical breast examination) furnished on or after July 1, 2001. Specifically, the revised benefit will allow for biennial coverage of screening pelvic examination for all women who do not qualify under the law for annual coverage of such tests. We estimate that this change in the frequency of coverage for certain beneficiaries will result in an increase in Medicare payments. These payments will be made to a large number of physicians and other practitioners who provide these tests, any medically necessary follow-up tests, or treatment that may be required as a result of the increased frequency of coverage of these tests. Medicare program expenditures associated with screening pelvic examinations have been included in the budget. The impact of this provision is shown in Table 8.

3. Screening for Glaucoma

As discussed in section III.C. of the preamble, section 102 of the BIPA authorizes coverage of glaucoma screening examinations effective January 1, 2002, subject to certain frequency and other limitations. We believe services provided as part of glaucoma screening will often overlap with other services a physician provides during a patient encounter that is associated with a higher payment amount. We believe that physicians will more commonly provide glaucoma tests in conjunction with other services and will rarely provide only glaucoma screening to Medicare patients. Based on the projected utilization of these screening services and related medically necessary follow-up tests and treatment that may be required for the beneficiaries screened, we estimate that this new benefit will result in an Start Printed Page 40401increase in Medicare payments. These payments will be made to ophthalmologists or optometrists who will provide these screening tests and related follow-up tests and treatment that may be required. Medicare program expenditures associated with the BIPA provision that establishes coverage for screening glaucoma are shown in Table 8.

4. Screening Colonoscopy

As discussed in section III.D. of the preamble, section 103 of the BIPA amended the Act to add coverage of screening colonoscopies once every 10 years for individuals not at high risk for colorectal cancer. We estimate that this new benefit will result in an increase in Medicare payments. These payments will be made to practitioners who will provide these screening tests and related follow-up tests and treatment that may be required. The impact of this provision is shown in Table 8.

5. Medical Nutrition Therapy

As discussed in section III.E. of the preamble, section 105 of the BIPA amended the Act to authorize Medicare coverage under Part B of medical nutrition therapy (MNT) for beneficiaries who have diabetes or renal disease, effective for services furnished on or after January 1, 2002. We propose to implement this provision at part 410, subpart G. Specifically, the proposed rule discusses the education, experience, and licensing requirements for dietitians or nutritionists furnishing the service. In addition, the proposed rule discusses the payment provisions, a referral requirement, and the manner by which the medical nutrition therapy and diabetes outpatient self-management training benefits will be coordinated to avoid duplicate payment. We also propose to establish payment amounts for these services under the physician fee schedule.

We estimate that this new benefit will result in an increase in Medicare payments. These payments will be made to dietitians and nutrition professionals who will provide these diagnostic therapy and counseling services. Costs to the Medicare program associated with this provision are shown in Table 8.

6. Telehealth

We estimate that the cost of providing office or other outpatient visits, consultation services, individual psychotherapy, and pharmacologic management in accordance with section 223 of the BIPA will be approximately $20 million in FY 2002 and approximately $60 million by FY 2006, as indicated above in Table 8.

This rule does not mandate that entities provide consultation, office or other outpatient visits, individual psychotherapy or pharmacological management services via a telecommunications system. Thus, this rule would not require entities to purchase telehealth equipment or to acquire the telecommunications infrastructure necessary to deliver these services via a telecommunications system. Therefore, this rule does not impose costs associated with starting and operating a telehealth network.

7. Indian Health Services

As discussed in section III.G. of the preamble, in addition to payment for Medicare services in hospitals and skilled nursing facilities, section 432 of the BIPA authorizes payment under the physician fee schedule to physicians and certain practitioners for services furnished in a hospital and an ambulatory care clinic, whether provider-based or free-standing, of the Indian Health Service effective for services furnished on or after July 1, 2001. We propose to add a new § 410.46 to conform our regulations to the statute. Costs to the Medicare program for this BIPA provision are shown in Table 8.

8. Pathology Services

As discussed in section III.H. of the preamble, in the November 2, 1999 physician fee schedule final rule (64 FR 59381), we stated that we would implement a policy to pay only hospitals for the TC of physician pathology services furnished to hospital inpatients. Before the effective date of this proposal, any independent laboratory could bill the carrier under the physician fee schedule for the TC of physician pathology to a hospital inpatient. The regulation provided that for services furnished on or after January 1, 2001, the carriers would no longer pay claims to an independent laboratory under the physician fee schedule for the TC of physician pathology services furnished for hospital inpatients. Similar treatment was provided under the hospital outpatient prospective payment system for the TC of physician pathology services to hospital outpatients. We delayed implementation of this provision for one year; it was to take effect for services furnished on or after January 1, 2001. The delay was intended to allow independent laboratories and hospitals sufficient time to negotiate arrangements.

Section 542 of the BIPA requires Medicare to continue to pay for the TC of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a covered hospital. This provision applies to TC services furnished during the 2-year period beginning on January 1, 2001.

In the November 2, 1999 final rule, we estimated that payment under the physician fee schedule for TC billings by independent laboratories would decrease by $6 million per year if the original proposal had been implemented on January 1, 2001. As a result of the BIPA, these savings are not realized for two years.

G. Budget Neutrality

Each year since the fee schedule has been implemented, our actuaries have determined any adjustments needed to meet the budget neutrality requirement of the statute. A component of the actuarial determination of budget-neutrality involves estimating the impact of changes in the volume and intensity of physicians' services provided to Medicare beneficiaries as a result of the proposed changes. Since the November 1998 final rule (63 FR 58891), we have used a model that assumes 30 percent of anticipated payment reductions will be offset through an increase in the volume and intensity of services. We will continue to use the same assumption in this year's final rule.

H. Impact on Beneficiaries

Although changes in physicians' payments were large when the physician fee schedule was implemented in 1992, we detected no problems with beneficiary access to care. Furthermore, since beginning our transition to a resource-based practice expense system in 1999, we have not found that there are problems with beneficiary access to care. In addition, the implementation of the BIPA proposals that are contained in this rule will improve beneficiary access to health care under the Medicare program since certain preventative services, such as screening glaucoma, will now be covered for the first time and coverage of several existing services is being expanded.

I. Federalism

We have examined this proposed rule in accordance with Executive Order 13132 and have determined that this regulation would not have any negative impact on the rights, roles, or responsibilities of State, local, or tribal governments.

In accordance with the provisions of Executive Order 12866, this regulation Start Printed Page 40402was reviewed by the Office of Management and Budget.

Start List of Subjects

List of Subjects

End List of Subjects

For the reasons set forth in the preamble, the Health Care Financing Administration proposes to amend 42 CFR chapter IV as follows:

Start Part

PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED

1. The authority citation for part 405 continues to read as follows:

Start Authority

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

End Authority

2. In § 405.534, an introductory paragraph is added to read as follows:

Limitation on payment for screening mammography services.

The provisions in paragraphs (a), (b), and (c) of this section apply for services provided from January 1, 1991 until December 31, 2001. Screening mammography services provided after December 31, 2001 are paid under the physician fee schedule in accordance with § 414.2 of this chapter.

* * * * *

3. In § 405.535, the section heading is revised and the introductory text is amended by adding two sentences to the beginning to read as follows:

Special rule for nonparticipating physicians and suppliers furnishing screening mammography services before January 1, 2002.

The provisions in this section apply for screening mammography services provided from January 1, 1991 until December 31, 2001. Screening mammography services provided after December 31, 2001 are paid under the physician fee schedule in accordance with § 414.2 of this chapter. * * *

* * * * *
End Part Start Part

PART 410—SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

1. The authority citation for part 410 continues to read as follows:

Start Authority

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

End Authority

2. Section 410.3 is amended by revising paragraph (a)(1) to read as follows:

Scope of benefits.

(a) * * *

(1) Medical and other health services such as physicians' services, outpatient services furnished by a hospital or a CAH, diagnostic tests, outpatient physical therapy and speech pathology services, rural health clinic services, Federally qualified health center services, IHS, Indian tribe, or tribal organization facility services, and outpatient renal dialysis services.

* * * * *

3. Section 410.10 is amended by adding paragraph (x) to read as follows:

Medical and other health services: Included services.
* * * * *

(x) IHS, Indian tribe, or tribal organization facility services.

4. Section 410.22 is redesignated as § 410.21, § 410.23 is redesignated as § 410.22, and a new § 410.23 is added to read as follows:

Screening for glaucoma: Conditions for and limitations on coverage.

(a) Definitions: As used in this section, the following definitions apply:

(1) Direct supervision in the office setting means the optometrist or the ophthalmologist must be present in the office suite and be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean the physician must be present in the room when the procedure is performed.

(2) Eligible beneficiary means:

(i) Individual with diabetes mellitus;

(ii) Individual with a family history of glaucoma; or

(iii) African-Americans age 50 and over.

(3) Screening for glaucoma means the following procedures furnished to an individual for the early detection of glaucoma:

(i) A dilated eye examination with an intraocular pressure measurement.

(ii) A direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination.

(b) Condition for coverage of screening for glaucoma.

Medicare Part B pays for glaucoma screening examinations provided to eligible beneficiaries as described in paragraph (a)(2) of this section if they are furnished by or under the direct supervision in the office setting of an optometrist or ophthalmologist who is legally authorized to perform these services under State law (or the State regulatory mechanism provided by State law) of the State in which the services are furnished, as would otherwise be covered if furnished by a physician or incident to a physician's professional service.

(c) Limitations on coverage of glaucoma screening examinations.

(1) Payment may not be made for a glaucoma screening examination that is performed for an individual who is not an eligible beneficiary as described in paragraph (a)(2) of this section.

(2) Payment may be made for a glaucoma screening examination that is performed on an individual who is an eligible beneficiary as described in paragraph (a)(2) of this section, after at least 11 months have passed following the month in which the last glaucoma screening examination was performed.

5. In § 410.26, paragraph (b) is redesignated as paragraph (c), paragraph (a) is redesignated as paragraph (b) and revised, a new paragraph (a) is added, and newly designated paragraph (c) is amended by adding a paragraph heading:

Services and supplies incident to a physician's professional service: Conditions.

(a) Definitions. For purposes of this section, the following definitions apply:

(1) Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician (or other practitioner) or of the same entity that employs or contracts with the physician (or other practitioner).

(2) Direct supervision means the level of supervision by the physician (or other practitioner) of auxiliary personnel as defined in § 410.32(b)(3)(ii).

(3) Independent contractor means an individual who performs part-time or full-time work for which the individual receives an IRS-1099 form.

(4) Leased employment means an employment relationship that is Start Printed Page 40403recognized by applicable State law and that is established by two employers by a contract such that one employer hires the services of an employee of the other employer.

(5) Noninstitutional setting means all settings other than a hospital or skilled nursing facility.

(6) Practitioner means a non-physician practitioner who is authorized by the Act to receive payment for services incident to his or her own services.

(7) Services and supplies means any service or supply (including any drug or biological that cannot be self-administered) that is included in section 1861(s)(2)(A) of the Act and is not specifically listed in the Act as a separate benefit included in the Medicare program.

(b) Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner).

(1) Services and supplies must be furnished in a noninstitutional setting to noninstitutional patients.

(2) Services and supplies must be 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.

(3) Services and supplies must be commonly furnished without charge or included in the bill of a physician (or other practitioner).

(4) Services and supplies must be of a type that are commonly furnished in the office or clinic of a physician (or other practitioner).

(5) Services and supplies must be furnished under the supervision of the physician (or other practitioner).

(6) Services and supplies must be furnished by the physician, practitioner with an incident to benefit, or auxiliary personnel.

(7) A physician (or other practitioner) may be an employee or an independent contractor.

(c) Limitation. * * *

6. In § 410.37, paragraphs (d), (e)(2), and (g) are revised and paragraph (e)(3) is added to read as follows:

Colorectal cancer screening tests: Conditions for and limitations on coverage.
* * * * *

(d) Condition for coverage of flexible sigmoidoscopy screening. Medicare Part B pays for a flexible sigmoidoscopy screening service if it is performed by a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Act), or by a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act and §§ 410.74, 410.75, and 410.76) who is authorized under State law to perform the examination.

(e) Limitations on coverage of screening flexible sigmoidoscopies. * * *

(2) For an individual 50 years of age or over, except as described in paragraph (e)(3) of this section, payment may be made for screening flexible sigmoidoscopy after at least 47 months have passed following the month in which the last screening flexible sigmoidoscopy or, as provided in paragraphs (h) and (i) of this section, the last screening barium enema was performed.

(3) In the case of an individual who is not at high risk for colorectal cancer as described in paragraph (a)(3) of this section but who has had a screening colonoscopy performed, payment may be made for a screening flexible sigmoidosocopy only after at least 119 months have passed following the month in which the last screening colonoscopy was performed.

* * * * *

(g) Limitations on coverage of screening colonoscopies. (1) Effective for services furnished on or after January 1, 1998 through June 30, 2001, payment may not be made for a screening colonoscopy for an individual who is not at high risk for colorectal cancer as described in paragraph (a)(3) of this section.

(2) Effective for services furnished on or after July 1, 2001, except as described in paragraph (g)(4) of this section, payment may be made for a screening colonoscopy performed for an individual who is not at high risk for colorectal cancer as described in paragraph (a)(3) of this section, after at least 119 months have passed following the month in which the last screening colonoscopy was performed.

(3) Payment may be made for a screening colonoscopy performed for an individual who is at high risk for colorectal cancer as described in paragraph (a)(3) of this section, after at least 23 months have passed following the month in which the last screening colonoscopy was performed, or, as provided in paragraphs (h) and (i) of this section, the last screening barium enema was performed.

(4) In the case of an individual who is not at high risk for colorectal cancer as described in paragraph (a)(3) of this section but who has had a screening flexible sigmoidoscopy performed, payment may be made for a screening colonoscopy only after at least 47 months have passed following the month in which the last screening flexible sigmoidoscopy was performed.

* * * * *

7. Section 410.46 is added to read as follows:

Physician and other practitioner services furnished in or at the direction of an IHS or Indian tribal hospital or clinic: Scope and conditions.

(a) Medicare Part B pays, in accordance with the physician fee schedule, for services furnished in or at the direction of a hospital or outpatient clinic (provider-based or free-standing) that is operated by the Indian Health Service (IHS) or by an Indian tribe or tribal organization (as those terms are defined in section 4 of the Indian Health Care Improvement Act). These services are subject to the same situations, terms, and conditions that would apply if the services were furnished in or at the direction of a hospital or clinic that is not operated by IHS or by an Indian tribe or tribal organization. Payments include health professional shortage areas incentive payments when the requirements for these incentive payments in § 414.42 of this chapter are met.

(b) Payment is not made under this section to the extent that Medicare otherwise pays for the same services under other provisions.

(c) Payment is made under these provisions for the following services:

(1) Services for which payment is made under the physician fee schedule in accordance with part 414 of this chapter.

(2) Services furnished by non-physician practitioners for which payment under Part B is made under the physician fee schedule.

(3) Services furnished by a physical therapist or occupational therapist, for which payment under Part B is made under the physician fee schedule.

(d) Payments under these provisions will be paid to the IHS or tribal hospital or clinic.

8. In § 410.56, paragraphs (b)(1), the introductory text of (b)(2), and (b)(3) are revised to read as follows:

Screening pelvic examinations.
* * * * *

(b) * * *

(1) General rule. Except as specified in paragraphs (b)(2) and (b)(3) of this section, payment may be made for a pelvic examination performed on an asymptomatic woman only if the individual has not had a pelvic examination paid for by Medicare during the preceding 23 months following the month in which her last Medicare-covered screening pelvic examination was performed. Start Printed Page 40404

(2) More frequent screening based on high-risk factors. Subject to the limitation as specified in paragraph (b)(4) of this section, payment may be made for a screening pelvic examination performed more frequently than once every 24 months if the test is performed by a physician or other practitioner specified in paragraph (a) of this section, and there is evidence that the woman is at high risk (on the basis of her medical history or other findings) of developing cervical cancer or vaginal cancer, as determined in accordance with the following risk factors:

* * * * *

(3) More frequent screening for women of childbearing age. Subject to the limitation as specified in paragraph (b)(4) of this section, payment may be made for a screening pelvic examination performed more frequently than once every 24 months if the test is performed by a physician or other practitioner as specified in paragraph (a) of this section for a woman of childbearing age who has had an examination that indicated the presence of cervical or vaginal cancer or other abnormality during any of the preceding 3 years. The term “woman of childbearing age” means a woman who is premenopausal, and has been determined by a physician, or a qualified practitioner, as specified in paragraph (a) of this section, to be of childbearing age, based on her medical history or other findings.

* * * * *

9. Section 410.78 is revised to read as follows:

Office and other outpatient visits, consultation, individual psychotherapy and pharmacologic management via an interactive telecommunications system.

(a) Definitions. For the purposes of this section the following definitions apply:

(1) Asynchronous store and forward technologies means the transmission of a patient's medical information from an originating site to the physician or practitioner at the distant site. The physician or practitioner at the distant site can review the medical case without the patient being present. An asynchronous telecommunications system in single media format does not include telephone calls, images transmitted via facsimile machines and text messages without visualization of the patient (electronic mail). Photographs visualized by a telecommunications system must be specific to the patient's medical condition and adequate for furnishing or confirming a diagnosis and or treatment plan. Dermatological photographs, for example, a photograph of a skin lesion, may be considered to meet the requirement of a single media format under this provision.

(2) Distant site means the site at which the physician or practitioner delivering the service is located at the time the service is provided via a telecommunications system.

(3) Interactive telecommunications system means 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 electronic mail systems do not meet the definition of an interactive telecommunications system.

(4) Originating site means, for purposes of a consultation, office or other outpatient visit, individual psychotherapy, or pharmacologic management via an interactive telecommunications system, the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. For asynchronous store and forward telecommunications technologies, the only originating sites are Federal telemedicine demonstration programs conducted in Alaska or Hawaii.

(b) General rule. Medicare Part B pays for office and other outpatient visits, professional consultation, individual psychotherapy, and pharmacologic management furnished by means of an interactive telecommunications system if the following conditions are met:

(1) The physician or practitioner at the distant site must be licensed to provide the service under State law. When the physician or practitioner at the distant site is licensed under State law to provide a covered telehealth service (that is, professional consultations, office and other outpatient visits, individual psychotherapy, and pharmacologic management), he or she may bill for, and receive payment for, this service when delivered via a telecommunications system.

(2) The practitioner at the distant site is one of the following:

(i) A physician as described in § 410.20.

(ii) A physician assistant as described § 410.74.

(iii) A nurse practitioner as described in § 410.75.

(iv) A clinical nurse specialist as described in § 410.76.

(v) A nurse-midwife as described in § 410.77.

(vi) A clinical psychologist as described in § 410.71.

(vii) A clinical social worker as described in § 410.73.

(3) The services are furnished to a beneficiary at an originating site, which is one of the following:

(i) The office of a physician or practitioner.

(ii) A critical access hospital (as described in section 1861(mm)(1) of the Act).

(iii) A rural health clinic (as described in section 1861(aa)(2) of the Act).

(iv) A Federally qualified health center (as defined in section 1861(aa)(4) of the Act).

(v) A hospital (as defined in section 1861(e) of the Act).

(4) Originating sites must be located in either a rural health professional shortage area as defined under section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A)) or in a county that is not included in a Metropolitan Statistical Area as defined in section 1886(d)(2)(D) of the Act. Entities participating in a Federal telemedicine demonstration project that have been approved by, or receive funding from, the Secretary as of December 31, 2000 qualify as an eligible originating site regardless of geographic location.

(5) The medical examination of the patient is under the control of the physician or practitioner at the distant site.

(c) Telepresenter not required. A telepresenter is not required as a condition of payment unless a telepresenter is medically necessary as determined by the physician or practitioner at the distant site.

(d) Exception to the interactive telecommunications system requirement. For Federal telemedicine demonstration programs conducted in Alaska or Hawaii only, Medicare payment is permitted for telehealth when asynchronous store and forward technologies, in single or multimedia formats, are used as a substitute for an interactive telecommunications system.

(e) Limitation. A clinical psychologist and a clinical social worker may bill and receive payment for individual psychotherapy via a telecommunications system, but may not seek payment for medical evaluation and management services.

10. A new subpart G is added to read as follows:

Subpart G—Medical Nutrition Therapy
Definitions.
Medical nutrition therapy.
Provider qualifications.
Start Printed Page 40405

Subpart G—Medical Nutrition Therapy

Definitions.

For the purposes of this subpart, the following definitions apply:

Chronic renal insufficiency is defined as the stage of renal disease associated with a reduction in renal function not severe enough to require dialysis or transplantation (glomerular filtration rate [GFR] 13-50 ml/min/1.73m2).

Diabetes is diabetes mellitus consisting of two types. Type 1 is an autoimmune disease that destroys the beta cells of the pancreas, leading to insulin deficiency. Type 2 is familial hyperglycemia that occurs primarily in adults but can also occur in children and adolescents. The diagnostic criterion for a diagnosis of diabetes for a fasting glucose tolerance test is greater than or equal to 126 mg/dL.

Episode of care means a time period not exceeding 12 months, starting with the assessment and including all covered interventions based on a referral from a physician as specified in § 410.132(c).

Medical nutrition therapy services means nutritional diagnostic, therapy, and counseling services provided by a registered dietitian or nutrition professional for the purpose of managing diabetes or renal disease.

Physician means a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he or she performs such function or action (including a physician within the meaning of section of 1101(a)(7) of the Act).

Renal disease means chronic renal insufficiency and the medical condition of a beneficiary who has been discharged from the hospital within the last six months after a successful renal transplant.

Medical nutrition therapy.

(a) Conditions for coverage of medical nutrition therapy services. Medicare Part B pays for medical nutrition therapy services provided by a registered dietitian or nutrition professional as defined in § 410.134 when the beneficiary is referred for the service by the treating physician. Services covered consist of nutritional assessment, interventions, and reassessment and follow-up interventions in accordance with nationally accepted dietary or nutritional protocols.

(b) Limitations on coverage of medical nutrition therapy services.

(1) Medical nutrition therapy services are not covered for beneficiaries receiving maintenance dialysis for which payment is made under section 1881 of the Act.

(2) If a beneficiary has both diabetes and renal disease, the beneficiary may receive both MNT and DSMT, but coverage is limited to the number of hours the beneficiary would receive under either the MNT benefit or the DSMT benefit for the episode of care, whichever is greater.

(3) Medical nutrition therapy is only covered if the beneficiary has not started initial training under the diabetes self-management training benefit as described in § 410.141 within the 12 months previous to initial referral for MNT, unless—

(i) The need for a reassessment and additional therapy has been documented by the referring physician as a result of a change in diagnosis or medical condition; or

(ii) The beneficiary is diagnosed with both diabetes and renal disease.

(4) If a beneficiary diagnosed with diabetes has been referred for both follow-up diabetes self-management training services and medical nutrition therapy, the number of hours the beneficiary may receive is limited to the number of hours under either follow-up diabetes self-management training services or medical nutrition therapy for any 12 month period.

(c) Referrals. Referral may only be made by the treating physician when the beneficiary has been diagnosed with diabetes or renal disease as defined in this subpart with documentation maintained by the referring physician in the beneficiary's medical record. Referrals must be made for each episode of care and any reassessments or follow-up interventions during an episode of care.

(d) Reassessments and follow-up interventions. Reassessments and follow-up interventions are only covered within an episode of care when the referring physician determines there is a change of diagnosis or medical condition within such episode of care that makes a change in diet necessary.

Provider qualifications.

For Medicare Part B coverage of medical nutrition therapy, only a registered dietitian or nutrition professional may provide the services. “Registered dietitian or nutrition professional” means an individual who on or after December 22, 2000—

(a) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics, as accredited by an appropriate national accreditation organization recognized for this purpose;

(b) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional; and

(c) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a “registered dietitian” by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a) and (b) of this section; or a dietitian or nutritionist licensed or certified in a State as of December 21, 2000.

End Part Start Part

PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT

1. The authority citation for part 411 continues to read as follows:

Start Authority

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

End Authority

2. In § 411.15, paragraph (a)(1) is revised, and a new paragraph (k)(10) is added to read as follows:

Particular services excluded from coverage.
* * * * *

(a) * * *

(1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening mammography, colorectal cancer screening tests, screening pelvic examinations, prostate cancer screening tests, or glaucoma screening exams that meet the criteria specified in paragraphs (k)(6) through (k)(10) of this section.

* * * * *

(k) * * *

(10) In the case of screening exams for glaucoma, for the purpose of early detection of glaucoma, subject to the conditions and limitations specified in § 410.23 of this chapter.

* * * * *
End Part Start Part

PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

1. The authority citation for part 414 continues to read as follows:

Start Authority

Authority: Secs. 1102, 1871, and 1881(b)(1) of the Social Security Act (42 U.S.C. 1302, 1395hh, and 1395rr(b)(1)).

End Authority

2. In 414.2, the definition of “Physician services” is amended by Start Printed Page 40406adding a new paragraph (8) to read as follows:

Definitions.
* * * * *

Physician Services * * *

(8) Screening mammography services.

* * * * *

3. A new § 414.64 is added to read as follows:

Payment for medical nutrition therapy.

(a) Payment under the physician fee schedule. Medicare payment for medical nutrition therapy is made under the physician fee schedule in accordance with subpart B of this part.

(b) To whom payment may be made. Payment may be made to a supplier (registered dietitian or nutrition professional) approved by CMS to furnish medical nutrition therapy in accordance with part 410, subpart G of this chapter.

(c) Effective date of payment. Medicare pays suppliers of medical nutrition therapy on or after the effective date of enrollment of the supplier at the carrier.

(d) Limitation on payment. Payment is made only for nutritional therapy sessions actually attended by the beneficiary and documented for payment purposes.

(e) Other conditions for fee-for-service payment. Payment is made only if the beneficiary:

(1) Is not an inpatient of a hospital, SNF, nursing home, or hospice.

(2) Is not receiving services in an RHC, FQHC or ESRD dialysis facility.

4. Section 414.65 is revised to read as follows:

Payment for office or other outpatient visits, consultation, individual psychotherapy, and pharmacologic management via interactive telecommunications systems.

(a) Professional service. Medicare payment for the professional service via an interactive telecommunications system is made according to the following limitations:

(1) The Medicare payment amount for office or other outpatient visits, consultation, individual psychotherapy, and pharmacologic management via an interactive telecommunications system is equal to the current fee schedule amount applicable to services of the physician or practitioner.

(2) Only the physician or practitioner at the distant site may bill and receive payment for the professional service via an interactive telecommunications system.

(3) Payments made to the physician or practitioner at the distant site, including deductible and coinsurance, for the professional service may not be shared with the referring practitioner or telepresenter.

(b) Originating site facility fee. For office or other outpatient visits, consultation, individual psychotherapy, or pharmacologic management services delivered via an interactive telecommunications system furnished on or after October 1, 2001.

(1) Payment amount. For services furnished on or after October 1, 2001 through December 31, 2002, the payment amount to the originating site is the lesser of the actual charge or the originating site facility fee of $20. For services furnished on or after January 1 of each subsequent year, the facility fee for the originating site will be updated by the Medicare Economic Index (MEI) as defined in section 1842(i)(3) of the Act.

(2) Who may bill for the originating site facility fee. Only the originating site may bill for the originating site facility fee and only on an assignment-related basis. The distant site physician or practitioner may not bill for or receive payment for facility fees associated with the professional service furnished via an interactive telecommunications system.

(c) Deductible and coinsurance apply. The payment for the professional service and originating site facility fee is subject to the coinsurance and deductible requirements of sections 1833(a)(1) and (b) of the Act.

(d) Sanctions. A distant site practitioner or originating site facility may be subject to the applicable sanctions provided for in chapter IV, part 402 and chapter V, parts 1001, 1002, and 1003 of this title if he or she does any of the following:

(1) Knowingly and willfully bills or collects for services in violation of the limitation of this section.

(2) Fails to timely correct excess charges by reducing the actual charge billed for the service in an amount that does not exceed the limiting charge for the service or fails to timely refund excess collections.

(3) Fails to submit a claim on a standard form for services provided for which payment is made on a fee schedule basis; or

(4) Imposes a charge for completing and submitting the standard claims form.

End Part Start Part

PART 415—SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS

1. The authority citation for part 415 continues to read as follows:

Start Authority

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

End Authority

2. Section 415.130 is amended by:

A. Redesignating paragraphs (a), (b), and (c) as paragraphs (b), (c), and (d).

B. Adding a new paragraph (a).

C. Amending newly designated paragraph (b)(3) by removing the reference “paragraph (b)” and adding “paragraph (c)” in its place.

D. Amending newly designated paragraph (b)(4) by removing the reference “paragraphs (b)(1), (b)(3), and (b)(4)” and adding “paragraphs (c)(1), (c)(3), and (c)(4)” in their place.

E. Revising newly designated paragraph (d).

Conditions for payment: Physician pathology services.

(a) Definitions. The following definitions are used in this section.

(1) Covered hospital means, with respect to an inpatient or an outpatient, a hospital that had an arrangement with an independent laboratory that was in effect as of July 22, 1999, under which a laboratory furnished the technical component of physician pathology services to fee-for-service Medicare beneficiaries who were hospital inpatients or outpatients, and submitted claims for payment for this technical component to a Medicare carrier and not to the hospital.

(2) Fee-for-service Medicare beneficiaries means those beneficiaries who are entitled to benefits under Part A or are enrolled under Part B of Title XVIII of the Act or both and are not enrolled in any of the following:

(i) A Medicare+Choice plan under Part C of Title XVIII of the Act.

(ii) A plan offered by an eligible organization under section 1876 of the Act;

(iii) A program of all-inclusive care for the elderly (PACE) under 1894 of the Act; or

(iv) A social health maintenance organization (SHMO) demonstration project established under section 4018(b) of the Omnibus Budget Reconciliation Act of 1987.

* * * * *

(d) Physician pathology services furnished by an independent laboratory. The technical component of physician pathology services furnished by an independent laboratory to a hospital inpatient or outpatient before January 1, 2001 may be paid on a fee schedule basis. After December 31, 2001 but before January 1, 2003, if an independent laboratory furnishes the technical component of a physician pathology service to a fee-for-service Medicare beneficiary who is an Start Printed Page 40407inpatient or outpatient of a covered hospital, the carrier will treat the technical component as a service for which payment will be made to the laboratory under the physician fee schedule. The service will not be treated as an inpatient hospital service for which payment is made to the hospital under section 1886(d) of the Act or as an outpatient hospital service for which payment is made to the hospital under section 1833(t) of the Act. After December 31, 2002, the technical component for physician pathology services furnished by an independent laboratory to a hospital inpatient or outpatient is paid only to the hospital.

Start Signature

(Catalog of Federal Domestic Assistance Program No. 93.774, Medicare—Supplementary Medical Insurance Program)

Dated: June 19, 2001.

Thomas A. Scully,

Administrator, Health Care Financing Administration.

Approved: July 12, 2001.

Tommy G. Thompson,

Secretary.

End Signature

Note:

These addenda will not appear in the Code of Federal Regulations.

Addendum A—Explanation and Use of Addenda B

The addenda on the following pages provide various data pertaining to the Medicare fee schedule for physicians' services furnished in 2002. Addendum B contains the RVUs for work, non-facility practice expense, facility practice expense, and malpractice expense, and other information for all services included in the physician fee schedule.

Addendum B—2002 Relative Value Units and Related Information Used in Determining Medicare Payments for 2002

This addendum contains the following information for each CPT code and alphanumeric HCPCS code, except for alphanumeric codes beginning with B (enteral and parenteral therapy), E (durable medical equipment), K (temporary codes for nonphysicians' services or items), or L (orthotics), and codes for anesthesiology.

1. CPT/HCPCS code. This is the CPT or alphanumeric HCPCS number for the service. Alphanumeric HCPCS codes are included at the end of this addendum.

2. Modifier. A modifier is shown if there is a technical component (modifier TC) and a professional component (PC) (modifier -26) for the service. If there is a PC and a TC for the service, Addendum B contains three entries for the code: One for the global values (both professional and technical); one for modifier -26 (PC); and one for modifier TC. The global service is not designated by a modifier, and physicians must bill using the code without a modifier if the physician furnishes both the PC and the TC of the service.

Modifier -53 is shown for a discontinued procedure. There will be RVUs for the code (CPT code 45378) with this modifier.

3. Status indicator. This indicator shows whether the CPT/HCPCS code is in the physician fee schedule and whether it is separately payable if the service is covered.

A = Active code. These codes are separately payable under the fee schedule if covered. There will be RVUs for codes with this status. The presence of an “A” indicator does not mean that Medicare has made a national decision regarding the coverage of the service. Carriers remain responsible for coverage decisions in the absence of a national Medicare policy.

B = Bundled code. Payment for covered services is always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient.)

C = Carrier-priced code. Carriers will establish RVUs and payment amounts for these services, generally on a case-by-case basis following review of documentation, such as an operative report.

D = Deleted code. These codes are deleted effective with the beginning of the calendar year.

E = Excluded from physician fee schedule by regulation. These codes are for items or services that we chose to exclude from the physician fee schedule payment by regulation. No RVUs are shown, and no payment may be made under the physician fee schedule for these codes. Payment for them, if they are covered, continues under reasonable charge or other payment procedures.

G = Code not valid for Medicare purposes. Medicare does not recognize codes assigned this status. Medicare uses another code for reporting of, and payment for, these services.

N = Noncovered service. These codes are noncovered services. Medicare payment may not be made for these codes. If RVUs are shown, they are not used for Medicare payment.

P = Bundled or excluded code. There are no RVUs for these services. No separate payment should be made for them under the physician fee schedule.

End Part

—If the item or service is covered as incident to a physician's service and is furnished on the same day as a physician's service, payment for it is bundled into the payment for the physician's service to which it is incident (an example is an elastic bandage furnished by a physician incident to a physician's service).

—If the item or service is covered as other than incident to a physician's service, it is excluded from the physician fee schedule (for example, colostomy supplies) and is paid under the other payment provisions of the Act.

R = Restricted coverage. Special coverage instructions apply. If the service is covered and no RVUs are shown, it is carrier-priced.

T = Injections. There are RVUs for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the service(s) for which payment is made.

X = Exclusion by law. These codes represent an item or service that is not within the definition of “physicians” services” for physician fee schedule payment purposes. No RVUs are shown for these codes, and no payment may be made under the physician fee schedule. (Examples are ambulance services and clinical diagnostic laboratory services.)

4. Description of code. This is an abbreviated version of the narrative description of the code.

5. Physician work RVUs. These are the RVUs for the physician work for this service in 2000. Codes that are not used for Medicare payment are identified with a “+.”

6. Facility practice expense RVUs. These are the fully implemented resource-based practice expense RVUs for facility settings.

7. Non-facility practice expense RVUs. These are the fully implemented resource-based practice expense RVUs for non-facility settings.

8. Malpractice expense RVUs. These are the RVUs for the malpractice expense for the service for 2000.

9. Facility total. This is the sum of the work, fully implemented facility practice expense, and malpractice expense RVUs.

10. Non-facility total. This is the sum of the work, fully implemented non-facility practice expense, and malpractice expense RVUs.Start Printed Page 40408

11. Global period. This indicator shows the number of days in the global period for the code (0, 10, or 90 days). An explanation of the alpha codes follows:

MMM = The code describes a service furnished in uncomplicated maternity cases including antepartum care, delivery, and postpartum care. The usual global surgical concept does not apply. See the 1999 Physicians' Current Procedural Terminology for specific definitions.

XXX = The global concept does not apply.

YYY = The global period is to be set by the carrier (for example, unlisted surgery codes).

ZZZ = The code is part of another service and falls within the global period for the other service.

—————————— 1 CPT codes and descriptions only are copyright 2001 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. 2 Copyright 1994 American Dental Association. All rights reserved. 3 + Indicates RVUs are not used for Medicare payments. 4 PE RVUs = Practice Expense Relative Value Units.Start Printed Page 40408

Addendum B.—Relative Value Units (RVUs) and Related Information

CPT 1/HCPCS 2MODStatusDescriptionPhysician Work RVUs 3Facility PE RVUsNon- Facility PE RVUsMal- Practice RVUsFacility TotalNon- Facility TotalGlobal
10040AAcne surgery of skin abscess1.180.521.630.051.752.86010
10060ADrainage of skin abscess1.170.661.350.081.912.60010
10061ADrainage of skin abscess2.401.152.070.173.724.64010
10080ADrainage of pilonidal cyst1.170.712.110.091.973.37010
10081ADrainage of pilonidal cyst2.451.552.890.194.195.53010
10120ARemove foreign body1.220.731.830.102.053.15010
10121ARemove foreign body2.691.772.830.254.715.77010
10140ADrainage of hematoma/fluid1.530.871.420.152.553.10010
10160APuncture drainage of lesion1.200.771.560.112.082.87010
10180AComplex drainage, wound2.251.251.510.253.754.01010
11000ADebride infected skin0.600.240.580.050.891.23000
11001ADebride infected skin add-on0.300.110.340.020.430.66ZZZ
11010ADebride skin, fx4.202.002.510.456.657.16010
11011ADebride skin/muscle, fx4.952.593.870.538.079.35000
11012ADebride skin/muscle/bone, fx6.884.215.670.8911.9813.44000
11040ADebride skin, partial0.500.210.500.050.761.05000
11041ADebride skin, full0.820.340.670.081.241.57000
11042ADebride skin/tissue1.120.460.950.111.692.18000
11043ADebride tissue/muscle2.381.382.600.244.005.22010
11044ADebride tissue/muscle/bone3.061.803.110.345.206.51010
11055RTrim skin lesion0.270.120.380.020.410.67000
11056RTrim skin lesion, 2 to 40.390.170.420.030.590.84000
11057RTrim skin lesions, over 40.500.220.460.040.761.00000
11100ABiopsy of skin lesion0.810.381.490.041.232.34000
11101ABiopsy, skin add-on0.410.200.700.020.631.13ZZZ
11200ARemoval of skin tags0.770.311.170.041.121.98010
11201ARemove skin tags add-on0.290.120.520.020.430.83ZZZ
11300AShave skin lesion0.510.221.020.030.761.56000
11301AShave skin lesion0.850.381.110.041.272.00000
11302AShave skin lesion1.050.481.210.051.582.31000
11303AShave skin lesion1.240.541.340.061.842.64000
11305AShave skin lesion0.670.290.810.041.001.52000
11306AShave skin lesion0.990.431.060.051.472.10000
11307AShave skin lesion1.140.511.180.051.702.37000
11308AShave skin lesion1.410.631.270.072.112.75000
11310AShave skin lesion0.730.331.120.041.101.89000
11311AShave skin lesion1.050.501.230.051.602.33000
11312AShave skin lesion1.200.571.300.061.832.56000
11313AShave skin lesion1.620.751.580.092.463.29000
11400ARemoval of skin lesion0.910.732.420.061.703.39010
11401ARemoval of skin lesion1.320.882.430.092.293.84010
11402ARemoval of skin lesion1.610.962.520.122.694.25010
11403ARemoval of skin lesion1.921.072.760.163.154.84010
11404ARemoval of skin lesion2.201.172.920.183.555.30010
11406ARemoval of skin lesion2.761.383.200.254.396.21010
11420ARemoval of skin lesion1.060.772.030.081.913.17010
11421ARemoval of skin lesion1.530.992.360.112.634.00010
11422ARemoval of skin lesion1.761.062.510.142.964.41010
11423ARemoval of skin lesion2.171.222.940.173.565.28010
11424ARemoval of skin lesion2.621.413.090.214.245.92010
11426ARemoval of skin lesion3.781.853.740.345.977.86010
11440ARemoval of skin lesion1.150.922.540.082.153.77010
11441ARemoval of skin lesion1.611.162.700.112.884.42010
11442ARemoval of skin lesion1.871.252.770.143.264.78010
11443ARemoval of skin lesion2.491.593.320.184.265.99010
11444ARemoval of skin lesion3.422.003.740.255.677.41010
11446ARemoval of skin lesion4.492.494.180.307.288.97010
11450ARemoval, sweat gland lesion2.731.054.020.264.047.01090
11451ARemoval, sweat gland lesion3.951.594.830.395.939.17090
11462ARemoval, sweat gland lesion2.510.984.140.233.726.88090
11463ARemoval, sweat gland lesion3.951.625.630.405.979.98090
11470ARemoval, sweat gland lesion3.251.284.410.304.837.96090
11471ARemoval, sweat gland lesion4.411.775.420.406.5810.23090
Start Printed Page 40409
11600ARemoval of skin lesion1.410.942.570.092.444.07010
11601ARemoval of skin lesion1.931.082.630.123.134.68010
11602ARemoval of skin lesion2.091.322.690.133.544.91010
11603ARemoval of skin lesion2.351.392.880.163.905.39010
11604ARemoval of skin lesion2.581.463.070.184.225.83010
11606ARemoval of skin lesion3.431.753.630.285.467.34010
11620ARemoval of skin lesion1.340.892.530.092.323.96010
11621ARemoval of skin lesion1.971.352.670.123.444.76010
11622ARemoval of skin lesion2.341.502.840.153.995.33010
11623ARemoval of skin lesion2.931.712.790.204.845.92010
11624ARemoval of skin lesion3.431.933.160.255.616.84010
11626ARemoval of skin lesion4.302.344.180.356.998.83010
11640ARemoval of skin lesion1.531.112.620.102.744.25010
11641ARemoval of skin lesion2.441.662.960.154.255.55010
11642ARemoval of skin lesion2.931.882.890.184.996.00010
11643ARemoval of skin lesion3.502.173.250.245.916.99010
11644ARemoval of skin lesion4.552.683.910.337.568.79010
11646ARemoval of skin lesion5.953.385.190.469.7911.60010
11719RTrim nail(s)0.110.070.540.010.190.66000
11720ADebride nail, 1-50.320.130.420.020.470.76000
11721ADebride nail, 6 or more0.540.220.530.040.801.11000
11730ARemoval of nail plate1.130.460.740.091.681.96000
11732ARemove nail plate, add-on0.570.240.290.050.860.91ZZZ
11740ADrain blood from under nail0.370.140.680.030.541.08000
11750ARemoval of nail bed1.860.791.550.162.813.57010
11752ARemove nail bed/finger tip2.671.751.990.334.754.99010
11755ABiopsy, nail unit1.310.591.030.061.962.40000
11760ARepair of nail bed1.581.191.700.172.943.45010
11762AReconstruction of nail bed2.891.872.150.325.085.36010
11765AExcision of nail fold, toe0.690.450.970.051.191.71010
11770ARemoval of pilonidal lesion2.611.262.970.244.115.82010
11771ARemoval of pilonidal lesion5.743.925.340.5610.2211.64090
11772ARemoval of pilonidal lesion6.984.366.120.6812.0213.78090
11900AInjection into skin lesions0.520.230.760.020.771.30000
11901AAdded skin lesions injection0.800.370.890.031.201.72000
11920RCorrect skin color defects1.610.832.240.172.614.02000
11921RCorrect skin color defects1.931.042.630.213.184.77000
11922RCorrect skin color defects0.490.260.390.050.800.93ZZZ
11950RTherapy for contour defects0.840.471.280.061.372.18000
11951RTherapy for contour defects1.190.541.710.101.833.00000
11952RTherapy for contour defects1.690.892.150.172.754.01000
11954RTherapy for contour defects1.850.942.850.192.984.89000
11960AInsert tissue expander(s)9.0810.76NA0.8820.72NA090
11970AReplace tissue expander7.065.06NA0.7712.89NA090
11971ARemove tissue expander(s)2.133.866.150.216.208.49090
11975NInsert contraceptive cap+1.480.591.540.142.213.16XXX
11976RRemoval of contraceptive cap1.780.771.580.172.723.53XXX
11977NRemoval/reinsert contra cap+3.301.302.250.314.915.86XXX
11980AImplant hormone pellet(s)1.480.631.130.102.212.71000
12001ARepair superficial wound(s)1.700.832.310.132.664.14010
12002ARepair superficial wound(s)1.860.862.410.152.874.42010
12004ARepair superficial wound(s)2.240.982.590.173.395.00010
12005ARepair superficial wound(s)2.861.233.050.234.326.14010
12006ARepair superficial wound(s)3.671.924.150.315.908.13010
12007ARepair superficial wound(s)4.122.244.630.376.739.12010
12011ARepair superficial wound(s)1.760.832.370.142.734.27010
12013ARepair superficial wound(s)1.990.892.530.163.044.68010
12014ARepair superficial wound(s)2.461.062.830.183.705.47010
12015ARepair superficial wound(s)3.191.263.260.244.696.69010
12016ARepair superficial wound(s)3.931.503.790.325.758.04010
12017ARepair superficial wound(s)4.712.445.410.397.5410.51010
12018ARepair superficial wound(s)5.532.696.310.468.6812.30010
12020AClosure of split wound2.621.452.600.244.315.46010
12021AClosure of split wound1.841.122.110.193.154.14010
12031ALayer closure of wound(s)2.151.192.740.153.495.04010
12032ALayer closure of wound(s)2.471.272.800.153.895.42010
12034ALayer closure of wound(s)2.921.443.060.214.576.19010
12035ALayer closure of wound(s)3.431.653.030.305.386.76010
12036ALayer closure of wound(s)4.052.475.200.416.939.66010
12037ALayer closure of wound(s)4.672.825.610.497.9810.77010
12041ALayer closure of wound(s)2.371.263.030.173.805.57010
12042ALayer closure of wound(s)2.741.413.010.174.325.92010
12044ALayer closure of wound(s)3.141.613.170.244.996.55010
12045ALayer closure of wound(s)3.641.843.580.345.827.56010
Start Printed Page 40410
12046ALayer closure of wound(s)4.252.535.310.407.189.96010
12047ALayer closure of wound(s)4.652.905.940.417.9611.00010
12051ALayer closure of wound(s)2.471.413.000.164.045.63010
12052ALayer closure of wound(s)2.771.372.970.174.315.91010
12053ALayer closure of wound(s)3.121.513.110.204.836.43010
12054ALayer closure of wound(s)3.461.633.430.255.347.14010
12055ALayer closure of wound(s)4.432.144.670.356.929.45010
12056ALayer closure of wound(s)5.242.866.760.438.5312.43010
12057ALayer closure of wound(s)5.963.886.670.5010.3413.13010
13100ARepair of wound or lesion3.121.853.380.215.186.71010
13101ARepair of wound or lesion3.922.313.610.226.457.75010
13102ARepair wound/lesion add-on1.240.580.740.101.922.08ZZZ
13120ARepair of wound or lesion3.301.923.490.235.457.02010
13121ARepair of wound or lesion4.332.403.820.256.988.40010
13122ARepair wound/lesion add-on1.440.670.860.122.232.42ZZZ
13131ARepair of wound or lesion3.792.223.730.256.267.77010
13132ARepair of wound or lesion5.953.284.560.329.5510.83010
13133ARepair wound/lesion add-on2.191.021.210.173.383.57ZZZ
13150ARepair of wound or lesion3.812.685.270.296.789.37010
13151ARepair of wound or lesion4.453.135.180.287.869.91010
13152ARepair of wound or lesion6.334.035.890.3810.7412.60010
13153ARepair wound/lesion add-on2.381.111.340.183.673.90ZZZ
13160ALate closure of wound10.486.24NA1.1917.91NA090
14000ASkin tissue rearrangement5.894.637.500.4610.9813.85090
14001ASkin tissue rearrangement8.475.998.930.6515.1118.05090
14020ASkin tissue rearrangement6.595.368.110.5012.4515.20090
14021ASkin tissue rearrangement10.067.169.380.6917.9120.13090
14040ASkin tissue rearrangement7.876.128.330.5314.5216.73090
14041ASkin tissue rearrangement11.497.9810.130.6820.1522.30090
14060ASkin tissue rearrangement8.506.978.820.5916.0617.91090
14061ASkin tissue rearrangement12.298.9210.970.7521.9624.01090
14300ASkin tissue rearrangement11.768.5010.370.8821.1423.01090
14350ASkin tissue rearrangement9.616.41NA1.0917.11NA090
15000ASkin graft4.001.922.520.376.296.89000
15001ASkin graft add-on1.000.430.560.111.541.67ZZZ
15050ASkin pinch graft4.303.944.910.468.709.67090
15100ASkin split graft9.056.176.260.9416.1616.25090
15101ASkin split graft add-on1.720.751.210.182.653.11ZZZ
15120ASkin split graft9.836.678.990.8717.3719.69090
15121ASkin split graft add-on2.671.251.570.274.194.51ZZZ
15200ASkin full graft8.035.649.590.7314.4018.35090
15201ASkin full graft add-on1.320.651.000.142.112.46ZZZ
15220ASkin full graft7.876.239.660.6814.7818.21090
15221ASkin full graft add-on1.190.581.000.121.892.31ZZZ
15240ASkin full graft9.047.129.280.7716.9319.09090
15241ASkin full graft add-on1.860.961.530.172.993.56ZZZ
15260ASkin full graft10.067.539.160.6318.2219.85090
15261ASkin full graft add-on2.231.161.630.173.564.03ZZZ
15342ACultured skin graft, 25 cm1.000.792.180.392.183.57010
15343ACulture skn graft addl 25 cm0.250.100.270.090.440.61ZZZ
15350ASkin homograft4.004.377.370.428.7911.79090
15351ASkin homograft add-on1.000.420.940.111.532.05ZZZ
15400ASkin heterograft4.004.964.960.409.369.36090
15401ASkin heterograft add-on1.000.461.140.111.572.25ZZZ
15570AForm skin pedicle flap9.216.278.420.9616.4418.59090
15572AForm skin pedicle flap9.276.187.540.9316.3817.74090
15574AForm skin pedicle flap9.886.948.530.9217.7419.33090
15576AForm skin pedicle flap8.696.358.970.7215.7618.38090
15600ASkin graft1.912.346.620.194.448.72090
15610ASkin graft2.422.704.560.255.377.23090
15620ASkin graft2.943.296.920.286.5110.14090
15630ASkin graft3.273.736.190.287.289.74090
15650ATransfer skin pedicle flap3.973.846.260.368.1710.59090
15732AMuscle-skin graft, head/neck17.8411.39NA1.5030.73NA090
15734AMuscle-skin graft, trunk17.7911.31NA1.9131.01NA090
15736AMuscle-skin graft, arm16.2710.77NA1.7828.82NA090
15738AMuscle-skin graft, leg17.9211.27NA1.9531.14NA090
15740AIsland pedicle flap graft10.257.128.870.6217.9919.74090
15750ANeurovascular pedicle graft11.418.05NA1.1220.58NA090
15756AFree muscle flap, microvasc35.2318.80NA3.1157.14NA090
15757AFree skin flap, microvasc35.2322.15NA3.3760.75NA090
15758AFree fascial flap, microvasc35.1022.48NA3.5261.10NA090
15760AComposite skin graft8.746.799.310.7216.2518.77090
15770ADerma-fat-fascia graft7.526.02NA0.7814.32NA090
Start Printed Page 40411
15775RHair transplant punch grafts3.961.583.040.435.977.43000
15776RHair transplant punch grafts5.542.943.880.609.0810.02000
15780AAbrasion treatment of skin7.296.306.300.4114.0014.00090
15781AAbrasion treatment of skin4.854.764.760.279.889.88090
15782AAbrasion treatment of skin4.324.104.100.218.638.63090
15783AAbrasion treatment of skin4.293.464.450.268.019.00090
15786AAbrasion, lesion, single2.031.271.690.113.413.83010
15787AAbrasion, lesions, add-on0.330.170.370.020.520.72ZZZ
15788RChemical peel, face, epiderm2.091.053.000.113.255.20090
15789RChemical peel, face, dermal4.923.675.590.278.8610.78090
15792RChemical peel, nonfacial1.861.812.770.103.774.73090
15793AChemical peel, nonfacial3.743.34NA0.177.25NA090
15810ASalabrasion4.743.853.850.429.019.01090
15811ASalabrasion5.394.034.030.529.949.94090
15819APlastic surgery, neck9.386.82NA0.7716.97NA090
15820ARevision of lower eyelid5.156.5510.910.3012.0016.36090
15821ARevision of lower eyelid5.726.6711.610.3112.7017.64090
15822ARevision of upper eyelid4.455.868.920.2210.5313.59090
15823ARevision of upper eyelid7.056.9510.060.3214.3217.43090
15824RRemoval of forehead wrinkles0.000.000.000.000.000.00XXX
15825RRemoval of neck wrinkles0.000.000.000.000.000.00XXX
15826RRemoval of brow wrinkles0.000.000.000.000.000.00XXX
15828RRemoval of face wrinkles0.000.000.000.000.000.00XXX
15829RRemoval of skin wrinkles0.000.000.000.000.000.00XXX
15831AExcise excessive skin tissue12.408.14NA1.3021.84NA090
15832AExcise excessive skin tissue11.597.81NA1.2120.61NA090
15833AExcise excessive skin tissue10.647.55NA1.1719.36NA090
15834AExcise excessive skin tissue10.856.03NA1.1818.06NA090
15835AExcise excessive skin tissue11.675.70NA1.1318.50NA090
15836AExcise excessive skin tissue9.346.16NA0.9516.45NA090
15837AExcise excessive skin tissue8.436.107.850.7815.3117.06090
15838AExcise excessive skin tissue7.135.70NA0.5813.41NA090
15839AExcise excessive skin tissue9.385.957.600.8816.2117.86090
15840AGraft for face nerve palsy13.269.84NA1.1524.25NA090
15841AGraft for face nerve palsy23.2615.24NA2.6541.15NA090
15842AFlap for face nerve palsy37.9621.68NA3.9963.63NA090
15845ASkin and muscle repair, face12.578.65NA0.8022.02NA090
15850BRemoval of sutures+0.780.311.370.041.132.19XXX
15851ARemoval of sutures0.860.351.560.051.262.47000
15852ADressing change,not for burn0.860.361.760.071.292.69000
15860ATest for blood flow in graft1.950.801.310.132.883.39000
15876RSuction assisted lipectomy0.000.000.000.000.000.00XXX
15877RSuction assisted lipectomy0.000.000.000.000.000.00XXX
15878RSuction assisted lipectomy0.000.000.000.000.000.00XXX
15879RSuction assisted lipectomy0.000.000.000.000.000.00XXX
15920ARemoval of tail bone ulcer7.955.38NA0.8314.16NA090
15922ARemoval of tail bone ulcer9.907.27NA1.0618.23NA090
15931ARemove sacrum pressure sore9.245.59NA0.9515.78NA090
15933ARemove sacrum pressure sore10.857.74NA1.1419.73NA090
15934ARemove sacrum pressure sore12.698.36NA1.3522.40NA090
15935ARemove sacrum pressure sore14.5710.35NA1.5626.48NA090
15936ARemove sacrum pressure sore12.388.98NA1.3222.68NA090
15937ARemove sacrum pressure sore14.2110.45NA1.5126.17NA090
15940ARemove hip pressure sore9.345.94NA0.9816.26NA090
15941ARemove hip pressure sore11.439.77NA1.2322.43NA090
15944ARemove hip pressure sore11.468.68NA1.2121.35NA090
15945ARemove hip pressure sore12.699.83NA1.3823.90NA090
15946ARemove hip pressure sore21.5714.57NA2.3238.46NA090
15950ARemove thigh pressure sore7.545.17NA0.8013.51NA090
15951ARemove thigh pressure sore10.727.67NA1.1419.53NA090
15952ARemove thigh pressure sore11.397.38NA1.1919.96NA090
15953ARemove thigh pressure sore12.638.89NA1.3822.90NA090
15956ARemove thigh pressure sore15.5210.60NA1.6427.76NA090
15958ARemove thigh pressure sore15.4810.97NA1.6628.11NA090
15999CRemoval of pressure sore0.000.000.000.000.000.00YYY
16000AInitial treatment of burn(s)0.890.271.060.061.222.01000
16010ATreatment of burn(s)0.870.381.170.071.322.11000
16015ATreatment of burn(s)2.350.971.930.223.544.50000
16020ATreatment of burn(s)0.800.261.170.061.122.03000
16025ATreatment of burn(s)1.850.681.870.162.693.88000
16030ATreatment of burn(s)2.080.933.030.183.195.29000
16035AIncision of burn scab, initi3.751.53NA0.365.64NA090
16036AIncise burn scab, addl incis1.500.61NA0.182.29NAZZZ
17000ADestroy benign/premal lesion0.600.271.090.030.901.72010
Start Printed Page 40412
17003ADestroy lesions, 2-140.150.070.240.010.230.40ZZZ
17004ADestroy lesions, 15 or more2.791.292.560.124.205.47010
17106ADestruction of skin lesions4.592.684.680.287.559.55090
17107ADestruction of skin lesions9.164.756.800.5314.4416.49090
17108ADestruction of skin lesions13.207.278.630.8921.3622.72090
17110ADestruct lesion, 1-140.650.261.070.040.951.76010
17111ADestruct lesion, 15 or more0.920.401.130.041.362.09010
17250AChemical cautery, tissue0.500.210.710.040.751.25000
17260ADestruction of skin lesions0.910.421.370.041.372.32010
17261ADestruction of skin lesions1.170.551.480.051.772.70010
17262ADestruction of skin lesions1.580.751.680.072.403.33010
17263ADestruction of skin lesions1.790.821.790.082.693.66010
17264ADestruction of skin lesions1.940.841.870.082.863.89010
17266ADestruction of skin lesions2.340.942.080.113.394.53010
17270ADestruction of skin lesions1.320.621.570.062.002.95010
17271ADestruction of skin lesions1.490.721.640.062.273.19010
17272ADestruction of skin lesions1.770.851.780.072.693.62010
17273ADestruction of skin lesions2.050.981.930.093.124.07010
17274ADestruction of skin lesions2.591.192.190.113.894.89010
17276ADestruction of skin lesions3.201.712.500.155.065.85010
17280ADestruction of skin lesions1.170.541.400.051.762.62010
17281ADestruction of skin lesions1.720.831.760.072.623.55010
17282ADestruction of skin lesions2.040.991.920.093.124.05010
17283ADestruction of skin lesions2.641.242.230.113.994.98010
17284ADestruction of skin lesions3.211.502.520.144.855.87010
17286ADestruction of skin lesions4.442.483.150.227.147.81010
17304AChemosurgery of skin lesion7.603.677.750.3111.5815.66000
17305A2nd stage chemosurgery2.851.383.600.124.356.57000
17306A3rd stage chemosurgery2.851.393.640.124.366.61000
17307AFollowup skin lesion therapy2.851.413.160.124.386.13000
17310AExtensive skin chemosurgery0.950.481.490.051.482.49000
17340ACryotherapy of skin0.760.271.360.041.072.16010
17360ASkin peel therapy1.430.701.480.062.192.97010
17380RHair removal by electrolysis0.000.000.000.000.000.00XXX
17999CSkin tissue procedure0.000.000.000.000.000.00YYY
19000ADrainage of breast lesion0.840.291.230.071.202.14000
19001ADrain breast lesion add-on0.420.150.830.030.601.28ZZZ
19020AIncision of breast lesion3.573.416.960.357.3310.88090
19030AInjection for breast x-ray1.530.5311.250.072.1312.85000
19100ABiopsy of breast1.270.453.560.101.824.93000
19101ABiopsy of breast, open3.183.0910.620.206.4714.00010
19102ABx breast percut w/image2.000.714.880.082.796.96000
19103ABx breast percut w/device2.370.8411.460.083.2913.91000
19110ANipple exploration4.304.408.430.449.1413.17090
19112AExcise breast duct fistula3.673.097.240.387.1411.29090
19120ARemoval of breast lesion5.563.554.410.569.6710.53090
19125AExcision, breast lesion6.063.705.020.6110.3711.69090
19126AExcision, addl breast lesion2.931.05NA0.304.28NAZZZ
19140ARemoval of breast tissue5.143.729.030.529.3814.69090
19160ARemoval of breast tissue5.994.52NA0.6111.12NA090
19162ARemove breast tissue, nodes13.537.94NA1.3822.85NA090
19180ARemoval of breast8.805.97NA0.8815.65NA090
19182ARemoval of breast7.735.01NA0.7913.53NA090
19200ARemoval of breast15.499.24NA1.5126.24NA090
19220ARemoval of breast15.729.22NA1.5626.50NA090
19240ARemoval of breast16.008.82NA1.6226.44NA090
19260ARemoval of chest wall lesion15.449.35NA1.6426.43NA090
19271ARevision of chest wall18.9011.61NA2.2732.78NA090
19272AExtensive chest wall surgery21.5512.54NA2.5436.63NA090
19290APlace needle wire, breast1.270.445.080.061.776.41000
19291APlace needle wire, breast0.630.221.720.030.882.38ZZZ
19295APlace breast clip, percut0.00NA2.650.01NA2.66ZZZ
19316ASuspension of breast10.697.65NA1.1519.49NA090
19318AReduction of large breast15.6210.47NA1.6927.78NA090
19324AEnlarge breast5.854.64NA0.6311.12NA090
19325AEnlarge breast with implant8.456.82NA0.9016.17NA090
19328ARemoval of breast implant5.684.63NA0.6110.92NA090
19330ARemoval of implant material7.595.35NA0.8113.75NA090
19340AImmediate breast prosthesis6.333.25NA0.6810.26NAZZZ
19342ADelayed breast prosthesis11.208.01NA1.2120.42NA090
19350ABreast reconstruction8.926.9214.290.9516.7924.16090
19355ACorrect inverted nipple(s)7.576.1012.050.8014.4720.42090
19357ABreast reconstruction18.1614.04NA1.9634.16NA090
19361ABreast reconstruction19.2612.20NA2.0833.54NA090
Start Printed Page 40413
19364ABreast reconstruction41.0022.78NA3.9167.69NA090
19366ABreast reconstruction21.2812.20NA2.2735.75NA090
19367ABreast reconstruction25.7315.53NA2.7844.04NA090
19368ABreast reconstruction32.4219.28NA3.5155.21NA090
19369ABreast reconstruction29.8218.49NA3.2451.55NA090
19370ASurgery of breast capsule8.056.21NA0.8615.12NA090
19371ARemoval of breast capsule9.357.32NA1.0117.68NA090
19380ARevise breast reconstruction9.147.21NA0.9817.33NA090
19396ADesign custom breast implant2.170.805.350.233.207.75000
19499CBreast surgery procedure0.000.000.000.000.000.00YYY
20000AIncision of abscess2.121.192.010.173.484.30010
20005AIncision of deep abscess3.422.202.920.345.966.68010
20100AExplore wound, neck10.084.475.920.9915.5416.99010
20101AExplore wound, chest3.221.303.000.244.766.46010
20102AExplore wound, abdomen3.941.673.340.355.967.63010
20103AExplore wound, extremity5.302.984.100.578.859.97010
20150AExcise epiphyseal bar13.697.83NA0.9622.48NA090
20200AMuscle biopsy1.460.621.720.172.253.35000
20205ADeep muscle biopsy2.350.983.720.233.566.30000
20206ANeedle biopsy, muscle0.990.363.150.061.414.20000
20220ABone biopsy, trocar/needle1.273.024.980.064.356.31000
20225ABone biopsy, trocar/needle1.873.034.520.115.016.50000
20240ABone biopsy, excisional3.234.07NA0.337.63NA010
20245ABone biopsy, excisional7.786.69NA0.4414.91NA010
20250AOpen bone biopsy5.034.30NA0.509.83NA010
20251AOpen bone biopsy5.564.74NA0.7911.09NA010
20500AInjection of sinus tract1.234.035.370.105.366.70010
20501AInject sinus tract for x-ray0.760.2613.460.031.0514.25000
20520ARemoval of foreign body1.853.375.400.175.397.42010
20525ARemoval of foreign body3.504.156.660.408.0510.56010
20550AInject tendon/ligament/cyst0.860.222.050.061.142.97000
20600ADrain/inject, joint/bursa0.660.271.380.060.992.10000
20605ADrain/inject, joint/bursa0.680.271.710.061.012.45000
20610ADrain/inject, joint/bursa0.790.562.110.081.432.98000
20615ATreatment of bone cyst2.282.514.520.194.986.99010
20650AInsert and remove bone pin2.232.904.380.285.416.89010
20660AApply,remove fixation device2.511.49NA0.484.48NA000
20661AApplication of head brace4.896.47NA0.9212.28NA090
20662AApplication of pelvis brace6.075.15NA0.8112.03NA090
20663AApplication of thigh brace5.434.78NA0.7710.98NA090
20664AHalo brace application8.068.21NA1.4917.76NA090
20665ARemoval of fixation device1.311.232.340.172.713.82010
20670ARemoval of support implant1.743.375.510.235.347.48010
20680ARemoval of support implant3.354.984.980.468.798.79090
20690AApply bone fixation device3.521.89NA0.475.88NA090
20692AApply bone fixation device6.412.50NA0.609.51NA090
20693AAdjust bone fixation device5.8611.53NA0.8518.24NA090
20694ARemove bone fixation device4.165.778.180.5710.5012.91090
20802AReplantation, arm, complete41.1531.17NA5.8178.13NA090
20805AReplant, forearm, complete50.0049.91NA3.95103.86NA090
20808AReplantation hand, complete61.6543.88NA6.49112.02NA090
20816AReplantation digit, complete30.9443.13NA3.0177.08NA090
20822AReplantation digit, complete25.5939.51NA3.0768.17NA090
20824AReplantation thumb, complete30.9436.86NA3.4871.28NA090
20827AReplantation thumb, complete26.4145.96NA3.2175.58NA090
20838AReplantation foot, complete41.4128.52NA5.8575.78NA090
20900ARemoval of bone for graft5.585.836.770.7712.1813.12090
20902ARemoval of bone for graft7.558.29NA1.0616.90NA090
20910ARemove cartilage for graft5.346.698.210.5012.5314.05090
20912ARemove cartilage for graft6.357.51NA0.5514.41NA090
20920ARemoval of fascia for graft5.315.57NA0.5411.42NA090
20922ARemoval of fascia for graft6.616.258.760.8813.7416.25090
20924ARemoval of tendon for graft6.486.73NA0.8214.03NA090
20926ARemoval of tissue for graft5.536.23NA0.7312.49NA090
20930BSpinal bone allograft0.000.000.000.000.000.00XXX
20931ASpinal bone allograft1.810.97NA0.343.12NAZZZ
20936BSpinal bone autograft0.000.000.000.000.000.00XXX
20937ASpinal bone autograft2.791.53NA0.434.75NAZZZ
20938ASpinal bone autograft3.021.63NA0.525.17NAZZZ
20950AFluid pressure, muscle1.262.10NA0.163.52NA000
20955AFibula bone graft, microvasc39.2130.01NA4.3573.57NA090
20956AIliac bone graft, microvasc39.2728.48NA5.7773.52NA090
20957AMt bone graft, microvasc40.6524.37NA5.7470.76NA090
20962AOther bone graft, microvasc39.2728.18NA5.1972.64NA090
Start Printed Page 40414
20969ABone/skin graft, microvasc43.9232.94NA4.3481.20NA090
20970ABone/skin graft, iliac crest43.0630.40NA4.6478.10NA090
20972ABone/skin graft, metatarsal42.9918.86NA6.0767.92NA090
20973ABone/skin graft, great toe45.7622.15NA4.6572.56NA090
20974AElectrical bone stimulation0.620.340.390.091.051.10000
20975AElectrical bone stimulation2.601.42NA0.424.44NA000
20979AUs bone stimulation0.620.250.560.040.911.22000
20999CMusculoskeletal surgery0.000.000.000.000.000.00YYY
21010AIncision of jaw joint10.147.05NA0.5417.73NA090
21015AResection of facial tumor5.297.20NA0.5213.01NA090
21025AExcision of bone, lower jaw10.066.867.380.7917.7118.23090
21026AExcision of facial bone(s)4.854.835.490.4010.0810.74090
21029AContour of face bone lesion7.716.116.870.7414.5615.32090
21030ARemoval of face bone lesion6.464.885.390.6011.9412.45090
21031ARemove exostosis, mandible3.242.113.340.285.636.86090
21032ARemove exostosis, maxilla3.242.153.300.275.666.81090
21034ARemoval of face bone lesion16.1710.6712.001.3728.2129.54090
21040ARemoval of jaw bone lesion2.111.852.980.194.155.28090
21041ARemoval of jaw bone lesion6.714.345.610.5611.6112.88090
21044ARemoval of jaw bone lesion11.867.92NA0.8720.65NA090
21045AExtensive jaw surgery16.1710.27NA1.2027.64NA090
21050ARemoval of jaw joint10.7711.32NA0.8422.93NA090
21060ARemove jaw joint cartilage10.2310.11NA1.1621.50NA090
21070ARemove coronoid process8.206.09NA0.6714.96NA090
21076APrepare face/oral prosthesis13.427.299.701.3622.0724.48010
21077APrepare face/oral prosthesis33.7518.3424.393.4355.5261.57090
21079APrepare face/oral prosthesis22.3412.6817.231.5936.6141.16090
21080APrepare face/oral prosthesis25.1014.2519.362.5541.9047.01090
21081APrepare face/oral prosthesis22.8812.9917.651.8737.7442.40090
21082APrepare face/oral prosthesis20.8711.3415.081.4633.6737.41090
21083APrepare face/oral prosthesis19.3010.9614.891.9632.2236.15090
21084APrepare face/oral prosthesis22.5112.7817.361.5736.8641.44090
21085APrepare face/oral prosthesis9.004.896.500.6514.5416.15010
21086APrepare face/oral prosthesis24.9214.1519.221.8640.9346.00090
21087APrepare face/oral prosthesis24.9213.5418.002.2240.6845.14090
21088CPrepare face/oral prosthesis0.000.000.000.000.000.00090
21089CPrepare face/oral prosthesis0.000.000.000.000.000.00090
21100AMaxillofacial fixation4.224.065.890.188.4610.29090
21110AInterdental fixation5.214.575.230.2810.0610.72090
21116AInjection, jaw joint x-ray0.810.308.080.051.168.94000
21120AReconstruction of chin4.936.3210.450.2911.5415.67090
21121AReconstruction of chin7.645.828.090.5614.0216.29090
21122AReconstruction of chin8.527.36NA0.5916.47NA090
21123AReconstruction of chin11.168.54NA1.1620.86NA090
21125AAugmentation, lower jaw bone10.628.729.170.7220.0620.51090
21127AAugmentation, lower jaw bone11.126.699.640.7618.5721.52090
21137AReduction of forehead9.826.95NA0.5317.30NA090
21138AReduction of forehead12.199.93NA1.4723.59NA090
21139AReduction of forehead14.619.39NA1.0225.02NA090
21141AReconstruct midface, lefort18.1011.14NA1.6330.87NA090
21142AReconstruct midface, lefort18.8111.26NA1.1631.23NA090
21143AReconstruct midface, lefort19.5811.74NA0.9032.22NA090
21145AReconstruct midface, lefort19.9411.43NA2.0933.46NA090
21146AReconstruct midface, lefort20.7112.11NA2.1334.95NA090
21147AReconstruct midface, lefort21.7713.27NA1.5236.56NA090
21150AReconstruct midface, lefort25.2414.91NA1.0941.24NA090
21151AReconstruct midface, lefort28.3018.38NA1.9848.66NA090
21154AReconstruct midface, lefort30.5218.49NA4.8653.87NA090
21155AReconstruct midface, lefort34.4518.24NA5.4858.17NA090
21159AReconstruct midface, lefort42.3821.37NA6.7470.49NA090
21160AReconstruct midface, lefort46.4424.49NA4.3975.32NA090
21172AReconstruct orbit/forehead27.8018.30NA1.9148.01NA090
21175AReconstruct orbit/forehead33.1718.70NA5.1657.03NA090
21179AReconstruct entire forehead22.2518.90NA2.4843.63NA090
21180AReconstruct entire forehead25.1919.28NA2.1546.62NA090
21181AContour cranial bone lesion9.908.90NA0.9719.77NA090
21182AReconstruct cranial bone32.1922.36NA2.5357.08NA090
21183AReconstruct cranial bone35.3123.10NA2.7561.16NA090
21184AReconstruct cranial bone38.2421.38NA4.1263.74NA090
21188AReconstruction of midface22.4615.78NA1.8540.09NA090
21193AReconst lwr jaw w/o graft17.1511.03NA1.5329.71NA090
21194AReconst lwr jaw w/graft19.8412.07NA1.3933.30NA090
21195AReconst lwr jaw w/o fixation17.2412.94NA1.2031.38NA090
21196AReconst lwr jaw w/fixation18.9112.88NA1.6233.41NA090
Start Printed Page 40415
21198AReconstr lwr jaw segment14.1611.84NA1.0527.05NA090
21199AReconstr lwr jaw w/advance16.0010.56NA1.0027.56NA090
21206AReconstruct upper jaw bone14.1010.13NA1.0125.24NA090
21208AAugmentation of facial bones10.238.4610.120.9219.6121.27090
21209AReduction of facial bones6.725.698.960.6013.0116.28090
21210AFace bone graft10.238.028.950.8819.1320.06090
21215ALower jaw bone graft10.776.888.751.0418.6920.56090
21230ARib cartilage graft10.7710.27NA0.9622.00NA090
21235AEar cartilage graft6.728.0311.810.5215.2719.05090
21240AReconstruction of jaw joint14.0511.49NA1.1526.69NA090
21242AReconstruction of jaw joint12.9511.53NA1.4025.88NA090
21243AReconstruction of jaw joint20.7914.75NA1.8537.39NA090
21244AReconstruction of lower jaw11.869.03NA0.9521.84NA090
21245AReconstruction of jaw11.8610.1516.560.8822.8929.30090
21246AReconstruction of jaw12.4710.9812.511.2124.6626.19090
21247AReconstruct lower jaw bone22.6318.84NA2.2143.68NA090
21248AReconstruction of jaw11.488.018.861.0120.5021.35090
21249AReconstruction of jaw17.5210.1611.381.3929.0730.29090
21255AReconstruct lower jaw bone16.7210.96NA1.1328.81NA090
21256AReconstruction of orbit16.1913.20NA1.0430.43NA090
21260ARevise eye sockets16.5211.65NA1.2529.42NA090
21261ARevise eye sockets31.4919.12NA2.2052.81NA090
21263ARevise eye sockets28.4214.84NA2.1645.42NA090
21267ARevise eye sockets18.9014.43NA1.3534.68NA090
21268ARevise eye sockets24.4811.93NA0.7937.20NA090
21270AAugmentation, cheek bone10.239.1010.490.7320.0621.45090
21275ARevision, orbitofacial bones11.2411.24NA1.0323.51NA090
21280ARevision of eyelid6.035.88NA0.2712.18NA090
21282ARevision of eyelid3.495.04NA0.218.74NA090
21295ARevision of jaw muscle/bone1.533.55NA0.135.21NA090
21296ARevision of jaw muscle/bone4.255.17NA0.309.72NA090
21299CCranio/maxillofacial surgery0.000.000.000.000.000.00YYY
21300ATreatment of skull fracture0.720.272.370.091.083.18000
21310ATreatment of nose fracture0.580.152.540.050.783.17000
21315ATreatment of nose fracture1.511.243.300.122.874.93010
21320ATreatment of nose fracture1.851.994.850.153.996.85010
21325ATreatment of nose fracture3.773.71NA0.317.79NA090
21330ATreatment of nose fracture5.385.50NA0.4811.36NA090
21335ATreatment of nose fracture8.617.10NA0.6416.35NA090
21336ATreat nasal septal fracture5.725.50NA0.4511.67NA090
21337ATreat nasal septal fracture2.703.175.020.226.097.94090
21338ATreat nasoethmoid fracture6.465.94NA0.5312.93NA090
21339ATreat nasoethmoid fracture8.096.95NA0.7615.80NA090
21340ATreatment of nose fracture10.779.36NA0.8520.98NA090
21343ATreatment of sinus fracture12.959.99NA1.0624.00NA090
21344ATreatment of sinus fracture19.7213.42NA1.7234.86NA090
21345ATreat nose/jaw fracture8.167.448.860.6016.2017.62090
21346ATreat nose/jaw fracture10.6110.35NA0.8521.81NA090
21347ATreat nose/jaw fracture12.699.36NA1.1423.19NA090
21348ATreat nose/jaw fracture16.6910.37NA1.5028.56NA090
21355ATreat cheek bone fracture3.772.414.840.296.478.90010
21356ATreat cheek bone fracture4.153.25NA0.367.76NA010
21360ATreat cheek bone fracture6.465.77NA0.5212.75NA090
21365ATreat cheek bone fracture14.9511.37NA1.3027.62NA090
21366ATreat cheek bone fracture17.7712.08NA1.4131.26NA090
21385ATreat eye socket fracture9.167.63NA0.6417.43NA090
21386ATreat eye socket fracture9.168.03NA0.7617.95NA090
21387ATreat eye socket fracture9.708.16NA0.7818.64NA090
21390ATreat eye socket fracture10.138.38NA0.7019.21NA090
21395ATreat eye socket fracture12.6810.07NA1.0923.84NA090
21400ATreat eye socket fracture1.401.082.930.122.604.45090
21401ATreat eye socket fracture3.263.255.590.346.859.19090
21406ATreat eye socket fracture7.016.60NA0.5914.20NA090
21407ATreat eye socket fracture8.617.71NA0.6716.99NA090
21408ATreat eye socket fracture12.389.70NA1.2423.32NA090
21421ATreat mouth roof fracture5.146.357.450.4211.9113.01090
21422ATreat mouth roof fracture8.327.21NA0.6916.22NA090
21423ATreat mouth roof fracture10.408.19NA0.9519.54NA090
21431ATreat craniofacial fracture7.055.25NA0.5812.88NA090
21432ATreat craniofacial fracture8.617.40NA0.5516.56NA090
21433ATreat craniofacial fracture25.3517.86NA2.4645.67NA090
21435ATreat craniofacial fracture17.2511.71NA1.6630.62NA090
21436ATreat craniofacial fracture28.0418.98NA2.3249.34NA090
21440ATreat dental ridge fracture2.703.385.430.226.308.35090
Start Printed Page 40416
21445ATreat dental ridge fracture5.385.377.070.5511.3013.00090
21450ATreat lower jaw fracture2.972.676.700.235.879.90090
21451ATreat lower jaw fracture4.875.496.580.3910.7511.84090
21452ATreat lower jaw fracture1.983.849.040.145.9611.16090
21453ATreat lower jaw fracture5.546.287.560.4912.3113.59090
21454ATreat lower jaw fracture6.466.01NA0.5513.02NA090
21461ATreat lower jaw fracture8.097.839.740.7316.6518.56090
21462ATreat lower jaw fracture9.797.9111.110.8018.5021.70090
21465ATreat lower jaw fracture11.917.37NA0.8420.12NA090
21470ATreat lower jaw fracture15.349.83NA1.3626.53NA090
21480AReset dislocated jaw0.610.181.590.050.842.25000
21485AReset dislocated jaw3.993.493.800.317.798.10090
21490ARepair dislocated jaw11.867.50NA1.3120.67NA090
21493ATreat hyoid bone fracture1.273.05NA0.104.42NA090
21494ATreat hyoid bone fracture6.285.28NA0.4412.00NA090
21495ATreat hyoid bone fracture5.694.83NA0.4110.93NA090
21497AInterdental wiring3.863.784.720.317.958.89090
21499CHead surgery procedure0.000.000.000.000.000.00YYY
21501ADrain neck/chest lesion3.813.574.310.367.748.48090
21502ADrain chest lesion7.127.71NA0.7915.62NA090
21510ADrainage of bone lesion5.746.86NA0.6713.27NA090
21550ABiopsy of neck/chest2.061.222.240.133.414.43010
21555ARemove lesion, neck/chest4.352.474.150.417.238.91090
21556ARemove lesion, neck/chest5.573.24NA0.519.32NA090
21557ARemove tumor, neck/chest8.887.74NA0.8517.47NA090
21600APartial removal of rib6.897.59NA0.8115.29NA090
21610APartial removal of rib14.6110.68NA1.8527.14NA090
21615ARemoval of rib9.878.29NA1.2019.36NA090
21616ARemoval of rib and nerves12.048.18NA1.3121.53NA090
21620APartial removal of sternum6.798.03NA0.7715.59NA090
21627ASternal debridement6.8112.78NA0.8220.41NA090
21630AExtensive sternum surgery17.3813.87NA1.9533.20NA090
21632AExtensive sternum surgery18.1412.62NA2.1632.92NA090
21700ARevision of neck muscle6.197.118.710.3113.6115.21090
21705ARevision of neck muscle/rib9.607.18NA0.9217.70NA090
21720ARevision of neck muscle5.687.017.610.8013.4914.09090
21725ARevision of neck muscle6.996.89NA0.9014.78NA090
21740AReconstruction of sternum16.5012.24NA2.0330.77NA090
21750ARepair of sternum separation10.779.98NA1.3522.10NA090
21800ATreatment of rib fracture0.961.012.210.092.063.26090
21805ATreatment of rib fracture2.754.06NA0.297.10NA090
21810ATreatment of rib fracture(s)6.866.27NA0.6013.73NA090
21820ATreat sternum fracture1.281.462.610.152.894.04090
21825ATreat sternum fracture7.4110.09NA0.8418.34NA090
21899CNeck/chest surgery procedure0.000.000.000.000.000.00YYY
21920ABiopsy soft tissue of back2.060.752.320.122.934.50010
21925ABiopsy soft tissue of back4.494.4710.950.449.4015.88090
21930ARemove lesion, back or flank5.002.654.560.498.1410.05090
21935ARemove tumor, back17.9613.26NA1.8733.09NA090
22100ARemove part of neck vertebra9.738.67NA1.5519.95NA090
22101ARemove part, thorax vertebra9.818.49NA1.5119.81NA090
22102ARemove part, lumbar vertebra9.818.70NA1.4619.97NA090
22103ARemove extra spine segment2.341.30NA0.374.01NAZZZ
22110ARemove part of neck vertebra12.7410.53NA2.2025.47NA090
22112ARemove part, thorax vertebra12.8110.60NA1.9625.37NA090
22114ARemove part, lumbar vertebra12.8110.34NA1.9825.13NA090
22116ARemove extra spine segment2.321.19NA0.403.91NAZZZ
22210ARevision of neck spine23.8216.94NA4.2344.99NA090
22212ARevision of thorax spine19.4214.35NA2.7836.55NA090
22214ARevision of lumbar spine19.4514.92NA2.7837.15NA090
22216ARevise, extra spine segment6.043.31NA0.9810.33NAZZZ
22220ARevision of neck spine21.3715.46NA3.6540.48NA090
22222ARevision of thorax spine21.5213.62NA3.0838.22NA090
22224ARevision of lumbar spine21.5215.68NA3.2040.40NA090
22226ARevise, extra spine segment6.043.30NA1.0110.35NAZZZ
22305ATreat spine process fracture2.051.873.030.294.215.37090
22310ATreat spine fracture2.613.284.380.376.267.36090
22315ATreat spine fracture8.848.89NA1.3719.10NA090
22318ATreat odontoid fx w/o graft21.5014.60NA4.2640.36NA090
22319ATreat odontoid fx w/graft24.0016.89NA4.7645.65NA090
22325ATreat spine fracture18.3014.45NA2.6135.36NA090
22326ATreat neck spine fracture19.5915.28NA3.5438.41NA090
22327ATreat thorax spine fracture19.2014.83NA2.7536.78NA090
22328ATreat each add spine fx4.612.30NA0.667.57NAZZZ
Start Printed Page 40417
22505AManipulation of spine1.873.014.590.275.156.73010
22520APercut vertebroplasty thor8.913.91NA0.8913.71NA010
22521APercut vertebroplasty lumb8.343.68NA0.8412.86NA010
22522APercut vertebroplasty addl3.001.19NA0.304.49NAZZZ
22548ANeck spine fusion25.8217.74NA4.9848.54NA090
22554ANeck spine fusion18.6213.65NA3.5135.78NA090
22556AThorax spine fusion23.4616.42NA3.7843.66NA090
22558ALumbar spine fusion22.2814.36NA3.1839.82NA090
22585AAdditional spinal fusion5.532.92NA0.989.43NAZZZ
22590ASpine & skull spinal fusion20.5115.33NA3.8139.65NA090
22595ANeck spinal fusion19.3914.31NA3.6237.32NA090
22600ANeck spine fusion16.1412.58NA2.8931.61NA090
22610AThorax spine fusion16.0212.54NA2.6631.22NA090
22612ALumbar spine fusion21.0015.36NA3.2839.64NA090
22614ASpine fusion, extra segment6.443.53NA1.0411.01NAZZZ
22630ALumbar spine fusion20.8415.57NA3.7940.20NA090
22632ASpine fusion, extra segment5.232.82NA0.908.95NAZZZ
22800AFusion of spine18.2513.64NA2.7134.60NA090
22802AFusion of spine30.8821.30NA4.4256.60NA090
22804AFusion of spine36.2724.04NA5.2365.54NA090
22808AFusion of spine26.2718.18NA4.3648.81NA090
22810AFusion of spine30.2719.81NA4.4954.57NA090
22812AFusion of spine32.7021.83NA4.6759.20NA090
22818AKyphectomy, 1-2 segments31.8321.14NA5.0157.98NA090
22819AKyphectomy, 3 or more36.4420.86NA5.2062.50NA090
22830AExploration of spinal fusion10.859.57NA1.7322.15NA090
22840AInsert spine fixation device12.548.37NA2.0322.94NAZZZ
22841BInsert spine fixation device0.000.000.000.000.000.00XXX
22842AInsert spine fixation device12.586.87NA2.0421.49NAZZZ
22843AInsert spine fixation device13.468.86NA2.1024.42NAZZZ
22844AInsert spine fixation device16.4410.54NA2.4229.40NAZZZ
22845AInsert spine fixation device11.967.95NA2.2222.13NAZZZ
22846AInsert spine fixation device12.428.21NA2.2622.89NAZZZ
22847AInsert spine fixation device13.808.97NA2.3625.13NAZZZ
22848AInsert pelv fixation device6.004.75NA0.8811.63NAZZZ
22849AReinsert spinal fixation18.5113.72NA2.8735.10NA090
22850ARemove spine fixation device9.528.41NA1.5119.44NA090
22851AApply spine prosth device6.715.08NA1.1112.90NAZZZ
22852ARemove spine fixation device9.018.18NA1.4018.59NA090
22855ARemove spine fixation device15.1311.28NA2.7429.15NA090
22899CSpine surgery procedure0.000.000.000.000.000.00YYY
22900ARemove abdominal wall lesion5.804.29NA0.5810.67NA090
22999CAbdomen surgery procedure0.000.000.000.000.000.00YYY
23000ARemoval of calcium deposits4.366.598.980.5011.4513.84090
23020ARelease shoulder joint8.9310.02NA1.2320.18NA090
23030ADrain shoulder lesion3.434.185.880.428.039.73010
23031ADrain shoulder bursa2.743.825.810.336.898.88010
23035ADrain shoulder bone lesion8.6114.53NA1.1924.33NA090
23040AExploratory shoulder surgery9.2010.87NA1.2821.35NA090
23044AExploratory shoulder surgery7.129.79NA0.9717.88NA090
23065ABiopsy shoulder tissues2.271.292.530.143.704.94010
23066ABiopsy shoulder tissues4.166.047.420.5010.7012.08090
23075ARemoval of shoulder lesion2.393.085.250.255.727.89010
23076ARemoval of shoulder lesion7.638.03NA0.8716.53NA090
23077ARemove tumor of shoulder16.0914.40NA1.8132.30NA090
23100ABiopsy of shoulder joint6.038.01NA0.8114.85NA090
23101AShoulder joint surgery5.588.10NA0.7714.45NA090
23105ARemove shoulder joint lining8.239.64NA1.1319.00NA090
23106AIncision of collarbone joint5.968.29NA0.8215.07NA090
23107AExplore treat shoulder joint8.629.61NA1.1919.42NA090
23120APartial removal, collar bone7.118.86NA0.9916.96NA090
23125ARemoval of collar bone9.3910.24NA1.2720.90NA090
23130ARemove shoulder bone, part7.559.11NA1.0617.72NA090
23140ARemoval of bone lesion6.898.21NA0.8215.92NA090
23145ARemoval of bone lesion9.0911.52NA1.2421.85NA090
23146ARemoval of bone lesion7.839.97NA1.1118.91NA090
23150ARemoval of humerus lesion8.489.44NA1.1419.06NA090
23155ARemoval of humerus lesion10.3510.88NA1.2022.43NA090
23156ARemoval of humerus lesion8.689.69NA1.1819.55NA090
23170ARemove collar bone lesion6.8610.32NA0.8418.02NA090
23172ARemove shoulder blade lesion6.9010.73NA0.9518.58NA090
23174ARemove humerus lesion9.5110.99NA1.3021.80NA090
23180ARemove collar bone lesion8.5314.68NA1.1824.39NA090
23182ARemove shoulder blade lesion8.1515.09NA1.0824.32NA090
Start Printed Page 40418
23184ARemove humerus lesion9.3814.91NA1.2425.53NA090
23190APartial removal of scapula7.248.12NA0.9716.33NA090
23195ARemoval of head of humerus9.8110.47NA1.3821.66NA090
23200ARemoval of collar bone12.0813.34NA1.4826.90NA090
23210ARemoval of shoulder blade12.4913.73NA1.6127.83NA090
23220APartial removal of humerus14.5614.41NA2.0331.00NA090
23221APartial removal of humerus17.7416.13NA2.5136.38NA090
23222APartial removal of humerus23.9219.80NA3.3747.09NA090
23330ARemove shoulder foreign body1.854.115.580.186.147.61010
23331ARemove shoulder foreign body7.388.97NA1.0217.37NA090
23332ARemove shoulder foreign body11.6211.35NA1.6224.59NA090
23350AInjection for shoulder x-ray1.000.359.720.051.4010.77000
23395AMuscle transfer,shoulder/arm16.8513.51NA2.2932.65NA090
23397AMuscle transfers16.1314.01NA2.2432.38NA090
23400AFixation of shoulder blade13.5412.98NA1.9128.43NA090
23405AIncision of tendon & muscle8.378.93NA1.1218.42NA090
23406AIncise tendon(s) & muscle(s)10.7910.89NA1.4823.16NA090
23410ARepair of tendon(s)12.4511.71NA1.7225.88NA090
23412ARepair of tendon(s)13.3112.29NA1.8627.46NA090
23415ARelease of shoulder ligament9.979.62NA1.3920.98NA090
23420ARepair of shoulder13.3013.10NA1.8628.26NA090
23430ARepair biceps tendon9.9810.45NA1.4021.83NA090
23440ARemove/transplant tendon10.4810.69NA1.4722.64NA090
23450ARepair shoulder capsule13.4012.40NA1.8627.66NA090
23455ARepair shoulder capsule14.3712.91NA2.0129.29NA090
23460ARepair shoulder capsule15.3713.57NA2.1731.11NA090
23462ARepair shoulder capsule15.3013.41NA2.1630.87NA090
23465ARepair shoulder capsule15.8512.40NA1.6129.86NA090
23466ARepair shoulder capsule14.2212.83NA2.0029.05NA090
23470AReconstruct shoulder joint17.1514.42NA2.4033.97NA090
23472AReconstruct shoulder joint21.1016.66NA2.3740.13NA090
23480ARevision of collar bone11.1811.16NA1.5623.90NA090
23485ARevision of collar bone13.4312.42NA1.8427.69NA090
23490AReinforce clavicle11.8610.64NA1.1123.61NA090
23491AReinforce shoulder bones14.2112.60NA2.0028.81NA090
23500ATreat clavicle fracture2.082.383.550.264.725.89090
23505ATreat clavicle fracture3.693.785.480.507.979.67090
23515ATreat clavicle fracture7.417.70NA1.0316.14NA090
23520ATreat clavicle dislocation2.162.423.490.264.845.91090
23525ATreat clavicle dislocation3.603.655.360.447.699.40090
23530ATreat clavicle dislocation7.318.24NA0.8516.40NA090
23532ATreat clavicle dislocation8.018.09NA1.1317.23NA090
23540ATreat clavicle dislocation2.232.404.130.244.876.60090
23545ATreat clavicle dislocation3.253.464.740.397.108.38090
23550ATreat clavicle dislocation7.247.74NA0.9415.92NA090
23552ATreat clavicle dislocation8.458.31NA1.1817.94NA090
23570ATreat shoulder blade fx2.232.493.530.295.016.05090
23575ATreat shoulder blade fx4.064.005.610.538.5910.20090
23585ATreat scapula fracture8.968.85NA1.2519.06NA090
23600ATreat humerus fracture2.933.375.090.396.698.41090
23605ATreat humerus fracture4.876.047.590.6711.5813.13090
23615ATreat humerus fracture9.359.54NA1.3120.20NA090
23616ATreat humerus fracture21.2715.63NA2.9839.88NA090
23620ATreat humerus fracture2.403.114.790.325.837.51090
23625ATreat humerus fracture3.935.076.640.539.5311.10090
23630ATreat humerus fracture7.357.69NA1.0316.07NA090
23650ATreat shoulder dislocation3.393.375.220.317.078.92090
23655ATreat shoulder dislocation4.574.06NA0.529.15NA090
23660ATreat shoulder dislocation7.497.67NA1.0116.17NA090
23665ATreat dislocation/fracture4.475.356.960.6010.4212.03090
23670ATreat dislocation/fracture7.908.14NA1.1017.14NA090
23675ATreat dislocation/fracture6.056.267.750.8313.1414.63090
23680ATreat dislocation/fracture10.069.35NA1.3920.80NA090
23700AFixation of shoulder2.523.22NA0.356.09NA010
23800AFusion of shoulder joint14.1613.57NA1.9729.70NA090
23802AFusion of shoulder joint16.6015.04NA2.3433.98NA090
23900AAmputation of arm & girdle19.7214.75NA2.4736.94NA090
23920AAmputation at shoulder joint14.6113.93NA1.9230.46NA090
23921AAmputation follow-up surgery5.496.54NA0.7812.81NA090
23929CShoulder surgery procedure0.000.000.000.000.000.00YYY
23930ADrainage of arm lesion2.943.865.960.327.129.22010
23931ADrainage of arm bursa1.793.385.500.215.387.50010
23935ADrain arm/elbow bone lesion6.0911.98NA0.8418.91NA090
24000AExploratory elbow surgery5.825.71NA0.7712.30NA090
Start Printed Page 40419
24006ARelease elbow joint9.318.16NA1.2718.74NA090
24065ABiopsy arm/elbow soft tissue2.083.255.410.145.477.63010
24066ABiopsy arm/elbow soft tissue5.216.398.700.6112.2114.52090
24075ARemove arm/elbow lesion3.925.878.100.4310.2212.45090
24076ARemove arm/elbow lesion6.306.92NA0.7013.92NA090
24077ARemove tumor of arm/elbow11.7613.74NA1.3226.82NA090
24100ABiopsy elbow joint lining4.935.51NA0.6211.06NA090
24101AExplore/treat elbow joint6.136.33NA0.8413.30NA090
24102ARemove elbow joint lining8.037.45NA1.0916.57NA090
24105ARemoval of elbow bursa3.614.84NA0.498.94NA090
24110ARemove humerus lesion7.399.03NA0.9917.41NA090
24115ARemove/graft bone lesion9.639.42NA1.1520.20NA090
24116ARemove/graft bone lesion11.8111.23NA1.6624.70NA090
24120ARemove elbow lesion6.656.33NA0.8713.85NA090
24125ARemove/graft bone lesion7.896.60NA0.8815.37NA090
24126ARemove/graft bone lesion8.317.22NA0.9016.43NA090
24130ARemoval of head of radius6.256.43NA0.8713.55NA090
24134ARemoval of arm bone lesion9.7315.45NA1.3126.49NA090
24136ARemove radius bone lesion7.996.71NA0.8515.55NA090
24138ARemove elbow bone lesion8.057.37NA1.1216.54NA090
24140APartial removal of arm bone9.1815.93NA1.2326.34NA090
24145APartial removal of radius7.5810.30NA1.0118.89NA090
24147APartial removal of elbow7.5410.34NA1.0418.92NA090
24149ARadical resection of elbow14.2010.85NA1.9026.95NA090
24150AExtensive humerus surgery13.2713.78NA1.8128.86NA090
24151AExtensive humerus surgery15.5815.36NA2.1933.13NA090
24152AExtensive radius surgery10.068.95NA1.1920.20NA090
24153AExtensive radius surgery11.547.34NA0.6419.52NA090
24155ARemoval of elbow joint11.738.81NA1.4221.96NA090
24160ARemove elbow joint implant7.837.33NA1.0716.23NA090
24164ARemove radius head implant6.236.36NA0.8413.43NA090
24200ARemoval of arm foreign body1.763.165.900.155.077.81010
24201ARemoval of arm foreign body4.566.758.450.5611.8713.57090
24220AInjection for elbow x-ray1.310.4710.760.071.8512.14000
24301AMuscle/tendon transfer10.208.94NA1.3020.44NA090
24305AArm tendon lengthening7.457.15NA0.9815.58NA090
24310ARevision of arm tendon5.987.77NA0.7414.49NA090
24320ARepair of arm tendon10.5610.12NA1.0021.68NA090
24330ARevision of arm muscles9.608.44NA1.2119.25NA090
24331ARevision of arm muscles10.658.80NA1.4120.86NA090
24340ARepair of biceps tendon7.897.23NA1.0816.20NA090
24341ARepair arm tendon/muscle7.907.30NA1.0816.28NA090
24342ARepair of ruptured tendon10.628.91NA1.4821.01NA090
24350ARepair of tennis elbow5.255.91NA0.7211.88NA090
24351ARepair of tennis elbow5.916.34NA0.8213.07NA090
24352ARepair of tennis elbow6.436.61NA0.9013.94NA090
24354ARepair of tennis elbow6.486.55NA0.8813.91NA090
24356ARevision of tennis elbow6.686.74NA0.9014.32NA090
24360AReconstruct elbow joint12.349.65NA1.6923.68NA090
24361AReconstruct elbow joint14.0810.36NA1.9526.39NA090
24362AReconstruct elbow joint14.9910.93NA1.9227.84NA090
24363AReplace elbow joint18.4913.26NA2.5234.27NA090
24365AReconstruct head of radius8.397.62NA1.1117.12NA090
24366AReconstruct head of radius9.138.06NA1.2818.47NA090
24400ARevision of humerus11.0611.89NA1.5324.48NA090
24410ARevision of humerus14.8213.84NA1.8930.55NA090
24420ARevision of humerus13.4415.43NA1.8230.69NA090
24430ARepair of humerus12.8112.15NA1.8026.76NA090
24435ARepair humerus with graft13.1713.11NA1.8428.12NA090
24470ARevision of elbow joint8.747.17NA1.2317.14NA090
24495ADecompression of forearm8.129.47NA0.9218.51NA090
24498AReinforce humerus11.9211.60NA1.6725.19NA090
24500ATreat humerus fracture3.213.114.670.416.738.29090
24505ATreat humerus fracture5.176.318.090.7212.2013.98090
24515ATreat humerus fracture11.6510.79NA1.6324.07NA090
24516ATreat humerus fracture11.6511.17NA1.6324.45NA090
24530ATreat humerus fracture3.504.445.640.478.419.61090
24535ATreat humerus fracture6.876.388.130.9614.2115.96090
24538ATreat humerus fracture9.439.79NA1.2520.47NA090
24545ATreat humerus fracture10.469.60NA1.4721.53NA090
24546ATreat humerus fracture15.6913.03NA2.1830.90NA090
24560ATreat humerus fracture2.802.894.480.356.047.63090
24565ATreat humerus fracture5.565.627.400.7411.9213.70090
24566ATreat humerus fracture7.799.23NA1.1018.12NA090
Start Printed Page 40420
24575ATreat humerus fracture10.668.03NA1.4420.13NA090
24576ATreat humerus fracture2.863.014.250.386.257.49090
24577ATreat humerus fracture5.795.757.510.8112.3514.11090
24579ATreat humerus fracture11.6010.69NA1.6223.91NA090
24582ATreat humerus fracture8.559.72NA1.2019.47NA090
24586ATreat elbow fracture15.2110.77NA