DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Care Financing Administration [HCFA-1170-PN] RIN 0938-AK56 Medicare Program; Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule AGENCY:

Health Care Financing Administration (HCFA), HHS.

ACTION:

Proposed notice.

 SUMMARY:

This proposed notice discusses changes to work relative value units (RVUs) affecting payment for physicians' services. Section 1848(c)(2)(B)(i) of the Social Security Act requires that we review RVUs no less often than every 5 years. This is the second review of work RVUs since we implemented the physician fee schedule on January 1, 1992. These work RVUs are proposed to be effective for services furnished beginning January 1, 2002.

 DATES:

To be assured of consideration, we must receive comments at the appropriate address, as provided below, no later than 5 p.m. on August 7, 2001.

 ADDRESSES:

Mail written comments (1 original and 3 copies) to the following address only: Health Care Financing Administration, Department of Health and Human Services, Attention: HCFA-1170-PN, P.O. Box 8013, Baltimore, MD 21244-8013.

Please allow sufficient time for mailed comments to be timely received in the event of delivery delays. If you prefer, you may deliver your written comments by courier (1 original and 3 copies) to one of the following addresses:

Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201,

  or

Room C5-14-03, 7500 Security Boulevard, Baltimore, MD 21244-8013

Comments mailed to the above addresses may be delayed and received too late to be considered.

Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. In commenting, please refer to file code HCFA-1170-PN. Comments received timely will be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document at the headquarters of the Health Care Financing Administration, 7500 Security Boulevard, Baltimore, Maryland, on Monday through Friday of each week from 8:30 a.m. to 5 p.m. Please call (410) 786-7197 to make an appointment to view the public comments.

 FOR FURTHER INFORMATION CONTACT: Jim Menas, (410) 786-4507. Rick Ensor, (410) 786-5617. Diane Milstead, (410) 786-3355. Marc Hartstein (Regulatory Impact Analysis), (410) 786-4539. Supplementary Information

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To assist readers in referencing sections contained in the preamble, we are providing the following table of contents:

Table of Contents I. Background A. Legislative History B. Published Changes to the Physician Fee Schedule C. Current Proposed Notice D. The 5-Year Review Process II. Discussion of Comments and Decisions A. Review of Comments B. Discussion of Comments by Clinical Area 1. Vascular Surgery 2. General Surgery/Colon and Rectal Surgery 3. Thoracic Surgery 4. Orthopedic Surgery 5. Ophthalmology 6. Urology 7. Obstetrics/Gynecology a. Specialty Comments b. Other Concerns 8. Gastroenterology 9. Pulmonary Medicine/Critical Care 10. Cardiology 11. Pediatrics 12. Pediatric Surgery 13. Radiology 14. Plastic Surgery C. Other Comments 1. Anesthesia Services 2. Spine Injection Procedures 3. Biofeedback 4. Surgical Management of Burn Wounds 5. Transplantation 6. Arthroscopy Services 7. Wheelchair Management 8. Psychological Testing 9. Podiatric Services D. Other Issues 1. Critical Care Services in a Global Period 2. Codes Referred to CPT 3. Budget Neutrality 4. Calculation of Practice Expense and Malpractice Relative Value Units 5. Nature and Format of Comments on Work Relative Value Units III. Collection of Information Requirements IV. Response to Comments V. Regulatory Impact Analysis

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

AANA Arthroscopy Association of North America AAO American Academy of Opthalmology AAP American Academy of Pediatrics ABA American Burn Association ACG American College of Gastroenterology ACOG American College of Obstetrics and Gynecology ACR American College of Radiology ACS American College of Surgeons AGA American Gastrointestinal Association AMA American Medical Association APMA American Podiatric Medical Association APSA American Pediatric Surgical Association APTA American Physical Therapy Association ASA American Society of Anesthesiologists ASCRS American Society of Colon and Rectal Surgeons ASGE American Society for Gastrointestinal Endoscopy ASPS American Society of Plastic Surgery ASTS American Society for Transplant Surgeons AUA American Urological Association BBA Balanced Budget Act CPT Current procedural terminology CY Calendar year ERCP Endoscopic retrograde cholangio-pancreatography FDA Food and Drug Administration FR  Federal Register GAF Geographic adjustment factor GCPI Geographic practice cost index GPO Government Printing Office HCFA Health Care Financing Administration HCPAC Health Care Professionals Advisory Committee HCPCS HCFA Common Procedure Coding System HHS Health and Human Services IWPUT Intra-service work per unit of time MEI Medicare economic index MQSA Mammography Quality Standards Act of 1992 MSA Metropolitan statistical area PE Practice expense PEAC Practice Expense Advisory Committee RFA Regulatory Flexibility Act RIA Regulatory impact analysis RUC [AMA's Specialty Society] Relative [Value] Update Committee RVU Relative value unit STS Society of Thoracic Surgeons SVS Society for Vascular Surgery I. Background A. Legislative History

Since January 1, 1992, Medicare has paid for physician services under section 1848 of the Social Security Act (the Act), “Payment for Physicians” Services.” This section contains three major elements, (1) a fee schedule for the payment of physicians' services; (2) a sustainable growth rate for the rates of increase in Medicare expenditures for physicians' services; and (3) limits on the amounts that nonparticipating physicians can charge beneficiaries. The Act requires that payments under the fee schedule be based on national uniform relative value units (RVUs) based on the resources used in furnishing a service. Section 1848(c) of the Act requires that national RVUs be established for physician work, practice expense, and malpractice expense.

Section 1848(c)(2)(B)(ii)(II) of the Act provides that adjustments in RVUs may not cause total physician fee schedule payments to differ by more than $20 million from what they would have been had the adjustments not been made. If this tolerance is exceeded, we must make adjustments to the conversion factors (CFs) to preserve budget neutrality.

B. Published Changes to the Physician Fee Schedule

In the July 2000 proposed rule (65 FR 44177), we listed all of the final rules published through November 1999, relating to updates to the RVUs and revisions to the payment policies under the physician fee schedule. In the November 2000 final rule (65 FR 65376), we finalized the calendar year (CY) 2000 interim physician work RVUs and issued new interim work RVUs for new and revised codes for CY 2001. The final rule also discussed the activities underway with respect to the second 5-year refinement of work RVUs.

C. Current Proposed Notice

This proposed notice discusses changes to work RVUs affecting payment for physicians' services. Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no less often than every 5 years. We implemented the physician fee schedule effective for services furnished beginning January 1, 1992: the first 5-year review of work was initiated in December 1994 and was effective for services furnished beginning January 1, 1997. The revisions proposed in this notice are subject to a 60-day public comment period. We will review public comments, make adjustments as appropriate, and include revised values in our physician fee schedule final rule, to be published by November 1, 2001, effective for services furnished beginning January 1, 2002.

D. The 5-Year Review Process

We initiated the second 5-year review by soliciting public comments on potentially misvalued work RVUs for all services in the 2000 physician fee schedule in our November 2, 1999 final rule (64 FR 59427). To allow sufficient time for recommendations, we provided a 120-day comment period. We included a discussion of the activities underway with respect to the second 5-year refinement of work RVUs in the July 17, 2000 proposed rule (65 FR 44201).

We received comments from approximately 30 specialty groups, organizations, and individuals involving over 900 CPT and HCPCS codes. We also received comments on the proposed process for the 5-year review. As we indicated in the November 2, 1999 final rule and in the July 17, 2000 proposed rule, we shared these comments with the AMA Specialty Society Relative Value Update Committee (RUC). The RUC was formed in November 1991 and grew out of a series of discussions between the AMA and major national medical specialty societies. The work of the RUC is supported by the RUC Advisory Committee, which is made up of representatives of 100 specialty societies in the AMA's House of Delegates.

The RUC currently makes recommendations to us on RVUs for new and revised CPT codes (hereafter referred to as codes). This process was used during the first 5-year review, and we believe that it was beneficial. We indicated that we believe the perspective of the RUC is helpful because of its experience in recommending RVUs for the codes that have been added to, or revised by, the CPT panel since we implemented the physician fee schedule in 1992. By virtue of its multispecialty membership and consultation with specialty societies, the RUC involves the medical community in formulating its recommendations. For codes used only by non-physician practitioners, the Health Care Professionals Advisory Committee (HCPAC), a companion to the RUC, has made recommendations to us.

As we stated in the first 5-year review, we retain the responsibility for analyzing the comments and recommendations, developing the proposed rule, evaluating comments on the proposed rule, and deciding whether to revise RVUs.

After we sent the RUC the comments we received on potentially misvalued services, the RUC identified specialty societies interested in making presentations concerning those misvalued services. In making presentations to the RUC, specialty societies compiled data using a standard survey instrument whereby respondents compared the surveyed service with similar “reference” services that have established, agreed upon work values. Respondents were asked to estimate the work for the survey code, the time to perform pre-, intra-, and postservice activities, and the technical skill, risk, and judgement involved with performing the service. Postservice activities were broken down into hospital and office visits and were assigned an appropriate evaluation and management code by the respondent. Each specialty society selected the physician sample that was surveyed. A minimum of 30 responses was required by the RUC for the survey to be considered valid.

For this 5-year review, the RUC permitted a specialty society to use a “minisurvey” for some codes if the number of codes a specialty was reviewing was extremely high. These minisurveys required less information from the respondent but were similar in design.

Some specialty societies used a “building-block” approach to validate the survey results for surgical services. In constructing the building blocks, a service is divided into “pre-”, “intra-”, and “post-” service components. The preservice component consists of all services furnished before the physician makes the skin incision (for example, preoperative evaluation and scrubbing) the intraservice component consists of the “skin-to-skin” time, and the postservice component includes immediate postsurgery services and subsequent hospital and office visits. Each component (or building block) is then assigned work RVUs. Preservice and intraservice work RVUs are based on time and intensity, and postservice work is based on the specified evaluation and management service for each postoperative visit. These three values are then summed to compute “building-block” work RVUs.

The results of the surveys were reviewed and organized by the specialty society and then presented to the RUC. Based on the survey results and a discussion, the RUC developed a recommendation. The RUC used six workgroups to evaluate the codes. Each workgroup evaluated a series of related codes and submitted its report to the full RUC. The RUC then evaluated those reports and sent recommendations to us. Both the workgroups and the RUC evaluated the relative work (time and intensity) for each service compared to other services on the fee schedule.

We received recommendations on work RVUs from the RUC for all of the codes we forwarded, with the exception of the anesthesia codes and conscious sedation codes.

II. Discussion of Comments and Decisions A. Review of Comments

During the comment period for our November 2, 1999 final rule, we received approximately 35 public comments on approximately 900 codes. After review by our medical staff, we forwarded all of the comments we received concerning misvalued services to the RUC. The RUC submitted work RVU recommendations for all of the codes we forwarded with the exception of the anesthesia codes and conscious sedation codes. The RUC used six workgroups to evaluate the codes. Each workgroup evaluated a series of related codes and submitted its report to the full RUC. The RUC then evaluated those reports and sent its recommendations to us. Both the workgroups and the RUC evaluated the relative work (time and intensity) for each service compared to other services on the fee schedule.

As discussed below, we further analyzed all of the RUC recommendations; we evaluated both the recommended work RVUs and the rationale for the recommendations. If we had concerns about the application of a particular methodology, we verified that the recommended work RVUs were appropriate by using alternative methodologies.

Table 1, Five-Year Review of Work Relative Value Units, lists the codes reviewed during the 5-year review. This table includes the following information:

• CPT/HCPCS Code. This is the CPT or alphanumeric HCPCS code for a service.

• Modifier. A modifier-26 is shown if the work RVUs represent the professional component of the service.

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

• 2000 Work RVUs. The work RVUs that appeared in the November 2, 1999 final rule are shown for each reviewed code.

• Requested Work RVUs. This column identifies the work RVUs requested by the commenting specialty or individual commenter. If we received more than one comment on a code, the code is listed more than once with the recommended RVUs. If the commenters did not recommend specific RVUs, we indicate this by “N/A”. A “WD” (withdrawal) indicates the commenter withdrew the request for review of a code and chose not to pursue review of the code under the 5-year review.

• RUC Recommendation. This column identifies the work RVUs recommended by the RUC. “CPT” indicates that that the RUC referred this code to the AMA CPT Editorial Panel for review and clarification and recommended maintaining the current work RVUs. An “(e)” indicates the commenting specialty withdrew the proposal; therefore, the RUC recommends maintaining the current work RVUs.

• HCPAC Recommendation. This column identifies the work RVUs recommended by the HCPAC. An “(a)” in this column indicates there was no HCPAC recommendation.

• HCFA Decision. This column indicates whether we agreed with the RUC recommendation (“agree”); we are proposing work RVUs higher than the RUC recommendation (“increase”); or we are proposing work RVUs that are less than the RUC recommendation (“decrease”). Codes for which we did not accept the RUC recommendation are discussed in greater detail following Table 1. An “(a)” in this column indicates that in the absence of a RUC recommendation we are proposing to maintain the present work RVUs. A “(b)” in this column indicates that these services were reviewed as part of the July 2000 Multispecialty Refinement Panels for new and/or revised services. (Meetings of Multispecialty Refinement Panels are conducted as needed to allow specialty representatives the opportunity to discuss the comments they submitted on our decisions on new or revised services published in the final rule. The goal of multispecialty refinement panels is to consider the interests of those who commented on the work RVUs against the redistributive effects that would occur in other specialties. Following each discussion of a specific service, panel members were instructed to individually rate the service under discussion. We then used a statistical analysis of these ratings to create final work RVUs for the services under discussion.) A “(d)” indicates there was no HCPAC recommendation. We propose maintaining current work RVUs.

• Proposed work RVUs: This column contains the 2002 proposed work RVUs.

The following is a categorization of our proposals as related to the RUC recommended work RVUs from the 5-year review of work RVUs. The RUC supplied us with recommendations on 857 services. We accepted RUC's recommended work RVUs for 792 of the services reviewed and disagreed with RUC's recommended work RVUs for 65 of the services reviewed. This is an acceptance percentage of 92 percent. Of the 65 services for which we did not accept the RUC's recommended work RVUs we increased the work RVUs for 37 services, decreased the work RVUs for 22 services, and rejected the RUC recommendation of an increase for 6 services that had already been reviewed at the Multispecialty Refinement Panel for CY 2000.

Additionally, the HCPAC reviewed a total of 12 services as part of the 5-year review. For 5 of the services reviewed, the HCPAC did not offer a recommendation. Of the remaining 7 services reviewed by the HCPAC, we have accepted the HCPAC recommendations.

—————————— 1  All CPT codes and descriptors copyright 2000 American Medical Association Table 1.—Five-Year Review of Work Relative Value Units CPT/HCPCS

  • code  1
    • Mod Descriptor 2000
  • work RVU
    • Requested
  • work RVU
    • RUC
  • REC
    • HCPAC
  • REC
    • HCFA
  • decision
    • Proposed
  • work RVU
    • 11055 Trim skin lesion 0.27 0.43 (a) (a) 0.27 11056 Trim skin lesion, 2 to 4 0.39 0.61 (a) (a) 0.39 11057 Trim skin lesions, over 4 0.50 0.79 (a) (a) 0.50 11100 Biopsy of skin lesion 0.81 WD (e) (a) 0.81 11402 Removal of skin lesion 1.61 2.20 1.61 agree 1.61 11642 Removal of skin lesion 2.93 3.05 2.93 agree 2.93 11642 Removal of skin lesion 2.93 3.87 2.93 agree 2.93 11719 Trim nail(s) 0.11 0.17 (a) (a) 0.11 11730 Removal of nail plate 1.13 WD (e) (a) 1.13 12001 Repair superficial wound(s) 1.70 N/A CPT CPT 1.70 12002 Repair superficial wound(s) 1.86 N/A CPT CPT 1.86 12011 Repair superficial wound(s) 1.76 2.37 1.76 agree 1.76 13101 Repair of wound or lesion 3.92 5.43 3.92 agree 3.92 13131 Repair of wound or lesion 3.79 4.79 3.79 agree 3.79 13132 Repair of wound or lesion 5.95 6.95 5.95 agree 5.95 15000 Skin graft 4.00 5.95 CPT CPT 4.00 15001 Skin graft add-on 1.00 2.50 CPT CPT 1.00 15100 Skin split graft 9.05 9.05 CPT CPT 9.05 15101 Skin split graft add-on 1.72 1.72 CPT CPT 1.72 15120 Skin split graft 9.83 9.83 CPT CPT 9.83 15121 Skin split graft add-on 2.67 2.67 CPT CPT 2.67 15350 Skin homograft 4.00 4.00 CPT CPT 4.00 15351 Skin homograft add-on 1.00 1.00 CPT CPT 1.00 15400 Skin heterograft 4.00 4.00 CPT CPT 4.00 15401 Skin heterograft add-on 1.00 1.00 CPT CPT 1.00 17000 Destroy benign/premal lesion 0.60 WD (e) (a) 0.60 17003 Destroy lesions, 2-14 0.15 WD (e) (a) 0.15 17004 Destroy lesions, 15 or more 2.79 WD (e) (a) 2.79 19000 Drainage of breast lesion 0.84 1.27 0.84 agree 0.84 19100 Biopsy of breast 1.27 3.88 1.27 agree 1.27 19125 Excision, breast lesion 6.06 9.00 6.06 agree 6.06 19160 Removal of breast tissue 5.99 8.38 5.99 agree 5.99 19162 Remove breast tissue, nodes 13.53 15.68 13.53 agree 13.53 19240 Removal of breast 16.00 18.87 16.00 agree 16.00 20205 Deep muscle biopsy 2.35 3.42 CPT CPT 2.35 20245 Bone biopsy, excisional 3.95 7.97 8.50 decrease 7.78 20600 Drain/inject, joint/bursa 0.66 WD (e) (a) 0.66 20605 Drain/inject, joint/bursa 0.68 WD (e) (a) 0.68 21740 Reconstruction of sternum 16.50 21.00 CPT CPT 16.50 21800 Treatment of rib fracture 0.96 1.77 0.96 agree 0.96 23076 Removal of shoulder lesion 7.63 13.40 CPT CPT 7.63 23472 Reconstruct shoulder joint 16.92 21.27 21.10 agree 21.10 23485 Revision of collar bone 13.43 18.73 13.43 agree 13.43 23585 Treat scapula fracture 8.96 11.46 8.96 agree 8.96 23615 Treat humerus fracture 9.35 15.85 9.35 agree 9.35 23630 Treat humerus fracture 7.35 12.45 7.35 agree 7.35 23680 Treat dislocation/fracture 10.06 13.10 10.06 agree 10.06 24076 Remove arm/elbow lesion 6.30 10.20 CPT CPT 6.30 24435 Repair humerus with graft 13.17 20.36 13.17 agree 13.17 24545 Treat humerus fracture 10.46 12.26 10.46 agree 10.46 25076 Removal of forearm lesion 4.92 12.96 CPT CPT 4.92 26562 Repair of web finger 9.68 12.56 15.00 agree 15.00 27048 Remove hip/pelvis lesion 6.25 13.01 CPT CPT 6.25 27075 Extensive hip surgery 17.23 28.52 35.00 agree 35.00 27077 Extensive hip surgery 23.13 30.00 40.00 agree 40.00 27216 Treat pelvic ring fracture 15.19 25.00 15.19 agree 15.19 27217 Treat pelvic ring fracture 14.11 17.11 14.11 agree 14.11 27218 Treat pelvic ring fracture 20.15 22.15 20.15 agree 20.15 27226 Treat hip wall fracture 14.91 19.91 14.91 agree 14.91 27236 Treat thigh fracture 15.60 17.60 15.60 agree 15.60 27280 Fusion of sacroiliac joint 13.39 21.00 13.39 agree 13.39 27282 Fusion of pubic bones 11.34 21.66 11.34 agree 11.34 27284 Fusion of hip joint 16.76 20.12 23.45 agree 23.45 27328 Removal of thigh lesion 5.57 8.70 CPT CPT 5.57 27472 Repair/graft of thigh 17.72 23.62 17.72 agree 17.72 27513 Treatment of thigh fracture 17.92 20.92 17.92 agree 17.92 27536 Treat knee fracture 15.65 19.00 15.65 agree 15.65 27590 Amputate leg at thigh 12.03 15.52 12.03 agree 12.03 27619 Remove lower leg lesion 8.40 10.02 CPT CPT 8.40 27724 Repair/graft of tibia 14.99 19.34 18.20 agree 18.20 27822 Treatment of ankle fracture 9.20 10.68 11.00 agree 11.00 27823 Treatment of ankle fracture 11.80 13.27 13.00 agree 13.00 27828 Treat lower leg fracture 16.23 19.00 16.23 agree 16.23 28299 Correction of bunion 8.88 11.90 9.18 agree 9.18 28322 Repair of metatarsals 8.34 13.26 8.34 agree 8.34 28420 Treat/graft heel fracture 16.64 23.52 16.64 agree 16.64 28445 Treat ankle fracture 9.33 15.97 15.62 agree 15.62 28705 Fusion of foot bones 15.21 20.46 18.80 agree 18.80 29450 Application of leg cast 1.02 3.00 2.08 agree 2.08 29450 Application of leg cast 1.02 N/A 2.08 agree 2.08 29881 Knee arthroscopy/surgery 7.76 WD (e) (a) 7.76 29883 Knee arthroscopy/surgery 9.46 12.00 11.05 agree 11.05 29889 Knee arthroscopy/surgery 15.13 16.68 16.00 agree 16.00 29889 Knee arthroscopy/surgery 15.13 18.47 16.00 agree 16.00 31600 Incision of windpipe 3.62 6.42 7.18 agree 7.18 31622 Dx bronchoscope/wash 2.78 4.17 2.78 agree 2.78 31622 Dx bronchoscope/wash 2.78 N/A 2.78 agree 2.78 31625 Bronchoscopy with biopsy 3.37 N/A 3.37 agree 3.37 31645 Bronchoscopy, clear airways 3.16 N/A 3.16 agree 3.16 32000 Drainage of chest 1.54 2.88 1.54 agree 1.54 32000 Drainage of chest 1.54 N/A 1.54 agree 1.54 32005 Treat lung lining chemically 2.19 N/A 2.19 agree 2.19 32020 Insertion of chest tube 3.98 N/A 3.98 agree 3.98 32035 Exploration of chest 8.67 N/A 8.67 agree 8.67 32095 Biopsy through chest wall 8.36 N/A 8.36 agree 8.36 32100 Exploration/biopsy of chest 11.84 N/A 15.24 agree 15.24 32110 Explore/repair chest 13.62 N/A 23.00 agree 23.00 32220 Release of lung 19.27 N/A 24.00 agree 24.00 32225 Partial release of lung 13.96 N/A 13.96 agree 13.96 32320 Free/remove chest lining 20.54 N/A 24.00 agree 24.00 32440 Removal of lung 21.02 35.08 25.00 agree 25.00 32440 Removal of lung 21.02 N/A 25.00 agree 25.00 32480 Partial removal of lung 18.32 27.17 23.75 agree 23.75 32480 Partial removal of lung 18.32 N/A 23.75 agree 23.75 32482 Bilobectomy 19.71 N/A 25.00 agree 25.00 32491 Lung volume reduction 21.25 N/A 21.25 agree 21.25 32500 Partial removal of lung 14.30 N/A 22.00 agree 22.00 32520 Remove lung & revise chest 21.68 N/A 21.68 agree 21.68 32602 Thoracoscopy, diagnostic 5.96 N/A 5.96 agree 5.96 32651 Thoracoscopy, surgical 12.91 N/A 12.91 agree 12.91 32652 Thoracoscopy, surgical 18.66 N/A 18.66 agree 18.66 32655 Thoracoscopy, surgical 13.10 N/A 13.10 agree 13.10 32657 Thoracoscopy, surgical 13.65 N/A 13.65 agree 13.65 33207 Insertion of heart pacemaker 8.04 WD (e) (a) 8.04 33234 Removal of pacemaker system 7.82 N/A 7.82 agree 7.82 33235 Removal of pacemaker electrode 9.40 N/A 9.40 agree 9.40 33400 Repair of aortic valve 25.34 N/A 28.50 agree 28.50 33405 Replacement of aortic valve 30.61 N/A 35.00 agree 35.00 33406 Replacement of aortic valve 32.30 N/A 37.50 agree 37.50 33410 Replacement of aortic valve 32.46 N/A 32.46 agree 32.46 33411 Replacement of aortic valve 32.47 N/A 36.25 agree 36.25 33412 Replacement of aortic valve 34.79 N/A 42.00 agree 42.00 33413 Replacement of aortic valve 35.24 N/A 43.50 agree 43.50 33415 Revision, subvalvular tissue 27.15 N/A 27.15 agree 27.15 33425 Repair of mitral valve 27.00 N/A 27.00 agree 27.00 33426 Repair of mitral valve 31.03 N/A 33.00 agree 33.00 33427 Repair of mitral valve 33.72 N/A 40.00 agree 40.00 33430 Replacement of mitral valve 31.43 N/A 33.50 agree 33.50 33468 Revision of tricuspid valve 30.12 N/A 30.12 agree 30.12 33475 Replacement, pulmonary valve 28.41 N/A 33.00 agree 33.00 33506 Repair artery, translocation 26.71 N/A 35.50 agree 35.50 33510 CABG, vein, single 25.12 N/A 29.00 agree 29.00 33511 CABG, vein, two 27.40 N/A 30.00 agree 30.00 33512 CABG, vein, three 29.67 N/A 31.80 agree 31.80 33513 CABG, vein, four 31.95 N/A 32.00 agree 32.00 33514 CABG, vein, five 35.00 N/A 32.75 agree 32.75 33516 Cabg, vein, six or more 37.40 N/A 35.00 agree 35.00 33517 CABG, artery-vein, single 2.57 N/A 2.57 agree 2.57 33518 CABG, artery-vein, two 4.85 N/A 4.85 agree 4.85 33519 CABG, artery-vein, three 7.12 N/A 7.12 agree 7.12 33521 CABG, artery-vein, four 9.40 N/A 9.40 agree 9.40 33522 CABG, artery-vein, five 11.67 N/A 11.67 agree 11.67 33523 Cabg, art-vein, six or more 13.95 N/A 13.95 agree 13.95 33530 Coronary artery, bypass/reop 5.86 N/A 5.86 agree 5.86 33533 CABG, arterial, single 25.83 N/A 30.00 agree 30.00 33534 CABG, arterial, two 28.82 N/A 32.20 agree 32.20 33535 CABG, arterial, three 31.81 N/A 34.50 agree 34.50 33536 Cabg, arterial, four or more 34.79 N/A 37.50 agree 37.50 33611 Repair double ventricle 32.30 N/A 34.00 agree 34.00 33612 Repair double ventricle 33.26 N/A 35.00 agree 35.00 33615 Repair, simple fontan 32.06 N/A 34.00 agree 34.00 33617 Repair, modified fontan 34.03 N/A 37.00 agree 37.00 33619 Repair single ventricle 37.57 N/A 45.00 agree 45.00 33641 Repair heart septum defect 21.39 N/A 21.39 agree 21.39 33660 Repair of heart defects 25.54 N/A 30.00 agree 30.00 33670 Repair of heart chambers 32.73 N/A 35.00 agree 35.00 33681 Repair heart septum defect 27.67 N/A 30.61 agree 30.61 33694 Repair of heart defects 31.73 N/A 34.00 agree 34.00 33697 Repair of heart defects 33.71 N/A 36.00 agree 36.00 33730 Repair heart-vein defect(s) 31.67 N/A 34.25 agree 34.25 33750 Major vessel shunt 21.41 N/A 21.41 agree 21.41 33767 Major vessel shunt 24.50 N/A 24.50 agree 24.50 33770 Repair great vessels defect 33.29 N/A 37.00 agree 37.00 33778 Repair great vessels defect 35.82 N/A 40.00 agree 40.00 33780 Repair great vessels defect 36.94 N/A 41.75 agree 41.75 33786 Repair arterial trunk 34.84 N/A 39.00 agree 39.00 33820 Revise major vessel 16.29 N/A 16.29 agree 16.29 33840 Remove aorta constriction 20.63 N/A 20.63 agree 20.63 33860 Ascending aortic graft 33.96 N/A 38.00 agree 38.00 33861 Ascending aortic graft 34.52 N/A 42.00 agree 42.00 33863 Ascending aortic graft 36.47 N/A 45.00 agree 45.00 33870 Transverse aortic arch graft 40.31 N/A 44.00 agree 44.00 33875 Thoracic aortic graft 33.06 N/A CPT CPT 33.06 33877 Thoracoabdominal graft 42.60 N/A CPT CPT 42.60 33917 Repair pulmonary artery 24.50 N/A 24.50 agree 24.50 33919 Repair pulmonary atresia 32.67 N/A 40.00 agree 40.00 33945 Transplantation of heart 42.10 N/A 42.10 agree 42.10 34001 Removal of artery clot 12.91 WD (e) (a) 12.91 34101 Removal of artery clot 9.97 N/A 10.00 agree 10.00 34111 Removal of arm artery clot 8.07 N/A 10.00 agree 10.00 34151 Removal of artery clot 16.86 27.51 25.00 agree 25.00 34151 Removal of artery clot 16.86 28.00 25.00 agree 25.00 34201 Removal of artery clot 9.13 10.40 10.03 agree 10.03 34201 Removal of artery clot 9.13 10.58 10.03 agree 10.03 34203 Removal of leg artery clot 12.21 14.99 16.50 agree 16.50 34203 Removal of leg artery clot 12.21 16.50 16.50 agree 16.50 34401 Removal of vein clot 12.86 26.63 25.00 agree 25.00 34401 Removal of vein clot 12.86 28.00 25.00 agree 25.00 34421 Removal of vein clot 9.93 15.75 12.00 agree 12.00 34421 Removal of vein clot 9.93 15.94 12.00 agree 12.00 34451 Removal of vein clot 14.44 29.05 27.00 agree 27.00 34451 Removal of vein clot 14.44 30.00 27.00 agree 27.00 34490 Removal of vein clot 7.60 N/A 9.86 agree 9.86 34501 Repair valve, femoral vein 10.93 N/A 16.00 agree 16.00 34510 Transposition of vein valve 13.25 N/A 18.95 agree 18.95 34520 Cross-over vein graft 13.74 N/A 17.95 agree 17.95 34530 Leg vein fusion 17.61 N/A 16.64 agree 16.64 35011 Repair defect of artery 11.65 14.10 18.00 agree 18.00 35011 Repair defect of artery 11.65 18.00 18.00 agree 18.00 35013 Repair artery rupture, arm 17.40 15.38 22.00 agree 22.00 35013 Repair artery rupture, arm 17.40 20.00 22.00 agree 22.00 35045 Repair defect of arm artery 11.26 11.05 17.57 agree 17.57 35045 Repair defect of arm artery 11.26 16.50 17.57 agree 17.57 35081 Repair defect of artery 28.01 33.13 28.01 agree 28.01 35082 Repair artery rupture, aorta 36.35 37.00 38.50 agree 38.50 35082 Repair artery rupture, aorta 36.35 41.80 38.50 agree 38.50 35092 Repair artery rupture, aorta 38.39 50.00 45.00 agree 45.00 35092 Repair artery rupture, aorta 38.39 58.61 45.00 agree 45.00 35103 Repair artery rupture, groin 33.57 41.00 40.50 agree 40.50 35103 Repair artery rupture, groin 33.57 44.12 40.50 agree 40.50 35111 Repair defect of artery 16.43 23.24 25.00 agree 25.00 35111 Repair defect of artery 16.43 28.00 25.00 agree 25.00 35112 Repair artery rupture,spleen 18.69 29.20 30.00 agree 30.00 35112 Repair artery rupture,spleen 18.69 30.00 30.00 agree 30.00 35121 Repair defect of artery 25.99 30.29 30.00 agree 30.00 35121 Repair defect of artery 25.99 32.00 30.00 agree 30.00 35122 Repair artery rupture, belly 33.45 36.83 35.00 agree 35.00 35122 Repair artery rupture, belly 33.45 37.00 35.00 agree 35.00 35131 Repair defect of artery 18.55 23.15 25.00 agree 25.00 35131 Repair defect of artery 18.55 28.00 25.00 agree 25.00 35132 Repair artery rupture, groin 21.95 30.00 30.00 agree 30.00 35132 Repair artery rupture, groin 21.95 30.54 30.00 agree 30.00 35141 Repair defect of artery 14.46 19.38 20.00 agree 20.00 35141 Repair defect of artery 14.46 20.00 20.00 agree 20.00 35142 Repair artery rupture, thigh 15.86 23.36 23.30 agree 23.30 35142 Repair artery rupture, thigh 15.86 25.00 23.30 agree 23.30 35151 Repair defect of artery 17.00 20.26 22.64 agree 22.64 35151 Repair defect of artery 17.00 22.00 22.64 agree 22.64 35152 Repair artery rupture, knee 16.70 24.98 25.62 agree 25.62 35152 Repair artery rupture, knee 16.70 27.50 25.62 agree 25.62 35182 Repair blood vessel lesion 17.74 N/A 30.00 agree 30.00 35184 Repair blood vessel lesion 12.25 N/A 18.00 agree 18.00 35189 Repair blood vessel lesion 18.43 N/A 28.00 agree 28.00 35190 Repair blood vessel lesion 12.75 N/A 12.75 agree 12.75 35201 Repair blood vessel lesion 9.99 12.74 16.14 agree 16.14 35201 Repair blood vessel lesion 9.99 18.35 16.14 agree 16.14 35206 Repair blood vessel lesion 9.25 N/A 13.25 agree 13.25 35221 Repair blood vessel lesion 16.42 26.00 24.39 agree 24.39 35221 Repair blood vessel lesion 16.42 28.95 24.39 agree 24.39 35226 Repair blood vessel lesion 9.06 14.00 14.50 agree 14.50 35226 Repair blood vessel lesion 9.06 15.82 14.50 agree 14.50 35231 Repair blood vessel lesion 12.00 15.64 20.00 agree 20.00 35231 Repair blood vessel lesion 12.00 18.90 20.00 agree 20.00 35236 Repair blood vessel lesion 10.54 12.85 17.11 agree 17.11 35236 Repair blood vessel lesion 10.54 18.00 17.11 agree 17.11 35246 Repair blood vessel lesion 19.84 26.00 26.45 agree 26.45 35246 Repair blood vessel lesion 19.84 N/A 26.45 agree 26.45 35251 Repair blood vessel lesion 17.49 31.00 30.20 agree 30.20 35251 Repair blood vessel lesion 17.49 34.04 30.20 agree 30.20 35256 Repair blood vessel lesion 11.38 N/A 18.36 agree 18.36 35261 Repair blood vessel lesion 11.63 15.51 17.80 agree 17.80 35261 Repair blood vessel lesion 11.63 18.90 17.80 agree 17.80 35266 Repair blood vessel lesion 10.30 15.79 14.91 agree 14.91 35266 Repair blood vessel lesion 10.30 17.00 14.91 agree 14.91 35276 Repair blood vessel lesion 18.75 22.00 24.25 agree 24.25 35276 Repair blood vessel lesion 18.75 N/A 24.25 agree 24.25 35281 Repair blood vessel lesion 16.48 29.00 28.00 agree 28.00 35281 Repair blood vessel lesion 16.48 32.01 28.00 agree 28.00 35286 Repair blood vessel lesion 11.87 N/A 16.16 agree 16.16 35311 Rechanneling of artery 23.85 30.00 27.00 agree 27.00 35311 Rechanneling of artery 23.85 N/A 27.00 agree 27.00 35321 Rechanneling of artery 11.97 16.47 16.00 agree 16.00 35321 Rechanneling of artery 11.97 18.35 16.00 agree 16.00 35331 Rechanneling of artery 23.52 24.81 26.20 agree 26.20 35331 Rechanneling of artery 23.52 28.01 26.20 agree 26.20 35351 Rechanneling of artery 20.11 24.09 23.00 agree 23.00 35351 Rechanneling of artery 20.11 25.50 23.00 agree 23.00 35355 Rechanneling of artery 16.09 20.01 18.50 agree 18.50 35355 Rechanneling of artery 16.09 20.75 18.50 agree 18.50 35361 Rechanneling of artery 23.59 29.08 28.20 agree 28.20 35361 Rechanneling of artery 23.59 30.00 28.20 agree 28.20 35363 Rechanneling of artery 24.66 32.00 30.20 agree 30.20 35363 Rechanneling of artery 24.66 35.67 30.20 agree 30.20 35371 Rechanneling of artery 11.64 12.97 14.72 agree 14.72 35371 Rechanneling of artery 11.64 17.75 14.72 agree 14.72 35372 Rechanneling of artery 13.56 18.04 18.00 agree 18.00 35372 Rechanneling of artery 13.56 19.53 18.00 agree 18.00 35381 Rechanneling of artery 15.81 N/A CPT CPT 15.81 35511 Artery bypass graft 16.83 19.75 21.20 agree 21.20 35511 Artery bypass graft 16.83 21.50 21.20 agree 21.20 35518 Artery bypass graft 15.42 18.59 21.20 agree 21.20 35518 Artery bypass graft 15.42 23.00 21.20 agree 21.20 35521 Artery bypass graft 16.17 20.46 22.20 agree 22.20 35521 Artery bypass graft 16.17 25.25 22.20 agree 22.20 35526 Artery bypass graft 20.00 30.00 29.95 agree 29.95 35526 Artery bypass graft 20.00 N/A 29.95 agree 29.95 35531 Artery bypass graft 25.61 33.62 36.20 agree 36.20 35531 Artery bypass graft 25.61 38.00 36.20 agree 36.20 35533 Artery bypass graft 20.52 28.00 28.00 agree 28.00 35533 Artery bypass graft 20.52 29.99 28.00 agree 28.00 35536 Artery bypass graft 23.11 25.33 31.70 agree 31.70 35536 Artery bypass graft 23.11 33.00 31.70 agree 31.70 35541 Artery bypass graft 25.80 N/A CPT CPT 25.80 35546 Artery bypass graft 25.54 N/A CPT CPT 25.54 35551 Artery bypass graft 26.67 N/A CPT CPT 26.67 35556 Artery bypass graft 21.76 24.50 21.76 agree 21.76 35556 Artery bypass graft 21.76 24.50 21.76 agree 21.76 35558 Artery bypass graft 14.04 22.00 21.20 agree 21.20 35558 Artery bypass graft 14.04 22.08 21.20 agree 21.20 35560 Artery bypass graft 23.56 28.19 32.00 agree 32.00 35560 Artery bypass graft 23.56 35.50 32.00 agree 32.00 35563 Artery bypass graft 15.14 24.00 24.20 agree 24.20 35563 Artery bypass graft 15.14 25.00 24.20 agree 24.20 35565 Artery bypass graft 15.14 23.65 23.20 agree 23.20 35565 Artery bypass graft 15.14 24.00 23.20 agree 23.20 35571 Artery bypass graft 18.58 23.65 24.06 agree 24.06 35571 Artery bypass graft 18.58 26.92 24.06 agree 24.06 35582 Vein bypass graft 27.13 N/A CPT CPT 27.13 35587 Vein bypass graft 19.05 24.47 24.75 agree 24.75 35587 Vein bypass graft 19.05 27.00 24.75 agree 24.75 35621 Artery bypass graft 14.54 16.53 20.00 agree 20.00 35621 Artery bypass graft 14.54 21.50 20.00 agree 20.00 35623 Bypass graft, not vein 16.62 17.62 24.00 agree 24.00 35623 Bypass graft, not vein 16.62 25.75 24.00 agree 24.00 35626 Artery bypass graft 23.63 27.58 27.75 agree 27.75 35626 Artery bypass graft 23.63 30.00 27.75 agree 27.75 35631 Artery bypass graft 24.60 32.51 34.00 agree 34.00 35631 Artery bypass graft 24.60 36.00 34.00 agree 34.00 35636 Artery bypass graft 22.46 27.32 29.50 agree 29.50 35636 Artery bypass graft 22.46 36.00 29.50 agree 29.50 35641 Artery bypass graft 24.57 N/A CPT CPT 24.57 35646 Artery bypass graft 25.81 N/A CPT CPT 25.81 35650 Artery bypass graft 14.36 15.74 19.00 agree 19.00 35650 Artery bypass graft 14.36 19.80 19.00 agree 19.00 35654 Artery bypass graft 18.61 23.54 25.00 agree 25.00 35654 Artery bypass graft 18.61 26.00 25.00 agree 25.00 35661 Artery bypass graft 13.18 17.89 19.00 agree 19.00 35661 Artery bypass graft 13.18 19.53 19.00 agree 19.00 35663 Artery bypass graft 14.17 20.90 22.00 agree 22.00 35663 Artery bypass graft 14.17 23.00 22.00 agree 22.00 35665 Artery bypass graft 15.40 19.84 21.00 agree 21.00 35665 Artery bypass graft 15.40 22.00 21.00 agree 21.00 35666 Artery bypass graft 19.19 20.00 22.19 agree 22.19 35666 Artery bypass graft 19.19 22.00 22.19 agree 22.19 35671 Artery bypass graft 14.80 17.80 19.33 agree 19.33 35671 Artery bypass graft 14.80 24.00 19.33 agree 19.33 35701 Exploration, carotid artery 5.55 9.38 8.50 agree 8.50 35701 Exploration, carotid artery 5.55 15.00 8.50 agree 8.50 35721 Exploration, femoral artery 5.28 N/A 7.18 agree 7.18 35741 Exploration popliteal artery 5.37 N/A 8.00 agree 8.00 35840 Explore abdominal vessels 9.77 N/A CPT CPT 9.77 35860 Explore limb vessels 5.55 N/A CPT CPT 5.55 35905 Excision, graft, thorax 18.19 32.00 31.25 agree 31.25 35905 Excision, graft, thorax 18.19 N/A 31.25 agree 31.25 35907 Excision, graft, abdomen 19.24 37.33 35.00 agree 35.00 35907 Excision, graft, abdomen 19.24 40.00 35.00 agree 35.00 36400 Drawing blood 0.18 N/A 0.38 decrease 0.18 36405 Drawing blood 0.18 N/A 0.32 decrease 0.18 36406 Drawing blood 0.18 N/A CPT CPT 0.18 36489 Insertion of catheter, vein 1.22 2.75 2.50 agree 2.50 36489 Insertion of catheter, vein 1.22 3.41 2.50 agree 2.50 36520 Plasma and/or cell exchange 1.74 N/A CPT CPT 1.74 36533 Insertion of access device 5.32 5.28 CPT CPT 5.32 36534 Revision of access device 2.80 5.15 CPT CPT 2.80 36535 Removal of access device 2.27 3.89 CPT CPT 2.27 36600 Withdrawal of arterial blood 0.32 WD (e) (a) 0.32 36620 Insertion catheter, artery 1.15 2.25 CPT CPT 1.15 36625 Insertion catheter, artery 2.11 2.65 2.11 agree 2.11 36822 Insertion of cannula(s) 5.42 19.00 5.42 agree 5.42 37565 Ligation of neck vein 4.44 9.01 10.88 agree 10.88 37565 Ligation of neck vein 4.44 14.50 10.88 agree 10.88 37600 Ligation of neck artery 4.57 9.19 11.25 agree 11.25 37600 Ligation of neck artery 4.57 14.00 11.25 agree 11.25 37605 Ligation of neck artery 6.19 11.85 13.11 agree 13.11 37605 Ligation of neck artery 6.19 17.50 13.11 agree 13.11 37609 Temporal artery procedure 2.30 3.38 3.00 agree 3.00 37609 Temporal artery procedure 2.30 N/A 3.00 agree 3.00 37615 Ligation of neck artery 5.73 12.31 CPT CPT 5.73 37615 Ligation of neck artery 5.73 18.00 CPT CPT 5.73 37617 Ligation of abdomen artery 15.95 N/A 22.06 agree 22.06 37618 Ligation of extremity artery 4.84 N/A CPT CPT 4.84 37650 Revision of major vein 5.13 N/A 7.80 agree 7.80 37660 Revision of major vein 10.61 N/A 21.00 agree 21.00 37700 Revise leg vein 3.73 N/A CPT CPT 3.73 37720 Removal of leg vein 5.66 10.71 CPT CPT 5.66 37730 Removal of leg veins 7.33 N/A CPT CPT 7.33 37735 Removal of leg veins/lesion 10.53 N/A CPT CPT 10.53 37760 Revision of leg veins 10.47 N/A CPT CPT 10.47 37785 Revision secondary varicosity 3.84 N/A CPT CPT 3.84 38100 Removal of spleen, total 13.01 14.70 14.50 agree 14.50 38100 Removal of spleen, total 13.01 16.21 14.50 agree 14.50 38101 Removal of spleen, partial 13.74 14.79 15.31 agree 15.31 38115 Repair of ruptured spleen 14.19 15.55 15.82 agree 15.82 38300 Drainage, lymph node lesion 1.53 1.01 1.99 agree 1.99 38305 Drainage, lymph node lesion 4.61 6.59 6.00 agree 6.00 38308 Incision of lymph channels 4.95 7.35 6.45 agree 6.45 38500 Biopsy/removal, lymph nodes 2.88 3.29 3.75 agree 3.75 38500 Biopsy/removal, lymph nodes 2.88 4.58 3.75 agree 3.75 38510 Biopsy/removal, lymph nodes 4.14 6.28 6.43 agree 6.43 38520 Biopsy/removal, lymph nodes 5.12 6.93 6.67 agree 6.67 38525 Biopsy/removal, lymph nodes 4.66 5.30 6.07 agree 6.07 38530 Biopsy/removal, lymph nodes 6.13 9.58 7.98 agree 7.98 38571 Laparoscopy, lymphadenectomy 12.38 19.84 12.38 agree 12.38 38572 Laparoscopy, lymphadenectomy 14.32 23.17 16.59 agree 16.59 38740 Remove armpit lymph nodes 6.77 10.68 8.42 increase 10.02 38745 Remove armpit lymph nodes 8.84 12.78 11.00 increase 13.00 38746 Remove thoracic lymph nodes 4.39 N/A 4.89 agree 4.89 38760 Remove groin lymph nodes 8.74 11.35 10.88 increase 12.94 38765 Remove groin lymph nodes 16.06 18.77 19.98 agree 19.98 38780 Remove abdomen lymph nodes 16.59 N/A 16.59 agree 16.59 39010 Exploration of chest 11.79 N/A 11.79 agree 11.79 39220 Removal chest lesion 17.42 N/A 17.42 agree 17.42 39400 Visualization of chest 5.61 N/A 5.61 agree 5.61 39503 Repair of diaphragm hernia 34.85 122.75 95.00 decrease 34.85 42205 Reconstruct cleft palate 9.59 12.00 13.29 agree 13.29 43107 Removal of esophagus 28.79 N/A 40.00 agree 40.00 43112 Removal of esophagus 31.22 N/A 43.50 agree 43.50 43117 Partial removal of esophagus 30.02 N/A 40.00 agree 40.00 43122 Parital removal of esophagus 29.11 N/A 40.00 agree 40.00 43215 Esophagus endoscopy 2.60 4.91 CPT CPT 2.60 43217 Esophagus endoscopy 2.90 3.63 2.90 agree 2.90 43219 Esophagus endoscopy 2.80 3.50 3.18 decrease 2.80 43228 Esoph endoscopy, ablation 3.77 4.72 3.77 agree 3.77 43239 Upper GI endoscopy, biopsy 2.69 2.96 2.87 decrease 2.69 43239 Upper GI endoscopy, biopsy 2.69 3.79 2.87 decrease 2.69 43244 Upper GI endoscopy/ligation 4.59 5.05 5.05 decrease 4.59 43246 Place gastrostomy tube 4.33 4.76 4.33 agree 4.33 43246 Place gastrostomy tube 4.33 5.04 4.33 agree 4.33 43247 Operative upper GI endoscopy 3.39 4.51 3.59 decrease 3.39 43249 Esoph endoscopy, dilation 2.90 5.01 3.35 decrease 2.90 43251 Operative upper GI endoscopy 3.70 4.44 3.70 agree 3.70 43255 Operative upper GI endoscopy 4.40 5.40 4.82 decrease 4.40 43258 Operative upper GI endoscopy 4.55 5.01 4.55 agree 4.55 43259 Endoscopic ultrasound exam 4.89 N/A 8.59 decrease 4.89 43263 Endo cholangiopancreatograph 6.19 7.12 7.29 decrease 6.19 43265 Endo cholangiopancreatograph 8.90 N/A 10.02 decrease 8.90 43269 Endo cholangiopancreatograph 6.04 7.50 8.21 decrease 6.04 43305 Repair esophagus and fistula 17.15 WD (e) (a) 17.15 43310 Repair of esophagus 25.39 50.50 CPT CPT 25.39 43312 Repair esophagus and fistula 28.42 56.75 CPT CPT 28.42 43320 Fuse esophagus & stomach 16.07 26.45 19.93 agree 19.93 43324 Revise esophagus & stomach 16.58 17.75 20.57 agree 20.57 43325 Revise esophagus & stomach 16.17 21.65 20.06 agree 20.06 43326 Revise esophagus & stomach 15.91 20.53 19.74 agree 19.74 43330 Repair of esophagus 15.94 15.44 19.77 agree 19.77 43331 Repair of esophagus 16.23 17.60 20.13 agree 20.13 43340 Fuse esophagus & intestine 15.81 26.72 19.61 agree 19.61 43341 Fuse esophagus & intestine 16.81 29.07 20.85 agree 20.85 43350 Surgical opening, esophagus 12.72 32.97 15.78 agree 15.78 43351 Surgical opening, esophagus 14.79 31.92 18.35 agree 18.35 43352 Surgical opening, esophagus 12.30 25.47 15.26 agree 15.26 43360 Gastrointestinal repair 28.78 61.17 35.70 agree 35.70 43361 Gastrointestinal repair 32.65 65.83 40.50 agree 40.50 43400 Ligate esophagus veins 17.09 29.96 21.20 agree 21.20 43401 Esophagus surgery for veins 17.81 34.94 22.09 agree 22.09 43405 Ligate/staple esophagus 16.13 36.67 20.01 agree 20.01 43410 Repair esophagus wound 10.86 13.65 13.47 agree 13.47 43415 Repair esophagus wound 17.06 30.45 25.00 agree 25.00 43420 Repair esophagus opening 11.57 14.10 14.35 agree 14.35 43425 Repair esophagus opening 16.95 26.93 21.03 agree 21.03 43500 Surgical opening of stomach 8.44 11.81 11.05 agree 11.05 43501 Surgical repair of stomach 15.31 20.44 20.04 agree 20.04 43502 Surgical repair of stomach 17.67 21.20 23.13 agree 23.13 43510 Surgical opening of stomach 9.99 18.81 13.08 agree 13.08 43520 Incision of pyloric muscle 7.63 8.88 9.99 agree 9.99 43605 Biopsy of stomach 9.15 10.41 11.98 agree 11.98 43610 Excision of stomach lesion 11.15 17.37 14.60 agree 14.60 43611 Excision of stomach lesion 13.63 23.82 17.84 agree 17.84 43620 Removal of stomach 22.54 33.61 30.04 agree 30.04 43621 Removal of stomach 23.06 35.55 30.73 agree 30.73 43622 Removal of stomach 24.41 35.56 32.53 agree 32.53 43631 Removal of stomach, partial 19.66 23.28 22.59 agree 22.59 43632 Removal of stomach, partial 19.66 25.92 22.59 agree 22.59 43633 Removal of stomach, partial 20.10 27.68 23.10 agree 23.10 43634 Removal of stomach, partial 21.86 34.19 25.12 agree 25.12 43638 Removal of stomach, partial 21.76 29.96 29.00 agree 29.00 43638 Removal of stomach, partial 21.76 39.80 29.00 agree 29.00 43639 Removal of stomach, partial 22.25 39.80 29.65 agree 29.65 43640 Vagotomy & pylorus repair 14.81 17.32 17.02 agree 17.02 43641 Vagotomy & pylorus repair 15.03 21.34 17.27 agree 17.27 43651 Laparoscopy, vagus nerve 10.15 15.17 10.15 agree 10.15 43652 Laparoscopy, vagus nerve 12.15 19.21 12.15 agree 12.15 43800 Reconstruction of pylorus 10.46 11.86 13.69 agree 13.69 43810 Fusion of stomach and bowel 11.19 13.81 14.65 agree 14.65 43820 Fusion of stomach and bowel 11.74 15.78 15.37 agree 15.37 43825 Fusion of stomach and bowel 14.68 18.16 19.22 agree 19.22 43830 Place gastrostomy tube 7.28 7.28 9.53 agree 9.53 43832 Place gastrostomy tube 11.92 11.92 15.60 agree 15.60 43840 Repair of stomach lesion 11.89 11.89 15.56 agree 15.56 43842 Gastroplasty for obesity 14.71 17.14 18.47 agree 18.47 43843 Gastroplasty for obesity 14.85 20.62 18.65 agree 18.65 43846 Gastric bypass for obesity 19.15 23.43 24.05 agree 24.05 43847 Gastric bypass for obesity 21.44 29.95 26.92 agree 26.92 43848 Revision gastroplasty 23.41 27.07 29.39 agree 29.39 43850 Revise stomach-bowel fusion 19.69 23.27 24.72 agree 24.72 43855 Revise stomach-bowel fusion 20.83 24.15 26.16 agree 26.16 43860 Revise stomach-bowel fusion 19.91 26.08 25.00 agree 25.00 43865 Revise stomach-bowel fusion 21.12 27.30 26.52 agree 26.52 43870 Repair stomach opening 7.40 9.65 9.69 agree 9.69 43880 Repair stomach-bowel fistula 19.63 23.60 24.65 agree 24.65 44005 Freeing of bowel adhesion 13.84 15.43 16.23 agree 16.23 44010 Incision of small bowel 10.68 15.90 12.52 agree 12.52 44020 Exploration of small bowel 11.93 15.04 13.99 agree 13.99 44021 Decompress small bowel 12.01 15.18 14.08 agree 14.08 44025 Incision of large bowel 12.18 14.08 14.28 agree 14.28 44050 Reduce bowel obstruction 11.40 13.75 14.03 agree 14.03 44050 Reduce bowel obstruction 11.40 14.58 14.03 agree 14.03 44055 Correct malrotation of bowel 13.14 22.00 22.00 agree 22.00 44110 Excision of bowel lesion(s) 10.07 14.39 11.81 agree 11.81 44111 Excision of bowel lesion(s) 12.19 16.32 14.29 agree 14.29 44120 Removal of small intestine 14.50 15.82 17.00 agree 17.00 44125 Removal of small intestine 14.96 17.54 17.54 agree 17.54 44130 Bowel to bowel fusion 12.36 17.87 14.49 agree 14.49 44130 Bowel to bowel fusion 12.36 N/A 14.49 agree 14.49 44140 Partial removal of colon 18.35 20.94 18.35 increase 21.00 44140 Partial removal of colon 18.35 24.58 18.35 increase 21.00 44143 Partial removal of colon 20.17 30.36 20.17 increase 22.99 44144 Partial removal of colon 18.89 29.46 18.89 increase 21.53 44144 Partial removal of colon 18.89 N/A 18.89 increase 21.53 44145 Partial removal of colon 23.18 27.91 23.18 increase 26.42 44146 Partial removal of colon 24.16 30.97 24.16 increase 27.54 44147 Partial removal of colon 18.17 N/A 18.17 increase 20.71 44150 Removal of colon 21.01 27.41 21.01 increase 23.95 44151 Removal of colon/ileostomy 20.04 32.89 20.04 increase 26.88 44151 Removal of colon/ileostomy 20.04 N/A 20.04 increase 26.88 44152 Removal of colon/ileostomy 24.41 33.61 24.41 increase 27.83 44153 Removal of colon/ileostomy 26.83 33.11 26.83 increase 30.59 44155 Removal of colon/ileostomy 24.44 33.61 24.44 increase 27.86 44156 Removal of colon/ileostomy 23.01 36.27 23.01 increase 30.79 44156 Removal of colon/ileostomy 23.01 N/A 23.01 increase 30.79 44160 Removal of colon 15.88 17.45 18.62 agree 18.62 44200 Laparoscopy, enterolysis 14.44 16.11 14.44 agree 14.44 44300 Open bowel to skin 8.88 13.09 12.11 agree 12.11 44310 Ileostomy/jejunostomy 11.70 18.14 15.95 agree 15.95 44312 Revision of ileostomy 5.88 6.79 8.02 agree 8.02 44314 Revision of ileostomy 11.04 14.45 15.05 agree 15.05 44316 Devise bowel pouch 15.47 26.57 21.09 agree 21.09 44320 Colostomy 12.94 18.84 17.64 agree 17.64 44340 Revision of colostomy 5.66 6.79 7.72 agree 7.72 44345 Revision of colostomy 11.32 14.45 15.43 agree 15.43 44346 Revision of colostomy 12.46 17.19 16.99 agree 16.99 44388 Colon endoscopy 2.82 3.10 3.70 decrease 2.82 44389 Colonoscopy with biopsy 3.13 3.44 4.26 decrease 3.13 44390 Colonoscopy for foreign body 3.83 4.21 4.81 decrease 3.83 44391 Colonoscopy for bleeding 4.32 4.75 5.18 decrease 4.32 44392 Colonoscopy and polypectomy 3.82 4.20 4.81 decrease 3.82 44393 Colonoscopy, lesion removal 4.84 5.32 5.00 decrease 4.84 44394 Colonoscopy w/snare 4.43 4.87 4.43 agree 4.43 44394 Colonoscopy w/snare 4.43 N/A 4.43 agree 4.43 44602 Suture, small intestine 10.61 15.26 11.91 increase 16.03 44603 Suture, small intestine 14.00 19.50 15.72 increase 18.66 44604 Suture, large intestine 14.28 16.59 16.03 agree 16.03 44605 Repair of bowel lesion 15.37 25.03 17.25 increase 19.53 44615 Intestinal stricturoplasty 14.19 18.97 15.93 agree 15.93 44620 Repair bowel opening 10.87 14.99 12.20 agree 12.20 44625 Repair bowel opening 13.41 16.79 15.05 agree 15.05 44626 Repair bowel opening 22.59 24.43 25.36 agree 25.36 44640 Repair bowel-skin fistula 14.83 22.29 16.65 increase 21.65 44650 Repair bowel fistula 15.25 22.29 17.12 increase 22.27 44660 Repair bowel-bladder fistula 14.63 24.70 16.42 increase 21.36 44661 Repair bowel-bladder fistula 16.99 25.63 19.07 increase 24.81 44680 Surgical revision, intestine 13.72 21.32 15.40 agree 15.40 44700 Suspend bowel w/prosthesis 14.35 19.35 16.11 agree 16.11 44800 Excision of bowel pouch 11.23 10.85 11.23 agree 11.23 44820 Excision of mesentery lesion 10.31 11.23 12.09 agree 12.09 44850 Repair of mesentery 9.57 12.00 10.74 agree 10.74 44900 Drain app abscess, open 8.82 11.79 10.14 agree 10.14 44950 Appendectomy 8.70 8.37 10.00 agree 10.00 44960 Appendectomy 10.74 13.67 12.34 agree 12.34 44970 Laparoscopy, appendectomy 8.70 10.26 8.70 agree 8.70 45000 Drainage of pelvic abscess 4.52 10.29 3.88 increase 4.52 45020 Drainage of rectal abscess 4.72 7.71 4.05 increase 4.72 45100 Biopsy of rectum 3.68 4.34 3.16 increase 3.68 45108 Removal of anorectal lesion 4.76 5.25 4.09 increase 4.76 45110 Removal of rectum 23.80 29.53 28.00 agree 28.00 45111 Partial removal of rectum 16.48 N/A 16.48 agree 16.48 45112 Removal of rectum 25.96 32.46 30.54 agree 30.54 45113 Partial proctectomy 25.99 33.11 30.58 agree 30.58 45114 Partial removal of rectum 23.22 29.46 27.32 agree 27.32 45116 Partial removal of rectum 20.89 21.98 24.58 agree 24.58 45119 Remove rectum w/reservoir 26.21 31.60 30.84 agree 30.84 45120 Removal of rectum 24.60 31.09 24.60 agree 24.60 45121 Removal of rectum and colon 27.04 32.14 27.04 agree 27.04 45123 Partial proctectomy 14.20 22.51 16.71 agree 16.71 45126 Pelvic exenteration 38.39 47.99 45.16 agree 45.16 45130 Excision of rectal prolapse 13.97 14.26 16.44 agree 16.44 45135 Excision of rectal prolapse 16.39 30.14 19.28 agree 19.28 45160 Excision of rectal lesion 13.02 19.86 15.32 agree 15.32 45170 Excision of rectal lesion 9.77 12.81 11.49 agree 11.49 45190 Destruction, rectal tumor 8.28 9.09 9.74 agree 9.74 45305 Proctosigmoidoscopy & biopsy 1.01 1.22 1.01 agree 1.01 45309 Proctosigmoidoscopy 2.01 2.45 2.01 agree 2.01 45330 Diagnostic sigmoidoscopy 0.96 1.39 0.96 agree 0.96 45337 Sigmoidoscopy & decompress 2.36 N/A 2.36 agree 2.36 45339 Sigmoidoscopy 3.14 N/A 3.14 agree 3.14 45378 Diagnostic colonoscopy 3.70 4.66 3.70 agree 3.70 45380 Colonoscopy and biopsy 4.01 5.01 4.44 decrease 4.01 45383 Lesion removal colonoscopy 5.87 7.34 5.87 agree 5.87 45384 Colonoscopy 4.70 5.88 4.70 agree 4.70 45385 Lesion removal colonoscopy 5.31 6.64 5.31 agree 5.31 45505 Repair of rectum 6.02 7.57 7.58 agree 7.58 45540 Correct rectal prolapse 12.92 17.79 16.27 agree 16.27 45541 Correct rectal prolapse 10.64 13.23 13.40 agree 13.40 45550 Repair rectum/remove sigmoid 18.26 27.91 23.00 agree 23.00 45560 Repair of rectocele 8.40 7.70 10.58 agree 10.58 45562 Exploration/repair of rectum 12.21 12.09 15.38 agree 15.38 45563 Exploration/repair of rectum 18.63 21.50 23.47 agree 23.47 45800 Repair rect/bladder fistula 14.11 14.36 17.77 agree 17.77 45805 Repair fistula w/colostomy 16.50 20.94 20.78 agree 20.78 45820 Repair rectourethral fistula 14.67 13.81 18.48 agree 18.48 45825 Repair fistula w/colostomy 16.87 20.38 21.25 agree 21.25 45900 Reduction of rectal prolapse 1.83 3.27 2.61 agree 2.61 45905 Dilation of anal sphincter 1.61 3.15 2.30 agree 2.30 45910 Dilation of rectal narrowing 1.96 3.23 2.80 agree 2.80 45910 Dilation of rectal narrowing 1.96 N/A 2.80 agree 2.80 45915 Remove rectal obstruction 2.20 3.58 3.14 agree 3.14 46040 Incision of rectal abscess 4.96 5.53 4.26 increase 4.96 46045 Incision of rectal abscess 4.32 5.38 3.71 increase 4.32 46060 Incision of rectal abscess 5.69 8.55 4.89 increase 5.69 46083 Incise external hemorrhoid 1.40 1.52 1.40 agree 1.40 46083 Incise external hemorrhoid 1.40 2.34 1.40 agree 1.40 46221 Ligation of hemorrhoid(s) 1.43 1.94 2.04 agree 2.04 46230 Removal of anal tabs 2.57 1.94 2.57 agree 2.57 46250 Hemorrhoidectomy 4.53 4.13 3.89 agree 3.89 46255 Hemorrhoidectomy 5.36 4.98 4.60 agree 4.60 46257 Remove hemorrhoids & fissure 6.28 5.43 5.40 agree 5.40 46258 Remove hemorrhoids & fistula 6.67 5.86 5.73 agree 5.73 46258 Remove hemorrhoids & fistula 6.67 N/A 5.73 agree 5.73 46260 Hemorrhoidectomy 7.42 6.18 6.37 agree 6.37 46261 Remove hemorrhoids & fissure 8.24 7.11 7.08 agree 7.08 46262 Remove hemorrhoids & fistula 8.73 7.11 7.50 agree 7.50 46270 Removal of anal fistula 3.72 4.28 3.20 increase 3.72 46275 Removal of anal fistula 4.56 5.18 3.92 increase 4.56 46280 Removal of anal fistula 5.98 5.95 5.14 increase 5.98 46288 Repair anal fistula 7.13 8.08 6.13 increase 7.13 46320 Removal of hemorrhoid clot 1.61 1.52 1.61 agree 1.61 46320 Removal of hemorrhoid clot 1.61 2.63 1.61 agree 1.61 46700 Repair of anal stricture 7.25 10.22 9.13 agree 9.13 46705 Repair of anal stricture 7.17 6.90 6.90 agree 6.90 46715 Repair of anovaginal fistula 7.46 7.20 7.20 agree 7.20 46716 Repair of anovaginal fistula 12.15 15.15 15.07 agree 15.07 46730 Construction of absent anus 21.57 25.50 26.75 agree 26.75 46735 Construction of absent anus 25.94 36.00 32.17 agree 32.17 46740 Construction of absent anus 23.11 35.00 30.00 agree 30.00 46742 Repair of imperforated anus 29.67 38.00 35.80 agree 35.80 46744 Repair of cloacal anomaly 33.21 52.00 52.63 agree 52.63 46746 Repair of cloacal anomaly 36.74 53.50 58.22 agree 58.22 46748 Repair of cloacal anomaly 40.52 55.00 64.21 agree 64.21 46750 Repair of anal sphincter 8.14 10.99 10.25 agree 10.25 46753 Reconstruction of anus 6.58 5.45 8.29 agree 8.29 46754 Removal of suture from anus 1.54 2.93 2.20 agree 2.20 46760 Repair of anal sphincter 11.46 21.77 14.43 agree 14.43 46761 Repair of anal sphincter 10.99 12.15 13.84 agree 13.84 46762 Implant artificial sphincter 10.09 15.01 12.71 agree 12.71 46900 Destruction, anal lesion(s) 1.91 1.32 1.91 agree 1.91 46910 Destruction, anal lesion(s) 1.86 1.72 1.86 agree 1.86 46916 Cryosurgery, anal lesion(s) 1.86 1.72 1.86 agree 1.86 46917 Laser surgery, anal lesions 1.86 3.32 1.86 agree 1.86 46922 Excision of anal lesion(s) 1.86 3.12 1.86 agree 1.86 46924 Destruction, anal lesion(s) 2.76 3.93 2.76 agree 2.76 46924 Destruction, anal lesion(s) 2.76 4.24 2.76 agree 2.76 46934 Destruction of hemorrhoids 4.08 4.63 3.51 agree 3.51 46935 Destruction of hemorrhoids 2.43 4.17 2.43 agree 2.43 46936 Destruction of hemorrhoids 4.30 5.12 3.69 agree 3.69 46940 Treatment of anal fissure 2.32 1.71 2.32 agree 2.32 46942 Treatment of anal fissure 2.04 1.71 2.04 agree 2.04 46945 Ligation of hemorrhoids 2.14 2.37 1.84 agree 1.84 46946 Ligation of hemorrhoids 3.00 2.57 2.58 agree 2.58 47010 Open drainage, liver lesion 10.28 16.25 16.01 agree 16.01 47015 Inject/aspirate liver cyst 9.70 19.15 15.11 agree 15.11 47100 Wedge biopsy of liver 7.49 9.24 11.67 agree 11.67 47120 Partial removal of liver 22.79 39.57 35.50 agree 35.50 47122 Extensive removal of liver 35.39 53.02 55.13 agree 55.13 47125 Partial removal of liver 31.58 44.50 49.19 agree 49.19 47130 Partial removal of liver 34.25 46.45 53.35 agree 53.35 47134 Partial removal, donor liver 39.15 49.00 CPT CPT 39.15 47300 Surgery for liver lesion 9.68 12.45 15.08 agree 15.08 47350 Repair liver wound 12.56 19.16 19.56 agree 19.56 47360 Repair liver wound 17.28 28.64 26.92 agree 26.92 47361 Repair liver wound 30.25 40.14 47.12 agree 47.12 47362 Repair liver wound 11.88 24.94 18.51 agree 18.51 47400 Incision of liver duct 20.86 35.12 32.49 agree 32.49 47420 Incision of bile duct 16.72 27.63 19.88 agree 19.88 47425 Incision of bile duct 16.68 32.49 19.83 agree 19.83 47460 Incise bile duct sphincter 15.17 25.74 18.04 agree 18.04 47480 Incision of gallbladder 9.10 15.26 10.82 agree 10.82 47562 Laparoscopic cholecystectomy 11.09 9.59 11.09 agree 11.09 47563 Laparoscopic cholecystectomy 11.94 12.40 11.94 agree 11.94 47564 Laparo cholecystectomy/explr 14.23 17.67 14.23 agree 14.23 47570 Laparo cholecystoenterostomy 12.58 18.62 12.58 agree 12.58 47600 Removal of gallbladder 11.42 11.67 13.58 agree 13.58 47605 Removal of gallbladder 12.36 13.26 14.69 agree 14.69 47610 Removal of gallbladder 15.83 17.97 18.82 agree 18.82 47612 Removal of gallbladder 15.80 22.68 18.78 agree 18.78 47620 Removal of gallbladder 17.36 24.70 20.64 agree 20.64 47701 Bile duct revision 27.81 36.50 27.81 agree 27.81 47711 Excision of bile duct tumor 19.37 31.38 23.03 agree 23.03 47712 Excision of bile duct tumor 25.44 38.58 30.24 agree 30.24 47715 Excision of bile duct cyst 15.81 32.81 18.80 agree 18.80 47716 Fusion of bile duct cyst 13.83 19.34 16.44 agree 16.44 47720 Fuse gallbladder & bowel 13.38 18.16 15.91 agree 15.91 47721 Fuse upper gi structures 16.08 21.91 19.12 agree 19.12 47740 Fuse gallbladder & bowel 15.54 20.63 18.48 agree 18.48 47741 Fuse gallbladder & bowel 17.95 24.39 21.34 agree 21.34 47760 Fuse bile ducts and bowel 21.74 21.91 25.85 agree 25.85 47765 Fuse liver ducts & bowel 20.93 30.62 24.88 agree 24.88 47780 Fuse bile ducts and bowel 22.29 26.86 26.50 agree 26.50 47785 Fuse bile ducts and bowel 26.23 36.32 31.18 agree 31.18 47800 Reconstruction of bile ducts 19.60 26.89 23.30 agree 23.30 47801 Placement, bile duct support 12.76 23.47 15.17 agree 15.17 47802 Fuse liver duct & intestine 18.13 34.11 21.55 agree 21.55 47900 Suture bile duct injury 16.74 20.50 19.90 agree 19.90 48000 Drainage of abdomen 14.91 40.79 28.07 agree 28.07 48001 Placement of drain, pancreas 18.83 55.20 35.45 agree 35.45 48005 Resect/debride pancreas 22.40 57.70 42.17 agree 42.17 48020 Removal of pancreatic stone 14.22 23.50 15.70 agree 15.70 48100 Biopsy of pancreas 11.08 14.57 12.23 agree 12.23 48120 Removal of pancreas lesion 14.36 26.05 15.85 agree 15.85 48140 Partial removal of pancreas 20.78 28.60 22.94 agree 22.94 48145 Partial removal of pancreas 21.76 34.32 24.02 agree 24.02 48146 Pancreatectomy 23.91 45.57 26.40 agree 26.40 48148 Removal of pancreatic duct 15.71 25.00 17.34 agree 17.34 48150 Partial removal of pancreas 43.48 54.73 48.00 agree 48.00 48150 Partial removal of pancreas 43.48 54.75 48.00 agree 48.00 48152 Pancreatectomy 39.63 39.63 43.75 agree 43.75 48153 Pancreatectomy 43.38 54.73 47.89 agree 47.89 48154 Pancreatectomy 39.95 51.80 44.10 agree 44.10 48155 Removal of pancreas 22.32 44.70 24.64 agree 24.64 48180 Fuse pancreas and bowel 22.39 32.52 24.72 agree 24.72 48500 Surgery of pancreas cyst 13.84 18.99 15.28 agree 15.28 48510 Drain pancreatic pseudocyst 12.96 16.08 14.31 agree 14.31 48520 Fuse pancreas cyst and bowel 14.12 19.68 15.59 agree 15.59 48540 Fuse pancreas cyst and bowel 17.86 21.28 19.72 agree 19.72 48545 Pancreatorrhaphy 16.47 33.39 18.18 agree 18.18 48547 Duodenal exclusion 23.40 41.76 25.83 agree 25.83 49000 Exploration of abdomen 11.68 13.42 11.68 agree 11.68 49002 Reopening of abdomen 10.49 12.67 10.49 agree 10.49 49010 Exploration behind abdomen 12.28 15.06 12.28 agree 12.28 49020 Drain abdominal abscess 16.79 28.33 20.73 increase 22.84 49040 Drain, open, abdom abscess 9.94 23.60 12.27 increase 13.52 49060 Drain, open, retrop abscess 11.66 19.52 14.40 increase 15.86 49085 Remove abdomen foreign body 8.93 14.23 11.03 increase 12.14 49200 Removal of abdominal lesion 10.25 12.19 10.25 agree 10.25 49201 Removal of abdominal lesion 14.84 16.27 14.84 agree 14.84 49215 Excise sacral spine tumor 22.36 24.96 33.50 agree 33.50 49215 Excise sacral spine tumor 22.36 30.00 33.50 agree 33.50 49220 Multiple surgery, abdomen 14.88 17.39 14.88 agree 14.88 49255 Removal of omentum 11.14 13.42 11.14 agree 11.14 49320 Diag laparo separate proc 5.10 5.95 5.10 agree 5.10 49321 Laparoscopy; biopsy 5.40 N/A 5.40 agree 5.40 49322 Laparoscopy; aspiration 5.70 N/A 5.70 agree 5.70 49421 Insert abdominal drain 5.54 6.99 5.54 agree 5.54 49422 Remove perm cannula/catheter 6.25 6.35 6.25 agree 6.25 49425 Insert abdomen-venous drain 11.37 13.82 11.37 agree 11.37 49426 Revise abdomen-venous shunt 9.63 11.10 9.63 agree 9.63 49428 Ligation of shunt 2.38 5.38 6.06 agree 6.06 49429 Removal of shunt 7.40 9.57 7.40 agree 7.40 49495 Repair inguinal hernia, init 5.89 6.96 CPT CPT 5.89 49495 Repair inguinal hernia, init 5.89 12.50 CPT CPT 5.89 49496 Repair inguinal hernia, init 8.79 10.56 CPT CPT 8.79 49496 Repair inguinal hernia, init 8.79 14.00 CPT CPT 8.79 49500 Repair inguinal hernia 4.68 7.61 5.48 agree 5.48 49501 Repair inguinal hernia, init 7.58 9.26 8.88 agree 8.88 49505 Repair inguinal hernia 6.49 8.31 7.60 agree 7.60 49505 Repair inguinal hernia 6.49 11.50 7.60 agree 7.60 49507 Repair inguinal hernia 8.17 11.38 9.57 agree 9.57 49520 Rerepair inguinal hernia 8.22 11.02 9.63 agree 9.63 49521 Repair inguinal hernia, rec 10.22 13.97 11.97 agree 11.97 49525 Repair inguinal hernia 7.32 8.36 8.57 agree 8.57 49540 Repair lumbar hernia 8.87 8.52 10.39 agree 10.39 49550 Repair femoral hernia 7.37 8.36 8.63 agree 8.63 49553 Repair femoral hernia, init 8.06 10.31 9.44 agree 9.44 49555 Repair femoral hernia 7.71 8.50 9.03 agree 9.03 49557 Repair femoral hernia, recur 9.52 11.82 11.15 agree 11.15 49560 Repair abdominal hernia 9.88 11.69 11.57 agree 11.57 49561 Repair incisional hernia 12.17 15.67 14.25 agree 14.25 49565 Rerepair abdominal hernia 9.88 14.03 11.57 agree 11.57 49566 Repair incisional hernia 12.30 16.43 14.40 agree 14.40 49570 Repair epigastric hernia 4.86 7.00 5.69 agree 5.69 49572 Repair epigastric hernia 5.75 9.77 6.73 agree 6.73 49580 Repair umbilical hernia 3.51 5.71 4.11 agree 4.11 49582 Repair umbilical hernia 5.68 9.99 6.65 agree 6.65 49585 Repair umbilical hernia 5.32 5.71 6.23 agree 6.23 49587 Repair umbilical hernia 6.46 9.34 7.56 agree 7.56 49590 Repair abdominal hernia 7.29 9.54 8.54 agree 8.54 49605 Repair umbilical lesion 22.66 97.62 76.00 decrease 22.66 49606 Repair umbilical lesion 18.60 21.31 18.60 agree 18.60 49650 Laparo hernia repair initial 6.27 7.66 6.27 agree 6.27 49651 Laparo hernia repair recur 8.24 7.88 8.24 agree 8.24 49900 Repair of abdominal wall 12.28 16.92 12.28 agree 12.28 49905 Omental flap 6.55 17.79 CPT CPT 6.55 50200 Biopsy of kidney 2.63 N/A CPT CPT 2.63 50230 Removal of kidney 22.07 N/A CPT CPT 22.07 51595 Remove bladder/revise tract 37.14 N/A 37.14 agree 37.14 51596 Remove bladder/create pouch 39.52 N/A 39.52 agree 39.52 52300 Cystoscopy and treatment 5.31 WD (e) (a) 5.31 52327 Cystoscopy, inject material 5.19 WD (e) (a) 5.19 52340 Cystoscopy and treatment 9.68 WD (e) (a) 9.68 56515 Destruction, vulva lesion(s) 1.88 3.09 2.76 agree 2.76 56740 Remove vagina gland lesion 3.76 5.74 4.57 agree 4.57 57100 Biopsy of vagina 0.97 1.90 1.20 agree 1.20 57130 Remove vagina lesion 2.43 5.67 2.43 agree 2.43 57292 Construct vagina with graft 13.09 N/A 13.09 agree 13.09 57307 Fistula repair & colostomy 15.93 20.24 15.93 agree 15.93 57410 Pelvic examination 1.75 4.08 1.75 agree 1.75 57505 Endocervical curettage 1.14 0.97 1.14 agree 1.14 57555 Remove cervix/repair vagina 8.95 WD (e) (a) 8.95 58150 Total hysterectomy 15.24 17.75 15.24 agree 15.24 58152 Total hysterectomy 15.09 20.60 20.60 agree 20.60 58260 Vaginal hysterectomy 12.20 12.98 12.98 agree 12.98 58262 Vaginal hysterectomy 13.99 17.88 14.77 agree 14.77 58263 Vaginal hysterectomy 15.28 21.26 16.06 agree 16.06 58267 Hysterectomy & vagina repair 15.00 17.55 17.04 agree 17.04 58270 Hysterectomy & vagina repair 13.48 15.58 14.26 agree 14.26 58275 Hysterectomy/revise vagina 14.98 N/A 15.76 agree 15.76 58280 Hysterectomy/revise vagina 15.41 N/A 17.01 agree 17.01 58285 Extensive hysterectomy 18.57 N/A 22.26 agree 22.26 58323 Sperm washing 0.23 0.55 0.23 agree 0.23 58400 Suspension of uterus 6.36 11.68 6.36 agree 6.36 58600 Division of fallopian tube 3.84 4.60 5.60 agree 5.60 58605 Division of fallopian tube 3.34 4.60 5.00 agree 5.00 58611 Ligate oviduct(s) add-on 0.63 N/A 1.45 agree 1.45 58700 Removal of fallopian tube 6.49 11.68 12.05 agree 12.05 58740 Revise fallopian tube(s) 5.83 11.29 14.00 agree 14.00 58805 Drainage of ovarian cyst(s) 5.88 11.68 5.88 agree 5.88 58820 Drain ovary abscess, open 4.22 6.03 4.22 agree 4.22 58825 Transposition, ovary(s) 6.13 11.68 10.98 agree 10.98 58920 Partial removal of ovary(s) 6.78 11.68 11.36 agree 11.36 58950 Resect ovarian malignancy 15.27 16.93 16.93 agree 16.93 58951 Resect ovarian malignancy 21.81 28.99 22.38 agree 22.38 59150 Treat ectopic pregnancy 6.89 11.67 11.67 agree 11.67 59151 Treat ectopic pregnancy 7.86 11.49 11.49 agree 11.49 59812 Treatment of miscarriage 3.25 4.01 4.01 agree 4.01 59870 Evacuate mole of uterus 4.28 5.00 6.01 agree 6.01 60100 Biopsy of thyroid 0.97 1.88 1.56 agree 1.56 60220 Partial removal of thyroid 10.53 11.82 11.90 agree 11.90 60220 Partial removal of thyroid 10.53 14.24 11.90 agree 11.90 60252 Removal of thyroid 18.20 22.32 20.57 agree 20.57 60254 Extensive thyroid surgery 23.88 27.43 26.99 agree 26.99 60260 Repeat thyroid surgery 15.46 18.83 17.47 agree 17.47 60270 Removal of thyroid 17.94 23.05 20.27 agree 20.27 60271 Removal of thyroid 14.89 18.68 16.83 agree 16.83 60280 Remove thyroid duct lesion 6.08 WD (e) (a) 6.08 60540 Explore adrenal gland 17.03 20.53 17.03 agree 17.03 60545 Explore adrenal gland 19.88 25.66 19.88 agree 19.88 62263 Lysis epidural adhesions 6.14 7.20 7.20 (b) 6.14 62310 Inject spine c/t 1.91 1.95 2.20 (b) 1.91 62311 Inject spine l/s (cd) 1.54 1.57 1.78 (b) 1.54 62318 Inject spine w/cath, c/t 2.04 2.26 2.35 (b) 2.04 62319 Inject spine w/cath l/s (cd) 1.87 1.88 2.15 (b) 1.87 65855 Laser surgery of eye 4.30 N/A 3.85 agree 3.85 66170 Glaucoma surgery 12.16 WD (e) (a) 12.16 66172 Incision of eye 15.04 WD (e) (a) 15.04 66180 Implant eye shunt 14.55 N/A 14.55 agree 14.55 66986 Exchange lens prosthesis 12.28 N/A 12.28 agree 12.28 67028 Injection eye drug 2.52 N/A 2.52 agree 2.52 67108 Repair detached retina 20.82 WD (e) (a) 20.82 67218 Treatment of retinal lesion 13.52 N/A 18.53 agree 18.53 67904 Repair eyelid defect 6.26 N/A 6.26 agree 6.26 69000 Drain external ear lesion 1.45 WD (e) (a) 1.45 69005 Drain external ear lesion 2.11 WD (e) (a) 2.11 69020 Drain outer ear canal lesion 1.48 WD (e) (a) 1.48 69100 Biopsy of external ear 0.81 WD (e) (a) 0.81 69105 Biopsy of external ear canal 0.85 WD (e) (a) 0.85 69110 Remove external ear, partial 3.44 WD (e) (a) 3.44 69120 Removal of external ear 4.05 WD (e) (a) 4.05 69140 Remove ear canal lesion(s) 7.97 WD (e) (a) 7.97 69145 Remove ear canal lesion(s) 2.62 WD (e) (a) 2.62 69150 Extensive ear canal surgery 13.43 WD (e) (a) 13.43 69155 Extensive ear/neck surgery 20.80 WD (e) (a) 20.80 69200 Clear outer ear canal 0.77 WD (e) (a) 0.77 69205 Clear outer ear canal 1.20 WD (e) (a) 1.20 69210 Remove impacted ear wax 0.61 WD (e) (a) 0.61 69220 Clean out mastoid cavity 0.83 WD (e) (a) 0.83 69222 Clean out mastoid cavity 1.40 WD (e) (a) 1.40 69300 Revise external ear 6.36 WD (e) (a) 6.36 69310 Rebuild outer ear canal 10.79 WD (e) (a) 10.79 69320 Rebuild outer ear canal 16.96 WD (e) (a) 16.96 69400 Inflate middle ear canal 0.83 WD (e) (a) 0.83 69401 Inflate middle ear canal 0.63 WD (e) (a) 0.63 69405 Catheterize middle ear canal 2.63 WD (e) (a) 2.63 69410 Inset middle ear (baffle) 0.33 WD (e) (a) 0.33 69420 Incision of eardrum 1.33 WD (e) (a) 1.33 69421 Incision of eardrum 1.73 WD (e) (a) 1.73 69424 Remove ventilating tube 0.85 WD (e) (a) 0.85 69433 Create eardrum opening 1.52 WD (e) (a) 1.52 69436 Create eardrum opening 1.96 WD (e) (a) 1.96 69440 Exploration of middle ear 7.57 WD (e) (a) 7.57 69450 Eardrum revision 5.57 WD (e) (a) 5.57 69501 Mastoidectomy 9.07 WD (e) (a) 9.07 69502 Mastoidectomy 12.38 WD (e) (a) 12.38 69505 Remove mastoid structures 12.99 WD (e) (a) 12.99 69511 Extensive mastoid surgery 13.52 WD (e) (a) 13.52 69530 Extensive mastoid surgery 19.19 WD (e) (a) 19.19 69535 Remove part of temporal bone 36.14 WD (e) (a) 36.14 69540 Remove ear lesion 1.20 WD (e) (a) 1.20 69550 Remove ear lesion 10.99 WD (e) (a) 10.99 69552 Remove ear lesion 19.46 WD (e) (a) 19.46 69554 Remove ear lesion 33.16 WD (e) (a) 33.16 69601 Mastoid surgery revision 13.24 WD (e) (a) 13.24 69602 Mastoid surgery revision 13.58 WD (e) (a) 13.58 69603 Mastoid surgery revision 14.02 WD (e) (a) 14.02 69604 Mastoid surgery revision 14.02 WD (e) (a) 14.02 69605 Remove mastoid structures 18.49 WD (e) (a) 18.49 69610 Repair of eardrum 4.43 WD (e) (a) 4.43 69620 Repair of eardrum 5.89 WD (e) (a) 5.89 69631 Rebuild eardrum structures 9.86 WD (e) (a) 9.86 69632 Rebuild eardrum structures 12.75 WD (e) (a) 12.75 69633 Rebuild eardrum structures 12.10 WD (e) (a) 12.10 69635 Repair eardrum structures 13.33 WD (e) (a) 13.33 69636 Rebuild eardrum structures 15.22 WD (e) (a) 15.22 69637 Rebuild eardrum structures 15.11 WD (e) (a) 15.11 69641 Revise middle ear & mastoid 12.71 WD (e) (a) 12.71 69642 Revise middle ear & mastoid 16.84 WD (e) (a) 16.84 69643 Revise middle ear & mastoid 15.32 WD (e) (a) 15.32 69644 Revise middle ear & mastoid 16.97 WD (e) (a) 16.97 69645 Revise middle ear & mastoid 16.38 WD (e) (a) 16.38 69646 Revise middle ear & mastoid 17.99 WD (e) (a) 17.99 69650 Release middle ear bone 9.66 WD (e) (a) 9.66 69660 Revise middle ear bone 11.90 WD (e) (a) 11.90 69661 Revise middle ear bone 15.74 WD (e) (a) 15.74 69662 Revise middle ear bone 15.44 WD (e) (a) 15.44 69666 Repair middle ear structures 9.75 WD (e) (a) 9.75 69667 Repair middle ear structures 9.76 WD (e) (a) 9.76 69670 Remove mastoid air cells 11.51 WD (e) (a) 11.51 69676 Remove middle ear nerve 9.52 WD (e) (a) 9.52 69700 Close mastoid fistula 8.23 WD (e) (a) 8.23 69711 Remove/repair hearing aid 10.44 WD (e) (a) 10.44 69720 Release facial nerve 14.38 WD (e) (a) 14.38 69725 Release facial nerve 25.38 WD (e) (a) 25.38 69740 Repair facial nerve 15.96 WD (e) (a) 15.96 69745 Repair facial nerve 16.69 WD (e) (a) 16.69 69801 Incise inner ear 8.56 WD (e) (a) 8.56 69802 Incise inner ear 13.10 WD (e) (a) 13.10 69805 Explore inner ear 13.82 WD (e) (a) 13.82 69806 Explore inner ear 12.35 WD (e) (a) 12.35 69820 Establish inner ear window 10.34 WD (e) (a) 10.34 69840 Revise inner ear window 10.26 WD (e) (a) 10.26 69905 Remove inner ear 11.10 WD (e) (a) 11.10 69910 Remove inner ear & mastoid 13.63 WD (e) (a) 13.63 69915 Incise inner ear nerve 21.23 WD (e) (a) 21.23 69930 Implant cochlear device 16.81 WD (e) (a) 16.81 69950 Incise inner ear nerve 25.64 WD (e) (a) 25.64 69955 Release facial nerve 27.04 WD (e) (a) 27.04 69960 Release inner ear canal 27.04 WD (e) (a) 27.04 69970 Remove inner ear lesion 30.04 WD (e) (a) 30.04 69990 Microsurgery add-on 3.47 N/A 3.47 agree 3.47 72275 Epidurography 0.76 0.83 0.83 (b) 0.76 76005 Fluoroguide for spine inject 0.60 0.60 10.60 agree 0.60 76065 X-rays, bone evaluation 0.28 0.60 0.70 agree 0.70 76090 Mammogram, one breast 0.58 0.64 0.70 agree 0.70 76091 Mammogram, both breasts 0.69 0.76 0.87 agree 0.87 76095 Stereotactic breast biopsy 1.59 3.58 1.59 agree 1.59 88170 Fine needle aspiration 1.27 3.28 1.27 agree 1.27 88171 Fine needle aspiration 1.27 2.63 1.27 agree 1.27 90901 Biofeedback train, any meth 0.41 N/A 0.41 agree 0.41 90911 Biofeedback peri/uro/rectal 0.89 N/A 0.89 agree 0.89 90935 Hemodialysis, one evaluation 1.22 N/A CPT CPT 1.22 90937 Hemodialysis, repeated eval 2.11 N/A CPT CPT 2.11 90945 Dialysis, one evaluation 1.28 N/A CPT CPT 1.28 90947 Dialysis, repeated eval 2.16 N/A CPT CPT 2.16 90989 Dialysis training, complete 0.00 N/A CPT CPT 0.00 90993 Dialysis training, incompl 0.00 N/A CPT CPT 0.00 90997 Hemoperfusion 1.84 N/A CPT CPT 1.84 92018 New eye exam & treatment 1.51 N/A 2.50 agree 2.50 93350 Echo transthoracic 0.78 N/A 1.48 agree 1.48 94640 Airway inhalation treatment 0.00 N/A 0.00 agree 0.00 94664 Aerosol or vapor inhalations 0.00 N/A CPT CPT 0.00 94665 Aerosol or vapor inhalations 0.00 N/A CPT CPT 0.00 96100 Psychological testing 0.00 2.00 (a) agree 0.00 96105 Assessment of aphasia 0.00 2.00 (a) agree 0.00 96110 Developmental test, lim 0.00 2.00 (a) agree 0.00 96115 Neurobehavior status exam 0.00 2.20 (a) agree 0.00 96117 Neuropsych test battery 0.00 2.20 (a) agree 0.00 97542 Wheelchair mngmnt training 0.25 0.45 0.45 agree 0.45 99233 Subsequent hospital care 1.51 N/A 1.51 agree 1.51 99273 Confirmatory consultation 1.19 N/A 1.19 agree 1.19 99274 Confirmatory consultation 1.73 N/A 1.73 agree 1.73 99291 Critical care, first hour 3.60 4.00 4.00 agree 4.00 99291 Critical care, first hour 3.60 5.50 4.00 agree 4.00 99291 Critical care, first hour 3.60 N/A 4.00 agree 4.00 99292 Critical care, addl 30 min 1.80 2.00 2.00 agree 2.00 99292 Critical care, addl 30 min 1.80 2.77 2.00 agree 2.00 99292 Critical care, addl 30 min 1.80 N/A 2.00 agree 2.00 99295 Neonatal critical care 16.00 N/A 16.00 agree 16.00 99296 Neonatal critical care 8.00 N/A 8.00 agree 8.00 99297 Neonatal critical care 4.00 N/A 4.00 agree 4.00 99298 Neonatal critical care 2.75 N/A 2.75 agree 2.75 99436 Attendance, birth 1.50 N/A 1.50 agree 1.50 99440 Newborn resuscitation 2.93 N/A 2.93 agree 2.93 G0127 Trim nail(s) 0.11 N/A (a) (a) 0.11    

     

     

     

    B. Discussion of Comments by Clinical Area 1. Vascular Surgery

    Comment: The Society for Vascular Surgery (SVS) and the North American Chapter of the International Society for Cardiovascular Surgery requested increases in work RVUs for 95 codes. Both groups commented that vascular surgery procedures were undervalued in the original Harvard Study and that only a small number of these RVUs have been adjusted since that time.

    The SVS's recommendations were based on surveys, a full RUC survey of 39 higher volume codes and minisurveys for 56 less frequently performed codes. (The full and minisurveys included estimates for each code of pre-, intra-, and postservice times and visits as well as estimates of physician work. The effect of these recommendations would be to correct current rank-order anomalies, while avoiding creation of new rank-order anomalies.) The SVS used a building-block approach to validate the survey results for each of their codes.

    RUC Recommendation

    Of the 95 codes, the RUC recommended increases for 91 codes, a decrease for 1 code and no changes for 3 codes. In 60 percent of cases, the RUC recommendations to increase the work RVUs were based on physician surveys. The recommendations were based on either the 25th percentile or the median of survey responses. In almost all other cases, the RUC recommendation for a specific code work RVU was based on the work value of another comparable code. The building-block approach was used only to corroborate findings from the surveys or validate a comparison to another procedure. The following are the RUC recommendations for the codes submitted. (Please note that throughout this document the value in parentheses represents the RUC-recommended work RVUs unless they are shown in columns.)

      CPT codes Work RVUs Family 1 Aneurysm Repairs in Abdomen 35111 25.00 35131 25.00 35112 30.00 35132 30.00 35121 30.00 35122 35.00 35082 38.50 35103 40.50 35092 45.00 Family 2 Bypass Grafts in the Abdomen 35665 21.00 35663 22.00 35565 23.20 35563 24.20 35636 29.50 35536 31.70 35560 32.00 35631 34.00 35531 36.20 Family 3 Embolectomy/Thrombectomy in the Abdomen 34401 25.00 34151 25.00 34451 27.00 Family 4 Endarterectomy in the Abdomen 35351 23.00 35331 26.20 35361 28.20 35363 30.20 Family 5 Repair Blood Vessels in the Abdomen 37660 21.00 37617 22.06 35221 24.39 35281 28.00 35251 30.20 Family 6 Explorations, Revisions, Other in Chest & Abdomen 35189 28.00 35182 30.00 35905 31.25 35907 35.00 Family 7 Extra-anatomic Bypass Grafts 35661 19.00 35650 19.00 35621 20.00 35558 21.20 35511 21.20 35518 21.20 35623 24.00 35521 22.20 35654 25.00 35533 28.00 Family 8 Arterial Bypass Grafts in Extremities 35666 22.19 35671 19.23 35571 24.06 35587 24.75 Family 9 Embolectomy/Thrombectomy by Extremity Incision 34490 9.86 34111 10.00 34201 10.03 34101 10.00 34421 12.00 34203 16.50 Family 10 Aneurysm Repairs in the Extremity 35045 17.57 35011 18.00 35141 20.00 35013 22.00 35151 22.64 35142 23.30 35152 25.62 Family 11 Endarterectomy of Extremity Arteries 35371 14.72 35321 16.00 35372 18.00 35355 18.50 Family 12 Arteriovenous Fistula Repairs in the Extremities 35190 No change in work RVUs 35184 18.00 Family 13 Peripheral Artery and Vein Ligations 35721 7.18 37650 7.80 35741 8.00 37618 No change in work RVUs 37565 10.88 37600 11.25 35701 8.50 37605 13.11 37615 No change in work RVUs Family 14 Vessel/Repairs in Extremities and Neck 35201 16.14 35206 13.25 35226 14.50 35266 14.91 35261 17.80 35286 16.16 35236 17.11 35231 20.00 35256 18.36 Family 15 Reconstruction for Chronic Venous Disease 34501 16.00 34520 17.95 34510 18.95 34530 16.64 (decrease) Family 16 Repairs, Bypass Grafts, Endarterectomies in the Chest 35276 24.25 35246 26.45 35626 27.75 35526 29.95 35311 27.00 Family 17 Ligation or Biopsy of Temporal Artery 37609 3.00 Family 18 Untitled 35081 28.01 35556 21.76

    The RUC recommended the following codes be submitted to the CPT Editorial Panel for further consideration: 35381, 35541, 35546, 35551, 35582, 35641, 35646, 35840, 35860, 37615, 37618, 37700, 37730, 37735, 37760, 37785.

    HCFA Proposal:

    We have reviewed and propose to accept all of the RUC recommendations for the vascular surgery codes. We believe that relativity is maintained, and the RVUs more appropriately reflect the work involved.

    2. General Surgery/Colon and Rectal Surgery

    Comment: The American Society of General Surgeons (ASGS) submitted 55 codes it believed to be undervalued. The ASGS recommended work RVUs for each service. After submitting the codes, the specialty society ultimately chose not to pursue review of RVUs for the following codes under the 5-year review: 20605, 34001, and 29881.

    The following codes 49505, 32440, 46320, 46924, 31622, 44140 (no change), 38500, 32480, 37609, 43239, 43638, 60220, 44050, 48150, and 38100 were also submitted for review by other specialty groups and are discussed in other sections. (Note that codes 56305, 56341, 56300, 56340, and 56306 are laparoscopic surgery codes also submitted for review by the specialty group; however, these services were deleted or renumbered by CPT for 2000.)

    RUC Recommendation:

    The RUC recommended that the work RVUs for the following codes be increased (the RUC-recommended work RVUs are in parentheses):

    Code 36489, Placement of central venous catheter (subclavian, jugular, or other vein (eg, for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy)); percutaneous, age 2 years or under (2.50) to correct a rank-order anomaly; 60100, Biopsy thyroid, percutaneous core needle (1.56), to appropriately reflect the work involved and fit in the range of biopsy codes; and 31600, Tracheostomy, planned (separate procedure) (7.18), based on the building-block approach and the comparison to similar procedures.

    For the following codes, the RUC stated that there was no compelling evidence provided to support increasing the work RVUs. Therefore, it recommended maintaining the current work RVUs for the following codes: 19100, 88170, 57410, 76095, 88171, 32000, 21800, 46083, 19000, 19125, 45330, 19160, 13101, 11402, 12011, 11642, 27590, 45378, 36625, 45309, 45305, 35081, 19240, 58150, 43246, 19162, and 35556. The RUC also recommended maintaining the current work RVUs for codes 49321 and 49322 because these services had recently been reviewed by the RUC.

    The RUC recommended that the following codes be referred to the CPT Editorial Panel for review or clarification: 37720 and 43215.

    HCFA Proposal:

    We have reviewed and propose to accept all of the RUC recommendations for these surgery codes.

    Comment:

    The American College of Surgeons (ACS) submitted general surgery codes for review that account for approximately 50 percent of general surgery's Medicare-allowed charges for services categorized as surgery under our “type of service” classification. The procedures are predominantly performed by general surgeons, and they involve the gastrointestinal tract, abdominal organs, thyroid, lymph system, and endocrine system. Requests for review of some of these codes were also submitted by other specialty groups.

    In its comments, the ACS emphasized that its analysis determined that the work of codes in general surgery has been systematically undervalued.

    The ACS used a building-block approach with panel-assigned intraoperative work intensities for procedures. Preoperative work RVUs were determined based on an assigned intensity multiplied by the number of preservice minutes. The assigned preservice work intensity was below that of an evaluation and management service. A panel of ASC members assigned intraservice work intensity to each code using a scale. The intensity of an evaluation and management service was the low end of the scale, and liver resection services were on the high end of the scale. The ends of the scale were chosen to represent “average” work intensity throughout a procedure. The ACS maintains that the work intensity of any surgical procedure is greater than the work intensity of an evaluation and management service. Postservice work RVUs were calculated using current work RVUs for hospital visits and discounted work RVUs for office visits. Pre, intra-, and postwork RVUs were summed to equal the new work RVUs that the ACS developed for each code.

    The ACS assigned over 300 codes to 31 families of similar services (for example, all codes related to hernia repair were in one family). It conducted a traditional RUC survey for 32 codes (either high volume services or the service most representative of the family of codes). A minisurvey, which did not include a respondent-recommended work value, was conducted for the remaining codes, with participation from other specialty groups. The ACS indicated that the survey respondents tended to overvalue codes at the low end of the scale and undervalue codes at the high end of the scale. As a result, ACS recommended using the 25th percentile of survey results at the low end and the 75th percentile for work RVUs at the high end of the scale for fully-surveyed codes. However, they stated that acceptance of these survey results without adjustments to other codes in the family that were not fully surveyed would distort the relativity within and across families. They recommended a regression methodology to extrapolate the fully-surveyed code results to the other codes.

    RUC Recommendation:

    The RUC workgroup reviewed the data collected for the 32 fully-surveyed ACS codes. It also reviewed the families of services proposed by ACS and modified the families that were too dissimilar to permit appropriate comparison within the family. After the anchor code was reviewed, each family was reviewed to determine whether the change to the anchor code should be applied to the entire family of codes. In some instances the RUC agreed that the recommended change in the anchor code should be extrapolated to the entire family to ensure that rank-order and relativity distortions were not created by a change to the anchor code. In other instances the RUC determined that the recommendation for the anchor code did not apply to the family of codes. In these instances, either new RVUs were recommended or the present work RVUs were maintained. The following are the code-specific RUC recommendations:

      CPT codes Work RVUs Family 1A & B Thyroid/Endocrine 60220 11.90 60252 20.57 60254 26.99 60260 17.47 60270 20.27 60271 16.83 60540 No change 60545 No change Family 2 Lymphadenectomy 38740 8.42 38745 11.00 38760 10.88 38765 19.98 Family 3 Lymph Nodes and Lymphatic Channels—Incision/Excision 38300 1.99 38305 6.00 38308 6.45 38500 3.75 38510 6.43 38520 6.67 38525 6.07 38530 7.98 Family 4 Intestines—Excision/Incision 44005 16.23 44010 12.52 44020 13.99 44021 14.08 44025 14.28 44050 14.03 44110 11.81 44111 14.29 44120 17.00 44125 17.54 44130 14.49 44160 18.62 44800 11.23 44820 12.09 Family 5 Intestines—External Fistulization 44300 12.11 44310 15.95 44312 8.02 44314 15.05 44316 21.09 44320 17.64 44340 17.72 44345 15.43 44346 16.99 Family 6 Intestines—Colectomy Codes 44140, 44143, 44144, 44145, 44146, 44150, 44151, 44152, 44153, 44155, and 44156. The RUC made no changes to any of these codes based on the lack of compelling evidence. Family 7 intestines—Repair 44602 11.91 44603 15.72 44604 16.03 44605 17.25 44615 15.93 44620 12.20 44625 15.05 44626 25.36 44640 16.65 44650 17.12 44660 16.42 44661 19.07 44680 15.40 44700 16.11 44850 10.74 Family 8 Anus/Rectum—Hemorrhoids/Fistula 45000 3.88 45020 4.05 45100 3.16 45108 4.09 46040 4.26 46045 3.71 46060 4.89 46250 3.89 46255 4.60 46257 5.40 46258 5.73 46260 6.37 46261 7.08 46262 7.50 46270 3.20 46275 3.92 46280 5.14 46288 6.13 46934 3.51 46936 3.69 46945 1.84 46946 2.58 Note: All of the work RVUs for Family 8 reflect a recommended decrease from the CY 2000 work RVUs. Family 9 A B &C Anus/Rectum, Anus (destruction)—10-day global 45900 2.61 45905 2.30 45910 2.80 45915 3.14 46221 2.04 46754 2.20 Note: Based on the lack of compelling evidence, the RUC recommended that no changes be made to the following Family 9 codes: 46083, 46230, 46320, 46935, 46940, 46942, 46900, 46910, 46916, 46917, 46922, and 46924. Family 10 Anus/Rectum Repair 45505 7.58 45540 16.27 45541 13.40 45550 23.00 45560 10.58 45562 15.38 45563 23.47 45800 17.77 45805 20.78 45820 18.48 45825 21.25 46700 9.13 46750 10.25 46753 8.29 46760 14.43 46761 13.84 46762 12.71 Family 11 Hernia 49500 5.48 49501 8.88 49505 7.60 49507 9.57 49520 9.63 49521 11.97 49525 8.57 49540 10.39 49550 8.63 49553 9.44 49555 9.03 49557 11.15 49560 11.57 49561 14.25 49565 11.57 49566 14.40 49570 5.69 49572 6.73 49580 4.11 49582 6.65 49585 6.23 49587 7.56 49590 8.54 Family 12 A & B Stomach—Gastrectomy and Gastrectomy/Vagotomy 43620 30.04 43621 30.73 43622 32.53 43638 29.00 43639 29.65 43631 22.59 43632 22.59 43633 23.10 43634 25.12 43640 17.02 43641 17.27 Family 13 A & B Stomach—Incision/Excision/Repair 43500 11.05 43501 20.04 43502 23.13 43510 13.08 43520 9.99 43605 11.98 43610 14.60 43611 17.84 43800 13.69 43810 14.65 43820 15.37 43825 19.22 43830 9.53 43832 15.60 43840 15.56 43870 9.69 43842 18.47 43843 18.65 43846 24.05 43847 26.92 43848 29.39 43850 24.72 43855 26.16 43860 25.00 43865 26.52 43880 24.65 Family 14 A Abdomen, Peritoneum, Omentum The RUC recommended no changes for codes 49000, 49002, 49010, 49200, 49201, 49220, 49255, 49900, 49421, 49422, 49425, 49426, and 49429. Family 14 B Abdomen, Peritoneum, Omentum 49020 20.73 49040 12.27 49060 14.40 49085 11.03 Family 14 C Abdomen, Peritoneum, Omentum 49428 6.06 Family 15 Appendix 44900 10.14 44950 10.00 44960 12.34 Family 16 Rectum—Proctectomy/Excision 45110 28.00 45112 30.54 45113 30.58 45114 27.32 45116 24.58 45119 30.84 45123 16.71 45126 45.16 45130 16.44 45135 19.28 45160 15.32 45170 11.49 45190 9.74 Family 17 Biliary Tract 47420 19.88 47425 19.83 47460 18.04 47480 10.82 47600 13.58 47605 14.69 47610 18.82 47612 18.78 47620 20.64 47711 23.03 47712 30.24 47715 18.80 47716 16.44 47720 15.91 47721 19.12 47740 18.48 47741 21.34 47760 25.85 47765 24.88 47780 26.50 47785 31.18 47800 23.30 47801 15.17 47802 21.55 47900 19.90 Family 18 Esophagus—Repair/Reconstruction 43320 19.93 43324 20.57 43325 20.06 43326 19.74 43330 19.77 43331 20.13 43340 19.61 43341 20.85 43350 15.78 43351 18.35 43352 15.26 43360 35.70 43361 40.50 43400 21.20 43401 22.09 43405 20.01 43410 13.47 43415 25.00 43420 14.35 43425 21.03 Family 19 Liver 47010 16.01 47015 15.11 47100 11.67 47120 35.50 47122 55.13 47125 49.19 47130 53.35 47300 15.08 47350 19.56 47360 26.92 47361 47.12 47362 18.51 47400 32.49 Family 20 A & B Spleen—Incision/Excision/Repair and Pancreatitis Management 38100 14.50 38101 15.31 38115 15.82 48000 28.07 48001 35.45 48005 42.17 Family 21 Pancreatectomy 48020 15.70 48100 12.23 48120 15.85 48140 22.94 48145 24.02 48146 26.40 48148 17.34 48150 48.00 48152 43.75 48153 47.89 48154 44.10 48155 24.64 48180 24.72 48500 15.28 48510 14.31 48520 15.59 48540 19.72 48545 18.18 48547 25.83 Family 22 Laparoscopy The RUC recommended no changes to the following codes based on lack of compelling evidence: 43651, 43652, 44200, 44970, 47562, 47563, 47564, 47570, 49320, 49650, and 49651.

    The RUC also recommended that the following codes be referred to the CPT Editorial Panel for review and clarification: 36533, 36534, 36535, 49495, and 49496.

    HCFA Proposal:

    The ACS conducted full surveys of 32 codes, and we agreed with the RUC analysis for most of the 32 codes. For the other codes the ACS did minisurveys that included pre-, intra-, and postservice times as well as the number and type of postservice visits. These minisurveys did not include an estimate of the relative work for the procedure. For this reason, the RUC used an extrapolation methodology to arrive at its work RVU recommendations for all codes that did not have a full RUC survey. To make appropriate extrapolations, the RUC divided all of the general surgery codes into families of related procedures. At least one code in each family was fully surveyed. After the RUC recommended work RVUs for each surveyed code, it applied the percent change for that code to all of the other codes in the family. When more than one code was fully surveyed within a family of services, the RUC extrapolated the percentage from the fully surveyed code that would produce the least increase in work RVUs.

    The validity of this extrapolation methodology relies on at least two things—first, that the relative work values of all codes in the family were correct before the extrapolation (or else the extrapolation perpetuates and magnifies any pre-existing anomalies), and second, that the relative misvaluation of each code in a family is similar.

    We did an analysis of all the families of codes in the general surgery group to determine whether the relative valuations in the 2001 physician fee schedule contained any anomalies. If any anomalies existed, we reviewed the RUC recommendations to determine whether the anomalies were addressed by the RUC recommendations. If the anomalies were not corrected, we took steps to correct them.

    We also analyzed all of the recommended values for general surgery to ensure that the percentage changes for each family were appropriate. To determine if the extrapolation for each family was correct, we compared each extrapolated code to codes in other families, and to codes in other specialties. We compared extrapolated codes to codes whose current or RUC recommended work RVUs (from the 5-year-review) were similar to the extrapolated code. We then compared the preservice, intraservice, and postservice physician times as well as the number of postoperative visits. In addition, we generally determined whether the survey vignette was typical for the procedure. The following is an example of our review of the general surgery codes. Code 35132 ( Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, iliac artery (common, internal, external ) (30.00 work RVUs) with a preservice time of 67 minutes, intraservice time of 180 minutes, seven hospital visits, and three office visits is similar to codes 47712 ( Excision of bile duct tumor, with or without primary repair of bile duct; intrahepatic ) (30.24 work RVUs) with a preservice time of 75 minutes, intraservice time of 210 minutes, one intensive care unit visit, nine hospital visits, and three office visits and 43638 ( Gastrectomy, partial, proximal, thoracic or abdominal approach and esophagogastrostomy with vagotomy ) (29.00 work RVUs ) with a preservice time of 75 minutes, intraservice time of 210 minutes, 10 hospital visits, and 4 office visits. A review of these codes demonstrates the similarity in preservice and intraservice time and the proposed RVUs maintain relativity across surgical specialties.

    Upon completion of this analysis, we propose to accept the RUC recommendations for the following families of services:

    Family 1A and 1B Thyroid and Endocrine. Family 3 Lymph Nodes and Lymphatic Channels—Incision/Excision. Family 4 Intestines—Excision/Incision. Family 5 Intestines—External Fistulization. Family 9 Anus/Rectum—10-day global period. Family 10 Anus/Rectum—Repair. Family 11 Hernia. Family 12 Stomach—Gastrectomy/Vagotomy. Family 13 Stomach—Incision/Excision/Repair. Family 14A and C Abdomen, Peritoneum, Omentum. Family 15 Appendectomy. Family 16 Rectum-Proctectomy/Excision. Family 17 Biliary Tract. Family 18 Esophagus—Repair/Reconstruction. Family 19 Liver. Family 20 Pancreas/Spleen—Incision/Excision/Repair. Family 21 Pancreatectomy. Family 22 Laparoscopy.

    For the above families, adopting the RUC-recommended RVUs maintains relativity of the codes based upon a comparison of the codes to procedures in other families and within the family.

    For other families of services, the extrapolation methodology inappropriately values codes or does not address current rank-order anomalies. Application of the percentage increases derived from the RUC's extrapolation methodology would only exacerbate any current rank-order anomalies within families. Below, we have outlined, for each family of services, our proposed work RVUs to rectify these problems.

    Family 2 Lymphadenectomy

    The RUC recommended an increase in work RVUs for the fully surveyed code 38745 ( Axillary lymphadenectomy; complete ) from 8.84 to 11.0 RVUs based on comparisons with codes 60210 ( Partial thyroid lobectomy, unilateral, with or without isthmusectomy ), and 32100 ( Thoracotomy, major with exploration and biopsy ). We disagree. Although codes 38745 and 60210 are performed in the outpatient setting and 32100 is not, code 38745 requires more postoperative wound care. Additionally, the RUC compared 38745 to the pre-5-year review value of 32100. Subsequently the RUC reviewed code 32100 for the 5-year review and is recommending an RVU increase to 15.24 RVUs. Because the intraservice times for codes 38745 and 32100 are identical and 38745 requires more postoperative wound care, a clear rank order anomaly would exist if 38745 was valued at 11.00 work RVUs and 32100 was valued at 15.24 work RVUs. Therefore, we are assigning the median survey RVUs of 13.00 to code 38745. We would also note that the survey RVU spread from the 25th percentile to the 75th percentile ranged from 12.15 to 14.29 RVUs, which is relatively small. An RVU of 13.00 places code 38745 in the correct rank order to the comparison codes. To maintain relativity within this family, we are extrapolating the 47 percent increase in work RVUs of code 38745 to codes 38740 ( Axillary lymphadenectomy; superficial ) and 38760 ( Inguinofemoral lymphadenectomy, superficial, including Cloquets node (separate procedure) ) for proposed work RVUs of 10.02 and 12.94, respectively. However, code 38765 ( Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) ) represents a rank-order anomaly as it is currently valued too high relative to the other codes in the family. Therefore, we are accepting the RUC recommendation for code 38765 of 19.98 work RVUs.

    Family 6 Colectomy

    The RUC recommended no change in the work RVUs for this family of codes based on lack of compelling evidence for changing the RVUs of the fully surveyed code 44140 ( Partial colectomy ). Moreover, the intraservice time for code 44140 had not changed since the last 5-year review. Additionally, the RUC compared code 44140 to code 32480 ( Removal of lung, other than total pneumonectomy; single lobe (lobectomy) ) and code 50230 ( Nephrectomy, including partial ureterectomy, any approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy ) that have similar work RVUs to 44140 and were believed to be longer, more intense procedures with more postoperative care. We disagree with this recommendation. If the RVUs for procedures in this family are not changed, the procedures will be significantly undervalued compared to other general surgery codes (Family 5 and Family 7) and vascular surgery codes. As an example, we note that the RUC-recommended work RVU for code 44153 Colectomy, total, abdominal, without proctectomy; with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop, will significantly undervalue this code compared to code 45113, Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with our without loop ileostomy, thus creating a rank-order anomaly.

    We compared code 44140 to code 32480 for which the RUC is recommending a work RVU increase to 23.75. These procedures have similar intraservice times, and the postoperative visits show that although the initial care required for code 32480 is more intense, the length of stay for code 44140 is frequently longer. We also compared code 44140 to codes 37617, Ligation, major artery (eg post-traumatic, rupture); abdomen, and 35221, Repair blood vessel, direct; intra-abdominal. Code 37617, for which the RUC recommended work RVUs of 22.06, is an emergency operation with a slightly shorter intraservice time and shorter hospital stay. Code 35221, which has RUC-recommended work RVUs of 24.39, is also an emergency operation with an intraservice time and length of stay identical to code 44140. Based on these comparisons, we believe that the survey's 25th percentile work RVUs of 21.00 are appropriate and correctly rank code 44140 to the comparison procedures. This increase is 14 percent greater than the current work RVUs and, with the exception of the two codes discussed below, applying this 14 percent increase to the other codes in this family will place them in proper relationship to other comparable procedures.

    Family 6 contains two current rank-order anomalies: code 44151, Colectomy, total, abdominal, without proctectomy; with continent ileostomy, has lower work RVUs than code 44150, Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy, and 44156, Colectomy, total, abdominal, with proctectomy; with continent ileostomy, has lower work RVUs than code 44155, Colectomy, total, abdominal, with proctectomy; with ileostomy. Code 44151 is identical to code 44150, and code 44156 is identical to code 44155, except that codes 44151 and 44156 involve the creation of a “continent ileostomy” instead of an “ileostomy or ileoproctostomy.” The work of creating a “continent ileostomy” is greater than the work of creating an “ileostomy or ileoproctostomy.” To correct this rank-order anomaly, we applied the 14 percent increase discussed above to codes 44150 and 44155. Next, we determined the proper incremental increase in work for creation of a “continent ileostomy” by looking to codes 44310, Ileostomy or jejunostomy, non-tube (separate procedure), and 44316, Continent Ileostomy (Kock procedure) (separate procedure), because the work RVUs of 44316 are the same as the work RVUs of 44310 with the addition of creating a continent ileostomy. We subtracted the RUC-recommended work RVUs of 15.95 for code 44310 from the RUC-recommended work RVUs of 21.09 for code 44316 and divided by 50 percent (50 percent approximates the intraservice portion of the extra work). This resulted in work RVUs of 2.57 that we increased by 14 percent to yield work RVUs of 2.93. We then added 2.93 work RVUs to the RVUs for codes 44150 and 44155 to yield proposed work RVUs of 26.88 for code 44151 and 30.79 for code 44156.

    In summary, we propose the following work RVUs for the codes in this family:

      Code Work RVUs 44140 21.00 44143 22.99 44144 21.53 44145 26.42 44146 27.54 44150 23.95 44151 26.88 44152 27.83 44153 30.59 44155 27.86 44156 30.79

    With these assigned work RVUs, we believe that Family 6 is ranked appropriately in relation to other general and vascular surgery codes.

    Family 7 Intestines—Repair

    The RUC recommended an increase of 14 percent for all work RVUs in this family based on a recommended increase in a fully surveyed code 44604 (Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy) from 14.28 work RVUs to 16.03 work RVUs.

    We agree with the increase in work RVUs for code 44604 but note that there are several rank-order anomalies currently in this family of codes that would be exacerbated by an across-the-board increase in work RVUs. Therefore, we propose to correct the rank-order anomalies as follows:

    We propose 16.03 work RVUs for 44602 (Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation). The work RVUs for code 44602 are identical to the work RVUs for code 44604 because they describe the same procedure except code 44604 is for the large intestine.

    We propose work RVUs of 19.53 for code 44605 (Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); with colostomy). The work RVUs for code 44605 are identical to the work RVUs for code 44604 except that code 44605 includes creating a colostomy with the attendant increase in postoperative wound care. The intraservice work of creating a colostomy is captured by subtracting the work RVUs for code 44140 from code 44143, which leaves 1.99 RVUs. In addition, there is one extra postoperative visit required for code 44605 that we believe is equivalent to code 99233 that has 1.51. work RVUs. Therefore, we added 1.99 and 1.51 work RVUs to the work RVUs for code 44604 to arrive at 19.53 work RVUs for code 44605.

    We propose 18.66 work RVUs for code 44603 (Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; multiple perforations). The additional work required for code 44603 as compared to code 44602 is similar to the additional work required for code 44605 as compared to code 44604 except, since there is no actual colostomy, the additional postoperative visit is comparable to code 99231 with 0.64 work RVUs. Therefore, we added work RVUs of 1.99 and 0.64 to the work RVUs of code 44602 to arrive at 18.66 work RVUs for code 44603.

    The current work RVUs for codes 44640 (Closure of intestinal cutaneous fistula); 44650 (Closure of enteroenteric or enterocolic fistula); 44660 (Closure of enterovesical fistula; without intestinal or bladder resection); and 44661 (Closure of enterovesical fistula; with bowel and/or bladder resection) are rank-order anomalies as they are undervalued compared to code 44604. However, relativity among codes 44640, 44650, 44660, and 44661 is appropriate. To correct the anomalies, we compared codes 44650 to 50525 (Closure of nephrovisceral fistula (eg renocolic) including visceral repair; abdominal approach), which involves similar intraoperative and postoperative work. The intraoperative work for code 50525 is greater than that of code 44650 because code 50525 involves visceral repair but the postoperative work for code 44650 is greater than the postoperative work for code 50525 because the fistula is enteroenteric or enterocolic as opposed to renovisceral (that is, renocolic). Therefore, we propose to assign 22.27 work RVUs to code 44650 and, to keep the current relativity with the other codes, we propose 21.65 work RVUs for code 44640, 21.36 work RVUs for code 44660, and 24.81 work RVUs for code 44661. We propose to accept the RUC recommendations for the remaining codes (44615, 44620, 44625, 44626, 44680, 44700, and 44850).

    Family 8 Anus/Rectum—Hemorrhoids/Fistula

    The RUC extrapolated a 14 percent decrease in work RVUs to all codes in this family based upon a decrease in work RVUs for the fully surveyed code 46262, Hemorrhoidectomy, internal and external, complex or extensive; with fistulectomy, with or without fissurectomy. We agree with the RUC recommendation for the surveyed code, but disagree with the extrapolation to the anal fistula repair codes and the anal abscess treatment codes. The surveyed intraoperative time for code 46262 is not consistent with the surveyed intraoperative times for many of the other codes in the family. Moreover, the work RVUs for many of the codes subject to the minisurveys are significantly less than for code 46262 and are not comparable. Therefore, we propose to maintain the current RVUs for codes 46270, 46275, 46280, 46288, 45000, 45020, 45100, 45108, 46040, 46045, and 46060. We agree with the RUC recommendations and propose to decrease the work RVUs for other codes in this family of codes (46250, 46255, 46257, 46258, 46260, 46261, 46262, 46934, 46936, 46945, and 46946).

    Family 14B Abdomen, Peritoneum, Omentum

    The RUC recommended an increase for the fully-surveyed code 49020, (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open,) from 16.79 work RVUs to 20.73 work RVUs, the 25th percentile of surveyed work RVUs, based on a comparison to code 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural). We disagree and propose the surveyed median work RVUs of 22.84. We compared code 49020 to code 35151 (Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, false aneurysm and associated occlusive disease, popliteal artery), 48000 (Placement of drains, peripancreatic, for acute pancreatitis), and code 48140 (Pancreatectomy, distal subtotal, with our without splenectomy; without pancreaticojejunostomy). Code 48000 involves sicker patients but the intraoperative time (120 minutes) and postoperative visits (10-day length of stay for code 48000 with two critical care visits versus an 11-day length of stay for code 49020 with one critical care visit) are similar, and code 48000 has RUC-recommended work RVUs of 28.07. Code 48140, with RUC-recommended work RVUs of 22.94, has a longer intraoperative time (150 minutes) with a shorter length of stay (9 days with one critical care visit) and involves less sick patients. Code 35151, with RUC-recommended work RVUs of 22.64, involves patients not nearly as ill as patients for whom code 49020 is reported, has a surveyed intraoperative time of 150 minutes, and a 5-day length of stay with no critical care visits. Therefore, we propose the median surveyed work RVUs of 22.84 for code 49020. Since the current relativity within this family is correct, we propose to extrapolate this increase of 36 percent to the other codes in this family and value the work as follows: 49040 (13.52), 49060 (15.86), and 49085 (12.14).

    Comment: The American Society of Colon and Rectal Surgeons collaborated with the ACS and submitted 12 codes for review that they believe to be undervalued. They also expressed support for the methodology proposed by ACS to value services. The specific codes referenced were: 44130, 44144, 44147, 44151, 44156, 44394, 45111, 45113, 45337, 45339, 45910, and 46258.

    RUC Recommendation:

    The RUC recommended increasing the work RVUs for the following codes: 44130 (14.49), 45113 (30.58), and 45910 (2.80) to retain current rank-order and relativity within the grouping of services. However, for code 46258, the RUC recommended decreasing the work RVUs to 5.73 to retain the current rank-order and relativity within these services.

    For codes 44147, 44394, 45111, 45337, 45339, 44144, 44151, and 44156, the RUC did not receive compelling evidence to suggest an increase was needed in the work RVUs; therefore, the RUC recommended that the current work RVUs for these codes be maintained.

    HCFA Proposal: We propose to accept all but one of the RUC recommendations for the surgical codes submitted by the American Society of Colon and Rectal Surgeons. For code 44147, Colectomy, partial; abdominal and transanal approach, we are proposing to increase the work RVUs by 14 percent to 20.71. This is similar to the increase applied to ACS family 6 and will prevent a rank-order anomaly.

    Comment: The American Academy of Otolaryngology-Head and Neck Surgery submitted codes, on behalf of the American Otological Society and the American Academy of Facial Plastic and Reconstructive Surgery, that they believe to be undervalued, along with suggested new work RVUs for each service. However, subsequent to the submission of their comments, the specialty society chose not to pursue revaluing of the following codes: (69450, 69436, 69440, 69631, 69205, 69801, 69633, 69501, 69632, 69905, 69666, 69650, 69806, 69667, 69720, 69641, 69550, 69636, 69637, 69643, 69140, 69505, 69635, 69502, 69645, 69511, 69601, 69602, 69642, 69603, 69644, 69910, 69660, 69604, 69646, 69662, 69661, 69930, 69145, 69676, 69310, 69620, 69805, 69670, 69700, 69802, 69320, 69530, 69820, 68711, 69840, 69540, 69421, 69552, 69150, 69915, 69605, 69300, 69000, 69005, 69020, 69711, 69100, 69105, 69110, 69120, 69140, 69145, 691500, 69155, 69200, 69205, 69210, 69220, 69222, 69300, 69310, 69320, 69400, 69401, 69405, 69410, 69420, 69421, 69424, 69433, 69436, 69535, 69554, 69610, 69725, 69740, 69745, 69950, 69955, 69960, 69970).

    RUC Recommendation: For codes 69990, 11642, 13131, and 13132, the RUC recommends no change to the current RVUs for these services, as compelling evidence was not provided to demonstrate the need for an increase.

    HCFA Proposal: We have reviewed and propose to accept all of the RUC recommendations for the surgical codes submitted by the American Academy of Otolaryngology-Head and Neck Surgery.

    3. Thoracic Surgery

    Comment: In their comments, the Society of Thoracic Surgeons (STS) indicated that there have been major changes in the practice of thoracic surgery since the initial development of the physician fee schedule. These major changes in surgical techniques, along with changes in the typical patient, have had an impact on physician work. Time and intensity of a number of procedures, including the reference procedures used by STS, have been affected.

    The STS grouped codes into three categories: general thoracic surgery, adult cardiac surgery, and congenital thoracic surgery. These three categories were grouped into 23 families of codes. Each family had an anchor code that received a full RUC survey. Each of the remaining codes in a family received a minisurvey. The minisurvey collected information on time and the number of postoperative visits. The minisurvey also asked respondents to estimate work RVUs for the procedure based on the reference service for the family of codes.

    The RUC had a number of concerns with the STS approach. They are as follows: (1) The RUC concluded that STS inappropriately had the same survey respondents review and estimate both misvalued services and reference services. (2) In many instances, the respondents valued the code under review relative to their perception of what the reference code value should be, not the current value of the reference code. (3) The STS also used too many minisurveys and too few full surveys. (4) Within a family of codes, the STS inappropriately mixed codes with different global periods.

    To overcome these methodological problems, the RUC first reviewed the reference service that was used for each family, and the resulting value was compared to the codes in each family. For the adult cardiac surgery codes, the RUC developed a building-block methodology to validate the survey results. For the congenital thoracic codes, previous RUC reviews of the codes were used to determine how the work has changed since the last 5-year review. In addition, for the pediatric thoracic codes, the specialty's society's presenter offered additional information demonstrating that the patient population has changed, (for example, more neonates) leading to a higher intensity of work.

    Additionally, The STS subsequently chose not to pursue review of code 33207 under the 5-year review.

    RUC Recommendations: The RUC reviewed 89 thoracic surgery codes. Of this total, the RUC recommended increases for 44 codes, no changes for 43 codes, and decreases for 2 codes. The recommendations by family are as follows:

    Family 1: The RUC generally found that the STS had not furnished compelling evidence or that the STS inappropriately compared codes with a zero global period to codes with a 90-day global period. The RUC recommended no increase in work RVUs for codes 32000, 32005, 32020, 32035, 32225, 32602, 32651, and 32652. The RUC recommended increases in work RVUs for code 32220 (24.00) and code 32320 (24.00), based on the median surveyed work RVUs which would place these codes in proper rank order.

    Family 2: The RUC recommended increases for code 32440 (25.00) based on the median survey value, and code 32480 (23.75) based on the value of 43415. The RUC also recommended increases in work RVUs for codes 32100 (15.24) and 32110 (23.00) based on a comparison to code 58150. These values place all these codes in proper rank order.

    Family 3: The RUC recommended increases in codes 32482 (25.00) and 32500 (22.00), based on the STS surveyed median work RVUs for each code, which would create the proper rank order within the family of codes.

    Family 4: The RUC recommended no increase for code 32655 because the STS had not furnished compelling evidence for an increase in work. The RUC recommended increases for codes 31600 (7.18) and 32500 (22.00) based on survey data, a sicker patient population, and, in the case of 31600, comparison to 35474.

    Family 5: The RUC recommended increases for codes 38746 (4.89) based on the work RVU for 38747, but recommended no increases for codes 39010, 39220 or 39400 due to lack of compelling evidence or inappropriate comparisons to codes with 90-day global periods.

    Family 6: The RUC agreed with the STS analysis of work for codes 43107 (40.00) and 43112 (43.50) and stated that using the survey median for each code correctly rank ordered these codes in the family of esophagectomy codes.

    Family 7: The RUC recommended an increase for code 43117 (40.00) after comparing it to the reference service code 43361 which had similar data. The RUC also recommended an increase for code 43122 (40.00) based on the survey median of 40.00 work RVUs which correctly rank ordered this code in the family of esophagectomy codes.

    Family 8: The RUC recommended no increase for codes 31625 or 31645 because the STS did not furnish compelling evidence for an increase in work.

    Family 9: The RUC recommended increases for the following codes: 33400 (28.50), 33405 (35.00), 33406 (37.50), 33411 (36.25), 33412 (42.00), and 33413 (43.50), based on a building-block approach that used code 33405 as the anchor code for this family.

    Family 10: The RUC recommended increases for the following codes: 33426 (33.00), 33427 (40.00), 33430 (33.50), and 33475 (33.00), based on a building-block approach that used code 33427 as the anchor code for this family. The RUC recommended no increases for codes 33425 or 33468 because the building-block approach did not support the STS's requested increase.

    Family 11: The RUC recommended increases for the following codes: 33510 (29.00), 33511 (30.00), 33512 (31.80), and 33513 (32.00), based on a building-block approach that used code 33512 as the anchor code for the family. The RUC recommended decreases for codes 33514 (32.75) and 33516 (35.00). These were the values recommended by the STS and validated through the building-block approach.

    Family 12: The RUC recommended no increases for the following add-on codes: 33517, 33518, 33519, 33521, 33522, 33523, and 33530, because it believes that they were inappropriately surveyed as 90-day global procedure codes and the results were not reliable.

    Family 13: The RUC recommended increases in work RVUs for the following codes: 33533 (30.00), 33534 (32.20), 33535 (34.50), and 33536 (37.50), based on a building-block approach that used code 33533 as the anchor code for the family of codes. The RUC recommended no increase for code 33530 because it is an add-on code and was inappropriately surveyed as a 90-day global surgical procedure.

    Family 14: The RUC recommended increases in work RVUs in the following codes: 33860 (38.00), 33861 (42.00), 33863 (45.00), and 33870 (44.00) based on a building-block approach that used code 33860 as the anchor code for the family. The RUC recommended no increase for code 33945 because the building-block approach did not support the higher value requested by the STS.

    Family 15: The RUC recommended no increases in work RVUs for the following codes: 33750, 33820, and 33840, due to lack of compelling evidence to support an increase.

    Family 16: The RUC recommended an increase in code 33660 (30.00) based on intraservice work RVUs for 33401 and pre- and postservice work RVUs for 33641. The RUC recommended no increase in code 33641 as it did not find any compelling evidence to warrant a change in the work RVUs.

    Family 17: The RUC recommended no increase in work RVUs for code 33415, because it did not believe that the typical patient for this procedure has changed, and the minisurvey did not provide compelling evidence to justify a change in the work RVUs. However, the RUC recommended an increase in work RVUs in code 33681 (30.61), because the intraservice intensity of 33681 is more complex than it was 5 years ago.

    Family 18: The RUC recommended increases in the following codes: 33615 (34.00), 33670 (35.00), and 33730 (34.25) based on a comparison to code 33412.

    Family 19: The RUC recommended increases in work RVUs for the following codes: 33611 (34.00), 33612 (35.00), 33694 (34.00) and 33697 (36.00). The RUC compared the intraservice time of code 33611 to the family anchor code of 33694 and recommended 34.00 work RVUs to maintain proper rank order in the family. The RUC compared code 33612 to code 33611 and agreed code 33612 was equivalent to 33611 plus 1 additional work RVU. The RUC compared code 33694 to 33412 and concluded that all measures of physician work were greater for 33694. The RUC compared code 33697 to 33694 and recommended 36.00 work RVUs to maintain rank order. The RUC recommended no increase for 33767 because there was no compelling evidence for a change in the work RVUs.

    Family 20: The RUC recommended an increase in code 33617 (37.00), after comparing it to code 33412 and noting that 33617 has greater intraservice time and higher intensity ranking than code 33412.

    Family 21: The RUC recommended an increase in code 33619 (45.00) after comparing it to codes 48150 and 62530.

    Family 22: The RUC recommended an increase in code 33506 (35.50) to preserve proper rank order within this family. The RUC recommended an increase in code 33770 (37.00) after finding that the work of this code is more than that of the comparison code 33697. The RUC recommended an increase in code 33778 (40.00), after comparing it to 33870, and 33412 which are less intense procedures. The RUC recommended an increase in code 33780 (41.75), based on a comparison to 33778. 33780 involves more work and warrants an additional 1.75 RVUs due to the additional 35 minutes of intraservice time.

    Family 23: The RUC recommended an increase in code 33786 (39.00) after comparing it to 33412, which has less time and intensity. Given the limited specialty survey data, the RUC believed that the recommended increase in code 33919 to 40.00 work RVUs was warranted, but that the survey did not support a value higher than the median survey value.

    Based on information supplied to the RUC, the RUC did not recommend a change in RVUs for codes 32520, 33917, 31622, and 32657. For codes 32095, 33410 and 32491, the RUC indicated that it had recently reviewed these codes, and thus it recommended no change. The RUC recommended that codes 33875, 33877, 43107, and 43112 be referred to the CPT Editorial Panel.

    HCFA Proposal:

    We validated the RUC recommendations by comparing the thoracic surgery codes to vascular surgery and general surgery codes and propose to use the RUC-recommended work RVUs for the thoracic codes based on our own analysis. The following is an example of our review of the thoracic surgery codes. We compared code 32440 ( Removal of lung, total pneumonectomy ) (25.00 work RVUs) with a preservice time of 90 minutes, intraservice time of 160 minutes, one intensive care unit visit, six hospital visits, and three office visits with the following surgical codes in other surgical specialties: code 34151 ( Embolectomy or thrombectomy, with or without catheter; renal, celiac, mesentery, aortoiliac artery, by abdominal incision ) (25.00 work RVUs) with a preservice time of 75 minutes, intraservice time of 150 minutes, seven hospital visits, and three office visits and code 44150 ( Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy ) (23.95 work RVUs) with a preservice time of 63 minutes, intraservice time of 200 minutes, eight hospital visits, and three office visits. A review of these codes demonstrates the similarity in preservice time and intraservice time and the proposed RVUs maintains relativity across surgical specialties.

    4. Orthopedic Surgery

    Comment: The American Academy of Orthopaedic Surgeons forwarded 42 codes for review. It indicated that these codes were undervalued when compared to their respective reference codes.

    RUC Recommendation:

    The RUC recommended increasing the work RVUs for the following codes: 29883 (11.05) because this service consists of two procedures; 29889 (16.00) based on increase in post and intraservice work; 29450 (2.08) based on the increased intraservice time for manipulating the foot of the patient; code 28299 (9.18) which is of value equal to the reference code, with the understanding that the code be sent to CPT Editorial Panel to better define the code; code 28705 (18.80), which more accurately reflects the work of the two distinct services of this procedure (ankle fusion and triple arthrodesis); code 23472 (21.10) to correct a rank-order anomaly; code 26562 (15.00) to correct a rank-order anomaly; code 20245 (8.50) to correct a rank-order anomaly; code 27075 (35.00) noting that this is a major operation and there is increased intraservice time with respect to the reference code; code 27077 (40.00) noting that this a major operation and there is increased intraservice time with respect to the reference code; 27284 (23.45) because this is the value for code 27227 that has identical pre-, intra-, and postservice times; code 27286 (23.45) to avoid creating a rank-order anomaly due to the recommended work RVUs increase of code 27284; code 27822 (11.00) to correct an existing rank-order anomaly; code 27823 (13.00) to avoid creating a rank-order anomaly caused by increasing code 27822; code 28445 (15.62) to correct a rank-order anomaly and appropriately reflect the work involved; code 27724 (18.20) to reflect the work for obtaining a graft that was not included in the last 5-year review.

    The RUC believed that the commenter provided no compelling evidence to revise the work RVUs for codes 27280, 27282, 23585, 23615, 23630, 23680, 24545, 27216, 27217, 27218, 27226, 27236, 27513, 27536, 27828, 23485, 24435, 27472, 28322, and 28420. Therefore, the RUC recommended the current work RVUs be maintained for these codes.

    The RUC referred the following codes to the CPT Editorial Panel for clarification: 23076, 24076, 25076, 27048, 27328, 27619, and 20205, because these codes are being reported incorrectly.

    HCFA Proposal:

    We propose to accept all but one of the of the RUC recommendations for the orthopedic surgery codes. For code 20245, ( Biopsy, bone, excisional; deep (eg, humerus, ischium, femur ), the RUC recommended an increase from 3.95 work RVUs to 8.5 work RVUs and compared code 20245 to codes 27635 ( Excision or curettage of bone cyst or benign tumor, tibia or fibula ), and 27607 ( Incision (eg, osteomyelitis or bone abscess), leg or ankle ) (work RVUs of 7.78 and 7.97, respectively), because it believed the work required for code 20245 was similar to the work required for these codes. The survey for code 20245 compared the code to code 27635. The intraservice times were similar (90 versus 85 minutes) and the amount of postservice was similar (169 versus 163 minutes). However, the survey median work RVUs were 13 and the 25th percentile RVUs were 8.5. The RUC recommended the 25th percentile RVUs because the RVUs were reasonably close to the RVUs for code 27635. We agree that the current work RVUs are a rank-order anomaly with code 20240 ( Biopsy, bone, excisional; superficial (eg, ilium, sternum, spinous process, ribs, trochanter or femur )); however, we disagree with the RUC recommendation. The intraservice work of a deep excisional bone biopsy is similar to the work of excising a bone cyst or benign tumor from the tibia and fibula (code 27635). This is reflected in the similarity in their pre-, intra-, and postservice times. Moreover, the vignette used for code 20245 was atypical in that it involved an ischial lesion, whereas the code is also to be reported for lesions of the humerus and femur. Lesions of the humerus and femur require less dissection and would be more comparable to lesions of the tibia and fibula. Moreover, code 27635 requires complete removal of a known lesion, whereas code 20245 is only an excisional biopsy. Additionally, we are concerned about the spread of work RVUs in the work survey (25th percentile was 8.5 RVUs and 50th percentile was 13.0 work RVUs) and lack of consistency with the time data from the survey. We do not believe there is compelling evidence that the work of code 20245 is greater than the work of code 27635 and are therefore proposing to assign 7.78 work RVUs to code 20245, which is identical to work RVUs for the reference service code 27635.

    5. Ophthalmology

    Comment: The American Academy of Ophthalmology submitted comments requesting nine codes be reviewed, including one code for evaluation of the global period and not the work RVU. The specialty society subsequently chose not to pursue review of codes 66170, 66172, and 67108.

    RUC Recommendation:

    The RUC agreed with the request from the specialty society to change the global period from 90 days to 10 days for code 65855 ( Laser surgery of eye ) and also reduced the work RVUs to 3.85 to account for this reduction in the global period. The RUC noted that code 67218 includes two procedures, and the specialty society indicated that this was not reflected in the original valuation. To correct this error, a building-block approach was used to arrive at new RVUs more reflective of the work of both procedures. The RUC recommended work RVUs of 18.53 for this service. For code 92018, the RUC acknowledged that the preservice work of this service was greater than the standard office procedure because of the need for anesthesia. While concerned about the reliability of the data provided, the RUC recommended that the work RVUs be increased to 2.50, as it suggested during the first 5-year review, with the understanding that the code would be sent to the CPT Editorial Panel for clarification.

    For codes 66180, 66986, 67028, and 67904, the RUC believed that the commenters provided no compelling evidence to justify an increase in the work RVUs; therefore, the RUC recommended maintaining the current value for this code.

    HCFA Proposal:

    We have reviewed and propose to accept all of the RUC recommendations for the ophthalmology codes.

    6. Urology

    Comment: The American Urological Association presented four codes for review: 50230, 51595, 51596, and 38780. They believed that the work RVUs for these codes do not account for all the in-hospital and office-based postoperative care.

    RUC Recommendation:

    The RUC questioned the arguments for an increase in RVUs, noting that there was no compelling evidence presented for recommending an increase for three of these codes (51595, 51596 and 38780). However, the RUC noted that the code descriptor for code 50230 includes the term “and/or vena caval thrombectomy” which impacts the work RVU. The RUC agreed to refer this code back to the CPT Editorial Panel to separate these two distinct services so each may be reported and valued appropriately.

    HCFA Proposal:

    We have reviewed and propose to accept all of the RUC recommendations for the urology codes.

    7. Obstetrics/Gynecology a. Specialty Comments

    Comment: The American College of Obstetrics and Gynecology (ACOG) referenced 35 codes in their written comments submitted to us. The specialty society chose not to pursue the review of work RVUs for code 57555, as well as the work RVUs for codes 59150 and 59151.

    RUC recommendation:

    The RUC recommended increases in the RVUs for the following codes: 38572 (16.59) that would align the code relative to the work of other laparoscopic codes; 56515 (2.76), which was not the value requested by the specialty group but was the value assigned to code 46924, which has comparable work and intraservice time; 56740 (4.57) based on a modified building-block approach, which was similar to ACOG's approach; 57100 (1.20) as presented by the specialty society; 58152 (20.60) in recognition that the current work RVUs are less than the RVUs for code 58150 performed alone even though 58152 combines the work of codes 58150 and 58840; 58260 (12.98) to reflect work of additional office visits included in the procedure; 58262 (14.77) to accurately reflect the work of its component procedures; 58263 (16.06), 58275 (15.76), 58270 (14.26) and 58280 (17.01) to maintain relativity within family of hysterectomy codes; 58267 (17.04) because the procedure is currently undervalued since it encompasses three separate components; 58285 (22.26), which was lower than requested by the specialty group, but which the RUC believed was more reflective of the work for the procedure; 58600 (5.60) based on similarity of this procedure to code 58670; 58605 (5.00) to reflect the slightly lower pre-, intra-, and post-times for this code as compared to 58670; 58611 (1.45) to appropriately reflect the increase in preservice work; 58700 (12.05) reflecting the higher technical skill associated with this procedure (removing only fallopian tube versus ovary and fallopian tube); 58740 (14.00) to reflect increase in intra-service time and postoperative work; 58825 (10.98) which aligns the work value with other codes with similar work; 58920 (11.36) to correct a rank-order anomaly; 58950 (16.93) which combines both codes 58720 and 49255 and applies the multiple procedure rule; 58951 (22.38) based on the similarity of work to 58285 which has the same recommended value; 59812 (4.01) based on the similarity of work to code 59820; 59870 (6.01) based on increased physician work and postoperative time.

    The RUC indicated that the commenter provided no compelling evidence to support an increase in the work RVUs for codes 38571, 57130, 57292, 57307, 57505, 58323, 58400, and 58805.

    For code 58820, the RUC indicated that this service had recently been reviewed by the RUC and, therefore, the current work RVUs should be maintained.

    HCFA Proposal:

    We have reviewed and propose to accept all of the RUC recommendations for the obstetrics/gynecology codes.

    b. Other Concerns

    We have been alerted to concerns that certain female-specific procedures may be undervalued. Our staff has reviewed the work RVUs associated with a number of female-specific procedures, including major and minor surgical procedures as well as several laparoscopic procedures and has determined that, for the most part, the RVUs assigned seem reasonable and consistent with the time, intensity, and postoperative care involved with the procedures. However, there were several codes that seemed to be inappropriately valued as compared to other similar procedures. These procedures are: code 56515 ( Destruction of vulvar lesions, extensive ); code 57100 ( Biopsy of vagina ); code 56605 ( Biopsy of vulva ); code 58100 ( Biopsy of endometrium ); and code 56810 ( Perineoplasty ).

    We forwarded two of these codes (codes 56515 and 57100) to the RUC for review under the 5-year refinement process, and the RUC has recommended an increase in work RVUs for both of these codes.

    We have referred the remaining three codes that appear to be misvalued to the RUC for review, and we anticipate receiving a response from the RUC that we can consider in the November 1, 2001 final rule.

    8. Gastroenterology

    Comment: The American Society for Gastrointestinal Endoscopy (ASGE), American College of Gastroenterology (ACG), and the American Gastrointestinal Association (AGA) provided comments describing gastrointestinal services that they believed to be misvalued. Their comments focused on the identification of specific services whose work RVUs they believe are too low in comparison to other gastroenterology services when comparing time and intensity of the procedures. They also expressed concern that the work RVUs for all gastroenterology procedures involving conscious sedation are substantially undervalued and need to be increased because of the added requirements associated with conscious sedation.

    RUC Recommendation:

    With regard to conscious sedation, the RUC was concerned about—(1) The need to break out different levels of physician work for conscious sedation, and (2) many gastroenterology codes have been previously valued with conscious sedation included and some codes were not valued with conscious sedation included. Therefore, the RUC agreed to create a joint RUC and CPT workgroup to review and define the issues related to conscious sedation. Based upon information presented by the specialty at the February 2001 RUC meeting, the RUC agreed that elements of conscious sedation have changed over the past 5 years; however, the RUC was not able to quantify the change in physician work. While the RUC did not recommend a specific increase, it did recommend and urge us to allow separate reporting and payment of conscious sedation codes 99141 and 99142 when conscious sedation is not inherently included as a component of the physician work of the procedure.

    Based on technological advances, increased complexity in procedure, and changes in patient population the RUC recommended an increase in work RVUs for the following codes: 43219 (3.18); 43239 (2.87); 43244 (5.05); 43247 (3.59): 43249 (3.35); 43255 (4.82); 43259 (8.59); 43263 (7.29); 43265 (10.02); 43269 (8.21); 44388 (3.70); 44389 (4.26); 44390 (4.81); 44391 (5.18); 44392 (4.81); 44393 (5.00); and 45380 (4.44).

    Based on the lack of compelling evidence to increase the work RVUs, the RUC recommended that the current work RVUs be maintained for the following codes: 43217, 43228, 43246, 43251, 43258, 44394, 45383, 45384, and 45385.

    HCFA Proposal:

    The RUC reviewed a selected series of gastrointestinal endoscopy codes for the 5-year review. These codes included endoscopy of the esophagus, stomach, duodenum, small intestine, large intestine, stoma, and biliary tree. The RUC recommended increases in work RVUs for some of the codes and no change in work for other codes. Unfortunately, the RUC could not review all of the endoscopy codes in each family and, therefore, was in the position of having to make recommendations that would likely cause new rank-order anomalies or exacerbate existing rank-order anomalies within and among these families. Furthermore, creation of rank-order anomalies across specialties was also likely. For example, a bronchoscopic biopsy would be valued significantly less than a gastrointestinal endoscopic biopsy if the gastrointestinal endoscopic biopsy was increased in value.

    Although we are concerned that some of these endoscopy codes may be misvalued, we are proposing to keep all work RVUs for gastrointestinal endoscopy codes unchanged. However, we believe that a comprehensive review of the work RVUs for all gastrointestinal endoscopy codes is warranted. Therefore, we are asking the RUC to perform a comprehensive review of all gastrointestinal endoscopy codes to ensure that all codes are properly valued, and that no rank-order anomalies within and across specialties are created or exacerbated. We hope to receive recommendations from the RUC for these codes in time for the proposed physician fee schedule regulation in 2002.

    Below we discuss our reasons for proposing to reject the recommended work increases for each code. However, we note that many new gastrointestinal endoscopy CPT codes were created for use in 2002 and reviewed by the RUC concurrent with the 5-year review. Recommendations for these new codes were made by comparing them to the current work RVUs of existing gastrointestinal endoscopy codes, some of which were reviewed as part of the 5-year review. Therefore, any increases in work RVUs for codes in the 5-year review will likely invalidate the work RVUs for many of the new codes reviewed by the RUC. Furthermore, proposals have been made for even more gastrointestinal endoscopy CPT codes for CYs 2002 and 2003. We want to ensure that these new codes are properly reviewed and appropriate work RVUs assigned. Until a comprehensive review of all gastrointestinal endoscopy codes is performed we do not believe this is possible.

    Code 43219, Esophagoscopy, rigid or flexible; with insertion of plastic tube or stent:

    The RUC recommended an increase in work RVUs from 2.8 to 3.18 based upon the increased complexity of the condition of patients receiving these stents. The current work increment between this code and 43200 (1.21 RVUs) has been used extensively by the RUC to make recommendations for other endoscopic stent placement procedures. Therefore, in spite of this recommendation, it appears that the RUC and the specialists who perform this procedure agree that the correct increment for stent placement is 1.21 work RVUs. If the work RVUs for code 43219 were accepted, many other recommendations from the RUC would need to be reevaluated. Furthermore, it is unclear from the vignette used to value this procedure whether or not predilation of the esophagus was included in the work of this code. Currently, code 43226 describes the work of predilation and may be billed in addition to code 43219. The incremental work for placing a tracheal stent with predilation (the difference in work between codes 31622 and 31631) is 1.59 work RVUs. This is significantly less than the current work increment for esophageal stent placement with predilation, 1.96 (1.21 + .75). Additionally, the vignette describes placement of an expandable wire mesh stent but the code is also used for plastic stents, placement of which may require less work. We propose maintaining the current RVU for this code in view of these concerns and the rank-order anomalies that would be created by accepting the RUC recommendation.

    Code 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple):

    The RUC recommended an increase in work RVUs from 2.69 to 2.87 based on a larger number of biopsies obtained during a procedure. The RUC also stated that technological advances allowing for greater precision and detail in finding abnormalities have increased the need for this service. The RUC also stated that technological advances have allowed for more immediacy of results which increases the post service work in conveying the biopsy information and treatment guidance to the patient. We would note that the current work increments for all endoscopic gastrointestinal biopsy codes (described as the base procedure with “biopsy, single or multiple”) are 0.3 RVUs. Accepting the RUC recommendation would increase this increment to 0.48 work RVUs while keeping all the other biopsy increments at 0.3 work RVUs, creating a clear rank-order anomaly. Furthermore, this code is used for “single” biopsies, and, with the increase in work, these biopsies would be overvalued. We also do not understand how technological advances in locating lesions and getting more immediate results increases the work of the procedure itself. Therefore, we propose maintaining the current work RVU for this procedure.

    Code 43244 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with band ligation of esophageal and/or gastric varices) and 43255 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method):

    The RUC recommended an increase in work RVUs for code 43255 from 4.4 to 4.82 work RVUs based on new technology, such as lasers, to control bleeding. The RUC also states that this new technology increases the intensity of the procedure. However, the vignette used to survey code 43255 describes use of cautery to control bleeding. The work for this code must be appropriate for all methods of controlling bleeding and the vignette must represent the typical case. The current work increment for “control of bleeding, any method” for gastrointestinal endoscopic procedures is 2.01 work RVUs. Acceptance of the RUC recommendation for code 43255 would make this work increment 2.43 RVUs, for upper gastrointestinal endoscopy only, creating a clear rank-order anomaly.

    The RUC recommended an increase in work RVUs for code 43244 from 4.59 to 5.05 RVUs, based on the increased number of bands used to treat esophageal varices. However, the RUC agreed that the work RVUs for code 43244 were similar to the work RVUs for code 43255. Therefore, accepting the RUC recommendation for code 43244 and not code 43255 would create a clear rank-order anomaly. We believe that these two codes should have similar work RVUs. Therefore, we propose to maintain the current work RVUs for these procedures.

    Code 43247 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body):

    The RUC recommended an increase in work RVUs for this code from 3.39 to 3.59 work RVUs based on increased complexity of the condition of patients undergoing this procedure with a concomitant increase in risk of morbidity. The RUC used a building-block approach to validate its acceptance of the median work RVUs from the survey. We do not fully understand the building-block analysis the RUC used but believe it was invalid. Moreover, the current work increment for “removal of foreign body” for gastrointestinal endoscopy procedures is 1.0 work RVUs. Acceptance of the RUC recommendation would create a clear rank-order anomaly. Therefore, we propose to maintain the current work RVUs for this procedure.

    Code 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30mm diameter)):

    The RUC recommended an increase from 2.9 to 3.35 work RVUs for this code based on increased complexity of the condition of patients undergoing this procedure. The current work increment for “balloon dilation of esophagus (less than 30 mm diameter)” is 0.51 RVUs for both the esophagus and upper gastrointestinal endoscopy families. Since this is the same procedure in both families, it is unclear why the work should be increased to 0.96 work RVUs for the upper gastrointestinal family only. Accepting the RUC recommendation would create a clear rank-order anomaly. Therefore, we are proposing to maintain the current work RVUs for this code.

    Code 43259 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination):

    The RUC recommended an increase in work RVUs from 4.59 to 8.59 based on the complexity of the equipment and the skill and judgement required. The RUC also noted that the survey results supported this procedure as more difficult than an endoscopic retrograde cholangio-pancreatography (ERCP). The RUC then used the following building-block methodology: (1) The RUC added 1.5 work RVUs, which was approximately 75 percent of the difference between the RUC recommendation from the last 5-year review (6.11 work RVUs) and the work RVUs that we assigned (4.0 work RVUs). (2) The RUC then added 2.2 work RVUs, which are the work RVUs of code 93312. Not only do we disagree with the RUC methodology for this recommendation, but we also note that the RUC has used the current work RVUs for code 43259 to value not only other gastrointestinal transendoscopic ultrasound procedures but also many transendoscopic ultrasound guided biopsy codes. We would also note that the RUC has recently re-evaluated code 43231, Esophagoscopy, rigid or flexible; with endoscopic ultrasound examination, and will be sending a new recommendation to us regarding the work valuation of this procedure. Accepting the RUC recommendation for this code would be inconsistent with the RUC's reevaluation of code 43231, would invalidate the work valuation of many other gastrointestinal endoscopy codes, and would create numerous rank-order anomalies. Therefore, we propose to maintain this code at its current work RVUs.

    Codes 43263 (Endoscopic retrograde cholangio-pancreatography (ERCP); with pressure measurement of sphincter of Oddi (pancreatic duct or common bile duct)), 43265 (ERCP; with endoscopic retrograde destruction, lithotripsy of stone(s), any method), and 43269 (ERCP; with endoscopic retrograde removal of foreign body and/or change of tube or stent):

    The RUC recommended an increase in work RVUs from 6.19 to 7.29 for code 43263 based on the need to measure pressures in both the biliary and pancreatic sphincters as well as the need for prolonged postoperative monitoring. The RUC arrived at its recommendation by adding 1.1 work RVUs (the value of code 99214) to the current work RVUs. We disagree with valuing a post procedure observation period as equal to an evaluation and management service. Furthermore, increasing the value of this code while not adjusting the values of codes 43262, 43267, and 43268 creates clear rank-order anomalies.

    The RUC recommended an increase in work RVUs from 8.9 to 10.02 for code 43265 based on a rank-order anomaly with code 43264. The RUC compared survey times to the Harvard study times for this code and used a building-block method to arrive at its recommendation. We do not fully understand the RUC methodology and disagree with the conclusion. The Harvard study time data show less time for code 43265 than for code 43264, which would indicate that the current valuations of these codes are correct. Moreover, increasing the value of 43265 while not adjusting codes 43264, 43267, and 43268 would create clear rank-order anomalies.

    The RUC recommended an increase in work RVUs from 6.04 to 8.21 for code 43269 based on a rank-order anomaly between this code and code 43268. The RUC used a building-block methodology adding 0.82 work RVUs to the work RVUs of code 43268 (7.39) to arrive at its recommendation. We disagree with the RUC methodology of using an evaluation and management service to arrive at its recommendation since this is an invasive procedure. Furthermore, we believe increasing the value of this code creates a rank-order anomaly with codes 43271 and 43272. Therefore, we are proposing maintaining the current work RVUs of all three of these codes.

    Codes 44388 (Colonoscopy through stoma; diagnostic with or without collection of specimen(s) by brushing or washing (separate procedure)), 44389 (Colonoscopy through stoma; with biopsy, single or multiple), 44390 (Colonoscopy through stoma; with removal of foreign body), 44391 (Colonoscopy through stoma; with control of bleeding, any method) 44392 (Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery), and 44393 (Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

    These codes are in the same family of codes, and the RUC recommended increases in work RVUs for all these codes based on a misvaluation of the base code in this family of codes, code 44388. The RUC valued it similarly to code 45378. We disagree. We think this creates a clear rank-order anomaly between the value of this family and the value of the colonoscopy family of codes beginning with code 45378. Colonoscopy through a stoma is clearly less work than colonoscopy of the complete colon and it has been valued as such since the inception of the physician fee schedule. We question the accuracy of the surveyed intraservice time for this service. Because of our nonacceptance of the increase in work RVUs for the base code in this family, we must also not accept the recommendations for all other increases in work RVUs for other codes in this family. Moreover, the recommendations create increments of work for “biopsy, single or multiple,” “removal of foreign body,” “control of bleeding, any method,” “removal of tumors,” and “ablation of tumors,” which are inconsistent with the same increments for the colonoscopy family of codes beginning with code 45378. Accepting these RUC recommendations would create clear rank-order anomalies that do not currently exist. Therefore, we are proposing to maintain the current work RVUs for these procedures.

    Code 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).

    The RUC recommended an increase in work RVUs from 3.98 to 4.44 for this code based on the increased number of biopsies generally taken during this procedure and the increased difficulty in removing these polyps. The current work increment for “biopsy, single or multiple” for gastrointestinal endoscopic procedures is 0.3 work RVUs. Accepting the RUC recommendation would create a clear rank-order anomaly. Moreover, we note that this code is also used for single biopsies that would become significantly overvalued if we accepted the RUC recommendation. Therefore, we are proposing to maintain the current work RVUs for this code.

    In summary, we believe the only way to accurately value gastrointestinal endoscopy procedures is to evaluate the entire series of codes, including all families of codes (esophagus, upper gastrointestinal, ERCP, and colonoscopy etc.) at the same time. Only then can appropriate incremental work RVUs be determined without creating rank-order anomalies. We would also suggest that the RUC consider reorganization of all these codes to facilitate more accurate coding (for example, to determine whether every family of codes needs a code for “removal of foreign body” or whether the base code be revalued to include more procedures than it currently does).

    We suggest that while the RUC is reevaluating these codes that it delay making recommendations on any new codes for this series so that conflicting recommendations are not made and the chance of creating rank-order anomalies is minimized.

    With respect to the RUC recommendation concerning reporting and payment of conscious sedation codes 90141 and 90142, we will be reviewing data concerning this issue. Any proposals we would have concerning payment and reporting of conscious sedation codes would be the subject of future rulemaking.

    9. Pulmonary Medicine/Critical Care

    Comment: Several specialty groups, including the societies for pulmonary medicine and critical care, indicated that codes 36620 and 36489 were undervalued. Commenters indicated that the work RVUs for code 36489 should be greater than the work RVUs for the reference service code, 36010, because there is more work involved. Commenters also stated that code 36620 is undervalued as compared to the reference code 36140, because there are more variables affecting the work involved with this procedure.

    These specialty groups also requested that codes 99291 and 99292 be evaluated because the groups claimed they were undervalued.

    RUC Recommendation:

    For code 36489, the RUC noted that there is additional work and postoperative time involved in this procedure as compared to that of the reference service code 36010, and recommended work RVUs of 2.50 which are higher than the reference service code 36010 (2.43), which corrects the rank-order anomaly. With respect to 36620, the RUC compared this procedure to the reference service (code 36140) and agreed that this service appeared to be undervalued. However, the RUC was concerned that anesthesiologists who perform this procedure over 80 percent of the time did not comment or participate in the survey conducted by the specialty groups. The RUC concluded that code 36620 should be referred to the CPT Editorial Panel to clarify the appropriate use of this code.

    The RUC recommended maintaining the work RVUs for critical care services (codes 99291 and 99292) due to the lack of compelling evidence to recommend an increase in the work RVUs above the 2001 work RVUs of 4.00 and 2.00, respectively.

    HCFA Proposal:

    We have reviewed and propose to accept all of the RUC recommendations for the pulmonary medicine and critical care codes.

    10. Cardiology

    Comment: The American College of Cardiology (ACC) recommended review of three procedure codes under the 5-year refinement. They are code 93350, which was not reviewed during the first 5-year review but which the ACC believes is undervalued; and codes 33234 and 33235, which ACC argues are undervalued because it does not believe the codes reflect the level of difficulty associated with the procedures.

    RUC Recommendation:

    The RUC supported an increase in the work RVUs for code 93350 to account for the increased work and more complex conditions of the patient population as supported by survey information submitted. The RUC recommendation was to increase the work RVUs to 1.48. For codes 33234 and 33235, they recommended that no change be made in the work RVUs because both procedures had been recently reviewed by the RUC.

    HCFA Proposal:

    We have reviewed and propose to accept all of the RUC recommendations for the cardiology codes.

    11. Pediatrics

    Comment: The American Academy of Pediatrics (AAP) submitted approximately 40 codes involving several specialty areas and indicated that they believed these services are undervalued, particularly when they are provided to the pediatric population. A few of these codes were also submitted by other specialty groups and are discussed under those areas (codes 29450, 99291, and 99292). The AAP subsequently indicated to the RUC that they were not interested in pursuing the review of the work RVUs for the following codes for this 5-year review: 11100, 11730, 17000, 17003, 17004, 20600, 36600, 52300, 52327, and 52340.

    RUC Recommendation:

    For codes 36400 and 36405, the RUC agreed that an increase in the work RVUs appeared to be warranted and recommended work RVUs of 0.38 and 0.32, respectively. However, for codes 94640, 99440, 99233, 99273, and 99274, the RUC indicated that compelling evidence was not provided to suggest a recommendation to increase the work RVUs and thus the current RVUs should be maintained for these services.

    The RUC recommended that the following codes be submitted to the CPT Editorial panel for further consideration: 12001, 12002, 36406, 36520, 50200, 90935, 90937, 90945, 90947, 90989, 90993, 90997, 94664, and 94665.

    For codes 99295, 99296, 99297, 99298, and 99436, the RUC recommended no change in the work RVUs for these services because these services had recently been reviewed by the RUC.

    HCFA Proposal:

    We have reviewed and propose to accept all but two of the RUC recommendations for the pediatric codes.

    For code 36400 (Venipuncture, under age 3 years; femoral, jugular or sagittal sinus) , the RUC recommended an increase in work RVUs from 0.18 to 0.38. The RUC survey compared this code to code 36410 (Drawing blood, child over 3 or adult, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes) (work RVUs of 0.18). The survey times indicated that the pre-, intra-, and postservice times for code 36400 were less than the times for code 36410. The median work RVUs from the survey were 0.71, and the 25th percentile work RVUs were 0.30. The specialty society recommended work RVUs of 0.71, citing the change in population of patients requiring this procedure (being younger and smaller). The RUC also compared code 36400 to code 99212 (Office/outpatient visit, established patient) with work RVUs of 0.45 and believed the work RVUs of code 36400 were comparable to the work RVUs of code 99212). The RUC then recommended work RVUs between the 25th percentile of the survey and the work RVUs of code 99212. We do not believe it is appropriate to compare the work RVUs of a venipuncture to the work of an evaluation and management service. Furthermore, we are concerned about the spread in the survey work RVUs from 0.30 at the 25th percentile to 0.71 at the median. In view of the survey times being less than the reference code (with work RVUs of 0.18), the inconsistency of the survey times with the survey RVUs, and the inappropriate comparison to an evaluation and management service, we are proposing to continue the work RVUs of code 36400 as 0.18 work RVUs.

    For code 36405 (Venipuncture, under age 3 years; scalp vein) , the RUC recommended an increase in work RVUs from 0.18 to 0.32. The survey compared code 36405 to code 36410. The pre-, intra-, and postservice times for code 36405 were less than the times for the reference code. The survey RVUs were widely spread with the 25th percentile work RVUs being 0.2 and the median work RVUs being 0.4. The RUC also compared code 36405 to code 99212 (0.45) and recommended a value between the survey 25th percentile work RVUs and the work RVUs for code 99212. Our concerns about this recommendation are similar to the concerns about the recommendation for code 36400. In view of the survey times, the wide range of survey work RVUs, and the inappropriate comparison to an evaluation and management service, we are proposing to continue the work RVUs of code 36405 at 0.18.

    12. Pediatric Surgery

    Comment: The American Pediatric Surgical Association (APSA) stated that the pediatric surgery procedure codes are misvalued and included recommended work RVUs. While they suggested reductions in the work RVUs of codes 46705 and 46715 to retain relativity in the family of services, they believed that the majority of the codes they provide are significantly undervalued. The association justifies the need to increase the work RVUs for these services based on one or more of the following rationales:

    • A change in practice and technology.

    • A change in the patient population for which the code is most frequently applied.

    • An undervaluation of the postservice work in the global period.

    • Rank-order anomalies.

    • Extended postoperative critical care. It is the provision of very intensive, prolonged services with long episodes of critical care and long hospital stays that account for the very high work RVUs recommended for some procedures. APSA subsequently indicated that they did not want to pursue review of two codes under the 5-year review: 43305 and 60280.

    RUC Recommendation:

    The RUC recommended that the suggested decreases in the work RVUs for codes 46705 and 46715 be implemented. The recommended work RVUs are 6.90 for code 46705 and 7.20 for code 46715.

    Based on the information provided by the specialty society, the RUC recommended increasing work RVUs for the following codes to address the undervalued physician work in the intra- and postservice periods, the extended critical care services, and a change in patient population: 39503 (95.00); 44055 (22.00); 46716 (15.07); 46730 (26.75); 46735 (32.17); 46740 (30.00); 46742 (35.80); 46744 (52.63); 46746 (58.22); 46748 (64.21); 49215 (33.50); and 49605 (76.00).

    The RUC did not receive compelling evidence to suggest that an increase is needed in the work RVUs for these codes: 36822, 45120, 45121, 47701, and 49606.

    The RUC recommended that the following codes be referred to the CPT Editorial Panel for clarification and review: 21740, 43310, 43312, 49495, and 49496. In some instances, new codes may need to be created to accurately value services performed on the pediatric and adult population.

    HCFA Proposal:

    We propose to accept all but two of the RUC recommendations for the pediatric surgery codes. The RUC recommended large increases in work RVUs for codes 39503 (Repair, neonatal hernia, with or without chest tube insertion and with or without creation of ventral hernia) and 49605 (Repair of large omphalocele or gastrochsis; with or without prosthesis) for both of these procedures (an increase from 37.54 to 95.0 work RVUs for code 39503 and from 24.94 to 76.0 work RVUs for code 49605). These increases were based entirely on the increase of postoperative work required for these procedures, resulting in an increase of approximately 50 work units for each code. Both procedures are performed on neonates who require prolonged stays in the intensive care unit postoperatively. We understand that the postoperative care may be performed by the surgeon, the intensivist, or both physicians. In situations where the postoperative care is provided by both physicians, we could make duplicate payments for postoperative care if we continue to value these as 90-day global procedures. To permit the physician who is performing the postoperative care to be appropriately paid, but prevent duplicate payment for the same services, we are considering a reduction in the global period (for example, making the global period 10 or 0 days). If we shortened the global period for these services, appropriate work RVUs consistent with this change would need to be developed. If the surgeon provides postoperative care outside of the 10-day global period (that is, 10 days after the date of surgery)or outside of the 0-day global period (that is, the day after surgery) he or she would bill separately for those services. Moreover, if the intensivist provides the postoperative care, then the intensivist would bill for the service, and there would be no duplicate payment to the surgeon.

    Based on the above discussion, we are proposing to maintain the current RVUs for these two CPT codes (39503 and 49605) as an interim for 2002 and would ask the RUC to submit work RVU recommendations for these codes valued with reduced global periods (a 0-day or 10-day period). We would consider the RUC recommendations and make a proposal to initiate a change to the global period as well as associated RVUs in next year's proposed rule. We invite comments on the issue of reducing the global period for these services and welcome any alternative suggestions that we could consider that address our concerns of eliminating duplicate payment.

    13. Radiology

    Comment: The American College of Radiology (ACR) identified three codes that they believe are undervalued. The code 76065, radiologic examination of an infant, is most commonly performed in the situation of alleged child abuse and requires a significant amount of physician work. Additionally, radiologists indicated that the work RVUs for two mammography procedure codes (codes 76090 and 76091) are not reflective of the amount of physician work necessary to perform all the requirements for the government regulated procedures and ACR standards. The level of quality control and quality assurance requirements instituted by the Food and Drug Administration (FDA) and Mammography Quality Standards Act of 1992 (MQSA) have increased the level of physician time outside of the direct patient care time. The current work RVUs assigned to these codes are not adequate to perform this procedure in accordance with Federal regulations or ACR standards. ACR contended the combination of increased mental effort and judgement, psychological stress, time, and intensity mandate that the work RVUs for these codes should be increased.

    RUC Recommendation:

    The RUC noted that the intensity for code 76065 is higher than the reference service code 76062 and that for intraservice work the physician typically reviews more films. The RUC recommended work RVUs of 0.70 for code 76065. For the mammography procedure codes, the RUC was in agreement that as a result of the revisions of the MQSA requirements, which require the physician to code radiologic results using BIRADs terminology and require that separate reports be sent to the patient and referring physician, the codes result in increased physician time, mental effort, and judgement. In addition, code 76091 is a bilateral mammography requiring two studies to be performed. Based on survey information, the RUC determined the 25th percentile of the survey was the appropriate value and recommended work RVUs of 0.70 for code 76090 and 0.87 for code 76091.

    HCFA Proposal:

    We have reviewed and propose to accept all of the RUC recommendations for the radiology codes discussed above.

    We would also note that section 104 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Public Law 106-554) puts screening mammography under the physician fee schedule for services furnished beginning January 1, 2002. We will include our recommendation of the work RVUs for this service for CY 2002 as part of the physician fee schedule proposed rule for CY 2002.

    Because this will be a new code in the physician fee schedule, we have asked the RUC to recommend work RVUs for screening mammography.

    14. Plastic Surgery

    Comment: The American Society of Plastic Surgery (ASPS) requested that codes 42205 and 49905 be reviewed under the 5-year review. ASPS indicated that there currently is a rank-order anomaly for code 42205 that was created when other codes in the family of codes were reviewed and increased during the first 5-year review. They recommended an increase to the work RVUs (9.59 to 12.0) for this code that would reestablish rank-order in the cleft palate family of codes. With respect to code 49905, ASPS stated that this code is currently designated as an add-on code, which was not the intent of the specialty group when they submitted the proposal to the AMA CPT Editorial Panel in 1991 for creation of this code. They also disagree with our assumption that pre- and postoperative work was included in the RUC-recommended work RVUs that we reduced. ASPA recommended that code 49905 be changed from an add-on to a primary procedure code with a 90-day global period and be assigned work RVUs comparable to those of code 15374 (17.79).

    RUC Recommendation:

    The RUC reviewed code 42205 and recommended an increase in the work RVUs (for work RVUs of 13.29), which will correct the existing rank-order anomaly in this family of codes. The RUC recommended that code 49905 be referred to the CPT Editorial Panel for review.

    HCFA Proposal:

    We have reviewed and proposed to accept the RUC recommendations for the plastic surgery codes.

    C. Other Comments 1. Anesthesia Services

    The American Society of Anesthesiologists (ASA) contended that the work of anesthesia services is undervalued by almost 31 percent. (This initial request was subsequently adjusted based on additional discussions with the RUC.)

    As required by law, we base Medicare payments for anesthesia services on allowable base and time units. We have developed a uniform relative value guide in which the base unit per anesthesia code is largely based on the American Society of Anesthesiologists' 1988 relative value guide. Anesthesiologists report the actual anesthesia time for each procedure on the claim, and the carrier converts the time to time units. The carriers then multiply the sum of the base units and time units by the anesthesia conversion factor.

    We used the results of the original Harvard Study on work to determine the adjustment to the anesthesia CF under the physician fee schedule in 1992. (Anesthesia services do not have work RVUs. Therefore, if work RVUs of other physician services are increased an adjustment has to be made to the anesthesia CF so that the work of anesthesia services remains on the same scale as other physician work.)

    In the first 5-year review of work, we accepted the RUC's recommendation that the work of anesthesia services was undervalued by 22.76 percent, which resulted in a 16 percent increase in the anesthesia CF.

    The approach to this 5-year review used by the ASA involves a physician survey and a consensus panel review. The survey was sent to 262 members of the ASA in a geographically representative sample. Eighty-five surveys were returned from respondents who were geographically representative of the specialty as a whole. The findings of the survey were presented to an expert consensus panel of 16 practicing anesthesiologists from the ASA's Relative Value System (RVS) Committee. The work of the anesthesia service was uniformly divided into five components. These components are—preoperative evaluation, equipment and supply preparation, induction period, postinduction anesthesia period, and postoperative care and visits. The survey median times were assigned to each of the five components. The consensus panel assigned the work RVUs of an evaluation and management code, usually codes 99202 or 99201, to the preoperative evaluation. The consensus panel developed a code-specific survey time estimate and intensity value for equipment and supply preparation. For postoperative care and visits, the consensus panel assigned work RVUs equivalent to those of an evaluation and management code, usually code 99211 or 99231. The survey median time for the postinduction anesthesia period was divided in quintiles and each quintile was assigned intensity work RVUs ranging from 0.026 to 0.085. The consensus panel identified the typical anesthetic by procedure code and generally used the intensity of code 31500, Intubation, endotracheal, emergency procedure, a similar CPT code, to value the work. This methodology was used for 19 high-volume surgical codes requiring anesthesia and representing a reasonable variety of surgical services.

    The following illustrates this approach for anesthesia code 00404 and the underlying surgical code 19240 (Modified radical mastectomy):

        Work RVUs Preanesthesia Median Time 15 min. • Preanesthesia reference code 99202    0.88 Equipment and Supply Preparation Median Time 10 min.   0.14 Induction Period Procedure Time 10 min.   0.93 Post Induction Anesthesia Period: Level 1 Time 87 min. Level 2 Time 10 min. Level 3 Time 10 min. Level 4 Time 0 min. Level 5 Time 0 min.   3.09 Postanesthesia Time 14 min. • Postanesthesia Reference Code 99231    0.64 Total Work RVUs    5.68

    For each code, the total work RVUs were compared to a Medicare fee schedule imputed work value. The Medicare imputed work value is computed by multiplying the average allowed anesthesia charge per code by the anesthesia work share and dividing by the national CF. The average anesthesia allowed charge is determined by surgical code from HCFA's 5 percent Beneficiary File.

    Based on this analysis, the ASA requested a 24 percent increase in anesthesia work.

    RUC Recommendation:

    The RUC furnished no recommendation on anesthesia services; instead it assigned to a newly created workgroup the responsibility for reviewing anesthesia services in the context of the physician fee schedule. The ASA will be working with this workgroup on clinical issues, such as induction and postinduction intensity RVUs.

    HCFA Proposal:

    We propose to make no changes to the anesthesia CF at this time to reflect the 5-year review of physician work for anesthesia services. However, we may make changes in response to recommendations the RUC may provide.

    2. Spine Injection Procedures

    Comment: The American Society of Anesthesiologists submitted a request for re-evaluation of seven spinal injection codes that they, along with several other medical associations, had expressed concern about when the codes were revalued for CY 2000. They continue to believe the work RVUs assigned by the RUC in 1999 and forwarded to HCFA were appropriate.

    RUC recommendation:

    In 1999, when the RUC forwarded revised work RVUs, we agreed with the relativity of the four injection codes (62310, 62311, 62318, and 62319), but applied a budget-neutrality factor that the specialties believe is inappropriate. In 1999, we also decreased the RUC-recommended work RVUs for codes 72275, 62263, and 76005 based on our belief that the values were too high. The RUC has now reviewed the original surveys and subsequent recommendations and continues to believe that its 1999 recommendations for work RVUs for these codes are appropriate. They recommended the following work RVUs for these services: 62310 (2.20); 62311 (1.78); 62318 (2.35); 62319 (2.15); 62263 (7.20); 72275 (0.83) and 76005 (0.60). (Note: for code 76005, the work RVUs were 0.60 for this service on the CY 2000 fee schedule)

    HCFA Proposal:

    We propose to reject the RUC recommendations for these codes for the following reasons:

    Codes 62310 (Single injection (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic)), 62311 (Single injection (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodoic, opioid, steroid, other solution), epidural or subarachnoid, lumbar, sacral(caudal)), 62318 (Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast(for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic), and 62319 (Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodoic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)).

    These were new codes for CY 2000. The RUC submitted recommendations for these codes in CY 1999. We accepted the RUC recommendations and made a work-neutrality adjustment because these new codes replaced codes under which these services were billed before 2000. The RUC and several specialty societies disagreed with the data we used in making our work-neutrality adjustment. (Work-neutrality adjustments ensure that the recommendations for work RVUs for new and revised services are adjusted so that the sum of the new or revised work RVUs (weighted by projected frequency of use).) for a family of codes will be the same as the sum of the current work RVUs (weighted by frequency of use). We have reviewed the data used to make our work-neutrality adjustment and have determined that the adjustment made was accurate. The RUC work recommendations for the 5-year review are identical to the recommendations we received and evaluated in CY 1999. In view of this, we are proposing to maintain the current work RVUs for these services.

    Code 62263 (Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, spring-wound catheter) including radiologic localization (includes contrast when administered).

    This was a new code for CY 2000. We received RUC recommendations in CY 1999 for this code and disagreed with them. The RUC recommendation was 7.20 work RVUs, and we made the interim work RVUs 6.02 for CY 2000. In the summer of 2000, we convened a multispecialty review panel that reviewed this code in detail and recommended work RVUs of 6.14. We finalized the multispecialty review panel recommendation of 6.14 work RVUs for CY 2001. The current RUC recommendation is identical to the RUC recommendation from CY 1999. We find no compelling reason to change the RVUs for this procedure, especially since this procedure was reviewed by a multispecialty panel less than 1 year ago. We propose to continue the current work RVUs for this procedure.

    Code 72275 (Epidurography, radiological supervision and interpretation).

    This code was new for CY 2000. The RUC submitted a recommendation for 0.83 RVUs. We disagreed with this recommendation and made the interim work RVUs 0.54 for CY 2000. We submitted this code to a multispecialty review panel that recommended an increase to 0.76 work RVUs that we implemented for CY 2001. The RUC now submits a recommendation of 0.83 work RVUs for this procedure, identical to its prior recommendation. In the absence of compelling reasons to change the current work RVUs, and because this code was reviewed by an objective multispecialty panel less than 1 year ago, we are proposing to continue the current work RVUs.

    Additionally, codes 62310, 62311, 62318, 62319, 62263, and 72275 were reviewed and finalized in the July 2000 Multispecialty Refinement Panels for new and/or revised services. Since the RUC recommendations have offered no evidence in addition to that which was presented at the July 2000 Multispecialty Refinement Panel Meeting, we propose to retain the existing work RVUs.

    3. Biofeedback

    Comment: One organization, Medcare, requested review of the work and practice expense RVUs for biofeedback codes 90911 and 90901, as it believes that these codes currently are undervalued.

    RUC Recommendation:

    The RUC reviewed the original survey data for code 90911 and noted that while we had decreased the original RUC-recommended work RVUs, we received no further information to indicate that our rationale for reducing the work RVUs was inappropriate, and the specialty societies that perform the service did not present new information in response to the decrease. The RUC recommended that the current RVUs be maintained since it received no compelling evidence to recommend an increase in work RVUs.

    HCPAC Recommendation:

    The HCPAC recommended that the current work RVUs be maintained for code 90901 because we received no additional information from the specialists who perform this service to warrant an increase in work RVUs.

    HCFA Proposal:

    We reviewed and propose to accept the RUC and HCPAC recommendations for biofeedback services.

    4. Surgical Management of Burn Wounds

    Comment: The American Burn Association (ABA) submitted codes commonly used for the surgical management of burn wounds (codes 15000 through 15641). The ABA requested assignment of RVUs for these codes that more appropriately reflect the work involved. ABA also requested the creation of more specific codes that would obviate the need for “G” codes. The ABA indicated that these codes should be exempt from CPT payment policies with respect to the 90-day global period, multiple procedures and staged procedures due to the unique clinical case management of burns.

    RUC Recommendation:

    The RUC recommended that the following codes be reviewed by the CPT Editorial Panel: 15000, 15001, 15100, 15101, 15120, 15121, 15350, 15351, 15400, and 15401.

    HCFA Proposal:

    We have reviewed and proposed to accept the RUC recommendation for these codes.

    5. Transplantation

    Comment: The American Society for Transplant Surgeons requested reassessment of the work RVUs for code 47134 because the current work RVUs do not accurately reflect the work involved (it contended that over 50 percent of these procedures involve right lobectomies that are more labor intensive than left lobectomies, on which the current work RVUs are based). As an alternative, the American Society for Transplant Surgeons also suggested referral to the CPT Editorial Panel for consideration of creation of an additional code.

    RUC Recommendation:

    The RUC recommended that code 47134 be forwarded to the CPT Editorial Panel for further consideration.

    HCFA Proposal:

    We have reviewed and propose to accept the RUC recommendation for this code.

    6. Arthroscopy Services

    Comment: The Arthroscopy Association of North America (AANA) requested that work for other arthroscopy services be reconsidered in light of the increase in work RVUs for code 29848 in the last 5-year review. The AANA also requested a specific increase in the work RVUs for code 29889. Subsequently, the specialty society chose not to pursue its request for consideration for code 29881.

    RUC Recommendations:

    For code 29883, the RUC noted that this service consisted of two procedures, medial and lateral meniscus repair. Because this service encompassed the work involved in code 29882 plus additional work for the lateral meniscus repair, and using the building-block approach, the RUC recommended work RVUs of 11.05 for this service. For code 29889, the RUC indicated that, due to the increase in post-and intraservice time, the work RVUs should be increased to 16.00.

    HCFA Proposal:

    We have reviewed and propose to accept the RUC recommendation for this code.

    7. Wheelchair Management

    Comment: The American Physical Therapy Association requested review of code 97542.

    HCPAC Proposal: We had revised the recommended work RVUs for this code when it was previously reviewed by the HCPAC in 1995, based on a comparison of code 97542 to code 97032 rather than to code 97110. The HCPAC concluded that our comparison was incorrect because code 97032 is the application of a modality, while code 97542 requires additional skills because the patients requiring this service have cognitive, sensory, and physical disabilities. In addition, HCPAC indicated that we may not have understood that this procedure is reported very infrequently. The HCPAC supports its original recommendation of 0.45 work RVUs for this service.

    HCFA Proposal:

    We have reviewed and propose to accept the HCPAC recommendation for this code.

    8. Psychological Testing

    Comment: The American Psychological Association recommended that we review five psychological testing codes (96100, 96105, 96110, 96115, and 96117).

    HCPAC Recommendation:

    The HCPAC did not have any recommendations for these codes at this time. However, it indicated that the American Psychological Association may request HCPAC to review these services at a future date once additional information is collected.

    HCFA Proposal:

    We propose to make no changes at this time. We believe more precise definitions of these services may be necessary to value them properly and to ensure proper coding and billing of these services.

    9. Podiatric Services

    Comment: The American Podiatric Medical Association submitted five codes (trim skin lesions/trim nails) for review (11719, 11055, 11056, 11057, and G0127) indicating that they are undervalued and do not accurately reflect the level of physician work involved.

    HCPAC Recommendation:

    The HCPAC reviewed these codes and had no information to support an increase in work RVUs. However, the HCPAC requested that we review our current utilization data to ensure that the original utilization assumptions were correct. The HCPAC recommended that the current review of data should be based on actual 1999 utilization data since these codes were not fully implemented until April 1, 1998.

    HCFA Proposal:

    Taking into account the recommendation of the HCPAC, we propose to review utilization data associated with the aforementioned codes to ensure the original assumptions are still correct. We will publish our final decision in the November 2001 final rule.

    D. Other Issues 1. Critical Care Services in a Global Period

    Validation of RUC recommendations for the work of many surgical procedures included the use of a “building-block” methodology as previously described. Before this 5-year review, the RUC compared the work of a postoperative intensive care unit visit by the surgeon to a level three subsequent hospital visit (code 99233) which is valued at 1.51 work RVUs. Now, for the first time since the inception of the physician fee schedule, one of the “building blocks” the RUC used to validate postoperative work by the surgeon in the intensive care unit is code 99291 ( Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes ), which is valued at 4.00 work RVUs. Specifically, the RUC validated the postoperative work of several thoracic, vascular, and general surgical procedures by comparing the surgeon's intensive care unit visits to code 99291.

    Current Medicare policy allows separate payment to the surgeon for postoperative critical care services during the surgical global period only when the patient has suffered trauma or burns. If the surgeon provides critical care services during the global period, for reasons unrelated to the surgery, that is separately payable as well.

    The RUC recommendations have raised several issues for which we are considering future action. In view of our desire to ensure that Medicare beneficiaries have appropriate access to critical care services, and to ensure that we make appropriate payments to physicians furnishing postoperative critical care services to Medicare beneficiaries, we are soliciting information and comments on the following questions and issues:

    1. If critical care (as described in CPT 2001) is provided postoperative, who typically provides this care? The surgeon, an intensivist, other physicians?

    2. Do surgeons typically meet the CPT requirements for billing critical care services (as described in CPT 2001) when making intensive care unit visits on their postoperative patients?

    3. Are surgeons currently performing more, or less, critical care on their postoperative patients than they were at the time of the last 5-year review?

    4. What is, or will be, the effect of “closed” intensive care units (a unit staffed by dedicated intensivists who manage the care for all patients in the intensive care unit) on who performs postoperative critical care services?

    5. What is the likelihood of making duplicate payment for critical care services if the surgical global period is valued with the inclusion of critical care in the postoperative work (for example, if we also pay an intensivist for postoperative critical care services)?

    6. If valuation of the surgical global period includes postoperative critical care, are there concerns about additional carrier scrutiny being applied to claims from intensivists for postoperative critical care services?

    7. Does valuation of the surgical global period with the inclusion of postoperative critical care create an incentive for the surgeon to either (a) not perform postoperative critical care services if there is an intensivist available or (b) to not consult an intensivist if one is available?

    Below are some of the options we are considering:

    • Removing work RVUs for critical care services from the surgical global period, valuing these services as subsequent hospital visits and allowing surgeons to bill separately for critical care (for an identified subset of surgical procedures where there is a high likelihood that the surgeon is typically providing critical care services).

    • Removing the work RVUs for critical care services from the surgical global period, valuing these services as subsequent hospital visits and not allowing surgeons to bill separately for critical care services.

    • Leaving the work RVUs for critical care services in the surgical global period, not allowing surgeons to bill separately for critical care services, requiring surgeons to follow documentation rules for critical care services and instructing carriers to make payment for medically necessary critical care services furnished by other physicians. (This option would facilitate tracking of critical care services, permit appropriate medical record review, and provide a basis to re-evaluate the work of the procedure.)

    Valuing the surgeon's postoperative intensive care unit visits as critical care services has raised a number of issues. We believe these issues will require a change in payment policy to ensure that postoperative critical care is appropriately paid. Therefore, we are proposing to make the work RVUs for those surgical codes where any postoperative intensive care unit visits were valued as critical care, interim, until we address the issues discussed above.

    2. Codes Referred to CPT

    As discussed in sections B and C above, there were some codes that commenters had submitted for review that the RUC recommended be referred to the CPT Editorial Panel for clarification or consideration of definitional changes. These codes are listed in Table 2, which follows.

    Table 2.—Codes Referred to CPT Editorial Panel From Five-Year Review of Work Relative Value Units CPT/HCPCS
  • code  1
    • Mod Descriptor     12001 Repair superficial wound(s) 12002 Repair superficial wound(s) 15000 Skin graft 15001 Skin graft add-on 15100 Skin split graft 15101 Skin split graft add-on 15120 Skin split graft 15121 Skin split graft add-on 15350 Skin homograft 15351 Skin homograft add-on 15400 Skin heterograft 15401 Skin heterograft add-on 20205 Deep muscle biopsy 21740 Reconstruction of sternum 23076 Removal of shoulder lesion 24076 Remove arm/elbow lesion 25076 Removal of forearm lesion 27048 Remove hip/pelvis lesion 27328 Removal of thigh lesion 27619 Remove lower leg lesion 33875 Thoracic aortic graft 33877 Thoracoabdominal graft 35381 Rechanneling of artery 35541 Artery bypass graft 35546 Artery bypass graft 35551 Artery bypass graft 35582 Vein bypass graft 35641 Artery bypass graft 35646 Artery bypass graft 35840 Explore abdominal vessels 35860 Explore limb vessels 36406 Drawing blood 36520 Plasma and/or cell exchange 36533 Insertion of access device 36534 Revision of access device 36535 Removal of access device 36620 Insertion catheter, artery 37615 Ligation of neck artery 37618 Ligation of extremity artery 37700 Revise leg vein 37720 Removal of leg vein 37730 Removal of leg veins 37735 Removal of leg veins/lesion 37760 Revision of leg veins 37785 Revision secondary varicosity 43215 Esophagus endoscopy 43310 Repair of esophagus 43312 Repair esophagus and fistula 47134 Partial removal, donor liver 49495 Repair inguinal hernia, init 49496 Repair inguinal hernia, init 49905 Omental flap 50200 Biopsy of kidney 50230 Removal of kidney 90935 Hemodialysis, one evaluation 90937 Hemodialysis, repeated eval 90945 Dialysis, one evaluation 90947 Dialysis, repeated eval 90989 Dialysis training, complete 90993 Dialysis training, incompl 90997 Hemoperfusion 94664 Aerosol or vapor inhalations 94665 Aerosol or vapor inhalations     3. Budget Neutrality

    Section 1848(c)(2)(B) of the Act requires that increases or decreases in relative value units may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes. If this threshold is exceeded, we make adjustments to preserve budget neutrality. This year, budget-neutrality adjustments will be required for changes in work relative value units resulting from the 5-year refinement. Revisions in payment policies, including the establishment of interim and final relative value units for coding changes that will be announced later this year, may result in additional budget-neutrality adjustments.

    We considered making the statutorily required budget-neutrality adjustments to account for the 5-year review of physician work by reducing all work RVUs. We estimate that all work RVUs would have to be reduced by 0.7 percent under this option. Alternatively, we considered making an adjustment to the physician fee schedule CF to meet the provisions of section 1848(c)(2)(B). This option would require an estimated 0.3 percent reduction in the conversion factor. For the 5-year review, we are proposing to reduce the conversion factor by 0.3 percent to meet the provisions of section 1848(c)(2)(B).

    HCFA Proposal:

    We propose to make the budget-neutrality adjustment by reducing the CF.

    4. Calculation of Practice Expense and Malpractice Expense RVUs

    As we noted in the November 2, 1999 final rule (64 FR 59427), practice expense and malpractice expense RVUs were not subject to comment and will not be recalculated (other than the change to practice expense RVUs that result from changes in work) as part of the 5-year review of work RVUs. Section 4505 of the BBA also provides for the gradual 4-year transition for resource-based practice expenses, with resource-based practice expenses becoming fully effective in CY 2002. We are currently in the process of developing our annual physician fee schedule proposed rule that will continue the 4-year refinement process for resource-based practice expense RVUs.

    Section 4505(f) of the Balanced Budget Act of 1997 (BBA) amended section 1848(c)(2)(C) of the Act and requires us to implement resource-based malpractice RVUs for services furnished beginning in CY 2000. A methodology for establishing resource-based malpractice RVUs was included in the November 1999 final rule and implemented January 1, 2000. In addition, based on concerns expressed by commenters, updated premium data used under this methodology were obtained and used to calculate malpractice RVUs for CY 2001.

    Since resource-based malpractice RVUs were recently implemented, and resource-based practice expenses are in the final phase of transition to a fully resource-based system, these components are not being included in this 5-year review. However, as stated above we expect to publish our annual physician fee schedule proposed rule that will propose continuing refinements to resource-based practice expense RVUs.

    5. Nature and Format of Comments on Work RVUs

    We will accept comments on the proposed work RVUs for the codes identified in the Addendum of this notice. We will also accept comments on the anesthesia codes. Comments should discuss how the work associated with a given CPT or HCPCS code is analogous to the work in other services or discuss the rationale for disagreeing with the proposed work RVU. We are especially interested in information or arguments that were not presented in earlier comments.

    III. Collection of Information Requirements

    This document does not impose information collection and recordkeeping requirements. Consequently it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq. )

    IV. Response to Comments

    Because of the large number of items of correspondence we normally receive on Federal Register documents published for comment, we are not able to acknowledge or respond to them individually. We will consider all comment received by the date and time specified in the DATES section of this preamble, and we will respond to the comments in the physician fee schedule final rule.

    V. Regulatory Impact Analysis A. Overall Impact

    We have examined the impacts of this proposed notice as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act (RFA) (September 9, 1980 Public Law 96-354). Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity).

    A regulatory impact analysis must be prepared for major rules with economically significant effects ($100 million or more annually). While the changes in the Medicare physician fee schedule due to the 5-year review are budget neutral, they do involve a redistribution of Medicare spending among procedures that will exceed $100 million. For this reason, we are considering this to be a major rule. We estimate that the aggregate amount of payments being redistributed among specialties as a result of the 5-year review will be over $200 million.

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

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

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

    For purposes of Executive Order 12866 and the RFA, we have prepared the following analysis, which, together with the rest of this preamble, meets all four assessment requirements. It explains the rationale for and purpose of the proposed notice, details the costs and benefits of the proposed notice, analyzes alternatives, and presents the measures we considered to minimize burden on small entities. Section 1848(c)(2)(B) of the Act requires that increases or decreases in RVUs may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes. If this threshold is exceeded, we make adjustments to preserve budget neutrality. This year, budget-neutrality adjustments will be required for changes in work relative value units resulting from the 5-year refinement. Revisions in payment policies, including the establishment of interim and final relative value units for coding changes that will be announced later this year, may result in additional budget-neutrality adjustments.

    We considered making the statutorily required budget-neutrality adjustments to account for the 5-year review of physician work by reducing all work RVUs. We estimate that all work RVUs would have to be reduced by 0.7 percent under this option. Alternatively, we considered making an adjustment to the physician fee schedule CF to meet the provisions of section 1848(c)(2)(B) of the Act. This option would require an estimated 0.3 percent reduction in the CF. For the 5-year review, we are proposing to reduce the CF by 0.3 percent to meet the provisions of section 1848(c)(2)(B) of the Act.

    Table 3.—Percent Change in Total Payments by Specialty Resulting From the 5 Year Review of Work Specialty Allowed charges
  • (billions)
    •  Percent change in total payments from increase in work Percent change in total payments from change in PE Total percent change in payments from 5 year review     Anesthesiology 1.5 1 0 1 Cardiac Surgery 0.3 5 1 6 Cardiology 4.2 0 −1 −1 Chiropractor 0.4 0 0 0 Clinics 1.6 0 0 0 Dermatology 1.4 0 0 0 Emergency Medicine 1.0 0 0 0 Family Practice 3.3 0 0 0 Gastroenterology 1.2 0 0 0 General Practice 1.0 0 0 0 General Surgery 2.0 3 1 4 Hematology Oncology 0.6 0 −1 −1 Internal Medicine 7.1 0 0 0 Nephrology 1.0 0 0 0 Neurology 0.9 0 0 0 Neurosurgery 0.4 0 0 0 Nonphysician Practitioner 1.2 0 0 0 Obstetrics/Gynecology 0.4 0 0 0 Ophthalmology 3.9 0 0 0 Optometrist 0.5 0 0 0 Orthopedic Surgery 2.3 0 0 0 Other Physician 1.6 0 0 0 Otolaryngology 0.6 0 0 0 Pathology 0.6 0 0 0 Plastic Surgery 0.2 0 0 0 Podiatry 1.1 0 0 0 Psychiatry 1.1 0 0 0 Pulmonary 1.1 0 0 0 Radiation Oncology 0.7 0 −1 −1 Radiology 3.3 0 −1 −1 Rheumatology 0.3 0 0 0 Suppliers 0.5 0 0 −1 Thoracic Surgery 0.5 4 1 5 Urology 1.3 0 0 0 Vascular Surgery 0.3 2 0 2 Note: This table incorporates two separate budget neutrality adjustments. The increase in practice expense relative value units is incorporated through a rescaling of all practice expense RVUs. In addition, all physician fee schedule payments (not the work RVUs) are reduced to make the increase in physician work RVUs budget neutral.

    The table above shows the specialty level payment impact of changes in work and practice expense relative values resulting from the 5-year review. The table includes the effect of budget-neutrality adjustments applied to the physician fee schedule CF. Since the practice expense RVUs are based, in part, on physician work, the table also reflects changes in practice expense RVUs that will result from the 5-year review of physician work. The changes in practice expense RVUs resulting from the changes in physician work RVUs were made budget neutral by rescaling all practice expense RVUs. This table shows the impact on payments per service at the specialty level that would result only from the 5-year review of physician work RVUs.

    We are in the process of developing our annual physician fee schedule proposed rule that will make refinements in practice expense RVUs and other policies that will affect payment for physician fee schedule services in CY 2002. As part of the physician fee schedule proposed rule, we expect to use revised physician times submitted to us by the RUC in the methodology for determining practice expense RVUs. The RUC is recommending that we use new time data for codes in which they recommended a change in work RVUs. In addition, the RUC is recommending a revision of the time data for many other codes. For some specialties, we expect that use of the revised times will change the impacts shown here.

    In particular, it appears that the revised times submitted to us by the RUC are less than the times included in our database for many heart and chest procedures. Our expectation is that use of the RUC recommended times will result in a reduction in the practice expense RVUs for these services that are predominantly performed by cardiac and thoracic surgeons. This means that our expectation is that the total payment increase shown here for these specialties will be less when the revised times are used to determine the practice expense RVUs. In addition, there may be other refinements to the practice expense RVUs or other changes in policies that may result in a specialty level payment impact for 2002 that we will announce in our proposed rule. We will show the combined payment impact by specialty, as a result of the revised times and other proposed policy changes, in our notice of proposed rulemaking that we expect to be published shortly.

    We will show the combined impact of all policy changes affecting physician fee schedule payments in 2002 in one final rule that we expect to be published no later than November 1, 2001.

    Federalism: Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have determined that this rule will not impose substantial direct requirement costs on State and local governments, preempt State law, or otherwise have Federalism implications.

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

    (42 U.S.C. 1395k(a)(2)(F) and 1395l(i)(1) and (2)); 42 CFR 416.120, 416.125, and 416.130) (Catalog of Federal Domestic Assistance Programs No. 93.774, Medicare—Supplementary Medical Insurance Program) Dated: April 17, 2001. Michael McMullan, Acting Deputy Administrator, Health Care Financing Administration. Dated: April 23, 2001. Tommy G. Thompson, Secretary. —————————— 1  All CPT codes and descriptors copyright 2000 American Medical Association Addendum—Codes Subject to Comment CPT/HCPCS
  • code  1
    • Mod Descriptor Proposed
  • work RVU
    • G0127 Trim nail(s) 0.11 11055 Trim skin lesion 0.27 11056 Trim skin lesion, 2 to 4 0.39 11057 Trim skin lesions, over 4 0.50 11402 Removal of skin lesion 1.61 11642 Removal of skin lesion 2.93 11642 Removal of skin lesion 2.93 11719 Trim nail(s) 0.11 12001 Repair superficial wound(s) 1.70 12002 Repair superficial wound(s) 1.86 12011 Repair superficial wound(s) 1.76 13101 Repair of wound or lesion 3.92 13131 Repair of wound or lesion 3.79 13132 Repair of wound or lesion 5.95 15000 Skin graft 4.00 15001 Skin graft add-on 1.00 15100 Skin split graft 9.05 15101 Skin split graft add-on 1.72 15120 Skin split graft 9.83 15121 Skin split graft add-on 2.67 15350 Skin homograft 4.00 15351 Skin homograft add-on 1.00 15400 Skin heterograft 4.00 15401 Skin heterograft add-on 1.00 19000 Drainage of breast lesion 0.84 19100 Biopsy of breast 1.27 19125 Excision, breast lesion 6.06 19160 Removal of breast tissue 5.99 19162 Remove breast tissue, nodes 13.53 19240 Removal of breast 16.00 20205 Deep muscle biopsy 2.35 20245 Bone biopsy, excisional 7.78 21740 Reconstruction of sternum 16.50 21800 Treatment of rib fracture 0.96 23076 Removal of shoulder lesion 7.63 23472 Reconstruct shoulder joint 21.10 23485 Revision of collar bone 13.43 23585 Treat scapula fracture 8.96 23615 Treat humerus fracture 9.35 23630 Treat humerus fracture 7.35 23680 Treat dislocation/fracture 10.06 24076 Remove arm/elbow lesion 6.30 24435 Repair humerus with graft 13.17 24545 Treat humerus fracture 10.46 25076 Removal of forearm lesion 4.92 26562 Repair of web finger 15.00 27048 Remove hip/pelvis lesion 6.25 27075 Extensive hip surgery 35.00 27077 Extensive hip surgery 40.00 27216 Treat pelvic ring fracture 15.19 27217 Treat pelvic ring fracture 14.11 27218 Treat pelvic ring fracture 20.15 27226 Treat hip wall fracture 14.91 27236 Treat thigh fracture 15.60 27280 Fusion of sacroiliac joint 13.39 27282 Fusion of pubic bones 11.34 27284 Fusion of hip joint 23.45 27328 Removal of thigh lesion 5.57 27472 Repair/graft of thigh 17.72 27513 Treatment of thigh fracture 17.92 27536 Treat knee fracture 15.65 27590 Amputate leg at thigh 12.03 27619 Remove lower leg lesion 8.40 27724 Repair/graft of tibia 18.20 27822 Treatment of ankle fracture 11.00 27823 Treatment of ankle fracture 13.00 27828 Treat lower leg fracture 16.23 28299 Correction of bunion 9.18 28322 Repair of metatarsals 8.34 28420 Treat/graft heel fracture 16.64 28445 Treat ankle fracture 15.62 28705 Fusion of foot bones 18.80 29450 Application of leg cast 2.08 29450 Application of leg cast 2.08 29883 Knee arthroscopy/surgery 11.05 29889 Knee arthroscopy/surgery 16.00 29889 Knee arthroscopy/surgery 16.00 31600 Incision of windpipe 7.18 31622 Dx bronchoscope/wash 2.78 31622 Dx bronchoscope/wash 2.78 31625 Bronchoscopy with biopsy 3.37 31645 Bronchoscopy, clear airways 3.16 32000 Drainage of chest 1.54 32000 Drainage of chest 1.54 32005 Treat lung lining chemically 2.19 32020 Insertion of chest tube 3.98 32035 Exploration of chest 8.67 32095 Biopsy through chest wall 8.36 32100 Exploration/biopsy of chest 15.24 32110 Explore/repair chest 23.00 32220 Release of lung 24.00 32225 Partial release of lung 13.96 32320 Free/remove chest lining 24.00 32440 Removal of lung 25.00 32440 Removal of lung 25.00 32480 Partial removal of lung 23.75 32480 Partial removal of lung 23.75 32482 Bilobectomy 25.00 32491 Lung volume reduction 21.25 32500 Partial removal of lung 22.00 32520 Remove lung & revise chest 21.68 32602 Thoracoscopy, diagnostic 5.96 32651 Thoracoscopy, surgical 12.91 32652 Thoracoscopy, surgical 18.66 32655 Thoracoscopy, surgical 13.10 32657 Thoracoscopy, surgical 13.65 33234 Removal of pacemaker system 7.82 33235 Removal of pacemaker electrode 9.40 33400 Repair of aortic valve 28.50 33405 Replacement of aortic valve 35.00 33406 Replacement of aortic valve 37.50 33410 Replacement of aortic valve 32.46 33411 Replacement of aortic valve 36.25 33412 Replacement of aortic valve 42.00 33413 Replacement of aortic valve 43.50 33415 Revision, subvalvular tissue 27.15 33425 Repair of mitral valve 27.00 33426 Repair of mitral valve 33.00 33427 Repair of mitral valve 40.00 33430 Replacement of mitral valve 33.50 33468 Revision of tricuspid valve 30.12 33475 Replacement, pulmonary valve 33.00 33506 Repair artery, translocation 35.50 33510 CABG, vein, single 29.00 33511 CABG, vein, two 30.00 33512 CABG, vein, three 31.80 33513 CABG, vein, four 32.00 33514 CABG, vein, five 32.75 33516 Cabg, vein, six or more 35.00 33517 CABG, artery-vein, single 2.57 33518 CABG, artery-vein, two 4.85 33519 CABG, artery-vein, three 7.12 33521 CABG, artery-vein, four 9.40 33522 CABG, artery-vein, five 11.67 33523 Cabg, art-vein, six or more 13.95 33530 Coronary artery, bypass/reop 5.86 33533 CABG, arterial, single 30.00 33534 CABG, arterial, two 32.20 33535 CABG, arterial, three 34.50 33536 Cabg, arterial, four or more 37.50 33611 Repair double ventricle 34.00 33612 Repair double ventricle 35.00 33615 Repair, simple fontan 34.00 33617 Repair, modified fontan 37.00 33619 Repair single ventricle 45.00 33641 Repair heart septum defect 21.39 33660 Repair of heart defects 30.00 33670 Repair of heart chambers 35.00 33681 Repair heart septum defect 30.61 33694 Repair of heart defects 34.00 33697 Repair of heart defects 36.00 33730 Repair heart-vein defect(s) 34.25 33750 Major vessel shunt 21.41 33767 Major vessel shunt 24.50 33770 Repair great vessels defect 37.00 33778 Repair great vessels defect 40.00 33780 Repair great vessels defect 41.75 33786 Repair arterial trunk 39.00 33820 Revise major vessel 16.29 33840 Remove aorta constriction 20.63 33860 Ascending aortic graft 38.00 33861 Ascending aortic graft 42.00 33863 Ascending aortic graft 45.00 33870 Transverse aortic arch graft 44.00 33875 Thoracic aortic graft 33.06 33877 Thoracoabdominal graft 42.60 33917 Repair pulmonary artery 24.50 33919 Repair pulmonary atresia 40.00 33945 Transplantation of heart 42.10 34101 Removal of artery clot 10.00 34111 Removal of arm artery clot 10.00 34151 Removal of artery clot 25.00 34151 Removal of artery clot 25.00 34201 Removal of artery clot 10.03 34201 Removal of artery clot 10.03 34203 Removal of leg artery clot 16.50 34203 Removal of leg artery clot 16.50 34401 Removal of vein clot 25.00 34401 Removal of vein clot 25.00 34421 Removal of vein clot 12.00 34421 Removal of vein clot 12.00 34451 Removal of vein clot 27.00 34451 Removal of vein clot 27.00 34490 Removal of vein clot 9.86 34501 Repair valve, femoral vein 16.00 34510 Transposition of vein valve 18.95 34520 Cross-over vein graft 17.95 34530 Leg vein fusion 16.64 35011 Repair defect of artery 18.00 35011 Repair defect of artery 18.00 35013 Repair artery rupture, arm 22.00 35013 Repair artery rupture, arm 22.00 35045 Repair defect of arm artery 17.57 35045 Repair defect of arm artery 17.57 35081 Repair defect of artery 28.01 35082 Repair artery rupture, aorta 38.50 35082 Repair artery rupture, aorta 38.50 35092 Repair artery rupture, aorta 45.00 35092 Repair artery rupture, aorta 45.00 35103 Repair artery rupture, groin 40.50 35103 Repair artery rupture, groin 40.50 35111 Repair defect of artery 25.00 35111 Repair defect of artery 25.00 35112 Repair artery rupture, spleen 30.00 35112 Repair artery rupture, spleen 30.00 35121 Repair defect of artery 30.00 35121 Repair defect of artery 30.00 35122 Repair artery rupture, belly 35.00 35122 Repair artery rupture, belly 35.00 35131 Repair defect of artery 25.00 35131 Repair defect of artery 25.00 35132 Repair artery rupture, groin 30.00 35132 Repair artery rupture, groin 30.00 35141 Repair defect of artery 20.00 35141 Repair defect of artery 20.00 35142 Repair artery rupture, thigh 23.30 35142 Repair artery rupture, thigh 23.30 35151 Repair defect of artery 22.64 35151 Repair defect of artery 22.64 35152 Repair artery rupture, knee 25.62 35152 Repair artery rupture, knee 25.62 35182 Repair blood vessel lesion 30.00 35184 Repair blood vessel lesion 18.00 35189 Repair blood vessel lesion 28.00 35190 Repair blood vessel lesion 12.75 35201 Repair blood vessel lesion 16.14 35201 Repair blood vessel lesion 16.14 35206 Repair blood vessel lesion 13.25 35221 Repair blood vessel lesion 24.39 35221 Repair blood vessel lesion 24.39 35226 Repair blood vessel lesion 14.50 35226 Repair blood vessel lesion 14.50 35231 Repair blood vessel lesion 20.00 35231 Repair blood vessel lesion 20.00 35236 Repair blood vessel lesion 17.11 35236 Repair blood vessel lesion 17.11 35246 Repair blood vessel lesion 26.45 35246 Repair blood vessel lesion 26.45 35251 Repair blood vessel lesion 30.20 35251 Repair blood vessel lesion 30.20 35256 Repair blood vessel lesion 18.36 35261 Repair blood vessel lesion 17.80 35261 Repair blood vessel lesion 17.80 35266 Repair blood vessel lesion 14.91 35266 Repair blood vessel lesion 14.91 35276 Repair blood vessel lesion 24.25 35276 Repair blood vessel lesion 24.25 35281 Repair blood vessel lesion 28.00 35281 Repair blood vessel lesion 28.00 35286 Repair blood vessel lesion 16.16 35311 Rechanneling of artery 27.00 35311 Rechanneling of artery 27.00 35321 Rechanneling of artery 16.00 35321 Rechanneling of artery 16.00 35331 Rechanneling of artery 26.20 35331 Rechanneling of artery 26.20 35351 Rechanneling of artery 23.00 35351 Rechanneling of artery 23.00 35355 Rechanneling of artery 18.50 35355 Rechanneling of artery 18.50 35361 Rechanneling of artery 28.20 35361 Rechanneling of artery 28.20 35363 Rechanneling of artery 30.20 35363 Rechanneling of artery 30.20 35371 Rechanneling of artery 14.72 35371 Rechanneling of artery 14.72 35372 Rechanneling of artery 18.00 35372 Rechanneling of artery 18.00 35381 Rechanneling of artery 15.81 35511 Artery bypass graft 21.20 35511 Artery bypass graft 21.20 35518 Artery bypass graft 21.20 35518 Artery bypass graft 21.20 35521 Artery bypass graft 22.20 35521 Artery bypass graft 22.20 35526 Artery bypass graft 29.95 35526 Artery bypass graft 29.95 35531 Artery bypass graft 36.20 35531 Artery bypass graft 36.20 35533 Artery bypass graft 28.00 35533 Artery bypass graft 28.00 35536 Artery bypass graft 31.70 35536 Artery bypass graft 31.70 35541 Artery bypass graft 25.80 35546 Artery bypass graft 25.54 35551 Artery bypass graft 26.67 35556 Artery bypass graft 21.76 35556 Artery bypass graft 21.76 35558 Artery bypass graft 21.20 35558 Artery bypass graft 21.20 35560 Artery bypass graft 32.00 35560 Artery bypass graft 32.00 35563 Artery bypass graft 24.20 35563 Artery bypass graft 24.20 35565 Artery bypass graft 23.20 35565 Artery bypass graft 23.20 35571 Artery bypass graft 24.06 35571 Artery bypass graft 24.06 35582 Vein bypass graft 27.13 35587 Vein bypass graft 24.75 35587 Vein bypass graft 24.75 35621 Artery bypass graft 20.00 35621 Artery bypass graft 20.00 35623 Bypass graft, not vein 24.00 35623 Bypass graft, not vein 24.00 35626 Artery bypass graft 27.75 35626 Artery bypass graft 27.75 35631 Artery bypass graft 34.00 35631 Artery bypass graft 34.00 35636 Artery bypass graft 29.50 35636 Artery bypass graft 29.50 35641 Artery bypass graft 24.57 35646 Artery bypass graft 25.81 35650 Artery bypass graft 19.00 35650 Artery bypass graft 19.00 35654 Artery bypass graft 25.00 35654 Artery bypass graft 25.00 35661 Artery bypass graft 19.00 35661 Artery bypass graft 19.00 35663 Artery bypass graft 22.00 35663 Artery bypass graft 22.00 35665 Artery bypass graft 21.00 35665 Artery bypass graft 21.00 35666 Artery bypass graft 22.19 35666 Artery bypass graft 22.19 35671 Artery bypass graft 19.33 35671 Artery bypass graft 19.33 35701 Exploration, carotid artery 8.50 35701 Exploration, carotid artery 8.50 35721 Exploration, femoral artery 7.18 35741 Exploration popliteal artery 8.00 35840 Explore abdominal vessels 9.77 35860 Explore limb vessels 5.55 35905 Excision, graft, thorax 31.25 35905 Excision, graft, thorax 31.25 35907 Excision, graft, abdomen 35.00 35907 Excision, graft, abdomen 35.00 36400 Drawing blood 0.18 36405 Drawing blood 0.18 36406 Drawing blood 0.18 36489 Insertion of catheter, vein 2.50 36489 Insertion of catheter, vein 2.50 36520 Plasma and/or cell exchange 1.74 36533 Insertion of access device 5.32 36534 Revision of access device 2.80 36535 Removal of access device 2.27 36620 Insertion catheter, artery 1.15 36625 Insertion catheter, artery 2.11 36822 Insertion of cannula(s) 5.42 37565 Ligation of neck vein 10.88 37565 Ligation of neck vein 10.88 37600 Ligation of neck artery 11.25 37600 Ligation of neck artery 11.25 37605 Ligation of neck artery 13.11 37605 Ligation of neck artery 13.11 37609 Temporal artery procedure 3.00 37609 Temporal artery procedure 3.00 37615 Ligation of neck artery 5.73 37615 Ligation of neck artery 5.73 37617 Ligation of abdomen artery 22.06 37618 Ligation of extremity artery 4.84 37650 Revision of major vein 7.80 37660 Revision of major vein 21.00 37700 Revise leg vein 3.73 37720 Removal of leg vein 5.66 37730 Removal of leg veins 7.33 37735 Removal of leg veins/lesion 10.53 37760 Revision of leg veins 10.47 37785 Revision secondary varicosity 3.84 38100 Removal of spleen, total 14.50 38100 Removal of spleen, total 14.50 38101 Removal of spleen, partial 15.31 38115 Repair of ruptured spleen 15.82 38300 Drainage, lymph node lesion 1.99 38305 Drainage, lymph node lesion 6.00 38308 Incision of lymph channels 6.45 38500 Biopsy/removal, lymph nodes 3.75 38500 Biopsy/removal, lymph nodes 3.75 38510 Biopsy/removal, lymph nodes 6.43 38520 Biopsy/removal, lymph nodes 6.67 38525 Biopsy/removal, lymph nodes 6.07 38530 Biopsy/removal, lymph nodes 7.98 38571 Laparoscopy, lymphadenectomy 12.38 38572 Laparoscopy, lymphadenectomy 16.59 38740 Remove armpit lymph nodes 10.02 38745 Remove armpit lymph nodes 13.00 38746 Remove thoracic lymph nodes 4.89 38760 Remove groin lymph nodes 12.94 38765 Remove groin lymph nodes 19.98 38780 Remove abdomen lymph nodes 16.59 39010 Exploration of chest 11.79 39220 Removal chest lesion 17.42 39400 Visualization of chest 5.61 39503 Repair of diaphragm hernia 34.85 42205 Reconstruct cleft palate 13.29 43107 Removal of esophagus 40.00 43112 Removal of esophagus 43.50 43117 Partial removal of esophagus 40.00 43122 Parital removal of esophagus 40.00 43215 Esophagus endoscopy 2.60 43217 Esophagus endoscopy 2.90 43219 Esophagus endoscopy 2.80 43228 Esoph endoscopy, ablation 3.77 43239 Upper GI endoscopy, biopsy 2.69 43239 Upper GI endoscopy, biopsy 2.87 43244 Upper GI endoscopy/ligation 4.59 43246 Place gastrostomy tube 4.33 43246 Place gastrostomy tube 4.33 43247 Operative upper GI endoscopy 3.39 43249 Esoph endoscopy, dilation 2.90 43251 Operative upper GI endoscopy 3.70 43255 Operative upper GI endoscopy 4.40 43258 Operative upper GI endoscopy 4.55 43259 Endoscopic ultrasound exam 4.89 43263 Endo cholangiopancreatograph 6.19 43265 Endo cholangiopancreatograph 8.90 43269 Endo cholangiopancreatograph 6.04 43310 Repair of esophagus 25.39 43312 Repair esophagus and fistula 28.42 43320 Fuse esophagus & stomach 19.93 43324 Revise esophagus & stomach 20.57 43325 Revise esophagus & stomach 20.06 43326 Revise esophagus & stomach 19.74 43330 Repair of esophagus 19.77 43331 Repair of esophagus 20.13 43340 Fuse esophagus & intestine 19.61 43341 Fuse esophagus & intestine 20.85 43350 Surgical opening, esophagus 15.78 43351 Surgical opening, esophagus 18.35 43352 Surgical opening, esophagus 15.26 43360 Gastrointestinal repair 35.70 43361 Gastrointestinal repair 40.50 43400 Ligate esophagus veins 21.20 43401 Esophagus surgery for veins 22.09 43405 Ligate/staple esophagus 20.01 43410 Repair esophagus wound 13.47 43415 Repair esophagus wound 25.00 43420 Repair esophagus opening 14.35 43425 Repair esophagus opening 21.03 43500 Surgical opening of stomach 11.05 43501 Surgical repair of stomach 20.04 43502 Surgical repair of stomach 23.13 43510 Surgical opening of stomach 13.08 43520 Incision of pyloric muscle 9.99 43605 Biopsy of stomach 11.98 43610 Excision of stomach lesion 14.60 43611 Excision of stomach lesion 17.84 43620 Removal of stomach 30.04 43621 Removal of stomach 30.73 43622 Removal of stomach 32.53 43631 Removal of stomach, partial 22.59 43632 Removal of stomach, partial 22.59 43633 Removal of stomach, partial 23.10 43634 Removal of stomach, partial 25.12 43638 Removal of stomach, partial 29.00 43638 Removal of stomach, partial 29.00 43639 Removal of stomach, partial 29.65 43640 Vagotomy & pylorus repair 17.02 43641 Vagotomy & pylorus repair 17.27 43651 Laparoscopy, vagus nerve 10.15 43652 Laparoscopy, vagus nerve 12.15 43800 Reconstruction of pylorus 13.69 43810 Fusion of stomach and bowel 14.65 43820 Fusion of stomach and bowel 15.37 43825 Fusion of stomach and bowel 19.22 43830 Place gastrostomy tube 9.53 43832 Place gastrostomy tube 15.60 43840 Repair of stomach lesion 15.56 43842 Gastroplasty for obesity 18.47 43843 Gastroplasty for obesity 18.65 43846 Gastric bypass for obesity 24.05 43847 Gastric bypass for obesity 26.92 43848 Revision gastroplasty 29.39 43850 Revise stomach-bowel fusion 24.72 43855 Revise stomach-bowel fusion 26.16 43860 Revise stomach-bowel fusion 25.00 43865 Revise stomach-bowel fusion 26.52 43870 Repair stomach opening 9.69 43880 Repair stomach-bowel fistula 24.65 44005 Freeing of bowel adhesion 16.23 44010 Incision of small bowel 12.52 44020 Exploration of small bowel 13.99 44021 Decompress small bowel 14.08 44025 Incision of large bowel 14.28 44050 Reduce bowel obstruction 14.03 44050 Reduce bowel obstruction 14.03 44055 Correct malrotation of bowel 22.00 44110 Excision of bowel lesion(s) 11.81 44111 Excision of bowel lesion(s) 14.29 44120 Removal of small intestine 17.00 44125 Removal of small intestine 17.54 44130 Bowel to bowel fusion 14.49 44130 Bowel to bowel fusion 14.49 44140 Partial removal of colon 21.00 44140 Partial removal of colon 21.00 44143 Partial removal of colon 22.99 44144 Partial removal of colon 21.53 44144 Partial removal of colon 21.53 44145 Partial removal of colon 26.42 44146 Partial removal of colon 27.54 44147 Partial removal of colon 20.71 44150 Removal of colon 23.95 44151 Removal of colon/ileostomy 26.88 44151 Removal of colon/ileostomy 26.88 44152 Removal of colon/ileostomy 27.83 44153 Removal of colon/ileostomy 30.59 44155 Removal of colon/ileostomy 27.86 44156 Removal of colon/ileostomy 30.79 44156 Removal of colon/ileostomy 30.79 44160 Removal of colon 18.62 44200 Laparoscopy, enterolysis 14.44 44300 Open bowel to skin 12.11 44310 Ileostomy/jejunostomy 15.95 44312 Revision of ileostomy 8.02 44314 Revision of ileostomy 15.05 44316 Devise bowel pouch 21.09 44320 Colostomy 17.64 44340 Revision of colostomy 7.72 44345 Revision of colostomy 15.43 44346 Revision of colostomy 16.99 44388 Colon endoscopy 2.82 44389 Colonoscopy with biopsy 3.13 44390 Colonoscopy for foreign body 3.83 44391 Colonoscopy for bleeding 4.32 44392 Colonoscopy and polypectomy 3.82 44393 Colonoscopy, lesion removal 4.84 44394 Colonoscopy w/snare 4.43 44394 Colonoscopy w/snare 4.43 44602 Suture, small intestine 16.03 44603 Suture, small intestine 18.66 44604 Suture, large intestine 16.03 44605 Repair of bowel lesion 19.53 44615 Intestinal stricturoplasty 15.93 44620 Repair bowel opening 12.20 44625 Repair bowel opening 15.05 44626 Repair bowel opening 25.36 44640 Repair bowel-skin fistula 21.65 44650 Repair bowel fistula 22.57 44660 Repair bowel-bladder fistula 21.36 44661 Repair bowel-bladder fistula 24.81 44680 Surgical revision, intestine 15.40 44700 Suspend bowel w/prosthesis 16.11 44800 Excision of bowel pouch 11.23 44820 Excision of mesentery lesion 12.09 44850 Repair of mesentery 10.74 44900 Drain app abscess, open 10.14 44950 Appendectomy 10.00 44960 Appendectomy 12.34 44970 Laparoscopy, appendectomy 8.70 45000 Drainage of pelvic abscess 4.52 45020 Drainage of rectal abscess 4.72 45100 Biopsy of rectum 3.68 45108 Removal of anorectal lesion 4.76 45110 Removal of rectum 28.00 45111 Partial removal of rectum 16.48 45112 Removal of rectum 30.54 45113 Partial proctectomy 30.58 45114 Partial removal of rectum 27.32 45116 Partial removal of rectum 24.58 45119 Remove rectum w/reservoir 30.84 45120 Removal of rectum 24.60 45121 Removal of rectum and colon 27.04 45123 Partial proctectomy 16.71 45126 Pelvic exenteration 45.16 45130 Excision of rectal prolapse 16.44 45135 Excision of rectal prolapse 19.28 45160 Excision of rectal lesion 15.32 45170 Excision of rectal lesion 11.49 45190 Destruction, rectal tumor 9.74 45305 Proctosigmoidoscopy & biopsy 1.01 45309 Proctosigmoidoscopy 2.01 45330 Diagnostic sigmoidoscopy 0.96 45337 Sigmoidoscopy & decompress 2.36 45339 Sigmoidoscopy 3.14 45378 Diagnostic colonoscopy 3.70 45380 Colonoscopy and biopsy 4.01 45383 Lesion removal colonoscopy 5.87 45384 Colonoscopy 4.70 45385 Lesion removal colonoscopy 5.31 45505 Repair of rectum 7.58 45540 Correct rectal prolapse 16.27 45541 Correct rectal prolapse 13.40 45550 Repair rectum/remove sigmoid 23.00 45560 Repair of rectocele 10.58 45562 Exploration/repair of rectum 15.38 45563 Exploration/repair of rectum 23.47 45800 Repair rect/bladder fistula 17.77 45805 Repair fistula w/colostomy 20.78 45820 Repair rectourethral fistula 18.48 45825 Repair fistula w/colostomy 21.25 45900 Reduction of rectal prolapse 2.61 45905 Dilation of anal sphincter 2.30 45910 Dilation of rectal narrowing 2.80 45910 Dilation of rectal narrowing 2.80 45915 Remove rectal obstruction 3.14 46040 Incision of rectal abscess 4.96 46045 Incision of rectal abscess 4.32 46060 Incision of rectal abscess 5.69 46083 Incise external hemorrhoid 1.40 46083 Incise external hemorrhoid 1.40 46221 Ligation of hemorrhoid(s) 2.04 46230 Removal of anal tabs 2.57 46250 Hemorrhoidectomy 3.89 46255 Hemorrhoidectomy 4.60 46257 Remove hemorrhoids & fissure 5.40 46258 Remove hemorrhoids & fistula 5.73 46258 Remove hemorrhoids & fistula 5.73 46260 Hemorrhoidectomy 6.37 46261 Remove hemorrhoids & fissure 7.08 46262 Remove hemorrhoids & fistula 7.50 46270 Removal of anal fistula 3.72 46275 Removal of anal fistula 4.56 46280 Removal of anal fistula 5.98 46288 Repair anal fistula 7.13 46320 Removal of hemorrhoid clot 1.61 46320 Removal of hemorrhoid clot 1.61 46700 Repair of anal stricture 9.13 46705 Repair of anal stricture 6.90 46715 Repair of anovaginal fistula 7.20 46716 Repair of anovaginal fistula 15.07 46730 Construction of absent anus 26.75 46735 Construction of absent anus 32.17 46740 Construction of absent anus 30.00 46742 Repair of imperforated anus 35.80 46744 Repair of cloacal anomaly 52.63 46746 Repair of cloacal anomaly 58.22 46748 Repair of cloacal anomaly 64.21 46750 Repair of anal sphincter 10.25 46753 Reconstruction of anus 8.29 46754 Removal of suture from anus 2.20 46760 Repair of anal sphincter 14.43 46761 Repair of anal sphincter 13.84 46762 Implant artificial sphincter 12.71 46900 Destruction, anal lesion(s) 1.91 46910 Destruction, anal lesion(s) 1.86 46916 Cryosurgery, anal lesion(s) 1.86 46917 Laser surgery, anal lesions 1.86 46922 Excision of anal lesion(s) 1.86 46924 Destruction, anal lesion(s) 2.76 46924 Destruction, anal lesion(s) 2.76 46934 Destruction of hemorrhoids 3.51 46935 Destruction of hemorrhoids 2.43 46936 Destruction of hemorrhoids 3.69 46940 Treatment of anal fissure 2.32 46942 Treatment of anal fissure 2.04 46945 Ligation of hemorrhoids 1.84 46946 Ligation of hemorrhoids 2.58 47010 Open drainage, liver lesion 16.01 47015 Inject/aspirate liver cyst 15.11 47100 Wedge biopsy of liver 11.67 47120 Partial removal of liver 35.50 47122 Extensive removal of liver 55.13 47125 Partial removal of liver 49.19 47130 Partial removal of liver 53.35 47134 Partial removal, donor liver 39.15 47300 Surgery for liver lesion 15.08 47350 Repair liver wound 19.56 47360 Repair liver wound 26.92 47361 Repair liver wound 47.12 47362 Repair liver wound 18.51 47400 Incision of liver duct 32.49 47420 Incision of bile duct 19.88 47425 Incision of bile duct 19.83 47460 Incise bile duct sphincter 18.04 47480 Incision of gallbladder 10.82 47562 Laparoscopic cholecystectomy 11.09 47563 Laparoscopic cholecystectomy 11.94 47564 Laparo cholecystectomy/explr 14.23 47570 Laparo cholecystoenterostomy 12.58 47600 Removal of gallbladder 13.58 47605 Removal of gallbladder 14.69 47610 Removal of gallbladder 18.82 47612 Removal of gallbladder 18.78 47620 Removal of gallbladder 20.64 47701 Bile duct revision 27.81 47711 Excision of bile duct tumor 23.03 47712 Excision of bile duct tumor 30.24 47715 Excision of bile duct cyst 18.80 47716 Fusion of bile duct cyst 16.44 47720 Fuse gallbladder & bowel 15.91 47721 Fuse upper gi structures 19.12 47740 Fuse gallbladder & bowel 18.48 47741 Fuse gallbladder & bowel 21.34 47760 Fuse bile ducts and bowel 25.85 47765 Fuse liver ducts & bowel 24.88 47780 Fuse bile ducts and bowel 26.50 47785 Fuse bile ducts and bowel 31.18 47800 Reconstruction of bile ducts 23.30 47801 Placement, bile duct support 15.17 47802 Fuse liver duct & intestine 21.55 47900 Suture bile duct injury 19.90 48000 Drainage of abdomen 28.07 48001 Placement of drain, pancreas 35.45 48005 Resect/debride pancreas 42.17 48020 Removal of pancreatic stone 15.70 48100 Biopsy of pancreas 12.23 48120 Removal of pancreas lesion 15.85 48140 Partial removal of pancreas 22.94 48145 Partial removal of pancreas 24.02 48146 Pancreatectomy 26.40 48148 Removal of pancreatic duct 17.34 48150 Partial removal of pancreas 48.00 48150 Partial removal of pancreas 48.00 48152 Pancreatectomy 43.75 48153 Pancreatectomy 47.89 48154 Pancreatectomy 44.10 48155 Removal of pancreas 24.64 48180 Fuse pancreas and bowel 24.72 48500 Surgery of pancreas cyst 15.28 48510 Drain pancreatic pseudocyst 14.31 48520 Fuse pancreas cyst and bowel 15.59 48540 Fuse pancreas cyst and bowel 19.72 48545 Pancreatorrhaphy 18.18 48547 Duodenal exclusion 25.83 49000 Exploration of abdomen 11.68 49002 Reopening of abdomen 10.49 49010 Exploration behind abdomen 12.28 49020 Drain abdominal abscess 22.84 49040 Drain, open, abdom abscess 13.52 49060 Drain, open, retrop abscess 15.86 49085 Remove abdomen foreign body 12.14 49200 Removal of abdominal lesion 10.25 49201 Removal of abdominal lesion 14.84 49215 Excise sacral spine tumor 33.50 49215 Excise sacral spine tumor 33.50 49220 Multiple surgery, abdomen 14.88 49255 Removal of omentum 11.14 49320 Diag laparo separate proc 5.10 49321 Laparoscopy; biopsy 5.40 49322 Laparoscopy; aspiration 5.70 49421 Insert abdominal drain 5.54 49422 Remove perm cannula/catheter 6.25 49425 Insert abdomen-venous drain 11.37 49426 Revise abdomen-venous shunt 9.63 49428 Ligation of shunt 6.06 49429 Removal of shunt 7.40 49495 Repair inguinal hernia, init 5.89 49495 Repair inguinal hernia, init 5.89 49496 Repair inguinal hernia, init 8.79 49496 Repair inguinal hernia, init 8.79 49500 Repair inguinal hernia 5.48 49501 Repair inguinal hernia, init 8.88 49505 Repair inguinal hernia 7.60 49505 Repair inguinal hernia 7.60 49507 Repair inguinal hernia 9.57 49520 Rerepair inguinal hernia 9.63 49521 Repair inguinal hernia, rec 11.97 49525 Repair inguinal hernia 8.57 49540 Repair lumbar hernia 10.39 49550 Repair femoral hernia 8.63 49553 Repair femoral hernia, init 9.44 49555 Repair femoral hernia 9.03 49557 Repair femoral hernia, recur 11.15 49560 Repair abdominal hernia 11.57 49561 Repair incisional hernia 14.25 49565 Rerepair abdominal hernia 11.57 49566 Repair incisional hernia 14.40 49570 Repair epigastric hernia 5.69 49572 Repair epigastric hernia 6.73 49580 Repair umbilical hernia 4.11 49582 Repair umbilical hernia 6.65 49585 Repair umbilical hernia 6.23 49587 Repair umbilical hernia 7.56 49590 Repair abdominal hernia 8.54 49605 Repair umbilical lesion 22.66 49606 Repair umbilical lesion 18.60 49650 Laparo hernia repair initial 6.27 49651 Laparo hernia repair recur 8.24 49900 Repair of abdominal wall 12.28 49905 Omental flap 6.55 50200 Biopsy of kidney 2.63 50230 Removal of kidney 22.07 51595 Remove bladder/revise tract 37.14 51596 Remove bladder/create pouch 39.52 56515 Destruction, vulva lesion(s) 2.76 56740 Remove vagina gland lesion 4.57 57100 Biopsy of vagina 1.20 57130 Remove vagina lesion 2.43 57292 Construct vagina with graft 13.09 57307 Fistula repair & colostomy 15.93 57410 Pelvic examination 1.75 57505 Endocervical curettage 1.14 58150 Total hysterectomy 15.24 58152 Total hysterectomy 20.60 58260 Vaginal hysterectomy 12.98 58262 Vaginal hysterectomy 14.77 58263 Vaginal hysterectomy 16.06 58267 Hysterectomy & vagina repair 17.04 58270 Hysterectomy & vagina repair 14.26 58275 Hysterectomy/revise vagina 15.76 58280 Hysterectomy/revise vagina 17.01 58285 Extensive hysterectomy 22.26 58323 Sperm washing 0.23 58400 Suspension of uterus 6.36 58600 Division of fallopian tube 5.60 58605 Division of fallopian tube 5.00 58611 Ligate oviduct(s) add-on 1.45 58700 Removal of fallopian tube 12.05 58740 Revise fallopian tube(s) 14.00 58805 Drainage of ovarian cyst(s) 5.88 58820 Drain ovary abscess, open 4.22 58825 Transposition, ovary(s) 10.98 58920 Partial removal of ovary(s) 11.36 58950 Resect ovarian malignancy 16.93 58951 Resect ovarian malignancy 22.38 59150 Treat ectopic pregnancy 11.67 59151 Treat ectopic pregnancy 11.49 59812 Treatment of miscarriage 4.01 59870 Evacuate mole of uterus 6.01 60100 Biopsy of thyroid 1.56 60220 Partial removal of thyroid 11.90 60220 Partial removal of thyroid 11.90 60252 Removal of thyroid 20.57 60254 Extensive thyroid surgery 26.99 60260 Repeat thyroid surgery 17.47 60270 Removal of thyroid 20.27 60271 Removal of thyroid 16.83 60540 Explore adrenal gland 17.03 60545 Explore adrenal gland 19.88 62263 Lysis epidural adhesions 6.14 62310 Inject spine c/t 1.91 62311 Inject spine l/s (cd) 1.54 62318 Inject spine w/cath, c/t 2.04 62319 Inject spine w/cath l/s (cd) 1.87 65855 Laser surgery of eye 3.85 66180 Implant eye shunt 14.55 66986 Exchange lens prosthesis 12.28 67028 Injection eye drug 2.52 67218 Treatment of retinal lesion 18.53 67904 Repair eyelid defect 6.26 69990 Microsurgery add-on 3.47 72275 Epidurography 0.76 76005 Fluoroguide for spine inject 0.60 76065 X-rays, bone evaluation 0.70 76090 Mammogram, one breast 0.70 76091 Mammogram, both breasts 0.87 76095 Stereotactic breast biopsy 1.59 88170 Fine needle aspiration 1.27 88171 Fine needle aspiration 1.27 90901 Biofeedback train, any meth 0.41 90911 Biofeedback peri/uro/rectal 0.89 90935 Hemodialysis, one evaluation 1.22 90937 Hemodialysis, repeated eval 2.11 90945 Dialysis, one evaluation 1.28 90947 Dialysis, repeated eval 2.16 90989 Dialysis training, complete 0.00 90993 Dialysis training, incompl 0.00 90997 Hemoperfusion 1.84 92018 New eye exam & treatment 2.50 93350 Echo transthoracic 1.48 94640 Airway inhalation treatment 0.00 94664 Aerosol or vapor inhalations 0.00 94665 Aerosol or vapor inhalations 0.00 96100 Psychological testing 0.00 96105 Assessment of aphasia 0.00 96110 Developmental test, lim 0.00 96115 Neurobehavior status exam 0.00 96117 Neuropsych test battery 0.00 97542 Wheelchair mngmnt training 0.45 99233 Subsequent hospital care 1.51 99273 Confirmatory consultation 1.19 99274 Confirmatory consultation 1.73 99291 Critical care, first hour 4.00 99291 Critical care, first hour 4.00 99291 Critical care, first hour 4.00 99292 Critical care, addl 30 min 2.00 99292 Critical care, addl 30 min 2.00 99292 Critical care, addl 30 min 2.00 99295 Neonatal critical care 16.00 99296 Neonatal critical care 8.00 99297 Neonatal critical care 4.00 99298 Neonatal critical care 2.75 99436 Attendance, birth 1.50 99440 Newborn resuscitation 2.93 1 All CPT codes and descriptors copyright 2000 American Medical Association        

     

     

     

     [FR Doc. 01-14336 Filed 6-7-01; 8:45 am] BILLING CODE 4120-01-P