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Proposed Rule

Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2003

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AGENCY:

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

ACTION:

Proposed rule.

SUMMARY:

The proposed rule would refine the resource-based practice expense relative value units (RVUs) and make other changes to Medicare Part B payment policy. The policy changes concern: Medicare Economic Index, pricing of the technical component for positron emission tomography (PET) scans, Medicare qualifications for clinical nurse specialists, a process to add or delete services to the definition of telehealth, definition for ZZZ global periods, global period for surface radiation, and an endoscopic base for urology codes. We also discuss the refinement of anesthesia work values, clinical social worker services, and how drugs are accounted for in the sustainable growth rate.

We are proposing these changes to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. We solicit comments on the proposed policy changes.

This proposed rule also clarifies the enrollment of physical and occupational therapists as therapists in private practice. In addition, this proposed rule discusses physical and occupational therapy payment caps and makes technical changes to outpatient rehabilitation services.

DATES:

We will consider comments if we receive them at the appropriate address, as provided below, no later than 5 p.m. on August 27, 2002.

ADDRESSES:

In commenting, please refer to file code CMS-1204-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. Mail written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1204-P, P.O. Box 8013, Baltimore, MD 21244-8013.

Please allow sufficient time for us to receive mailed comments on time in the event of delivery delays.

If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) to one of the following addresses: Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201, or Room C5-14-03, 7500 Security Boulevard, Baltimore, MD 21244-8013.

(Because access to the interior of the HHH Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available if you wish to retain proof of filing by stamping in and retaining an extra copy of the comments being filed.)

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and could be considered late.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

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FOR FURTHER INFORMATION CONTACT:

Carolyn Mullen, (410) 786-4589, Marc Hartstein, (410) 786-4539, or Stephanie Monroe (410) 786-6864 (for issues related to resource-based practice expense relative value units).

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

Marc Hartstein, (410) 786-4539 (for issues related to sustainable growth rate).

Gail Addis, (410) 786-4522 (for issues related to PET scans and HCPCS codes).

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

Terri Harris, (410) 786-6830 (for issues related to physical and occupational therapy).

Latesha Walker, (410) 786-1101 (for all other issues).

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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 the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone (410) 786-7197.

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 toll-free at 1-888-293-6498) 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 web site 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 V.

Table of Contents

I. Background

A. Legislative History

B. Published Changes to the Fee Schedule

II. Provisions of the Proposed Regulations

A. Resource-Based Practice Expense Relative Value Units

B. Anesthesia Issues

C. Changes to the Physician Fee Schedule Update Calculation and the Sustainable Growth Rate (SGR)

D. Pricing of Technical Components (TC) for Positron Emissions Tomography (PET) Scans

E. Enrollment of Physical and Occupational Therapists as Therapists in Private Practice

F. Clinical Social Worker Services

G. Medicare Qualifications for Clinical Nurse Specialists Start Printed Page 43847

H. Process to Add or Delete Services to the Definition of Telehealth

I. Definition for ZZZ Global Periods

J. Change in Global Period for CPT Code 77789 (Surface Application of Radiation Source)

K. Technical Change: § 410.61(d)(iii) Outpatient Rehabilitation Services

L. New HCPCS G-Codes

M. Endoscopic Base for Urology Codes

N. Physical Therapy and Occupational Therapy Caps

III. Collection of Information Requirements

IV. Response to Comments

V. Regulatory Impact Analysis

Addendum A—Explanation and Use of Addendum B

Addendum B—2003 Relative Value Units and Related Information Used in Determining Medicare Payments for 2003.

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

CMS—Centers for Medicare & Medicaid Services

CNS—Clinical Nurse Specialist

CPT—(Physicians') Current Procedural Terminology (4th Edition, 2002, copyrighted by the American Medical Association)

CPEP—Clinical Practice Expert Panel

CRNA—Certified Registered Nurse Anesthetist

E/M—Evaluation and management

FMR—Fair market rental

GAF—Geographic adjustment factor

GPCI—Geographic practice cost index

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

PET—Positron Emission Tomography

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

SNF—Skilled Nursing Facility

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) limits on the amounts that nonparticipating physicians can charge beneficiaries; and (3) a sustainable growth rate for the rates of increase in Medicare expenditures for physicians' services. 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. In the August 2001 proposed rule (66 FR 40372) we discussed the November 2000 final rule relating to the updates to the RVUs and revisions to payment policies under the physician fee schedule.

In the November 2001 final rule with comment period (66 FR 55246), we revised the policy for resource-based practice expense RVUs; 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 also addressed comments received on the June 8, 2001 proposed notice (66 FR 31028) for the 5-year review of work RVUs and finalized these work RVUs. In addition, we acknowledged comments received in response to a discussion of modifier-62, which is used to report the work of co-surgeons. The November 2001 final rule also updated the list of services that are subject to the physician self-referral prohibitions in order to reflect CPT and Healthcare Common Procedure Coding System (HCPCS) code changes that were effective January 1, 2002. All these revisions ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services.

The Medicare, Medicaid, and State Child Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 (Pub. L. 106-554) (BIPA) modernized the mammography screening benefit and authorized payment under the physician fee schedule effective January 1, 2002. It provided for biennial screening pelvic examinations for certain beneficiaries and expanded coverage for screening colonoscopies to all beneficiaries effective July 1, 2001. It provided for annual glaucoma screenings for high-risk beneficiaries and established coverage for medical nutrition therapy services for certain beneficiaries effective January 1, 2002. It expanded payment for telehealth services effective October 1, 2001; required certain Indian Health Service providers to be paid for some services under the physician fee schedule effective July 1, 2001; and revised the payment for certain physician pathology services effective January 1, 2001. This final rule conformed our regulations to reflect these statutory provisions.

The final rule also announced the calendar year 2002 physician fee schedule conversion factor of $36.1992.

II. Provisions of the Proposed Regulations

This proposed rule would affect the regulations set forth at part 410, Supplementary medical insurance (SMI) benefits and part 414, Payment for Part B medical and other health services.

A. Resource-Based Practice Expense Relative Value Units

1. Resource-Based Practice Expense Legislation

Section 121 of the Social Security Act Amendments of 1994 (Pub. L. 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 1998. 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 Start Printed Page 43848practice 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 Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33), enacted on August 5, 1997, 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.

Further legislation affecting resource-based practice expense RVUs was included in the Medicare, Medicaid and State Child Health Insurance Program (SCHIP) Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106-113), enacted on November 29, 1999. 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. (In the 1999 final rule (64 FR 59380), we extended, for an additional 2 years, the period during which we would accept supplementary data.)

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.

a. Major Steps

A brief discussion of the major steps involved in the determination of the practice expense RVUs follows. (Please see the November 1, 2001 final rule (66 FR 55249) for a more detailed explanation of the top-down methodology.)

  • Step 1—Determine the specialty specific practice expense per hour of physician direct patient care. We used the AMA's SMS survey of actual aggregate cost data by specialty to determine the practice expenses per hour for each specialty. We calculated the practice expenses per hour for the specialty by dividing the aggregate practice expenses for the specialty by the total number of hours spent in patient care activities.
  • Step 2—Create a specialty specific practice expense pool of practice expense costs for treating Medicare patients. To calculate the total number of hours spent treating Medicare patients for each specialty, we used the physician time assigned to each procedure code and the Medicare utilization data. We then calculated the specialty specific practice expense pools by multiplying the specialty practice expenses per hour by the total physician hours.
  • Step 3—Allocate the specialty specific practice expense pool to the specific services performed by each specialty. For each specialty, we divided the practice expense pool into two groups based on whether direct or indirect costs were involved and used a different allocation basis for each group.

(i) Direct costs—For direct costs (which include clinical labor, medical supplies, and medical equipment), we used the procedure specific CPEP data on the staff time, supplies, and equipment as the allocation basis.

(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 combined with the physician fee schedule work RVUs. We converted the work RVUs to dollars using the Medicare CF (expressed in 1995 dollars for consistency with the SMS survey years).

  • Step 4—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.

b. Other Methodological Issues

(i) Zero Physician Work Pool—For services with physician work RVUs equal to zero (including those services with a technical and professional component), we created a separate practice expense pool using the average clinical staff time from the CPEP data and the “all physicians” practice expense per hour.

We then used the adjusted 1998 practice expense RVUs to allocate this pool to each service. Also, for all radiology services that are assigned physician 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.

(ii) Crosswalks for Specialties without Practice Expense Survey Data

Since many specialties identified in our claims data did not correspond exactly to the specialties included in the SMS survey data, it was necessary to crosswalk these specialties to the most appropriate SMS specialty.

(iii) Because we believe that most physical therapy services furnished in physicians' offices are performed by physical therapists, we crosswalked all utilization for therapy services in the CPT 97000 series to the physical and occupational therapy practice expense pool.

B. Practice Expense Proposals for Calendar Year 2003

1. CPEP Data

a. Ophthalmology Services—Rank Order Anomalies

Rank order anomalies were created in three ophthalmology families of codes because only certain services in each family were brought to the Practice Expense Advisory Committee (PEAC) for refinement, while CPEP data for the other codes were left unchanged. The American Academy of Ophthalmology has requested that we make the following changes in the CPEP data to ensure that the more complex services in a family of codes are not paid less than the simpler services and we are proposing to do so.

CPT code 67820, Revise eyelashes—remove ophthane from the supply list.

CPT code 67825, Revise eyelashes—remove the bipolar handpiece from the supply list.

CPT code 65220, Removal foreign body from eye—use the supply list and clinical staff time assigned to CPT code 65222. The exam lane should be the only equipment assigned.

CPT codes 92081 and 92083, Visual field examination(s)—Assign the same supplies and equipment as CPT code 92082; assign 35 minutes of clinical staff time to 92081 and 70 minutes to 92083.

b. Practice Expense Inputs for Thermotherapy Procedures

There are three CPT codes for transurethral destruction of prostate tissue: CPT 53850, by microwave Start Printed Page 43849therapy, CPT 53852, by radiofrequency thermotherapy, and CPT 53853, by water-induced thermotherapy (WIT). A manufacturer of WIT equipment has expressed concern that the practice expense inputs currently assigned to CPT 53853 underestimate the costs associated with that procedure relative to the other two codes. We have compared the inputs of the three codes and agree that the WIT procedure has not been assigned many of the basic supply and equipment inputs that are included in the CPEP inputs for the other two procedures. Therefore, we are proposing to add, on an interim basis, the following inputs: Power table, ultrasound unit, mayo stand, endoscopy stretcher, light source, chux, sani-wipe, patient education book, sterile towel, sterile gloves, specimen cup, alcohol swab, gauze, tape, lidocaine, betadine, 10 cc syringe, 30 cc syringe, sterile water, leg bag. These inputs would be in addition to the thermotherapy unit, treatment catheter, drainage bag, cystopak (which contains drapes, syringe, irrigation tubing, surgical lubricant, sterile cup, gauze pad and cysto tubing) and minimum visit package for each visit (which contains patient gown, unsterile gloves, exam table paper, pillow case and thermometer probe cover) that are currently assigned as practice expense inputs for this procedure.

We are also proposing to change on an interim basis the staff type for CPT code 53853 from the RN/LPN/MTA blend to RN in order to make the staff type consistent among these three similar procedures. In addition, we have corrected for all three procedures the minutes assigned to each piece of equipment to reflect the intra- and post-clinical staff times only, rather than the total clinical staff times as we do for all services.

We will request that these three procedures be reexamined by the PEAC at the same time in order to ensure that there is a consistent approach to the assignment of direct cost inputs.

We have also received questions regarding the large disparity in prices that we have used for the three different thermotherapy machines. Currently, the thermotherapy equipment for CPT code 53850 is priced at $180,000, code 53852 at $42,995 and code 53853 at $18,500. The first two prices were given to us in 1999 and we have been sent documentation that indicates that the prices have fallen dramatically since that time. This documentation indicates that the current price for the thermotherapy equipment for CPT 53580 is somewhere between $55,000 and $100,000 and for code 53852 between $25,000 and $30,000. We are proposing to set the prices at $60,000 and $30,000, respectively and are also requesting that commenters furnish any additional available price documentation, particularly invoices for recently purchased equipment, so that we can ensure that any differences in assigned prices accurately reflect actual differences in costs.

c. Revision to Inputs for Iontophoresis

It has been brought to our attention that the electrodes assigned to the supply list for CPT code 97033, Iontophoresis, are not the type of electrodes required for this procedure. We are proposing to substitute two electrodes with a medication vesicle as the appropriate supply for iontophoresis.

d. Correction to Price for Sterile Water

The current price of $40.00 for 1000 ml of sterile water that is listed in our CPEP supply database is incorrect. We are proposing to change this to $3.00.

2. Zero Physician Work Pool for Practice Expense

a. Discussion of Alternatives to the Zero Physician Work Pool

Within the last year, there have been two reports that have addressed the zero physician work pool. The GAO released a report in October 2001 that recommended eliminating the zero physician work pool (GAO-02-53, page 25). The Lewin Group, under contract with us, provided a draft report on June 5, 2001 analyzing the zero physician work pool and provided several ideas that we could study as alternatives. As we indicated in the November 2, 1998 final rule (63 FR 58821), we created the zero physician work pool as an interim measure until we could further analyze the effect of the top-down methodology on the Medicare payment for services that do not have physician work RVUs. Given our interest in finding alternatives to the zero physician work pool, we have analyzed the following possible ideas:

  • Eliminate the Zero Physician Work Pool.

The Lewin Group indicated that one idea could be to eliminate the zero physician work pool, as recommended by the GAO (the Lewin Group, page 19). We do not believe that the zero physician work pool should be eliminated at this time. In the absence of a change to the methodology or additional data, eliminating the zero physician work pool would result in large reductions in payments for some of the specialties whose services are included in the pool. The Lewin Group also indicated that this idea is not a “viable alternative to the current zero (physician) work pool approach.” (The Lewin Group, pages 19-20).

  • Develop Specialty-Specific Zero Physician Work Pools.

Under this approach, the Lewin Group report described an idea for maintaining the general zero physician work pool approach with specialty-specific zero physician work pools (the Lewin Group, page 20). Since the zero physician work pool is an exception to the basic methodology, we are not currently interested in developing another exception to replace it. We are interested in finding a single methodology that would apply to all physicians' services. While we are not adopting this suggestion, we do appreciate the Lewin Group's work in developing this and many other ideas for consideration as we make refinements to the practice expense methodology.

  • Make Technical Component Equal Global Less Professional Component RVUs.

Many of the services that are affected by the zero physician work pool are services that have both professional and technical components. Under current policy, the technical component practice expense RVU is determined in the zero physician work pool. It is added to the practice expense RVUs for the professional component determined under the basic methodology to determine payment for the global service. This Lewin Group idea would change this to make the technical component RVUs equal the difference between the global and the professional component RVUs while other zero physician work services would be returned to the basic methodology (The Lewin Group, page 21).

If we were to adopt this approach, the zero physician work pool would no longer have any effect. The zero physician work pool would not have any effect on the professional and technical component services since the global service from the basic methodology would be used to derive the technical component value. The practice expense RVUs for other zero physician work services would be priced under the basic methodology. In the absence of a change to the methodology or additional data, this idea would result in large reductions in payments for some of the specialties whose services are included in the pool.

As we have indicated above, we are concerned about adopting this idea at this time. While we are not currently proposing to adopt this idea as an alternative to the zero physician work Start Printed Page 43850pool, we do believe there is merit in making the technical component value equal the difference between the global and professional component RVU for services that are unaffected by the zero physician work pool. We receive many more bills for the global than the technical component only. Since it is far more common to receive a global than a technical component only bill, it is far more likely that using the global to value the technical component service will result in a payment that is more typical of the relative actual practice expense associated with the service.

For this reason, we are proposing to make the technical component value equal to the difference between the global and the professional component for procedure codes that are not included in the zero physician work pool. We will continue to make the global value equal to the sum of the professional and the technical component values for procedure codes that remain in the zero physician work pool. However, we may revisit this decision in the future if we can address issues related to the zero physician work pool. We have provided more detail on the redistributive impact of this proposal among all physician specialties in the impact section of this proposed rule.

  • Develop Proxy Physician Work RVUs for Zero Physician Work Services.

Finally, the Lewin Group described an idea that would retain work and direct expenses as the basic allocators of indirect costs but create proxy physician work values for services that have no physician work (the Lewin Group, pages 22-23). The GAO suggests that the basic method for allocating indirect expenses does not adequately account for the indirect costs associated with services that do not have physician work RVUs (GAO-02-53, page 22). We do not believe that the large payment reductions that would occur if some zero physician work services were priced under the basic methodology are necessarily associated with the indirect cost allocation methodology. While the zero physician work pool is of benefit to many of the services that were originally included, some specialties commented that this methodological change negatively affected the particular services they provide. As a result, we allowed specialties to request that their services be removed from the zero physician work pool (see July 22, 1999 proposed rule (64 FR 39620)). If there are shortcomings in the indirect cost allocation for services that have zero physician work, it seems likely that the values for all zero physician work services would be adversely affected. However, since many zero physician work services are not adversely affected under the top down methodology, it seems unlikely that the indirect cost allocation explains the adverse payment impact that would result for some services from elimination of the zero physician work pool. For this reason, we do not anticipate modifying the indirect cost allocation for zero physician work services.

Based on our analysis of the Lewin suggestions, we do not believe that allocation of either direct or indirect expenses explains the effect of the top down methodology on zero physician work services. Rather, we believe it is likely that a relatively low practice expense per hour for some of the specialties included in the zero physician work pool explains why their payments are adversely affected by its elimination.

The specialties whose services are affected by the zero physician work pool may want to conduct supplemental practice expense surveys if they believe there are shortcomings in the practice expense per hour information that we use as part of the basic methodology. We have published in this issue of the Federal Register, an interim final rule with comment that will modify the criteria for acceptance of supplemental data. This should make it easier for specialties to incorporate new practice expense survey information into the methodology. Further, as we indicated previously in the November 1, 2000 Federal Register (65 FR 65384), we believe that there are significant advantages to receiving practice cost information through multi-specialty surveys. For this reason, we would welcome a multi-specialty practice expense survey from all of the specialties that have payments affected by the zero physician work pool.

b. Other Proposals for Changes to the Zero Physician Work Pool

(i) Adjustment to Oncology Supplies Practice Expense Per Hour

In the June 5, 1998 proposed rule (63 FR 30832), we proposed an adjustment to the medical supplies practice expense per hour for oncology as a result of a concern that their inordinately high practice expense per hour included expenses associated with separately payable cancer drugs. We proposed to substitute the “all physician” average for the oncology-specific medical supplies practice expense per hour. We received public comments indicating that, even after excluding the effect of higher drug expenses, oncologists have higher medical supply expenses than the average physician because of high supply costs associated with the administration of chemotherapy. These commenters suggested alternatives to using the average physician rate. In our November 2, 1998 (63 FR 58825) final rule, we made an adjustment to the medical supplies practice expense per hour for oncology and indicated our belief that oncology medical supply expenses would not necessarily exceed those of the average physician. However, the adjustment has largely had no effect since the practice expense RVUs for chemotherapy administration services are determined in the zero physician work pool.

In its October 2001 report, the GAO recommended that we examine the effect of the adjustment made to oncologists' reported medical supplies expenses per hour. GAO did not suggest a specific alternative to the adjustment we made (GAO-02-53, pages 24-25). Consistent with the GAO recommendation, we have examined this adjustment and its impact on Medicare payments to oncologists. Upon further review, we believe that there is merit in reconsidering the adjustment that we made to the medical supply expenses for oncologists in combination with removing chemotherapy administration services from the zero physician work pool.

At this time, we have no specific information on oncology medical supply expenses net of separately payable drugs. However, we have established a process that would allow specialties to submit supplemental practice expense survey data to us. While the criteria for performing a survey require consistency with the SMS, we are amenable to modifications to the survey instrument so that it can address questions that are of concern to a specific medical specialty. For instance, we would allow an oncology survey to request that respondents distinguish between drug and other medical supply related expenses. We believe that using specific data on this question from a survey would be preferable to developing an alternative adjustment that requires us to make assumptions about oncology medical supply expenses. However, if further survey information is unavailable to us, we are considering information that could be used as a reasonable proxy to determine the portion of the supplies practice expense per hour that is attributable to medical supplies that are not separately payable. Such an idea was suggested in the public comments on the June 5, 1998 proposed rule. We are considering other alternatives as well. These approaches to the supplies Start Printed Page 43851practice expense per hour would apply if chemotherapy administration services were removed from the zero physician work pool.

(ii) Change to Staff Time Used To Create the Pool

In the November 2, 1998 final rule (63 FR 58841), we indicated that average clinical staff time was used in the creation of the zero physician work pool. Since the cost pools are created based on physician time and, by definition, zero physician work services have no physician time, we need to use staff time to create the cost pool. If our database indicates that multiple staff types are typically involved in the service, we have used an average of the different clinical staff times. We are proposing to create the cost pool using the highest staff time in place of average staff time. The impact of this proposal is shown in the impact section of this proposed rule.

(iii) Removal of Non-Invasive Vascular Diagnostic Study Codes From the Zero Physician Work Pool

We are proposing to remove the non-invasive vascular diagnostic study codes (CPT codes 93875-93990) from the zero physician work pool based on a request from the American Association for Vascular Surgery and the Society for Vascular Surgery. The impact of this proposal is also described further in the impact section.

(iv) Removal of Immunization CPT Codes 90471 and 90472 From the Zero Physician Work Pool

As discussed above, in the November 2, 1998 final rule (63 FR 58841), in response to the many commenters who were concerned about the proposed reductions for services with zero physician work RVUs, we created a separate practice expense pool for all services with zero physician work RVUs. The assignment of services to this zero physician work pool was of benefit to most services in this expense pool. However, some specialties were negatively affected by this methodology, and we have allowed specialties to indicate whether their services should be priced in this pool.

Immunization administration services do not have physician work RVUs and have been included in the zero physician work pool. So that the direct practice expense resource costs associated with the immunization administration services are recognized, we propose removing these services from the zero physician work pool methodology and treating them like the vast majority of services on the physician fee schedule. Using the direct cost practice expense inputs as recommended by the AMA's RUC, the proposed practice expense relative value units will be 0.22 for CPT code 90471 and 0.09 for CPT code 90472. This change will nearly double payment for CPT code 90471 and slightly reduce payment for CPT code 90472. Procedure CPT code 90471 is used for immunization administration and CPT code 90472 is used for each additional vaccine. Since CPT code 90472 must be billed in conjunction with CPT code 90471, the total payment for these procedures will increase when billed together.

We have not assigned immunization administration physician work RVUs because this service does not typically involve a physician. The nurse that administers the vaccine typically provides the necessary counseling to the patient and this time is accounted for in the practice expense RVU.

In addition, we would note that not all services represented by CPT codes 90471 and 90472 are covered by Medicare. For example, medically necessary administrations of tetanus toxoid (such as following a severe injury) would be covered whereas preventive administration of this vaccine would not be covered. Also, we will consider whether the amount of counseling of the patient and/or family may be different for childhood immunizations than for the typical Medicare service. Therefore, we are considering whether coding changes to reflect these differences would be appropriate.

3. Utilization Data

As indicated earlier, Medicare utilization is an important data source used in determining the practice expense RVUs. In our final rule published on November 2, 1998 (63 FR 58815), we used 1997 Medicare utilization data to create the original resource-based practice expense RVUs. Based on a public comment, we indicated in our November 2, 1999 final rule (64 FR 59405) that we would use 1998 Medicare utilization to develop the fully implemented RVUs that appear in that final rule. Because these data were unavailable to us for the proposed rule, the first time we could act on this public comment was in the final rule. We have continued our policy of using the latest utilization data to develop each successive year's fully implemented practice expense RVUs during each year of the transition (see 65 FR 65436, published on November 1, 2000, and 66 FR 55322, published on November 1, 2001).

While substituting the latest year's utilization data into the practice expense methodology generally made little difference on total Medicare payments per specialty, it had a larger impact on services that have values affected by the zero physician work pool. The practice expense values for the technical component and other services included in the zero physician work pool declined 4 percent in 2002 as a result of using the most recent Medicare utilization data. Since the technical component is used to derive the global practice expense RVUs for professional and technical component services, there was also a reduction in the practice expense RVU for the global service.

The specialties that provide many of the services that are included in the zero physician work pool have expressed concern about the impact of the most recent data on utilization on values for their services. They recently suggested that we use combined utilization data from 1997 to 2000 to determine the practice expense values. Alternatively, these commenters suggested using either the 1997 or 1999 utilization as a “base year” until an alternative to the zero physician work pool can be developed. These commenters further indicated that, once an option is chosen, we should not use more recent utilization data until comprehensive reform of the zero physician work methodology is adopted.

We believe the suggestion of using multiple years of utilization data in the practice expense methodology has merit. Using multiple years of data has the potential to minimize the effect of year to year case mix changes on practice expense RVUs and improves the stability of our payment systems. We are proposing to develop the practice expense RVUs using Medicare utilization data from 1997-2000. More information on the impact of this proposal can be found in the regulatory impact statement of this proposed rule.

We also agree with the suggestion that the utilization data not change annually until the zero physician work pool is eliminated. In fact, we are reconsidering whether to continue the practice of using the most recent utilization to develop each successive year's practice expense RVUs. As we have indicated elsewhere in this and earlier rules, we are continuing the refinement process beyond the 1998-2002 transition period mandated by the BBA. Once the refinement process is complete, we believe that the physician community has a reasonable expectation that the practice expense RVUs will not change from year to year unless further Start Printed Page 43852refinement is undertaken. Once the initial refinement of practice expense RVUs is complete, we expect to make additional refinements at least every 5 years as provided for in section 1848(c)(2)(B) of the Act. As the refinement process continues, there have been fewer widespread changes to Medicare payments and there has been increased year-to-year consistency in the practice expense RVUs. We believe this stability would improve if we incorpoated the most recent utilization data into the practice expense methodology only when we undertake substantial refinement as part of a 5-year review. For this reason, we are proposing to use the 1997-2000 utilization data to develop the CY 2003 practice expense RVUs and not further update the utilization data to incorporate the 2001 utilization data in this year's final rule. Further, we are proposing to continue using the 1997-2000 utilization data in the practice expense methodology until we undertake the 5-year review of practice expense RVUs. We invite comments on these issues.

4. Site of Service

As part of our resource-based practice expense methodology, we make a distinction between the practice expense RVUs for the non-facility and the facility setting.

This distinction is needed because of the higher resource costs to the physician in the non-facility setting when the practitioner typically bears the cost of the resources associated with the service. In addition, the distinction ensures that we do not make a duplicate payment for any of the practice expenses incurred in performing a service for a Medicare beneficiary. When the beneficiary is a facility patient, we pay the facility for the clinical staff, supplies, and equipment needed to care for the patient. A generally lower facility practice expense rate is paid to the practitioner. Currently, we have designated only hospitals, skilled nursing facilities (SNFs), and community mental health centers (CMHCs) as facilities for purposes of calculating practice expense. An ambulatory surgical center (ASC) is designated as a facility if it is the place of service for a procedure on the ASC list. All other places of service are currently considered non-facility.

Several new places of service are now in use for which we need to assign a site-of-service designation. Also, we are proposing revisions to the site-of-service designation for several existing places of service. We are proposing to assign a facility site of service where a facility or other payment will be made, in addition to the physician fee schedule payment to the practitioner, to reflect the practice expenses incurred in providing a service to a Medicare patient. We are proposing to designate all other places of service as non-facilities.

The following is a list of the new places of service, along with their place of service numerical codes and their proposed site of service designations using the above criteria:

04—Homeless Shelter—

We are proposing that this be considered a nonfacility setting.

05—Indian Health Service Free-Standing Facility—

We are proposing that this be considered a nonfacility setting.

06—Indian Health Service Provider-Based Facility—

We are proposing that this be considered a facility setting.

07—Tribal 638—Free-Standing Facility—

We are proposing that this be considered a nonfacility setting.

08—Tribal 638—Provider-Based Facility—

We are proposing that this be considered a facility setting.

15—Mobile Unit

We are proposing that this be considered a nonfacility setting.

If a mobile unit provides a service to a facility patient, the appropriate place-of-service code for the facility should be used. For instance, if a portable X-ray service is provided to a patient in a Part A skilled nursing facility stay, the place of service is 31, Skilled Nursing Facility. No payment is made under Part B for the technical component of a diagnostic test, portable x-ray transportation or portable x-ray set up. Payment is made to the SNF for Part A services and includes payment for diagnostic services that may be needed by the patient. This policy is consistent with recommendations made by the Inspector General in a recent report, Review of Improper Payments Made by Medicare Part B for Covered Services under the Part A Skilled Nursing Facility Prospective Payment System (A-01-00-00538).

20—Urgent Care Facility—

We are proposing that this be considered a nonfacility setting.

We are proposing changes in site of service to the following current designations:

26—Military Treatment Facility—

Currently this is designated as a nonfacility. We are proposing that this be considered a facility setting.

41—Ambulance-Land

42—Ambulance Air or Water—

Currently codes 41 and 42 are designated as nonfacility. We would propose to designate them as facilities because we make payments for ambulance services using the ambulance fee schedule that covers the direct practice expense.

52—Psychiatric Facility Partial Hospitalization—

Currently, this is designated as a nonfacility. We are proposing that this be considered a facility setting.

56—Psychiatric Residential Treatment Facility—

Currently, this is designated as a nonfacility. We are proposing that this be considered a facility setting.

In the chart below is a complete list of all the existing place-of-service codes along with the appropriate site-of-service designation and the descriptor for each. These codes are used on all professional claims to specify the entity where services are furnished.

Place of Service Codes for Professional Claims; Database as of 1/11/2002

Facility vs nonfacility designationPlace of service code(s)Place of service namePlace of service description
01-02UnassignedN/A.
NF03SchoolA facility whose primary purpose is education.
NF04Homeless ShelterA facility or location whose primary purpose is to provide temporary housing to homeless individuals (for example, emergency shelters, individual or family shelters).
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NF05Indian Health Service Free-standing FacilityA facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization.
F06Indian Health Service Provider-based FacilityA facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients.
NF07Tribal 638 Free-standing FacilityA facility or location owned and operated by a Federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non- surgical), and rehabilitation services to tribal members who do not require hospitalization.
F08Tribal 638 Provider-based FacilityA facility or location owned and operated by a Federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non- surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients.
09-10UnassignedN/A.
NF11OfficeLocation, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
NF12HomeLocation, other than a hospital or other facility, where the patient receives care in a private residence.
13-14UnassignedN/A.
NF (*See above explanation)15Mobile UnitA facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.
16-19UnassignedN/A.
NF20Urgent Care FacilityLocation, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
F21Inpatient HospitalA facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
F22Outpatient HospitalA portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
F23Emergency Room—HospitalA portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
F when performing a service on the Medicare ASC list, otherwise a NF.24Ambulatory Surgical CenterA freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.
NF25Birthing CenterA facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of newborn infants.
F26Military Treatment FacilityA medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).
27-30UnassignedN/A.
F31Skilled Nursing FacilityA facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
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NF32Nursing FacilityA facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.
NF33Custodial Care FacilityA facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
F34HospiceA facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families is provided.
35-40UnassignedN/A.
F41Ambulance—LandA land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
F42Ambulance—Air or WaterAn air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
43-49UnassignedN/A.
NF50Federally Qualified Health CenterA facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.
F51Inpatient Psychiatric FacilityA facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
F52Psychiatric Facility-Partial HospitalizationA facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.
F53Community Mental Health CenterA facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility; 24-hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of that admission; and consultation and education services.
NF54Intermediate Care Facility/Mentally RetardedA facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.
NF55Residential Substance-Abuse Treatment FacilityA facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
NF56Psychiatric Residential Treatment CenterA facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.
57-59UnassignedN/A.
NF60Mass Immunization CenterA location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as a public health center, pharmacy, or mall, but may include a physician office setting.
NF61Comprehensive Inpatient Rehabilitation FacilityA facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.
NF62Comprehensive Outpatient Rehabilitation FacilityA facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.
63-64UnassignedN/A.
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NF65End-Stage Renal Disease Treatment FacilityA facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.
66-70UnassignedN/A.
NF71State or Local Public Health ClinicA facility maintained by either State or local health departments which provides ambulatory primary medical care under the general direction of a physician.
NF72Rural Health ClinicA certified facility which is located in a rural medically-underserved area that provides ambulatory primary medical care under the general direction of a physician.
73-80UnassignedN/A.
NF81Independent LaboratoryA laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.
82-98UnassignedN/A.
99Other Place of ServiceOther place of service not identified above.

B. Anesthesia Issues

1. Five-Year Review of Anesthesia Work

Medical and surgical services paid under the physician fee schedule have three separate relative value components, a work RVU, a practice expense RVU and a malpractice RVU. Physician anesthesia services are paid under the physician fee schedule, but the payment method is different than the payment method for physician medical and surgical services. Payment for anesthesia services is based on the sum of base units and anesthesia time units multiplied by an anesthesia CF that is different from the physician fee schedule CF for medical and surgical services.

The law requires that we review RVUs no less than every 5 years. The first 5-year review of work RVUs was completed and the revised work RVUs were implemented in 1997. The second 5-year review (with the exception of anesthesia services) was completed and the revised work RVUs implemented in CY 2002.

In the first 5-year review of work RVUs, we accepted the American Medical Association's (AMA's) Relative Value Update Committee's (RUC's) recommendation that the work of anesthesia services was undervalued by approximately 23 percent. Since anesthesia services do not have individual work RVUs per code, the adjustment in anesthesia work was made to the anesthesia CF and not to the anesthesia codes themselves. This resulted in a 16-percent increase in the anesthesia CF. Budget neutrality was maintained by making an adjustment to the general physician fee schedule.

For the second 5-year review, the American Society of Anesthesiologists (ASA) submitted comments to us contending that the work of anesthesia services is still undervalued by almost 31 percent. The Society subsequently reduced this to a request for a 26-percent increase in work based on additional discussions with the RUC.

We can impute an anesthesia work value from the current allowed charge for an anesthesia service. This work value can be compared to the work value for anesthesia services that is derived from a building block approach. Under the building block approach, uniform individual components of the anesthesia service are identified and the work value of each component is estimated on the basis of a comparable physician medical or surgical service. The ASA derived a work value for an anesthesia code by dividing the anesthesia service into five uniform components and compared the work of each component to a comparable medical or surgical service. The five components are—preoperative evaluation, equipment and supply preparation, induction period, postinduction period, and postoperative care and visits. Using this method, the ASA proposed work values for 19 high volume anesthesia codes. The 19 codes represent a reasonable variety of surgical procedure types, including general surgery, vascular surgery, neurosurgery, urology, orthopedics, cardiac surgery, and ophthalmology. The base units of the 19 anesthesia codes reviewed range from three to twenty units.

During this second 5-year review of work, four RUC workgroups have reviewed the ASA comments and received supplemental information through presentations from the ASA. Most of these workgroups have expressed concerns about some of the intensity values that ASA assigned to the individual anesthesia components, most notably, the induction and postinduction time periods. Each of these workgroups expressed serious concern about extrapolating the imputed work undervaluation from the 19 survey codes to all anesthesia service codes, even though these 19 codes account for more than 40 percent of all anesthesia associated with surgical services.

Despite the efforts of its workgroups, the RUC furnished no recommendation to us on whether the work of anesthesia services is over-or undervalued. In the November 1, 2001 physician fee schedule final rule, we stated that:

The RUC has informed us that it will continue to look at anesthesia work beginning at its first meeting in CY 2002. We will review the RUC recommendation and address anesthesia work in next year's proposed physician fee schedule rule.

The RUC recently presented us with the analysis and findings of its April 2002 anesthesia workgroup. Despite its detailed analysis and laborious discussions of this issue, the RUC concluded that it was unable to make a recommendation regarding modification to the physician work valuation of anesthesia codes. Specifically, the RUC indicated the following:

“The RUC, having carefully considered the information presented, and having a reasonable level of confidence in the data which was presented and developed by the RUC, is unable to make a recommendation to CMS regarding modification to the physician work valuation of anesthesia codes.”

At the April 2002 meeting, the RUC anesthesia workgroup reviewed the postinduction intensity values for the 19 anesthesia codes. The group also Start Printed Page 43856reviewed each anesthesia code, the benchmark surgical code, and the five codes mapped to that anesthesia code that accounted for the largest percentage of total volume. The group considered the extent to which the anesthesia work of the benchmark surgical code is representative of other surgical codes that would be covered by the anesthesia code.

We will review the information forwarded by the RUC and all comments we receive during the comment period to determine if an appropriate adjustment can be made to anesthesia work. We would note that any such adjustment would also require an adjustment to the conversion factor for all physicians' services, as required by section 1848(c)(2)(B)(ii) of the Act. For example, a 26 percent increase in anesthesia work, an amount which was requested last year, would require a reduction of about 0.4 percent in the conversion factor for all services. We welcome comments on these issues.

2. Add-on Anesthesia Codes

Current Policy

As we discuss above, payment for anesthesia services is based on the sum of an anesthesia code-specific base unit value plus anesthesia time units multiplied by an anesthesia CF. If the physician is involved in multiple anesthesia services for the same patient during the same operative session, payment is based on the base unit assigned to the anesthesia service having the highest base unit value and anesthesia time that encompasses the multiple services. This policy was adopted at the start of the physician fee schedule in 1992 and is incorporated in § 414.48(g).

Claims processing manuals instruct the carrier on the method for handling anesthesia associated with multiple or bilateral surgical procedures. Under Medicare Carrier Manual (MCM) 4830 D, the carrier instructs the physician to report the anesthesia procedure with the highest base unit value with the multiple procedures modifier, “51”, and to report total time across all surgical procedures. Thus, the carrier is recognizing payment for one anesthesia code, despite the billing of multiple surgical codes by a surgeon.

Proposed Policy for Add-on Codes

In 2001 and 2002, the CPT has added new anesthesia codes, some of which are add-on codes. The objective is that the add-on code would be billed with a primary code and the base unit of each code would be allowed.

In the burn area, CPT code 01953 (1 base unit) is used in conjunction with CPT code 01952 (5 base units). In the obstetrical area, CPT code 01968 (2 base units) is used in conjunction with CPT code 01967 (5 base units) and CPT code 01969 (5 base units) is used in conjunction with CPT code 01967 (5 base units).

The application of the multiple anesthesia service policy means that the base units of the add-on codes would never be recognized. Only the base units of the primary code would be allowed. We believe that anesthesia add-on codes should be priced differently than other multiple anesthesia codes. As a result, we are proposing to revise the regulations in § 414.46(g) to include an exception to the usual multiple anesthesia services policy for add-on codes.

C. Changes to the Physician Fee Schedule Update Calculation and the Sustainable Growth Rate (SGR)

1. Medicare Economic Index Productivity Adjustment

In its March 2002 Report to Congress, MedPAC recommended that “The Secretary should revise the productivity adjustment for physicians' services and make it a multifactor instead of labor-only adjustment.” In this section, we review the history of the Medicare Economic Index (MEI) productivity adjustment, describe the current MEI productivity adjustment, and identify and evaluate possible alternative MEI productivity adjustments based on the individual contributions we solicited from experts on this topic. We conclude by proposing that the MEI productivity adjustment be changed to reflect an economy-wide multifactor productivity adjustment.

a. History of MEI Productivity Adjustment

The MEI is based on the fourth sentence of section 1842(b)(3) of the Act that states that prevailing charge levels beginning after June 30, 1973 may not exceed the level from the previous year except to the extent that the Secretary finds, on the basis of appropriate economic index data, that such higher level is justified by year-to-year economic changes. S. Rept. No. 92-1230 at 191 (1972) provides slightly more detail on that index, stating that:

Initially, the Secretary would be expected to base the proposed economic indexes on presently available information on changes in expenses of practice and general earnings levels combined in a matter consistent with available data on the ratio of the expenses of practice to income from practice occurring among self-employed physicians as a group.

Based on this legislative intent, in 1975, we determined that the MEI would be based on a broad wage measure reflecting overall earnings growth, rather than direct inclusion of physicians' net income. We used average weekly earnings of nonagricultural production (nonsupervisory) workers, net of worker's productivity, as the wage proxy in the initial MEI. We included the productivity adjustment because it avoided double counting of gains in earnings resulting from growth in productivity and produced a MEI that approximated an economy-wide output price index like the Consumer Price Index (CPI). The productivity adjustment we used was the annual change in economy-wide private nonfarm business labor productivity, applied only to the physicians' earnings portion of the MEI (then 60 percent).

As noted, the productivity adjustment in the MEI serves to avoid the double counting of productivity gains. Absent the adjustment, productivity gains from producing additional outputs (procedures) with a given amount of inputs would be included in both the earnings component of the MEI (reflecting growth in overall economy-wide productivity) and in the additional procedures that are billed (reflecting physicians' own productivity gains). Therefore, general economic labor productivity growth is removed from the labor portion of the price update.

The basic structure of the MEI remained relatively unchanged from its effective date (July 1, 1975) to 1992, although its weights were updated periodically and a component was added for professional liability insurance. Section 9331 of the Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99-509) (OBRA) mandated a study of the MEI and a notice and opportunity for public comment before revision of the methodology for calculating the MEI. Based on this requirement, we held a workshop with experts on the MEI in March 1987 to discuss topics ranging from the specific type of index to use (Laspeyres versus Paasche) to revising the method of reflecting productivity changes. Participants in the meeting included the Federal government, the Physician Payment Review Commission (PPRC), the Congressional Budget Office, the American Medical Association (AMA), and several consulting firms. The meeting participants concluded that a productivity adjustment was appropriate and that an acceptable measure of physician-specific productivity did not exist. Many alternative approaches were discussed, Start Printed Page 43857including the use of a policy-based “target” measure and several existing economic productivity measures.

Using recommendations from the meeting participants, we revised the MEI and the productivity adjustment with the implementation of the physician fee schedule as discussed in the November 1992 final rule (57 FR 55896). While we retained an adjustment for economy-wide labor productivity, it was applied to all of the direct labor categories of the MEI (70.448 percent), not just physicians' earnings, and was based on the 10-year moving average percent change (instead of annual percent changes). This form of the index has been used since that time, and was most recently discussed in the November 1998 final rule (63 FR 58845) when the MEI weights were rebased to a 1996 base year.

The Balanced Budget Act replaced the Medicare Volume Performance Standard (MVPS) with a Sustainable Growth Rate (SGR). Section 1848(f) of the Act specifies the formula for establishing yearly SGR target for physicians' services under Medicare. The use of SGR targets is intended to control the actual growth in aggregate Medicare expenditures for physicians' services. The SGR targets are not limits on expenditures. Payments for services are not withheld if the SGR target is exceeded by actual expenditures. Rather, the appropriate fee schedule update, as specified in section 1848(d)(3) of the Act, is adjusted to reflect the success or failure in meeting the SGR target. If expenditures are less than the target, the update is increased. If expenditures exceed the target, the update is reduced. Specifically, expenditures are allowed to increase by fee-for-service Medicare enrollment growth, physician fee increases, increases in real per capita Gross Domestic Product (GDP), and changes in laws or regulations. Consequently, the statute links allowable increases in the volume of services resulting from physician productivity gains—together with volume and intensity increases due to technology and other factors—to the real per capita GDP.

When the SGR was enacted, the Congress specified continued use of the MEI. By 1997, this index, including its productivity adjustment, had been used in updating Medicare payments to physicians for over twenty years. We did not propose any changes to the productivity adjustment used in the MEI because its continued use was consistent with the newly mandated SGR. If we did not make the adjustment in the MEI, general economic productivity gains would be reflected in two of the SGR factors, the MEI and real per-capita GDP (which reflects real GDP per hour worked, or labor productivity, and hours worked per person). We believe it is reasonable to remove the effect of general economic productivity from one of these factors (the MEI) to avoid double counting.

b. Current MEI Productivity Adjustment

The current MEI productivity adjustment is based on the 10-year moving average percent change in private nonfarm business (referred to hereafter as “economy-wide”) labor productivity, published by the Bureau of Labor Statistics (BLS) on a quarterly basis. A 10-year moving average is used to limit the impact of cyclical fluctuations in productivity. The productivity adjustment is applied only to the direct labor portions of the MEI (currently estimated at 71.272 percent). Therefore, the MEI is not reduced by the full change in labor productivity, but instead by only a portion of the change.

In addition, the most recently available historical data are used for the update for the upcoming calendar year (for example, data available through the second quarter of CY 2001 was used for the CY 2002 update).

Under this method, the current estimate of the existing MEI for the CY 2003 fee schedule update would be 2.3 percent. The 10-year moving average percent change in economy-wide labor productivity for the CY 2003 update is estimated to be 2.1 percent. However, since this adjustment is applied only to the direct labor portion of the MEI, the actual adjustment would be 1.5 percent. By comparison, the most recent forecast by DRI-WEFA, a Global Insight Company, of the CPI for all items for this same period is 1.6 percent.

As noted previously, since its original development, the MEI productivity adjustment has been based on economy-wide productivity changes. This practice arose from the fact that the physicians' compensation portion of the MEI is proxied to grow at the same rate as general earnings in the overall economy, which reflect growth in overall economy-wide productivity. Removing labor productivity growth reflected in general earnings from the labor portion of the MEI produces an index that is consistent with other economy-wide output price indexes, like the CPI. Although some commenters have argued that use of a physician-specific productivity measure would be more appropriate, no such published measure existed at the time of the MEI's development; nor does one exist today.

c. Research on Alternative MEI Productivity Adjustments

We conducted a number of research activities to evaluate whether the current productivity adjustment is still the most appropriate adjustment to use in the MEI. First, we evaluated the currently available productivity estimates that are produced by the BLS to develop a better understanding of the strengths and weaknesses of these measures. We also reviewed the theoretical foundation of the MEI to understand how labor and multifactor productivity relate to the current physician payment system. Then we studied the limited publicly available data to begin to develop preliminary estimates of trends in physician-specific productivity to better understand the current market conditions facing physicians. Finally, we solicited the individual contributions of academic and other professional economic experts on prices and productivity. They included experts from MedPAC, AMA, OMB, Dr. Uwe Reinhardt from Princeton University, Dr. Joe Newhouse from Harvard University, Dr. Ernst Berndt from MIT, and Dr. Joel Popkin from Joel Popkin and Company (former Assistant Commissioner of Prices at BLS). Based on the information we gathered during these research efforts, we evaluated six possible options for a productivity adjustment to the MEI. Our findings on each of the options we investigated are summarized below:

  • Option 1—Using a physician-specific productivity adjustment.

This option would entail using an estimate of physician-specific productivity to adjust the MEI. This option may have some theoretical attractiveness, but there are major problems obtaining accurate measures of physician-specific productivity. First, no published measure of physician-specific productivity is available. The Federal agency that produces the official government statistics on productivity, BLS, does not calculate or publish productivity measures for any health sector. Nor are there alternative measures of physician-specific productivity that incorporate the BLS methodology of measuring productivity and that would meet the BLS standard of publication. Second, it is not clear that using physician-specific productivity within the current structure of the MEI would be appropriate. Because we believe the MEI appropriately uses an economy-wide wage measure as the proxy for physician wages, using physician specific productivity could overstate or Start Printed Page 43858understate the appropriate wage increase in the MEI.

We do believe, however, that it is important to understand the rate of change in physician-specific productivity. Toward this end, we have performed our own preliminary analysis of physician-specific productivity, using the limited publicly available data on physician outputs and inputs. Our analysis attempted to simulate the methodology the BLS would use to measure productivity. While this information cannot be interpreted as an official measure of productivity, we do believe it is a rough indication of the current market conditions facing physicians. We used this information to help form our determination of the most appropriate productivity adjustment to incorporate in the MEI, fully recognizing its preliminary nature and other limitations. The results of our preliminary analysis suggest that long-run physician-specific productivity growth is currently at approximately the same level as economy-wide multifactor productivity growth. Prior to the recent period, however, our preliminary estimates suggested that physician productivity gains were generally significantly greater than general economy-wide multifactor productivity gains.

As we have emphasized, our rough estimates are inadequate for establishing a formal basis for the productivity adjustment to the MEI. Nor is the underlying economic theory sufficiently compelling, at this time, to adopt a physician-specific productivity measure, even if a suitable one were available. We conclude, however, that economy-wide multifactor productivity growth appears to be roughly comparable to current physician-specific productivity growth.

  • Option 2—Retaining the current productivity adjustment.

We investigated retaining the current productivity adjustment, that is, applying the 10-year moving average percent change in economy-wide labor productivity to the labor portion of the MEI. We have applied economy-wide labor productivity to a portion of the index in some form since the inception of the MEI in 1975. This current form has been used since the last major revision to the index in 1992 and was developed from the contributions of the 1987 expert panel. That panel concluded that using labor productivity applied to the labor portion of the index was a technically sound way to account for productivity in the physician update. This method makes optimal use of the available data since labor productivity data were, and are, available on a more timely basis than economy-wide multifactor productivity. By applying this measure to the labor portion of the index, the mix of physician-specific labor and nonlabor inputs is reflected. Also, the use of a 10-year moving average percentage change reduces the volatility of annual labor productivity changes.

Our research, however, has indicated that using multifactor productivity applied to the entire index is superior to using an economy-wide labor productivity measure applied only to the labor portion of the index. The experts with whom we consulted believed it was more appropriate to reflect the explicit contribution to output from all inputs. The current measure explicitly reflects the changes in economy-wide labor inputs but does not reflect the actual change in nonlabor inputs. Instead, it implicitly assumes that nonlabor inputs would grow at the rate necessary to produce an economy-wide multifactor measure that is equivalent to the current MEI productivity adjustment. That implicit assumption is less precise than a direct, explicit calculation.

In addition, while the implicit approach produced an MEI productivity adjustment in most years that was reasonably consistent with overall multifactor productivity growth, it now appears less consistent with the actual change in nonlabor inputs in the economy. In recent years, economy-wide labor productivity has grown very rapidly. This acceleration is partly the result of major investments in computers (a nonlabor input) that have helped create a more productive work force. Also, the Bureau of Economic Analysis (BEA) has adopted methodological changes in accounting for computer software purchases in measuring GDP. These changes have significantly increased the measured historical growth rates in real GDP and labor productivity. As a result of these developments, the MEI productivity adjustment based on labor productivity applied only to the labor portion of the MEI has increased very rapidly. Since the multifactor definition is an explicit calculation of the change in economic output relative to the change in both labor and nonlabor inputs, it better reflects the trend changes.

Finally, as noted previously, our preliminary estimates of physician-specific productivity suggest a current growth pattern that is similar to growth in multifactor productivity in the economy overall. In consideration of the economic theory underlying productivity measurement, especially in view of the recent developments in labor versus nonlabor economic input growth trends, we concluded that using a multifactor productivity adjustment is superior to the current methodology for adjustment for productivity in the MEI.

  • Option 3—Changing to using economy-wide multifactor productivity.

One option for adjusting for productivity gains in the MEI would be to continue to use an economy-wide productivity measure, but to use multifactor productivity applied to the entire index, instead of labor productivity applied to the labor portion of the MEI. As noted previously, this approach was recommended by MedPAC in its March 2002 Report to the Congress. This option would better satisfy the theoretical requirements of an output price, in this case the MEI, by explicitly reflecting the productivity gains from all inputs. In addition, the use of economy-wide multifactor productivity would still be consistent with the MEI's use of economy-wide wages as a proxy for physician earnings. While annual multifactor productivity can fluctuate considerably, though usually less than labor productivity, using a moving-average would produce a relatively stable and predictable adjustment.

Each expert with whom we consulted believed that using a multifactor productivity measure was theoretically superior to the existing method because it reflected the actual changes in nonlabor inputs instead of reflecting an implicit assumption. They also believed that the lack of timely data on multifactor productivity was not as important as would have appeared initially. Instead, the experts believed it was more appropriate that the adjustment be based on a long-run average that was stable and predictable rather than on annual changes in productivity. Thus, if a long-run average were used, the increased lag time associated with the availability of published data on multifactor productivity would become less significant. Finally, one expert believed that changing to economy-wide multifactor productivity applied to the entire MEI would make it easier to understand the magnitude of the productivity adjustment.

Use of multifactor productivity to adjust the MEI poses two concerns. First, multifactor productivity is much harder to measure than labor productivity. Economic inputs other than labor hours can be very difficult to identify and calculate properly. The experts at BLS, however, have adequately overcome these difficulties, and we are satisfied that their official published measurements are sound for Start Printed Page 43859the purpose at hand. Moreover, use of a 10-year moving average increase helps to mitigate any remaining measurement variation from year to year.

The second concern relates to the timeliness of the data. BLS publishes multifactor productivity levels and changes only annually (as opposed to the quarterly release of labor productivity data) and with an extended time lag (about 11/2 years). These timeframes arise unavoidably from the difficulties of measurement mentioned above, but imply that the timeframe of data used to adjust the MEI would not match that of the historical data on wages and prices underlying the MEI. For the CY 2003 physician payment update, for example, we would use data on wages and prices through the second quarter of CY 2002, but would have to use multifactor productivity data only through CY 2000. Although the misalignment of data periods is a concern, we believe it is a reasonable trade-off in view of the improvement offered by the explicit measurement of nonlabor inputs. Also, since use of a 10-year moving average is intended to reduce fluctuations and provide a more stable level of the productivity adjustment, availability of the most recent data is of less importance.

The 10-year moving average percent change in economy-wide multifactor productivity that would be used for the CY 2003 update (historical data through CY 2000) is currently estimated at 0.8 percent. Our preliminary internal analysis of physician-specific productivity gains suggests that these economy-wide multifactor measures are somewhat consistent with those trends. Thus, using economy-wide multifactor productivity for MEI productivity adjustment theoretically would be superior to using labor productivity growth applied to the labor portion of the MEI. In addition, the use of a 10-year moving average would help alleviate the lag in the availability of the data. Lastly, the current 10-year moving average growth in economy-wide multifactor productivity appears to be within the range we have estimated for physician-specific multifactor productivity. One possible weakness of using economy-wide multifactor productivity is that it does not reflect physician-specific measures, whereas the existing methodology reflects the distribution of labor and nonlabor inputs used in the production of physician services. In practice, however, the balance between these factors of production is not substantially different for physician practices versus the overall economy.

  • Option 4—Changing to using economy-wide multifactor productivity with physician-specific input weights.

Another option we explored was using economy-wide labor and capital productivity measures (which, when weighted together, produce multifactor productivity), but with physician-specific input weights. This method would better reflect the proportion of labor and capital inputs used by physicians, yet still reflect the explicit contribution to productivity of labor and nonlabor inputs. The experts with whom we discussed this option thought it was theoretically consistent with a measure of multifactor productivity, even though different productivity measures would be applied to different components of the MEI.

As noted above, the labor and capital shares for the overall economy do not appear to vary enough from the physician-specific shares in the MEI to result in a significantly different measure. A weakness of this method is that the BLS capital productivity series is not widely used or cited; therefore, we are unsure of the accuracy and reliability of this measure. This method also adds another layer of complexity to the formula, however, making it more difficult to understand the adjustment. We would prefer that any method we choose be straightforward so that everyone can readily understand the adjustment. Overall, we believe that this method does not provide enough of a technical improvement to justify the added complexity that would be required to implement it.

  • Option 5—Adjusting productivity using a “Policy Standard”.

In its March 2002 Report to the Congress, MedPAC suggested establishing a policy target for the productivity adjustment. Under this methodology, the level of the policy target would be based on the productivity gains that we believe physicians could attain. This level would be set through policy and would likely be based on a long-run average of either economy-wide labor or multifactor productivity (but could reflect other, possibly judgmental, factors). Generally, the level of the policy standard would remain constant for several years; periodically, the policy target would be reviewed, and possibly adjusted.

Some of the experts we consulted believed that a policy target would lessen the volatility of the adjustment since the target would not be changed often. Conversely, others noted the large, abrupt changes that could result if actual economic performance deviated from the policy standard requiring subsequent adjustments to the standard. Some believed that this method adjusts for the problem of precisely measuring productivity. If we used a policy standard we could avoid having to develop an exact measure. Using a policy target, however, may appear arbitrary without a theoretical basis to support its use.

The policy target recommended by MedPAC was 0.5 percentage points per year. Its justification for this number was the fact that the long-run average of economy-wide multifactor productivity was close to 0.5 percent (the most recent 10-year average is now 0.8 percent). We do not believe this is a preferred option for adjusting the MEI for productivity improvements. Our preference is to use a long-term data-based approach that will produce results that are not inconsistent with a policy standard and that will automatically reflect changes in actual economic performance over time, and not through abrupt periodic large adjustments. Thus, we conclude that a policy target does not provide an improvement over any of the data-based methodologies.

  • Option 6—Eliminate Productivity Adjustment from the MEI.

Questions are raised occasionally as to the possibility of eliminating the productivity adjustment from the MEI. We did not consider this to be a viable option. Our research concluded that adjusting for productivity in the MEI is necessary to have a technically correct measure of an output price increase, free of double-counting the impact of productivity. Every expert with whom we consulted agreed that a productivity adjustment was appropriate. They believed that the important question is which adjustment is the most appropriate. Therefore, we conclude, again, that it is not acceptable for the productivity adjustment to be removed from the MEI.

d. Use of a Forecasted MEI and Productivity Adjustment

MedPAC, in its March 2002 Report to the Congress, recommended the use of a forecasted MEI value, rather than the current historical increase. However, implementation of this option raises several legal as well as practical issues. The 1972 Senate Finance Committee report language reflects Congress' intent that the MEI should “follow rather than lead” overall inflation. Because of this, updates to the physician fee schedule have always been based on historical, rather than forecasted, MEI data. In this way, increases in the MEI do not lead the current measures of inflation but follow them based on historical trends. Furthermore, at the time of Start Printed Page 43860implementation of the SGR system, the Congress specified that the SGR system should use the MEI that existed at that time, which was based on historical data measures. The law did not recommend or specify a change in the MEI methodology; the assumption is that the Congress was satisfied that the MEI was functioning as designed.

If we were to change to a forecasted MEI and productivity adjustment, there are also several practical issues that would need to be addressed. One is that changing from a historical-based MEI to a projected MEI would cause transitional problems because there would be a period of data that would not be accounted for in the year of implementation. For example, the CY 2002 MEI update was based on historical data through the second quarter of 2001. If we were to use a forecasted MEI in the update for CY 2003, the changes between the second quarter of 2001 and the first quarter of 2003 would not be accounted for in the update. Finally, changing to a forecasted MEI and productivity adjustment raises additional questions about correcting for forecast errors. Based on these problems, we will continue to use historical data to make updates under the physician fee schedule.

e. Proposed Productivity Adjustment to the MEI

Based on the research we conducted on this issue, we are proposing to change the methodology for adjusting for productivity in the MEI. We propose that the MEI used for the CY 2003 physician payment update reflect changes in the 10-year moving average of private nonfarm business (economy-wide) multifactor productivity applied to the entire index. The current method accounts for productivity by adjusting the labor portion of the MEI by the 10-year moving average change in private nonfarm business (economy-wide) labor productivity.

We propose to make this change because: (1) It is theoretically more appropriate to explicitly reflect the productivity gains associated with all inputs (both labor and nonlabor); (2) the recent growth rate in economy-wide multifactor productivity appears more consistent with the current market conditions facing physicians; and (3) the MEI still uses economy-wide wage changes as a proxy for physician wage changes. We believe that using a 10-year moving average change in economy-wide multifactor productivity produces a stable and predictable adjustment and is consistent with the moving-average methodology used in the existing MEI. We propose that the adjustment be based on the latest available actual historical economy-wide multifactor productivity data, as measured by BLS. Based on these proposed changes, we currently estimate the MEI to increase 3.0 percent for CY 2003. This is the result of a 3.8-percent increase in the price portion of the MEI, adjusted downward by a 0.8-percent increase in the 10-year moving average change in economy-wide multifactor productivity. Table 1 shows the detailed cost categories of the proposed MEI update for CY 2003. Since the current estimate of the MEI increase for CY 2003 is based on incomplete historical data, it may change slightly before we announce the final MEI no later than November 1, 2002.

Table 1.—Increase in the Medicare Economic Index Update for Calendar Year 2003 1

Cost categories and price measures1996 weights 2CY 2003 percent changes
Medicare Economic Index Total, productivity adjustedn/a3.0
Productivity: 10-year moving average of Multifactor productivity, private nonfarm business sectorn/a0.8
Medicare Economic Index Total, without productivity adjustment100.03.8
1. Physician's Own Time 354.54.1
a. Wages and Salaries: Average hourly earnings Private nonfarm44.23.9
b. Fringe Benefits: Employment Cost Index, benefits, private nonfarm10.34.8
2. Physician's Practice Expense 345.53.6
a. Nonphysician Employee Compensation16.84.1
1. Wages and Salaries: Employment Cost Index, wages and salaries, weighted by occupation12.43.7
2. Fringe Benefits: Employment Cost Index, fringe benefits, white collar4.45.4
b. Office Expense: Consumer Price Index for Urban Consumers (CPI-U), housing11.62.6
c. Medical Materials and Supplies: Producer Price Index (PPI), ethical drugs/PPI, surgical appliances and supplies/CPI-U, medical equipment and supplies (equally weighted)4.52.1
d. Professional Liability Insurance: CMS professional liability insurance survey 43.211.3
e. Medical Equipment: PPI, medical instruments and equipment1.91.6
f. Other Professional Expense7.61.6
1. Professional Car: CPI-U, private transportation1.3−2.9
2. Other: CPI-U, all items less food and energy6.32.5
1 The rates of historical change are estimated for the 12-month period ending June 30, 2002, which is the period used for computing the calendar year 2003 update. The price proxy values are based upon the latest available Bureau of Labor Statistics data as of April 2002.
2 The weights shown for the MEI components are the 1996 base-year weights, which may not sum to subtotals or totals because of rounding. The MEI is a fixed-weight, Laspeyres-type input price index whose category weights indicate the distribution of expenditures among the inputs to physicians' services for calendar year 1996. To determine the MEI level for a given year, the price proxy level for each component is multiplied by its 1996 weight. The sum of these products (weights multiplied by the price index levels) over all cost categories yields the composite MEI level for a given year. The annual percent change in the MEI levels is an estimate of price change over time for a fixed market basket of inputs to physicians' services.
3 The measures of productivity, average hourly earnings, Employment Cost Indexes, as well as the various Producer and Consumer Price Indexes can be found on the Bureau of Labor Statistics website—http://stats.bls.gov.
4 Derived from a CMS survey of several major insurers (the latest available historical percent change data are for the period ending second quarter of 2002).
n/a Productivity is factored into the MEI compensation categories as an adjustment to the price variables; therefore, no explicit weight exists for productivity in the MEI.
Start Printed Page 43861

2. Sustainable Growth Rate (SGR)

Section 1848(f)(2) of the Act specifies a formula for calculating annual SGR targets for Medicare physicians' services. The formula includes four factors. Section 1848(f)(2)(A) of the Act specifies that the first factor is the Secretary's estimate of weighted average percentage increase in fees for all physicians' services. We have calculated this factor as a weighted average of the CY 2002 fee increases that apply for the different types of services included in the definition of physicians' services for the SGR. (For a complete list of these services see the November 1, 2001 Federal Register (66 FR 55316).) Drugs furnished in a physician's office that are not usually self-administered are generally covered “incident to” a physician's service under section 1861(s)(2)(A) of the Act and included in the SGR. In the past, we have used the MEI as an approximation of the drug price increase. In the final revisions we make to the CY 2001 SGR later this year, we will account for drug price growth using a refined methodology that uses growth in drug prices instead of the MEI as a proxy. In addition, we will account for drug price growth using this refined methodology in the SGRs for CY 2002 and subsequent years.

Under section 1848(d) of the Act, the update for any year is equal to the MEI increased or decreased by an update adjustment factor determined using a statutory formula. The statute limits the update adjustment factor to +3.0 and −7.0 percentage points. On March 1, 2002, we provided our estimate of the CY 2003 physician fee schedule update to the Medicare Payment Advisory Committee (MedPAC) and made this information available to the public. We estimated the update adjustment factor would be −13.1 percent. If the only change to our March 2002 estimate was accounting for drug price growth in the SGR, we estimate the update adjustment factor would be −12.8 percent. Since the statute limits the update adjustment factor to −7.0 percent, we expect the CY 2002 physician fee schedule update to equal the MEI reduced by 7.0 percentage points.

D. Pricing of Technical Components (TC) for Positron Emission Tomography (PET) Scans

Currently all components of HCPCS code G0125, Lung image PET scan, are nationally priced. However, the technical component (TC) and global value for all other PET scans are carrier priced. To keep pricing consistent with other PET scans, we propose to have the carriers price the TC and global values of HCPCS code G0125.

E. Enrollment of Physical and Occupational Therapists as Therapists in Private Practice

In the November 2, 1998 final rule (63 FR 58814), we defined private practice for physical therapists (PTs) or occupational therapists (OTs) to include a therapist whose practice is in an—

  • Unincorporated solo practice;
  • Unincorporated partnership; or
  • Unincorporated group practice.

Private practice also includes an individual who is furnishing therapy as an employee of one of the above, a professional corporation, or other incorporated therapy practice. Some carriers and fiscal intermediaries have interpreted the regulation to mean that occupational and physical therapists employed by physicians cannot be enrolled as therapists in private practice. In these carrier areas, therapy services provided in a physician's office must instead be billed as incident to a physician's service.

A specialty society representing occupational therapists has requested that carriers be able to enroll OTs in physician-directed groups as occupational therapists in private practice. A group representing PTs believes that provider numbers should be issued only to PTs working as employees in practices owned and operated by therapists.

We are proposing to clarify national policy—we would allow carriers to enroll therapists as physical or occupational therapists in private practice when they are employed by physician groups. We believe that this would reflect actual practice patterns and would permit more flexible employment opportunities for therapists. We also believe that this would increase beneficiaries' access to therapy services, particularly in rural areas. Therefore, we would revise §§ 410.59 and 410.60 to reflect this change.

F. Clinical Social Worker Services

Currently, § 410.73(b)(2)(ii) states that, for purposes of billing Medicare Part B, clinical social worker (CSW) services do not include services furnished by a CSW to an inpatient of a Medicare-participating skilled nursing facility (SNF). Under this rule, CSWs cannot receive Medicare Part B payment for diagnostic and therapeutic mental health services when the services are furnished to patients in participating SNFs, but they can receive payment for these same mental health services when furnished in most other settings. Additionally, clinical psychologists (CPs) may receive Medicare Part B payment for these same diagnostic and therapeutic mental health services when furnished to patients in participating SNFs. The effective date of the rule that precluded Medicare Part B payment to CSWs for services furnished to patients in participating SNFs was June 22, 1998. However, the provisions under this rule were suspended for two years beyond the effective date. Accordingly, these provisions that terminated payment for CSW services in the SNF setting were delayed until June 22, 2000. Announcement of the two-year suspension of the provisions was made in a letter signed by the Administrator to the National Association of Social Workers rather than publishing it in the Federal Register.

In order to redress this issue, on October 19, 2000, we published a notice of proposed rulemaking in the Federal Register (65 FR 62681), in which we proposed to pay CSWs for CPT psychiatry codes 90801, 90802, 90816, 90818, 90821, 90823, 90826, 90828, 90846, 90847, 90853, and 90857 when furnished to patients in participating SNFs who are not in a covered Part A stay. At this time, we are reprinting our proposal to allow CSWs to bill for the listed CPT psychiatry codes when furnished to patients in participating SNFs who are not under a covered Part A stay. Since we have already received comments on our previously published proposed rule both supporting and opposing our proposal, we are not now seeking comments in this proposed rule. However, we will respond to the comments already received on the issue of CSW services provided to beneficiaries in SNFs when we publish this year's physician fee schedule final rule.

G. Medicare Qualifications For Clinical Nurse Specialists

Section 4511(d)(3)(B) of the Balanced Budget Act of 1997 (Pub. L. 105-33) (BBA) defined a clinical nurse specialist as an individual who—

(i) Is a registered nurse and is licensed to practice nursing in the State in which the clinical nurse specialist services are performed; and

(ii) Holds a master's degree in a defined clinical area of nursing from an accredited educational institution.

When implementing the regulation for this benefit, we added a provision requiring that a CNS must be certified by the American Nurses Credentialing Center (ANCC). It has recently been pointed out to us that the ANCC does not provide certification for CNSs who Start Printed Page 43862specialize in fields such as oncology, critical care, or rehabilitation.

We are proposing to revise § 410.76(b)(3) to read as follows: “Be certified as a clinical nurse specialist by a national certifying body that has established standards for clinical nurse specialists and that is approved by the Secretary.” This revision would be consistent with certification criteria for nurse practitioners.

H. Process to Add or Delete Services to the Definition of Telehealth

1. Background

Effective October 1, 2001, section 1834(m) of the Act provides for an expansion of the definition of a Medicare telehealth service. The law defines telehealth services as professional consultations, office and other outpatient visits, and office psychiatry services (identified as of July 1, 2000, by HCPCS codes 99241-99275, 99201-99215, 90804-90809 and 90862) and any additional service specified by the Secretary. In addition, the law requires the Secretary to establish a process for adding or deleting services to the list of telehealth services on an annual basis.

In this proposed rule, we are proposing (1) to establish a process for adding or deleting services from the list of telehealth services, and (2) to add specific services to the list of telehealth services for CY 2003.

To evaluate services that may be appropriate for Medicare telehealth, we would accept requests for adding services to, or deleting services from, the list of Medicare telehealth services. We would accept proposals from any interested individuals or organizations from either the public or the private sectors, for example, from medical specialty societies, individual physicians or practitioners, hospitals, and State or Federal agencies. (We may also generate additions or deletions of services internally.) We would post instructions on our website outlining the steps necessary to submit a proposal. Information on applying for a new HCPCS code may be found on our website at www.hcfa.gov/​Medicare/​hcpcs.htm, then select “HCPCS Coding Request Information.”

Each proposal would have to address the items outlined below.

  • Name(s), address(es) and contact information of the requestor.
  • The HCPCS code(s) that describes the service(s) proposed for addition or deletion to the list of Medicare telehealth services. If the requestor does not know the applicable HCPCS code, the request should include a description of services furnished during the telehealth session.
  • A description of the type(s) of medical professional(s) providing the telehealth service at the distant site.
  • A detailed discussion of the reasons the proposed service should be added to the definition of Medicare telehealth.
  • An explanation as to why the requested service cannot be billed under the current scope of telehealth services, for example, the reason why the HCPCS codes currently on the list of Medicare telehealth services would not be appropriate for billing the service requested.
  • An application for a new HCPCS code if the requestor believes that neither the HCPCS codes currently on the list of telehealth services nor any other HCPCS code would be adequate for describing the service requested.
  • If available, data showing that the use of a telecommunications system does not change the diagnosis or treatment plan as compared to the face-to-face delivery of the service.
  • If available, data showing that patients who receive this service via a telecommunications system are satisfied with the service that is delivered.

2. Categories for Additions

We would assign any request to add a service to the definition of Medicare telehealth services to one of the following categories:

  • Category #1: Services similar to office and other outpatient visits, consultation, and office psychiatry services. We would review these requests to ensure that the services proposed for addition to the list of Medicare telehealth services are similar to the current telehealth services. For example, we would look for similarities between the proposed and existing telehealth services in terms of the roles of, and interactions among, the beneficiary, the physician (or other practitioner) at the distant site and, if necessary, the telepresenter. We would also look for similarities in the telecommunications system used to deliver the proposed service, for example, the use of interactive audio and video equipment. If a proposed service meets the criteria set forth above, we would add it to the list of Medicare telehealth services.
  • Category #2: Services that are not similar to the current list of telehealth services, for example, physical therapy services, endoscopy services, and distant monitoring of patients in intensive care units. Our review of these requests would include an assessment of whether the use of a telecommunications system to deliver the service produces similar diagnostic findings or therapeutic interventions as compared with a face-to-face “hands on” delivery of the same service. In other words, the discrete outcome of the interaction between the clinician and patient facilitated by a telecommunications system should correlate well with the discrete outcome of the clinician-patient interaction when performed face-to-face.

Requestors should submit evidence indicating that the use of a telecommunications system does not affect the diagnosis or treatment plan as compared to a face-to-face delivery of the service. If the evidence shows that the proposed telehealth service is equivalent to the face-to-face delivery of the service, we would add it to the list of telehealth services. However, if we determine that the use of a telecommunications system changes the nature or outcome of the service, for example, the nature of clinical intervention, as compared with the face-to-face delivery of the service, we would view the request as a request for a new service, rather than a different method of delivering an existing Medicare service. Under Medicare, new services: (1) Must fall into a benefit category; (2) must be reasonable and necessary in accordance with section 1862(a)(1)(A) of the Act; and (3) must not be specifically excluded from coverage. The requestor would have the option of applying for a national coverage determination. Information on applying for a national coverage determination may be found on our website at http://www.hcfa.gov;​ then select “Coverage Policies,” then “Process.”

3. Our Review of Requests to Add Services

Our review of submitted requests to add services may result in the following outcomes:

  • Adding an existing HCPCS code to the list of Medicare telehealth services.
  • Determining that the requested service is already described by an existing telehealth service.
  • Creating a new HCPCS code to describe the requested service and adding it to the list of Medicare telehealth services.
  • Requesting further information.
  • Notifying the requestor that a national coverage determination is necessary before a decision to accept or reject a proposal can be made.
  • Rejecting the request.

4. Deletion of Services

We may choose to remove a service currently on the list of Medicare telehealth services. We would remove a Start Printed Page 43863service from that list if, upon review of the available evidence, we determine that a Medicare telehealth service is not safe, effective, or medically beneficial.

5. Implementation

We propose to make additions or deletions to the list of Medicare telehealth services effective on a CY basis. We would 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 for making these changes.

We will accept requests for adding services to the list of Medicare telehealth services on an ongoing basis; requests must be received no later than December 31 of each CY to be considered for the next proposed rule.

We are requesting specific comments on this approach to adding or deleting services and HCPCS codes to the definition of telehealth services.

6. Proposed Addition to the Definition of Medicare Telehealth for Calendar Year 2003

Section 1834(m) of the Act defines Medicare telehealth services as office and other outpatient visits, consultation, and office psychiatry services as described by the following HCPCS codes: 99201-99215; 99241-99275; 90804-90809; and 90862. We stated in the CY 2002 final rule (66 FR 55283) that we believed it would be inappropriate to expand the definition of Medicare telehealth services beyond the services explicitly listed in the Act until we have developed a process for adding or deleting services.

However, after further review of the comments submitted in response to the proposed rule for CY 2002, we believe that the psychiatric diagnostic interview is similar to the Medicare telehealth services listed in the statute. Specifically, we believe this service would meet the criteria set forth in Category 1 of the proposed process for adding services.

As defined by CPT 2002, a psychiatric diagnostic interview includes “a history, mental status, and a disposition, and may include communication with family or other sources, ordering and medical interpretation of laboratory or other medical diagnostic studies.” These components would be comparable to an initial office visit, or consultation services, which are currently Medicare telehealth services. Additionally, an initial psychiatric diagnostic interview is typically the first step in treating mental illness and is required before psychotherapy can begin. Therefore, we propose to add psychiatric diagnostic interview examination as represented by HCPCS code 90801 to the list of Medicare telehealth services.

We would revise § 410.78 and § 414.65 to reflect this proposed addition to the list of Medicare telehealth services.

I. Definition for ZZZ Global Periods

Services with ZZZ global periods are add-on services, which can only be billed along with another service. The current policy associated with a code with a global indicator of ZZZ recognizes only the incremental intra-service work and practice expense associated with the add-on service. Any pre-service or post-service work associated with a service with a global indicator of ZZZ is considered accounted for in the base procedure with which these add-on services must be billed.

Several specialties, as well as the RUC, have stated that some add-on services contain separately identifiable postservice work and practice expense. The RUC has recommended that we revise our current definition of the global indicator ZZZ to clarify that there may be postservice work associated with a limited number of ZZZ global services.

Consistent with this recommendation, we propose to revise the current definition of a ZZZ global period. “ZZZ = Code related to another service and is always included in the global period of the other service (Note: Physician work is associated with intra-service time and in some instances the post-service time).”

We plan to work with the RUC to identify those services with a global period of ZZZ that also have separately identifiable postservice work.

J. Change in Global Period for CPT code 77789 (Surface Application of Radiation Source)

The RUC has suggested a change in the global period for CPT code 77789 (surface application of radiation source) from a 90-day global period to a 000-day global period. We agree that all work is provided on the day of the procedure and no other visits for pre- and post-care are necessary. Therefore, we are proposing to assign a 000-day global period to this service. We have examined this code and believe that the current work value accurately reflects a 000-day global period and, therefore, needs no adjustment. We would adjust the clinical staff practice expense inputs to reflect that there is no post-procedure visit. The supplies and equipment inputs are appropriate for a 000-day global and need no revision.

K. Technical Change for § 410.61(d)(1)(iii) Outpatient Rehabilitation Services

The occupational therapists have pointed out that § 410.61(d)(1)(iii) incorrectly references “physical” therapy when it should reference “occupational” therapy. Therefore, we are proposing to revise § 410.61(d)(1)(iii) to correct this error.

L. New HCPCS G-Codes

1. Codes for Treatment of Peripheral Neuropathy

Effective for services furnished on or after July 1, 2002, Medicare will cover an evaluation (examination and treatment) of the feet every six months for individuals with a documented diagnosis.

G0245: Initial physician evaluation of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) which must include the procedure used to diagnose LOPS; a patient history; and a physical examination that consists of at least the following elements—

(a) Visual inspection of the forefoot, hindfoot and toeweb spaces;

(b) Evaluation of protective sensation;

(c) Evaluation of foot structure and biomechanics;

(d) Evaluation of vascular status and skin integrity;

(e) Evaluation and recommendation of footwear; and

(f) Patient education.

We are proposing to crosswalk the work, practice expense, and malpractice RVUs from CPT code 99202, a level two, new patient office visit code. We are proposing to crosswalk the practice expense inputs from CPT code 99202 and revalue the practice expense RVU using the practice expense methodology once we have utilization for these codes.

G0246: Follow-up evaluation of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include at least the following, a patient history and physical examination that includes—

(a) Visual inspection of the forefoot, hindfoot and toeweb spaces;

(b) Evaluation of protective sensation;

(c) Evaluation of foot structure and biomechanics;

(d) Evaluation of vascular status and skin integrity;

(e) Evaluation and recommendation of footwear; and

(f) Patient education.

We are proposing to crosswalk the work, practice expense, and malpractice RVUs from CPT code 99212, a level two, established patient office visit code. We Start Printed Page 43864are proposing to crosswalk the practice expense inputs from CPT code 99212 and revalue the practice expense RVU using the practice expense methodology once we have utilization for these codes.

G0247: Routine foot care of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include if present, at least the following—

(a) Local care of superficial wounds;

(b) Debridement of corns and calluses; and

(c) Trimming and debridement of nails.

We are proposing to crosswalk the work, practice expense, and malpractice RVUs from CPT code 11040, Debridement; skin; partial thickness. We are proposing to crosswalk the practice expense inputs from CPT code 11040 and will revalue the practice expense RVUs using the practice expense methodology once we have utilization for this code.

2. Current Perception Sensory Nerve Conduction Threshold Test (SNCT)

G0255: Current Perception Threshold/Sensory Nerve Conduction Test, (SNCT) per limb, any nerve.

We have created a G-code that represents SNCT as a diagnostic test used to diagnose sensory neuropathies. The test is noninvasive and uses a transcutaeous electrical stimulus to evoke a sensation. We have determined that there is insufficient scientific or clinical evidence to consider the use of this device as reasonable and necessary within the meaning of section 1862(a)(1)(A) of the Act, and, therefore, Medicare will not pay for this type of test.

3. Positron Emission Tomography (PET) Codes for Breast Imaging

Medicare has expanded the coverage indications for PET scanning to include imaging for breast cancer. We have created codes that describe staging and restaging after or prior to the course of treatment of breast cancer. We have also created a PET scan code to evaluate the response to treatment of breast cancer.

PET imaging for initial diagnosis of breast cancer and/or surgical planning for breast cancer are described by a CPT code, but Medicare will not cover this diagnosis.

G0252: PET imaging for initial diagnosis of breast cancer and/or surgical planning for breast cancer (for example, initial staging of axillary lymph nodes), not covered by Medicare. This code is not covered by Medicare because there is a national non-coverage determination for initial diagnosis of breast cancer and initial staging of axillary lymph nodes.

G0253: PET imaging for breast cancer, full and partial-ring PET scanners only, staging/restaging after or prior to course of treatment.

G0254: PET imaging for breast cancer, full and partial-ring PET scanners only, evaluation of response to treatment, performed during course of treatment.

We are proposing that the TC and global for both of these codes be carrier priced.

For both procedure codes G0253 and G0254, we propose to make the PC work RVU equal to 1.87. There are no direct inputs for PC services. We propose to use practice expense RVUs of 0.58 and malpractice RVUs of 0.07 for these services.

4. Home Prothrombin Time International Normalized Ratio (INR) Monitoring for Anticoagulation Management

For services furnished on or after July 1, 2002, Medicare will cover the use of home prothrombin time or INR monitoring in a patient's home for anticoagulation management for patients with mechanical heart valves. A physician must prescribe the testing. The patient must have been anticoagulated for at least three months prior to use of the home INR device; and the patient must undergo an education program. The testing with the device is limited to a frequency of once per week.

G0248: Demonstration, at initial use, of home INR monitoring for a patient with mechanical heart valve(s) who meets Medicare coverage criteria, under the direction of a physician; includes: demonstration use and care of the INR monitor, obtaining at least one blood sample provision of instructions for reporting home INR test results and documentation of a patient's ability to perform testing.

We are proposing that this code be assigned no work RVUs and .01 malpractice RVUs. For the practice expense inputs, we are proposing 75 minutes of RN/LPN/MTA staff time; a supply list, including four test strips, lancets and alcohol pads, a patient education booklet, and batteries for the monitor; and equipment, consisting of a home INR monitor. Using these proposed inputs in the practice expense methodology will produce an estimated practice expense RVU of 2.92.

G0249: Provision of test materials and equipment for home INR monitoring to patient with mechanical heart valve(s) who meets Medicare coverage criteria. Includes provision of materials for use in the home and reporting of test results to physician; per 4 tests.

We are proposing that this code be assigned no work RVUs and .01 malpractice RVUs. For the practice expense inputs, we are proposing 13 minutes of RN/LPN/MTA staff time, a supply list, including four test strips, lancets and alcohol pads, and equipment, consisting of a home INR monitor. Using these proposed inputs in the practice expense methodology will produce an estimated practice expense RVU of 2.08.

G0250: Physician review/ interpretation and patient management of home INR test for a patient with mechanical heart valve(s) who meets other coverage criteria; per 4 tests (does not require face-to-face service)

We are proposing that this code be assigned 0.18 work RVUs and .01 malpractice RVUs. There would be no direct practice expense inputs for this code. We will use practice expense methodology to develop a practice expense RVU that will reflect indirect costs of the physicians performing this service. The estimated practice expense RVU will equal 0.07.

5. Bone Marrow Aspiration and Biopsy on the Same Date of Service

We are proposing to create a new G-code that reflects a bone marrow biopsy and aspiration procedure that is performed on the same date, at the same encounter, through the same incision. Because it is our understanding that the typical case involves an aspiration and biopsy through the same incision, we are creating a G-code to reflect this service. If the two procedures, aspiration and biopsy, are performed at different sites (for example, contralateral illiac crests, sternum/illiac crest, two separate incisions on the same iliac crest or two patient encounters on the same date of service), the -59 modifier would be appropriate to use. In this instance, the CPT codes for aspiration and biopsy would each be used.

GXXXX: Bone marrow aspiration and biopsy performed on the same day.

We are proposing physician work RVUs of 1.56 and malpractice RVUs of 0.04. We propose to crosswalk the practice expense inputs from CPT code 38220, Bone marrow aspiration, with the assignment of an additional five minutes of clinical staff time. Using these proposed inputs in the practice expense methodology will produce an estimated practice expense RVU of 3.32 in the nonfacility setting. The practice expense RVU in the facility setting is estimated at 0.60.

M. Endoscopic Base for Urology Codes

Cystoscopy and treatment CPT codes 52234, 52235, and 52240 were Start Printed Page 43865inadvertently identified in the Medicare Physician Fee Schedule Database as services subject to multiple procedural reductions as opposed to the procedural reduction rules specific to endoscopic services. Multiple procedural reduction rules allow full payment for the primary services with a 50 percent reduction to the RVUs for each additional service. The endoscopic reduction rules establish payment using the full value of the highest valued endoscopic service plus the difference between the next highest valued service and the base endoscopic service. The inadvertent application of the multiple procedural reduction as opposed to the endoscopic procedural reduction has resulted in our overpaying for these services. We propose applying the endoscopic reduction rules to these services and have identified CPT code 52000 as the endoscopic base code for these services.

N. Physical Therapy and Occupational Therapy Caps

Section 4541(c) of the Balanced Budget Act of 1997 required application of a payment limitation to all rehabilitation services provided on or after January 1, 1999. The limitation was an annual per beneficiary limit of $1500 on all outpatient physical therapy services (including speech-language pathology services). A separate $1500 limit was applied to all occupational therapy services. (The limitation amounts were to be increased to reflect medical inflation.) The annual limitation did not apply to services furnished directly or under arrangement by a hospital to an outpatient or to an inpatient who is not in a covered Part A stay.

Section 221 of the Balanced Budget Refinement Act of 1999 (Pub. L. 106-113, enacted on November 29, 1999) (BBRA) placed a moratorium on the application of the payment limitation for two years from January 1, 2000 through December 31, 2001. Section 421 of the Medicare, Medicaid, and SCHIP Beneficiary Improvement and Protection Act of 2000 (Pub. L. 106-554, enacted on December 21, 2000) (BIPA), extended the moratorium on application of the limitation to claims for outpatient rehabilitation services with dates of service January 1, 2002 through December 31, 2002. Therefore, the moratorium applies to outpatient rehabilitation claims with dates of service January 1, 2001 through December 31, 2002. Outpatient rehabilitation claims for services rendered on or after January 1, 2003 will be subject to the payment limitation unless Congress acts to extend the moratorium.

III. Collection of Information Requirements

This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995.

IV. 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.

V. Regulatory Impact Analysis

We have examined the impact of this rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA) (September 16, 1980 Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.

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 in any one year, 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 have simulated the effect of the proposed changes to practice expense RVUs described earlier. The net effect of the changes we are proposing will not materially increase or decrease Medicare expenditures for physicians' services because the statute requires that changes to RVUs cannot increase or decrease expenditures more than $20 million. Since increases in payments resulting from RVU changes must be offset by decreases in payments for other services, the proposed practice expense changes will result in a redistribution of payments among physician specialties. The proposed changes to the MEI would result in increases in Medicare expenditures for physicians' services of $150 million in fiscal year (FY) 2003, $340 million in FY 2004, and $550 million in FY 2005. Therefore, this proposed rule is considered to be a major rule because it is economically significant, and, thus, we have prepared a regulatory impact analysis.

The RFA requires that we analyze regulatory options for small businesses and other entities. We prepare a Regulatory Flexibility Analysis unless we certify that a rule would not have a significant economic impact on a substantial number of small entities. The analysis must include a justification concerning the reason action is being taken, the kinds and number of small entities the rule affects, and an explanation of any meaningful options that achieve the objectives and less significant adverse economic impact on the small entities.

Section 1102(b) of the 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.

For purposes of the RFA, physicians, nonphysicians, and suppliers are considered small businesses if they generate revenues of $6 million or less. Approximately 95 percent of physicians (except mental health specialists) are considered to be small entities. There are about 700,000 physicians, other practitioners and medical suppliers that receive Medicare payment under the physician fee schedule.

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 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. Start Printed Page 43866

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. As indicated elsewhere in this proposed rule, we propose to make changes to the Medicare Economic Index, refine resource-based practice based practice expense RVUs and make a variety of other minor changes to our regulations, payments or payment policy to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. We provide information for each of the proposed policy changes in the relevant sections in this proposed rule. As discussed elsewhere in this proposed rule, the provisions of this proposed rule, if adopted, would only change Medicare payment rates for physician fee schedule services. While this rule would allow physical and occupational therapists that are employed by physicians to separately enroll in the Medicare program, it does not impose reporting, recordkeeping and other compliance requirements. We are unaware of any relevant Federal rules that duplicate, overlap or conflict with this proposed rule. The relevant sections of this proposed rule contain a description of significant alternatives.

A. Resource-Based Practice Expense Relative Value Units

Under section 1848(c)(2) of the Act, adjustments to RVUs may not cause the amount of expenditures to differ by more than $20 million from the amount of expenditures that would have resulted without such adjustments. We are proposing several changes that would result in a change of expenditures that would exceed $20 million if we made no offsetting adjustments to either the conversion factor or RVUs.

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 estimate the aggregate number of practice expense relative values that will be paid under current and proposed policy in CY 2003. We apply a uniform adjustment factor to make the aggregate number of proposed practice expense relative values equal the number estimated that would be paid under current policy.

Table 2 shows the specialty level impact on payment of changes being proposed for CY 2003. In past years, we have shown the Medicare payment impact of redistributive changes in RVUs for all specialties that can bill for Medicare physician fee schedule services. We included some of the smaller specialty categories in closely related larger ones and have shown payment impacts for 35 different specialty categories. For this proposed rule, we are showing separate impacts for 49 different specialty categories. We are separately showing specialties that have more than $50 million in total Medicare allowed charges for physician fee schedule services. We are changing the way we illustrate impacts based on comments and suggestions that have come to us from the physician community. The payment impacts reflect averages for each specialty based on Medicare utilization. The payment impact for an individual physician would be different from the average, based on the mix of services the physician provides. The average change in total revenues would be less than the impact displayed here since physicians furnish services to both Medicare and non-Medicare patients and specialties may receive substantial Medicare revenues for services that are not paid under the physician fee schedule. For instance, independent laboratories receive more than 80 percent of their Medicare revenues from clinical laboratory services that are not paid under the physician fee schedules. This table shows only the payment impact on physician fee schedule services.

We modeled the impact of five changes to the practice expense methodology. The column labeled “Input Changes” shows the effect of proposed changes described in section II. A. As indicated in that section, we are making several changes to the inputs that are used to value several ophthalmology and thermotherapy procedures and lontophoresis. We also revised the price we are using for sterile water. These changes will result in very little specialty impact with a small reduction in payment to optometry.

The column labeled “Staff Time” shows the impact of our proposal to use staff time in place of average staff time in creation of the zero physician work pool. This proposal would result in increases in payment for services that are included in the zero physician work pool while broadly distributing reductions in payments to all other physician fee schedule services.

The column labeled “Professional Technical Changes” refers to our proposal to change the calculation of the practice expense RVUs for codes with professional and technical components. As indicated earlier, we are proposing to make the technical component value equal the difference between the global and the professional component for procedure codes that are not included in the zero physician work pool. For procedure codes that would remain in the zero physician work pool, we would continue to make the global equal the sum of the professional and the technical component values.

The column labeled “Zero Physician Work Pool” refers to our proposal to remove several services from the zero physician work pool based on requests from the physician specialties that perform the predominant number of services for a given family of codes. The practice expense RVUs for these codes would no longer be determined under the zero physician work methodology. If the services have professional and technical components, the professional component practice expense RVU would be subtracted from the global practice expense RVU to determine the technical component practice value.

The column labeled “Multi-Year Utilization” refers to our proposal to use multiple years of utilization data in the practice expense methodology. The figures shown in Table 2 may change if we make any changes to the zero physician work pool following the consideration of public comments.

Several physician specialties (Allergy/Immunology, Cardiology, Hematology/Oncology, Interventional Radiology, Radiation Oncology, Radiology) that derive a significant portion of their Medicare revenues from services affected by the zero physician work pool calculations would see an increase in payment from the proposed changes. Other physician specialties would see an increase in payment from the change to the practice expense RVUs for professional and technical component services and/or from removing services from the zero physician work pool (neurology, physical medicine, vascular surgery).

Payments to pathology would be reduced by approximately 2 percent. This is largely attributable to the change in the practice expense RVU calculations for professional and technical component services. While payments for pathology would decline, as we noted earlier, since it is far more common for our carriers to receive a global than a technical-component-only bill, we believe it is far more likely that using the global to value the technical component service would result in a payment that is more typical of the practice expense associated with the service. We reviewed the Medicare utilization and found 42.8 million Start Printed Page 43867allowed services associated with a global pathology service and 4.3 million for the technical component only. Several other specialties may also experience small reductions in aggregate payments from these proposed changes.

As a result of changing the practice expense RVU calculation for professional and technical component services, payments for physician fee schedule services to independent laboratories would decline by approximately 8 percent. However, physician fee schedule services account for approximately 17 percent of total Medicare revenues for independent laboratories. The impact on total Medicare revenues from this reduction would be approximately −1 percent. The figures in Table 2 may change if we if we make any changes to the zero physician work pool following the consideration of public comments.

The net effect of these proposals would also increase payments for several types of suppliers that provide services that are affected by the zero physician work pool methodology. Payments to Independent Diagnostic and Treatment Facilities would increase by approximately 9 percent. Portable X-ray suppliers would receive an approximate increase of 8 percent in payments for services paid under the physician fee schedule. However, we would note that only about 47 percent of Medicare revenues received by portable X-ray suppliers are attributable to physician fee schedule services. The other Medicare revenues received by portable X-ray suppliers are attributed to the transportation of X-ray equipment paid at rates determined by the Medicare carrier. Any change to the rates for carrier priced services would be made at local carrier discretion. The total change in payments (before application of the estimated 4.4 percent reduction to the physician fee schedule conversion factor discussed next) will be about 3 percent.

Table 2 shows the estimated change in payment rates based on provisions of this proposed rule. If we change any of these proposals following our consideration of comments, these figures may change.

Table 2.—Impact of Practice Expense Changes on Total Medicare Allowed Charges by Physician, Practitioner and Supplier Subcategory

CategoryMedicare allowed charges ($ in billions)Input changes (percent)Maximum staff time (percent)Professional technical changes (percent)Zero physician work pool (percent)Multi-year utilizationTotal (percent)
Physicians:
ALLERGY/IMMUNOLOGY$0.14010002
ANESTHESIOLOGY1.1700000−1
CARDIAC SURGERY0.27000000
CARDIOLOGY4.28010011
CLINICS1.81000000
DERMATOLOGY1.430−1000−2
EMERGENCY MEDICINE1.04000000
ENDOCRINOLOGY0.20000000
FAMILY PRACTICE3.27000000
GASTROENTEROLOGY1.250000−1−1
GENERAL PRACTICE0.87000000
GENERAL SURGERY1.9400000−1
GERIATRICS0.08000000
HEMATOLOGY/ONCOLOGY0.90010011
INFECTIOUS DISEASE0.2500000−1
INTERNAL MEDICINE6.42000000
INTERVENTIONAL RADIOLOGY0.13000001
NEPHROLOGY1.0300000−1
NEUROLOGY0.8501300−1
NEUROSURGERY0.3500000−1
OBSTETRICS/GYNECOLOGY0.45000000
OPHTHALMOLOGY3.690−100−1−1
ORTHOPEDIC SURGERY2.22000000
OTOLARNGOLOGY0.63000000
PATHOLOGY0.6300−200−2
PEDIATRICS0.05000000
PHYSICAL MEDICINE0.48001001
PLASTIC SURGERY0.230000−1−1
PSYCHIATRY1.00000000
PULMONARY DISEASE1.07001000
RADIATION ONCOLOGY0.72020023
RADIOLOGY3.12010012
RHEUMATOLOGY0.30000000
THORACIC SURGERY0.44000000
UROLOGY0.440000−1−1
VASCULAR SURGERY0.34000202
Other Practitioners:
CHIROPRACTOR0.440000−1−1
CLINICAL PSYCHOLOGIST0.38000011
CLINICAL SOCIAL WORKER0.21000010
NURSE ANESTHETIST0.3500000−1
NURSE PRACTITIONER0.21000000
OPTOMETRY0.50−1−100−1−2
PHYSICAL/OCCUPATIONAL THERAPY0.47000000
Start Printed Page 43868
PHYSICIAN ASSISTANTS0.17000000
PODIATRY1.1000000−1
Suppliers:
DIAGNOSTIC TREATMENT FACILITY0.35031139
INDEPENDENT LABORATORY0.380−1−902−8
PORTABLE XRAY SUPPLIER0.06040038
ALL OTHER0.29000000
TOTAL49.21000000

In previous years, we have not included the effect of the physician fee schedule update in our impact tables. The statutory methodology for updating physician rates for CY 2001 and subsequent years is specified in section 1848(d)(4) of the Act. Section 1848(d)(4) of the Act indicates that physician fee schedule rates are updated by the MEI increased or decreased by an “update adjustment factor.” The update adjustment factor reflects a comparison of actual and target expenditures under the sustainable growth rate system (SGR) under section 1848(f) of the Act. If actual expenditures exceed target expenditures, the update adjustment factor is negative. If actual expenditures are less than target expenditures, the update adjustment factor is positive. The update adjustment factor is limited to +3.0 and −7.0 percentage points. We do not have authority to change physician fee schedule update formula specified in statute. Since the application of the update cannot be changed through the rulemaking process, we have not shown the effect of the physician fee schedule update in our impact tables. However, public comment indicates an interest in our illustrating the effect of the update on payments to physicians in the impact section of our regulation.

Consistent with the requirements of section 1848(d)(1)(E) of the Act, we made an estimate of the physician fee schedule update for CY 2003 available to the Medicare Payment Advisory Commission (MedPAC) and the public on March 1, 2002. At that time, we provided our latest estimate of the MEI for CY 2003 and indicated that the update adjustment factor would likely equal the −7.0 percentage point limit established in statute. That is, the CY 2003 update would equal the MEI reduced by 7.0 percentage points. Section 1848(d)(4)(F) of the Act requires the update to be reduced by an additional −0.2 percentage points.

We currently estimate that the CY 2003 MEI will equal 2.3 percent using an adjustment based on a 10-year average economy-wide labor productivity. If we substitute a 10-year average economy-wide multifactor productivity as proposed in this proposed rule, the CY 2003 MEI is estimated to be 3.0 percent. Substituting multifactor for labor productivity increases the MEI by 0.7 percentage points. We believe that it remains likely that the update adjustment factor will equal the statutory limit of −7.0 percentage points specified in section 1848(d)(4) of the Act. Taking the following factors into account, we estimate that the CY 2003 physician fee schedule update will equal the product of the following 3 factors:

MEI 3.0% (1.030)

Update Adjustment Factor −7.0% (0.930)

Legislative Factor −0.2% (0.998)

Update −4.4% (0.956)

The MEI is based on the 3 complete quarters and 1 projected quarter of information and may change slightly before we announce the final MEI no later than November 1, 2002. Incorporating the estimated update with the practice expense impacts shown above will produce the following estimated impact on payments for physician fee schedule services. Table 3 shows the estimated change in average payments by specialty based on provisions of this proposed rule and the estimated physician fee schedule update. If we change any of these provisions based on public comment or if the actual MEI is different than our estimate, these figures may change.

Table 3.—Estimated Impact Practice Expense and Update on Total Medicare Allowed Charges by Specialty

SpecialtyMedicare allowed charges ($ in billions)Combined practice expense changes (percent)Estimated update (percent)Total (percent)
Physicians:
ALLERGY/IMMUNOLOGY$0.142−4.4−3
ANESTHESIOLOGY1.17−1−4.4−5
CARDIAC SURGERY0.270−5.5−5
CARDIOLOGY4.281−4.4−4
CLINICS1.810−4.4−5
DERMATOLOGY1.43−2−4.4−6
EMERGENCY MEDICINE1.040−4.4−4
ENDOCRINOLOGY0.200−4.4−5
FAMILY PRACTICE3.270−4.4−5
GASTROENTEROLOGY1.25−1−4.4−5
GENERAL PRACTICE0.870−4.4−4
Start Printed Page 43869
GENERAL SURGERY1.94−1−4.4−5
GERIATRICS0.080−4.4−5
HEMATOLOGY/ONCOLOGY0.901−4.4−3
INFECTIOUS DISEASE0.25−1−4.4−5
INTERNAL MEDICINE6.420−4.4−5
INTERVENTIONAL RADIOLOGY0.131−4.4−4
NEPHROLOGY1.03−1−4.4−5
NEUROLOGY0.852−4.4−1
NEUROSURGERY0.35−1−4.4−5
OBSTETRICS/GYNECOLOGY0.450−4.4−5
OPHTHALMOLOGY3.69−1−4.4−5
ORTHOPEDIC SURGERY2.220−4.4−5
OTOLARNGOLOGY0.630−4.4−5
PATHOLOGY0.63−2−4.4−6
PEDIATRICS0.050−4.4−4
PHYSICAL MEDICINE0.481−4.4−3
PLASTIC SURGERY0.23−1−4.4−5
PSYCHIATRY1.000−4.4−5
PULMONARY DISEASE1.070−4.4−4
RADIATION ONCOLOGY0.723−4.4−3
RADIOLOGY3.122−4.4−3
RHEUMATOLOGY0.300−4.4−4
THORACIC SURGERY0.440−4.4−4
UROLOGY1.28−1−4.4−4
VASCULAR SURGERY0.342−4.4−3
Other Practitioners:
CHIROPRACTOR0.44−1−4.4−5
CLINICAL PSYCHOLOGIST0.381−4.4−4
CLINICAL SOCIAL WORKER0.210−4.4−4
NURSE ANESTHETIST0.35−1−4.4−5
NURSE PRACTITIONER0.210−4.4−5
OPTOMETRY0.50−2−4.4−4
PHYSICAL/OCCUPATIONAL THERAPY0.470−4.4−5
PHYSICIANS ASSISTANT0.170−4.4−5
PODIATRY1.10−1−4.4−5
Suppliers:
DIAGNOSTIC TREATMENT FACILITY0.359−4.41
INDEPENDENT LABORATORY0.38−8−4.4−9
PORTABLE X-RAY SUPPLIER0.068−4.4−1
ALL OTHER0.290−4.4−5
TOTAL49.210−4.4−4.4

Table 4 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 the practice expense RVUs and the estimated physician fee schedule update on total payment for the procedure. There are separate columns that show the change in the facility rates and the nonfacility rates. For an explanation of facility and non-facility practice expense refer to § 414.22(b)(5)(i). The table shows the estimated change in payment rates based on provisions of this proposed rule and the estimated physician fee schedule update. If we change any of the provisions following the consideration of public comments or if the actual MEI is different than our estimate, these figures may change.

Table 4.—Impact of Proposed Rule and Physician Fee Schedule Update on Medicare Payment for Selected Procedures

HCPCSMODDESCFacility paymentNonfacility payment
OldNew% ChangeOldNew% Change
11721Debride nail, 6 or more$28.96$27.34−6$36.92$34.95−5
17000Detroy benign/premal lesion32.9431.15−562.6258.48−7
27130Total hip arthroplasty1,452.311,376.62−5N/AN/AN/A
27236Treat thigh fracture1,113.851,053.40−5N/AN/AN/A
27244Treat thigh fracture1,137.381,074.86−5N/AN/AN/A
Start Printed Page 43870
27447Total knee arthroplasty1,514.211,433.72−5N/AN/AN/A
33533CABG, arterial, single1,827.341,742.75−5N/AN/AN/A
35301Rechanneling of artery1,061.361,011.18−5N/AN/AN/A
43239Upper GI endoscopy, biopsy154.93146.73−5354.75316.30−11
45385Lesion removal colonoscopy287.78273.04−5571.22511.82−10
66821After cataract laser surgery213.94203.83−5229.50219.40−4
66984Cataract surg w/iol, i stage669.32636.06−5N/AN/AN/A
67210Treatment of retinal lesion546.61519.095603.08575.15−5
7101026Chest x-ray9.058.65−49.058.65−4
7102026Chest x-ray11.2210.38−711.2210.38−7
76091Mammogram, both breastsN/AN/AN/A90.5090.320
7609126Mammogram, both breasts43.4441.53−443.4441.53−4
76092Mammogram, screeningN/AN/AN/A81.8178.21−4
7609226Mammogram, screening35.4833.91−435.4833.91−4
77427Radiation tx management, x5167.96159.88−5167.96159.88−5
7846526Heart image (3d), multiple74.9370.94−574.9370.94−5
8830526Tissue exam by pathologist40.5438.41−540.5438.41−5
90801Psy dx interview137.19130.81−5144.80138.08−5
90806Psytx, off, 45-50 min91.2287.55−495.9392.05−4
90807Psytx, off, 45-50 min w/e&m98.8294.13−5103.5398.28−5
90862Medication management46.3343.95−551.0448.45−5
90921ESRD related services, month273.30258.16−6273.30258.16−6
90935Hemodialysis, one evaluation76.3871.98−6N/AN/AN/A
92004Eye exam, new patient87.9683.05−6123.44117.66−5
92012Eye exam established pat35.8433.91−561.1858.48−4
92014Eye exam & treatment58.6455.37−691.2286.86−5
92980Insert itracoronary stent790.59748.18−5N/AN/AN/A
92982Coronary artery dilation584.26553.00−5N/AN/AN/A
93000Electrocardiogram, completeN/AN/AN/A25.3425.260
93010Electrocardiogram report9.058.31−89.058.31−8
93015Cardiovascular stress testN/AN/AN/A99.91100.010
9330726Echo exam of heart48.1445.33−648.1445.33−6
9351026Left heart catheterization230.59218.02−5230.59218.02−5
98941Chiropractic manipulation31.1329.42−535.4833.57−5
99202Office/outpatient visit, new45.6143.26−561.5458.14−6
99203Office/outpatient visit, new69.5066.10−591.9586.86−6
99204Office/outpatient visit, new102.8197.93−5130.68123.89−5
99205Office/outpatient visit, new136.47129.43−5166.15157.46−5
99211Office/outpatient visit, est8.698.31−420.2719.03−6
99212Office/outpatient visit, est23.1721.80−636.2033.91−6
99213Office/outpatient visit, est34.0332.53−450.3247.76−5
99214Office/outpatient visit, est56.1153.29−578.9174.75−5
99215Office/outpatient visit, est90.5085.82−5115.84109.35−6
99221Initial hospital care65.1661.94−5N/AN/AN/A
99222Initial hospital care108.24102.78−5N/AN/AN/A
99223Initial hospital care150.95143.27−5N/AN/AN/A
99231Subsequent hospital care32.5830.80−5N/AN/AN/A
99232Subsequent hospital care53.5750.87−5N/AN/AN/A
99233Subsequent hospital care76.3872.33−5N/AN/AN/A
99236Observ/hosp same date214.66204.87−5N/AN/AN/A
99238Hospital discharge day66.2462.98−5N/AN/AN/A
99239Hospital discharge day90.8686.17−5N/AN/AN/A
99241Office consultation33.3031.15−647.0644.64−5
99242Office consultation68.0564.02−687.2482.36−6
99243Office consultation90.1485.48−5115.84109.35−6
99244Office consultation133.58126.66−5164.34155.38−5
99245Office consultation177.01167.84−5212.85201.41−5
99251Initial inpatient consult34.7532.88−5N/AN/AN/A
99252Initial inpatient consult69.8666.10−5N/AN/AN/A
99253Initial inpatient consult95.2090.32−5N/AN/AN/A
99254Initial inpatient consult136.83129.77−5N/AN/AN/A
99255Initial inpatient consult188.60178.57−5N/AN/AN/A
99261Follow-up inpatient consult21.7220.76−4N/AN/AN/A
99262Follow-up inpatient consult43.4441.18−5N/AN/AN/A
99263Follow-up inpatient consult64.8061.25−5N/AN/AN/A
99282Emergency dept visit26.4325.26−4N/AN/AN/A
99283Emergency dept visit59.3756.75−4N/AN/AN/A
99284Emergency dept visit92.6788.59−4N/AN/AN/A
Start Printed Page 43871
99285Emergency dept visit144.80138.08−5N/AN/AN/A
99291Critical care, first hour198.37188.60−5208.87197.60−5
99292Critical care, addl 30 min98.8294.13−5108.24101.05−7
99301Nursing facility care60.0957.45−470.2366.79−5
99302Nursing facility care80.7276.83−595.5791.01−5
99303Nursing facility care100.2795.51−5118.73112.82−5
99311Nursing fac care, subseq30.0528.72−440.1838.41−4
99312Nursing fac care, subseq49.9547.41−561.9058.83−5
99313Nursing fac care, subseq70.9567.48−584.3480.29−5
99348Home visit, est patientN/AN/AN/A73.8569.90−5
99350Home visit, est patientN/AN/AN/A166.52157.46−5

B. Proposed Productivity Adjustment to the MEI

As indicated in section II.D of this proposed rule, we are proposing to change the methodology for adjusting for productivity in the MEI. We propose that the MEI used for the CY 2003 physician payment update reflect changes in the 10-year moving average of private nonfarm business (economy-wide) multifactor productivity applied to the entire index. The prior method accounted for productivity by adjusting the labor portion of the MEI by the 10-year moving average change in private nonfarm business (economy-wide) labor productivity. Our reasons for proposing this change and the alternatives we considered are discussed in detail in section II.D.

We believe that we have developed a revised MEI methodology that is technically superior to the current MEI and more adequately reflects annual changes in the cost of furnishing services in efficient physicians' practices. We estimate that the proposed changes to the MEI would raise the index by 0.7 percentage points from 2.3 percent to 3.0 percent for CY 2003 based on 3 complete quarters and 1 projected quarter of information. This figure may change based on complete data. We estimate that this proposed change would increase Federal expenditures by $150 million in FY 2003. The outyear impact is a function of numerous economic variables that fluctuate unpredictably. Our estimate of the impact beyond FY 2003 is based on projections of both the current and proposed revised index. We estimate the proposed change would increase Federal expenditures by $340 million in FY 2004 and $550 million in FY 2005.

C. Site of Service

Relative values for practice expense are determined for both “facility” and “nonfacility” settings. (See Addendum B.) We propose to clarify which place of service codes are assigned to facility relative values and which place of service codes are assigned to nonfacility relative values. This clarification should benefit physicians, providers, and Medicare contractors by making the payment rules clearer. We are proposing to update facility and nonfacility designations for several new place of service codes and change the designations for several place of service codes already in existence. The update for the new place of service codes will have no effect on Medicare spending. The place of service codes in which we are changing the designation are infrequently used for physician fee schedule services. Any effect of this proposal would result in very minor redistribution in payment among physician fee schedule services through the practice expense budget-neutrality adjustments.

D. Pricing of Technical Components (TC) for Positron Emission Tomography (PET) Scans

As stated earlier, to keep pricing consistent with the manner in which other PET scan services are paid, we are proposing a change from national pricing to having the carriers price the TC and global value for HCPCS code G0125 Lung Image PET scans. The budgetary impact on the Medicare program and providers would be uncertain since we do not know the payment amounts that carriers would use for this service.

E. Medicare Qualifications for Clinical Nurse Specialists (CNSs)

As previously stated, we are proposing to revise regulations regarding qualifications for CNSs by allowing flexibility as to certifying bodies. We believe this change would make the Medicare requirements more consistent with criteria for other practitioners. We also believe there would be additional enrollment of CNSs that would qualify for Medicare enrollment. We expect that this proposal would have little effect on Medicare expenditures.

F. Process To Add or Delete Services to the Definition of Telehealth

We are proposing a process for adding or deleting services from the list of telehealth services, as well as for adding specific services to the list for CY 2003. There are no costs or savings to the Medicare program associated with this proposal. In addition, we are proposing to add psychiatric diagnostic interview examination, as represented by HCPCS code 90801, to the list of Medicare telehealth services. We believe this would have little effect on Medicare expenditures.

G. Change in Global Period for CPT Code 77789 (Surface Application of Radiation Source

We are proposing a change in the global period for CPT code 77789 (surface application of radiation source) from a 90-day global period to a 000-day global period. We believe physicians that furnish these services would benefit from this change because it would simplify their billing processes. We do not expect it would have a significant impact on the Medicare program because the change would reflect current practices.

H. New HCPCS G-Codes

We are proposing to add new G-codes to describe evaluation (examination and treatment) of the feet no more often than every 6 months for individuals with a documented diagnosis of diabetic peripheral neuropathy with loss of protective sensation. We established Start Printed Page 43872payment for these codes in CY 2002 to allow for payment consistent with a national coverage decision clarifying coverage for routine foot exams. This provision would have no impact on the program because the codes will be implemented through a program memorandum to reflect new national policy effective July 1, 2002.

I. Endoscopic Base for Urology Codes

We are proposing to correct the pricing of certain endoscopic services. As we indicated in section II.N., we propose to use CPT procedure code 52000 as the endoscopic base code for CPT procedure codes 52234, 52235, and 52240. This proposed change would result in a reduction in payment in instances when these codes are billed in conjunction with either CPT procedure code 52000 or other codes that have CPT procedure code 52000 as the endscopic base code. We expect the savings would be negligible.

J. Physical Therapy and Occupational Therapy Caps

There were no proposals made in this area. The imposition of the physical and occupational therapy caps will occur as a result of application of section 4541(c) of the BBA. While section 221 of the BBRA and section 421 of BIPA placed a moratorium on application of these caps, the moratorium expires for physical and occupational therapy services rendered after December 31, 2002. We estimate that application of the caps will reduce Medicare expenditures for physical and occupational therapy services by $240 million in 2003.

K. Enrollment of Physical and Occupational Therapists as Therapists in Private Practice

This proposal would clarify Medicare enrollment criteria for therapists and provide consistency among Medicare contractors. This would allow flexibility for therapists in how they choose to practice by allowing all therapists that met the enrollment criteria to enroll in Medicare.

L. Alternatives Considered

This proposed rule contains a range of policies. The preamble identifies those policies when discretion has been exercised and presents rationale for our decisions, including a presentation of nonselected options.

M. 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. We do not believe that there would be any problem with access to care as a result of the proposed changes in this rule. While it has been suggested that the negative update for 2003 may affect beneficiary access to care, we note that the formula to determine this update is set by statute and this regulation cannot, and does not, change it. Furthermore, since beginning our transition to a resource-based practice expense system in CY 1999, we have not found that there are problems with beneficiary access to care.

As indicated above, the imposition of the physical and occupational therapy caps will occur as a result of application of section 4541(c) of the BBA. It is possible that application of physical and occupational therapy caps will have an impact on Medicare beneficiaries either through increased liability for services exceeding the cap or fewer services being provided. We contracted with the Urban Institute to perform analyses related to the implementation of the therapy caps, based on an analysis of a sample of therapy services provided from 1998 through 2000. The draft reports are available on the CMS website. The contractor report indicated that in 2000, about 12 percent of patients who received therapy services would have exceeded the caps. More than 50 percent of those who exceeded the caps did so by $500 or more. The caps are more likely to be exceeded in skilled nursing facilities, comprehensive outpatient rehabilitation facilities, and other rehabilitation facility settings. The caps do not apply to outpatient therapy services provided in an outpatient hospital. The report does not make assumptions about changes in behavior in response to the caps. Without more experience with the caps, it is difficult to predict the precise impact on beneficiaries.

In accordance with the provisions of Executive Order 12866, this regulation was 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 Centers for Medicare & Medicaid Services proposes to amend 42 CFR chapter IV as follows:

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 410.59 is amended as follows:

A. Paragraph (c)(1)(ii)(C) is revised.

B. A new paragraph (c)(1)(ii)(D) is added.

The revision and addition read as follows:

Outpatient occupational therapy services: conditions.
* * * * *

(c) * * *

(1) * * *

(ii) * * *

(C) An unincorporated solo practice, partnership, or group practice, or a professional corporation or other incorporated occupational therapy practice.

(D) A physician group.

* * * * *

3. Section 410.60 is amended as follows:

A. Paragraph (c)(1)(ii)(C) is revised.

B. A new paragraph (c)(1)(ii)(D) is added.

The revision and addition read as follows:

Outpatient physical therapy services: conditions.
* * * * *

(c) * * *

(1) * * *

(ii) * * *

(C) An unincorporated solo practice, partnership, or group practice, or a professional corporation or other incorporated physical therapy practice.

(D) An employee of a physician group.

* * * * *

4. Section 410.61 is amended by revising paragraph (d)(1)(iii) to read as follows:

Outpatient rehabilitation services.
* * * * *

(d) * * *

(1) * * *

(iii) The occupational therapist that furnishes the occupational therapy services.

* * * * *

5. Section 410.76 is amended by revising paragraph (b)(3) to read as follows:

Start Printed Page 43873
Clinical nurse specialists' services.
* * * * *

(b) * * *

(3) Be certified as a clinical nurse specialist by a national certifying body that has established standards for clinical nurse specialists and that is approved by the Secretary.

* * * * *

6. Section 410.78 is amended as follows:

a. Revise the heading of the section.

b. Revise paragraph (b) introductory text.

c. Revise paragraph (b)(1).

The revisions read as follows:

Telehealth services.
* * * * *

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

(1) The physician or practitioner at the distant site must be licensed to furnish the service under State law. The physician or practitioner at the distant site who is licensed under State law to furnish a covered telehealth service described in this section may bill, and receive payment for, the service when it is delivered via a telecommunications system.

* * * * *
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. Section 414.46is amended by revising paragraph (g) to read as follows:

Additional rules for payment of anesthesia services.
* * * * *

(g) Physician involved in multiple anesthesia services. If the physician is involved in multiple anesthesia services for the same patient during the same operative session, the carrier makes payment according to the base unit associated with the anesthesia service having the highest base unit value and anesthesia time that encompasses the multiple services. If the multiple anesthesia services involve add-on anesthesia codes, as described in program operating instructions, the carrier makes payment for the add-on codes according to the usual anesthesia payment rules in paragraph (b) of this section.

3. Section 414.65, is amended as follows:

a. Revise the heading of the section.

b. Revise paragraph (a)(1).

c. Revise paragraph (b) introductory text.

The revisions read as follows:

Payment for telehealth services.

(a) * * *

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

* * * * *

(b) Originating site facility fee. For telehealth services furnished on or after October 1, 2001:

* * * * *
Start Signature

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

Dated: May 21, 2002.

Thomas A. Scully,

Administrator, Centers for Medicare & Medicaid Services.

End Signature Start Signature

Approved: June 5, 2002.

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 2003. 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 will no longer publish alpha numeric codes for which there is no physician fee schedule coverage or payment or services paid on the clinical lab fee schedule.

Addendum B—2003 Relative Value Units and Related Information Used in Determining Medicare Payments for 2003

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 Start Printed Page 43874these 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 2003. 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 2003.

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.

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 = Code related to another service that is always included in the global period of the other service. (Note: Physician work and practice expense are associated with intra service time and in some instances the post service time.)

—————————— 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 (D0110-D9999). 3 +Indicates RVUs are not use for Medicate payments. 4 PE RVUs = Practice Expense Relative Value Units. Start Printed Page 43874

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

CPT 1/ HCPCS 2MODStatusDescriptionPhysician Work RVUs 3Facility PE RVUsNon- Facility PE RVUsMal- Practice RVUsGlobal
0001TCEndovas repr abdo ao aneurys0.000.000.000.00XXX
0002TCEndovas repr abdo ao aneurys0.000.000.000.00XXX
0003TCCervicography0.000.000.000.00XXX
0005TCPerc cath stent/brain cv art0.000.000.000.00XXX
0006TCPerc cath stent/brain cv art0.000.000.000.00XXX
0007TCPerc cath stent/brain cv art0.000.000.000.00XXX
0008TCUpper gi endoscopy w/suture0.000.000.000.00XXX
0009TCEndometrial cryoablation0.000.000.000.00XXX
0010TCTb test, gamma interferon0.000.000.000.00XXX
0012TCOsteochondral knee autograft0.000.000.000.00XXX
0013TCOsteochondral knee allograft0.000.000.000.00XXX
0014TCMeniscal transplant, knee0.000.000.000.00XXX
0016TCThermotx choroid vasc lesion0.000.000.000.00XXX
0017TCPhotocoagulat macular drusen0.000.000.000.00XXX
0018TCTranscranial magnetic stimul0.000.000.000.00XXX
0019TCExtracorp shock wave tx, ms0.000.000.000.00XXX
0020TCExtracorp shock wave tx, ft0.000.000.000.00XXX
0021TCFetal oximetry, trnsvag/cerv0.000.000.000.00XXX
0023TCPhenotype drug test, hiv 10.000.000.000.00XXX
0024TCTranscath cardiac reduction0.000.000.000.00XXX
0025TCUltrasonic pachymetry0.000.000.000.00XXX
0026TCMeasure remnant lipoproteins0.000.000.000.00XXX
10021AFna w/o image1.27NA1.000.10XXX
10022AFna w/image1.27NA1.260.08XXX
Start Printed Page 43875
10040AAcne surgery1.180.530.930.05010
10060ADrainage of skin abscess1.170.671.470.08010
10061ADrainage of skin abscess2.401.421.830.17010
10080ADrainage of pilonidal cyst1.170.732.120.09010
10081ADrainage of pilonidal cyst2.451.542.880.19010
10120ARemove foreign body1.220.361.480.10010
10121ARemove foreign body2.691.782.930.25010
10140ADrainage of hematoma/fluid1.530.871.490.15010
10160APuncture drainage of lesion1.200.420.720.11010
10180AComplex drainage, wound2.251.261.470.25010
11000ADebride infected skin0.600.240.630.05000
11001ADebride infected skin add-on0.300.110.370.02ZZZ
11010ADebride skin, fx4.201.982.390.45010
11011ADebride skin/muscle, fx4.952.593.820.53000
11012ADebride skin/muscle/bone, fx6.884.215.470.89000
11040ADebride skin, partial0.500.210.540.05000
11041ADebride skin, full0.820.330.690.08000
11042ADebride skin/tissue1.120.461.040.11000
11043ADebride tissue/muscle2.381.382.650.24010
11044ADebride tissue/muscle/bone3.061.823.260.34010
11055RTrim skin lesion0.430.180.510.02000
11056RTrim skin lesions, 2 to 40.610.260.570.03000
11057RTrim skin lesions, over 40.790.330.640.04000
11100ABiopsy of skin lesion0.810.371.460.04000
11101ABiopsy, skin add-on0.410.190.690.02ZZZ
11200ARemoval of skin tags0.770.311.160.04010
11201ARemove skin tags add-on0.290.120.510.02ZZZ
11300AShave skin lesion0.510.221.010.03000
11301AShave skin lesion0.850.391.090.04000
11302AShave skin lesion1.050.471.180.05000
11303AShave skin lesion1.240.541.310.06000
11305AShave skin lesion0.670.280.740.04000
11306AShave skin lesion0.990.431.000.05000
11307AShave skin lesion1.140.501.120.05000
11308AShave skin lesion1.410.611.260.07000
11310AShave skin lesion0.730.331.110.04000
11311AShave skin lesion1.050.501.200.05000
11312AShave skin lesion1.200.571.270.06000
11313AShave skin lesion1.620.741.550.09000
11400ARemoval of skin lesion0.910.351.630.06010
11401ARemoval of skin lesion1.320.511.760.09010
11402ARemoval of skin lesion1.610.952.510.12010
11403ARemoval of skin lesion1.921.072.750.16010
11404ARemoval of skin lesion2.201.152.910.18010
11406ARemoval of skin lesion2.761.363.210.25010
11420ARemoval of skin lesion1.060.431.460.08010
11421ARemoval of skin lesion1.530.621.770.11010
11422ARemoval of skin lesion1.761.042.530.14010
11423ARemoval of skin lesion2.171.222.920.17010
11424ARemoval of skin lesion2.621.383.040.21010
11426ARemoval of skin lesion3.781.823.700.34010
11440ARemoval of skin lesion1.150.512.180.08010
11441ARemoval of skin lesion1.610.722.380.11010
11442ARemoval of skin lesion1.871.252.790.14010
11443ARemoval of skin lesion2.491.573.300.18010
11444ARemoval of skin lesion3.421.983.750.25010
11446ARemoval of skin lesion4.492.454.200.30010
11450ARemoval, sweat gland lesion2.730.974.110.26090
11451ARemoval, sweat gland lesion3.951.444.910.39090
11462ARemoval, sweat gland lesion2.510.954.080.23090
11463ARemoval, sweat gland lesion3.951.575.550.40090
11470ARemoval, sweat gland lesion3.251.244.660.30090
11471ARemoval, sweat gland lesion4.411.725.690.40090
11600ARemoval of skin lesion1.411.022.410.09010
11601ARemoval of skin lesion1.931.302.460.12010
11602ARemoval of skin lesion2.091.352.580.13010
Start Printed Page 43876
11603ARemoval of skin lesion2.351.422.830.16010
11604ARemoval of skin lesion2.581.493.150.18010
11606ARemoval of skin lesion3.431.773.760.28010
11620ARemoval of skin lesion1.341.032.390.09010
11621ARemoval of skin lesion1.971.372.500.12010
11622ARemoval of skin lesion2.341.542.780.15010
11623ARemoval of skin lesion2.931.763.180.20010
11624ARemoval of skin lesion3.431.983.590.25010
11626ARemoval of skin lesion4.302.464.360.35010
11640ARemoval of skin lesion1.531.232.450.10010
11641ARemoval of skin lesion2.441.712.850.15010
11642ARemoval of skin lesion2.931.943.260.18010
11643ARemoval of skin lesion3.502.213.690.24010
11644ARemoval of skin lesion4.552.814.650.33010
11646ARemoval of skin lesion5.953.625.520.46010
11719RTrim nail(s)0.170.070.250.01000
11720ADebride nail, 1-50.320.130.340.02000
11721ADebride nail, 6 or more0.540.210.430.04000
11730ARemoval of nail plate1.130.440.810.09000
11732ARemove nail plate, add-on0.570.230.300.05ZZZ
11740ADrain blood from under nail0.370.140.810.03000
11750ARemoval of nail bed1.860.771.710.16010
11752ARemove nail bed/finger tip2.671.742.100.33010
11755ABiopsy, nail unit1.310.561.070.06000
11760ARepair of nail bed1.581.241.780.17010
11762AReconstruction of nail bed2.891.862.230.32010
11765AExcision of nail fold, toe0.690.491.130.05010
11770ARemoval of pilonidal lesion2.611.232.930.24010
11771ARemoval of pilonidal lesion5.743.915.500.56090
11772ARemoval of pilonidal lesion6.984.366.350.68090
11900AInjection into skin lesions0.520.220.750.02000
11901AAdded skin lesions injection0.800.360.870.03000
11920RCorrect skin color defects1.610.802.210.17000
11921RCorrect skin color defects1.931.002.600.21000
11922RCorrect skin color defects0.490.250.390.05ZZZ
11950RTherapy for contour defects0.840.421.200.06000
11951RTherapy for contour defects1.190.521.570.10000
11952RTherapy for contour defects1.690.702.010.17000
11954RTherapy for contour defects1.850.932.620.19000
11960AInsert tissue expander(s)9.0811.15NA0.88090
11970AReplace tissue expander7.065.01NA0.77090
11971ARemove tissue expander(s)2.133.886.270.21090
11975NInsert contraceptive cap1.480.571.560.14XXX
11976RRemoval of contraceptive cap1.780.701.670.17000
11977NRemoval/reinsert contra cap3.301.282.270.31XXX
11980AImplant hormone pellet(s)1.480.561.120.10000
11981AInsert drug implant device1.480.571.560.14XXX
11982ARemove drug implant device1.780.691.680.17XXX
11983ARemove/insert drug implant3.301.282.270.31XXX
12001ARepair superficial wound(s)1.700.442.090.13010
12002ARepair superficial wound(s)1.860.932.150.15010
12004ARepair superficial wound(s)2.241.042.410.17010
12005ARepair superficial wound(s)2.861.232.960.23010
12006ARepair superficial wound(s)3.671.543.610.31010
12007ARepair superficial wound(s)4.121.834.050.37010
12011ARepair superficial wound(s)1.760.452.250.14010
12013ARepair superficial wound(s)1.990.962.390.16010
12014ARepair superficial wound(s)2.461.092.680.18010
12015ARepair superficial wound(s)3.191.283.280.24010
12016ARepair superficial wound(s)3.931.563.760.32010
12017ARepair superficial wound(s)4.711.90NA0.39010
12018ARepair superficial wound(s)5.532.27NA0.46010
12020AClosure of split wound2.621.422.480.24010
12021AClosure of split wound1.841.021.610.19010
12031ALayer closure of wound(s)2.150.772.150.15010
12032ALayer closure of wound(s)2.471.282.770.15010
Start Printed Page 43877
12034ALayer closure of wound(s)2.921.453.040.21010
12035ALayer closure of wound(s)3.431.673.080.30010
12036ALayer closure of wound(s)4.052.455.200.41010
12037ALayer closure of wound(s)4.672.795.490.49010
12041ALayer closure of wound(s)2.370.832.340.17010
12042ALayer closure of wound(s)2.741.422.980.17010
12044ALayer closure of wound(s)3.141.613.150.24010
12045ALayer closure of wound(s)3.641.863.530.34010
12046ALayer closure of wound(s)4.252.525.480.40010
12047ALayer closure of wound(s)4.652.885.920.41010
12051ALayer closure of wound(s)2.471.413.000.16010
12052ALayer closure of wound(s)2.771.382.920.17010
12053ALayer closure of wound(s)3.121.543.090.20010
12054ALayer closure of wound(s)3.461.653.440.25010
12055ALayer closure of wound(s)4.432.184.490.35010
12056ALayer closure of wound(s)5.243.056.550.43010
12057ALayer closure of wound(s)5.963.756.070.50010
13100ARepair of wound or lesion3.121.823.340.21010
13101ARepair of wound or lesion3.922.293.540.22010
13102ARepair wound/lesion add-on1.240.570.730.10ZZZ
13120ARepair of wound or lesion3.301.873.450.23010
13121ARepair of wound or lesion4.332.393.760.25010
13122ARepair wound/lesion add-on1.440.650.860.12ZZZ
13131ARepair of wound or lesion3.792.213.700.25010
13132ARepair of wound or lesion5.953.254.480.32010
13133ARepair wound/lesion add-on2.191.011.190.17ZZZ
13150ARepair of wound or lesion3.812.665.170.29010
13151ARepair of wound or lesion4.453.105.040.28010
13152ARepair of wound or lesion6.334.005.710.38010
13153ARepair wound/lesion add-on2.381.091.320.18ZZZ
13160ALate closure of wound10.486.28NA1.19090
14000ASkin tissue rearrangement5.894.687.310.46090
14001ASkin tissue rearrangement8.475.998.550.65090
14020ASkin tissue rearrangement6.595.397.780.50090
14021ASkin tissue rearrangement10.067.159.050.69090
14040ASkin tissue rearrangement7.876.108.030.53090
14041ASkin tissue rearrangement11.497.939.730.68090
14060ASkin tissue rearrangement8.506.958.540.59090
14061ASkin tissue rearrangement12.298.7910.700.75090
14300ASkin tissue rearrangement11.768.449.900.88090
14350ASkin tissue rearrangement9.616.37NA1.09090
15000ASkin graft4.001.882.440.37000
15001ASkin graft add-on1.000.430.580.11ZZZ
15050ASkin pinch graft4.303.965.050.46090
15100ASkin split graft9.056.166.250.94090
15101ASkin split graft add-on1.720.741.200.18ZZZ
15120ASkin split graft9.836.758.400.87090
15121ASkin split graft add-on2.671.221.600.27ZZZ
15200ASkin full graft8.035.579.300.73090
15201ASkin full graft add-on1.320.641.070.14ZZZ
15220ASkin full graft7.876.239.260.68090
15221ASkin full graft add-on1.190.580.920.12ZZZ
15240ASkin full graft9.047.068.900.77090
15241ASkin full graft add-on1.860.941.460.17ZZZ
15260ASkin full graft10.067.538.860.63090
15261ASkin full graft add-on2.231.141.560.17ZZZ
15342ACultured skin graft, 25 cm1.001.032.140.09010
15343ACulture skn graft addl 25 cm0.250.100.410.02ZZZ
15350ASkin homograft4.004.408.430.42090
15351ASkin homograft add-on1.000.410.920.11ZZZ
15400ASkin heterograft4.004.794.790.40090
15401ASkin heterograft add-on1.000.461.110.11ZZZ
15570AForm skin pedicle flap9.216.118.170.96090
15572AForm skin pedicle flap9.275.837.680.93090
15574AForm skin pedicle flap9.886.858.310.92090
15576AForm skin pedicle flap8.696.348.800.72090
Start Printed Page 43878
15600ASkin graft1.912.396.220.19090
15610ASkin graft2.422.673.380.25090
15620ASkin graft2.943.426.820.28090
15630ASkin graft3.273.716.100.28090
15650ATransfer skin pedicle flap3.973.776.110.36090
15732AMuscle-skin graft, head/neck17.8411.31NA1.50090
15734AMuscle-skin graft, trunk17.7911.18NA1.91090
15736AMuscle-skin graft, arm16.2710.73NA1.78090
15738AMuscle-skin graft, leg17.9211.17NA1.95090
15740AIsland pedicle flap graft10.257.058.550.62090
15750ANeurovascular pedicle graft11.418.17NA1.12090
15756AFree muscle flap, microvasc35.2320.87NA3.11090
15757AFree skin flap, microvasc35.2322.03NA3.37090
15758AFree fascial flap, microvasc35.1022.06NA3.52090
15760AComposite skin graft8.746.668.880.72090
15770ADerma-fat-fascia graft7.526.03NA0.78090
15775RHair transplant punch grafts3.961.553.070.43000
15776RHair transplant punch grafts5.542.883.900.60000
15780AAbrasion treatment of skin7.296.416.410.41090
15781AAbrasion treatment of skin4.854.744.840.27090
15782AAbrasion treatment of skin4.324.134.210.21090
15783AAbrasion treatment of skin4.293.474.550.26090
15786AAbrasion, lesion, single2.031.271.730.11010
15787AAbrasion, lesions, add-on0.330.160.310.02ZZZ
15788RChemical peel, face, epiderm2.091.032.900.11090
15789RChemical peel, face, dermal4.923.465.920.27090
15792RChemical peel, nonfacial1.862.082.780.10090
15793AChemical peel, nonfacial3.743.33NA0.17090
15810ASalabrasion4.743.833.830.42090
15811ASalabrasion5.394.756.100.52090
15819APlastic surgery, neck9.386.69NA0.77090
15820ARevision of lower eyelid5.157.0811.630.30090
15821ARevision of lower eyelid5.727.2212.140.31090
15822ARevision of upper eyelid4.456.4710.500.22090
15823ARevision of upper eyelid7.057.5511.570.32090
15824RRemoval of forehead wrinkles0.000.000.000.00000
15825RRemoval of neck wrinkles0.000.000.000.00000
15826RRemoval of brow wrinkles0.000.000.000.00000
15828RRemoval of face wrinkles0.000.000.000.00000
15829RRemoval of skin wrinkles0.000.000.000.00000
15831AExcise excessive skin tissue12.407.66NA1.30090
15832AExcise excessive skin tissue11.597.75NA1.21090
15833AExcise excessive skin tissue10.647.04NA1.17090
15834AExcise excessive skin tissue10.856.98NA1.18090
15835AExcise excessive skin tissue11.676.80NA1.13090
15836AExcise excessive skin tissue9.346.19NA0.95090
15837AExcise excessive skin tissue8.436.347.480.78090
15838AExcise excessive skin tissue7.135.68NA0.58090
15839AExcise excessive skin tissue9.385.777.290.88090
15840AGraft for face nerve palsy13.269.80NA1.15090
15841AGraft for face nerve palsy23.2614.52NA2.65090
15842AFlap for face nerve palsy37.9622.95NA3.99090
15845ASkin and muscle repair, face12.578.54NA0.80090
15850BRemoval of sutures0.780.301.430.04XXX
15851ARemoval of sutures0.860.341.610.05000
15852ADressing change,not for burn0.860.361.770.07000
15860ATest for blood flow in graft1.950.801.310.13000
15876RSuction assisted lipectomy0.000.000.000.00000
15877RSuction assisted lipectomy0.000.000.000.00000
15878RSuction assisted lipectomy0.000.000.000.00000
15879RSuction assisted lipectomy0.000.000.000.00000
15920ARemoval of tail bone ulcer7.955.50NA0.83090
15922ARemoval of tail bone ulcer9.907.35NA1.06090
15931ARemove sacrum pressure sore9.245.56NA0.95090
15933ARemove sacrum pressure sore10.858.00NA1.14090
15934ARemove sacrum pressure sore12.698.34NA1.35090
Start Printed Page 43879
15935ARemove sacrum pressure sore14.5710.04NA1.56090
15936ARemove sacrum pressure sore12.388.86NA1.32090
15937ARemove sacrum pressure sore14.2110.36NA1.51090
15940ARemove hip pressure sore9.345.94NA0.98090
15941ARemove hip pressure sore11.439.87NA1.23090
15944ARemove hip pressure sore11.468.67NA1.21090
15945ARemove hip pressure sore12.699.63NA1.38090
15946ARemove hip pressure sore21.5714.05NA2.32090
15950ARemove thigh pressure sore7.545.16NA0.80090
15951ARemove thigh pressure sore10.728.02NA1.14090
15952ARemove thigh pressure sore11.397.43NA1.19090
15953ARemove thigh pressure sore12.638.87NA1.38090
15956ARemove thigh pressure sore15.5210.48NA1.64090
15958ARemove thigh pressure sore15.4810.79NA1.66090
15999CRemoval of pressure sore0.000.000.000.00YYY
16000AInitial treatment of burn(s)0.890.271.070.06000
16010ATreatment of burn(s)0.870.361.180.07000
16015ATreatment of burn(s)2.350.941.880.22000
16020ATreatment of burn(s)0.800.261.210.06000
16025ATreatment of burn(s)1.850.671.870.16000
16030ATreatment of burn(s)2.080.903.030.18000
16035AIncision of burn scab, initi3.751.50NA0.36090
16036AIncise burn scab, addl incis1.500.60NA0.11ZZZ
17000ADetroy benign/premal lesion0.600.271.060.03010
17003ADestroy lesions, 2-140.150.070.230.01ZZZ
17004ADestroy lesions, 15 or more2.791.282.510.12010
17106ADestruction of skin lesions4.592.764.580.28090
17107ADestruction of skin lesions9.164.946.880.53090
17108ADestruction of skin lesions13.207.188.800.89090
17110ADestruct lesion, 1-140.650.261.090.04010
17111ADestruct lesion, 15 or more0.920.381.160.04010
17250AChemical cautery, tissue0.500.210.740.04000
17260ADestruction of skin lesions0.910.401.340.04010
17261ADestruction of skin lesions1.170.551.450.05010
17262ADestruction of skin lesions1.580.741.650.07010
17263ADestruction of skin lesions1.790.821.760.08010
17264ADestruction of skin lesions1.940.851.830.08010
17266ADestruction of skin lesions2.340.962.040.11010
17270ADestruction of skin lesions1.320.601.540.06010
17271ADestruction of skin lesions1.490.711.610.06010
17272ADestruction of skin lesions1.770.841.750.07010
17273ADestruction of skin lesions2.050.951.890.09010
17274ADestruction of skin lesions2.591.182.150.11010
17276ADestruction of skin lesions3.201.682.470.15010
17280ADestruction of skin lesions1.170.531.370.05010
17281ADestruction of skin lesions1.720.821.720.07010
17282ADestruction of skin lesions2.040.971.880.09010
17283ADestruction of skin lesions2.641.232.180.11010
17284ADestruction of skin lesions3.211.492.470.14010
17286ADestruction of skin lesions4.442.483.120.22010
17304AChemosurgery of skin lesion7.603.657.570.31000
17305A2nd stage chemosurgery2.851.373.510.12000
17306A3rd stage chemosurgery2.851.383.510.12000
17307AFollowup skin lesion therapy2.851.403.520.12000
17310AExtensive skin chemosurgery0.950.471.500.05000
17340ACryotherapy of skin0.760.260.370.04010
17360ASkin peel therapy1.430.711.450.06010
17380RHair removal by electrolysis0.000.000.000.00000
17999CSkin tissue procedure0.000.000.000.00YYY
19000ADrainage of breast lesion0.840.291.230.07000
19001ADrain breast lesion add-on0.420.140.840.03ZZZ
19020AIncision of breast lesion3.573.386.840.35090
19030AInjection for breast x-ray1.530.523.740.07000
19100ABx breast percut w/o image1.270.441.460.10000
19101ABiopsy of breast, open3.181.935.240.20010
19102ABx breast percut w/image2.000.695.110.13000
Start Printed Page 43880
19103ABx breast percut w/device3.701.2712.710.16000
19110ANipple exploration4.304.408.560.44090
19112AExcise breast duct fistula3.673.079.110.38090
19120ARemoval of breast lesion5.563.094.920.56090
19125AExcision, breast lesion6.063.255.030.61090
19126AExcision, addl breast lesion2.931.03NA0.30ZZZ
19140ARemoval of breast tissue5.143.659.290.52090
19160ARemoval of breast tissue5.994.48NA0.61090
19162ARemove breast tissue, nodes13.537.93NA1.38090
19180ARemoval of breast8.805.97NA0.88090
19182ARemoval of breast7.735.01NA0.79090
19200ARemoval of breast15.499.09NA1.51090
19220ARemoval of breast15.729.14NA1.56090
19240ARemoval of breast16.008.78NA1.62090
19260ARemoval of chest wall lesion15.449.02NA1.64090
19271ARevision of chest wall18.9011.09NA2.27090
19272AExtensive chest wall surgery21.5511.93NA2.54090
19290APlace needle wire, breast1.270.433.000.06000
19291APlace needle wire, breast0.630.221.760.03ZZZ
19295APlace breast clip, percut0.00NA2.880.01ZZZ
19316ASuspension of breast10.697.64NA1.15090
19318AReduction of large breast15.6210.30NA1.69090
19324AEnlarge breast5.854.29NA0.63090
19325AEnlarge breast with implant8.456.29NA0.90090
19328ARemoval of breast implant5.684.59NA0.61090
19330ARemoval of implant material7.595.27NA0.81090
19340AImmediate breast prosthesis6.333.19NA0.68ZZZ
19342ADelayed breast prosthesis11.207.92NA1.21090
19350ABreast reconstruction8.926.8713.930.95090
19355ACorrect inverted nipple(s)7.575.4713.390.80090
19357ABreast reconstruction18.1613.88NA1.96090
19361ABreast reconstruction19.2611.98NA2.08090
19364ABreast reconstruction41.0023.88NA3.91090
19366ABreast reconstruction21.2811.71NA2.27090
19367ABreast reconstruction25.7315.24NA2.78090
19368ABreast reconstruction32.4218.77NA3.51090
19369ABreast reconstruction29.8218.13NA3.24090
19370ASurgery of breast capsule8.056.15NA0.86090
19371ARemoval of breast capsule9.357.24NA1.01090
19380ARevise breast reconstruction9.147.13NA0.98090
19396ADesign custom breast implant2.170.926.660.23000
19499CBreast surgery procedure0.000.000.000.00YYY
20000AIncision of abscess2.121.192.150.17010
20005AIncision of deep abscess3.422.192.990.34010
20100AExplore wound, neck10.084.375.830.99010
20101AExplore wound, chest3.221.482.820.24010
20102AExplore wound, abdomen3.941.763.390.35010
20103AExplore wound, extremity5.303.004.250.57010
20150AExcise epiphyseal bar13.698.96NA0.96090
20200AMuscle biopsy1.460.601.690.17000
20205ADeep muscle biopsy2.350.953.860.23000
20206ANeedle biopsy, muscle0.990.353.180.06000
20220ABone biopsy, trocar/needle1.273.025.050.06000
20225ABone biopsy, trocar/needle1.873.064.460.11000
20240ABone biopsy, excisional3.234.12NA0.33010
20245ABone biopsy, excisional7.786.74NA0.44010
20250AOpen bone biopsy5.034.25NA0.50010
20251AOpen bone biopsy5.564.78NA0.79010
20500AInjection of sinus tract1.233.885.680.10010
20501AInject sinus tract for x-ray0.760.263.220.03000
20520ARemoval of foreign body1.853.465.490.17010
20525ARemoval of foreign body3.504.266.930.40010
20526ATher injection carpal tunnel0.860.380.770.06000
20550AInject tendon/ligament/cyst0.860.260.840.06000
20551AInject tendon origin/insert0.860.380.770.06000
20552AInject trigger point, 1 or 20.860.380.770.06000
Start Printed Page 43881
20553AInject trigger points, > 30.860.380.770.06000
20600ADrain/inject, joint/bursa0.660.350.640.06000
20605ADrain/inject, joint/bursa0.680.360.750.06000
20610ADrain/inject, joint/bursa0.790.410.930.08000
20615ATreatment of bone cyst2.282.634.680.19010
20650AInsert and remove bone pin2.233.184.940.28010
20660AApply, remove fixation device2.511.46NA0.48000
20661AApplication of head brace4.896.61NA0.92090
20662AApplication of pelvis brace6.075.27NA0.81090
20663AApplication of thigh brace5.434.70NA0.77090
20664AHalo brace application8.068.30NA1.49090
20665ARemoval of fixation device1.311.242.300.17010
20670ARemoval of support implant1.743.305.630.23010
20680ARemoval of support implant3.355.105.100.46090
20690AApply bone fixation device3.521.84NA0.47090
20692AApply bone fixation device6.413.07NA0.60090
20693AAdjust bone fixation device5.8612.41NA0.85090
20694ARemove bone fixation device4.166.128.770.57090
20802AReplantation, arm, complete41.1529.57NA5.81090
20805AReplant, forearm, complete50.0044.44NA3.95090
20808AReplantation hand, complete61.6548.81NA6.49090
20816AReplantation digit, complete30.9446.19NA3.01090
20822AReplantation digit, complete25.5942.70NA3.07090
20824AReplantation thumb, complete30.9444.93NA3.48090
20827AReplantation thumb, complete26.4144.52NA3.21090
20838AReplantation foot, complete41.4128.98NA5.85090
20900ARemoval of bone for graft5.586.146.310.77090
20902ARemoval of bone for graft7.558.77NA1.06090
20910ARemove cartilage for graft5.346.698.560.50090
20912ARemove cartilage for graft6.357.57NA0.55090
20920ARemoval of fascia for graft5.315.57NA0.54090
20922ARemoval of fascia for graft6.616.329.030.88090
20924ARemoval of tendon for graft6.486.98NA0.82090
20926ARemoval of tissue for graft5.536.22NA0.73090
20930BSpinal bone allograft0.000.000.000.00XXX
20931ASpinal bone allograft1.810.95NA0.34ZZZ
20936BSpinal bone autograft0.000.000.000.00XXX
20937ASpinal bone autograft2.791.47NA0.43ZZZ
20938ASpinal bone autograft3.021.58NA0.52ZZZ
20950AFluid pressure, muscle1.262.08NA0.16000
20955AFibula bone graft, microvasc39.2129.77NA4.35090
20956AIliac bone graft, microvasc39.2728.02NA5.77090
20957AMt bone graft, microvasc40.6520.15NA5.74090
20962AOther bone graft, microvasc39.2727.75NA5.19090
20969ABone/skin graft, microvasc43.9232.44NA4.34090
20970ABone/skin graft, iliac crest43.0629.88NA4.64090
20972ABone/skin graft, metatarsal42.9918.59NA6.07090
20973ABone/skin graft, great toe45.7627.95NA4.65090
20974AElectrical bone stimulation0.620.330.410.09000
20975AElectrical bone stimulation2.601.37NA0.42000
20979AUs bone stimulation0.620.240.570.04000
20999CMusculoskeletal surgery0.000.000.000.00YYY
21010AIncision of jaw joint10.147.22NA0.54090
21015AResection of facial tumor5.297.27NA0.52090
21025AExcision of bone, lower jaw10.066.807.270.79090
21026AExcision of facial bone(s)4.855.055.300.40090
21029AContour of face bone lesion7.716.146.850.74090
21030ARemoval of face bone lesion6.464.765.330.60090
21031ARemove exostosis, mandible3.242.123.310.28090
21032ARemove exostosis, maxilla3.242.243.280.27090
21034ARemoval of face bone lesion16.1710.5810.581.37090
21040ARemoval of jaw bone lesion2.111.802.980.19090
21041ARemoval of jaw bone lesion6.714.335.550.56090
21044ARemoval of jaw bone lesion11.867.93NA0.87090
21045AExtensive jaw surgery16.1710.23NA1.20090
21050ARemoval of jaw joint10.7711.68NA0.84090
Start Printed Page 43882
21060ARemove jaw joint cartilage10.2310.19NA1.16090
21070ARemove coronoid process8.205.97NA0.67090
21076APrepare face/oral prosthesis13.427.179.541.36010
21077APrepare face/oral prosthesis33.7518.0323.993.43090
21079APrepare face/oral prosthesis22.3412.4716.961.59090
21080APrepare face/oral prosthesis25.1014.0119.052.55090
21081APrepare face/oral prosthesis22.8812.7717.361.87090
21082APrepare face/oral prosthesis20.8711.1514.831.46090
21083APrepare face/oral prosthesis19.3010.7714.651.96090
21084APrepare face/oral prosthesis22.5112.5617.081.57090
21085APrepare face/oral prosthesis9.004.816.400.65010
21086APrepare face/oral prosthesis24.9213.9118.911.86090
21087APrepare face/oral prosthesis24.9213.3117.712.22090
21088CPrepare face/oral prosthesis0.000.000.000.00090
21089CPrepare face/oral prosthesis0.000.000.000.00090
21100AMaxillofacial fixation4.223.955.670.18090
21110AInterdental fixation5.214.255.180.28090
21116AInjection, jaw joint x-ray0.810.297.900.05000
21120AReconstruction of chin4.936.069.690.29090
21121AReconstruction of chin7.646.187.710.56090
21122AReconstruction of chin8.527.53NA0.59090
21123AReconstruction of chin11.168.13NA1.16090
21125AAugmentation, lower jaw bone10.628.019.320.72090
21127AAugmentation, lower jaw bone11.127.389.510.76090
21137AReduction of forehead9.828.13NA0.53090
21138AReduction of forehead12.199.40NA1.47090
21139AReduction of forehead14.618.88NA1.02090
21141AReconstruct midface, lefort18.1010.71NA1.63090
21142AReconstruct midface, lefort18.8112.16NA1.16090
21143AReconstruct midface, lefort19.5810.98NA0.90090
21145AReconstruct midface, lefort19.9411.18NA2.09090
21146AReconstruct midface, lefort20.7111.91NA2.13090
21147AReconstruct midface, lefort21.7712.00NA1.52090
21150AReconstruct midface, lefort25.2416.28NA1.09090
21151AReconstruct midface, lefort28.3020.03NA1.98090
21154AReconstruct midface, lefort30.5219.05NA4.86090
21155AReconstruct midface, lefort34.4520.69NA5.48090
21159AReconstruct midface, lefort42.3827.58NA6.74090
21160AReconstruct midface, lefort46.4426.69NA4.39090
21172AReconstruct orbit/forehead27.8015.81NA1.91090
21175AReconstruct orbit/forehead33.1720.14NA5.16090
21179AReconstruct entire forehead22.2517.94NA2.48090
21180AReconstruct entire forehead25.1918.89NA2.15090
21181AContour cranial bone lesion9.908.49NA0.97090
21182AReconstruct cranial bone32.1921.96NA2.53090
21183AReconstruct cranial bone35.3123.64NA2.75090
21184AReconstruct cranial bone38.2424.65NA4.12090
21188AReconstruction of midface22.4615.57NA1.85090
21193AReconst lwr jaw w/o graft17.1510.69NA1.53090
21194AReconst lwr jaw w/graft19.8412.65NA1.39090
21195AReconst lwr jaw w/o fixation17.2412.28NA1.20090
21196AReconst lwr jaw w/fixation18.9112.87NA1.62090
21198AReconstr lwr jaw segment14.1611.59NA1.05090
21199AReconstr lwr jaw w/advance16.0010.19NA1.26090
21206AReconstruct upper jaw bone14.109.66NA1.01090
21208AAugmentation of facial bones10.238.449.460.92090
21209AReduction of facial bones6.725.817.840.60090
21210AFace bone graft10.238.148.780.88090
21215ALower jaw bone graft10.777.018.711.04090
21230ARib cartilage graft10.7710.20NA0.96090
21235AEar cartilage graft6.728.1212.040.52090
21240AReconstruction of jaw joint14.0511.42NA1.15090
21242AReconstruction of jaw joint12.9511.21NA1.40090
21243AReconstruction of jaw joint20.7913.90NA1.85090
21244AReconstruction of lower jaw11.869.13NA0.95090
21245AReconstruction of jaw11.8610.1713.170.88090
Start Printed Page 43883
21246AReconstruction of jaw12.4710.0410.041.21090
21247AReconstruct lower jaw bone22.6316.47NA2.21090
21248AReconstruction of jaw11.487.758.791.01090
21249AReconstruction of jaw17.5210.1111.331.39090
21255AReconstruct lower jaw bone16.7211.37NA1.13090
21256AReconstruction of orbit16.1913.42NA1.04090
21260ARevise eye sockets16.5211.01NA1.25090
21261ARevise eye sockets31.4919.83NA2.20090
21263ARevise eye sockets28.4214.74NA2.16090
21267ARevise eye sockets18.9014.58NA1.35090
21268ARevise eye sockets24.4816.16NA0.79090
21270AAugmentation, cheek bone10.239.489.480.73090
21275ARevision, orbitofacial bones11.2411.04NA1.03090
21280ARevision of eyelid6.036.19NA0.27090
21282ARevision of eyelid3.495.30NA0.21090
21295ARevision of jaw muscle/bone1.534.33NA0.13090
21296ARevision of jaw muscle/bone4.254.65NA0.30090
21299CCranio/maxillofacial surgery0.000.000.000.00YYY
21300ATreatment of skull fracture0.720.272.760.09000
21310ATreatment of nose fracture0.580.152.660.05000
21315ATreatment of nose fracture1.511.283.410.12010
21320ATreatment of nose fracture1.852.034.810.15010
21325ATreatment of nose fracture3.773.69NA0.31090
21330ATreatment of nose fracture5.385.55NA0.48090
21335ATreatment of nose fracture8.617.14NA0.64090
21336ATreat nasal septal fracture5.725.55NA0.45090
21337ATreat nasal septal fracture2.703.275.220.22090
21338ATreat nasoethmoid fracture6.466.07NA0.53090
21339ATreat nasoethmoid fracture8.096.73NA0.76090
21340ATreatment of nose fracture10.779.18NA0.85090
21343ATreatment of sinus fracture12.959.77NA1.06090
21344ATreatment of sinus fracture19.7213.45NA1.72090
21345ATreat nose/jaw fracture8.167.929.460.60090
21346ATreat nose/jaw fracture10.6110.05NA0.85090
21347ATreat nose/jaw fracture12.699.56NA1.14090
21348ATreat nose/jaw fracture16.6911.03NA1.50090
21355ATreat cheek bone fracture3.772.284.370.29010
21356ATreat cheek bone fracture4.153.25NA0.36010
21360ATreat cheek bone fracture6.465.65NA0.52090
21365ATreat cheek bone fracture14.9511.39NA1.30090
21366ATreat cheek bone fracture17.7711.96NA1.41090
21385ATreat eye socket fracture9.167.53NA0.64090
21386ATreat eye socket fracture9.168.06NA0.76090
21387ATreat eye socket fracture9.708.27NA0.78090
21390ATreat eye socket fracture10.138.57NA0.70090
21395ATreat eye socket fracture12.689.83NA1.09090
21400ATreat eye socket fracture1.401.063.160.12090
21401ATreat eye socket fracture3.263.194.700.34090
21406ATreat eye socket fracture7.016.80NA0.59090
21407ATreat eye socket fracture8.617.84NA0.67090
21408ATreat eye socket fracture12.3810.11NA1.24090
21421ATreat mouth roof fracture5.146.037.170.42090
21422ATreat mouth roof fracture8.327.52NA0.69090
21423ATreat mouth roof fracture10.408.07NA0.95090
21431ATreat craniofacial fracture7.056.81NA0.58090
21432ATreat craniofacial fracture8.617.67NA0.55090
21433ATreat craniofacial fracture25.3517.13NA2.46090
21435ATreat craniofacial fracture17.2512.51NA1.66090
21436ATreat craniofacial fracture28.0417.24NA2.32090
21440ATreat dental ridge fracture2.703.555.460.22090
21445ATreat dental ridge fracture5.385.156.850.55090
21450ATreat lower jaw fracture2.972.716.490.23090
21451ATreat lower jaw fracture4.875.556.440.39090
21452ATreat lower jaw fracture1.984.109.170.14090
21453ATreat lower jaw fracture5.546.367.310.49090
21454ATreat lower jaw fracture6.465.64NA0.55090
Start Printed Page 43884
21461ATreat lower jaw fracture8.097.939.060.73090
21462ATreat lower jaw fracture9.798.0310.310.80090
21465ATreat lower jaw fracture11.917.79NA0.84090
21470ATreat lower jaw fracture15.349.88NA1.36090
21480AReset dislocated jaw0.610.181.580.05000
21485AReset dislocated jaw3.993.323.760.31090
21490ARepair dislocated jaw11.867.46NA1.31090
21493ATreat hyoid bone fracture1.273.58NA0.10090
21494ATreat hyoid bone fracture6.284.85NA0.44090
21495ATreat hyoid bone fracture5.695.02NA0.41090
21497AInterdental wiring3.863.914.640.31090
21499CHead surgery procedure0.000.000.000.00YYY
21501ADrain neck/chest lesion3.813.534.350.36090
21502ADrain chest lesion7.127.29NA0.79090
21510ADrainage of bone lesion5.746.92NA0.67090
21550ABiopsy of neck/chest2.061.232.200.13010
21555ARemove lesion, neck/chest4.352.434.180.41090
21556ARemove lesion, neck/chest5.573.21NA0.51090
21557ARemove tumor, neck/chest8.887.58NA0.85090
21600APartial removal of rib6.897.47NA0.81090
21610APartial removal of rib14.6110.91NA1.85090
21615ARemoval of rib9.877.85NA1.20090
21616ARemoval of rib and nerves12.049.08NA1.31090
21620APartial removal of sternum6.797.96NA0.77090
21627ASternal debridement6.8112.18NA0.82090
21630AExtensive sternum surgery17.3813.60NA1.95090
21632AExtensive sternum surgery18.1411.81NA2.16090
21700ARevision of neck muscle6.196.978.430.31090
21705ARevision of neck muscle/rib9.607.55NA0.92090
21720ARevision of neck muscle5.686.728.250.80090
21725ARevision of neck muscle6.997.43NA0.90090
21740AReconstruction of sternum16.5012.21NA2.03090
21750ARepair of sternum separation10.779.44NA1.35090
21800ATreatment of rib fracture0.961.062.270.09090
21805ATreatment of rib fracture2.754.46NA0.29090
21810ATreatment of rib fracture(s)6.866.73NA0.60090
21820ATreat sternum fracture1.281.502.720.15090
21825ATreat sternum fracture7.419.85NA0.84090
21899CNeck/chest surgery procedure0.000.000.000.00YYY
21920ABiopsy soft tissue of back2.060.752.270.12010
21925ABiopsy soft tissue of back4.494.6111.730.44090
21930ARemove lesion, back or flank5.002.614.500.49090
21935ARemove tumor, back17.9613.13NA1.87090
22100ARemove part of neck vertebra9.738.62NA1.55090
22101ARemove part, thorax vertebra9.818.86NA1.51090
22102ARemove part, lumbar vertebra9.818.93NA1.46090
22103ARemove extra spine segment2.341.24NA0.37ZZZ
22110ARemove part of neck vertebra12.7410.73NA2.20090
22112ARemove part, thorax vertebra12.8110.64NA1.96090
22114ARemove part, lumbar vertebra12.8110.88NA1.98090
22116ARemove extra spine segment2.321.19NA0.40ZZZ
22210ARevision of neck spine23.8216.92NA4.23090
22212ARevision of thorax spine19.4214.62NA2.78090
22214ARevision of lumbar spine19.4515.07NA2.78090
22216ARevise, extra spine segment6.043.14NA0.98ZZZ
22220ARevision of neck spine21.3715.34NA3.65090
22222ARevision of thorax spine21.5212.81NA3.08090
22224ARevision of lumbar spine21.5215.67NA3.20090
22226ARevise, extra spine segment6.043.15NA1.01ZZZ
22305ATreat spine process fracture2.051.933.170.29090
22310ATreat spine fracture2.613.454.650.37090
22315ATreat spine fracture8.849.14NA1.37090
22318ATreat odontoid fx w/o graft21.5014.70NA4.26090
22319ATreat odontoid fx w/graft24.0017.01NA4.76090
22325ATreat spine fracture18.3014.66NA2.61090
22326ATreat neck spine fracture19.5915.40NA3.54090
Start Printed Page 43885
22327ATreat thorax spine fracture19.2015.11NA2.75090
22328ATreat each add spine fx4.612.31NA0.66ZZZ
22505AManipulation of spine1.872.984.570.27010
22520APercut vertebroplasty thor8.914.13NA0.99010
22521APercut vertebroplasty lumb8.343.90NA0.93010
22522APercut vertebroplasty addl4.311.74NA0.33ZZZ
22548ANeck spine fusion25.8217.74NA4.98090
22554ANeck spine fusion18.6213.67NA3.51090
22556AThorax spine fusion23.4616.51NA3.78090
22558ALumbar spine fusion22.2814.98NA3.18090
22585AAdditional spinal fusion5.532.82NA0.98ZZZ
22590ASpine & skull spinal fusion20.5115.32NA3.81090
22595ANeck spinal fusion19.3914.31NA3.62090
22600ANeck spine fusion16.1412.63NA2.89090
22610AThorax spine fusion16.0212.73NA2.66090
22612ALumbar spine fusion21.0015.47NA3.28090
22614ASpine fusion, extra segment6.443.39NA1.04ZZZ
22630ALumbar spine fusion20.8415.73NA3.79090
22632ASpine fusion, extra segment5.232.68NA0.90ZZZ
22800AFusion of spine18.2513.89NA2.71090
22802AFusion of spine30.8821.32NA4.42090
22804AFusion of spine36.2723.91NA5.23090
22808AFusion of spine26.2718.18NA4.36090
22810AFusion of spine30.2719.74NA4.49090
22812AFusion of spine32.7021.34NA4.67090
22818AKyphectomy, 1-2 segments31.8320.75NA5.01090
22819AKyphectomy, 3 or more36.4421.64NA5.20090
22830AExploration of spinal fusion10.859.91NA1.73090
22840AInsert spine fixation device12.546.50NA2.03ZZZ
22841BInsert spine fixation device0.000.000.000.00XXX
22842AInsert spine fixation device12.586.57NA2.04ZZZ
22843AInsert spine fixation device13.466.74NA2.10ZZZ
22844AInsert spine fixation device16.448.94NA2.42ZZZ
22845AInsert spine fixation device11.966.13NA2.22ZZZ
22846AInsert spine fixation device12.426.38NA2.26ZZZ
22847AInsert spine fixation device13.807.19NA2.36ZZZ
22848AInsert pelv fixation device6.003.26NA0.88ZZZ
22849AReinsert spinal fixation18.5113.89NA2.87090
22850ARemove spine fixation device9.528.72NA1.51090
22851AApply spine prosth device6.713.39NA1.11ZZZ
22852ARemove spine fixation device9.018.51NA1.40090
22855ARemove spine fixation device15.1311.41NA2.74090
22899CSpine surgery procedure0.000.000.000.00YYY
22900ARemove abdominal wall lesion5.804.30NA0.58090
22999CAbdomen surgery procedure0.000.000.000.00YYY
23000ARemoval of calcium deposits4.367.108.920.50090
23020ARelease shoulder joint8.9310.37NA1.23090
23030ADrain shoulder lesion3.434.306.000.42010
23031ADrain shoulder bursa2.744.065.820.33010
23035ADrain shoulder bone lesion8.6115.80NA1.19090
23040AExploratory shoulder surgery9.2011.54NA1.28090
23044AExploratory shoulder surgery7.1210.28NA0.97090
23065ABiopsy shoulder tissues2.271.332.520.14010
23066ABiopsy shoulder tissues4.166.177.650.50090
23075ARemoval of shoulder lesion2.393.135.270.25010
23076ARemoval of shoulder lesion7.638.17NA0.87090
23077ARemove tumor of shoulder16.0914.36NA1.81090
23100ABiopsy of shoulder joint6.038.64NA0.81090
23101AShoulder joint surgery5.588.53NA0.77090
23105ARemove shoulder joint lining8.2310.09NA1.13090
23106AIncision of collarbone joint5.968.75NA0.82090
23107AExplore treat shoulder joint8.6210.28NA1.19090
23120APartial removal, collar bone7.119.58NA0.99090
23125ARemoval of collar bone9.3910.54NA1.27090
23130ARemove shoulder bone, part7.559.62NA1.06090
23140ARemoval of bone lesion6.898.23NA0.82090
Start Printed Page 43886
23145ARemoval of bone lesion9.0911.43NA1.24090
23146ARemoval of bone lesion7.8310.60NA1.11090
23150ARemoval of humerus lesion8.489.84NA1.14090
23155ARemoval of humerus lesion10.3511.93NA1.20090
23156ARemoval of humerus lesion8.6810.27NA1.18090
23170ARemove collar bone lesion6.8610.65NA0.84090
23172ARemove shoulder blade lesion6.9010.05NA0.95090
23174ARemove humerus lesion9.5111.76NA1.30090
23180ARemove collar bone lesion8.5315.70NA1.18090
23182ARemove shoulder blade lesion8.1516.31NA1.08090
23184ARemove humerus lesion9.3816.25NA1.24090
23190APartial removal of scapula7.248.36NA0.97090
23195ARemoval of head of humerus9.8110.62NA1.38090
23200ARemoval of collar bone12.0813.91NA1.48090
23210ARemoval of shoulder blade12.4913.95NA1.61090
23220APartial removal of humerus14.5615.15NA2.03090
23221APartial removal of humerus17.7416.33NA2.51090
23222APartial removal of humerus23.9220.37NA3.37090
23330ARemove shoulder foreign body1.853.575.690.18010
23331ARemove shoulder foreign body7.389.51NA1.02090
23332ARemove shoulder foreign body11.6211.93NA1.62090
23350AInjection for shoulder x-ray1.000.347.630.05000
23395AMuscle transfer, shoulder/arm16.8513.82NA2.29090
23397AMuscle transfers16.1314.11NA2.24090
23400AFixation of shoulder blade13.5413.98NA1.91090
23405AIncision of tendon & muscle8.379.37NA1.12090
23406AIncise tendon(s) & muscle(s)10.7911.52NA1.48090
23410ARepair of tendon(s)12.4512.33NA1.72090
23412ARepair of tendon(s)13.3112.90NA1.86090
23415ARelease of shoulder ligament9.979.97NA1.39090
23420ARepair of shoulder13.3013.81NA1.86090
23430ARepair biceps tendon9.9811.10NA1.40090
23440ARemove/transplant tendon10.4811.33NA1.47090
23450ARepair shoulder capsule13.4012.82NA1.86090
23455ARepair shoulder capsule14.3713.39NA2.01090
23460ARepair shoulder capsule15.3713.99NA2.17090
23462ARepair shoulder capsule15.3013.69NA2.16090
23465ARepair shoulder capsule15.8513.73NA1.61090
23466ARepair shoulder capsule14.2213.36NA2.00090
23470AReconstruct shoulder joint17.1514.91NA2.40090
23472AReconstruct shoulder joint21.1017.03NA2.37090
23480ARevision of collar bone11.1811.52NA1.56090
23485ARevision of collar bone13.4312.95NA1.84090
23490AReinforce clavicle11.8611.82NA1.11090
23491AReinforce shoulder bones14.2113.26NA2.00090
23500ATreat clavicle fracture2.082.503.770.26090
23505ATreat clavicle fracture3.693.915.790.50090
23515ATreat clavicle fracture7.418.12NA1.03090
23520ATreat clavicle dislocation2.162.553.830.26090
23525ATreat clavicle dislocation3.603.825.950.44090
23530ATreat clavicle dislocation7.317.83NA0.85090
23532ATreat clavicle dislocation8.018.17NA1.13090
23540ATreat clavicle dislocation2.232.504.400.24090
23545ATreat clavicle dislocation3.253.564.890.39090
23550ATreat clavicle dislocation7.248.12NA0.94090
23552ATreat clavicle dislocation8.458.73NA1.18090
23570ATreat shoulder blade fx2.232.623.760.29090
23575ATreat shoulder blade fx4.064.166.010.53090
23585ATreat scapula fracture8.969.26NA1.25090
23600ATreat humerus fracture2.933.585.500.39090
23605ATreat humerus fracture4.876.368.100.67090
23615ATreat humerus fracture9.3510.05NA1.31090
23616ATreat humerus fracture21.2715.83NA2.98090
23620ATreat humerus fracture2.403.325.210.32090
23625ATreat humerus fracture3.935.417.180.53090
23630ATreat humerus fracture7.358.12NA1.03090
Start Printed Page 43887
23650ATreat shoulder dislocation3.393.505.460.31090
23655ATreat shoulder dislocation4.574.21NA0.52090
23660ATreat shoulder dislocation7.497.91NA1.01090
23665ATreat dislocation/fracture4.475.667.410.60090
23670ATreat dislocation/fracture7.908.56NA1.10090
23675ATreat dislocation/fracture6.056.538.150.83090
23680ATreat dislocation/fracture10.069.65NA1.39090
23700AFixation of shoulder2.523.39NA0.35010
23800AFusion of shoulder joint14.1614.08NA1.97090
23802AFusion of shoulder joint16.6013.40NA2.34090
23900AAmputation of arm & girdle19.7215.42NA2.47090
23920AAmputation at shoulder joint14.6113.65NA1.92090
23921AAmputation follow-up surgery5.496.51NA0.78090
23929CShoulder surgery procedure0.000.000.000.00YYY
23930ADrainage of arm lesion2.943.895.980.32010
23931ADrainage of arm bursa1.793.615.670.21010
23935ADrain arm/elbow bone lesion6.0912.53NA0.84090
24000AExploratory elbow surgery5.825.91NA0.77090
24006ARelease elbow joint9.318.43NA1.27090
24065ABiopsy arm/elbow soft tissue2.083.255.340.14010
24066ABiopsy arm/elbow soft tissue5.216.538.660.61090
24075ARemove arm/elbow lesion3.925.967.990.43090
24076ARemove arm/elbow lesion6.307.14NA0.70090
24077ARemove tumor of arm/elbow11.7614.01NA1.32090
24100ABiopsy elbow joint lining4.935.85NA0.62090
24101AExplore/treat elbow joint6.136.70NA0.84090
24102ARemove elbow joint lining8.037.72NA1.09090
24105ARemoval of elbow bursa3.615.08NA0.49090
24110ARemove humerus lesion7.399.51NA0.99090
24115ARemove/graft bone lesion9.6310.31NA1.15090
24116ARemove/graft bone lesion11.8112.01NA1.66090
24120ARemove elbow lesion6.656.67NA0.87090
24125ARemove/graft bone lesion7.897.07NA0.88090
24126ARemove/graft bone lesion8.317.77NA0.90090
24130ARemoval of head of radius6.256.73NA0.87090
24134ARemoval of arm bone lesion9.7315.85NA1.31090
24136ARemove radius bone lesion7.996.40NA0.85090
24138ARemove elbow bone lesion8.057.76NA1.12090
24140APartial removal of arm bone9.1816.80NA1.23090
24145APartial removal of radius7.5811.15NA1.01090
24147APartial removal of elbow7.5411.09NA1.04090
24149ARadical resection of elbow14.2010.98NA1.90090
24150AExtensive humerus surgery13.2714.58NA1.81090
24151AExtensive humerus surgery15.5816.06NA2.19090
24152AExtensive radius surgery10.069.58NA1.19090
24153AExtensive radius surgery11.547.21NA0.64090
24155ARemoval of elbow joint11.739.34NA1.42090
24160ARemove elbow joint implant7.837.59NA1.07090
24164ARemove radius head implant6.236.71NA0.84090
24200ARemoval of arm foreign body1.763.295.660.15010
24201ARemoval of arm foreign body4.566.688.700.56090
24220AInjection for elbow x-ray1.310.4611.200.07000
24300AManipulate elbow w/anesth3.755.26NA0.52090
24301AMuscle/tendon transfer10.209.03NA1.30090
24305AArm tendon lengthening7.457.49NA0.98090
24310ARevision of arm tendon5.988.14NA0.74090
24320ARepair of arm tendon10.5610.72NA1.00090
24330ARevision of arm muscles9.608.62NA1.21090
24331ARevision of arm muscles10.659.19NA1.41090
24332ATenolysis, triceps7.455.13NA0.77090
24340ARepair of biceps tendon7.897.61NA1.08090
24341ARepair arm tendon/muscle7.907.61NA1.08090
24342ARepair of ruptured tendon10.629.17NA1.48090
24343ARepr elbow lat ligmnt w/tiss8.657.60NA1.21090
24344AReconstruct elbow lat ligmnt14.0010.42NA1.95090
24345ARepr elbw med ligmnt w/tiss8.657.60NA1.21090
Start Printed Page 43888
24346AReconstruct elbow med ligmnt14.0010.42NA1.95090
24350ARepair of tennis elbow5.256.11NA0.72090
24351ARepair of tennis elbow5.916.59NA0.82090
24352ARepair of tennis elbow6.436.90NA0.90090
24354ARepair of tennis elbow6.486.84NA0.88090
24356ARevision of tennis elbow6.687.02NA0.90090
24360AReconstruct elbow joint12.349.93NA1.69090
24361AReconstruct elbow joint14.0810.92NA1.95090
24362AReconstruct elbow joint14.9910.88NA1.92090
24363AReplace elbow joint18.4913.42NA2.52090
24365AReconstruct head of radius8.397.93NA1.11090
24366AReconstruct head of radius9.138.34NA1.28090
24400ARevision of humerus11.0612.49NA1.53090
24410ARevision of humerus14.8213.83NA1.89090
24420ARevision of humerus13.4416.46NA1.82090
24430ARepair of humerus12.8112.66NA1.80090
24435ARepair humerus with graft13.1713.78NA1.84090
24470ARevision of elbow joint8.746.47NA1.23090
24495ADecompression of forearm8.1210.00NA0.92090
24498AReinforce humerus11.9212.18NA1.67090
24500ATreat humerus fracture3.213.244.960.41090
24505ATreat humerus fracture5.176.638.630.72090
24515ATreat humerus fracture11.6511.15NA1.63090
24516ATreat humerus fracture11.6511.68NA1.63090
24530ATreat humerus fracture3.504.686.020.47090
24535ATreat humerus fracture6.876.568.590.96090
24538ATreat humerus fracture9.4310.31NA1.25090
24545ATreat humerus fracture10.469.97NA1.47090
24546ATreat humerus fracture15.6913.38NA2.18090
24560ATreat humerus fracture2.803.044.740.35090
24565ATreat humerus fracture5.565.737.730.74090
24566ATreat humerus fracture7.799.79NA1.10090
24575ATreat humerus fracture10.668.21NA1.44090
24576ATreat humerus fracture2.863.144.520.38090
24577ATreat humerus fracture5.795.987.940.81090
24579ATreat humerus fracture11.6010.66NA1.62090
24582ATreat humerus fracture8.5510.24NA1.20090
24586ATreat elbow fracture15.2110.83NA2.12090
24587ATreat elbow fracture15.1610.68NA2.14090
24600ATreat elbow dislocation4.234.906.630.49090
24605ATreat elbow dislocation5.424.87NA0.72090
24615ATreat elbow dislocation9.427.76NA1.31090
24620ATreat elbow fracture6.986.42NA0.90090
24635ATreat elbow fracture13.1916.18NA1.84090
24640ATreat elbow dislocation1.201.783.350.11010
24650ATreat radius fracture2.162.794.440.28090
24655ATreat radius fracture4.405.107.130.58090
24665ATreat radius fracture8.149.27NA1.13090
24666ATreat radius fracture9.4910.03NA1.32090
24670ATreat ulnar fracture2.542.994.370.33090
24675ATreat ulnar fracture4.725.367.320.65090
24685ATreat ulnar fracture8.809.64NA1.23090
24800AFusion of elbow joint11.209.64NA1.41090
24802AFusion/graft of elbow joint13.6911.21NA1.89090
24900AAmputation of upper arm9.6010.94NA1.18090
24920AAmputation of upper arm9.5412.50NA1.22090
24925AAmputation follow-up surgery7.079.22NA0.95090
24930AAmputation follow-up surgery10.2511.52NA1.23090
24931AAmputate upper arm & implant12.7211.44NA1.56090
24935ARevision of amputation15.5612.31NA1.58090
24940CRevision of upper arm0.000.000.000.00090
24999CUpper arm/elbow surgery0.000.000.000.00YYY
25000AIncision of tendon sheath3.387.25NA0.45090
25001AIncise flexor carpi radialis3.384.22NA0.45090
25020ADecompress forearm 1 space5.9211.04NA0.75090
25023ADecompress forearm 1 space12.9616.91NA1.50090
Start Printed Page 43889
25024ADecompress forearm 2 spaces9.507.91NA1.20090
25025ADecompress forearm 2 spaces16.5411.74NA1.91090
25028ADrainage of forearm lesion5.259.85NA0.61090
25031ADrainage of forearm bursa4.149.83NA0.50090
25035ATreat forearm bone lesion7.3616.18NA0.98090
25040AExplore/treat wrist joint7.189.13NA0.96090
25065ABiopsy forearm soft tissues1.992.382.380.12010
25066ABiopsy forearm soft tissues4.138.15NA0.49090
25075ARemove forearm lesion subcut3.747.22NA0.40090
25076ARemove forearm lesion deep4.9212.49NA0.59090
25077ARemove tumor, forearm/wrist9.7615.45NA1.10090
25085AIncision of wrist capsule5.5010.81NA0.71090
25100ABiopsy of wrist joint3.907.28NA0.50090
25101AExplore/treat wrist joint4.697.67NA0.60090
25105ARemove wrist joint lining5.8510.73NA0.77090
25107ARemove wrist joint cartilage6.4311.20NA0.82090
25110ARemove wrist tendon lesion3.928.38NA0.48090
25111ARemove wrist tendon lesion3.396.44NA0.42090
25112AReremove wrist tendon lesion4.537.30NA0.54090
25115ARemove wrist/forearm lesion8.8216.72NA1.11090
25116ARemove wrist/forearm lesion7.1115.66NA0.90090
25118AExcise wrist tendon sheath4.377.78NA0.55090
25119APartial removal of ulna6.0411.06NA0.80090
25120ARemoval of forearm lesion6.1014.75NA0.81090
25125ARemove/graft forearm lesion7.4815.74NA1.02090
25126ARemove/graft forearm lesion7.5515.44NA1.00090
25130ARemoval of wrist lesion5.268.12NA0.66090
25135ARemove & graft wrist lesion6.898.89NA0.89090
25136ARemove & graft wrist lesion5.978.13NA0.58090
25145ARemove forearm bone lesion6.3715.22NA0.82090
25150APartial removal of ulna7.0911.83NA0.96090
25151APartial removal of radius7.3915.63NA0.93090
25170AExtensive forearm surgery11.0917.44NA1.52090
25210ARemoval of wrist bone5.958.47NA0.73090
25215ARemoval of wrist bones7.8912.05NA1.02090
25230APartial removal of radius5.237.95NA0.66090
25240APartial removal of ulna5.1710.49NA0.69090
25246AInjection for wrist x-ray1.450.5010.630.07000
25248ARemove forearm foreign body5.1410.05NA0.54090
25250ARemoval of wrist prosthesis6.608.76NA0.84090
25251ARemoval of wrist prosthesis9.5712.73NA1.15090
25259AManipulate wrist w/anesthes3.755.23NA0.52090
25260ARepair forearm tendon/muscle7.8016.77NA0.97090
25263ARepair forearm tendon/muscle7.8216.43NA0.94090
25265ARepair forearm tendon/muscle9.8817.18NA1.19090
25270ARepair forearm tendon/muscle6.0015.70NA0.76090
25272ARepair forearm tendon/muscle7.0416.21NA0.89090
25274ARepair forearm tendon/muscle8.7516.53NA1.11090
25275ARepair forearm tendon sheath8.507.32NA1.11090
25280ARevise wrist/forearm tendon7.2215.52NA0.91090
25290AIncise wrist/forearm tendon5.2917.77NA0.66090
25295ARelease wrist/forearm tendon6.5515.16NA0.84090
25300AFusion of tendons at wrist8.8010.05NA1.07090
25301AFusion of tendons at wrist8.409.74NA1.08090
25310ATransplant forearm tendon8.1416.12NA1.01090
25312ATransplant forearm tendon9.5717.04NA1.22090
25315ARevise palsy hand tendon(s)10.2017.68NA1.26090
25316ARevise palsy hand tendon(s)12.3319.36NA1.74090
25320ARepair/revise wrist joint10.7711.21NA1.32090
25332ARevise wrist joint11.4111.65NA1.46090
25335ARealignment of hand12.8814.66NA1.66090
25337AReconstruct ulna/radioulnar10.1713.29NA1.31090
25350ARevision of radius8.7816.51NA1.17090
25355ARevision of radius10.1717.17NA1.44090
25360ARevision of ulna8.4316.47NA1.17090
25365ARevise radius & ulna12.4018.00NA1.67090
Start Printed Page 43890
25370ARevise radius or ulna13.3617.37NA1.88090
25375ARevise radius & ulna13.0418.01NA1.84090
25390AShorten radius or ulna10.4017.23NA1.38090
25391ALengthen radius or ulna13.6518.62NA1.73090
25392AShorten radius & ulna13.9517.19NA1.73090
25393ALengthen radius & ulna15.8719.88NA1.87090
25394ARepair carpal bone, shorten10.408.24NA1.15090
25400ARepair radius or ulna10.9217.53NA1.50090
25405ARepair/graft radius or ulna14.3820.00NA1.95090
25415ARepair radius & ulna13.3519.08NA1.87090
25420ARepair/graft radius & ulna16.3320.93NA2.20090
25425ARepair/graft radius or ulna13.2126.13NA1.61090
25426ARepair/graft radius & ulna15.8219.87NA2.23090
25430AVasc graft into carpal bone9.257.60NA0.56090
25431ARepair nonunion carpal bone10.446.28NA0.56090
25440ARepair/graft wrist bone10.4410.99NA1.41090
25441AReconstruct wrist joint12.9012.22NA1.83090
25442AReconstruct wrist joint10.8511.22NA1.24090
25443AReconstruct wrist joint10.3913.58NA1.30090
25444AReconstruct wrist joint11.1513.83NA1.43090
25445AReconstruct wrist joint9.6913.12NA1.26090
25446AWrist replacement16.5514.38NA2.20090
25447ARepair wrist joint(s)10.3711.02NA1.34090
25449ARemove wrist joint implant14.4917.69NA1.77090
25450ARevision of wrist joint7.8712.63NA0.88090
25455ARevision of wrist joint9.4914.17NA1.07090
25490AReinforce radius9.5416.27NA1.19090
25491AReinforce ulna9.9617.52NA1.41090
25492AReinforce radius and ulna12.3316.91NA1.62090
25500ATreat fracture of radius2.452.824.140.28090
25505ATreat fracture of radius5.215.507.550.69090
25515ATreat fracture of radius9.189.59NA1.22090
25520ATreat fracture of radius6.266.127.720.85090
25525ATreat fracture of radius12.2411.46NA1.68090
25526ATreat fracture of radius12.9814.97NA1.80090
25530ATreat fracture of ulna2.092.774.100.27090
25535ATreat fracture of ulna5.145.547.360.68090
25545ATreat fracture of ulna8.909.70NA1.23090
25560ATreat fracture radius & ulna2.442.814.150.27090
25565ATreat fracture radius & ulna5.635.717.770.76090
25574ATreat fracture radius & ulna7.018.63NA0.96090
25575ATreat fracture radius/ulna10.4510.51NA1.46090
25600ATreat fracture radius/ulna2.632.984.410.34090
25605ATreat fracture radius/ulna5.815.947.970.81090
25611ATreat fracture radius/ulna7.779.77NA1.08090
25620ATreat fracture radius/ulna8.559.47NA1.17090
25622ATreat wrist bone fracture2.612.974.380.33090
25624ATreat wrist bone fracture4.535.207.190.61090
25628ATreat wrist bone fracture8.439.54NA1.14090
25630ATreat wrist bone fracture2.883.034.530.37090
25635ATreat wrist bone fracture4.394.527.160.39090
25645ATreat wrist bone fracture7.259.13NA0.93090
25650ATreat wrist bone fracture3.053.124.610.37090
25651APin ulnar styloid fracture5.364.32NA0.73090
25652ATreat fracture ulnar styloid7.606.74NA0.97090
25660ATreat wrist dislocation4.765.24NA0.59090
25670ATreat wrist dislocation7.929.34NA1.07090
25671APin radioulnar dislocation6.005.89NA0.75090
25675ATreat wrist dislocation4.675.177.080.57090
25676ATreat wrist dislocation8.049.33NA1.10090
25680ATreat wrist fracture5.996.29NA0.61090
25685ATreat wrist fracture9.7810.12NA1.25090
25690ATreat wrist dislocation5.506.77NA0.78090
25695ATreat wrist dislocation8.349.43NA1.07090
25800AFusion of wrist joint9.7610.62NA1.30090
25805AFusion/graft of wrist joint11.2811.48NA1.51090
Start Printed Page 43891
25810AFusion/graft of wrist joint10.5711.05NA1.37090
25820AFusion of hand bones7.459.43NA0.96090
25825AFuse hand bones with graft9.2710.37NA1.20090
25830AFusion, radioulnar jnt/ulna10.0616.56NA1.27090
25900AAmputation of forearm9.0114.17NA1.08090
25905AAmputation of forearm9.1215.42NA1.06090
25907AAmputation follow-up surgery7.8014.95NA1.01090
25909AAmputation follow-up surgery8.9614.98NA1.07090
25915AAmputation of forearm17.0818.26NA2.41090
25920AAmputate hand at wrist8.689.69NA1.06090
25922AAmputate hand at wrist7.428.88NA0.93090
25924AAmputation follow-up surgery8.469.99NA1.07090
25927AAmputation of hand8.8013.97NA1.02090
25929AAmputation follow-up surgery7.597.68NA0.89090
25931AAmputation follow-up surgery7.8115.33NA0.88090
25999CForearm or wrist surgery0.000.000.000.00YYY
26010ADrainage of finger abscess1.543.825.060.14010
26011ADrainage of finger abscess2.196.237.160.25010
26020ADrain hand tendon sheath4.6712.63NA0.59090
26025ADrainage of palm bursa4.8212.62NA0.60090
26030ADrainage of palm bursa(s)5.9313.31NA0.72090
26034ATreat hand bone lesion6.2314.59NA0.79090
26035ADecompress fingers/hand9.5115.91NA1.12090
26037ADecompress fingers/hand7.2512.45NA0.87090
26040ARelease palm contracture3.3312.35NA0.45090
26045ARelease palm contracture5.5613.61NA0.74090
26055AIncise finger tendon sheath2.697.497.830.36090
26060AIncision of finger tendon2.817.56NA0.35090
26070AExplore/treat hand joint3.6910.87NA0.35090
26075AExplore/treat finger joint3.7911.81NA0.40090
26080AExplore/treat finger joint4.2412.65NA0.52090
26100ABiopsy hand joint lining3.678.19NA0.45090
26105ABiopsy finger joint lining3.7112.40NA0.45090
26110ABiopsy finger joint lining3.5311.82NA0.44090
26115ARemove hand lesion subcut3.867.537.530.48090
26116ARemove hand lesion, deep5.5313.37NA0.69090
26117ARemove tumor, hand/finger8.5515.03NA1.01090
26121ARelease palm contracture7.5415.37NA0.94090
26123ARelease palm contracture9.2916.33NA1.17090
26125ARelease palm contracture4.612.53NA0.57ZZZ
26130ARemove wrist joint lining5.4215.51NA0.65090
26135ARevise finger joint, each6.9616.70NA0.87090
26140ARevise finger joint, each6.1715.80NA0.76090
26145ATendon excision, palm/finger6.3216.06NA0.77090
26160ARemove tendon sheath lesion3.157.627.630.39090
26170ARemoval of palm tendon, each4.778.46NA0.60090
26180ARemoval of finger tendon5.188.79NA0.64090
26185ARemove finger bone5.258.79NA0.67090
26200ARemove hand bone lesion5.5113.62NA0.71090
26205ARemove/graft bone lesion7.7015.10NA0.95090
26210ARemoval of finger lesion5.1513.97NA0.64090
26215ARemove/graft finger lesion7.1014.34NA0.77090
26230APartial removal of hand bone6.3312.72NA0.84090
26235APartial removal, finger bone6.1912.25NA0.78090
26236APartial removal, finger bone5.3212.30NA0.66090
26250AExtensive hand surgery7.5516.60NA0.92090
26255AExtensive hand surgery12.4319.40NA1.05090
26260AExtensive finger surgery7.0316.45NA0.83090
26261AExtensive finger surgery9.0912.97NA0.84090
26262APartial removal of finger5.6714.23NA0.70090
26320ARemoval of implant from hand3.9812.78NA0.49090
26340AManipulate finger w/anesth2.504.48NA0.32090
26350ARepair finger/hand tendon5.9919.56NA0.73090
26352ARepair/graft hand tendon7.6819.76NA0.93090
26356ARepair finger/hand tendon8.0720.93NA0.99090
26357ARepair finger/hand tendon8.5820.73NA1.02090
Start Printed Page 43892
26358ARepair/graft hand tendon9.1420.89NA1.07090
26370ARepair finger/hand tendon7.1120.10NA0.90090
26372ARepair/graft hand tendon8.7621.36NA1.06090
26373ARepair finger/hand tendon8.1621.27NA0.98090
26390ARevise hand/finger tendon9.1916.47NA1.09090
26392ARepair/graft hand tendon10.2622.37NA1.26090
26410ARepair hand tendon4.6315.82NA0.57090
26412ARepair/graft hand tendon6.3116.90NA0.80090
26415AExcision, hand/finger tendon8.3415.74NA0.77090
26416AGraft hand or finger tendon9.3718.18NA1.20090
26418ARepair finger tendon4.2515.67NA0.50090
26420ARepair/graft finger tendon6.7717.31NA0.83090
26426ARepair finger/hand tendon6.1516.47NA0.77090
26428ARepair/graft finger tendon7.2117.52NA0.84090
26432ARepair finger tendon4.0212.82NA0.48090
26433ARepair finger tendon4.5613.74NA0.56090
26434ARepair/graft finger tendon6.0914.25NA0.71090
26437ARealignment of tendons5.8213.75NA0.74090
26440ARelease palm/finger tendon5.0217.99NA0.62090
26442ARelease palm & finger tendon8.1619.45NA0.94090
26445ARelease hand/finger tendon4.3117.85NA0.54090
26449ARelease forearm/hand tendon7.0019.18NA0.84090
26450AIncision of palm tendon3.678.30NA0.46090
26455AIncision of finger tendon3.648.16NA0.47090
26460AIncise hand/finger tendon3.467.79NA0.44090
26471AFusion of finger tendons5.7313.37NA0.73090
26474AFusion of finger tendons5.3213.83NA0.69090
26476ATendon lengthening5.1813.19NA0.62090
26477ATendon shortening5.1513.34NA0.60090
26478ALengthening of hand tendon5.8014.10NA0.77090
26479AShortening of hand tendon5.7414.56NA0.76090
26480ATransplant hand tendon6.6919.03NA0.84090
26483ATransplant/graft hand tendon8.2919.62NA1.03090
26485ATransplant palm tendon7.7019.60NA0.94090
26489ATransplant/graft palm tendon9.5516.48NA0.98090
26490ARevise thumb tendon8.4114.89NA1.05090
26492ATendon transfer with graft9.6215.61NA1.19090
26494AHand tendon/muscle transfer8.4715.87NA1.13090
26496ARevise thumb tendon9.5915.10NA1.17090
26497AFinger tendon transfer9.5715.87NA1.17090
26498AFinger tendon transfer14.0018.34NA1.74090
26499ARevision of finger8.9816.54NA0.94090
26500AHand tendon reconstruction5.9614.55NA0.66090
26502AHand tendon reconstruction7.1414.85NA0.87090
26504AHand tendon reconstruction7.4714.56NA0.84090
26508ARelease thumb contracture6.0114.04NA0.76090
26510AThumb tendon transfer5.4313.79NA0.71090
26516AFusion of knuckle joint7.1514.41NA0.90090
26517AFusion of knuckle joints8.8315.76NA0.96090
26518AFusion of knuckle joints9.0215.46NA1.13090
26520ARelease knuckle contracture5.3018.02NA0.65090
26525ARelease finger contracture5.3318.22NA0.66090
26530ARevise knuckle joint6.6918.75NA0.86090
26531ARevise knuckle with implant7.9119.26NA1.01090
26535ARevise finger joint5.2410.66NA0.66090
26536ARevise/implant finger joint6.3717.39NA0.80090
26540ARepair hand joint6.4314.40NA0.81090
26541ARepair hand joint with graft8.6215.99NA1.12090
26542ARepair hand joint with graft6.7814.13NA0.87090
26545AReconstruct finger joint6.9215.10NA0.79090
26546ARepair nonunion hand8.9215.75NA1.14090
26548AReconstruct finger joint8.0315.67NA0.98090
26550AConstruct thumb replacement21.2423.51NA1.80090
26551AGreat toe-hand transfer46.5826.34NA6.57090
26553ASingle transfer, toe-hand46.2728.71NA1.99090
26554ADouble transfer, toe-hand54.9533.50NA7.76090
Start Printed Page 43893
26555APositional change of finger16.6320.49NA2.13090
26556AToe joint transfer47.2629.09NA6.67090
26560ARepair of web finger5.3812.75NA0.60090
26561ARepair of web finger10.9217.37NA0.69090
26562ARepair of web finger15.0019.74NA0.98090
26565ACorrect metacarpal flaw6.7414.45NA0.84090
26567ACorrect finger deformity6.8214.29NA0.84090
26568ALengthen metacarpal/finger9.0819.51NA1.10090
26580ARepair hand deformity18.1816.16NA1.46090
26585DRepair finger deformity14.0512.93NA1.08090
26587AReconstruct extra finger14.05NA5.981.08090
26590ARepair finger deformity17.9616.68NA1.32090
26591ARepair muscles of hand3.2513.51NA0.37090
26593ARelease muscles of hand5.3113.02NA0.64090
26596AExcision constricting tissue8.959.78NA0.87090
26597DRelease of scar contracture9.8211.29NA1.20090
26600ATreat metacarpal fracture1.962.714.040.25090
26605ATreat metacarpal fracture2.854.185.880.38090
26607ATreat metacarpal fracture5.368.18NA0.70090
26608ATreat metacarpal fracture5.368.54NA0.73090
26615ATreat metacarpal fracture5.338.14NA0.70090
26641ATreat thumb dislocation3.944.716.400.42090
26645ATreat thumb fracture4.415.137.100.54090
26650ATreat thumb fracture5.728.72NA0.77090
26665ATreat thumb fracture7.609.17NA0.97090
26670ATreat hand dislocation3.694.636.180.36090
26675ATreat hand dislocation4.644.426.350.56090
26676APin hand dislocation5.528.82NA0.76090
26685ATreat hand dislocation6.988.77NA0.95090
26686ATreat hand dislocation7.949.30NA1.05090
26700ATreat knuckle dislocation3.692.924.990.35090
26705ATreat knuckle dislocation4.194.266.200.50090
26706APin knuckle dislocation5.125.80NA0.64090
26715ATreat knuckle dislocation5.748.29NA0.75090
26720ATreat finger fracture, each1.661.662.990.20090
26725ATreat finger fracture, each3.333.175.140.43090
26727ATreat finger fracture, each5.238.73NA0.69090
26735ATreat finger fracture, each5.988.65NA0.77090
26740ATreat finger fracture, each1.942.553.740.24090
26742ATreat finger fracture, each3.855.116.980.49090
26746ATreat finger fracture, each5.818.77NA0.74090
26750ATreat finger fracture, each1.702.363.560.19090
26755ATreat finger fracture, each3.103.054.970.37090
26756APin finger fracture, each4.398.61NA0.56090
26765ATreat finger fracture, each4.177.78NA0.51090
26770ATreat finger dislocation3.022.684.740.27090
26775ATreat finger dislocation3.713.945.900.43090
26776APin finger dislocation4.808.58NA0.63090
26785ATreat finger dislocation4.217.62NA0.54090
26820AThumb fusion with graft8.2615.82NA1.11090
26841AFusion of thumb7.1314.94NA0.97090
26842AThumb fusion with graft8.2415.72NA1.10090
26843AFusion of hand joint7.6114.38NA0.99090
26844AFusion/graft of hand joint8.7315.70NA1.12090
26850AFusion of knuckle6.9714.21NA0.89090
26852AFusion of knuckle with graft8.4615.08NA1.05090
26860AFusion of finger joint4.6913.11NA0.60090
26861AFusion of finger jnt, add-on1.740.96NA0.22ZZZ
26862AFusion/graft of finger joint7.3714.75NA0.92090
26863AFuse/graft added joint3.902.16NA0.51ZZZ
26910AAmputate metacarpal bone7.6013.76NA0.90090
26951AAmputation of finger/thumb4.5912.67NA0.56090
26952AAmputation of finger/thumb6.3113.99NA0.74090
26989CHand/finger surgery0.000.000.000.00YYY
26990ADrainage of pelvis lesion7.4815.56NA0.92090
26991ADrainage of pelvis bursa6.689.3811.530.85090
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26992ADrainage of bone lesion13.0219.43NA1.75090
27000AIncision of hip tendon5.627.33NA0.76090
27001AIncision of hip tendon6.948.22NA0.95090
27003AIncision of hip tendon7.349.11NA0.93090
27005AIncision of hip tendon9.6610.42NA1.36090
27006AIncision of hip tendons9.6810.43NA1.33090
27025AIncision of hip/thigh fascia11.1610.31NA1.38090
27030ADrainage of hip joint13.0112.23NA1.81090
27033AExploration of hip joint13.3912.33NA1.87090
27035ADenervation of hip joint16.6918.01NA1.70090
27036AExcision of hip joint/muscle12.8813.67NA1.80090
27040ABiopsy of soft tissues2.874.015.900.21010
27041ABiopsy of soft tissues9.898.47NA1.01090
27047ARemove hip/pelvis lesion7.457.019.270.79090
27048ARemove hip/pelvis lesion6.257.86NA0.73090
27049ARemove tumor, hip/pelvis13.6613.36NA1.60090
27050ABiopsy of sacroiliac joint4.366.97NA0.53090
27052ABiopsy of hip joint6.238.29NA0.85090
27054ARemoval of hip joint lining8.5410.53NA1.17090
27060ARemoval of ischial bursa5.437.70NA0.60090
27062ARemove femur lesion/bursa5.377.17NA0.74090
27065ARemoval of hip bone lesion5.908.66NA0.76090
27066ARemoval of hip bone lesion10.3312.36NA1.42090
27067ARemove/graft hip bone lesion13.8314.25NA1.95090
27070APartial removal of hip bone10.7217.92NA1.36090
27071APartial removal of hip bone11.4618.86NA1.51090
27075AExtensive hip surgery35.0025.41NA2.22090
27076AExtensive hip surgery22.1219.90NA2.86090
27077AExtensive hip surgery40.0028.73NA3.18090
27078AExtensive hip surgery13.4415.54NA1.67090
27079AExtensive hip surgery13.7515.04NA1.86090
27080ARemoval of tail bone6.397.56NA0.80090
27086ARemove hip foreign body1.873.815.530.17010
27087ARemove hip foreign body8.548.85NA1.09090
27090ARemoval of hip prosthesis11.1511.14NA1.55090
27091ARemoval of hip prosthesis22.1416.20NA3.11090
27093AInjection for hip x-ray1.300.50