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Proposed Rule

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

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AGENCY:

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

ACTION:

Proposed rule.

SUMMARY:

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

DATES:

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

ADDRESSES:

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

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

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

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

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

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

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

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

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

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

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

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

Start Further Info

FOR FURTHER INFORMATION CONTACT:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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SUPPLEMENTARY INFORMATION:

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

Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Start Printed Page 41687Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

Table of Contents

I. Executive Summary and Background

A. Executive Summary

B. Background

II. Provisions of the Proposed Rule for PFS

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

B. Determination of Malpractice Relative Value Units (RVUs)

C. Potentially Misvalued Services Under the Physician Fee Schedule

D. Refinement Panel

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

F. Target for Relative Value Adjustments for Misvalued Services

G. Phase-In of Significant RVU Reductions

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

I. Valuation of Specific Codes

J. Medicare Telehealth Services

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

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

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

III. Other Provisions of the Proposed Regulations

A. Proposed Provisions Associated With the Ambulance Fee Schedule

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

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

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

E. Part B Drugs—Biosimilars

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

G. Appropriate Use Criteria for Advanced Diagnostic Imaging Services

H. Physician Compare Web site

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

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

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

L. Medicare Shared Savings Program

M. Value-Based Payment Modifier and Physician Feedback Program

N. Physician Self-Referral Updates

O. Private Contracting/Opt-Out

IV. Collection of Information Requirements

V. Response to Comments

VI. Regulatory Impact Analysis

Regulations Text

Acronyms

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:

AAA Abdominal aortic aneurysms

ACO Accountable care organization

AMA American Medical Association

ASC Ambulatory surgical center

ATA American Telehealth Association

ATRA American Taxpayer Relief Act (Pub. L. 112-240)

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

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

CAD Coronary artery disease

CAH Critical access hospital

CBSA Core-Based Statistical Area

CCM Chronic care management

CEHRT Certified EHR technology

CF Conversion factor

CG-CAHPS Clinician and Group Consumer Assessment of Healthcare Providers and Systems

CLFS Clinical Laboratory Fee Schedule

CNM Certified nurse-midwife

CP Clinical psychologist

CPC Comprehensive Primary Care

CPEP Clinical Practice Expert Panel

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

CQM Clinical quality measure

CSW Clinical social worker

CT Computed tomography

CY Calendar year

DFAR Defense Federal Acquisition Regulations

DHS Designated health services

DM Diabetes mellitus

DSMT Diabetes self-management training

eCQM Electronic clinical quality measures

EHR Electronic health record

E/M Evaluation and management

EP Eligible professional

eRx Electronic prescribing

ESRD End-stage renal disease

FAR Federal Acquisition Regulations

FFS Fee-for-service

FQHC Federally qualified health center

FR Federal Register

GAF Geographic adjustment factor

GAO Government Accountability Office

GPCI Geographic practice cost index

GPO Group purchasing organization

GPRO Group practice reporting option

GTR Genetic Testing Registry

HCPCS Healthcare Common Procedure Coding System

HHS [Department of] Health and Human Services

HOPD Hospital outpatient department

HPSA Health professional shortage area

IDTF Independent diagnostic testing facility

IPPS Inpatient Prospective Payment System

IQR Inpatient Quality Reporting

ISO Insurance service office

IWPUT Intensity of work per unit of time

LCD Local coverage determination

MA Medicare Advantage

MAC Medicare Administrative Contractor

MAP Measure Applications Partnership

MAPCP Multi-payer Advanced Primary Care Practice

MAV Measure application validity [process]

MCP Monthly capitation payment

MedPAC Medicare Payment Advisory Commission

MEI Medicare Economic Index

MFP Multi-Factor Productivity

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

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

MP Malpractice

MPPR Multiple procedure payment reduction

MRA Magnetic resonance angiography

MRI Magnetic resonance imaging

MSA Metropolitan Statistical Areas

MSPB Medicare Spending per Beneficiary

MSSP Medicare Shared Savings Program

MU Meaningful use

NCD National coverage determination

NCQDIS National Coalition of Quality Diagnostic Imaging Services

NP Nurse practitioner

NPI National Provider Identifier

NPP Nonphysician practitioner

NQS National Quality Strategy

OACT CMS's Office of the Actuary

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

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

OES Occupational Employment Statistics

OMB Office of Management and Budget

OPPS Outpatient prospective payment system

OT Occupational therapy

PA Physician assistant

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

PC Professional component

PCIP Primary Care Incentive Payment

PE Practice expense

PE/HR Practice expense per hour

PEAC Practice Expense Advisory Committee

PECOS Provider Enrollment, Chain, and Ownership System

PFS Physician Fee Schedule

PLI Professional Liability Insurance

PMA Premarket approval

PQRS Physician Quality Reporting System

PPIS Physician Practice Expense Information Survey

PT Physical therapy

PY Performance year

QCDR Qualified clinical data registry

QRUR Quality and Resources Use Report

RBRVS Resource-based relative value scaleStart Printed Page 41688

RFA Regulatory Flexibility Act

RHC Rural health clinic

RIA Regulatory impact analysis

RUC American Medical Association/Specialty Society Relative (Value) Update Committee

RUCA Rural Urban Commuting Area

RVU Relative value unit

SBA Small Business Administration

SGR Sustainable growth rate

SIM State Innovation Model

SLP Speech-language pathology

SMS Socioeconomic Monitoring System

SNF Skilled nursing facility

TAP Technical Advisory Panel

TC Technical component

TIN Tax identification number

UAF Update adjustment factor

UPIN Unique Physician Identification Number

USPSTF United States Preventive Services Task Force

VBP Value-based purchasing

VM Value-Based Payment Modifier

Addenda Available Only Through the Internet on the CMS Web Site

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

CPT (Current Procedural Terminology) Copyright Notice

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

I. Executive Summary and Background

A. Executive Summary

1. Purpose

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

2. Summary of the Major Provisions

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

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

3. Summary of Costs and Benefits

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

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

B. Background

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

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

1. Development of the Relative Values

a. Work RVUs

The work RVUs established for the initial fee schedule, which was implemented on January 1, 1992, were developed with extensive input from the physician community. A research team at the Harvard School of Public Health developed the original work RVUs for most codes under a cooperative agreement with the Department of Health and Human Services (HHS). In constructing the code-specific vignettes used in determining the original physician work Start Printed Page 41689RVUs, Harvard worked with panels of experts, both inside and outside the federal government, and obtained input from numerous physician specialty groups.

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

b. Practice Expense RVUs

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

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

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

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

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

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

c. Malpractice RVUs

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

d. Refinements to the RVUs

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

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

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

In addition to the five-year reviews, beginning for CY 2009, CMS, and the RUC have identified and reviewed a number of potentially misvalued codes on an annual basis based on various identification screens. This annual review of work and PE RVUs for potentially misvalued codes was supplemented by the amendments to section 1848 of the Act, as enacted by section 3134 of the Affordable Care Act, which requires the agency to periodically identify, review and adjust values for potentially misvalued codes.Start Printed Page 41690

e. Application of Budget Neutrality to Adjustments of RVUs

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

2. Calculation of Payments Based on RVUs

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

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

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

3. Separate Fee Schedule Methodology for Anesthesia Services

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

4. Most Recent Changes to the Fee Schedule

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

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

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

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

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

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

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

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

II. Provisions of the Proposed Rule for PFS

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

1. Overview

Practice expense (PE) is the portion of the resources used in furnishing a service that reflects the general categories of physician and practitioner expenses, such as office rent and personnel wages, but excluding malpractice expenses, as specified in section 1848(c)(1)(B) of the Act. As required by section 1848(c)(2)(C)(ii) of the Act, we use a resource-based system for determining PE RVUs for each physicians' service. We develop PE RVUs by considering the direct and indirect practice resources involved in furnishing each service. Direct expense categories include clinical labor, medical supplies, and medical Start Printed Page 41691equipment. Indirect expenses include administrative labor, office expense, and all other expenses. The sections that follow provide more detailed information about the methodology for translating the resources involved in furnishing each service into service-specific PE RVUs. We refer readers to the CY 2010 PFS final rule with comment period (74 FR 61743 through 61748) for a more detailed explanation of the PE methodology.

2. Practice Expense Methodology

a. Direct Practice Expense

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

b. Indirect Practice Expense per Hour Data

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

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

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

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

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

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

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

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

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

c. Allocation of PE to Services

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

(1) Direct Costs

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

(2) Indirect Costs

Section II.A.2.b. of this proposed rule describes the current data sources for specialty-specific indirect costs used in our PE calculations. We allocated the Start Printed Page 41692indirect costs to the code level on the basis of the direct costs specifically associated with a code and the greater of either the clinical labor costs or the work RVUs. We also incorporated the survey data described earlier in the PE/HR discussion. The general approach to developing the indirect portion of the PE RVUs is as follows:

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

(4) Facility and Nonfacility Costs

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

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

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

(6) PE RVU Methodology

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

(a) Setup File

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

(b) Calculate the Direct Cost PE RVUs

Sum the costs of each direct input.

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

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

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

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

Step 5: Convert the results of Step 4 to an RVU scale for each service. To do this, divide the results of Step 4 by the CF. Note that the actual value of the CF used in this calculation does not influence the final direct cost PE RVUs, as long as the same CF is used in Step 2 and Step 5. Different CFs will result in different direct PE scaling factors, but Start Printed Page 41693this has no effect on the final direct cost PE RVUs since changes in the CFs and changes in the associated direct scaling factors offset one another.

(c) Create the Indirect Cost PE RVUs

Create indirect allocators.

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

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

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

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

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

There are two situations where this formula is modified:

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

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

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

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

Apply a scaling adjustment to the indirect allocators.

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

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

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

Calculate the indirect practice cost index.

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

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

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

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

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

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

(d) Calculate the Final PE RVUs

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

(e) Setup File Information

  • Specialties excluded from ratesetting calculation: For the purposes of calculating the PE RVUs, we exclude certain specialties, such as certain nonphysician practitioners paid at a percentage of the PFS and low-volume specialties, from the calculation. These specialties are included for the purposes of calculating the BN adjustment. They are displayed in Table 1.Start Printed Page 41694

Table 1—Specialties Excluded from Ratesetting Calculation

Specialty codeSpecialty description
49Ambulatory surgical center.
50Nurse practitioner.
51Medical supply company with certified orthotist.
52Medical supply company with certified prosthetist.
53Medical supply company with certified prosthetist-orthotist.
54Medical supply company not included in 51, 52, or 53.
55Individual certified orthotist.
56Individual certified prosthetist.
57Individual certified prosthetist-orthotist.
58Medical supply company with registered pharmacist.
59Ambulance service supplier, e.g., private ambulance companies, funeral homes, etc.
60Public health or welfare agencies.
61Voluntary health or charitable agencies.
73Mass immunization roster biller.
74Radiation therapy centers.
87All other suppliers (e.g., drug and department stores).
88Unknown supplier/provider specialty.
89Certified clinical nurse specialist.
96Optician.
97Physician assistant.
A0Hospital.
A1SNF.
A2Intermediate care nursing facility.
A3Nursing facility, other.
A4HHA.
A5Pharmacy.
A6Medical supply company with respiratory therapist.
A7Department store.
B2Pedorthic personnel.
B3Medical supply company with pedorthic personnel.
  • Crosswalk certain low volume physician specialties: Crosswalk the utilization of certain specialties with relatively low PFS utilization to the associated specialties.
  • Physical therapy utilization: Crosswalk the utilization associated with all physical therapy services to the specialty of physical therapy.
  • Identify professional and technical services not identified under the usual TC and 26 modifiers: Flag the services that are PC and TC services but do not use TC and 26 modifiers (for example, electrocardiograms). This flag associates the PC and TC with the associated global code for use in creating the indirect PE RVUs. For example, the professional service, CPT code 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), is associated with the global service, CPT code 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report).
  • Payment modifiers: Payment modifiers are accounted for in the creation of the file consistent with current payment policy as implemented in claims processing. For example, services billed with the assistant at surgery modifier are paid 16 percent of the PFS amount for that service; therefore, the utilization file is modified to only account for 16 percent of any service that contains the assistant at surgery modifier. Similarly, for those services to which volume adjustments are made to account for the payment modifiers, time adjustments are applied as well. For time adjustments to surgical services, the intraoperative portion in the work time file is used; where it is not present, the intraoperative percentage from the payment files used by contractors to process Medicare claims is used instead. Where neither is available, we use the payment adjustment ratio to adjust the time accordingly. Table 2 details the manner in which the modifiers are applied.

Table 2—Application of Payment Modifiers to Utilization Files

ModifierDescriptionVolume adjustmentTime adjustment
80,81,82Assistant at Surgery16%Intraoperative portion.
ASAssistant at Surgery—Physician Assistant14% (85% * 16%)Intraoperative portion.
50 or LT and RTBilateral Surgery150%150% of work time.
51Multiple Procedure50%Intraoperative portion.
52Reduced Services50%50%.
53Discontinued Procedure50%50%.
54Intraoperative Care onlyPreoperative + Intraoperative Percentages on the payment files used by Medicare contractors to process Medicare claimsPreoperative + Intraoperative portion.
55Postoperative Care onlyPostoperative Percentage on the payment files used by Medicare contractors to process Medicare claimsPostoperative portion.
62Co-surgeons62.5%50%.
Start Printed Page 41695
66Team Surgeons33%33%.

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

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

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

(7) Equipment Cost Per Minute

The equipment cost per minute is calculated as:

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

Where:

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

usage = variable, see discussion below.

price = price of the particular piece of equipment.

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

maintenance = factor for maintenance; 0.05.

interest rate = variable, see discussion below.

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

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

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

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

Table 3—SBA Maximum Interest Rates

PriceUseful lifeInterest rate (%)
<$25K<7 Years7.50
$25K to $50K<7 Years6.50
>$50K<7 Years5.50
<$25K7+ Years8.00
$25K to $50K7+ Years7.00
>$50K7+ Years6.00
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Table 4—Calculation of PE RVUS Under Methodology for Selected Codes

StepSourceFormula99213 Office visit, est nonfacility33533 CABG, arterial, single facility71020 chest x-ray nonfacility71020-TC chest x-ray, nonfacility71020-26 chest x-ray, nonfacility93000 ECG, complete, nonfacility93005 ECG, tracing nonfacility93010 ECG, report nonfacility
(1) Labor cost (Lab)Step 1AMA13.3277.525.745.7405.15.10
(2) Supply cost (Sup)Step 1AMA2.987.340.530.5301.191.190
(3) Equipment cost (Eqp)Step 1AMA0.170.587.087.0800.090.090
(4) Direct cost (Dir)Step 1=(1)+(2)+(3)16.4885.4513.3613.3606.386.380
(5) Direct adjustment (Dir. Adj.)Steps 2-4See footnote*0.60030.60030.60030.60030.60030.60030.60030.6003
(6) Adjusted LaborSteps 2-4=Labor * Dir Adj=(1)*(5)846.533.453.4503.063.060
(7) Adjusted SuppliesSteps 2-4=Eqp * Dir Adj=(2)*(5)1.794.410.320.3200.720.720
(8) Adjusted EquipmentSteps 2-4=Sup * Dir Adj=(3)*(5)0.100.354.254.2500.050.050
(9) Adjusted DirectSteps 2-4=(6)+(7)+(8)9.8951.298.028.0203.833.830
(10) Conversion Factor (CF)Step 5PFS35.933535.933535.933535.933535.933535.933535.933535.9335
(11) Adj. labor cost convertedStep 5=(Lab * Dir Adj)/CF=(6)/(10)0.221.30.10.100.090.090
(12) Adj. supply cost convertedStep 5=(Sup * Dir Adj)/CF=(7)/(10)0.050.120.010.0100.020.020
(13) Adj. equipment cost convertedStep 5=(Eqp * Dir Adj)/CF=(8)/(10)00.010.120.120000
(14) Adj. direct cost convertedStep 5=(11)+(12)+(13)0.281.430.220.2200.110.110
(15) Work RVUSetup FilePFS0.9733.750.2200.220.1700.17
(16) Dir_pctSteps 6,7Surveys0.250.170.290.290.290.290.290.29
(17) Ind_pctSteps 6,7Surveys0.750.830.710.710.710.710.710.71
(18) Ind. Alloc. Formula (1st part)Step 8See Step 8(14)/ (16)*(17)(14)/ (16)*(17)(14)/ (16)*(17)(14)/ (16)*(17)(14)/ (16)*(17)(14)/ (16)*(17)(14)/ (16)*(17)(14)/ (16)*(17)
(19) Ind. Alloc.(1st part)Step 8See 180.836.750.540.5400.260.260
(20) Ind. Alloc. Formula (2nd part)Step 8See Step 8(15)(15)(15+11)(11)(15)(15+11)(11)(15)
(21) Ind. Alloc.(2nd part)Step 8See 200.9733.750.320.10.220.260.090.17
(22) Indirect Allocator (1st + 2nd)Step 8=(19)+(21)1.840.500.860.640.220.520.350.17
(23) Indirect Adjustment (Ind. Adj.)Steps 9-11See Footnote**0.38110.38110.38110.38110.38110.38110.38110.3811
(24) Adjusted Indirect AllocatorSteps 9-11=Ind Alloc * Ind Adj0.6915.430.330.240.080.20.130.06
(25) Ind. Practice Cost Index (IPCI)Steps 12-161.070.760.980.980.980.90.90.9
(26) Adjusted IndirectStep 17= Adj.Ind Alloc * PCI=(24)*(25)0.7311.680.320.240.080.180.120.06
(27) Final PE RVUStep 18=(Adj Dir + Adj Ind) * Other Adj=((14)+(26)) * Other Adj)1.0113.150.540.460.080.280.230.06
CPT codes and descriptions are copyright 2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.
Notes: PE RVUs above (row 27), may not match Addendum B due to rounding.
The use of any particular conversion factor (CF) in the table to illustrate the PE Calculation has no effect on the resulting RVUs.
*The direct adj = [current pe rvus * CF * avg dir pct]/[sum direct inputs] = [step2]/[step3]; **The indirect adj =[current pe rvus * avg ind pct]/[sum of ind allocators]=[step9]/[step10]
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c. Changes to Direct PE Inputs for Specific Services

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

(1) PE Inputs for Digital Imaging Services

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

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

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

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

(2) Standardization of Clinical Labor Tasks

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

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

(a) Clinical Labor Tasks Associated With Digital Imaging

In PFS rulemaking for CY 2015, we noted that the RUC recommendation regarding inputs for digital imaging services indicated that, as each code is reviewed under the misvalued code initiative, the clinical labor tasks associated with digital technology (instead of film) would need to be addressed. When we reviewed that recommendation, we did not have the capability of assigning standard clinical labor times for the hundreds of individual codes since the direct PE Start Printed Page 41698input database did not previously allow for comprehensive adjustments for clinical labor times based on particular clinical labor tasks. Therefore, consistent with the recommendation, we proposed to remove film-based supply and equipment items but maintain clinical labor minutes that were assigned based on film technology.

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

Table 5—Clinical Labor Tasks Associated With Digital Technology

Clinical labor taskTypical minutes
Availability of prior images confirmed2
Patient clinical information and questionnaire reviewed by technologist, order from physician confirmed and exam protocoled by radiologist2
Technologist QC's * images in PACS, checking for all images, reformats, and dose page2
Review examination with interpreting MD2
Exam documents scanned into PACS. Exam completed in RIS system to generate billing process and to populate images into Radiologist work queue1
* This clinical labor task is listed as it appears on the “PE worksheets.” QC refers to quality control, which we understand to mean the verification of the image using the PACS workstation.

(b) Pathology Clinical Labor Tasks

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

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

Table 6—Standard Times for Clinical Labor Tasks Associated With Pathology Services

Clinical Labor TaskStandard clinical labor time
Accession specimen/prepare for examination4
Assemble and deliver slides with paperwork to pathologists0.5
Assemble other light microscopy slides, open nerve biopsy slides, and clinical history, and present to pathologist to prepare clinical pathologic interpretation0.5
Assist pathologist with gross specimen examination3
Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure)1
Dispose of remaining specimens, spent chemicals/other consumables, and hazardous waste1
Enter patient data, computational prep for antibody testing, generate and apply bar codes to slides, and enter data for automated slide stainer1
Instrument start-up, quality control functions, calibration, centrifugation, maintaining specimen tracking, logs and labeling13
Load specimen into flow cytometer, run specimen, monitor data acquisition and data modeling, and unload flow cytometer7
Preparation: labeling of blocks and containers and document location and processor used0.5
Prepare automated stainer with solutions and load microscopic slides4
Prepare specimen containers/preload fixative/label containers/distribute requisition form(s) to physician0.5
Prepare, pack and transport specimens and records for in-house storage and external storage (where applicable)1
Print out histograms, assemble materials with paperwork to pathologists. Review histograms and gating with pathologist.2
Receive phone call from referring laboratory/facility with scheduled procedure to arrange special delivery of specimen procurement kit, including muscle biopsy clamp as needed. Review with sender instructions for preservation of specimen integrity and return arrangements. Contact courier and arrange delivery to referring laboratory/facility5
Register the patient in the information system, including all demographic and billing information.4
Stain air dried slides with modified Wright stain. Review slides for malignancy/high cellularity (cross contamination)3
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(c) Clinical Labor Task: “Complete Botox Log”

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

(3) Clinical Labor Input Inconsistencies

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

(4) Freezer

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

(5) Updates to Price for Existing Direct Inputs

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

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

For CY 2015, we received a request to update the price for supply item “kit, HER-2/neu DNA Probe” (SL196) from $105 to $144.50. Accordingly, we proposed to update the price to $144.50. In the CY 2015 final rule with comment period, we indicated that we obtained new information suggesting that further study of the price of this item was necessary before proceeding to update Start Printed Page 41700the input price. We obtained pricing information readily available on the Internet that indicated a price of $94 for this item for a particular hospital. Subsequent to the CY 2015 final rule with comment period, stakeholders requested that we use the updated price of $144.50. One stakeholder suggested that the price of $94 likely reflected discounts for volume purchases not received by the typical laboratory. We are seeking comment on how to consider the higher-priced invoice, which is 53 percent higher than the price listed, relative to the price currently in the direct PE database. Specifically, we are seeking information on the price of the disposable supply in the typical case of the service furnished to a Medicare beneficiary, including, based on data, whether the typical Medicare case is furnished by an entity likely to receive a volume discount.

(6) Typical Supply and Equipment Inputs for Pathology Services

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

d. Developing Nonfacility Rates

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

(1) Request for Information on Nonfacility Cataract Surgery

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

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

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

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

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

B. Determination of Malpractice Relative Value Units (RVUs)

1. Overview

Section 1848(c) of the Act requires that each service paid under the PFS be comprised of three components: work, PE, and malpractice (MP) expense. As required by section 1848(c)(2)(C)(iii) of the Act, beginning in CY 2000, MP RVUs are resource based. Malpractice RVUs for new codes after 1991 were Start Printed Page 41701extrapolated from similar existing codes or as a percentage of the corresponding work RVU. Section 1848(c)(2)(B)(i) of the Act also requires that we review, and if necessary adjust, RVUs no less often than every 5 years. In the CY 2015 PFS final rule with comment period, we implemented the third review and update of MP RVUs. For a discussion of the third review and update of MP RVUs see the CY 2015 proposed rule (79 FR 40349 through 40355) and final rule with comment period (79 FR 67591 through 67596).

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

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

2. Proposed Annual Update of MP RVUs

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

We are also proposing an additional refinement in our process for assigning MP RVUs to individual codes. Historically, we have used a floor of 0.01 MP RVUs for all nationally-priced PFS codes. This means that even when the code-level calculation for the MP RVU falls below 0.005, we have rounded to 0.01. In general, we believe this approach accounts for the minimum MP costs associated with each service furnished to a Medicare beneficiary. However, in examining the calculation of MP RVUs, we do not believe that this floor should apply to add-on codes. Since add-on codes must be reported with another code, there is already an MP floor of 0.01 that applies to the base code, and therefore, to each individual service. By applying the floor to add-on codes, the current methodology practically creates a 0.02 floor for any service reported with one add-on code, and 0.03 for those with 2 add-on codes, etc. Therefore, we are proposing to maintain the 0.01 MP RVU floor for all nationally-priced PFS services that are described by base codes, but not for add-on codes. We will continue to calculate, display, and make payments that include MP RVUs for Start Printed Page 41702add-on codes that are calculated to 0.01 or greater, including those that round to 0.01. We are only proposing to allow the MP RVUs for add-on codes to round to 0.00 where the calculated MP RVU is less than 0.005.

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

3. MP RVU Update for Anesthesia Services

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

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

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

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

4. MP RVU Methodology Refinements

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

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

Additionally, in the calculation of the national average premium for each specialty as discussed above, our current methodology used the total RVUs in each area as the weight in the numerator (that is, for premiums), and total MP RVUs as the weights in the denominator (that is, for the MP GPCIs). After further consideration, we believe that the use of these RVU weights is problematic. Use of weights that are central to the process at hand presents potential circularity since both weights incorporate MP RVUs as part of the computation to calculate MP RVUs. The use of different weights for the numerator and denominator introduces potential inconsistency. Instead, we believe that it would be better to use a different measure that is independent of MP RVUs and better represents the reason for weighting. Specifically, we are proposing to use area population as a share of total U.S. population as the weight. The premium data are for all MP premium costs, not just those associated with Medicare patients, so we believe that the distribution of the population does a better job of capturing the role of each area's premium in the “national” premium for each specialty than our previous Medicare-specific measure. Use of population weights also avoids the potential problems of circularity and inconsistency.Start Printed Page 41703

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

C. Potentially Misvalued Services Under the Physician Fee Schedule

1. Background

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

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

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

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

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

2. Progress in Identifying and Reviewing Potentially Misvalued Codes

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

Since CY 2009, as a part of the annual potentially misvalued code review and Five-Year Review process, we have reviewed over 1,560 potentially misvalued codes to refine work RVUs and direct PE inputs. We have assigned appropriate work RVUs and direct PE inputs for these services as a result of these reviews. A more detailed discussion of the extensive prior reviews of potentially misvalued codes is included in the CY 2012 PFS final rule with comment period (76 FR 73052 Start Printed Page 41704through 73055). In the CY 2012 final rule with comment period, we finalized our policy to consolidate the review of physician work and PE at the same time (76 FR 73055 through 73958), and established a process for the annual public nomination of potentially misvalued services.

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

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

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

3. Validating RVUs of Potentially Misvalued Codes

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

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

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

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

4. CY 2016 Identification of Potentially Misvalued Services for Review

a. Public Nomination of Potentially Misvalued Codes

In the CY 2012 PFS final rule with comment period, we finalized a process for the public to nominate potentially misvalued codes (76 FR 73058). The public and stakeholders may nominate potentially misvalued codes for review by submitting the code with supporting documentation during the 60-day public comment period following the release of the annual PFS final rule with comment period. Supporting documentation for codes nominated for the annual review of potentially misvalued codes may Start Printed Page 41705include, but are not limited to, the following:

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

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

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

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

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

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

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

Table 7—Proposed Potentially Misvalued Codes Identified in the Electronic Analysis of Implanted Neurostimulator Family

HCPCSShort descriptor
95970Analyze neurostim no prog.
95974Cranial neurostim complex.
95975Cranial neurostim complex.
95978Analyze neurostim brain/1h.
95979Analyz neurostim brain addon.
95980Io anal gast n-stim init.
95981Io anal gast n-stim subsq.
95982Io ga n-stim subsq w/reprog.

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

In the CY 2015 PFS rule, we proposed and finalized the high expenditure screen as a tool to identify potentially misvalued codes in the statutory category of “codes that account for the majority of spending under the PFS.” We also identified codes through this screen and proposed them as potentially misvalued in the CY 2015 PFS proposed rule (79 FR 40337-40338). However, given the resources required for the revaluation of codes with 10- and 90-day global periods, we did not finalize those codes as potentially misvalued codes in the CY 2015 PFS final rule with comment period. We stated that we would re-run the high expenditure screen at a future date, and subsequently propose the specific set of Start Printed Page 41706codes that meet the high expenditure criteria as potentially misvalued codes (79 FR 67578).

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

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

Table 8—Proposed Potentially Misvalued Codes Identified Through High Expenditure by Specialty Screen

HCPCSShort descriptor
10022Fna w/image
11100Biopsy skin lesion
11101Biopsy skin add-on
11730Removal of nail plate
20550Inj tendon sheath/ligament
20552Inj trigger point 1/2 muscl
20553Inject trigger points 3/>
22614Spine fusion extra segment
22840Insert spine fixation device
22842Insert spine fixation device
22845Insert spine fixation device
27370Injection for knee x-ray
29580Application of paste boot
31500Insert emergency airway
31575Diagnostic laryngoscopy
31579Diagnostic laryngoscopy
31600Incision of windpipe
33518Cabg artery-vein two
36215Place catheter in artery
36556Insert non-tunnel cv cath
36569Insert picc cath
36620Insertion catheter artery
38221Bone marrow biopsy
51700Irrigation of bladder
51702Insert temp bladder cath
51720Treatment of bladder lesion
51728Cystometrogram w/vp
51729Cystometrogram w/vp&up
51784Anal/urinary muscle study
51797Intraabdominal pressure test
51798Us urine capacity measure
52000Cystoscopy
55700Biopsy of prostate
58558Hysteroscopy biopsy
67820Revise eyelashes
70491Ct soft tissue neck w/dye
70543Mri orbt/fac/nck w/o &w/dye
70544Mr angiography head w/o dye
70549Mr angiograph neck w/o&w/dye
71010Chest x-ray 1 view frontal
71020Chest x-ray 2vw frontal&latl
71260Ct thorax w/dye
71270Ct thorax w/o & w/dye
72195Mri pelvis w/o dye
72197Mri pelvis w/o & w/dye
73110X-ray exam of wrist
73130X-ray exam of hand
73718Mri lower extremity w/o dye
73720Mri lwr extremity w/o&w/dye
74000X-ray exam of abdomen
74022X-ray exam series abdomen
74181Mri abdomen w/o dye
74183Mri abdomen w/o & w/dye
75635Ct angio abdominal arteries
75710Artery x-rays arm/leg
75978Repair venous blockage
76512Ophth us b w/non-quant a
76519Echo exam of eye
76536Us exam of head and neck
77059Mri both breasts
77263Radiation therapy planning
77334Radiation treatment aid(s)
77470Special radiation treatment
78306Bone imaging whole body
78452Ht muscle image spect mult
88185Flowcytometry/tc add-on
88189Flowcytometry/read 16 & >
88321Microslide consultation
88360Tumor immunohistochem/manual
88361Tumor immunohistochem/comput
91110Gi tract capsule endoscopy
92002Eye exam new patient
92136Ophthalmic biometry
92240Icg angiography
92250Eye exam with photos
92275Electroretinography
92557Comprehensive hearing test
92567Tympanometry
93280Pm device progr eval dual
93288Pm device eval in person
93293Pm phone r-strip device eval
93294Pm device interrogate remote
93295Dev interrog remote 1/2/mlt
93296Pm/icd remote tech serv
93306Tte w/doppler complete
93350Stress tte only
93351Stress tte complete
93503Insert/place heart catheter
93613Electrophys map 3d add-on
93965Extremity study
94010Breathing capacity test
94620Pulmonary stress test/simple
95004Percut allergy skin tests
95165Antigen therapy services
95957Eeg digital analysis
96101Psycho testing by psych/phys
96116Neurobehavioral status exam
96118Neuropsych tst by psych/phys
96360Hydration iv infusion init
96372Ther/proph/diag inj sc/im
96374Ther/proph/diag inj iv push
96375Tx/pro/dx inj new drug addon
96401Chemo anti-neopl sq/im
96402Chemo hormon antineopl sq/im
96409Chemo iv push sngl drug
96411Chemo iv push addl drug
96567Photodynamic tx skin
96910Photochemotherapy with uv-b
97032Electrical stimulation
97035Ultrasound therapy
97110Therapeutic exercises
97112Neuromuscular reeducation
97113Aquatic therapy/exercises
97116Gait training therapy
97140Manual therapy 1/regions
97530Therapeutic activities
97535Self care mngment training
G0283Elec stim other than wound

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

The CPT manual includes more than 400 diagnostic and therapeutic procedures, listed in Appendix G, for which CPT has determined that moderate sedation is an inherent part of furnishing the procedure. Therefore, only the procedure code is reported when furnishing the service, and in developing RVUs for these services, we include the resource costs associated with moderate sedation in the valuation of these diagnostic and therapeutic procedures. To the extent that moderate sedation is inherent in the diagnostic or therapeutic service, we believe that the inclusion of moderate sedation in the valuation of the procedure is accurate. In the CY 2015 PFS proposed rule (79 FR 40349), we noted that it appeared that practice patterns for endoscopic procedures were changing, with anesthesia increasingly being separately reported for these procedures. Due to the changing nature of medical practice, we noted that we were considering establishing a uniform approach to valuation for all Appendix G services. We continue to seek an approach that is based on using the best available objective information about the provision of moderate sedation broadly, rather than merely addressing this issue on a code-by-code basis using RUC survey data when individual procedures Start Printed Page 41707are revalued. We sought public comment on approaches to address the appropriate valuation of these services given that moderate sedation is no longer inherent for many of these services. To the extent that Appendix G procedure values are adjusted to no longer include moderate sedation, we requested suggestions as to how moderate sedation should be reported and valued, and how to remove from existing valuations the RVUs and inputs related to moderate sedation.

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

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

6. Improving the Valuation and Coding of the Global Package

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

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

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

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

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

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

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

Since section 1848(c)(8)(B)(i) of the Act, as added by section 523(a) of the MACRA, requires us to use rulemaking Start Printed Page 41708to develop and implement the process to gather information needed to value surgical services no later than January 1, 2017, we are seeking input from stakeholders on various aspects of this task. We are soliciting comments from the public regarding the kinds of auditable, objective data (including the number and type of visits and other services furnished by the practitioner reporting the procedure code during the current post-operative periods) needed to increase the accuracy of the values for surgical services. We are also seeking comment on the most efficient means of acquiring these data as accurately and efficiently as possible. For example, we seek information on the extent to which individual practitioners or practices may currently maintain their own data on services, including those furnished during the post-operative period, and how we might collect and objectively evaluate those data for use in increasing the accuracy of the values beginning in CY 2019. We will use the information from the public comments to help develop a proposed approach for the collection of this information in future rulemaking.

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

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

D. Refinement Panel

1. Background

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

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

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

2. CY 2016 Refinement Panel Proposal

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

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

We are committed to supporting primary care, and we have increasingly recognized care management as one of the critical components of primary care that contributes to better health for individuals and reduced expenditure growth (77 FR 68978). Accordingly, we have prioritized the development and implementation of a series of initiatives designed to improve the accuracy of payment for, and encourage long-term investment in, care management services.Start Printed Page 41709

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

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

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

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

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

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

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

Like CCM, we would require that the patient have an established relationship with the billing professional; and additionally, the use of an add-on code would require the extended professional resources to be reported with another Start Printed Page 41710separately payable service. However, in contrast to the CCM code, the new codes might be reported based on the resources involved in professional work, instead of the resource costs in terms of clinical staff time. The codes might also apply broadly to patients in a number of different circumstances, and would not necessarily make reporting the code(s) contingent on particular business models or technologies for medical practices. We are interested in stakeholder comments on the kinds of services that involve the type of cognitive work described above and whether or not the creation of particular codes might improve the accuracy of the relative values used for such services on the PFS. Finally, we are interested in receiving information from stakeholders on the overlap between the kinds of cognitive resource costs discussed above and those already accounted for through the currently payable codes that describe CCM and other care management services.

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

2. Establishing Separate Payment for Collaborative Care

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

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

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

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

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

Because this particular kind of collaborative care model has been tested and documented in medical literature, we are particularly interested in seeking comment on how coding under the PFS might facilitate appropriate valuation of the services furnished under such a collaborative care model. As these kinds of collaborative models of care become more prevalent, we will evaluate potential refinements to the PFS to account for the provision of services through such a model. We are seeking information to assist us in considering refinements to coding and payment to Start Printed Page 41711address this model in particular. We also would assess application of the collaborative care model for other diagnoses and treatment modalities. For example, we seek comments on how a code similar to the CCM code applicable to multiple diagnoses and treatment plans could be used to describe collaborative care services, as well as other interprofessional services and could be appropriately valued and reported within the resource-based relative value PFS system, and how the resources involved in furnishing such services could be incorporated into the current set of PFS codes without overlap. We also request input on whether requirements similar to those used for CCM services should apply to a new collaborative care code, and whether such a code could be reported in conjunction with CCM or other E/M services. For example, we might consider whether the code should describe a minimum amount of time spent by the psychiatric consultant for a particular patient per one calendar month and be complemented by either the CCM or other care management code to support the care management and primary care elements of the collaborative care model. As with our discussion on interprofessional consultation in this section of the proposed rule, because the patient may not have direct contact with the psychiatric consultant, we seek comment on whether and, if so, how written consent for the non-face-to-face services should be required prior to practitioners reporting any new interprofessional consultation code or the care management code.

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

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

3. CCM and TCM Services

a. Reducing Administrative Burden for CCM and TCM Services

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

b. Payment for CPT Codes Related to CCM Services

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

F. Target for Relative Value Adjustments for Misvalued Services

Section 220(d) of the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. 113-93, enacted on April 1, 2014) added a new subparagraph at section 1848(c)(2) of the Act to establish an annual target for reductions in PFS expenditures resulting from adjustments to relative values of misvalued codes. Under section 1848(c)(2)(O)(ii) of the Act, if the estimated net reduction in expenditures for a year is equal to or greater than the target for the year, reduced expenditures attributable to such adjustments shall be redistributed in a budget-neutral manner within the PFS in accordance with the existing budget neutrality requirement under section 1848(c)(2)(B)(ii)(II) of the Act. The provision also specifies that the amount by which such reduced expenditures exceeds the target for a given year shall be treated as a net reduction in expenditures for the succeeding year, for purposes of determining whether the target has been met for that subsequent year. Section 1848(c)(2)(O)(iv) of the Act defines a target recapture amount as the amount by which the target for the year exceeds the estimated net reduction in expenditures under the PFS resulting from adjustments to RVUs for misvalued codes. Section 1848(c)(2)(O)(iii) of the Start Printed Page 41712Act specifies that, if the estimated net reduction in PFS expenditures for the year is less than the target for the year, an amount equal to the target recapture amount shall not be taken into account when applying the budget neutrality requirements specified in section 1848(c)(2)(B)(ii)(II) of the Act. Section 220(d) of the PAMA applied to calendar years (CYs) 2017 through 2020 and set the target under section 1848(c)(2)(O)(v) of the Act at 0.5 percent of the estimated amount of expenditures under the PFS for each of those 4 years.

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

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

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

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

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

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

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

For recent years, interim final values for misvalued codes (year 2) have generally reflected reductions relative to original values (year 1), and for most codes, the interim final values (year 2) are maintained and finalized (year 3). However, when values for particular Start Printed Page 41713codes have changed between the interim final (year 2) and final values (year 3) based on public comment, the general tendency has been that codes increase in the final value (year 3) relative to the interim final value (year 2), even in cases where the final value (year 3) represents a decrease from the original value (year 1). Therefore, for these codes, the year 2 changes compared to year 1 would risk over-representing the overall reduction, while the year 3 to year 2 changes would represent an increase in value. If there were similar targets in every PFS year, and a similar number of misvalued code changes made on an interim final basis, the incongruence in measuring what is really a 3-year change in 2-year increments might not be particularly problematic since each year's calculation would presumably include a similar number of codes measured between years 1 and 2 and years 2and 3.

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

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

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

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

2. Calculating “Net Reduction”

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

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

3. Measuring the Adjustments

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

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

However, this approach would mean that the calculation of the net reduction in expenditures would occur within various steps of the PFS ratesetting methodology. While we believe that this approach would be transparent and external stakeholders could replicate this method, it may be difficult and time-consuming for stakeholders to do so. We also noted that when we modeled the interaction of the phase-in legislation and the calculation of the target using this approach during the development of this proposal, there were methodological challenges in making these calculations. When we simulated the two approaches using Start Printed Page 41714information from prior PFS years, we found that both approaches generally resulted in similar estimated net reductions. After considering these options, we are proposing to use the approach of comparing the total RVUs (by volume) for the relevant set of codes in the current year to the update year, and divide that result by the total RVUs (by volume) for the current year. We seek comment on whether comparing the update year's work RVUs, direct PE RVUs, indirect PE RVUs, and MP RVUs for the relevant set of codes (by volume) prior to the application of any scaling factors or adjustments to those of the current year would be a preferable methodology for determining the estimated net reduction.

4. Estimating the Target for CY 2016

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

G. Phase-in of Significant RVU Reductions

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

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

1. Identifying Services that are Not New or Revised Codes

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

2. Estimating the 20 Percent Threshold

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

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

Section 1848(c)(7) of the Act states that the applicable adjustments in work, PE, and MP RVUs shall be phased-in over a 2-year period when the RVU reduction for a code is estimated to be equal to or greater than 20 percent. We believe that there are two reasonable ways to determine the portion of the reduction to be phase-in for the first year. Most recent RVU transitions have distributed the values evenly across several years. For example, for a 2-year transition we would estimate the fully implemented value and set a rate Start Printed Page 41715approximately 50 percent between the value for the current year and the value for the update year. We believe that this is the most intuitive approach to the phase-in and is likely the expectation for many stakeholders. However, we believe that the 50 percent phase-in in the first year has a significant drawback. For instance, since the statute establishes a 20 percent threshold as the trigger for phasing in the change in RVUs, under the 50 percent phase-in approach, a service that is estimated to be reduced by a total of 19 percent for an update year would be reduced by a full 19 percent in that update year, while a service that is estimated to be reduced by 20 percent in an update year would only be reduced 10 percent in that update year.

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

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

4. Applicable Adjustments to RVUs

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

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

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

Therefore, we have concluded that applying the adjustments to the PE RVUs for individual codes in order to effect the appropriate phase-in amount is the most straightforward and fair approach to mitigate the impact of significant reductions of total RVUs for services furnished by individual practitioners. The list of codes subject to the phase-in, and the RVUs that result from this proposed methodology, is available on the CMS Web site under downloads for the CY 2016 PFS proposed rule with comment period at http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​PhysicianFeeSched/​PFS-Federal-Regulation-Notices.html. Start Printed Page 41716

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

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

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

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

I. Valuation of Specific Codes

1. Background

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

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

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

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

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

3. Methodology for Establishing Work RVUs

We conducted a review of each code identified in this section and reviewed the current work RVU (if any), RUC-Start Printed Page 41717recommended work RVUs, intensity, time to furnish the preservice, intraservice, and postservice activities, as well as other components of the service that contribute to the value. Our review of recommended work RVUs and time generally includes, but is not limited to, a review of information provided by the RUC, HCPAC, and other public commenters, medical literature, and comparative databases, as well as a comparison with other codes within the Medicare PFS, consultation with other physicians and health care professionals within CMS and the federal government, as well as Medicare claims data. We also assessed the methodology and data used to develop the recommendations submitted to us by the RUC and other public commenters and the rationale for the recommendations. In the CY 2011 PFS final rule with comment period (75 FR 73328 through 73329), we discussed a variety of methodologies and approaches used to develop work RVUs, including survey data, building blocks, crosswalk to key reference or similar codes, and magnitude estimation. More information on these issues is available in that rule. When referring to a survey, unless otherwise noted, we mean the surveys conducted by specialty societies as part of the formal RUC process. The building block methodology is used to construct, or deconstruct, the work RVU for a CPT code based on component pieces of the code. Components used in the building block approach may include preservice, intraservice, or postservice time and post-procedure visits. When referring to a bundled CPT code, the building block components could be the CPT codes that make up the bundled code and the inputs associated with those codes. Magnitude estimation refers to a methodology for valuing physician work that determines the appropriate work RVU for a service by gauging the total amount of physician work for that service relative to the physician work for similar service across the PFS without explicitly valuing the components of that work.

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

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

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

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

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

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

a. Background

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

Our review and refinement of RUC-recommended direct PE input includes many refinements that are common Start Printed Page 41718across codes as well as refinements that are specific to particular services. Table 13 details our refinements of the RUC's direct PE recommendations at the code-specific level. In this proposed rule, we address several refinements that are common across codes, and refinements to particular codes are addressed in the portions of this section that are dedicated to particular codes. We note that for each refinement, we indicate the impact on direct costs for that service. We point out that, on average, in any case where the impact on the direct cost for a particular refinement is $0.32 or less, the refinement has no impact on the final PE RVUs. This calculation considers both the impact on the direct portion of the PE RVU as well as the impact on the indirect allocator for the average service. We also note that nearly half of the refinements listed in Table 13 result in changes under the $0.32 threshold and are unlikely to result in a change to the final RVUs.

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

b. Common Refinements

(1) Changes in Work Time

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

(2) Equipment Time

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

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

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

(3) Standard Tasks and Minutes for Clinical Labor Tasks

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

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

In conducting our review of the RUC recommendations for CY 2016, we noted that several of the recommended times for clinical labor tasks associated with pathology services differed across codes, both within the CY 2016 recommendations and in comparison to codes currently in the direct PE database. We refer readers to Table 6 in section II.A.3. of this proposed rule where we outline our proposed standard times for clinical labor tasks associated with pathology services.Start Printed Page 41719

(4) Recommended Items That Are Not Direct PE Inputs

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

(5) Moderate Sedation Inputs

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

(6) New Supply and Equipment Items

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

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

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

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

(8) Duplicative Inputs

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

5. Methodology for Establishing Malpractice RVUs

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

Table 9—Invoices Received for New Direct PE Inputs

CPT/HCPCS CodesItem nameCMS CodeAverage priceNumber of invoicesEstimated non-facility allowed services for HCPCS codes using this item
31626Gold Fiducial MarkerSB05313516
Start Printed Page 41720
3160A, 3160B, 3160Cendoscope, ultrasound radial probeES04500212
3725AIVUS catheterSD30410253795
3725AIVUS Catheter Sterile CoverSD3051203795
3725A, 3725BIVUS systemES047134,02532,948
44385, 44386, 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45340, 45346Video SigmoidoscopeES043215,00118,058
44401, 45346, 45388catheter, RF ablation, endoscopicSC1031,78013,543
44401, 45346radiofrequency generator, endoscopyEQ369108,291.671174
45350, 45398hemorrhoidal banding systemSA115223.5043
5039D, 5039MNephroureteral CatheterSD306117.90170
657XGsuture, nylon, 10-0SC10412.172
657XGintrastromal corneal ringSA1201,1457
657XGpatient/laser interface (single—use, disposable)SD307172.501
657XGfemtosecond laserES048293,0002
657XGincision programming softwareES04910,012.501
692XXearwash bottle disposable tipsSD3081.721
77385, 77386, 77402, 77407, 77412Power ConditionerER10226,40022,198,441
7778A, 7778B, 7778C, 7778D, 7778Ebrachytherapy treatment vaultES052175,000124,936
88104, 88106, 88108fixative spray for cytospinSL5031.53162,552
88108Shannon cyto funnel, cytospinSD2982.27148,740
88108slide, microscope coated cytospin (single circle)SL5040.39148,740
88182ProteaseSL5060.431568
88346, 8835XImmunofluorescent mounting mediaSD3093.501114,211
88346, 8835XZeus mediumSL5180.852114,211
88346, 8835XHydrophobic PAP PenSK1201.76 (100 uses)1114,211
88360, 88361Antibody Estrogen Receptor monoclonalSL49313.893116,718

Table 10—Invoices Received for Existing Direct PE Inputs

CPT/HCPCS CodesItem nameCMS CodeCurrent priceUpdated pricePercent changeNumber of invoicesEstimated non-facility allowed services for HCPCS codes using this item
31300, 31320, 31360, 31365, 31367, 31368, 31370, 31375, 31380, 31382, 31390, 31395, 31628, 31632, 31750, 31755, 31800, 41120, 41130, 41135, 41140, 41145, 41150, 41153, 41155, 41500, 41510, 41512, 41530, 42120, 42842, 42844, 42845, 42870, 42890, 42892, 42894, 42950, 42953, 42955, 43215, 43247, 58555, 58558, 58562, 58563, 60605, 92511, 92612endosheathSD0709.5017.2582165,318
41530, 43228, 43229, 43270, 64633, 64634, 64635, 64636radiofrequency generator (NEURO)EQ21432,90010,000−701265,270
88341, 88342, 88343, 88344, 88360, 88361Benchmark ULTRA automated slide preparation systemEP112134,000150,0001213,279,993
8835Xantibody IgA FITCSL01271.4041.18−42193,520
95018benzylpenicilloyl polylysine (eg, PrePen) 0.25ml uouSH10372.4583.0015160,683
Start Printed Page 41721
95923kit, electrode, iontophoresisSA01411.994.01−67396,189

6. CY 2016 Valuation of Specific Codes

Table 11—CY 2016 Proposed Work RVUs for New, Revised and Potentially Misvalued Codes

HCPCSDescriptorCurrent work RVURUC work RVUCMS work RVUCMS time refinement
11750Removal of nail2.51.991.58No.
20240Biopsy of bone, open procedure3.283.732.61No.
27280Arthrodesis, open, sacroiliac joint including obtaining bone graft14.642020No.
3160ABronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node statNEW54.71No.
3160BBronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node statiNEW5.55.21No.
3160CBronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition toNEW1.71.4No.
31622Diagnostic examination of lung airways using an endoscope2.782.782.78No.
31625Biopsy of lung airways using an endoscope3.363.363.36No.
31626Insertion of radiation therapy markers into lung airways using an endoscope4.164.164.16No.
31628Biopsy of one lobe of lung using an endoscope3.83.83.8No.
31629Needle biopsy of windpipe cartilage, airway, and/or lung using an endoscope4.0944No.
31632Biopsy of lung using an endoscope1.031.031.03No.
31633Needle biopsy of lung using an endoscope1.321.321.32No.
3347ATranscatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performedNEW2525No.
37215Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection19.681818No.
3725AIntravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial non-coronary vessel (List separately in addition to code for primary procedure)NEW1.81.8No.
3725BIntravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedureNEW1.441.44No.
38570Removal of abdominal cavity lymph nodes using an endoscope9.349.348.49No.
38571Removal of total lymph nodes of both sides of pelvis using an endoscope14.761212No.
38572Removal of total lymph nodes of both sides of pelvis and abdominal lymph node biopsy using an endoscope16.9415.615.6No.
3940AMediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performedNEW5.445.44No.
3940BMediastinoscopy; with lymph node biopsy(ies) (eg, lung cancer staging)NEW7.57.25No.
43775Stomach reduction procedure with partial removal of stomach using an endoscopeC21.420.38No.
44380Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed1.050.970.9No.
44381Ileoscopy, through stoma; with transendoscopic balloon dilationN/A1.481.48Yes
44382Ileoscopy, through stoma; with biopsy, single or multiple1.271.271.2No.
44384Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)N/A3.112.88No.
Start Printed Page 41722
44385Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); diagnostic, including collection of specimen(s) by brushing or washing, when performed1.821.31.23No.
44386Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple2.121.61.53No.
44388Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)2.822.822.75No.
44389Colonoscopy through stoma; with biopsy, single or multiple3.133.123.05No.
44390Colonoscopy through stoma; with removal of foreign body3.823.823.77No.
44391Colonoscopy through stoma; with control of bleeding, any method4.314.224.22No.
44392Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery3.813.633.63No.
44394Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique4.424.134.13No.
44401Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion (includes pre-and post-dilation and guide wire passage, when performed)N/A4.444.44No.
44402Colonoscopy through stoma; with endoscopic stent placement (including pre- and post-dilation and guidewire passage, when performed)N/A4.964.73No.
44403Colonoscopy through stoma; with endoscopic mucosal resectionN/A5.815.53No.
44404Colonoscopy through stoma; with directed submucosal injection(s), any substanceN/A3.133.05No.
44405Colonoscopy through stoma; with transendoscopic balloon dilationN/A3.333.33No.
44406Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structuresN/A4.414.13No.
44407Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjaceN/A5.065.06No.
44408Colonoscopy through stoma; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performedN/A4.244.24No.
45330Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing when performed0.960.840.77No.
45331Sigmoidoscopy, flexible; with biopsy, single or multiple1.151.141.07No.
45332Sigmoidoscopy, flexible; with removal of foreign body1.791.851.79No.
45333Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps1.791.651.65No.
45334Sigmoidoscopy, flexible; with control of bleeding, any method2.732.12.1No.
45335Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance1.461.151.07No.
45337Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed2.362.22.2No.
45338Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique2.342.152.15No.
45340Sigmoidoscopy, flexible; with transendoscopic balloon dilation1.891.351.35No.
45341Sigmoidoscopy, flexible; with endoscopic ultrasound examination2.62.432.15No.
45342Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)4.053.083.08No.
45346Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)N/A2.972.84No.
45347Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)N/A2.982.75No.
45349Sigmoidoscopy, flexible; with endoscopic mucosal resectionN/A3.833.55No.
45350Sigmoidoscopy, flexible;with banding (eg, hemorrhoids)N/A1.781.78No.
45378Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed, (separate procedure)3.693.363.29No.
45379Colonoscopy, flexible; with removal of foreign body4.684.374.31No.
45380Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple4.433.663.59No.
45381Colonoscopy, flexible; with directed submucosal injection(s), any substance4.193.673.59No.
45382Colonoscopy, flexible; with control of bleeding, any method5.684.764.76No.
Start Printed Page 41723
45384Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery4.694.174.17No.
45385Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique5.34.674.67No.
45386Colonoscopy, flexible; with transendoscopic balloon dilation4.573.873.87No.
45388Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)N/A4.984.98No.
45389Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed)N/A5.55.27No.
45390Colonoscopy, flexible; with endoscopic mucosal resectionN/A6.356.07No.
45391Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures5.094.954.67No.
45392Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and a6.545.65.6No.
45393Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performedN/A4.784.78No.
45398Colonoscopy, flexible; with banding, (eg, hemorrhoids)N/A4.34.3No.
46500Injection of hemorrhoids1.691.691.42No.
46601Anoscopy; diagnostic, with high-resolution magnificationN/A1.61.6No.
46607Anoscopy; with high-resolution magnification (hra), with biopsy, single or multipleN/A2.22.2No.
47135Transplantation of donor liver to anatomic position83.6491.7890No.
50390Aspiration and/or injection kidney cyst, accessed through the skin1.961.961.96No.
5039AInjection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; new accessNEW3.153.15No.
5039BInjection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; existing accessNEW1.421.1No.
5039CPlacement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretationNEW4.74.25No.
5039DPlacement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, new accessNEW5.755.3No.
5039EExchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretationNEW21.82No.
5039MConvert nephrostomy catheter to nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretationNEW4.24No.
5069GPlacement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; pre-existing nephrostomyNEW4.64.21No.
5069HPlacement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; new access, without separateNEW65.5No.
5069IPlacement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; new access, with separateNEW7.557.05No.
5443ARepair of traumatic corporeal tear(s)NEW11.511.5No.
5443BReplantation, penis, complete amputation including urethral repairNEW24.522.1No.
Start Printed Page 41724
63045Laminectomy, facetectomy and foraminotomy; cervical17.9517.9517.95No.
63046Laminectomy, facetectomy and foraminotomy; thoracic17.2517.2517.25No.
657XGImplantation of intrastromal corneal ring segmentsNEW5.935.39No.
68801Dilation of tear-drainage opening110.82No.
68810Insertion of probe into the tear duct2.151.541.54No.
68811Insertion of probe into the tear duct under anesthesia2.452.031.74No.
68815Probing of nasal-tear duct with insertion of tube or stent3.332.7No.
68816Probing of nasal-tear duct with balloon catheter dilation3.062.352.1No.
71100Radiologic examination, ribs, unilateral; 2 views0.220.220.22No.
72070Radiologic examination, spine; thoracic, 2 views0.220.220.22No.
7208AEntire spine x ray, one viewNEW0.30.26No.
7208BEntire spine x-ray; 2 or 3 viewsNEW0.350.31No.
7208CEntire spine x-ray; 4 or 5 viewsNEW0.390.35No.
7208DEntire spine x-ray; min 6 viewsNEW0.450.41No.
73060Radiologic examination; humerus, minimum of 2 views0.170.160.16No.
73560Radiologic examination, knee; 1 or 2 views0.170.160.16No.
73562Radiologic examination, knee; 3 views0.180.180.18No.
73564Radiologic examination, knee; complete, 4 or more views0.220.220.22No.
73565Radiologic examination, knee; both knees, standing, anteroposterior0.170.160.16No.
73590Radiologic examination; tibia and fibula, 2 views0.170.160.16No.
73600Radiologic examination, ankle; 2 views0.160.160.16No.
76999Ultrasound procedureCCCN/A
77387Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking when performedN/A0.580.58No.
7778BRemote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesionsNEW1.41.4No.
7778CRemote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channelNEW1.951.95No.
7778DRemote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channelsNEW3.83.8No.
7778ERemote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channelsNEW5.45.4No.
88346Antibody evaluation0.860.740.56No.
8835XImmunofluorescence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure)NEW0.70.53No.
88367Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen: initial single probe stain procedure0.730.860.73No.
88368Morphometric analysis, in situ hybridization (quantitative or semi-quantitative) manual, per specimen; initial single probe stain procedure0.880.880.88No.
91299Procedure for gastrointestinal diagnosisCCCN/A
9254ACaloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations)NEW0.80.6No.
9254BCaloric vestibular test with recording, bilateral; monothermal (ie, one irrigation in each ear for a total of two irrigations)NEW0.550.3No.
99174Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateralN0NNo.
9917XInstrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysisNEW0NNo.
G0104Colorectal cancer screening; flexible sigmoidoscopy0.960.840.77No.
G0105Colorectal cancer screening; colonoscopy on individual at high risk3.363.363.29No.
G0121Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk3.363.363.29No.
Start Printed Page 41725

Table 12—CY 2016 Proposed Codes With Direct PE Input Recommendations Accepted Without Refinement

HCPCSDescriptor
20245Bone biopsy excisional.
20697Comp ext fixate strut change.
27280Fusion of sacroiliac joint.
3160ABronch ebus 141 gmt. 141 ng 1/2 node.
3160BBronch ebus 141 gmt. 141 ng 3/> node.
3160CBronch ebus ivntj perph les.
31622Dx bronchoscope/wash.
31625Bronchoscopy w/biopsy(s).
31626Bronchoscopy w/markers.
31628Bronchoscopy/lung bx each.
31629Bronchoscopy/needle bx each.
31632Bronchoscopy/lung bx addl.
31633Bronchoscopy/needle bx addl.
3347AImplant tcat pulm vlv perq.
37215Transcath stent cca w/eps.
3725AIntrvasc us noncoronary 1st.
3725BIntrvasc us noncoronary addl.
38570Laparoscopy lymph node biop.
38571Laparoscopy lymphadenectomy.
3940AMediastinoscpy w/medstnl bx.
3940BMediastinoscpy w/lmph nod bx.
44384Small bowel endoscopy.
44402Colonoscopy w/stent plcmt.
44403Colonoscopy w/resection.
44406Colonoscopy w/ultrasound.
44407Colonoscopy w/ndl aspir/bx.
44408Colonoscopy w/decompression.
45337Sigmoidoscopy & decompress.
45341Sigmoidoscopy w/ultrasound.
45342Sigmoidoscopy w/us guide bx.
45347Sigmoidoscopy w/plcmt stent.
45349Sigmoidoscopy w/resection.
45389Colonoscopy w/stent plcmt.
45390Colonoscopy w/resection.
45391Colonoscopy w/endoscope us.
45392Colonoscopy w/endoscopic fnb.
45393Colonoscopy w/decompression.
47135Transplantation of liver.
5443BReplantation of penis.
63045Remove spine lamina 1 crvl.
63046Remove spine lamina 1 thrc.
68811Probe nasolacrimal duct.
68815Probe nasolacrimal duct.
692XXRemove impacted ear wax uni.
76948Echo guide ova aspiration.
7778AHdr rdncl skn surf brachytx.
7778BHdr rdncl skn surf brachytx.
7778CHdr rdncl ntrstl/icav brchtx.
7778DHdr rdncl ntrstl/icav brchtx.
7778EHdr rdncl ntrstl/icav brchtx.
88346Immunofluorescent study.
8835XImmunofluor antb addl stain.
9254ACaloric vstblr test w/rec.
9254BCaloric vstblr test w/rec.
9935AProlong clincl staff svc.
9935BProlong clincl staff svc add.

Table 13—CY 2016 Proposed Codes With Direct PE Input Recommendations Accepted With Refinements

HCPCS codeHCPCS code descriptionInput codeInput code descriptionNF/FLabor activity (where applicable)RUC recommendation or current value (min or qty)CMS refinement (min or qty)CommentDirect costs change ($)
10021Fna w/o imageEF015mayo standNF2428Refined equipment time to conform to established policies for non-highly technical equipment
EF023table, examNF2928Refined equipment time to conform to established policies for non-highly technical equipment
L037DRN/LPN/MTANFGreet patient, provide gowning, ensure appropriate medical records are available10Typically billed with an E/M or other evaluation service(0.37)
11750Removal of nail bedEF015mayo standNF2745Refined equipment time to conform to established policies for non-highly technical equipment0.02
EF031table, powerNF5462Refined equipment time to conform to established policies for non-highly technical equipment0.13
EQ137instrument pack, basic ($500-$1,499)NF3445Refined equipment time to conform to established policies for non-highly technical equipment0.03
EQ168light, examNF5462Refined equipment time to conform to established policies for non-highly technical equipment0.03
L037DRN/LPN/MTANFProvide pre-service education/obtain consent02Refined time to standard time for this clinical labor task0.74
SG067penrose drain (0.25in x 4in)NF10Removed supply not typically used in this service(0.50)
11760Repair of nail bedEF014light, surgicalNF4543Refined equipment time to conform to established policies for non-highly technical equipment(0.02)
EF015mayo standNF4543Refined equipment time to conform to established policies for non-highly technical equipment
Start Printed Page 41726
EF031table, powerNF7270Refined equipment time to conform to established policies for non-highly technical equipment(0.03)
EQ137instrument pack, basic ($500-$1,499)NF5247Refined equipment time to conform to established policies for instrument packs(0.01)
EQ168light, examNF7270Refined equipment time to conform to established policies for non-highly technical equipment(0.01)
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFComplete pre-service diagnostic & referral forms50Emergency procedure, input would not typically be used(1.85)
L037DRN/LPN/MTANFCoordinate pre-surgery services30Emergency procedure, input would not typically be used(1.11)
L037DRN/LPN/MTANFProvide pre-service education/obtain consent50Duplication with other clinical labor task(1.85)
12005Rpr s/n/a/gen/trk12.6-20.0cmEF023table, examNF4044Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ110electrocautery-hyfrecator, up to 45 wattsNF4044Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ168light, examNF4044Refined equipment time to conform to established policies for non-highly technical equipment0.02
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFCheck dressings & wound/home care instructions/coordinate office visits/prescriptions73Refined time to standard time for this clinical labor task(1.48)
12006Rpr s/n/a/gen/trk20.1-30.0cmEF031table, powerNF4549Refined equipment time to conform to established policies for non-highly technical equipment0.07
EQ110electrocautery-hyfrecator, up to 45 wattsNF4549Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ168light, examNF4549Refined equipment time to conform to established policies for non-highly technical equipment0.02
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFCheck dressings & wound/home care instructions/coordinate office visits/prescriptions73Refined time to standard time for this clinical labor task(1.48)
12007Rpr s/n/ax/gen/trnk >30.0 cmEF031table, powerNF5054Refined equipment time to conform to established policies for non-highly technical equipment0.07
Start Printed Page 41727
EQ110electrocautery-hyfrecator, up to 45 wattsNF5054Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ168light, examNF5054Refined equipment time to conform to established policies for non-highly technical equipment0.02
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFCheck dressings & wound/home care instructions/coordinate office visits/prescriptions73Refined time to standard time for this clinical labor task(1.48)
12013Rpr f/e/e/n/l/m 2.6-5.0 cmEF031table, powerNF2733Refined equipment time to conform to established policies for non-highly technical equipment0.10
EQ110electrocautery-hyfrecator, up to 45 wattsNF2733Refined equipment time to conform to established policies for non-highly technical equipment0.02
EQ168light, examNF2733Refined equipment time to conform to established policies for non-highly technical equipment0.03
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFCheck dressings & wound/home care instructions/coordinate office visits/prescriptions53Refined time to standard time for this clinical labor task(0.74)
12014Rpr f/e/e/n/l/m 5.1-7.5 cmEF031table, powerNF3238Refined equipment time to conform to established policies for non-highly technical equipment0.10
EQ110electrocautery-hyfrecator, up to 45 wattsNF3238Refined equipment time to conform to established policies for non-highly technical equipment0.02
EQ168light, examNF3238Refined equipment time to conform to established policies for non-highly technical equipment0.03
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFCheck dressings & wound/home care instructions/coordinate office visits/prescriptions53Refined time to standard time for this clinical labor task(0.74)
12015Rpr f/e/e/n/l/m 7.6-12.5 cmEF031table, powerNF3743Refined equipment time to conform to established policies for non-highly technical equipment0.10
EQ110electrocautery-hyfrecator, up to 45 wattsNF3743Refined equipment time to conform to established policies for non-highly technical equipment0.02
EQ168light, examNF3743Refined equipment time to conform to established policies for non-highly technical equipment0.03
Start Printed Page 41728
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFCheck dressings & wound/home care instructions/coordinate office visits/prescriptions53Refined time to standard time for this clinical labor task(0.74)
12016Rpr fe/e/en/l/m 12.6-20.0 cmEF031table, powerNF4248Refined equipment time to conform to established policies for non-highly technical equipment0.10
EQ110electrocautery-hyfrecator, up to 45 wattsNF4248Refined equipment time to conform to established policies for non-highly technical equipment0.02
EQ168light, examNF4248Refined equipment time to conform to established policies for non-highly technical equipment0.03
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFCheck dressings & wound/home care instructions/coordinate office visits/prescriptions53Refined time to standard time for this clinical labor task(0.74)
12041Intmd rpr n-hf/genit 2.5cm/<ED004camera, digital (6 mexapixel)F027Input added to maintain consistency with all other codes within family0.10
ED004camera, digital (6 mexapixel)NF6027Refined equipment time to conform to office visit duration(0.12)
EF014light, surgicalNF3342Refined equipment time to conform to established policies for non-highly technical equipment0.09
EF015mayo standNF3342Refined equipment time to conform to established policies for non-highly technical equipment0.01
EF023table, examNF6027Refined equipment time to conform to office visit duration(0.10)
EF031table, powerNF3342Refined equipment time to conform to established policies for non-highly technical equipment0.15
EQ110electrocautery-hyfrecator, up to 45 wattsNF3342Refined equipment time to conform to established policies for non-highly technical equipment0.02
EQ137instrument pack, basic ($500-$1,499)NF046Equipment item replaces another item (EQ138); see preamble0.11
EQ138instrument pack, medium ($1,500 and up)NF400Equipment item replaced by another item (EQ137); see preamble(0.28)
EQ168light, examNF6027Refined equipment time to conform to office visit duration(0.14)
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTAFProvide pre-service education/obtain consent20Intraservice direct PE inputs are not included in the facility setting; See preamble text(0.74)
Start Printed Page 41729
L037DRN/LPN/MTANFComplete pre-service diagnostic & referral forms50Emergency procedure, input would not typically be used(1.85)
L037DRN/LPN/MTANFCoordinate pre-surgery services30Emergency procedure, input would not typically be used(1.11)
L037DRN/LPN/MTANFFollow-up phone calls and prescriptions30Emergency procedure, input would not typically be used(1.11)
12054Intmd rpr face/mm 7.6-12.5cmED004camera, digital (6 mexapixel)NF9027Refined equipment time to conform to office visit duration(0.24)
EF014light, surgicalNF6371Refined equipment time to conform to established policies for non-highly technical equipment0.08
EF015mayo standNF6371Refined equipment time to conform to established policies for non-highly technical equipment0.01
EF023table, examNF9027Refined equipment time to conform to office visit duration(0.19)
EF031table, powerNF6371Refined equipment time to conform to established policies for non-highly technical equipment0.13
EQ110electrocautery-hyfrecator, up to 45 wattsNF6371Refined equipment time to conform to established policies for non-highly technical equipment0.02
EQ138instrument pack, medium ($1,500 and up)NF7580Refined equipment time to conform to established policies for instrument packs0.03
EQ168light, examNF9027Refined equipment time to conform to office visit duration(0.27)
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTAFProvide pre-service education/obtain consent20Intraservice direct PE inputs are not included in the facility setting; See preamble text(0.74)
L037DRN/LPN/MTANFComplete pre-service diagnostic & referral forms50Emergency procedure, input would not typically be used(1.85)
L037DRN/LPN/MTANFCoordinate pre-surgery services30Emergency procedure, input would not typically be used(1.11)
L037DRN/LPN/MTANFFollow-up phone calls and prescriptions30Emergency procedure, input would not typically be used(1.11)
12055Intmd rpr face/mm 12.6-20 cmED004camera, digital (6 mexapixel)NF13663Refined equipment time to conform to office visit duration(0.27)
EF014light, surgicalNF7381Refined equipment time to conform to established policies for non-highly technical equipment0.08
EF015mayo standNF7381Refined equipment time to conform to established policies for non-highly technical equipment0.01
EF023table, examNF13663Refined equipment time to conform to office visit duration(0.22)
EF031table, powerNF7381Refined equipment time to conform to established policies for non-highly technical equipment0.13
Start Printed Page 41730
EQ110electrocautery-hyfrecator, up to 45 wattsNF7381Refined equipment time to conform to established policies for non-highly technical equipment0.02
EQ138instrument pack, medium ($1,500 and up)NF8590Refined equipment time to conform to established policies for instrument packs0.03
EQ168light, examNF13663Refined equipment time to conform to office visit duration(0.32)
L037DRN/LPN/MTAFProvide pre-service education/obtain consent20Intraservice direct PE inputs are not included in the facility setting; See preamble text(0.74)
L037DRN/LPN/MTANFComplete pre-service diagnostic & referral forms50Emergency procedure, input would not typically be used(1.85)
L037DRN/LPN/MTANFCoordinate pre-surgery services30Emergency procedure, input would not typically be used(1.11)
L037DRN/LPN/MTANFFollow-up phone calls and prescriptions30Emergency procedure, input would not typically be used(1.11)
SA054pack, post-op incision care (suture)F21No rationale was provided for quantity change relative to current value; maintaining current value(4.91)
12057Intmd rpr face/mm >30.0 cmED004camera, digital (6 mexapixel)NF16663Refined equipment time to conform to office visit duration(0.39)
EF014light, surgicalNF103111Refined equipment time to conform to established policies for non-highly technical equipment0.08
EF015mayo standNF103111Refined equipment time to conform to established policies for non-highly technical equipment0.01
EF023table, examNF16663Refined equipment time to conform to office visit duration(0.31)
EF031table, powerNF103111Refined equipment time to conform to established policies for non-highly technical equipment0.13
EQ110electrocautery-hyfrecator, up to 45 wattsNF103111Refined equipment time to conform to established policies for non-highly technical equipment0.02
EQ138instrument pack, medium ($1,500 and up)NF115120Refined equipment time to conform to established policies for instrument packs0.03
EQ168light, examNF16663Refined equipment time to conform to office visit duration(0.45)
L037DRN/LPN/MTAFProvide pre-service education/obtain consent20Intraservice direct PE inputs are not included in the facility setting; See preamble text(0.74)
L037DRN/LPN/MTANFComplete pre-service diagnostic & referral forms50Emergency procedure, input would not typically be used(1.85)
L037DRN/LPN/MTANFCoordinate pre-surgery services30Emergency procedure, input would not typically be used(1.11)
L037DRN/LPN/MTANFFollow-up phone calls and prescriptions30Emergency procedure, input would not typically be used(1.11)
SA054pack, post-op incision care (suture)F21No rationale was provided for quantity change relative to current value; maintaining current value(4.91)
Start Printed Page 41731
SA054pack, post-op incision care (suture)NF21No rationale was provided for quantity change relative to current value; maintaining current value(4.91)
20240Bone biopsy excisionalL037DRN/LPN/MTAFDischrg gmt. same day (0.5 x 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
30300Remove nasal foreign bodyEF008chair with headrest, exam, recliningNF5967Refined equipment time to conform to established policies for non-highly technical equipment0.09
EF015mayo standNF2240Refined equipment time to conform to established policies for non-highly technical equipment0.02
EQ137instrument pack, basic ($500-$1,499)NF2947Refined equipment time to conform to established policies for instrument packs0.04
EQ167light source, xenonF270Redundant when used together with EQ170; see preamble(0.72)
EQ167light source, xenonNF590Redundant when used together with EQ170; see preamble(1.57)
EQ170light, fiberoptic headlight w-sourceNF5967Refined equipment time to conform to established policies for non-highly technical equipment0.06
EQ234suction and pressure cabinet, ENT (SMR)NF5967Refined equipment time to conform to established policies for non-highly technical equipment0.07
ES013endoscope, rigid, sinoscopyNF7174Refined equipment time to conform to established policies for scopes0.02
ES031video system, endoscopy (processor, digital capture, monitor, printer, cart)NF5967Refined equipment time to conform to established policies for non-highly technical equipment1.03
L037DRN/LPN/MTAFDischarge day management60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
SA041pack, basic injectionNF10Supply item replaced by another item (component parts); see preamble(11.67)
SB001cap, surgicalNF01Supply item replaces another item (SA041); see preamble0.21
SB012drape, sterile, for Mayo standNF01Supply item replaces another item (SA041); see preamble1.69
SB024gloves, sterileNF02Supply item replaces another item (SA041); see preamble1.68
SB027gown, staff, imperviousNF02Supply item replaces another item (SA041); see preamble2.37
SB033mask, surgicalNF01Supply item replaces another item (SA041); see preamble0.20
SB044underpad 2ft x 3ft (Chux)NF01Supply item replaces another item (SA041); see preamble0.23
SG009applicator, sponge-tippedNF03Supply item replaces another item (SA041); see preamble0.42
SG055gauze, sterile 4in x 4inNF02Supply item replaces another item (SA041); see preamble0.32
SM010cleaning brush, endoscopeF21Refined supply quantity to what is typical for the procedure(4.99)
Start Printed Page 41732
SM010cleaning brush, endoscopeNF42Refined supply quantity to what is typical for the procedure(9.98)
30903Control of nosebleedEF008chair with headrest, exam, recliningNF54110Refined equipment time to conform to established policies for equipment with 4× monitoring time0.60
EQ110electrocautery-hyfrecator, up to 45 wattsNF5450Refined equipment time to conform to established policies for non-highly technical equipment(0.01)
EQ137instrument pack, basic ($500-$1,499)NF6154Refined equipment time to conform to established policies for instrument packs(0.02)
EQ170light, fiberoptic headlight w-sourceNF5450Refined equipment time to conform to established policies for non-highly technical equipment(0.03)
EQ234suction and pressure cabinet, ENT (SMR)NF54110Refined equipment time to conform to established policies for equipment with 4× monitoring time0.52
L037DRN/LPN/MTAFDischrg gmt. same day (0.5 x 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
30905Control of nosebleedEF008chair with headrest, exam, recliningNF72128Refined equipment time to conform to established policies for equipment with 4× monitoring time0.60
EQ110electrocautery-hyfrecator, up to 45 wattsNF7268Refined equipment time to conform to established policies for non-highly technical equipment(0.01)
EQ137instrument pack, basic ($500-$1,499)NF7972Refined equipment time to conform to established policies for instrument packs(0.02)
EQ170light, fiberoptic headlight w-sourceNF7268Refined equipment time to conform to established policies for non-highly technical equipment(0.03)
EQ234suction and pressure cabinet, ENT (SMR)NF72128Refined equipment time to conform to established policies for equipment with 4× monitoring time0.52
L037DRN/LPN/MTAFDischrg gmt. same day (0.5 x 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
30906Repeat control of nosebleedEF008chair with headrest, exam, recliningNF84140Refined equipment time to conform to established policies for equipment with 4× monitoring time0.60
EQ110electrocautery-hyfrecator, up to 45 wattsNF8480Refined equipment time to conform to established policies for non-highly technical equipment(0.01)
EQ137instrument pack, basic ($500-$1,499)NF9184Refined equipment time to conform to established policies for instrument packs(0.02)
EQ170light, fiberoptic headlight w-sourceNF8480Refined equipment time to conform to established policies for non-highly technical equipment(0.03)
EQ234suction and pressure cabinet, ENT (SMR)NF84140Refined equipment time to conform to established policies for equipment with 4× monitoring time0.52
31295Sinus endo w/balloon dilEF008chair with headrest, exam, recliningNF50103Refined equipment time to conform to established policies for equipment with 4× monitoring time0.57
Start Printed Page 41733
EF015mayo standNF3243Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ137instrument pack, basic ($500-$1,499)NF4247Refined equipment time to conform to established policies for instrument packs0.01
EQ167light source, xenonNF500Redundant when used together with EQ170; see preamble(1.33)
EQ170light, fiberoptic headlight w-sourceNF5043Refined equipment time to conform to established policies for non-highly technical equipment(0.06)
EQ234suction and pressure cabinet, ENT (SMR)NF50103Refined equipment time to conform to established policies for equipment with 4× monitoring time0.49
ES013endoscope, rigid, sinoscopyNF4447Refined equipment time to conform to established policies for scopes0.02
ES031video system, endoscopy (processor, digital capture, monitor, printer, cart)NF5043Refined equipment time to conform to established policies for non-highly technical equipment(0.90)
L037DRN/LPN/MTAFDischrg gmt. same day (0.5 × 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFComplete pre-service diagnostic & referral forms50See preamble text(1.85)
L037DRN/LPN/MTANFProvide pre-service education/obtain consent73Refined time to standard time for this clinical labor task(1.48)
L037DRN/LPN/MTANFSedate/Apply anesthesia52Refined time to standard time for this clinical labor task(1.11)
SJ037oxymetazoline nasal spray (Afrin) (15ml uou)NF31Refined supply quantity to what is typical for the procedure(3.66)
31296Sinus endo w/balloon dilEF008chair with headrest, exam, recliningNF60113Refined equipment time to conform to established policies for equipment with 4× monitoring time0.57
EF015mayo standNF6053Refined equipment time to conform to established policies for non-highly technical equipment(0.01)
EQ137instrument pack, basic ($500-$1,499)NF5257Refined equipment time to conform to established policies for instrument packs0.01
EQ167light source, xenonNF600Redundant when used together with EQ170; see preamble(1.60)
EQ170light, fiberoptic headlight w-sourceNF6053Refined equipment time to conform to established policies for non-highly technical equipment(0.06)
EQ234suction and pressure cabinet, ENT (SMR)NF60113Refined equipment time to conform to established policies for equipment with 4× monitoring time0.49
ES013endoscope, rigid, sinoscopyNF5457Refined equipment time to conform to established policies for scopes0.02
ES031video system, endoscopy (processor, digital capture, monitor, printer, cart)NF6053Refined equipment time to conform to established policies for non-highly technical equipment(0.90)
Start Printed Page 41734
L037DRN/LPN/MTAFDischrg gmt. same day (0.5 × 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFComplete pre-service diagnostic & referral forms50See preamble text(1.85)
L037DRN/LPN/MTANFProvide pre-service education/obtain consent73Refined time to standard time for this clinical labor task(1.48)
L037DRN/LPN/MTANFSedate/Apply anesthesia52Refined time to standard time for this clinical labor task(1.11)
SJ037oxymetazoline nasal spray (Afrin) (15ml uou)NF31Refined supply quantity to what is typical for the procedure(3.66)
31297Sinus endo w/balloon dilEF008chair with headrest, exam, recliningNF58111Refined equipment time to conform to established policies for equipment with 4× monitoring time0.57
EF015mayo standNF4051Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ137instrument pack, basic ($500-$1,499)NF4755Refined equipment time to conform to established policies for instrument packs0.02
EQ167light source, xenonNF580Redundant when used together with EQ170; see preamble(1.55)
EQ170light, fiberoptic headlight w-sourceNF5851Refined equipment time to conform to established policies for non-highly technical equipment(0.06)
EQ234suction and pressure cabinet, ENT (SMR)NF58111Refined equipment time to conform to established policies for equipment with 4× monitoring time0.49
ES013endoscope, rigid, sinoscopyNF5255Refined equipment time to conform to established policies for scopes0.02
ES031video system, endoscopy (processor, digital capture, monitor, printer, cart)NF5851Refined equipment time to conform to established policies for non-highly technical equipment(0.90)
L037DRN/LPN/MTAFDischrg gmt. same day (0.5 × 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFComplete pre-service diagnostic & referral forms50See preamble text(1.85)
L037DRN/LPN/MTANFProvide pre-service education/obtain consent73Refined time to standard time for this clinical labor task(1.48)
L037DRN/LPN/MTANFSedate/Apply anesthesia52Refined time to standard time for this clinical labor task(1.11)
SJ037oxymetazoline nasal spray (Afrin) (15ml uou)NF31Refined supply quantity to what is typical for the procedure(3.66)
38572Laparoscopy lymphadenectomySA051pack, pelvic examF10Removed supply not typically used in this service(1.17)
40804Removal foreign body mouthEF008chair with headrest, exam, recliningNF7482Refined equipment time to conform to established policies for non-highly technical equipment0.09
EQ110electrocautery-hyfrecator, up to 45 wattsNF2939Refined equipment time to conform to established policies for non-highly technical equipment0.03
Start Printed Page 41735
EQ137instrument pack, basic ($500-$1,499)NF3638Refined equipment time to conform to established policies for instrument packs
EQ170light, fiberoptic headlight w-sourceNF7482Refined equipment time to conform to established policies for non-highly technical equipment0.06
EQ234suction and pressure cabinet, ENT (SMR)F270Equipment usage not typical for a follow-up office visit(0.25)
EQ234suction and pressure cabinet, ENT (SMR)NF6139Refined equipment time to conform to established policies for non-highly technical equipment(0.20)
L037DRN/LPN/MTAFDischrg gmt. same day (0.5 × 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
SD009canister, suctionNF21Refined supply quantity to what is typical for the procedure(3.91)
42809Remove pharynx foreign bodyEF008chair with headrest, exam, recliningNF5874Refined equipment time to conform to established policies for non-highly technical equipment0.17
EF015mayo standNF2647Refined equipment time to conform to established policies for non-highly technical equipment0.02
EQ137instrument pack, basic ($500-$1,499)NF6051Refined equipment time to conform to established policies for instrument packs(0.02)
EQ170light, fiberoptic headlight w-sourceNF5874Refined equipment time to conform to established policies for non-highly technical equipment0.13
EQ234suction and pressure cabinet, ENT (SMR)F270Equipment usage not typical for a follow-up office visit(0.25)
EQ234suction and pressure cabinet, ENT (SMR)NF5847Refined equipment time to conform to established policies for non-highly technical equipment(0.10)
ES020fiberscope, flexible, rhinolaryngoscopyNF115128Refined equipment time to conform to established policies for scopes0.47
L037DRN/LPN/MTAFDischrg gmt. same day (0.5 × 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
SA048pack, minimum multi-specialty visitF21Refined supply quantity to what is typical for the procedure(1.14)
44380Small bowel endoscopy br/waEF018stretcherNF7377Standard time for moderate sedation equipment0.02
EF027table, instrument, mobileNF2977Standard time for moderate sedation equipment0.07
EF031table, powerNF290Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.47)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5277Standard time for moderate sedation equipment0.35
EQ032IV infusion pumpNF5277Standard time for moderate sedation equipment0.16
44381Small bowel endoscopy br/waEF018stretcherNF8387Standard equipment and time for moderate sedation0.02
EF027table, instrument, mobileNF3987Standard equipment and time for moderate sedation0.07
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6287Standard equipment and time for moderate sedation0.35
Start Printed Page 41736
EQ032IV infusion pumpNF6287Standard equipment and time for moderate sedation0.16
44382Small bowel endoscopyEF018stretcherNF7882Standard time for moderate sedation equipment0.02
EF027table, instrument, mobileNF3482Standard time for moderate sedation equipment0.07
EF031table, powerNF340Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.56)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5782Standard time for moderate sedation equipment0.35
EQ032IV infusion pumpNF5782Standard time for moderate sedation equipment0.16
44385Endoscopy of bowel pouchEF027table, instrument, mobileNF2977Standard time for moderate sedation equipment0.07
EF031table, powerNF290Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.47)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5277Refined equipment time to conform to established policies for equipment with 4× monitoring time0.35
EQ032IV infusion pumpNF5277Standard time for moderate sedation equipment0.16
44386Endoscopy bowel pouch/biopEF027table, instrument, mobileNF3179Standard time for moderate sedation equipment0.07
EF031table, powerNF310Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.51)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5479Standard time for moderate sedation equipment0.35
EQ032IV infusion pumpNF5479Standard time for moderate sedation equipment0.16
44388Colonoscopy thru stoma spxEF027table, instrument, mobileNF5787Standard time for moderate sedation equipment0.04
EF031table, powerNF390Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.64)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5787Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF5787Standard time for moderate sedation equipment0.19
44389Colonoscopy with biopsyEF027table, instrument, mobileNF6292Standard time for moderate sedation equipment0.04
EF031table, powerNF440Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.72)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6292Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF6292Standard time for moderate sedation equipment0.19
44390Colonoscopy for foreign bodyEF027table, instrument, mobileNF6797Standard time for moderate sedation equipment0.04
EF031table, powerNF490Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.80)
Start Printed Page 41737
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6797Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF6797Standard time for moderate sedation equipment0.19
44391Colonoscopy for bleedingEF027table, instrument, mobileNF72102Standard time for moderate sedation equipment0.04
EF031table, powerNF540Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.88)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF72102Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF72102Standard time for moderate sedation equipment0.19
44392Colonoscopy & polypectomyEF027table, instrument, mobileNF6292Standard time for moderate sedation equipment0.04
EF031table, powerNF440Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.72)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6292Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF6292Standard time for moderate sedation equipment0.19
44394Colonoscopy w/snareEF027table, instrument, mobileNF6292Standard time for moderate sedation equipment0.04
EF031table, powerNF440Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.72)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6292Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF6292Standard time for moderate sedation equipment0.19
44401Colonoscopy with ablationEF027table, instrument, mobileNF6292Standard equipment and time for moderate sedation0.04
EF031table, powerNF440Refined equipment time to conform to established policies for non-highly technical equipment(0.72)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6292Standard equipment and time for moderate sedation0.42
EQ032IV infusion pumpNF6292Standard equipment and time for moderate sedation0.19
44404Colonoscopy w/injectionEF027table, instrument, mobileNF6292Standard equipment and time for moderate sedation0.04
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6292Standard equipment and time for moderate sedation0.42
EQ032IV infusion pumpNF6292Standard equipment and time for moderate sedation0.19
44405Colonoscopy w/dilationEF027table, instrument, mobileNF40100Standard equipment and time for moderate sedation0.08
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF50100Standard equipment and time for moderate sedation0.70
EQ032IV infusion pumpNF50100Standard equipment and time for moderate sedation0.32
45330Diagnostic sigmoidoscopyEF027table, instrument, mobileNF120No moderate sedation(0.02)
Start Printed Page 41738
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF180No moderate sedation(0.25)
EQ235suction machine (Gomco)NF1222Increased to reflect Intra-Service clinical labor tasks0.02
ES031video system, endoscopy (processor, digital capture, monitor, printer, cart)NF1222Increased to reflect Intra-Service clinical labor tasks1.29
ES043Video Sigmoid- oscopeNF4249Refined equipment time to conform to established policies for scopes0.49
45331Sigmoidoscopy and biopsyEF027table, instrument, mobileNF120No moderate sedation(0.02)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF330No moderate sedation(0.46)
EQ235suction machine (Gomco)NF1227Matches time spent using endoscope system0.03
ES031video system, endoscopy (processor, digital capture, monitor, printer, cart)NF1227Increased to reflect Intra-Service clinical labor tasks1.93
ES043Video Sigmoid- oscopeNF4254Refined equipment time to conform to established policies for scopes0.83
45332Sigmoidoscopy w/fb removalEF027table, instrument, mobileNF3482Standard time for moderate sedation equipment0.07
EF031table, powerNF340Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.56)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5782Standard time for moderate sedation equipment0.35
EQ032IV infusion pumpNF5782Standard time for moderate sedation equipment0.16
45333Sigmoidoscopy & polypectomyEF027table, instrument, mobileNF2977Standard time for moderate sedation equipment0.07
EF031table, powerNF290Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.47)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5277Standard time for moderate sedation equipment0.35
EQ032IV infusion pumpNF5277Standard time for moderate sedation equipment0.16
45334Sigmoidoscopy for bleedingEF027table, instrument, mobileNF3482Standard time for moderate sedation equipment0.07
EF031table, powerNF340Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.56)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5782Standard time for moderate sedation equipment0.35
EQ032IV infusion pumpNF5782Standard time for moderate sedation equipment0.16
45335Sigmoidoscopy w/submuc injEF027table, instrument, mobileNF2977Standard time for moderate sedation equipment0.07
EF031table, powerNF290Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.47)
Start Printed Page 41739
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5277Standard time for moderate sedation equipment0.35
EQ032IV infusion pumpNF5277Standard time for moderate sedation equipment0.16
45338Sigmoidoscopy w/tumr removeEF027table, instrument, mobileNF2977Standard time for moderate sedation equipment0.07
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5277Standard time for moderate sedation equipment0.35
EQ032IV infusion pumpNF5277Standard time for moderate sedation equipment0.16
45340Sig w/tndsc balloon dilationEF027table, instrument, mobileNF3482Standard time for moderate sedation equipment0.07
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5782Standard time for moderate sedation equipment0.35
EQ032IV infusion pumpNF5782Standard time for moderate sedation equipment0.16
45346Sigmoidoscopy w/ablationEF027table, instrument, mobileNF3482Standard equipment and time for moderate sedation0.07
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5782Standard equipment and time for moderate sedation0.35
EQ032IV infusion pumpNF5782Standard equipment and time for moderate sedation0.16
45350Sgmdsc w/band ligationEF027table, instrument, mobileNF9482Standard equipment and time for moderate sedation(0.02)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF9482Standard equipment and time for moderate sedation(0.17)
EQ032IV infusion pumpNF9482Standard equipment and time for moderate sedation(0.08)
SH074water, sterile for irrigation (250-1000ml uou)NF10This input is not contained within any other code in this family; maintaining consistency with all other codes within family(2.09)
SK087water, distilledNF05This input is not contained within any other code in this family; maintaining consistency with all other codes within family0.07
45378Diagnostic colonoscopyEF027table, instrument, mobileNF5787Standard time for moderate sedation equipment0.04
EF031table, powerNF390Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.64)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5787Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF5787Standard time for moderate sedation equipment0.19
EQ235suction machine (Gomco)NF7239Matches time spent using endoscope system(0.07)
45379Colonoscopy w/fb removalEF027table, instrument, mobileNF6797Standard time for moderate sedation equipment0.04
EF031table, powerNF490Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.80)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6797Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF6797Standard time for moderate sedation equipment0.19
Start Printed Page 41740
EQ235suction machine (Gomco)NF9249Matches time spent using endoscope system(0.08)
45380Colonoscopy and biopsyEF027table, instrument, mobileNF6090Standard time for moderate sedation equipment0.04
EF031table, powerNF420Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.69)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6090Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF6090Standard time for moderate sedation equipment0.19
EQ235suction machine (Gomco)NF7842Matches time spent using endoscope system(0.07)
45381Colonoscopy submucous njxEF027table, instrument, mobileNF6090Standard time for moderate sedation equipment0.04
EF031table, powerNF420Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.69)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6090Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF6090Standard time for moderate sedation equipment0.19
EQ235suction machine (Gomco)NF7842Matches time spent using endoscope system(0.07)
45382Colonoscopy w/control bleedEF027table, instrument, mobileNF72102Standard time for moderate sedation equipment0.04
EF031table, powerNF540Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.88)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF72102Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF72102Standard time for moderate sedation equipment0.19
EQ235suction machine (Gomco)NF10254Matches time spent using endoscope system(0.09)
45384Colonoscopy w/lesion removalEF027table, instrument, mobileNF6090Standard time for moderate sedation equipment0.04
EF031table, powerNF420Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.69)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6090Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF6090Standard time for moderate sedation equipment0.19
EQ235suction machine (Gomco)NF7842Matches time spent using endoscope system(0.07)
45385Colonoscopy w/lesion removalEF027table, instrument, mobileNF6292Standard time for moderate sedation equipment0.04
EF031table, powerNF440Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.72)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6292Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF6292Standard time for moderate sedation equipment0.19
EQ235suction machine (Gomco)NF8244Matches time spent using endoscope system(0.07)
45386Colonoscopy w/balloon dilatEF027table, instrument, mobileNF6797Standard time for moderate sedation equipment0.04
Start Printed Page 41741
EF031table, powerNF490Equipment removed due to redundancy when used together with equipment item EF018, stretcher(0.80)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6797Standard time for moderate sedation equipment0.42
EQ032IV infusion pumpNF6797Standard time for moderate sedation equipment0.19
EQ235suction machine (Gomco)NF9249Matches time spent using endoscope system(0.08)
45388Colonoscopy w/ablationEF027table, instrument, mobileNF6797Standard equipment and time for moderate sedation0.04
EF031table, powerNF490Refined equipment time to conform to established policies for non-highly technical equipment(0.80)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF6797Standard equipment and time for moderate sedation0.42
EQ032IV infusion pumpNF6797Standard equipment and time for moderate sedation0.19
EQ235suction machine (Gomco)NF9249Matches time spent using endoscope system(0.08)
45398Colonoscopy w/band ligationEF027table, instrument, mobileNF5282Standard equipment and time for moderate sedation0.04
EF031table, powerNF340Refined equipment time to conform to established policies for non-highly technical equipment(0.56)
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF5282Standard equipment and time for moderate sedation0.42
EQ032IV infusion pumpNF5282Standard equipment and time for moderate sedation0.19
EQ235suction machine (Gomco)NF6234Matches time spent using endoscope system(0.06)
46500Injection into hemorrhoid(s)EF014light, surgicalNF7360Refined equipment time to conform to established policies for non-highly technical equipment(0.13)
EF031table, powerNF7360Refined equipment time to conform to established policies for non-highly technical equipment(0.21)
EQ235suction machine (Gomco)NF7360Refined equipment time to conform to established policies for non-highly technical equipment(0.03)
ES002anoscope with light sourceNF7860Refined equipment time to conform to established policies for non-highly technical equipment(0.07)
L037DRN/LPN/MTAFCleaning scope at POV50Included in clinical labor task “Clean room, equipment, and supplies” included in post-operative visit(1.85)
L037DRN/LPN/MTAFComplete pre-service diagnostic and referral forms30Standard 0 day global pre-service times; exception not accepted as service is rarely furnished in the facility(1.11)
L037DRN/LPN/MTAFCoordinate pre-surgery services30Standard 0 day global pre-service times; exception not accepted as service is rarely furnished in the facility(1.11)
L037DRN/LPN/MTAFFollow-up phone calls and prescriptions30Standard 0 day global pre-service times; exception not accepted as service is rarely furnished in the facility(1.11)
Start Printed Page 41742
L037DRN/LPN/MTAFSchedule space and equipment in facility30Standard 0 day global pre-service times; exception not accepted as service is rarely furnished in the facility(1.11)
L037DRN/LPN/MTAFSetup scope at POV50Included in clinical labor task “Prepare room, equipment, supplies” included in post-operative visit(1.85)
L037DRN/LPN/MTANFClean scope50Included in clinical labor task “Clean room, equipment, and supplies”(1.85)
L037DRN/LPN/MTANFCleaning scope at POV50Included in clinical labor task “Clean room, equipment, and supplies” included in post-operative visit(1.85)
L037DRN/LPN/MTANFFollow-up phone calls and prescriptions30Typically billed with an E/M or other evaluation service(1.11)
L037DRN/LPN/MTANFSetup scope (non facility setting only)50Included in clinical labor task “Prepare room, equipment, supplies”(1.85)
L037DRN/LPN/MTANFSetup scope at POV50Included in clinical labor task “Clean room, equipment, and supplies” included in post-operative visit(1.85)
SA042pack, cleaning and disinfecting, endoscopeNF20Removed supply associated with equipment item not typically used in this service(34.12)
46601Diagnostic anoscopyEF031table, powerNF4133Refined equipment time to conform to established policies for non-highly technical equipment(0.13)
46607Diagnostic anoscopy & biopsyEF031table, powerNF4938Refined equipment time to conform to established policies for non-highly technical equipment(0.18)
5039ANjx px nfrosgrm &/urtrgrmED050PACS Workstation ProxyNF5867Refined equipment time to conform to clinical labor time0.20
EF027table, instrument, mobileNF284277Standard equipment and time for moderate sedation(0.01)
EL011room, angiographyNF440Equipment item replaced by another item; see preamble(231.21)
EL014room, radiographic-fluoroscopicNF044Equipment item replaces another item; see preamble61.30
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF284277Standard equipment and time for moderate sedation(0.10)
EQ032IV infusion pumpNF284277Standard equipment and time for moderate sedation(0.04)
EQ168light, examNF4462Refined equipment time to conform to established policies for non-highly technical equipment0.08
L037DRN/LPN/MTANFMonitor pt following service/check tubes, monitors, drains (not related to moderate sedation)045Clinical labor type replaces another clinical labor type; see preamble16.65
L051ARNNFMonitor pt following service/check tubes, monitors, drains (not related to moderate sedation)450Clinical labor type replaced by another labor type; see preamble(22.95)
SA019kit, iv starterNF10Duplicative; a similar item is already included in this service(1.60)
Start Printed Page 41743
SA042pack, cleaning and disinfecting, endoscopeNF10Removed supply associated with equipment item not typically used in this service(17.06)
SB022gloves, non-sterileNF20Duplicative; items included in pack, minimum multi-specialty visit (SA048)(0.17)
SB024gloves, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(0.84)
SB028gown, surgical, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(4.67)
SC049stop cock, 3-wayNF10Duplicative; items included in pack, moderate sedation (SA044)(1.18)
5039BNjx px nfrosgrm &/urtrgrmED050PACS Workstation ProxyNF2145Refined equipment time to conform to clinical labor time (Full intraservice period minus monitoring time)0.53
EF027table, instrument, mobileNF2240Refined equipment time to conform to established policies for non-highly technical equipment0.03
EL011room, angiographyNF220Equipment item replaced by another item; see preamble(115.60)
EL014room, radiographic-fluoroscopicNF022Equipment item replaces another item; see preamble30.65
EQ168light, examNF2240Refined equipment time to conform to established policies for non-highly technical equipment0.08
L037DRN/LPN/MTANFAssist physician in performing procedure150Removed clinical labor associated with moderate sedation; moderate sedation not typical for this procedure(5.55)
SA042pack, cleaning and disinfecting, endoscopeNF10Removed supply associated with equipment item not typically used in this service(17.06)
SB001cap, surgicalNF43Aligned supply quantities with changes to number of clinical labor staff(0.21)
SB022gloves, non-sterileNF20Duplicative; items included in pack, minimum multi-specialty visit (SA048)(0.17)
SB033mask, surgicalNF21Aligned supply quantities with changes to number of clinical labor staff(0.20)
SB039shoe covers, surgicalNF43Aligned supply quantities with changes to number of clinical labor staff(0.34)
5039CPlmt nephrostomy catheterED050PACS Workstation ProxyNF7180Refined equipment time to conform to clinical labor time0.20
EF027table, instrument, mobileNF300290Standard equipment and time for moderate sedation(0.01)
EL011room, angiographyNF600Equipment item replaced by another item; see preamble(315.28)
EL014room, radiographic-fluoroscopicNF060Equipment item replaces another item; see preamble83.59
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF300290Standard equipment and time for moderate sedation(0.14)
EQ032IV infusion pumpNF300290Standard equipment and time for moderate sedation(0.06)
EQ168light, examNF6075Refined equipment time to conform to established policies for non-highly technical equipment0.06
Start Printed Page 41744
L037DRN/LPN/MTANFMonitor pt following service/check tubes, monitors, drains (not related to moderate sedation)045Clinical labor type replaces another clinical labor type; see preamble16.65
L041BRadiologic TechnologistNFClean room/equipment by physician staff63Refined time to standard time for this clinical labor task(1.23)
L051ARNNFMonitor pt. following service/check tubes, monitors, drains (not related to moderate sedation)450Clinical labor type replaced by another labor type; see preamble(22.95)
SA019kit, iv starterNF10Duplicative; items included in pack, moderate sedation (SA044)(1.60)
SA042pack, cleaning and disinfecting, endoscopeNF10Removed supply associated with equipment item not typically used in this service(17.06)
SB022gloves, non-sterileNF20Duplicative; items included in pack, minimum multi-specialty visit (SA048)(0.17)
SB024gloves, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(0.84)
SB028gown, surgical, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(4.67)
SC049stop cock, 3-wayNF10Duplicative; items included in pack, moderate sedation (SA044)(1.18)
5039DPlmt nephroureteral catheterED050PACS Workstation ProxyNF8392Refined equipment time to conform to clinical labor time0.20
EF027table, instrument, mobileNF312302Standard equipment and time for moderate sedation(0.01)
EL011room, angiographyNF720Equipment item replaced by another item; see preamble(378.34)
EL014room, radiographic-fluoroscopicNF072Equipment item replaces another item; see preamble100.30
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF312302Standard equipment and time for moderate sedation(0.14)
EQ032IV infusion pumpNF312302Standard equipment and time for moderate sedation(0.06)
EQ168light, examNF7287Refined equipment time to conform to established policies for non-highly technical equipment0.06
L037DRN/LPN/MTANFMonitor pt. following service/check tubes, monitors, drains (not related to moderate sedation)045Clinical labor type replaces another clinical labor type; see preamble16.65
L041BRadiologic TechnologistNFClean room/equipment by physician staff63Refined time to standard time for this clinical labor task(1.23)
L051ARNNFMonitor pt. following service/check tubes, monitors, drains (not related to moderate sedation)450Clinical labor type replaced by another labor type; see preamble(22.95)
SA019kit, iv starterNF10Duplicative; a similar item is already included in this service(1.60)
Start Printed Page 41745
SA042pack, cleaning and disinfecting, endoscopeNF10Removed supply associated with equipment item not typically used in this service(17.06)
SB022gloves, non-sterileNF20Duplicative; items included in pack, minimum multi-specialty visit (SA048)(0.17)
SB024gloves, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(0.84)
SB028gown, surgical, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(4.67)
SC049stop cock, 3-wayNF10Duplicative; items included in pack, moderate sedation (SA044)(1.18)
SD306Nephroureteral CatheterNF10Supply not mentioned in SOR work description(117.90)
5039EExchange nephrostomy cathED050PACS Workstation ProxyNF2150Refined equipment time to conform to clinical labor time0.64
EF027table, instrument, mobileNF9045Refined equipment time to conform to established policies for non-highly technical equipment(0.06)
EL011room, angiographyNF300Equipment item replaced by another item; see preamble(157.64)
EL014room, radiographic-fluoroscopicNF030Equipment item replaces another item; see preamble41.79
EQ168light, examNF3045Refined equipment time to conform to established policies for non-highly technical equipment0.06
L037DRN/LPN/MTANFAssist physician in performing procedure200Clinical labor type replaced by another labor type; see preamble(7.40)
L041BRadiologic TechnologistNFClean room/equipment by physician staff63Refined time to standard time for this clinical labor task(1.23)
SA031kit, suture removalNF10Redundant when used together with supply catheter percutaneous fastener (Percu—Stay) (SD146)(1.05)
SA042pack, cleaning and disinfecting, endoscopeNF10Removed supply associated with equipment item not typically used in this service(17.06)
SB001cap, surgicalNF43Aligned supply quantities with changes to number of clinical labor staff(0.21)
SB022gloves, non-sterileNF20Duplicative; items included in pack, minimum multi-specialty visit (SA048)(0.17)
SB033mask, surgicalNF21Aligned supply quantities with changes to number of clinical labor staff(0.20)
SB039shoe covers, surgicalNF43Aligned supply quantities with changes to number of clinical labor staff(0.34)
5039MConvert nephrostomy catheterED050PACS Workstation ProxyNF6877Refined equipment time to conform to clinical labor time0.20
EF027table, instrument, mobileNF297287Standard equipment and time for moderate sedation(0.01)
EL011room, angiographyNF570Equipment item replaced by another item; see preamble(299.52)
EL014room, radiographic-fluoroscopicNF057Equipment item replaces another item; see preamble79.41
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF297287Standard equipment and time for moderate sedation(0.14)
EQ032IV infusion pumpNF297287Standard equipment and time for moderate sedation(0.06)
Start Printed Page 41746
EQ168light, examNF5772Refined equipment time to conform to established policies for non-highly technical equipment0.06
L037DRN/LPN/MTANFMonitor pt following service/check tubes, monitors, drains (not related to moderate sedation)045Clinical labor type replaces another clinical labor type; see preamble16.65
L041BRadiologic TechnologistNFClean room/equipment by physician staff63Refined time to standard time for this clinical labor task(1.23)
L051ARNNFMonitor pt following service/check tubes, monitors, drains (not related to moderate sedation)450Clinical labor type replaced by another labor type; see preamble(22.95)
SA019kit, iv starterNF10Duplicative; items included in pack, moderate sedation (SA044)(1.60)
SA031kit, suture removalNF10Redundant when used together with supply catheter percutaneous fastener (Percu—Stay) (SD146)(1.05)
SA042pack, cleaning and disinfecting, endoscopeNF10Removed supply associated with equipment item not typically used in this service(17.06)
SB022gloves, non-sterileNF20Duplicative; items included in pack, minimum multi-specialty visit (SA048)(0.17)
SB024gloves, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(0.84)
SB028gown, surgical, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(4.67)
SC049stop cock, 3-wayNF10Duplicative; items included in pack, moderate sedation (SA044)(1.18)
5069GPlmt ureteral stent prqED050PACS Workstation ProxyNF6877Refined equipment time to conform to clinical labor time0.20
EF027table, instrument, mobileNF297287Standard equipment and time for moderate sedation(0.01)
EL011room, angiographyNF570Equipment item replaced by another item; see preamble(299.52)
EL014room, radiographic-fluoroscopicNF057Equipment item replaces another item; see preamble79.41
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF297287Standard equipment and time for moderate sedation(0.14)
EQ032IV infusion pumpNF297287Standard equipment and time for moderate sedation(0.06)
EQ168light, examNF5772Refined equipment time to conform to established policies for non-highly technical equipment0.06
L037DRN/LPN/MTANFMonitor pt. following service/check tubes, monitors, drains (not related to moderate sedation)045Clinical labor type replaces another clinical labor type; see preamble16.65
L041BRadiologic TechnologistNFClean room/equipment by physician staff63Refined time to standard time for this clinical labor task(1.23)
Start Printed Page 41747
L051ARNNFMonitor pt. following service/check tubes, monitors, drains (not related to moderate sedation)450Clinical labor type replaced by another labor type; see preamble(22.95)
SA019kit, iv starterNF10Duplicative; items included in pack, moderate sedation (SA044)(1.60)
SA031kit, suture removalNF10Redundant when used together with supply catheter percutaneous fastener (Percu—Stay) (SD146)(1.05)
SA042pack, cleaning and disinfecting, endoscopeNF10Removed supply associated with equipment item not typically used in this service(17.06)
SB022gloves, non-sterileNF20Duplicative; items included in pack, minimum multi-specialty visit (SA048)(0.17)
SB024gloves, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(0.84)
SB028gown, surgical, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(4.67)
SC049stop cock, 3-wayNF10Duplicative; items included in pack, moderate sedation (SA044)(1.18)
5069HPlmt ureteral stent prqED050PACS Workstation ProxyNF8594Refined equipment time to conform to clinical labor time0.20
EF027table, instrument, mobileNF314304Standard equipment and time for moderate sedation(0.01)
EL011room, angiographyNF740Equipment item replaced by another item; see preamble(388.85)
EL014room, radiographic-fluoroscopicNF074Equipment item replaces another item; see preamble103.09
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF314304Standard equipment and time for moderate sedation(0.14)
EQ032IV infusion pumpNF314304Standard equipment and time for moderate sedation(0.06)
EQ168light, examNF7489Refined equipment time to conform to established policies for non-highly technical equipment0.06
L037DRN/LPN/MTANFMonitor pt. following service/check tubes, monitors, drains (not related to moderate sedation)045Clinical labor type replaces another clinical labor type; see preamble16.65
L041BRadiologic TechnologistNFAcquire images (75%)4746Rounding error in CL time calculation(0.41)
L041BRadiologic TechnologistNFClean room/equipment by physician staff63Refined time to standard time for this clinical labor task(1.23)
L051ARNNFMonitor pt. following service/check tubes, monitors, drains (not related to moderate sedation)450Clinical labor type replaced by another labor type; see preamble(22.95)
SA019kit, iv starterNF10Duplicative; items included in pack, moderate sedation (SA044)(1.60)
SA042pack, cleaning and disinfecting, endoscopeNF10Removed supply associated with equipment item not typically used in this service(17.06)
Start Printed Page 41748
SB022gloves, non-sterileNF20Duplicative; items included in pack, minimum multi-specialty visit (SA048)(0.17)
SB024gloves, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(0.84)
SB028gown, surgical, sterileNF21Duplicative; a similar item is already included in this service(4.67)
SC049stop cock, 3-wayNF10Duplicative; items included in pack, moderate sedation (SA044)(1.18)
5069IPlmt ureteral stent prqED050PACS Workstation ProxyNF98107Refined equipment time to conform to clinical labor time0.20
EF027table, instrument, mobileNF327317Standard equipment and time for moderate sedation(0.01)
EL011room, angiographyNF870Equipment item replaced by another item; see preamble(457.16)
EL014room, radiographic-fluoroscopicNF087Equipment item replaces another item; see preamble121.20
EQ011ECG, 3-channel (with SpO2, NIBP, temp, resp)NF327317Standard equipment and time for moderate sedation(0.14)
EQ032IV infusion pumpNF327317Standard equipment and time for moderate sedation(0.06)
EQ168light, examNF87102Refined equipment time to conform to established policies for non-highly technical equipment0.06
L037DRN/LPN/MTANFMonitor pt. following service/check tubes, monitors, drains (not related to moderate sedation)045Clinical labor type replaces another clinical labor type; see preamble16.65
L041BRadiologic TechnologistNFClean room/equipment by physician staff63Refined time to standard time for this clinical labor task(1.23)
L051ARNNFMonitor pt. following service/check tubes, monitors, drains (not related to moderate sedation)450Clinical labor type replaced by another labor type; see preamble(22.95)
SA019kit, iv starterNF10Duplicative; items included in pack, moderate sedation (SA044)(1.60)
SA042pack, cleaning and disinfecting, endoscopeNF10Removed supply associated with equipment item not typically used in this service(17.06)
SB022gloves, non-sterileNF20Duplicative; items included in pack, minimum multi-specialty visit (SA048)(0.17)
SB024gloves, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(0.84)
SB028gown, surgical, sterileNF21Duplicative; items included in pack, moderate sedation (SA044)(4.67)
SC049stop cock, 3-wayNF10Duplicative; items included in pack, moderate sedation (SA044)(1.18)
5443ARepair corporeal tearEF031table, powerF144135Refined equipment time to conform to clinical labor time(0.15)
EF031table, powerNF144135Refined equipment time to conform to clinical labor time(0.15)
Start Printed Page 41749
EQ168light, examF144135Refined equipment time to conform to clinical labor time(0.04)
EQ168light, examNF144135Refined equipment time to conform to clinical labor time(0.04)
657XGImpltj ntrstrml crnl rng segL038ACOMT/COT/RN/CSTFDischarge day management same day 99238 -6 minutes60Aligned clinical labor discharge day management time with the work time discharge day code(2.28)
68801Dilate tear duct openingL038ACOMT/COT/RN/CSTFDischarge day management same day 99238 -6 minutes60Aligned clinical labor discharge day management time with the work time discharge day code(2.28)
68810Probe nasolacrimal ductL038ACOMT/COT/RN/CSTFDischarge day management same day 99238 -6 minutes60Aligned clinical labor discharge day management time with the work time discharge day code(2.28)
68816Probe nl duct w/balloonEL006lane, screening (oph)NF1647Refined equipment time to conform to clinical labor time2.77
69200Clear outer ear canalEF008chair with headrest, exam, recliningNF2227Refined equipment time to conform to established policies for non-highly technical equipment0.05
EF015mayo standNF1927Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ137instrument pack, basic ($500-$1,499)NF2631Refined equipment time to conform to established policies for instrument packs0.01
EQ170light, fiberoptic headlight w-sourceNF2227Refined equipment time to conform to established policies for non-highly technical equipment0.04
EQ183microscope, operatingNF2227Refined equipment time to conform to established policies for non-highly technical equipment0.14
EQ234suction and pressure cabinet, ENT (SMR)NF2227Refined equipment time to conform to established policies for non-highly technical equipment0.05
L037DRN/LPN/MTAFDischrg gmt. same day (0.5 × 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
SH047lidocaine 1%-2% inj (Xylocaine)NF50Supply item replaced by another item (SH050); see preamble(0.18)
SH050lidocaine 4% soln, topical (Xylocaine)NF03Supply item replaces another item (SH047); see preamble0.46
69220Clean out mastoid cavityEF008chair with headrest, exam, recliningNF2025Refined equipment time to conform to established policies for non-highly technical equipment0.05
EF015mayo standNF1725Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ137instrument pack, basic ($500-$1,499)NF029Equipment item replaces another item (EQ138); see preamble0.07
EQ138instrument pack, medium ($1,500 and up)NF290Equipment item replaced by another item (EQ137); see preamble(0.20)
EQ183microscope, operatingNF2025Refined equipment time to conform to established policies for non-highly technical equipment0.14
Start Printed Page 41750
EQ234suction and pressure cabinet, ENT (SMR)NF2025Refined equipment time to conform to established policies for non-highly technical equipment0.05
L037DRN/LPN/MTAFDischrg day gmt. (0.5 × 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
L037DRN/LPN/MTANFClean surgical instrument package1510Refined time to standard time for this clinical labor task(1.85)
L037DRN/LPN/MTANFProvide pre-service education/obtain consent02Refined time to standard time for this clinical labor task0.74
7208AX-ray exam entire spi 1 vwED050PACS Workstation ProxyNF2125Refined equipment time to conform to clinical labor time0.09
7208BX-ray exam entire spi 2/3 vwED050PACS Workstation ProxyNF3640Refined equipment time to conform to clinical labor time0.09
7208CX-ray exam entire spi 4/5 vwED050PACS Workstation ProxyNF4448Refined equipment time to conform to clinical labor time0.09
7208DX-ray exam entire spi 6/ vwED050PACS Workstation ProxyNF5357Refined equipment time to conform to clinical labor time0.09
73565X-ray exam of kneesL041BRadiologic TechnologistNFGreet patient and provide gowning03Input added to maintain consistency with all other codes within family1.23
77385Ntsty modul rad tx dlvr smplEQ139intercom (incl. master, pt substation, power, wiring)NF270Indirect Practice Expense; not individually allocable to a particular patient for a particular service(0.10)
ER040laser, diode, for patient positioning (Probe)NF2927Refined equipment time to conform to established policies for highly technical equipment(0.12)
ER056radiation treatment vaultNF2927Refined equipment time to conform to established policies for highly technical equipment(3.15)
ER065water chiller (radiation treatment)NF2927Refined equipment time to conform to established policies for highly technical equipment(0.13)
ER089IMRT acceleratorNF2927Refined equipment time to conform to established policies for highly technical equipment(16.14)
ER102Power conditionerNF2927Refined equipment time to conform to established policies for highly technical equipment(0.17)
77386Ntsty modul rad tx dlvr cplxEQ139intercom (incl. master, pt substation, power, wiring)NF420Indirect Practice Expense; not individually allocable to a particular patient for a particular service(0.15)
ER040laser, diode, for patient positioning (Probe)NF4442Refined equipment time to conform to established policies for highly technical equipment(0.12)
ER056radiation treatment vaultNF4442Refined equipment time to conform to established policies for highly technical equipment(3.15)
ER065water chiller (radiation treatment)NF4442Refined equipment time to conform to established policies for highly technical equipment(0.13)
ER089IMRT acceleratorNF4442Refined equipment time to conform to established policies for highly technical equipment(16.14)
Start Printed Page 41751
ER102Power conditionerNF4442Refined equipment time to conform to established policies for highly technical equipment(0.17)
L050CRadiation TherapistNFCheck dressings & wound/home care instructions/coordinate office visits/prescriptions21Refined to conform with identical labor activity in other codes in the family(0.50)
77402Radiation treatment deliveryEQ139intercom (incl. master, pt substation, power, wiring)NF120Indirect Practice Expense; not individually allocable to a particular patient for a particular service(0.04)
ER040laser, diode, for patient positioning (Probe)NF1412Refined equipment time to conform to established policies for highly technical equipment(0.12)
ER056radiation treatment vaultNF1412Refined equipment time to conform to established policies for highly technical equipment(3.15)
ER065water chiller (radiation treatment)NF1412Refined equipment time to conform to established policies for highly technical equipment(0.13)
ER089IMRT acceleratorNF1412Refined equipment time to conform to established policies for highly technical equipment(16.14)
ER102Power conditionerNF1412Refined equipment time to conform to established policies for highly technical equipment(0.17)
77407Radiation treatment deliveryEQ139intercom (incl. master, pt substation, power, wiring)NF170Indirect Practice Expense; not individually allocable to a particular patient for a particular service(0.06)
ER040laser, diode, for patient positioning (Probe)NF1917Refined equipment time to conform to established policies for highly technical equipment(0.12)
ER056radiation treatment vaultNF1917Refined equipment time to conform to established policies for highly technical equipment(3.15)
ER065water chiller (radiation treatment)NF1917Refined equipment time to conform to established policies for highly technical equipment(0.13)
ER089IMRT acceleratorNF1917Refined equipment time to conform to established policies for highly technical equipment(16.14)
ER102Power conditionerNF1917Refined equipment time to conform to established policies for highly technical equipment(0.17)
77412Radiation treatment deliveryEQ139intercom (incl. master, pt substation, power, wiring)NF210Indirect Practice Expense; not individually allocable to a particular patient for a particular service(0.08)
ER040laser, diode, for patient positioning (Probe)NF2321Refined equipment time to conform to established policies for highly technical equipment(0.12)
ER056radiation treatment vaultNF2321Refined equipment time to conform to established policies for highly technical equipment(3.15)
ER065water chiller (radiation treatment)NF2321Refined equipment time to conform to established policies for highly technical equipment(0.13)
Start Printed Page 41752
ER089IMRT acceleratorNF2321Refined equipment time to conform to established policies for highly technical equipment(16.14)
ER102Power conditionerNF2321Refined equipment time to conform to established policies for highly technical equipment(0.17)
88104Cytopath fl nongyn smearsEP024microscope, compoundNF6056Refined to conform with identical labor activity in other codes in the family(0.15)
L033ALab TechnicianNFOrder, restock, and distribute specimen containers with requisition forms.0.50Indirect Practice Expense; not individually allocable to a particular patient for a particular service(0.17)
88106Cytopath fl nongyn filterL033ALab TechnicianNFOrder, restock, and distribute specimen containers with requisition forms.0.50Indirect Practice Expense; not individually allocable to a particular patient for a particular service(0.17)
88108Cytopath concentrate techL033ALab TechnicianNFOrder, restock, and distribute specimen containers with requisition forms.0.50Indirect Practice Expense; not individually allocable to a particular patient for a particular service(0.17)
88160Cytopath smear other sourceEP038solvent recycling systemNF10Refined equipment time to conform to clinical labor time(0.05)
L035ALab Tech/HistotechnologistNFPrepare automated stainer with solutions and load microscopic slides. Set and confirm stainer program. Set and confirm stainer program64Refined time to standard time for this clinical labor task(0.70)
L035ALab Tech/HistotechnologistNFStain air dried slides with modified Wright stain. Review slides for malignancy/high cellularity (cross contamination)50See preamble text(1.75)
88161Cytopath smear other sourceEP038solvent recycling systemNF10Refined equipment time to conform to clinical labor time(0.05)
Cytopath smear other sourceL035ALab Tech/HistotechnologistNFPrepare automated stainer with solutions and load microscopic slides. Set and confirm stainer program. Set and confirm stainer program64Refined time to standard time for this clinical labor task(0.70)
Cytopath smear other sourceL035ALab Tech/HistotechnologistNFStain air dried slides with modified Wright stain. Review slides for malignancy/high cellularity (cross contamination)53Refined time to standard time for this clinical labor task(0.70)
88162Cytopath smear other sourceEP038solvent recycling systemNF10Refined equipment time to conform to clinical labor time(0.05)
Start Printed Page 41753
Cytopath smear other sourceL035ALab Tech/HistotechnologistNFOther Clinical Activity (please specify): Prepare automated stainer with solutions and load microscopic slides64Refined time to standard time for this clinical labor task(0.70)
88182Cell marker studyL033ALab TechnicianNFAccession specimen/prepare for examination64Refined time to standard time for this clinical labor task(0.66)
Cell marker studyL033ALab TechnicianNFClean room/equipment following procedure (including any equipment maintenance that must be done after the procedure)21Refined time to standard time for this clinical labor task(0.33)
L033ALab TechnicianNFDispose of remaining specimens, spent chemicals/other consumables, and hazardous waste21Refined time to standard time for this clinical labor task(0.33)
L033ALab TechnicianNFPrepare, pack and transport specimens and records for in-house storage and external storage (where applicable)21Refined time to standard time for this clinical labor task(0.33)
L045ACytotechnologistNFClean room/equipment following procedure (including any equipment maintenance that must be done after the procedure)21Refined time to standard time for this clinical labor task(0.45)
L045ACytotechnologistNFEnter data into laboratory information system, multiparameter analyses and field data en20Refined time to standard time for this clinical labor task(0.90)
L045ACytotechnologistNFPrint out histograms, assemble materials with paperwork to pathologists Review histograms and gating with pathologist52Refined time to standard time for this clinical labor task(1.35)
88184Flowcytometry/tc 1 markerED031printer, dye sublimation (photo, color)NF51Refined equipment time to conform to clinical labor time(0.04)
L033ALab TechnicianNFClean room/equipment following procedure (including any equipment maintenance that must be done after the procedure)21Refined time to standard time for this clinical labor task(0.33)
Start Printed Page 41754
L033ALab TechnicianNFEnter data into laboratory information system, multiparameter analyses and field data en40Refined time to standard time for this clinical labor task(1.32)
L045ACytotechnologistNFInstrument start-up, quality control functions, calibration, centrifugation, maintaining specimen tracking, logs and labeling1513Refined to conform with identical labor activity in other codes in the family(0.90)
L045ACytotechnologistNFOther Clinical Activity (please specify) Load specimen into flow cytometer, run specimen, monitor data acquisition, and107Refined to conform with identical labor activity in other codes in the family(1.35)
L045ACytotechnologistNFPrint out histograms, assemble materials with paperwork to pathologists Review histograms and gating with pathologist52Refined time to standard time for this clinical labor task(1.35)
88185Flowcytometry/tc add-onED031printer, dye sublimation (photo, color)NF21Refined equipment time to conform to clinical labor time(0.01)
L033ALab TechnicianNFEnter data into laboratory information system, multiparameter analyses and field data en10Refined time to standard time for this clinical labor task(0.33)
88321Microslide consultationL033ALab TechnicianNFAccession specimen/prepare for examination40Duplication with other clinical labor task(1.32)
L033ALab TechnicianNFRegister the patient in the information system, including all demographic and billing information. In addition to stand135See preamble text(2.64)
L037BHistotechnologistNFPhone calls for clarifications and/or additional materials03Input added to maintain consistency with all other codes within family1.11
88323Microslide consultationL033ALab TechnicianNFRegister the patient in the information system, including all demographic and billing information. In addition to stand135Non-standard refinement, see preamble text(2.64)
L037BHistotechnologistNFAssemble and deliver slides with paperwork to pathologists10Duplication with other clinical labor task(0.37)
L037BHistotechnologistNFClean equipment while performing service10Duplication with other clinical labor task(0.37)
SL063eosin yNF80Redundant when used together with SL135(6.41)
Start Printed Page 41755
SL135stain, hematoxylinNF328Refined supply quantity to what is typical for the procedure(1.06)
88325EP019hood, ventilator with blowerNF10See preamble text
EP033slide coverslipper, roboticNF60See preamble text(0.57)
EP034slide dryerNF10See preamble text
EP035slide etcher-labelerNF10See preamble text(0.05)
EP036slide stainer, automated, high-volume throughputNF120See preamble text(0.55)
EP038solvent recycling systemNF40See preamble text(0.18)
EP043water bath, general purpose (lab)NF60See preamble text(0.01)
ER041microtomeNF60See preamble text(0.26)
L033ALab TechnicianNFPrepare room. Filter and replenish stains and supplies. (including OCT blocks, set up grossing station with colored stain100Indirect Practice Expense; not individually allocable to a particular patient for a particular service(3.30)
L033ALab TechnicianNFAccession specimen/prepare for examination40Duplication with other clinical labor task(1.32)
L033ALab TechnicianNFDispose of remaining specimens, spent chemicals/other consumables, and hazardous waste10See preamble text(0.33)
L033ALab TechnicianNFRegister the patient in the information system, including all demographic and billing information. In addition to stand135See preamble text(2.64)
L033ALab TechnicianNFprepare, pack and transport specimens and records for in-house storage and external storage20See preamble text(0.66)
L037BHistotechnologistNFClean equipment while performing service10Duplication with other clinical labor task(0.37)
L037BHistotechnologistNFComplete workload recording logs. Collate slides and paperwork. Deliver to pathologist10See preamble text(0.37)
L037BHistotechnologistNFPrepare automated coverslipper, remove slides from stainer and place on coverslipper10See preamble text(0.37)
Start Printed Page 41756
L037BHistotechnologistNFPrepare automated stainer with solutions and load microscopic slides. Set and confirm stainer program. Set and confirm stainer program10See preamble text(0.37)
L037BHistotechnologistNFSlide preparation sectioning and recuts, quality control function, maintaining specimen tracking, logs and labeling40See preamble text(1.48)
SB023gloves, non-sterile, nitrileNF20See preamble text(0.38)
SB027gown, staff, imperviousNF0.10See preamble text(0.12)
SF004blade, microtomeNF0.20See preamble text(0.34)
SL020bleachNF100See preamble text(0.01)
SL030cover slip, glassNF20See preamble text(0.16)
SL063eosin yNF80See preamble text(6.41)
SL078histology freezing spray (Freeze-It)NF0.20See preamble text(0.29)
SL085label for microscope slidesNF2010See preamble text(0.26)
SL095mounting media (Histomount)NF20See preamble text(0.07)
SL122slide, microscopeNF20See preamble text(0.11)
SL135stain, hematoxylinNF320See preamble text(1.41)
SL151xylenes solventNF600See preamble text(0.72)
SL189ethanol, 100%NF600See preamble text(0.20)
SL190ethanol, 70%NF80See preamble text(0.03)
SL248ethanol, 95%NF360See preamble text(0.12)
SM027wipes, lens cleaning (per wipe) (Kimwipe)NF20See preamble text(0.03)
88329Path consult intropL037BHistotechnologistNFAssist pathologist with gross specimen examination103Refined time to standard time for this clinical labor task(2.59)
L037BHistotechnologistNFClean room/equipment following procedure (including any equipment maintenance that must be done after the procedure)51Refined time to standard time for this clinical labor task(1.48)
88331Path consult intraop 1 blocL033ALab TechnicianNFPrepare room. Filter and replenish stains and supplies. (including OCT blocks, set up grossing station with colored stai100Indirect Practice Expense; not individually allocable to a particular patient for a particular service1.48
L037BHistotechnologistNFAccession specimen/prepare for examination04Input added to maintain consistency with all other codes within family1.48
L037BHistotechnologistNFAssemble and deliver slides with paperwork to pathologists20.5Refined time to standard time for this clinical labor task(0.56)
L037BHistotechnologistNFAssist pathologist with gross specimen examination103Refined time to standard time for this clinical labor task(2.59)
Start Printed Page 41757
L037BHistotechnologistNFClean room/equipment following procedure (including any equipment maintenance that must be done after the procedure)101Refined time to standard time for this clinical labor task(3.33)
SL134stain, frozen section, H&E (1ml per slide)NF01Supply item replaces another item (SL231); see preamble0.57
SL231kit, stain, H&ENF0.10Supply item replaced by another item (SL134); see preamble(9.80)
88332Path consult intraop addlL037BHistotechnologistNFAssemble and deliver slides with paperwork to pathologists20.5Refined time to standard time for this clinical labor task(0.56)
L037BHistotechnologistNFAssist pathologist with gross specimen examination23Refined time to standard time for this clinical labor task0.37
L037BHistotechnologistNFClean room/equipment following procedure (including any equipment maintenance that must be done after the procedure)01Input added to maintain consistency with all other codes within family0.37
SF047scalpel, safety, surgical, with blade (#10-20)NF01Input added to maintain consistency with all other codes within family2.14
SL134stain, frozen section, H&E (1ml per slide)NF01Supply item replaces another item (SL231); see preamble0.57
SL231kit, stain, H&ENF0.10Supply item replaced by another item (SL134); see preamble(9.80)
88333Intraop cyto path consult 1L033ALab TechnicianNFPrepare room. Filter and replenish stains and supplies. (including OCT blocks, set up grossing station with colored stai100Indirect Practice Expense; not individually allocable to a particular patient for a particular service(3.30)
L037BHistotechnologistNFAccession specimen/prepare for examination04Input added to maintain consistency with all other codes within family1.48
L037BHistotechnologistNFAssemble and deliver slides with paperwork to pathologists20.5Refined time to standard time for this clinical labor task(1.48)
L037BHistotechnologistNFAssist pathologist with gross specimen examination (including performance of intraoperative frozen sections)73Refined time to standard time for this clinical labor task(1.48)
L037BHistotechnologistNFClean room/equipment following procedure (including any equipment maintenance that must be done after the procedure)51Refined time to standard time for this clinical labor task(1.48)
Start Printed Page 41758
SL122slide, microscopeNF104Refined supply quantity to what is typical for the procedure(0.33)
SL231kit, stain, H&ENF0.10Removed supply not typically used in this service(9.80)
88334Intraop cyto path consult 2L037BHistotechnologistNFAssemble and deliver slides with paperwork to pathologists20.5Refined time to standard time for this clinical labor task(0.56)
L037BHistotechnologistNFAssist pathologist with gross specimen examination (including performance of intraoperative frozen sections)53Refined time to standard time for this clinical labor task(0.74)
L037BHistotechnologistNFClean room/equipment following procedure (including any equipment maintenance that must be done after the procedure)01Input added to maintain consistency with all other codes within family0.37
SL122slide, microscopeNF104Refined supply quantity to what is typical for the procedure(0.33)
SL231kit, stain, H&ENF0.10Removed supply not typically used in this service(9.80)
88355Analysis skeletal muscleEP046freezer, ultradeep (−70 degrees)NF300Indirect Practice Expense; not individually allocable to a particular patient for a particular service(1.32)
L033ALab TechnicianNFAccession specimen/prepare for examination64Refined time to standard time for this clinical labor task(0.66)
L033ALab TechnicianNFAssemble and deliver slides with paperwork to pathologists20.5Refined time to standard time for this clinical labor task(0.50)
L033ALab TechnicianNFClean room, equipment following procedure including any equipment maintenance that must be done after the procedure21Refined time to standard time for this clinical labor task(0.33)
L033ALab TechnicianNFDispose of remaining specimens, spent chemicals/other consumables, and hazardous waste21Refined time to standard time for this clinical labor task(0.33)
L033ALab TechnicianNFPrepare specimen containers/preload fixative/label containers/distribute requisition form(s) to physician90.5Refined time to standard time for this clinical labor task(2.81)
L033ALab TechnicianNFPrepare specimen for −70 degree storage, log specimen and place in freezer for retrieval and performance of quantitative50Refined time to standard time for this clinical labor task(1.65)
Start Printed Page 41759
L033ALab TechnicianNFPrepare, pack and transport specimens and records for storage41Refined time to standard time for this clinical labor task(0.99)
L033ALab TechnicianNFReceive phone call from referring laboratory/facility with scheduled procedure to arrange special delivery of specimen p75See preamble text(0.66)
L037BHistotechnologistNFAssist pathologist with gross examination73Refined time to standard time for this clinical labor task(1.48)
88360Tumor immunohistochem/manualEP024microscope, compoundNF3625See preamble text(0.41)
L033ALab TechnicianNFRecycle xylene from tissue processor and stainer10Non-standard clinical labor task(0.33)
L037BHistotechnologistNFEnter patient data, computational prep for antibody testing, generate and apply bar codes to slides, and enter data for51Refined time to standard time for this clinical labor task(1.48)
L037BHistotechnologistNFVerify results and complete work load recording logs10Refined time to standard time for this clinical labor task(0.37)
88361Tumor immunohistochem/computL033ALab TechnicianNFRecycle xylene from tissue processor and stainer10Non-standard clinical labor task(0.33)
L037BHistotechnologistNFEnter patient data, computational prep for antibody testing, generate and apply bar codes to slides, and enter data for51Refined time to standard time for this clinical labor task(1.48)
L037BHistotechnologistNFVerify results and complete work load recording logs10Refined time to standard time for this clinical labor task(0.37)
88362Nerve teasing preparationsL033ALab TechnicianNFAssemble and deliver cedar mounted slides with paperwork to pathologists20.5Refined time to standard time for this clinical labor task(0.50)
L033ALab TechnicianNFAssemble other light microscopy slides, epon nerve biopsy slides, and clinical history, and present to pathologist to pr50.5Refined time to standard time for this clinical labor task(1.49)
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L033ALab TechnicianNFClean room/equipment following procedure (including dissecting microscope and dissection work area. Cedar oil specific c71Refined time to standard time for this clinical labor task(1.98)
L033AElectrodiagnostic TechnologistNFPreparation: labeling of blocks and containers and document location and processor used20.5Refined time to standard time for this clinical labor task(0.50)
L037BHistotechnologistNFAccession specimen and prepare for examination104Refined time to standard time for this clinical labor task(2.22)
L037BHistotechnologistNFAssist pathologist with gross specimen examination including the following; A ; Selection of fresh unfixed tissue samp105Non-standard refinement, see preamble text(1.85)
L037BHistotechnologistNFConsult with pathologist regarding representation needed, block selection and appropriate technique70Task would not be required for the typical procedure(2.59)
L037BHistotechnologistNFDispose of remaining specimens, spent chemicals/other consumables, and hazardous waste21Refined time to standard time for this clinical labor task(0.37)
L037BHistotechnologistNFManage any relevant utilization review/quality assurance activities and regulatory compliance documentation20Refined time to standard time for this clinical labor task(0.74)
L037BHistotechnologistNFPrepare specimen containers preload fixative label containers distribute requisition form(s) to physician120.5Refined time to standard time for this clinical labor task(4.26)
L037BHistotechnologistNFPrepare, pack and transport cedar oiled glass slides and records for in-house special storage (need to be stored flat)100Refined time to standard time for this clinical labor task(3.70)
L037BHistotechnologistNFPrepare, pack and transport specimens and records for in-house storage and external storage (where applicable)21Refined time to standard time for this clinical labor task(0.37)
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L037BHistotechnologistNFStorage remaining specimen. (Osmicated nerve strands, potential for additional teased specimens)50Refined time to standard time for this clinical labor task(1.85)
92511NasopharyngoscopyEF008chair with headrest, exam, recliningNF1926Refined equipment time to conform to established policies for non-highly technical equipment0.08
EQ167light source, xenonNF190Redundant when used together with EQ170; see preamble(0.51)
EQ170light, fiberoptic headlight w-sourceNF1926Refined equipment time to conform to established policies for non-highly technical equipment0.06
ES020fiberscope, flexible, rhinolaryngoscopyNF4653Refined equipment time to conform to established policies for scopes0.26
ES031video system, endoscopy (processor, digital capture, monitor, printer, cart)NF1926Refined equipment time to conform to established policies for non-highly technical equipment0.90
L037DRN/LPN/MTAFDischrge Day mgmt. (0.5 × 99238) (enter 6 min)60Aligned clinical labor discharge day management time with the work time discharge day code(2.22)
SB006drape, non-sterile, sheet 40in x 60inNF10Removed supply not typically used in this service(0.22)
SB027gown, staff, imperviousNF20Removed supply not typically used in this service(2.37)
SB033mask, surgicalNF20Removed supply not typically used in this service(0.39)
SD070endosheathNF10Removed supply not typically used in this service(17.25)
95812Eeg 41-60 minutesEF003bedroom furniture (hospital bed, table, reclining chair)NF12499Refined equipment time to conform to established policies for non-highly technical equipment(0.15)
EQ017EEG, digital, prolonged testing system (computer w-remote camera)NF13399Refined equipment time to conform to established policies for non-highly technical equipment(4.99)
L047BREEGTNFAssist physician in performing procedure7950Refined clinical labor time to match physician intraservice time(13.63)
L047BREEGTNFEnter patient information into laboratory log book20Refined to conform with identical labor activity in other codes in the family(0.94)
L047BREEGTNFProvide pre-service education/obtain consent20Duplication with other clinical labor task(0.94)
L047BREEGTNFTransfer data to reading station & archive data42Refined time to standard time for this clinical labor task(0.94)
95813Eeg over 1 hourEF003bedroom furniture (hospital bed, table, reclining chair)NF147129Refined equipment time to conform to established policies for non-highly technical equipment(0.11)
EQ017EEG, digital, prolonged testing system (computer w-remote camera)NF156129Refined equipment time to conform to established policies for non-highly technical equipment(3.96)
L047BREEGTNFAssist physician in performing procedure10280Refined clinical labor time to match physician intraservice time(10.34)
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L047BREEGTNFEnter patient information into laboratory log book20Refined to conform with identical labor activity in other codes in the family(0.94)
L047BREEGTNFProvide pre-service education/obtain consent20Duplication with other clinical labor task(0.94)
L047BREEGTNFTransfer data to reading station & archive data42Refined time to standard time for this clinical labor task(0.94)
95863Muscle test 3 limbsEF023table, examNF5255Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ024EMG-NCV-EP system, 8 channelNF5255Refined equipment time to conform to established policies for non-highly technical equipment0.44
L037AElectrodiagnostic TechnologistNFClean room/equipment by physician staff03Refined to conform with identical labor activity in other codes in the family1.11
95864Muscle test 4 limbsEF023table, examNF6265Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ024EMG-NCV-EP system, 8 channelNF6265Refined equipment time to conform to established policies for non-highly technical equipment0.44
L037AElectrodiagnostic TechnologistNFOther Clinical Activity—specify:Prepare technician report, summarize clinical and electrodiagnostic data, and interpre60Refined to conform with identical labor activity in other codes in the family(2.22)
95869Muscle test thor paraspinalEF023table, examNF2730Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ024EMG-NCV-EP system, 8 channelNF2730Refined equipment time to conform to established policies for non-highly technical equipment0.44
L037AElectrodiagnostic TechnologistNFClean room/equipment by physician staff03Refined to conform with identical labor activity in other codes in the family1.11
95870Muscle test nonparaspinalEF023table, examNF2730Refined equipment time to conform to established policies for non-highly technical equipment0.01
EQ024EMG-NCV-EP system, 8 channelNF2730Refined equipment time to conform to established policies for non-highly technical equipment0.44
L037AElectrodiagnostic TechnologistNFClean room/equipment by physician staff03Refined to conform with identical labor activity in other codes in the family1.11
SD275Disposable electrode packNF61Refined supply quantity to what is typical for the procedure(13.75)
95923Autonomic nrv syst funj testEF023table, examNF5143Refined equipment time to conform to established policies for non-highly technical equipment(0.02)
EQ035QSART acquisition system (Q-Sweat)NF4643Refined equipment time to conform to established policies for non-highly technical equipment(0.33)
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EQ124stimulator, constant current, w-stimulating and grounding electrodes (Grass Telefactor)NF4643Refined equipment time to conform to established policies for non-highly technical equipment(0.01)
EQ171light, infra-red, ceiling mountNF4643Refined equipment time to conform to established policies for non-highly technical equipment
L037AElectrodiagnostic TechnologistNFClean room/equipment by physician staff50Typically billed with an E/M or other evaluation service(1.85)
L037AElectrodiagnostic TechnologistNFComplete diagnostic forms, lab & X-ray requisitions50Typically billed with an E/M or other evaluation service(1.85)
L037AElectrodiagnostic TechnologistNFComplete pre-service diagnostic & referral forms52Refined to conform with identical labor activity in other codes in the family(1.11)
L037AElectrodiagnostic TechnologistNFPrepare room, equipment, supplies02Refined time to standard time for this clinical labor task0.74
SA014kit, electrode, iontophoresisNF43See preamble text(4.01)
SA048pack, minimum multi-specialty visitNF10Typically billed with an E/M or other evaluation service(1.14)
95928C motor evoked uppr limbsEF023table, examNF6545Refined equipment time to conform to established policies for non-highly technical equipment(0.06)
EQ024EMG-NCV-EP system, 8 channelNF6545Refined equipment time to conform to established policies for non-highly technical equipment(2.95)
EQ178magnetic stimulator hand coil (70-90mm)NF6545Refined equipment time to conform to established policies for non-highly technical equipment(0.16)
EQ180magnetic stimulator system (BiStim)NF6545Refined equipment time to conform to established policies for non-highly technical equipment(1.43)
L047BREEGTNFAssist physician in performing procedure6040Refined clinical labor time to match physician intraservice time(9.40)
L047BREEGTNFOther Clinical Activity—specify: Review requisition. Assess for special needs. Give patient instructions for test prepa30Duplication with other clinical labor task(1.41)
SA048pack, minimum multi-specialty visitNF10Typically billed with an E/M or other evaluation service(1.14)
95929C motor evoked lwr limbsEF023table, examNF6545Refined equipment time to conform to established policies for non-highly technical equipment(0.06)
EQ024EMG-NCV-EP system, 8 channelNF6545Refined equipment time to conform to established policies for non-highly technical equipment(2.95)
EQ179magnetic stimulator leg coil (110mm)NF6545Refined equipment time to conform to established policies for non-highly technical equipment(0.24)
EQ180magnetic stimulator system (BiStim)NF6545Refined equipment time to conform to established policies for non-highly technical equipment(1.43)
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L047BREEGTNFAssist physician in performing procedure6040Refined clinical labor time to match physician intraservice time(9.40)
L047BREEGTNFOther Clinical Activity—specify:Review requisition. Assess for special needs. Give patient instructions for test prepa30Duplication with other clinical labor task(1.41)
95933Blink reflex testL037AElectrodiagnostic TechnologistNFClean room/equipment by physician staff53Refined time to standard time for this clinical labor task(0.74)
L037AElectrodiagnostic TechnologistNFPrepare room, equipment, supplies02Refined time to standard time for this clinical labor task0.74
95956Eeg monitor technol attendedEF003bedroom furniture (hospital bed, table, reclining chair)NF772769Refined equipment time to conform to established policies for non-highly technical equipment(0.02)
EQ017EEG, digital, prolonged testing system (computer w-remote camera)NF772769Refined equipment time to conform to established policies for non-highly technical equipment(0.44)
EQ047air compressor, safetyNF5249Refined equipment time to conform to established policies for non-highly technical equipment
L047BREEGTNFOther Clinical Activity—specify: Coordinate pretesting services/review test/exam results30Duplication with other clinical labor task(1.41)
L047BREEGTNFProvide pre-service education/obtain consent20Duplication with other clinical labor task(0.94)

Table 14—Crosswalk for Establishing CY 2016 New, Revised, and Potentially Misvalued Codes Malpractice RVUs

CY 2016 New, Revised or Potentially Misvalued CodeMalpractice Risk Factor Crosswalk Code
11750Removal of nail bed11750Removal of nail bed.
20240Bone biopsy excisional20240Bone biopsy excisional.
27280Fusion of sacroiliac joint27280Fusion of sacroiliac joint.
31622Dx bronchoscope/wash31622Dx bronchoscope/wash.
3160ABronch ebus sampling 1/2 node31620Endobronchial us add-on.
3160BBronch ebus samplng 3/> node31620Endobronchial us add-on.
31625Bronchoscopy w/biopsy(s)31625Bronchoscopy w/biopsy(s).
31626Bronchoscopy w/markers31626Bronchoscopy w/markers.
31628Bronchoscopy/lung bx each31628Bronchoscopy/lung bx each.
31629Bronchoscopy/needle bx each31629Bronchoscopy/needle bx each.
3160CBronch ebus ivntj perph les31620Endobronchial us add-on.
31632Bronchoscopy/lung bx addl31632Bronchoscopy/lung bx addl.
31633Bronchoscopy/needle bx addl31633Bronchoscopy/needle bx addl.
3347AImplant tcat pulm vlv perq93581Transcath closure of vsd.
3725AIntrvasc us noncoronary 1st37250Iv us first vessel add-on.
3725BIntrvasc us noncoronary addl37251Iv us each add vessel add-on.
38570Laparoscopy lymph node biop38570Laparoscopy lymph node biop.
38571Laparoscopy lymphadenectomy38571Laparoscopy lymphadenectomy.
38572Laparoscopy lymphadenectomy38572Laparoscopy lymphadenectomy.
3940AMediastinoscpy w/medstnl bx33924Remove pulmonary shunt.
3940BMediastinoscpy w/lmph nod bx32606Thoracoscopy w/bx med space.
44380Small bowel endoscopy br/wa44380Small bowel endoscopy br/wa.
44381Small bowel endoscopy br/wa45340Sig w/tndsc balloon dilation.
44382Small bowel endoscopy44382Small bowel endoscopy.
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44384Small bowel endoscopy44383Ileoscopy w/stent.
44385Endoscopy of bowel pouch44385Endoscopy of bowel pouch.
44386Endoscopy bowel pouch/biop44386Endoscopy bowel pouch/biop.
44388Colonoscopy thru stoma spx44388Colonoscopy thru stoma spx.
44389Colonoscopy with biopsy44389Colonoscopy with biopsy.
44390Colonoscopy for foreign body44390Colonoscopy for foreign body.
44391Colonoscopy for bleeding44391Colonoscopy for bleeding.
44392Colonoscopy & polypectomy44392Colonoscopy & polypectomy.
44394Colonoscopy w/snare44394Colonoscopy w/snare.
44401Colonoscopy with ablation44393Colonoscopy lesion removal.
44402Colonoscopy w/stent plcmt44397Colonoscopy w/stent.
44403Colonoscopy w/resection44392Colonoscopy & polypectomy.
44404Colonoscopy w/injection44389Colonoscopy with biopsy.
44405Colonoscopy w/dilation44390Colonoscopy for foreign body.
44406Colonoscopy w/ultrasound44394Colonoscopy w/snare.
45330Diagnostic sigmoidoscopy45330Diagnostic sigmoidoscopy.