[Federal Register Volume 78, Number 237 (Tuesday, December 10, 2013)]
[Rules and Regulations]
[Pages 74230-74823]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-28696]
[[Page 74229]]
Vol. 78
Tuesday,
No. 237
December 10, 2013
Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 405, 410, 411, et al.
Medicare Program; Revisions to Payment Policies Under the Physician
Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to
Part B for CY 2014; Final Rule
Federal Register / Vol. 78 , No. 237 / Tuesday, December 10, 2013 /
Rules and Regulations
[[Page 74230]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 405, 410, 411, 414, 423, and 425
[CMS-1600-FC]
RIN 0938-AR56
Medicare Program; Revisions to Payment Policies Under the
Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other
Revisions to Part B for CY 2014
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule with comment period.
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SUMMARY: This major final rule with comment period addresses changes to
the physician fee schedule, clinical laboratory fee schedule, and other
Medicare Part B payment policies to ensure that our payment systems are
updated to reflect changes in medical practice and the relative value
of services. This final rule with comment period also includes a
discussion in the Supplementary Information regarding various programs.
(See the Table of Contents for a listing of the specific issues
addressed in the final rule with comment period.)
DATES: Effective date: The provisions of this final rule with comment
period are effective on January 1, 2014, except for the amendments to
Sec. Sec. 405.350, 405.355, 405.405.2413, 405.2415, 405.2452, 410.19,
410.26, 410.37, 410.71, 410.74, 410.75, 410.76, 410.77, and 414.511,
which are effective January 27, 2014, and the amendments to Sec. Sec.
405.201, Sec. 405.203, Sec. 405.205, Sec. 405.207, Sec. 405.209,
Sec. 405.211, Sec. 405.212, Sec. 405.213, Sec. 411.15, and 423.160,
which are effective on January 1, 2015.
The incorporation by reference of certain publications listed in
the rule is approved by the Director of the Federal Register as of
January 1, 2014.
Applicability dates: Additionally, the policies specified in under
the following preamble sections are applicable January 27, 2014:
Physician Compare Web site (section III.G.);
Physician Self-Referral Prohibition: Annual Update to the
List of CPT/HCPCS Codes. (section III.N.)
Comment date: To be assured consideration, comments must be
received at one of the addresses provided below, no later than 5 p.m.
on January 27, 2014. (See the SUPLEMENTARY INFORMATION section of this
final rule with comment period for a list of the provisions open for
comment.)
ADDRESSES: In commenting, please refer to file code CMS-1600-FC.
Because of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to www.regulations.gov. Follow the instructions for
``submitting a comment.''
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-1600-FC, P.O. Box 8013,
Baltimore, MD 21244-8013.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-1600-FC, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments before the close of the comment period
to either of the following addresses:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
please call telephone number (410) 786-7195 in advance to schedule your
arrival with one of our staff members.
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
FOR FURTHER INFORMATION CONTACT:
Elliott Isaac, (410) 786-4735 or cms.hhs.gov">Elliott.Isaac@cms.hhs.gov, for any
physician payment issues not identified below.
Chava Sheffield, (410) 786-2298 or cms.hhs.gov">Chava.Sheffield@cms.hhs.gov, for
issues related to practice expense methodology, impacts, the
sustainable growth rate, or conversion factors.
Ryan Howe, (410) 786-3355 or cms.hhs.gov">Ryan.Howe@cms.hhs.gov, for issues
related to direct practice expense inputs or interim final direct PE
inputs.
Kathy Kersell, (410) 786-2033 or cms.hhs.gov">Kathleen.Kersell@cms.hhs.gov, for
issues related to misvalued services.
Jessica Bruton, (410) 786-5991 or cms.hhs.gov">Jessica.Bruton@cms.hhs.gov, for
issues related to work or malpractice RVUs.
Heidi Oumarou, (410) 786-7942 or cms.hhs.gov">Heidi.Oumarou@cms.hhs.gov, for
issues related to the revision of Medicare Economic Index (MEI).
Gail Addis, (410) 786-4552 or cms.hhs.gov">Gail.Addis@cms.hhs.gov, for issues
related to the refinement panel.
Craig Dobyski, (410) 786-4584 or cms.hhs.gov">Craig.Dobyski@cms.hhs.gov, for
issues related to geographic practice cost indices.
Ken Marsalek, (410) 786-4502 or cms.hhs.gov">Kenneth.Marsalek@cms.hhs.gov, for
issues related to telehealth services.
Simone Dennis, (410) 786-8409 or cms.hhs.gov">Simone.Dennis@cms.hhs.gov, for
issues related to therapy caps.
Darlene Fleischmann, (410) 786-2357 or
cms.hhs.gov">Darlene.Fleischmann@cms.hhs.gov, for issues related to ``incident to''
services or complex chronic care management services.
Corinne Axelrod, (410) 786-5620 or cms.hhs.gov">Corrine.Axelrod@cms.hhs.gov, for
issues related to ``incident to'' services in Rural Health Clinics or
Federally Qualified Health Centers.
Roberta Epps, (410) 786-4503 or cms.hhs.gov">Roberta.Epps@cms.hhs.gov, for
issues related to chiropractors billing for evaluation and management
services.
Rosemarie Hakim, (410) 786-3934 or cms.hhs.gov">Rosemarie.Hakim@cms.hhs.gov, for
issues related to coverage of items and services furnished in FDA-
approved investigational device exemption clinical trials.
Jamie Hermansen, (410) 786-2064 or cms.hhs.gov">Jamie.Hermansen@cms.hhs.gov or
Jyme Schafer, (410) 786-4643 or cms.hhs.gov">Jyme.Schafer@cms.hhs.gov, for issues
related to ultrasound screening for abdominal aortic aneurysms or
colorectal cancer screening.
Anne Tayloe-Hauswald, (410) 786-4546 or Anne-E-Tayloe.Hauswald@
[[Page 74231]]
cms.hhs.gov, for issues related to ambulance fee schedule and clinical
lab fee schedule.
Ronke Fabayo, (410) 786-4460 or cms.hhs.gov">Ronke.Fabayo@cms.hhs.gov or Jay
Blake, (410) 786-9371 or cms.hhs.gov">Jay.Blake@cms.hhs.gov, for issues related to
individual liability for payments made to providers and suppliers and
handling of incorrect payments.
Rashaan Byers, (410) 786-2305 or cms.hhs.gov">Rashaan.Byers@cms.hhs.gov, for
issues related to physician compare.
Christine Estella, (410) 786-0485 or cms.hhs.gov">Christine.Estella@cms.hhs.gov,
for issues related to the physician quality reporting system and EHR
incentive program.
Sandra Adams, (410) 786-8084 or cms.hhs.gov">Sandra.Adams@cms.hhs.gov, for
issues related to Medicare Shared Savings Program.
Michael Wrobleswki, (410) 786-4465 or
cms.hhs.gov">Michael.Wrobleswki@cms.hhs.gov, for issues related to value-based
modifier and improvements to physician feedback.
Andrew Morgan, (410) 786-2543 or cms.hhs.gov">Andrew.Morgan@cms.hhs.gov, for
issues related to e-prescribing under Medicare Part D.
Pauline Lapin, (410)786-6883 or cms.hhs.gov">Pauline.Lapin@cms.hhs.gov, for
issues related to the chiropractic services demonstration budget
neutrality issue.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
Table of Contents
I. Executive Summary and Background
A. Executive Summary
B. Background
II. Provisions of the Final Rule With Comment Period for PFS
A. Resource-Based Practice Expense (PE) Relative Value Units
(RVUs)
B. Misvalued Services
C. Malpractice RVUs
D. Medicare Economic Index (MEI)
E. Establishing RVUs for CY 2014
F. Geographic Practice Cost Indices (GPCIs)
G. Allowed Expenditures for Physicians' Services and the
Sustainable Growth Rate
H. Medicare Telehealth Services for the Physician Fee Schedule
I. Therapy Caps
J. Requirements for Billing ``Incident to'' Services
K. Chronic Care Management (CCM) Services
L. Collecting Data on Services Furnished in Off-Campus Provider-
Based Departments
M. Chiropractors Billing for Evaluation & Management Services
III. Other Provisions of the Proposed Regulations
A. Medicare Coverage of Items and Services in FDA-Approved
Investigational Device Exemption Clinical Studies--Revisions of
Medicare Coverage Requirements
B. Ultrasound Screening for Abdominal Aortic Aneurysms
C. Colorectal Cancer Screening: Modification to Coverage of
Screening Fecal Occult Blood Tests
D. Ambulance Fee Schedule
E. Policies Regarding the Clinical Laboratory Fee Schedule
F. Liability for Overpayments to or on Behalf of Individuals
Including Payments to Providers or Other Persons
G. Physician Compare Web site
H. Physician Payment, Efficiency, and Quality Improvements--
Physician Quality Reporting System
I. Electronic Health Record (EHR) Incentive Program
J. Medicare Shared Savings Program
K. Value-Based Payment Modifier and Physician Feedback Program
L. Updating Existing Standards for E-Prescribing Under Medicare
Part D
M. Discussion of Budget Neutrality for the Chiropractic Services
Demonstration
N. Physician Self-Referral Prohibition: Annual Update to the
List of CPT/HCPCS Codes
IV. Collection of Information Requirements
V. Response to Comments
VI. Waiver of Proposed Rulemaking and Waiver of Delay of Effective
Date
VII. Regulatory Impact Analysis
Regulations Text
Acronyms
In addition, because of the many organizations and terms to which
we refer by acronym in this final rule with comment period, we are
listing these acronyms and their corresponding terms in alphabetical
order below:
AAA Abdominal aortic aneurysms
ACA Affordable Care Act (Pub. L. 111-148)
ACO Accountable care organization
AHE Average hourly earnings
AMA American Medical Association
AMA RUC AMA [Specialty Society] Relative (Value) Update Committee
ASC Ambulatory surgical center
ATRA American Taxpayer Relief Act (Pub. L. 112-240)
AWV Annual wellness visit
BBA Balanced Budget Act of 1997 (Pub. L. 105-33)
BBRA [Medicare, Medicaid and State Child Health Insurance Program]
Balanced Budget Refinement Act of 1999 (Pub. L. 106-113)
BEA Bureau of Economic Analysis
CAH Critical access hospital
CBSA Core-Based Statistical Area
CCM Chronic Care Management
CED Coverage with evidence development
CEHRT Certified EHR technology
CF Conversion factor
CLFS Clinical Laboratory Fee Schedule
CMD Contractor medical director
CMHC Community mental health center
CMT Chiropractic manipulative treatment
CORF Comprehensive outpatient rehabilitation facility
CPC Comprehensive Primary Care
CPEP Clinical Practice Expert Panel
CPI-U Consumer Price Index for Urban Areas
CPS Current Population Survey
CPT [Physicians] Current Procedural Terminology (CPT codes,
descriptions and other data only are copyright 2013 American Medical
Association. All rights reserved.)
CQM Clinical quality measure
CT Computed tomography
CTA Computed tomographic angiography
CY Calendar year
DFAR Defense Federal Acquisition Regulations
DHS Designated health services
DRA Deficit Reduction Act of 2005 (Pub. L. 109-171)
DSMT Diabetes self-management training
ECEC Employer Costs for Employee Compensation
ECI Employment Cost Index
eCQM Electronic clinical quality measures
EHR Electronic health record
EMTALA Emergency Medical Treatment and Labor Act
eRx Electronic prescribing
ESRD End-stage renal disease
FAR Federal Acquisition Regulations
FFS Fee-for-service
FOBT Fecal occult blood test
FQHC Federally qualified health center
FR Federal Register
GAF Geographic adjustment factor
GAO Government Accountability Office
GPCI Geographic practice cost index
GPRO Group practice reporting option
HCPCS Healthcare Common Procedure Coding System
HHS [Department of] Health and Human Services
HOPD Hospital outpatient department
HPSA Health professional shortage area
IDE Investigational device exemption
IDTF Independent diagnostic testing facility
IOM Institute of Medicine
IPPE Initial Preventive Physical Examination
IPPS Inpatient Prospective Payment System
IQR Inpatient Quality Reporting
IWPUT Intensity of work per unit of time
KDE Kidney disease education
[[Page 74232]]
LCD Local coverage determination
LDT Laboratory-developed test
MA Medicare Advantage
MAC Medicare Administrative Contractor
MAPCP Multi-payer Advanced Primary Care Practice
MCTRJCA Middle Class Tax Relief and Job Creation Act of 2012 (Pub.
L. 112-96)
MDC Major diagnostic category
MedPAC Medicare Payment Advisory Commission
MEI Medicare Economic Index
MFP Multi-Factor Productivity
MGMA Medical Group Management Association
MIEA-TRHCA The Medicare Improvements and Extension Act, Division B
of the Tax Relief and Health Care Act (Pub. L. 109-432)
MIPPA Medicare Improvements for Patients and Providers Act (Pub. L.
110-275)
MMEA Medicare and Medicaid Extenders Act (Pub. L. 111-309)
MMSEA Medicare, Medicaid, and State Children's Health Insurance
Program Extension Act (Pub. L. 110-73)
MP Malpractice
MPPR Multiple procedure payment reduction
MRA Magnetic resonance angiography
MRI Magnetic resonance imaging
MSA Metropolitan Statistical Areas
MSPB Medicare Spending per Beneficiary
MSSP Medicare Shared Savings Program
MU Meaningful use
NCD National coverage determination
NCQDIS National Coalition of Quality Diagnostic Imaging Services
NP Nurse practitioner
NPI National Provider Identifier
NPP Nonphysician practitioner
OACT CMS's Office of the Actuary
OBRA '89 Omnibus Budget Reconciliation Act of 1989
OBRA '90 Omnibus Budget Reconciliation Act of 1990
OES Occupational Employment Statistics
OMB Office of Management and Budget
OPPS Outpatient prospective payment system
PC Professional component
PCIP Primary Care Incentive Payment
PDP Prescription Drug Plan
PE Practice expense
PE/HR Practice expense per hour
PEAC Practice Expense Advisory Committee
PECOS Provider Enrollment, Chain, and Ownership System
PFS Physician Fee Schedule
PLI Professional Liability Insurance
PMA Premarket approval
POS Place of Service
PQRS Physician Quality Reporting System
PPIS Physician Practice Expense Information Survey
QRUR Quality and Resources Use Report
RBRVS Resource-based relative value scale
RFA Regulatory Flexibility Act
RHC Rural health clinic
RIA Regulatory impact analysis
RoPR Registry of Patient Registries
RUCA Rural Urban Commuting Area
RVU Relative value unit
SBA Small Business Administration
SGR Sustainable growth rate
SMS Socioeconomic Monitoring System
SNF Skilled nursing facility
SOI Statistics of Income
TAP Technical Advisory Panel
TC Technical component
TIN Tax identification number
TPTCCA Temporary Payroll Tax Cut Continuation Act (Pub. L. 112-78)
UAF Update adjustment factor
USPSTF United States Preventive Services Task Force
VBP Value-based purchasing
VBM Value-Based Modifier
Addenda Available Only Through the Internet on the CMS Web site
The PFS Addenda along with other supporting documents and tables
referenced in this final rule with comment period are available through
the Internet on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. Click on the link on the left side of the
screen titled, ``PFS Federal Regulations Notices'' for a chronological
list of PFS Federal Register and other related documents. For the CY
2014 PFS final rule with comment period, refer to item CMS-1600-FC.
Readers who experience any problems accessing any of the Addenda or
other documents referenced in this final rule with comment period and
posted on the CMS Web site identified above should contact
cms.hhs.gov">Elliot.Isaac@cms.hhs.gov.
CPT (Current Procedural Terminology) Copyright Notice
Throughout this final rule with comment period, we use CPT codes
and descriptions to refer to a variety of services. We note that CPT
codes and descriptions are copyright 2013 American Medical Association.
All Rights Reserved. CPT is a registered trademark of the American
Medical Association (AMA). Applicable Federal Acquisition Regulations
(FAR) and Defense Federal Acquisition Regulations (DFAR) apply.
I. Executive Summary and Background
A. Executive Summary
1. Purpose
This major final rule with comment period revises payment polices
under the Medicare Physician Fee Schedule (PFS) and makes other policy
changes related to Medicare Part B payment. Unless otherwise noted,
these changes are applicable to services furnished in CY 2014.
2. Summary of the Major Provisions
The Social Security Act (Act) requires us to establish payments
under the PFS based on national uniform relative value units (RVUs)
that account for the relative resources used in furnishing a service.
The Act requires that RVUs be established for three categories of
resources: work, practice expense (PE); and malpractice (MP) expense;
and that we establish by regulation each year payment amounts for all
physicians' services, incorporating geographic adjustments to reflect
the variations in the costs of furnishing services in different
geographic areas. In this major final rule with comment period, we
establish RVUs for CY 2014 for the PFS, and other Medicare Part B
payment policies, to ensure that our payment systems are updated to
reflect changes in medical practice and the relative value of services
as well as changes in the statute. In addition, this final rule with
comment period includes discussions and/or policy changes regarding:
Misvalued PFS Codes.
Telehealth Services.
Applying Therapy Caps to Outpatient Therapy Services
Furnished by CAHs.
Requiring Compliance with State law as a Condition of
Payment for Services Furnished Incident to Physicians' (and Other
Practitioners') Services.
Revising the MEI based on MEI TAP Recommendations.
Updating the Ambulance Fee Schedule regulations.
Adjusting the Clinical Laboratory Fee Schedule based on
technological changes
Updating the--
++ Physician Compare Web site.
++ Physician Quality Reporting System.
++ Electronic Prescribing (eRx) Incentive Program.
++ Medicare Shared Savings Program.
++ Electronic Health Record (EHR) Incentive Program.
Budget Neutrality for the Chiropractic Services
Demonstration.
Physician Value-Based Payment Modifier and the Physician
Feedback Reporting Program.
3. Summary of Costs and Benefits
We have determined that this final rule with comment period is
economically significant. For a detailed discussion of the economic
impacts, see section VII. of this final rule with comment period.
B. Background
Since January 1, 1992, Medicare has paid for physicians' services
under section 1848 of the Act, ``Payment for
[[Page 74233]]
Physicians' Services.'' The system relies on national relative values
that are established for work, PE, and MP, which are then adjusted for
geographic cost variations. These values are multiplied by a conversion
factor (CF) to convert the RVUs into payment rates. The concepts and
methodology underlying the PFS were enacted as part of the Omnibus
Budget Reconciliation Act of 1989 (OBRA '89) (Pub. L. 101-239, enacted
on December 19, 1989), and the Omnibus Budget Reconciliation Act of
1990 (OBRA '90 (Pub. L. 101-508, enacted on November 5, 1990). The
final rule published on November 25, 1991 (56 FR 59502) set forth the
first fee schedule used for payment for physicians' services.
We note that throughout this final rule with comment period, unless
otherwise noted, the term ``practitioner'' is used to describe both
physicians and nonphysician practitioners who are permitted to bill
Medicare under the PFS for services furnished to Medicare
beneficiaries.
1. Development of the Relative Values
a. Work RVUs
The physician work RVUs established for the implementation of the
fee schedule in January 1992 were developed with extensive input from
the physician community. A research team at the Harvard School of
Public Health developed the original physician work RVUs for most codes
under a cooperative agreement with the Department of Health and Human
Services (HHS). In constructing the code-specific vignettes used in
determining the original physician work RVUs, Harvard worked with
panels of experts, both inside and outside the federal government, and
obtained input from numerous physician specialty groups.
We establish work RVUs for new and revised codes based, in part, on
our review of recommendations received from the American Medical
Association/Specialty Society Relative Value Update Committee (AMA
RUC).
b. Practice Expense RVUs
Initially, only the work RVUs were resource-based, and the PE and
MP RVUs were based on average allowable charges. Section 121 of the
Social Security Act Amendments of 1994 (Pub. L. 103-432, enacted on
October 31, 1994), amended section 1848(c)(2)(C)(ii) of the Act and
required us to develop resource-based PE RVUs for each physicians'
service beginning in 1998. We were required to consider general
categories of expenses (such as office rent and wages of personnel, but
excluding malpractice expenses) comprising PEs. Originally, this method
was to be used beginning in 1998, but section 4505(a) of the Balanced
Budget Act of 1997 (BBA) (Pub. L. 105-33, enacted on August 5, 1997)
delayed implementation of the resource-based PE RVU system until
January 1, 1999. In addition, section 4505(b) of the BBA provided for a
4-year transition period from the charge-based PE RVUs to the resource-
based PE RVUs.
We established the resource-based PE RVUs for each physicians'
service in a final rule, published November 2, 1998 (63 FR 58814),
effective for services furnished in CY 1999. Based on the requirement
to transition to a resource-based system for PE over a 4-year period,
payment rates were not fully based upon resource-based PE RVUs until CY
2002. This resource-based system was based on two significant sources
of actual PE data: The Clinical Practice Expert Panel (CPEP) data and
the AMA's Socioeconomic Monitoring System (SMS) data. (These data
sources are described in greater detail in the CY 2012 final rule with
comment period (76 FR 73033).)
Separate PE RVUs are established for services furnished in facility
settings, such as a hospital outpatient department (HOPD) or an
ambulatory surgical center (ASC), and in non-facility settings, such as
a physician's office. The nonfacility RVUs reflect all of the direct
and indirect PEs involved in furnishing a service described by a
particular HCPCS code. The difference, if any, in these PE RVUs
generally results in a higher payment in the nonfacility setting
because in the facility settings some costs are borne by the facility.
Medicare's payment to the facility (such as the outpatient prospective
payment system (OPPS) payment to the HOPD) would reflect costs
typically incurred by the facility. Thus, payment associated with those
facility resources is not made under the PFS.
Section 212 of the Balanced Budget Refinement Act of 1999 (BBRA)
(Pub. L. 106-113, enacted on November 29, 1999) directed the Secretary
of Health and Human Services (the Secretary) to establish a process
under which we accept and use, to the maximum extent practicable and
consistent with sound data practices, data collected or developed by
entities and organizations to supplement the data we normally collect
in determining the PE component. On May 3, 2000, we published the
interim final rule (65 FR 25664) that set forth the criteria for the
submission of these supplemental PE survey data. The criteria were
modified in response to comments received, and published in the Federal
Register (65 FR 65376) as part of a November 1, 2000 final rule. The
PFS final rules published in 2001 and 2003, respectively, (66 FR 55246
and 68 FR 63196) extended the period during which we would accept these
supplemental data through March 1, 2005.
In the CY 2007 PFS final rule with comment period (71 FR 69624), we
revised the methodology for calculating direct PE RVUs from the top-
down to the bottom-up methodology beginning in CY 2007. We adopted a 4-
year transition to the new PE RVUs. This transition was completed for
CY 2010. In the CY 2010 PFS final rule with comment period, we updated
the practice expense per hour (PE/HR) data that are used in the
calculation of PE RVUs for most specialties (74 FR 61749). In CY 2010,
we began a 4-year transition to the new PE RVUs using the updated PE/HR
data, which was completed for CY 2013.
c. Malpractice RVUs
Section 4505(f) of the BBA amended section 1848(c) of the Act to
require that we implement resource-based MP RVUs for services furnished
on or after CY 2000. The resource-based MP RVUs were implemented in the
PFS final rule with comment period published November 2, 1999 (64 FR
59380). The MP RVUs are based on malpractice insurance premium data
collected from commercial and physician-owned insurers from all the
states, the District of Columbia, and Puerto Rico.
d. Refinements to the RVUs
Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no
less often than every 5 years. Prior to CY 2013, we conducted periodic
reviews of work RVUs and PE RVUs independently. We completed Five-Year
Reviews of Work RVUs that were effective for calendar years 1997, 2002,
2007, and 2012.
While refinements to the direct PE inputs initially relied heavily
on input from the AMA RUC Practice Expense Advisory Committee (PEAC),
the shifts to the bottom-up PE methodology in CY 2007 and to the use of
the updated PE/HR data in CY 2010 have resulted in significant
refinements to the PE RVUs in recent years.
In the CY 2012 PFS final rule with comment period (76 FR 73057), we
finalized a proposal to consolidate reviews of work and PE RVUs under
section 1848(c)(2)(B) of the Act and reviews of potentially misvalued
codes
[[Page 74234]]
under section 1848(c)(2)(K) of the Act into one annual process.
With regard to MP RVUs, we completed Five-Year Reviews of MP that
were effective in CY 2005 and CY 2010.
In addition to the Five-Year Reviews, beginning for CY 2009, CMS
and the AMA RUC have identified and reviewed a number of potentially
misvalued codes on an annual basis based on various identification
screens. This annual review of work and PE RVUs for potentially
misvalued codes was supplemented by the amendments to section 1848 of
the Act, as enacted by section 3134 of the Affordable Care Act, which
requires the agency to periodically identify, review and adjust values
for potentially misvalued codes with an emphasis on seven specific
categories (see section II.C.2. of this final rule with comment
period).
e. Application of Budget Neutrality to Adjustments of RVUs
As described in section VII.C.1. of this final rule with comment
period, in accordance with section 1848(c)(2)(B)(ii)(II) of the Act, if
revisions to the RVUs would cause expenditures for the year to change
by more than $20 million, we make adjustments to ensure that
expenditures do not increase or decrease by more than $20 million.
2. Calculation of Payments Based on RVUs
To calculate the payment for each physicians' service, the
components of the fee schedule (work, PE, and MP RVUs) are adjusted by
geographic practice cost indices (GPCIs) to reflect the variations in
the costs of furnishing the services. The GPCIs reflect the relative
costs of physician work, PE, and MP in an area compared to the national
average costs for each component. (See section II.F.2 of this final
rule with comment period for more information about GPCIs.)
RVUs are converted to dollar amounts through the application of a
CF, which is calculated based on a statutory formula by CMS's Office of
the Actuary (OACT). The CF for a given year is calculated using (a) the
productivity-adjusted increase in the Medicare Economic Index (MEI) and
(b) the Update Adjustment Factor (UAF), which is calculated by taking
into account the Medicare Sustainable Growth Rate (SGR), an annual
growth rate intended to control growth in aggregate Medicare
expenditures for physicians' services, and the allowed and actual
expenditures for physicians' services. For a more detailed discussion
of the calculation of the CF, the SGR, and the MEI, we refer readers to
section II.G. of this final rule with comment period.
The formula for calculating the Medicare fee schedule payment
amount for a given service and fee schedule area can be expressed as:
Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x
GPCI MP)] x CF.
3. Separate Fee Schedule Methodology for Anesthesia Services
Section 1848(b)(2)(B) of the Act specifies that the fee schedule
amounts for anesthesia services are to be based on a uniform relative
value guide, with appropriate adjustment of an anesthesia conversion
factor, in a manner to assure that fee schedule amounts for anesthesia
services are consistent with those for other services of comparable
value. Therefore, there is a separate fee schedule methodology for
anesthesia services. Specifically, we establish a separate conversion
factor for anesthesia services and we utilize the uniform relative
value guide, or base units, as well as time units, to calculate the fee
schedule amounts for anesthesia services. Since anesthesia services are
not valued using RVUs, a separate methodology for locality adjustments
is also necessary. This involves an adjustment to the national
anesthesia CF for each payment locality.
4. Most Recent Changes to the Fee Schedule
The CY 2013 PFS final rule with comment period (77 FR 68892)
implemented changes to the PFS and other Medicare Part B payment
policies. It also finalized many of the CY 2012 interim final RVUs and
established interim final RVUs for new and revised codes for CY 2013 to
ensure that our payment system is updated to reflect changes in medical
practice, coding changes, and the relative values of services. It also
implemented certain statutory provisions including provisions of the
Affordable Care Act (Pub. L. 111-148) and the Middle Class Tax Relief
and Jobs Creation Act (MCTRJCA) (Pub. L. 112-96), including claims-
based data reporting requirements for therapy services.
In the CY 2013 PFS final rule with comment period, we announced the
following for CY 2013: the total PFS update of -26.5 percent; the
initial estimate for the SGR of -19.7 percent; and the CY 2013 CF of
$25.0008. These figures were calculated based on the statutory
provisions in effect on November 1, 2012, when the CY 2013 PFS final
rule with comment period was issued.
On January 2, 2013, the American Taxpayer Relief Act (ATRA) of 2012
(Pub. L. 112-240) was signed into law. Section 601(a) of the ATRA
specified a zero percent update to the PFS CF for CY 2013. As a result,
the CY 2013 PFS conversion factor was revised to $34.0320. In addition,
the ATRA extended and added several provisions affecting Medicare
services furnished in CY 2013, including:
Section 602--extending the 1.0 floor on the work
geographic practice cost index through CY 2013;
Section 603--extending the exceptions process for
outpatient therapy caps through CY 2013, extending the application of
the cap and manual medical review threshold to services furnished in
the HOPD through CY 2013, and requiring the counting of a proxy amount
for therapy services furnished in a Critical Access Hospital (CAH)
toward the cap and threshold during CY 2013.
In addition to the changes effective for CY 2013, section 635 of
ATRA revised the equipment utilization rate assumption for advanced
imaging services furnished on or after January 1, 2014.
A correction document (78 FR 48996) was issued to correct several
technical and typographical errors that occurred in the CY 2013 PFS
final rule with comment period.
II. Provisions of the Final Rule With Comment Period for PFS
A. Resource-Based Practice Expense (PE) Relative Value Units (RVUs)
1. Overview
Practice expense (PE) is the portion of the resources used in
furnishing a service that reflects the general categories of physician
and practitioner expenses, such as office rent and personnel wages, but
excluding malpractice expenses, as specified in section 1848(c)(1)(B)
of the Act. Section 121 of the Social Security Amendments of 1994 (Pub.
L. 103-432), enacted on October 31, 1994, amended section
1848(c)(2)(C)(ii) of the Act to require us to develop a methodology for
a resource-based system for determining PE RVUs for each physician's
service. We develop PE RVUs by looking at the direct and indirect
practice resources involved in furnishing each service. Direct expense
categories include clinical labor, medical supplies, and medical
equipment. Indirect expenses include administrative labor, office
expense, and all other expenses. The sections that follow provide more
[[Page 74235]]
detailed information about the methodology for translating the
resources involved in furnishing each service into service-specific PE
RVUs. We refer readers to the CY 2010 PFS final rule with comment
period (74 FR 61743 through 61748) for a more detailed explanation of
the PE methodology.
In addition, we note that section 1848(c)(2)(B)(ii)(II) of the Act
provides that adjustments in RVUs for a year may not cause total PFS
payments to differ by more than $20 million from what they would have
otherwise been if the adjustments were not made. Therefore, if
revisions to the RVUs cause expenditures to change by more than $20
million, we make adjustments to ensure that expenditures do not
increase or decrease by more than $20 million.
2. Practice Expense Methodology
a. Direct Practice Expense
We determine the direct PE for a specific service by adding the
costs of the direct resources (that is, the clinical staff, equipment,
and supplies) typically involved with furnishing that service. The
costs of the resources are calculated using the refined direct PE
inputs assigned to each CPT code in our PE database, which are based on
our review of recommendations received from the AMA RUC and those
provided in response to public comment periods. For a detailed
explanation of the direct PE methodology, including examples, we refer
readers to the Five-Year Review of Work Relative Value Units Under the
PFS and Proposed Changes to the Practice Expense Methodology proposed
notice (71 FR 37242) and the CY 2007 PFS final rule with comment period
(71 FR 69629).
b. Indirect Practice Expense per Hour Data
We use survey data on indirect PEs incurred per hour worked in
developing the indirect portion of the PE RVUs. Prior to CY 2010, we
primarily used the practice expense per hour (PE/HR) by specialty that
was obtained from the AMA's Socioeconomic Monitoring Surveys (SMS). The
AMA administered a new survey in CY 2007 and CY 2008, the Physician
Practice Expense Information Survey (PPIS). The PPIS is a
multispecialty, nationally representative, PE survey of both physicians
and nonphysician practitioners (NPPs) paid under the PFS using a survey
instrument and methods highly consistent with those used for the SMS
and the supplemental surveys. The PPIS gathered information from 3,656
respondents across 51 physician specialty and health care professional
groups. We believe the PPIS is the most comprehensive source of PE
survey information available. We used the PPIS data to update the PE/HR
data for the CY 2010 PFS for almost all of the Medicare-recognized
specialties that participated in the survey.
When we began using the PPIS data in CY 2010, we did not change the
PE RVU methodology itself or the manner in which the PE/HR data are
used in that methodology. We only updated the PE/HR data based on the
new survey. Furthermore, as we explained in the CY 2010 PFS final rule
with comment period (74 FR 61751), because of the magnitude of payment
reductions for some specialties resulting from the use of the PPIS
data, we transitioned its use over a 4-year period (75 percent old/25
percent new for CY 2010, 50 percent old/50 percent new for CY 2011, 25
percent old/75 percent new for CY 2012, and 100 percent new for CY
2013) from the previous PE RVUs to the PE RVUs developed using the new
PPIS data. As provided in the CY 2010 PFS final rule with comment
period (74 FR 61751), the transition to the PPIS data was complete for
CY 2013. Therefore, the CY 2013 and CY 2014 PE RVUs are developed based
entirely on the PPIS data, except as noted in this section.
Section 1848(c)(2)(H)(i) of the Act requires us to use the medical
oncology supplemental survey data submitted in 2003 for oncology drug
administration services. Therefore, the PE/HR for medical oncology,
hematology, and hematology/oncology reflects the continued use of these
supplemental survey data.
Supplemental survey data on independent labs from the College of
American Pathologists were implemented for payments beginning in CY
2005. Supplemental survey data from the National Coalition of Quality
Diagnostic Imaging Services (NCQDIS), representing independent
diagnostic testing facilities (IDTFs), were blended with supplementary
survey data from the American College of Radiology (ACR) and
implemented for payments beginning in CY 2007. Neither IDTFs, nor
independent labs, participated in the PPIS. Therefore, we continue to
use the PE/HR that was developed from their supplemental survey data.
Consistent with our past practice, the previous indirect PE/HR
values from the supplemental surveys for these specialties were updated
to CY 2006 using the MEI to put them on a comparable basis with the
PPIS data.
We also do not use the PPIS data for reproductive endocrinology and
spine surgery since these specialties currently are not separately
recognized by Medicare, nor do we have a method to blend the PPIS data
with Medicare-recognized specialty data.
We do not use the PPIS data for sleep medicine since there is not a
full year of Medicare utilization data for that specialty given the
specialty code was only available beginning in October 1, 2012. We
anticipate using the PPIS data to create PE/HR for sleep medicine for
CY 2015 when we will have a full year of data to make the calculations.
Previously, we established PE/HR values for various specialties
without SMS or supplemental survey data by crosswalking them to other
similar specialties to estimate a proxy PE/HR. For specialties that
were part of the PPIS for which we previously used a crosswalked PE/HR,
we instead used the PPIS-based PE/HR. We continue previous crosswalks
for specialties that did not participate in the PPIS. However,
beginning in CY 2010 we changed the PE/HR crosswalk for portable x-ray
suppliers from radiology to IDTF, a more appropriate crosswalk because
these specialties are more similar to each other with respect to
physician time.
For registered dietician services, the resource-based PE RVUs have
been calculated in accordance with the final policy that crosswalks the
specialty to the ``All Physicians'' PE/HR data, as adopted in the CY
2010 PFS final rule with comment period (74 FR 61752) and discussed in
more detail in the CY 2011 PFS final rule with comment period (75 FR
73183).
c. Allocation of PE to Services
To establish PE RVUs for specific services, it is necessary to
establish the direct and indirect PE associated with each service.
(1) Direct Costs
The relative relationship between the direct cost portions of the
PE RVUs for any two services is determined by the relative relationship
between the sum of the direct cost resources (that is, the clinical
staff, equipment, and supplies) typically involved with furnishing each
of the services. The costs of these resources are calculated from the
refined direct PE inputs in our PE database. For example, if one
service has a direct cost sum of $400 from our PE database and another
service has a direct cost sum of $200, the direct portion of the PE
RVUs of the first service would be twice as much as the direct portion
of the PE RVUs for the second service.
[[Page 74236]]
(2) Indirect Costs
Section II.B.2.b. of this final rule with comment period describes
the current data sources for specialty-specific indirect costs used in
our PE calculations. We allocated the indirect costs to the code level
on the basis of the direct costs specifically associated with a code
and the greater of either the clinical labor costs or the physician
work RVUs. We also incorporated the survey data described earlier in
the PE/HR discussion. The general approach to developing the indirect
portion of the PE RVUs is described as follows:
For a given service, we use the direct portion of the PE
RVUs calculated as previously described and the average percentage that
direct costs represent of total costs (based on survey data) across the
specialties that furnish the service to determine an initial indirect
allocator. In other words, the initial indirect allocator is calculated
so that the direct costs equal the average percentage of direct costs
of those specialties furnishing the service. For example, if the direct
portion of the PE RVUs for a given service is 2.00 and direct costs, on
average, represented 25 percent of total costs for the specialties that
furnished the service, the initial indirect allocator would be
calculated so that it equals 75 percent of the total PE RVUs. Thus, in
this example the initial indirect allocator would equal 6.00, resulting
in a total PE RVUs of 8.00 (2.00 is 25 percent of 8.00 and 6.00 is 75
percent of 8.00).
Next, we add the greater of the work RVUs or clinical
labor portion of the direct portion of the PE RVUs to this initial
indirect allocator. In our example, if this service had work RVUs of
4.00 and the clinical labor portion of the direct PE RVUs was 1.50, we
would add 4.00 (since the 4.00 work RVUs are greater than the 1.50
clinical labor portion) to the initial indirect allocator of 6.00 to
get an indirect allocator of 10.00. In the absence of any further use
of the survey data, the relative relationship between the indirect cost
portions of the PE RVUs for any two services would be determined by the
relative relationship between these indirect cost allocators. For
example, if one service had an indirect cost allocator of 10.00 and
another service had an indirect cost allocator of 5.00, the indirect
portion of the PE RVUs of the first service would be twice as great as
the indirect portion of the PE RVUs for the second service.
Next, we incorporate the specialty-specific indirect PE/HR
data into the calculation. In our example, if based on the survey data,
the average indirect cost of the specialties furnishing the first
service with an allocator of 10.00 was half of the average indirect
cost of the specialties furnishing the second service with an indirect
allocator of 5.00, the indirect portion of the PE RVUs of the first
service would be equal to that of the second service.
d. Facility and Nonfacility Costs
For procedures that can be furnished in a physician's office, as
well as in a hospital or facility setting, we establish two PE RVUs:
Facility and nonfacility. The methodology for calculating PE RVUs is
the same for both the facility and nonfacility RVUs, but is applied
independently to yield two separate PE RVUs. Because in calculating the
PE RVUs for services furnished in a facility, we do not include
resources that would generally not be provided by physicians when
furnishing the service in a facility, the facility PE RVUs are
generally lower than the nonfacility PE RVUs. Medicare makes a separate
payment to the facility for its costs of furnishing a service.
e. Services With Technical Components (TCs) and Professional Components
(PCs)
Diagnostic services are generally comprised of two components: A
professional component (PC); and a technical component (TC). The PC and
TC may be furnished independently or by different providers, or they
may be furnished together as a ``global'' service. When services have
separately billable PC and TC components, the payment for the global
service equals the sum of the payment for the TC and PC. To achieve
this we use a weighted average of the ratio of indirect to direct costs
across all the specialties that furnish the global service, TCs, and
PCs; that is, we apply the same weighted average indirect percentage
factor to allocate indirect expenses to the global service, PCs, and
TCs for a service. (The direct PE RVUs for the TC and PC sum to the
global under the bottom-up methodology.)
f. PE RVU Methodology
For a more detailed description of the PE RVU methodology, we refer
readers to the CY 2010 PFS final rule with comment period (74 FR 61745
through 61746).
(1) Setup File
First, we create a setup file for the PE methodology. The setup
file contains the direct cost inputs, the utilization for each
procedure code at the specialty and facility/nonfacility place of
service level, and the specialty-specific PE/HR data calculated from
the surveys.
(2) Calculate the Direct Cost PE RVUs
Sum the costs of each direct input.
Step 1: Sum the direct costs of the inputs for each service. Apply
a scaling adjustment to the direct inputs.
Step 2: Calculate the aggregate pool of direct PE costs for the
current year. This is the product of the current aggregate PE (direct
and indirect) RVUs, the CF, and the average direct PE percentage from
the survey data used for calculating the PE/HR by specialty.
Step 3: Calculate the aggregate pool of direct PE costs for use in
ratesetting. This is the product of the aggregated direct costs for all
services from Step 1 and the utilization data for that service. For CY
2014, we adjusted the aggregate pool of direct PE costs in proportion
to the change in the PE share in the revised MEI, as discussed in
section II.D. of this final rule with comment period.
Step 4: Using the results of Step 2 and Step 3, calculate a direct
PE scaling adjustment to ensure that the aggregate pool of direct PE
costs calculated in Step 3 does not vary from the aggregate pool of
direct PE costs for the current year. Apply the scaling factor to the
direct costs for each service (as calculated in Step 1).
Step 5: Convert the results of Step 4 to an RVU scale for each
service. To do this, divide the results of Step 4 by the CF. Note that
the actual value of the CF used in this calculation does not influence
the final direct cost PE RVUs, as long as the same CF is used in Step 2
and Step 5. Different CFs will result in different direct PE scaling
factors, but this has no effect on the final direct cost PE RVUs since
changes in the CFs and changes in the associated direct scaling factors
offset one another.
(3) Create the Indirect Cost PE RVUs
Create indirect allocators.
Step 6: Based on the survey data, calculate direct and indirect PE
percentages for each physician specialty.
Step 7: Calculate direct and indirect PE percentages at the service
level by taking a weighted average of the results of Step 6 for the
specialties that furnish the service. Note that for services with TCs
and PCs, the direct and indirect percentages for a given service do not
vary by the PC, TC, and global service.
Step 8: Calculate the service level allocators for the indirect PEs
based on the percentages calculated in Step 7. The indirect PEs are
allocated based on the three components: the direct PE RVUs; the
clinical PE RVUs; and the work RVUs.
For most services the indirect allocator is: Indirect PE percentage
*
[[Page 74237]]
(direct PE RVUs/direct percentage) + work RVUs.
There are two situations where this formula is modified:
If the service is a global service (that is, a service
with global, professional, and technical components), then the indirect
PE allocator is: indirect percentage (direct PE RVUs/direct percentage)
+ clinical PE RVUs + work RVUs.
If the clinical labor PE RVUs exceed the work RVUs (and
the service is not a global service), then the indirect allocator is:
indirect PE percentage (direct PE RVUs/direct percentage) + clinical PE
RVUs.
(Note: For global services, the indirect PE allocator is based on
both the work RVUs and the clinical labor PE RVUs. We do this to
recognize that, for the PC service, indirect PEs will be allocated
using the work RVUs, and for the TC service, indirect PEs will be
allocated using the direct PE RVUs and the clinical labor PE RVUs. This
also allows the global component RVUs to equal the sum of the PC and TC
RVUs.)
For presentation purposes in the examples in Table 1, the formulas
were divided into two parts for each service.
The first part does not vary by service and is the
indirect percentage (direct PE RVUs/direct percentage).
The second part is either the work RVU, clinical labor PE
RVU, or both depending on whether the service is a global service and
whether the clinical PE RVUs exceed the work RVUs (as described earlier
in this step).
Apply a scaling adjustment to the indirect allocators.
Step 9: Calculate the current aggregate pool of indirect PE RVUs by
multiplying the current aggregate pool of PE RVUs by the average
indirect PE percentage from the survey data.
Step 10: Calculate an aggregate pool of indirect PE RVUs for all
PFS services by adding the product of the indirect PE allocators for a
service from Step 8 and the utilization data for that service. For CY
2014, we adjusted the indirect cost pool in proportion to the change in
the PE share in the revised MEI, as discussed in section II.D. of this
final rule with comment period.
Step 11: Using the results of Step 9 and Step 10, calculate an
indirect PE adjustment so that the aggregate indirect allocation does
not exceed the available aggregate indirect PE RVUs and apply it to
indirect allocators calculated in Step 8.
Calculate the indirect practice cost index.
Step 12: Using the results of Step 11, calculate aggregate pools of
specialty-specific adjusted indirect PE allocators for all PFS services
for a specialty by adding the product of the adjusted indirect PE
allocator for each service and the utilization data for that service.
Step 13: Using the specialty-specific indirect PE/HR data,
calculate specialty-specific aggregate pools of indirect PE for all PFS
services for that specialty by adding the product of the indirect PE/HR
for the specialty, the physician time for the service, and the
specialty's utilization for the service across all services furnished
by the specialty.
Step 14: Using the results of Step 12 and Step 13, calculate the
specialty-specific indirect PE scaling factors.
Step 15: Using the results of Step 14, calculate an indirect
practice cost index at the specialty level by dividing each specialty-
specific indirect scaling factor by the average indirect scaling factor
for the entire PFS.
Step 16: Calculate the indirect practice cost index at the service
level to ensure the capture of all indirect costs. Calculate a weighted
average of the practice cost index values for the specialties that
furnish the service. (Note: For services with TCs and PCs, we calculate
the indirect practice cost index across the global service, PCs, and
TCs. Under this method, the indirect practice cost index for a given
service (for example, echocardiogram) does not vary by the PC, TC, and
global service.)
Step 17: Apply the service level indirect practice cost index
calculated in Step 16 to the service level adjusted indirect allocators
calculated in Step 11 to get the indirect PE RVUs.
(4) Calculate the Final PE RVUs
Step 18: Add the direct PE RVUs from Step 6 to the indirect PE RVUs
from Step 17 and apply the final PE budget neutrality (BN) adjustment
and the MEI revision adjustment.
The final PE BN adjustment is calculated by comparing the results
of Step 18 to the current pool of PE RVUs (prior to the adjustments
corresponding with the MEI revision described in section II.D. of this
final rule with comment period). This final BN adjustment is required
to redistribute RVUs from step 18 to all PE RVUs in the PFS, and
because certain specialties are excluded from the PE RVU calculation
for ratesetting purposes, but we note that all specialties are included
for purposes of calculating the final BN adjustment. (See ``Specialties
excluded from ratesetting calculation'' later in this section.)
(5) Setup File Information
Specialties excluded from ratesetting calculation: For the
purposes of calculating the PE RVUs, we exclude certain specialties,
such as certain nonphysician practitioners paid at a percentage of the
PFS and low-volume specialties, from the calculation. These specialties
are included for the purposes of calculating the BN adjustment. They
are displayed in Table 1.
Table 1--Specialties Excluded From Ratesetting Calculation
------------------------------------------------------------------------
Specialty code Specialty description
------------------------------------------------------------------------
49............................... Ambulatory surgical center.
50............................... Nurse practitioner.
51............................... Medical supply company with certified
orthotist.
52............................... Medical supply company with certified
prosthetist.
53............................... Medical supply company with certified
prosthetist[dash]orthotist.
54............................... Medical supply company not included
in 51, 52, or 53.
55............................... Individual certified orthotist.
56............................... Individual certified prosthestist.
57............................... Individual certified
prosthetist[dash]orthotist.
58............................... Individuals not included in 55, 56,
or 57.
59............................... Ambulance service supplier, e.g.,
private ambulance companies, funeral
homes, etc.
60............................... Public health or welfare agencies.
61............................... Voluntary health or charitable
agencies.
73............................... Mass immunization roster biller.
74............................... Radiation therapy centers.
87............................... All other suppliers (e.g., drug and
department stores).
88............................... Unknown supplier/provider specialty.
89............................... Certified clinical nurse specialist.
95............................... Competitive Acquisition Program (CAP)
Vendor.
96............................... Optician.
97............................... Physician assistant.
A0............................... Hospital.
A1............................... SNF.
A2............................... Intermediate care nursing facility.
A3............................... Nursing facility, other.
A4............................... HHA.
A5............................... Pharmacy.
A6............................... Medical supply company with
respiratory therapist.
A7............................... Department store.
1................................ Supplier of oxygen and/or oxygen
related equipment.
2................................ Pedorthic personnel.
3................................ Medical supply company with pedorthic
personnel.
------------------------------------------------------------------------
Crosswalk certain low volume physician specialties:
Crosswalk the utilization of certain specialties with relatively low
PFS utilization to the associated specialties.
Physical therapy utilization: Crosswalk the utilization
associated with all physical therapy services to the specialty of
physical therapy.
Identify professional and technical services not
identified under the usual
[[Page 74238]]
TC and 26 modifiers: Flag the services that are PC and TC services, but
do not use TC and 26 modifiers (for example, electrocardiograms). This
flag associates the PC and TC with the associated global code for use
in creating the indirect PE RVUs. For example, the professional
service, CPT code 93010 (Electrocardiogram, routine ECG with at least
12 leads; interpretation and report only), is associated with the
global service, CPT code 93000 (Electrocardiogram, routine ECG with at
least 12 leads; with interpretation and report).
Payment modifiers: Payment modifiers are accounted for in
the creation of the file consistent with current payment policy as
implemented in claims processing. For example, services billed with the
assistant at surgery modifier are paid 16 percent of the PFS amount for
that service; therefore, the utilization file is modified to only
account for 16 percent of any service that contains the assistant at
surgery modifier. Similarly, for those services to which volume
adjustments are made to account for the payment modifiers, time
adjustments are applied as well. For time adjustments to surgical
services, the intraoperative portion in the physician time file is
used; where it is not present, the intraoperative percentage from the
payment files used by contractors to process Medicare claims is used
instead. Where neither is available, we use the payment adjustment
ratio to adjust the time accordingly. Table 2 details the manner in
which the modifiers are applied.
Table 2--Application of Payment Modifiers to Utilization Files
----------------------------------------------------------------------------------------------------------------
Modifier Description Volume adjustment Time adjustment
----------------------------------------------------------------------------------------------------------------
80,81,82............................. Assistant at Surgery... 16%.................... Intraoperative portion.
AS................................... Assistant at Surgery-- 14% (85% * 16%)........ Intraoperative portion.
Physician Assistant.
50 or................................ Bilateral Surgery...... 150%................... 150% of physician time.
LT and RT............................
51................................... Multiple Procedure..... 50%.................... Intraoperative portion.
52................................... Reduced Services....... 50%.................... 50%.
53................................... Discontinued Procedure. 50%.................... 50%.
54................................... Intraoperative Care Preoperative + Preoperative +
only. Intraoperative Intraoperative
Percentages on the portion.
payment files used by
Medicare contractors
to process Medicare
claims.
55................................... Postoperative Care only Postoperative Postoperative portion.
Percentage on the
payment files used by
Medicare contractors
to process Medicare
claims.
62................................... Co-surgeons............ 62.5%.................. 50%.
66................................... Team Surgeons.......... 33%.................... 33%.
----------------------------------------------------------------------------------------------------------------
We also make adjustments to volume and time that correspond to
other payment rules, including special multiple procedure endoscopy
rules and multiple procedure payment reductions (MPPR). We note that
section 1848(c)(2)(B)(v) of the Act exempts certain reduced payments
for multiple imaging procedures and multiple therapy services from the
BN calculation under section 1848(c)(2)(B)(ii)(II) of the Act. These
MPPRs are not included in the development of the RVUs.
For anesthesia services, we do not apply adjustments to volume
since the average allowed charge is used when simulating RVUs, and
therefore, includes all adjustments. A time adjustment of 33 percent is
made only for medical direction of two to four cases since that is the
only situation where time units are duplicative.
Work RVUs: The setup file contains the work RVUs from this
final rule with comment period.
(6) Equipment Cost per Minute
The equipment cost per minute is calculated as:
(1/(minutes per year * usage)) * price * ((interest rate/(1-(1/((1 +
interest rate)[caret] life of equipment)))) + maintenance)
Where:
minutes per year = maximum minutes per year if usage were continuous
(that is, usage = 1); generally 150,000 minutes.
usage = variable, see discussion below.
price = price of the particular piece of equipment.
life of equipment = useful life of the particular piece of
equipment.
maintenance = factor for maintenance; 0.05.
interest rate = variable, see discussion below.
Usage: We currently use an equipment utilization rate assumption of
50 percent for most equipment, with the exception of expensive
diagnostic imaging equipment. For CY 2013, expensive diagnostic imaging
equipment, which is equipment priced at over $1 million (for example,
computed tomography (CT) and magnetic resonance imaging (MRI)
scanners), we use an equipment utilization rate assumption of 75
percent. Section 1848(b)(4)(C) of the Act, as modified by section 635
of the ATRA), requires that for fee schedules established for CY 2014
and subsequent years, in the methodology for determining PE RVUs for
expensive diagnostic imaging equipment, the Secretary shall use a 90
percent assumption. The provision also requires that the reduced
expenditures attributable to this change in the utilization rate for CY
2014 and subsequent years shall not be taken into account when applying
the BN limitation on annual adjustments described in section
1848(c)(2)(B)(ii)(II) of the Act. We are applying the 90 percent
utilization rate assumption in CY 2014 to all of the services to which
the 75 percent equipment utilization rate assumption applied in CY
2013. These services are listed in a file called ``CY 2014 CPT Codes
Subject to 90 Percent Usage Rate,'' available on the CMS Web site under
downloads for the CY 2014 PFS final rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. These codes are
also displayed in Table 3.
[[Page 74239]]
Table 3--CPT Codes Subject to 90 Percent Equipment Utilization Rate
Assumption
------------------------------------------------------------------------
CPT code Short descriptor
------------------------------------------------------------------------
70336............................ Mri, temporomandibular joint(s).
70450............................ Ct head/brain w/o dye.
70460............................ Ct head/brain w/dye.
70470............................ Ct head/brain w/o & w/dye.
70480............................ Ct orbit/ear/fossa w/o dye.
70481............................ Ct orbit/ear/fossa w/dye.
70482............................ Ct orbit/ear/fossa w/o & w/dye.
70486............................ Ct maxillofacial w/o dye.
70487............................ Ct maxillofacial w/dye.
70488............................ Ct maxillofacial w/o & w/dye.
70490............................ Ct soft tissue neck w/o dye.
70491............................ Ct soft tissue neck w/dye.
70492............................ Ct soft tissue neck w/o & w/dye.
70496............................ Ct angiography, head.
70498............................ Ct angiography, neck.
70540............................ Mri orbit/face/neck w/o dye.
70542............................ Mri orbit/face/neck w/dye.
70543............................ Mri orbit/face/neck w/o & w/dye.
70544............................ Mr angiography head w/o dye.
70545............................ Mr angiography head w/dye.
70546............................ Mr angiography head w/o & w/dye.
70547............................ Mr angiography neck w/o dye.
70548............................ Mr angiography neck w/dye.
70549............................ Mr angiography neck w/o & w/dye.
70551............................ Mri brain w/o dye.
70552............................ Mri brain w/dye.
70553............................ Mri brain w/o & w/dye.
70554............................ Fmri brain by tech.
71250............................ Ct thorax w/o dye.
71260............................ Ct thorax w/dye.
71270............................ Ct thorax w/o & w/dye.
71275............................ Ct angiography, chest.
71550............................ Mri chest w/o dye.
71551............................ Mri chest w/dye.
71552............................ Mri chest w/o & w/dye.
71555............................ Mri angio chest w/ or w/o dye.
72125............................ CT neck spine w/o dye.
72126............................ Ct neck spine w/dye.
72127............................ Ct neck spine w/o & w/dye.
72128............................ Ct chest spine w/o dye.
72129............................ Ct chest spine w/dye.
72130............................ Ct chest spine w/o & w/dye.
72131............................ Ct lumbar spine w/o dye.
72132............................ Ct lumbar spine w/dye.
72133............................ Ct lumbar spine w/o & w/dye.
72141............................ Mri neck spine w/o dye.
72142............................ Mri neck spine w/dye.
72146............................ Mri chest spine w/o dye.
72147............................ Mri chest spine w/dye.
72148............................ Mri lumbar spine w/o dye.
72149............................ Mri lumbar spine w/dye.
72156............................ Mri neck spine w/o & w/dye.
72157............................ Mri chest spine w/o & w/dye.
72158............................ Mri lumbar spine w/o & w/dye.
72159............................ Mr angio spine w/o & w/dye.
72191............................ Ct angiography, pelv w/o & w/dye.
72192............................ Ct pelvis w/o dye.
72193............................ Ct pelvis w/dye.
72194............................ Ct pelvis w/o & w/dye.
72195............................ Mri pelvis w/o dye.
72196............................ Mri pelvis w/dye.
72197............................ Mri pelvis w/o & w/dye.
72198............................ Mri angio pelvis w/or w/o dye.
73200............................ Ct upper extremity w/o dye.
73201............................ Ct upper extremity w/dye.
73202............................ Ct upper extremity w/o & w/dye.
73206............................ Ct angio upper extr w/o & w/dye.
73218............................ Mri upper extr w/o dye.
73219............................ Mri upper extr w/dye.
73220............................ Mri upper extremity w/o & w/dye.
73221............................ Mri joint upper extr w/o dye.
73222............................ Mri joint upper extr w/dye.
73223............................ Mri joint upper extr w/o & w/dye.
73225............................ Mr angio upr extr w/o & w/dye.
73700............................ Ct lower extremity w/o dye.
73701............................ Ct lower extremity w/dye.
73702............................ Ct lower extremity w/o & w/dye.
73706............................ Ct angio lower ext w/o & w/dye.
73718............................ Mri lower extremity w/o dye.
73719............................ Mri lower extremity w/dye.
73720............................ Mri lower ext w/& w/o dye.
73721............................ Mri joint of lwr extre w/o dye.
73722............................ Mri joint of lwr extr w/dye.
73723............................ Mri joint of lwr extr w/o & w/dye.
73725............................ Mr angio lower ext w or w/o dye.
74150............................ Ct abdomen w/o dye.
74160............................ Ct abdomen w/dye.
74170............................ Ct abdomen w/o & w/dye.
74174............................ Ct angiography, abdomen and pelvis w/
o & w/dye.
74175............................ Ct angiography, abdom w/o & w/dye.
74176............................ Ct abdomen and pelvis w/o dye.
74177............................ Ct abdomen and pelvis w/dye.
74178............................ Ct abdomen and pelvis w/ and w/o dye.
74181............................ Mri abdomen w/o dye.
74182............................ Mri abdomen w/dye.
74183............................ Mri abdomen w/o and w/dye.
74185............................ Mri angio, abdom w/or w/o dye.
74261............................ Ct colonography, w/o dye.
74262............................ Ct colonography, w/dye.
75557............................ Cardiac mri for morph.
75559............................ Cardiac mri w/stress img.
75561............................ Cardiac mri for morph w/dye.
75563............................ Cardiac mri w/stress img & dye.
75565............................ Card mri vel flw map add-on.
75571............................ Ct hrt w/o dye w/ca test.
75572............................ Ct hrt w/3d image.
75573............................ Ct hrt w/3d image, congen.
75574............................ Ct angio hrt w/3d image.
75635............................ Ct angio abdominal arteries.
76380............................ CAT scan follow up study.
77058............................ Mri, one breast.
77059............................ Mri, broth breasts.
77078............................ Ct bone density, axial.
77084............................ Magnetic image, bone marrow.
------------------------------------------------------------------------
Comment: Several commenters objected to the statutorily-mandated
change in equipment utilization rate assumptions, but none provided
evidence that CMS has authority to use a different equipment
utilization assumption for these services.
Response: As mandated by statute, we are finalizing our proposed
change in the equipment utilization rate for these services.
Interest Rate: In the CY 2013 final rule with comment period (77 FR
68902), we updated the interest rates used in developing an equipment
cost per minute calculation. The interest rate was based on the Small
Business Administration (SBA) maximum interest rates for different
categories of loan size (equipment cost) and maturity (useful life).
The interest rates are listed in Table 4. (See 77 FR 68902 for a
thorough discussion of this issue.)
Table 4--SBA Maximum Interest Rates
------------------------------------------------------------------------
Interest
Price Useful life rate
(percent)
------------------------------------------------------------------------
<$25K.............................. <7 Years.............. 7.50
$25K to $50K....................... <7 Years.............. 6.50
>$50K.............................. <7 Years.............. 5.50
<$25K.............................. 7+ Years.............. 8.00
$25K to $50K....................... 7+ Years.............. 7.00
>$50K.............................. 7+ Years.............. 6.00
------------------------------------------------------------------------
See 77 FR 68902 for a thorough discussion of this issue.
[[Page 74240]]
Table 5--Calculation of PE RVUs Under Methodology for Selected Codes
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
99213 33533
Office CABG, 71020 71020-TC 71020-26 93000 ECG, 93005 ECG, 93010 ECG,
Step Source Formula visit, est arterial, Chest x- Chest x- Chest x- complete, tracing report Non-
Non- single ray Non- ray, Non- ray, Non- Non- Non- facility
facility Facility facility facility facility facility facility
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(1) Labor cost (Lab)............. Step 1............. AMA................ ................... 13.32 77.52 5.74 5.74 0.00 5.10 5.10 0.00
(2) Supply cost (Sup)............ Step 1............. AMA................ ................... 2.98 7.34 3.39 3.39 0.00 1.19 1.19 0.00
(3) Equipment cost (Eqp)......... Step 1............. AMA................ ................... 0.17 0.58 7.24 7.24 0.00 0.09 0.09 0.00
(4) Direct cost (Dir)............ Step 1............. ................... =(1)+(2)+(3)....... 16.48 85.45 16.38 16.38 0.00 6.38 6.38 0.00
(5) Direct adjustment (Dir. Adj.) Steps 2-4.......... See footnote *..... ................... 0.5511 0.5511 0.5511 0.5511 0.5511 0.5511 0.5511 0.5511
(6) Adjusted Labor............... Steps 2-4.......... =Lab * Dir Adj..... =(1)*(5)........... 7.34 42.72 3.16 3.16 0.00 2.81 2.81 0.00
(7) Adjusted Supplies............ Steps 2-4.......... =Eqp * Dir Adj..... =(2)*(5)........... 1.64 4.05 1.87 1.87 0.00 0.66 0.66 0.00
(8) Adjusted Equipment........... Steps 2-4.......... =Sup * Dir Adj..... =(3)*(5)........... 0.10 0.32 3.99 3.99 0.00 0.05 0.05 0.00
(9) Adjusted Direct.............. Steps 2-4.......... ................... =(6)+(7)+(8)....... 9.08 47.09 9.03 9.03 0.00 3.52 3.52 0.00
(10) Conversion Factor (CF)...... Step 5............. PFS................ ................... 34.0230 34.0230 34.0230 34.0230 34.0230 34.0230 34.0230 34.0230
(11) Adj. labor cost converted... Step 5............. =(Lab * Dir Adj)/CF =(6)/(10).......... 0.22 1.26 0.09 0.09 0.00 0.08 0.08 0.00
(12) Adj. supply cost converted.. Step 5............. =(Sup * Dir Adj)/CF =(7)/(10).......... 0.05 0.12 0.05 0.05 0.00 0.02 0.02 0.00
(13) Adj. equipment cost Step 5............. =(Eqp * Dir Adj)/CF =(8)/(10).......... 0.00 0.01 0.12 0.12 0.00 0.00 0.00 0.00
converted.
(14) Adj. direct cost converted.. Step 5............. ................... =(11)+(12)+(13).... 0.27 1.38 0.27 0.27 0.00 0.10 0.10 0.00
(15) Work RVU.................... Setup File......... PFS................ ................... 0.97 33.75 0.22 0.00 0.22 0.17 0.00 0.17
(16) Dir--pct.................... Steps 6,7.......... Surveys............ ................... 0.31 0.18 0.31 0.31 0.31 0.31 0.31 0.31
(17) Ind--pct.................... Steps 6,7.......... Surveys............ ................... 0.69 0.82 0.69 0.69 0.69 0.69 0.69 0.69
(18) Ind. Alloc. Formula (1st Step 8............. See Step 8......... ................... ((14)/ ((14)/ ((14)/ ((14)/ ((14)/ ((14)/ ((14)/ ((14)/
part). (16))*(17) (16))*(17) (16))*(17) (16))*(17) (16))*(17) (16))*(17) (16))*(17) (16))*(17)
(19) Ind. Alloc.(1st part)....... Step 8............. ................... See 18............. 0.81 6.51 0.65 0.65 0 0.26 0.26 0
(20) Ind. Alloc. Formula (2nd Step 8............. See Step 8......... ................... (15) (15) (15+11) (11) (15) (15+11) (11) (15)
part).
(21) Ind. Alloc.(2nd part)....... Step 8............. ................... See 20............. 0.97 33.75 0.31 0.09 0.22 0.25 0.08 0.17
(22) Indirect Allocator (1st + Step 8............. ................... =(19)+(21)......... 1.78 40.26 0.96 0.74 0.22 0.51 0.34 0.17
2nd).
(23) Indirect Adjustment (Ind. Steps 9-11......... See Footnote **.... ................... 0.3848 0.3848 0.3848 0.3848 0.3848 0.3848 0.3848 0.3848
Adj.).
(24) Adjusted Indirect Allocator. Steps 9-11......... =Ind Alloc * Ind ................... 0.68 15.49 0.37 0.29 0.08 0.20 0.13 0.07
Adj.
(25) Ind. Practice Cost Index Steps 12-16........ ................... ................... 1.07 0.76 0.95 0.95 0.95 0.91 0.91 0.91
(IPCI).
(26) Adjusted Indirect........... Step 17............ = Adj.Ind Alloc * =(24)*(25)......... 0.73 11.74 0.35 0.27 0.08 0.18 0.12 0.06
PCI.
(27) PE RVU...................... Step 18............ =(Adj Dir + Adj =((14)+(26)) * 1.00 13.08 0.63 0.55 0.08 0.28 0.22 0.06
Ind) * Other Adj. Other Adj).
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: PE RVUs in Table 5, row 27, may not match Addendum B due to rounding.
* The direct adj = [current pe rvus * CF * avg dir pct]/[sum direct inputs] = [step2]/[step3]
** The indirect adj = [current pe rvus * avg ind pct]/[sum of ind allocators] = [step9]/[step10]
Note: The use of any particular conversion factor (CF) in Table 5 to illustrate the PE Calculation has no effect on the resulting RVUs.
Note: The Other Adjustment includes an adjustment for the equipment utilization change.
[[Page 74241]]
3. Adjusting RVUs To Match PE Share of the Medicare Economic Index
(MEI)
For CY 2014, as explained in detail in section II.D of this final
rule with comment period, we are finalizing revisions to the MEI based
on the recommendations of the MEI Technical Advisory Panel (TAP). The
MEI is an index that measures the price change of the inputs used to
furnish physician services. This measure was authorized by statute and
is developed by the CMS Office of the Actuary. We believe that the MEI
is the best measure available of the relative weights of the three
components in payments under the PFS--work, PE and malpractice.
Accordingly, we believe that to assure that the PFS payments reflect
the resources in each of these components as required by section
1848(c)(3) of the Act, the RVUs used in developing rates should reflect
the same weights in each component as the MEI. We proposed to
accomplish this by holding the work RVUs constant and adjusting the PE
RVUs, the MP RVUs and the CF to produce the appropriate balance in RVUs
among components and payments. In the proposed rule and above, we
detailed the steps necessary to accomplish this result (see steps 3,
10, and 18).
This proposed adjustment is consistent with our longstanding
practice to make adjustments to match the RVUs for the PFS components
with the MEI cost share weights for the components, including the
adjustments described in the CY 1999 PFS Final Rule (63 FR 58829), CY
2004 PFS Final Rule 68 FR 63246-63247, and CY 2011 PFS Final Rule (75
FR 73275). We note that the revisions to the MEI finalized in section
II.D of this final rule are made to the MEI as rebased for CY 2011, and
that the RVUs we proposed for CY 2014 reflect the weights of the MEI as
rebased for CY 2011 and revised for CY 2014. As such, the relationships
among the work, PE, and malpractice RVUs under the PFS are aligned with
those under the revised 2006-based MEI.
Comment: Several commenters requested explanation regarding the
relationship between the proposed MEI revision and the proposed RVUs.
One commenter suggested that it would be better to scale the work RVUs
upward instead of scaling the PE RVUs downward to achieve the weighting
adjustment.
Response: The change in the relationship among work, PE, and
malpractice RVUs could be accomplished by applying adjustments directly
to the work, PE, and malpractice RVUs or by holding the RVUs constant
for one component, scaling the other two components and applying a
budget neutrality adjustment to the conversion factor. We proposed to
make the adjustment by holding work RVUs constant consistent with prior
adjustments and in response to many public comments made during
previous rulemaking (see, for example, 75 FR 73275) indicating a strong
preference and persuasive arguments in favor of keeping the work RVUs
stable over time since work RVUs generally only change based on reviews
of particular services. In contrast, PE RVUs are developed annually,
irrespective of changes in the direct PE inputs for particular
services, so that scaling of PE RVUs is less disruptive to the public
review of values that determine PFS payment rates. We took this
approach for the CY 2014 adjustment because we believe the methodology
and reasons for making the adjustment in this way are settled and
remain valid. For these reasons, we are finalizing the proposed
rebasing of the relationship among RVU components by holding the work
RVUs constant, decreasing the PE RVUs and the MP RVUs, and applying a
budget neutrality adjustment to the CF.
Comment: Several commenters argued that the RVU components should
not be weighted consistent with the revised MEI as it was it was
entirely appropriate to include nurse practitioner and physician
assistant wages in the physician practice expense calculation because
physicians often employ nurse practitioners, physician assistants and
other non[hyphen]physicians.
Response: We refer commenters to section II.D. of the final rule
with comment period regarding the appropriate classification of wages
in the MEI. Regarding classification of labor inputs in the RVU
components, the decision as to whether something should be considered a
practice expense or work under the PFS does not depend on the
employment status of the health care professional furnishing the
service. Resource inputs are classified based on whether they relate to
the ``work'' or ``practice expense'' portion of a service. The clinical
labor portion of the direct PE input database includes the portion of
services provided by practitioners who do not bill Medicare directly,
such as registered nurses and other clinical labor. We do not include
in this category the costs of nurse practitioners and others who can
bill Medicare directly. Under the PFS, the work component of a service
is valued based on the work involved in furnishing the typical service.
The value is the same whether the service is billed by a physician or
another practitioner (such as a nurse practitioner or physician
assistant) who is permitted to bill Medicare directly for the service.
We acknowledge that these practitioners may perform a variety of
services in a physician office--some of which would be included in the
work portion and others that would be included in the PE portion as
clinical labor. Similarly, it is not unusual for physicians to hire
other physicians to work in their practices, but we likewise do not
consider those costs to be part of the clinical labor that is included
as a practice expense. Since values for services under the PFS are
based upon the typical case rather than the type of practitioner that
performs the service in a particular situation, we continue to believe
it is appropriate to include the work performed by professionals
eligible to bill Medicare directly in the work component of PFS
payments, even in cases when they are employed by physicians.
Additionally, we note that none of the commenters who questioned
the appropriate accounting for the work of these nonphysician
practitioners addressed how it would be appropriate to treat the costs
for these nonphysician practitioners differently for purposes of
calculating RVUs and the MEI. The labor of nonphysician practitioners
who can bill independently for their services under the PFS is
considered as work under the physician fee schedule since these
services are also furnished by physicians and the RVUs for these PFS
services do not vary based on whether furnished by a physician or
nonphysician. As such, we believe that the change in the MEI to shift
these costs from the PE to the work category as described in section
II.D. of this final rule with comment period is entirely consistent
with the PFS in this regard.
We would also note that the change in the MEI was recommended by
the MEI TAP that identified a discrepancy between how the work of non-
physician practitioners is captured in the RVUs, how billing works
under the PFS, and how costs are accounted for in the MEI. With the
change in the MEI being finalized in this final rule with comment
period, we continue to believe that the MEI weights are the best
reflection of the PFS component weights, and we believe it is
appropriate to finalize this adjustment in the RVUs as well.
Comment: Several commenters strongly urged the agency, in adjusting
weights among the PFS components to reflect the MEI cost weight
changes, to consider alternative methodologies that would mitigate the
redistribution of RVUs from the PE to the work category. These
commenters pointed out that the
[[Page 74242]]
practitioners who furnish services with a higher proportion of PE RVUs
are hit hardest by these changes. These comments also suggested that
CMS should consider postponing this adjustment of the RVUs until such a
methodology can be vetted.
Several commenters suggested that, given the magnitude of the
reductions, CMS should consider a phase-in of this change. These
commenters pointed out that CMS has used a phase-in approach in the
past to mitigate the effects of methodological changes to the
calculation of payment rates under the MPFS, including a four-year
phase-in of the transition from the top-down to the bottom-up
methodology of calculating direct PE RVUs.
Response: We appreciate that the increase in the work RVUs relative
to PE RVUs will generally result in lower payments for practitioners
who furnish more services with a higher proportion of PE RVUs. However,
we continue to believe that the MEI cost share weights are the best
reflection of the PFS component weights. The CY 2014 revisions to the
MEI, following the rebasing for 2011 and consideration by the MEI TAP,
reflect the best available information. As such, we believe that the
relationship among the RVU components should conform to the revised
cost weights adopted for the MEI.
While we understand and recognize the general preference to avoid
significant year-to-year reductions in Medicare payment, including
practitioners' interests in phasing in any reduction, and we
acknowledge that this revision of the PFS component weights results in
an increase in work RVUs relative to PE RVUs, we note that the 2011
rebasing of the MEI resulted in a change of greater magnitude that
increased the PE RVUs relative to work RVUs. That change was not phased
in. Based on consideration of these comments, we are finalizing as
proposed the adjustment to the relationship among the work, PE, and
malpractice component RVUs to reflect the MEI cost share being
finalized in this final rule with comment period, with the necessary
adjustment to the conversion factor and to PE and MP RVUs to maintain
budget neutrality.
4. Changes to Direct PE Inputs for Specific Services
In this section, we discuss other CY 2014 proposals and revisions
related to direct PE inputs for specific services. The final direct PE
inputs are included in the final rule with comment period CY 2014
direct PE input database, which is available on the CMS Web site under
under downloads for the CY 2014 PFS final rule with comment period at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
a. Anomalous Supply Inputs
In the CY 2013 PFS final rule with comment period, we established
interim final direct PE inputs based on acceptance, with refinement, of
recommendations submitted by the AMA RUC. Although we generally address
public comments on the current year's interim final direct PE inputs in
the following year's final rule with comment period, several commenters
raised an issue regarding anomalous supply items for codes that were
not subject to comment in the CY 2013 final rule with comment period.
Since changes were being suggested to codes not subject to comment, we
believed these comments were best addressed through proposed revisions
to the direct PE inputs in the proposed rule allowing the opportunity
for public comment before implementation.
For the CY 2013 interim final direct PE inputs for a series of
codes that describe six levels of surgical pathology services (CPT
codes 88300, 88302, 88304, 88305, 88307, 88309), we did not accept the
AMA RUC recommendation to create two new direct PE supply inputs
because we did not consider these items to be disposable supplies (77
FR 69074) and thus they did not meet the criteria for direct PE inputs.
These items were called ``specimen, solvent, and formalin disposal
cost,'' and ``courier transportation costs.'' In the CY 2013 PFS final
rule with comment period, we explained that neither the specimen and
supply disposal nor courier costs for transporting specimens are
appropriately considered disposable medical supplies. Instead, we
stated these costs are incorporated into the PE RVUs for these services
through the indirect PE allocation. We also noted that the current
direct PE inputs for these and similar services across the PFS do not
include these kinds of costs as disposable supplies.
Several commenters noted that, contrary to our assertion in the CY
2013 final rule with comment period, there are items incorporated in
the direct PE input database as ``supplies'' that are no more
disposable supplies than the new items recommended by the AMA RUC for
the surgical pathology codes. These commenters identified seven supply
inputs in particular that they believe are analogous to the items that
we did not accept in establishing CY 2013 interim final direct PE
inputs. These items and their associated HCPCS codes are listed in
Table 6.
Table 6--Items Identified by Commenters
------------------------------------------------------------------------
CMS supply code Item description Affected CPT codes
------------------------------------------------------------------------
SK106.................. device shipping cost... 93271, 93229, 93268.
SK112.................. Federal Express cost 64650, 88363, 64653.
(average across all
zones).
SK113.................. communication, wireless 93229.
per service.
SK107.................. fee, usage, cycletron/ 77423, 77422.
accelerator,
gammaknife, Lincac SRS
System.
SK110.................. fee, image analysis.... 96102, 96101, 99174.
SK111.................. fee, licensing, 96102, 96101, 96103,
computer, psychology. 96120.
SD140.................. bag system, 1000ml (for 93451, 93452, 93453,
angiographywaste 93454, 93455, 93456,
fluids). 93457, 93458, 93459,
93460, 93461.
------------------------------------------------------------------------
We reviewed each of these items for consistency with the general
principles of the PE methodology regarding the categorization of all
costs. Within the PE methodology, all costs other than clinical labor,
disposable supplies, and medical equipment are considered indirect
costs. For six of the items contained in Table 6, we agreed with the
commenters that the items should not be considered disposable supplies.
We believed that these items are more appropriately categorized as
indirect PE costs, which are reflected in the allocation of indirect PE
RVUs rather than through direct PE inputs. Therefore, we proposed to
remove the following six items from the direct PE
[[Page 74243]]
input database for CY 2014: ``device shipping cost'' (SK106); ``Federal
Express cost (average across all zones)'' (SK112); ``communication,
wireless per service'' (SK113); ``fee, usage, cycletron/accelerator,
gammaknife, Lincac SRS System'' (SK107); ``fee, image analysis''
(SK110); and ``fee, licensing, computer, psychology'' (SK111).
In the case of the supply item called ``bag system, 1000ml (for
angiography waste fluids)'' (SD140), we did not agree with the
commenters that this item is analogous to the specimen disposal costs
recommended for the surgical pathology codes. This supply input
represents only the costs of the disposable material items associated
with the removal of waste fluids that typically result from a
particular procedure. In contrast, the item recommended by the AMA RUC
for surgical pathology consisted of an amortized portion of a specimen
disposal contract that includes costs for resources such as labor and
transportation. Furthermore, we did not believe that the specimen
disposal contract is attributable to individual procedures within the
established PE methodology. We believe that a disposable supply is one
that is attributable, in its entirety, to an individual patient for a
particular service. An amortized portion of a specimen disposal
contract does not meet these criteria. Accordingly, as stated in the CY
2013 final rule with comment period, we did not accept the AMA RUC
recommendation to create a new supply item related to specimen disposal
costs. We believe that many physician offices and other nonfacility
settings where Medicare beneficiaries receive services incur costs
related to waste management or other service contracts, but none of
these costs are currently incorporated into the PE methodology as
disposable supplies. Instead, these costs are appropriately categorized
as indirect costs, which are reflected in the PE RVUs through the
allocation of indirect PE. We clarified that we believe that supply
costs related to specimen disposal attributable to individual services
may be appropriately categorized as disposable supplies, but that
specimen disposal costs related to an allocated portion of service
contracts cannot be attributed to individual services and should not be
incorporated into the direct PE input database as disposable supplies.
Moreover, because we do not agree with commenters that the ``bag
system, 1000ml (for angiography waste fluids)'' (SD140) is analogous to
a specimen disposal contract for the reasons state above, we continued
to believe that SD140 is a direct expense. Accordingly, we did not
propose to remove SD140 from the direct PE input database.
Comment: One commenter objected to CMS's proposal to remove the
``device shipping cost'' (SK106) and ``communication, wireless per
service'' (SK113) from the direct PE input database as they are more
analogous to the angiography waste fluid bag system than the other
items since both items represent costs associated with a specific
procedure rather than an amortization of costs associated with a
service contract.
Response: We agree with the commenter that both of these items may
represent costs associated with a specific procedure. However, as we
articulated in making the proposal to remove these items, we do not
believe these items are disposable supplies and we believe all costs
other than clinical labor, disposable supplies, and medical equipment
should be considered indirect costs in order to maintain consistency
and relativity within the PE methodology. We believe that there are a
variety of costs allocable to individual services that are
appropriately considered part of indirect cost categories for purposes
of the PE methodology. Were all these included as direct PE inputs for
services across the PFS, regardless of whether or not the items were
reasonably described as clinical labor, disposable supplies, or medical
equipment, then the relationship between direct and indirect costs
would be significantly skewed. This skewing could be compounded since
the amount of indirect PE allocated to particular codes is partly
determined by the amount of direct costs associated with the codes.
Therefore, the inaccurate inclusion of indirect costs as direct costs
would not only result in duplicative accounting for the items (as both
indirect and direct PE costs) but also an additional allocation of
indirect PE based on the item's inclusion as a direct cost. Therefore,
we are finalizing removal of these items from the direct PE input
database as proposed.
Comment: Several commenters suggested that CMS should change its
understanding of direct and indirect practice expense items. One
commenter suggested that all variable costs proportional to the number
of services furnished per day be considered direct. Another commenter
suggested that the only costs that can be considered indirect costs are
those that are required by all services, those that do not vary from
one service type to the next; and those that are not based on service
volume. Therefore CMS should allow all other recommended direct PE
inputs to be allowed as direct PE inputs.
Response: We note that there is a longstanding PE methodology,
established through notice and comment rulemaking that includes
principles for determining whether an expense is direct or indirect.
Under the established PE methodology, whether or not a particular cost
is variable has little bearing on the appropriate classification of a
particular item as a direct or indirect cost. Although we have
previously pointed out that the current methodology does not
accommodate costs that cannot be allocated to particular services as
direct costs, this does not mean that all costs that can be allocated
to particular services are necessarily direct costs. Instead, a
significant number of costs considered to be indirect for purposes of
the PE methodology are variable costs proportional to the kind and
number of services furnished each day. For example, administrative and
clerical resource costs associated with medical billing are likely to
be incurred with each service furnished. Presumably, practitioners
incur greater resource cost associated with administrative and clerical
labor and supplies based on the volume of services furnished.
Similarly, some kinds of services may require more administrative
resources than others. Some complex services, for example, may require
advance or follow-up administrative work that is not required for less
complex services. General office expenses may also vary depending on
the number and kind of services furnished. For example, practices that
furnish a greater number of services to a greater number of patients
generally require larger waiting rooms and additional waiting room
furniture. Other services such as those that are furnished without
having the patient present may not require patient waiting rooms at
all. We note that some services require a different amount of
electricity than others and some require more space than others. We
believe that the PE methodology accounts for these costs in the
allocation of indirect PE RVUs included in the payment rate for each
service furnished to Medicare beneficiaries. We do not believe it would
appropriate in the current methodology to include all such variable
costs as direct PE inputs. Therefore, we do not agree with commenters'
assertions regarding the appropriateness of these items as direct
costs. Instead, we continue to believe that these costs represent
indirect costs that are incorporated in the PE RVUs for these services
through the allocation of
[[Page 74244]]
indirect PE RVUs. We also direct readers to section II.E.2.b. of this
final rule for a discussion of comments received regarding the CY 2013
interim final direct PE inputs for surgical pathology services.
After consideration of these comments, we are finalizing our
proposal to remove the specified anomalous supply items from the direct
PE input database. The CY 2014 direct PE input database and the PE RVUs
displayed in Addendum B of this final rule with comment period reflect
the finalization of this proposal.
b. Direct PE Input Refinements Based on Routine Data Review
In reviewing the direct PE input database, we identified several
discrepancies that we proposed to address for CY 2014. In the following
paragraphs, we identify the nature of these discrepancies, the affected
codes, and the adjustments proposed in the CY 2014 proposed rule direct
PE input database. As part of our internal review of information in the
direct PE input database, we identified supply items that appeared
without quantities for CPT code 51710 (Change of cystostomy tube;
complicated). Upon reviewing these items we believed that the code
should include the items at the quantities listed in Table 7.
Table 7--Supply Items and Quantities for CPT Code 51710
------------------------------------------------------------------------
NF
Supply code Description of supply item quantity
------------------------------------------------------------------------
SA069...................... tray, suturing................... 1.0
SB007...................... drape, sterile barrier 16in x 1.0
29in.
SC029...................... needle, 18-27g................... 1.0
SC051...................... syringe 10-12ml.................. 1.0
SD024...................... catheter, Foley.................. 1.0
SD088...................... Guidewire........................ 1.0
SF036...................... suture, nylon, 3-0 to 6-0, c..... 1.0
SG055...................... gauze, sterile 4in x 4in......... 1.0
SG079...................... tape, surgical paper 1in 6.0
(Micropore).
SH075...................... water, sterile inj............... 3.0
SJ032...................... lubricating jelly (K-Y) (5gm uou) 1.0
SJ041...................... povidone soln (Betadine)......... 20.0
------------------------------------------------------------------------
Upon reviewing the direct PE inputs for CPT code 51710 and the
related code 51705 (Change of cystostomy tube; simple), we also noted
that the direct PE input database includes an anomalous 0.5 minutes of
clinical labor time in the post-service period. We believe that this
small portion of clinical labor time is the result of a rounding error
in our data and should be removed from the direct PE input database.
Comment: One commenter supported the inclusion of the supply items
for CPT code 51710. We received no comments regarding the change in
clinical labor time for codes 51710 and 51705.
Response: Based on these comments and for the reasons stated, we
are finalizing the removal of these items in the CY 2014 final direct
PE input database.
During our review of the data, we noted an invalid supply code
(SM037) that appears in the direct PE input database for CPT codes
88312 and 88313. Upon review of the code, we believe that the supply
item called ``wipes, lens cleaning (per wipe) (Kimwipe)'' (SM027)
should be included for these codes instead of the invalid supply code.
We did not receive any comments regarding this proposed revision.
Therefore, we are finalizing this revision as proposed for CY 2014.
Additionally, we conducted a routine review of the codes valued in
the nonfacility setting for which moderate sedation is inherent in the
procedure. Consistent with the standard moderate sedation package
finalized in the CY 2012 PFS final rule with comment period (76 FR
73043), we have made minor adjustments to the nurse time and equipment
time for 18 of these codes. These codes appear in Table 8.
Comment: One commenter agreed with this proposal to standardize
moderate sedation inputs for codes valued in the nonfacility setting.
We received no comments on the correction on the invalid supply item.
Response: After considering this comment, we are finalizing the
minor adjustments to the moderate sedation inputs as proposed. The CY
2014 direct PE database reflects these adjustments.
Table 8--Codes With Minor Adjustments to Moderate Sedation Inputs
------------------------------------------------------------------------
CPT Code Descriptor
------------------------------------------------------------------------
31629............................ Bronchoscopy/needle bx each.
31645............................ Bronchoscopy clear airways.
31646............................ Bronchoscopy reclear airway.
32405............................ Percut bx lung/mediastinum.
32550............................ Insert pleural cath.
35471............................ Repair arterial blockage.
37183............................ Remove hepatic shunt (tips).
37210............................ Embolization uterine fibroid.
43453............................ Dilate esophagus.
43458............................ Dilate esophagus.
44394............................ Colonoscopy w/snare.
45340............................ Sig w/balloon dilation.
47000............................ Needle biopsy of liver.
47525............................ Change bile duct catheter.
49411............................ Ins mark abd/pel for rt perq.
50385............................ Change stent via transureth.
50386............................ Remove stent via transureth.
57155............................ Insert uteri tandem/ovoids.
93312............................ Echo transesophageal.
93314............................ Echo transesophageal.
G0341............................ Percutaneous islet celltrans.
------------------------------------------------------------------------
c. Adjustments to Pre-Service Clinical Labor Minutes
As we noted in the CY 2014 PFS proposed rule, we had recently
received a recommendation from the AMA RUC regarding appropriate pre-
service clinical labor minutes in the facility setting for codes with
000-day global periods. In general, the AMA RUC recommended that codes
with 000-day global period include a maximum of 30 minutes of clinical
labor time in the pre-service period in the facility setting. The AMA
RUC identified 48 codes that currently include more clinical labor time
than this recommended maximum and provided us with recommended pre-
service clinical labor minutes in the facility setting of 30 minutes or
fewer for these 48 codes. We reviewed the AMA RUC's recommendation and
agree that the recommended reductions would be appropriate to maintain
relativity with other 000-day global codes. Therefore, we proposed to
amend the pre-service clinical labor minutes for the codes listed in
Table 9, consistent with the AMA RUC recommendation.
Comment: One commenter supported this proposal based on the AMA
RUC's recommendation.
Response: After considering the supporting comment, we are
finalizing these changes as proposed. The CY 2014 direct PE input
database reflects these changes.
[[Page 74245]]
Table 9--000-Day Global Codes With Changes to Pre-Service CL Time
------------------------------------------------------------------------
CL Pre- Service
Existing CL facility
CPT code Short descriptor Pre- Service minutes (AMA
facility RUC
minutes recommendation)
------------------------------------------------------------------------
20900.............. Removal of bone 60 30
for graft.
20902.............. Removal of bone 60 30
for graft.
33224.............. Insert pacing lead 35 30
& connect.
33226.............. Reposition l 35 30
ventric lead.
36800.............. Insertion of 60 0
cannula.
36861.............. Cannula declotting 37 0
37202.............. Transcatheter 45 0
therapy infuse.
50953.............. Endoscopy of 60 30
ureter.
50955.............. Ureter endoscopy & 60 30
biopsy.
51726.............. Complex 41 30
cystometrogram.
51785.............. Anal/urinary 34 30
muscle study.
52250.............. Cystoscopy and 37 30
radiotracer.
52276.............. Cystoscopy and 32 30
treatment.
52277.............. Cystoscopy and 37 30
treatment.
52282.............. Cystoscopy implant 31 30
stent.
52290.............. Cystoscopy and 31 30
treatment.
52300.............. Cystoscopy and 36 30
treatment.
52301.............. Cystoscopy and 36 30
treatment.
52334.............. Create passage to 31 30
kidney.
52341.............. Cysto w/ureter 42 30
stricture tx.
52342.............. Cysto w/up 42 30
stricture tx.
52343.............. Cysto w/renal 42 30
stricture tx.
52344.............. Cysto/uretero 55 30
stricture tx.
52345.............. Cysto/uretero w/up 55 30
stricture.
52346.............. Cystouretero w/ 55 30
renal strict.
52351.............. Cystouretero & or 45 30
pyeloscope.
52352.............. Cystouretero w/ 50 30
stone remove.
52353.............. Cystouretero w/ 50 30
lithotripsy.
52354.............. Cystouretero w/ 50 30
biopsy.
52355.............. Cystouretero w/ 50 30
excise tumor.
54100.............. Biopsy of penis... 33 30
61000.............. Remove cranial 60 15
cavity fluid.
61001.............. Remove cranial 60 15
cavity fluid.
61020.............. Remove brain 60 15
cavity fluid.
61026.............. Injection into 60 15
brain canal.
61050.............. Remove brain canal 60 15
fluid.
61055.............. Injection into 60 15
brain canal.
61070.............. Brain canal shunt 60 15
procedure.
62268.............. Drain spinal cord 36 30
cyst.
67346.............. Biopsy eye muscle. 42 30
68100.............. Biopsy of eyelid 32 30
lining.
93530.............. Rt heart cath 35 30
congenital.
93531.............. R & l heart cath 35 30
congenital.
93532.............. R & l heart cath 35 30
congenital.
93533.............. R & l heart cath 35 30
congenital.
93580.............. Transcath closure 35 30
of asd.
93581.............. Transcath closure 35 30
of vsd.
------------------------------------------------------------------------
d. Price Adjustment for Laser Diode
As we noted in the CY 2013 PFS proposed rule, it has come to our
attention that the price associated with the equipment item called
``laser, diode, for patient positioning (Probe)'' (ER040) in the direct
PE input database is $7,678 instead of $18,160 as listed in the CY 2013
PFS final rule with comment period (77 FR 68922). We proposed to revise
the direct PE input database to reflect the corrected price.
Comment: Several commenters expressed support for this proposal.
Response: We appreciate the commenters' support and have revised
the CY 2014 final direct PE input database as proposed.
e. Direct PE Inputs for Stereotactic Radiosurgery (SRS) Services (CPT
Codes 77372 and 77373)
Since 2001, Medicare has used HCPCS G-codes, in addition to the CPT
codes, for stereotactic radiosurgery (SRS) to distinguish robotic and
non-robotic methods of delivery. Based on our review of the current SRS
technology, it is our understanding that most services currently
furnished with linac-based SRS technology, including services currently
billed using the non-robotic codes, incorporate some type of robotic
feature. Therefore, we believe that it is no longer necessary to
continue to distinguish robotic versus non-robotic linac-based SRS
through the HCPCS G-codes. For purposes of the hospital outpatient
prospective payment system (OPPS), we proposed to replace the existing
four SRS HCPCS G-codes G0173 (Linear accelerator based stereotactic
radiosurgery, complete course of therapy in one session),
[[Page 74246]]
G0251(Linear accelerator based stereotactic radiosurgery, delivery
including collimator changes and custom plugging, fractionated
treatment, all lesions, per session, maximum five sessions per course
of treatment), G0339 (Image-guided robotic linear accelerator-based
stereotactic radiosurgery, complete course of therapy in one session or
first session of fractionated treatment), and G0340 (Image-guided
robotic linear accelerator-based stereotactic radiosurgery, delivery
including collimator changes and custom plugging, fractionated
treatment, all lesions, per session, second through fifth sessions,
maximum five sessions per course of treatment), with the SRS CPT codes
77372 (Radiation treatment delivery, stereotactic radiosurgery (SRS),
complete course of treatment of cranial lesion(s) consisting of 1
session; linear accelerator based) and 77373 (Stereotactic body
radiation therapy, treatment delivery, per fraction to 1 or more
lesions, including image guidance, entire course not to exceed 5
fractions) that do not distinguish between robotic and non-robotic
methods of delivery. We refer readers to section II.C.3 of the CY 2014
OPPS proposed rule for more discussion of that proposal. We also refer
readers to the CY 2007 OPPS final rule (71 FR 68023 through 68026) for
a detailed discussion of the history of the SRS codes.
Two of the four current SRS G-codes are paid in the nonfacility
setting through the PFS. These two codes, G0339 and G0340, describe
robotic SRS treatment delivery and are contractor-priced. CPT codes
77372 and 77373, which describe SRS treatment delivery without regard
to the method of delivery, are currently paid in the nonfacility
setting based on resource-based RVUs developed through the standard PE
methodology. We noted in the proposed rule that if the CY 2014 OPPS
proposal were finalized, it would appear that there would no longer be
a need for G-codes to describe robotic SRS treatment and delivery. We
did not propose to replace the contractor-priced G-codes for PFS
payment but did seek comment from the public and stakeholders,
including the AMA RUC, regarding whether or not the direct PE inputs
for CPT codes 77372 and 77373 would continue to accurately estimate the
resources used in furnishing typical SRS delivery were there no coding
distinction between robotic and non-robotic methods of delivery.
Comment: Several commenters, including the AMA RUC, responded to
our request for information regarding whether the direct PE inputs for
CPT codes 77372 and 77373 would continue to accurately estimate the
resources used in furnishing typical SRS delivery were there no coding
distinction between robotic and non-robotic methods of delivery. Most
commenters, including the AMA RUC, stated that the most recently
recommended direct PE inputs for these services would accurately
estimate the resources. One commenter suggested this was not the case
and that CMS should maintain the G-codes for purposes of PFS payment.
Response: We appreciate stakeholders' responsiveness to our request
for information. We will consider the information submitted in public
comments as we consider future rulemaking for these codes.
2. Using OPPS and ASC Rates in Developing PE RVUs
We typically establish two separate PE RVUs for services that can
be furnished in either a nonfacility setting, like a physician's
office, or a facility setting, like a hospital. The nonfacility PE RVUs
reflect all of the direct and indirect practice expenses involved in
furnishing a particular service when the entire service is furnished in
a nonfacility setting. The facility PE RVUs reflect the direct and
indirect practice expenses associated with furnishing a particular
service in a setting such as a hospital or ASC where those facilities
incur a portion or all of the costs and receive a separate Medicare
payment for the service.
When services are furnished in the facility setting, such as a HOPD
or an ASC, the total combined Medicare payment (made to the facility
and the professional) typically exceeds the Medicare payment made for
the same service when furnished in the physician office or other
nonfacility setting. We believe that this payment difference generally
reflects the greater costs that facilities incur than those incurred by
practitioners furnishing services in offices and other nonfacility
settings. For example, hospitals incur higher overhead costs because
they maintain the capability to furnish services 24 hours a day and 7
days per week, generally furnish services to higher acuity patients
than those who receive services in physicians' offices, and have
additional legal obligations such as complying with the Emergency
Medical Treatment and Labor Act (EMTALA). Additionally, hospitals must
meet conditions of participation and ASCs must meet conditions for
coverage in order to participate in Medicare.
However, we have found that for some services, the total Medicare
payment when the service is furnished in the physician office setting
exceeds the total Medicare payment when the service is furnished in an
HOPD or an ASC. When this occurs, we believe it is not the result of
appropriate payment differentials between the services furnished in
different settings. Rather, we believe it is due to anomalies in the
data we use under the PFS and in the application of our resource-based
PE methodology to the particular services.
The PFS PE RVUs rely heavily on the voluntary submission of
information by individuals furnishing the service and who are paid at
least in part based on the data provided. Currently, we have little
means to validate whether the information is accurate or reflects
typical resource costs. Furthermore, in the case of certain direct
costs, like the price of high-cost disposable supplies and expensive
capital equipment, even voluntary information has been very difficult
to obtain. In some cases the PE RVUs are based upon single price quotes
or one paid invoice. We have addressed these issues extensively in
previous rulemaking (for example, 75 FR 73252). Such incomplete, small
sample, potentially biased or inaccurate resource input costs may
distort the resources used to develop nonfacility PE RVUs used in
calculating PFS payment rates for individual services.
In addition to the accuracy issues with some of the physician PE
resource inputs, the data used in the PFS PE methodology can often be
outdated. As we have previously noted (77 FR 68921) there is no
practical means for CMS or stakeholders to engage in a complete
simultaneous review of the input resource costs for all HCPCS codes
paid under the PFS on an annual or even regular basis. Thus, the
information used to estimate PE resource costs for PFS services is not
routinely updated. Instead, we strive to maintain relativity by
reviewing at the same time the work RVUs, physician time, and direct PE
inputs for a code, and reviewing all codes within families of codes
where appropriate. Nonetheless, outdated resource input costs may
distort RVUs used to develop nonfacility PFS payment rates for
individual services. In the case of new medical devices for which a
high growth in the volume of a service as it diffuses into clinical
practice may lead to a decrease in the cost of expensive items,
outdated price inputs can result in significant overestimation of
resource costs.
Such inaccurate resource input costs may distort the nonfacility PE
RVUs used to calculate PFS payment rates for individual services. As we
have previously noted, OPPS payment rates are based on auditable
hospital data and are updated annually. Given the
[[Page 74247]]
differences in the validity of the data used to calculate payments
under the PFS and OPPS, we believe that the nonfacility PFS payment
rates for procedures that exceed those for the same procedure when
furnished in a facility result from inadequate or inaccurate direct PE
inputs, especially in price or time assumptions, as compared to the
more accurate OPPS data. On these bases, we proposed a change in the PE
methodology beginning in CY 2014. To improve the accuracy of PFS
nonfacility payment rates for each calendar year, we proposed to use
the current year OPPS or ASC rates as a point of comparison in
establishing PE RVUs for services under the PFS. In setting PFS rates,
we proposed to compare the PFS payment rate for a service furnished in
an office setting to the total combined Medicare payment to
practitioners and facilities for the same service when furnished in a
hospital outpatient setting. For services on the ASC list, we proposed
to make the same comparison except we would use the ASC rate as the
point of comparison instead of the OPPS rate.
We proposed to limit the nonfacility PE RVUs for individual codes
so that the total nonfacility PFS payment amount would not exceed the
total combined amount that Medicare would pay for the same code in the
facility setting. That is, if the nonfacility PE RVUs for a code would
result in a higher payment than the corresponding combined OPPS or ASC
payment rate and PFS facility PE RVUs (when applicable) for the same
code, we would reduce the nonfacility PE RVU rate so that the total
nonfacility payment does not exceed the total Medicare payment made for
the service in the facility setting. To maintain the greatest
consistency and transparency possible, we proposed to use the current
year PFS conversion factor. Similarly, we proposed to use current year
OPPS or ASC rates in the comparison. For services with no work RVUs, we
proposed to compare the total nonfacility PFS payment to the OPPS
payment rates directly since no PFS payment is made for these services
when furnished in the facility setting.
We proposed to exempt the following services from this policy:
Services Without Separate OPPS Payment Rates: We proposed
to exclude services without separately payable OPPS rates from this
methodical change since there would be no OPPS rate to which we could
compare the PFS nonfacility PE RVUs. We note that there would also be
no ASC rate for these services since ASCs are only approved to furnish
a subset of OPPS services.
Codes Subject to the DRA Imaging Cap: We proposed to
exclude from this policy services capped at the OPPS payment rate in
accordance with the Deficit Reduction Act of 2005 (DRA) (Pub. L. 109-
171). The DRA provision limits PFS payment for most imaging procedures
to the amount paid under the OPPS system. This policy applies to the
technical component of imaging services, including X-ray, ultrasound,
nuclear medicine, MRI, CT, and fluoroscopy services. Screening and
diagnostic mammograms are exempt. Since payment for these procedures is
capped by statute we proposed to exclude them from this policy.
Codes with Low Volume in the OPPS or ASC: We proposed to
exclude any service for which 5 percent or less of the total number of
services are furnished in the OPPS setting relative to the total number
of PFS/OPPS allowed services.
Codes with ASC Rates Based on PFS Payment Rates: To avoid
issues of circularity, we proposed to exclude ASC services that are
subject to the ``office-based'' procedure payment policies for which
payment rates are based on the PFS nonfacility PE RVUs. We directed
interested readers to the CY 2013 OPPS final rule (77 FR 68444) for
additional information regarding this payment policy.
Codes Paid in the Facility at Nonfacility PFS Rates: To
avoid issues of circularity, we also proposed to exclude services that
are paid in the facility setting at nonfacility payment rates.
This would include certain professional-only services where the
resource costs for practitioners are assumed to be similar in both
settings.
Codes with PE RVUs Developed Outside the PE Methodology:
We also proposed to exclude services with PE RVUs established through
notice and comment rulemaking outside the PE Methodology.
Addendum B of the proposed rule displayed the PE RVUs that would
result from implementation of the proposed change in the PE
methodology.
In discussing resource input issues, some stakeholders have
previously suggested that the direct costs (for example, clinical
labor, disposable supplies and medical equipment) involved in
furnishing a service are similar in both the nonfacility and facility
settings. Others have suggested that facilities, like hospitals, have
greater purchasing power for medical equipment and disposable supplies
so that the direct costs for a facility to furnish a service can be
lower than costs for a physician practice furnishing the same service.
Our proposed policy did not assume that the direct costs to furnish a
service in the nonfacility setting are always lower than in the
facility setting. Medicare payment methodologies, including both OPPS
and the PFS PE methodology, incorporate both direct and indirect costs
(administrative labor, office expenses, and all other expenses). Our
proposed policy was premised on the idea that there are significantly
greater indirect resource costs that are carried by facilities even in
the event that the direct costs involved in furnishing a service in the
office and facility settings are comparable.
We stated our belief that our proposal provides a reliable means
for Medicare to set upper payment limits for office-based procedures
based on relatively more reliable cost information available for the
same procedures when furnished in a facility setting where the cost
structure would be expected to be somewhat, if not significantly,
higher than the office setting. We believe that the current basis for
estimating the resource costs involved in furnishing a PFS service is
significantly encumbered by our current inability to obtain accurate
information regarding supply and equipment prices, as well as procedure
time assumptions. We believe that our proposed policy would mitigate
the negative impact of these difficulties on both the appropriate
relativity of PFS services and overall Medicare spending. A wide range
of stakeholders and public commenters have pointed to the nonfacility
setting as the most cost-effective location for services. Given the
significantly higher cost structure of facilities (as discussed above)
we believe that this presumption is accurate. In its March 2012 report
to Congress, MedPAC recommended that Medicare should seek to pay
similar amounts for similar services across payment settings, taking
into account differences in the definitions of services and patient
severity. (MedPAC March 2012 Report to Congress, page 46) We believe
that the proposed change to our PFS PE methodology would more
appropriately reflect resource costs in the nonfacility setting.
Comment: One commenter representing primary care physicians
supported the proposal and indicated a belief that the proposed policy
would help to correct misvaluation between primary care services and
the services affected by the policy. Another commenter supported the
policy as an interim step until an expedited review of the services
could be conducted. Other commenters, while not
[[Page 74248]]
supporting the proposal due to the financial impact on certain
services, stated that hospitals and ASCs do typically incur higher
overhead costs in delivering services than physician offices.
The overwhelmingly majority of commenters objected to the proposed
policy. Several commenters believed the services impacted by the policy
were potentially misvalued, but still opposed our policy. Many
commenters questioned whether facilities' costs for providing all
services are necessarily higher than the costs of physicians or other
practitioners. Commenters stated that the resources required to furnish
services in nonfacility physician settings cannot be accurately
measured using the OPPS methodology and that our proposal would result
in rank order anomalies. Commenters indicated that it was inappropriate
to base PFS payment on OPPS payment since a single APC contains
multiple services that can involve a wide a range of costs that are
averaged under the OPPS methodology. Many commenters also stated that
since OPPS payment rates rely on the accuracy of APC payments,
developed through hospitals accurately allocating their costs and
charges to particular departments/APCs. These commenters stated that
hospitals may have little incentive to accurately allocate their costs
and charges to particular departments/APCs since they typically provide
a broad range of services and therefore have the ability to make up for
losses on one service with profits on another. The argument is that
this ability makes the precise pricing of individual services less
important in the OPPS system than it is in the physician setting. Also,
the argument is that if physicians are going to be paid based upon the
OPPS system it should be for all services so that like the hospitals
they benefit from those overpaid in the hospital. Many commenters also
questioned CMS' authority to use payment rates from other Medicare
payment methodologies to cap PFS rates since they asserted the policy
violated the statutory requirement that the PFS PE relative values be
based on the resources used in furnishing the service. Some commenters
also cited the financial impact of our proposed policy on the PFS rates
as a further reason that the policy was inappropriate.
For all of these reasons, these commenters recommended that we not
adopt the proposed policy. Many of these commenters also suggested
modifications to the policy if CMS did decide to move forward.
Commenters suggested that since the ASC rates reflect the OPPS relative
weights to determine payment rates under the ASC payment system, and
are not based on cost information collected from ASCs, the ASC rates
should not be used in the proposed policy.
Commenters also stated a strong preference to use prospective year
OPPS rates instead of current year OPPS rates as the point of
comparison to prospective year PFS rates. The CY 2014 OPPS proposed
rule proposed significant packaging that raised payment for many APCs,
and therefore, raised the associated PFS cap rate.
Some commenters stated that they believed that CMS does not have
authority to use any conversion factor in the policy other than the one
calculated under existing law for CY 2014.
Commenters stated that the low-volume threshold (a minimum of 5
percent in the hospital outpatient setting) was proposed with
insufficient rationale and recommended either a 50 percent threshold or
an absolute volume threshold. Commenters also argued that there should
be an ASC low-volume threshold for using ASC rates.
Commenters urged CMS to establish a means for stakeholders to
demonstrate the validity of office costs relative to OPPS payments
prior to implementing a cap for any particular code. Commenters also
suggested that the AMA RUC should examine each code prior to the
implementation of the policy for that code.
Commenters suggested excluding codes recently revalued, such as
certain surgical pathology codes, from the cap as their resource inputs
and costs are more accurate than those less recently revalued.
Commenters suggested that CMS should make the cap more transparent
by identifying all affected codes and displaying the data used in
establishing the capped values.
Several commenters suggested using the individual OPPS HCPCS code
costs that are used to calculate the APC payment, rather than the APC
payment rate itself, as a way of avoiding the problems caused by the
averaging that goes on in calculating the APC rates. These commenters
argued that individual code costs are a more appropriate comparison
than APC payment rates.
Response: As we stated in the proposed rule, when services are
furnished in the facility setting, such as an HOPD or ASC, the total
Medicare payment (made to the facility and the professional combined)
typically exceeds the Medicare payment made for the same service when
furnished in the physician office or other nonfacility setting. We
continue to believe that this payment difference generally reflects the
greater costs that facilities incur compared to those incurred by
practitioners furnishing services in offices and other non-facility
settings. We also continue to believe that if the total Medicare
payment when a service is furnished in the physician office setting
exceeds the total Medicare payment when a service is furnished in an
HOPD or an ASC, this is generally not the result of appropriate payment
differentials between the services furnished in different settings.
Rather, we continue to believe that it is primarily due to anomalies in
the data we use under the PFS and in the application of our resource-
based PE methodology to the particular services.
We greatly appreciate all of the comments that we received on our
proposal. Given the many thoughtful and detailed technical comments
that we received, we are not finalizing our proposed policy in this
final rule with comment period. We will consider more fully all the
comments received, including those suggesting technical improvements to
our proposed methodology. After further consideration of the comments,
we expect to develop a revised proposal for using OPPS and ASC rates in
developing PE RVUs which we will propose through future notice and
comment rulemaking.
At this time, we do not believe that our standard process for
evaluating potentially misvalued codes, including the use of the AMA
RUC is an effective means of addressing these codes. As we stated in
the proposed rule, we do not believe that the direct practice expense
information we currently use to value these codes is accurate or
reflects typical resource costs. We have addressed these issues
extensively in previous rulemaking (for example, 75 FR 73252) and again
in section II.B.4. of this final rule with comment period. We believe
the current review process for direct PE inputs only accommodates
incomplete, small sample, and potentially biased or inaccurate resource
input costs that may distort the resources used to develop nonfacility
PE RVUs used in calculating PFS payment rates for individual services.
3. Ultrasound Equipment Recommendations
In the CY 2012 PFS proposed rule (76 FR 42796), we asked the AMA
RUC to review the ultrasound equipment described in the direct PE input
database. We specifically asked for review of the ultrasound equipment
items described in the direct PE input database and whether the
ultrasound
[[Page 74249]]
equipment listed for specific procedure codes is clinically necessary.
In response, the AMA RUC recommended creating several new equipment
inputs in addition to the revision of current equipment inputs for
ultrasound services. The AMA RUC also forwarded pricing information for
new and existing equipment items from certain medical specialty
societies that represent the practitioners who furnish these services.
In the following paragraphs, we summarize the AMA RUC recommendations,
address our review of the provided information, and describe a series
of changes we proposed to the direct PE inputs used in developing PE
RVUs for these services for CY 2014.
(1) Equipment Rooms
The AMA RUC made a series of recommendations regarding the
ultrasound equipment items included in direct PE input equipment
packages called ``rooms.'' Specifically, the AMA RUC recommended adding
several new equipment items to the equipment packages called ``room,
ultrasound, general'' (EL015) and ``room, ultrasound, vascular''
(EL016). The AMA RUC also recommended creating a similar direct PE
input equipment package called ``room, ultrasound, cardiovascular.'' In
considering these recommendations, we identified a series of new
concerns regarding the makeup of these equipment packages and because
there are several different ways to handle these concerns. In the CY
2014 PFS proposed rule we sought public comment from stakeholders prior
to proposing to implement any of these recommended changes through
future rulemaking.
We noted that the existing ``rooms'' for ultrasound technology
include a greater number of individual items than the ``rooms'' for
other kinds of procedures. For example, the equipment package for the
``room, basic radiology'' (EL012) contains only two items: an x-ray
machine and a camera. Ordinarily under the PFS, direct PE input
packages for ``rooms'' include only equipment items that are typically
used in furnishing every service in that room. When equipment items
beyond those included in a ``room'' are typically used in furnishing a
particular procedure, the additional equipment items for that procedure
are separately reflected in the direct PE input database in addition to
the ``room'' rather than being included in the room. When handled in
this way, the room includes only those inputs that are common to all
services furnished in that room type, and thus the direct PE inputs are
appropriate for the typical case of each particular service. When
additional equipment items are involved in furnishing a particular
service, they are included as an individual PE input only for that
particular service.
In contrast, the equipment items currently included in the ``room,
ultrasound, general'' are: the ultrasound system, five different
transducers, two probe starter kits, two printers, a table, and various
other items. In the proposed rule, we stated that we do not believe
that it is likely that all of these items would be typically used in
furnishing each service. For example, we do not believe that the
typical ultrasound study would require the use of five different
ultrasound transducers. However, the costs of all of these items are
incorporated into the resource inputs for every service for which the
ultrasound room is a direct PE input, regardless of whether each of
those items is typically used in furnishing the particular service.
This increases the resource cost for every service that uses the room
regardless of whether or not each of the individual items is typically
used in furnishing a particular procedure.
Instead of proposing to incorporate the AMA RUC's recommendation to
add more equipment items to these ultrasound equipment ``room''
packages, we stated our intention to continue to consider the
appropriateness of the full number of items in the ultrasound ``rooms''
in the context of maintaining appropriate relativity with other
services across the PFS. We sought comment from stakeholders, including
the AMA RUC, on the items included in the ultrasound rooms, especially
as compared to the items included in other equipment ``rooms.'' We
stated that we thought that it would be appropriate to consider these
comments in future rulemaking instead of proposing to alter the
existing ``rooms'' just for ultrasound equipment items for CY 2014.
Specifically we sought comment on whether equipment packages called
``rooms'' should include all of the items that might be included in an
actual room, just the items typically used for every service in such a
room, or all of the items typically used in typical services furnished
in the room. We stated that we believed that it would be most
appropriate to propose changes to the ``room, ultrasound, general''
(EL015) and ``room, ultrasound, vascular'' (EL016) in the context of
considering comments on this broader issue. We also stated that we
believed that consideration of the broader issue will help determine
whether it would be appropriate to create a ``room, ultrasound,
cardiovascular,'' and if so, what items would be included in this
equipment package.
Comment: Several commenters, including the AMA RUC, suggested that
equipment room packages should include all items that are typically in
the room and cannot be used for another patient, in order to furnish
all typical services performed in that room. In its comment letter, the
AMA RUC urged CMS to adopt its previous recommendations and pointed out
that CMS has previously stated that equipment time is comprised of any
time that clinical labor is using the piece of equipment, plus any
additional time the piece of equipment is not available for use with
another patient due to its use during the procedure in question.
Therefore, any time a piece of equipment is not available for use with
another patient, the equipment should be allocated minutes. The AMA RUC
also pointed out, as an example, that the equipment item called
``otoscope-ophthalmoscope (wall unit)'' (EQ189) is a standard equipment
input for all E/M codes even though it may not be typically used for
each E/M service. Therefore, items included in the room but not
necessarily typically used in furnishing particular services should be
included as equipment minutes for all codes that typically use the
room.
Response: We appreciate the responses of the AMA RUC and others
regarding our questions regarding equipment packages. We remain
concerned about the appropriate estimate of resources regarding
equipment items, especially those in room packages. We note that in our
previous statements regarding allocation of equipment minutes, we have
articulated that equipment minutes should be allocated to particular
items when those items are unavailable for use with another patient
``due to its use during the procedure in question.'' Based on the
recommended equipment room packages, we are concerned that this
definition may not apply consistently in the direct PE input database.
While we understand the example of the ``otoscope-ophthalmoscope (wall
unit)'' (EQ189) for E/M services, we believe that there may be other
medical equipment items in a typical evaluation room in addition to the
otoscope-ophthalmoscope (wall unit) and an exam table.
These comments reinforce our belief that, for the sake of
relativity and accuracy, changes to particular equipment room packages
should be made in the context of a broader examination of all equipment
packages, as well as assumed equipment utilization rates for these
packages.
[[Page 74250]]
In addition to the concerns regarding the contents of the
ultrasound ``room'' packages, we also expressed concerned about the
pricing information submitted through the AMA RUC to support its
recommendation to add equipment to the ultrasound room packages. The
highest-price item used in pricing the existing equipment input called
``room, ultrasound, general'' (EL015), is a ``GE Logic 9 ultrasound
system,'' currently priced at $220,000. As part of the AMA RUC
recommendation described in the proposal, a medical specialty society
recommended increasing the price of that item to $314,500. However,
that recommendation did not include documentation to support the
pricing level, such as a copy of a paid invoice for the equipment.
Furthermore, the recommended price conflicts with certain publicly
available information. For example, the Milwaukee Sentinel-Journal
reported in a February 9, 2013 article that the price for GE ultrasound
equipment ranges from ``$7,900 for a hand-held ultrasound to $200,000
for its most advanced model.'' The same article points to an item
called the ``Logiq E9'' as the ultrasound machine most used by
radiologists and priced from $150,000 to $200,000. http://www.jsonline.com/business/ge-sees-strong-future-with-its-ultrasound-business-uj8mn79-190533061.html.
In the proposed rule, we noted that we were unsure how to best
reconcile the information disclosed by the manufacturer to the press
and the prices submitted by the medical specialty society for use in
updating the direct PE input prices. We believe discrepancies, such as
these, exemplify the potential problem with updating prices for
particular items based solely on price quotes or information other than
copies of paid invoices. However, copies of paid invoices must also be
evaluated carefully. The information presented in the article regarding
the price for hand-held ultrasound devices raises questions about the
adequacy of paid invoices, too, in determining appropriate input costs.
The direct PE input described in the database as ``ultrasound unit,
portable'' (EQ250) is currently priced at $29,999 based on a submitted
invoice, while the article cites that GE sells a portable unit for as
low as $7,900. We sought comment on the appropriate price to use as the
typical for portable ultrasound units.
Comment: We received several comments regarding the appropriate
means to price the direct PE inputs. The AMA RUC and several specialty
expressed concern that it is difficult for medical specialty societies
to obtain paid invoices for equipment and supplies, especially for
large equipment items that are bought infrequently.
Several medical specialty societies suggested that their members
are often uncomfortable sending invoices for expensive items since the
prices are often proprietary and even though identifying information is
redacted, the invoices are sometimes distributed to all AMA RUC meeting
participants and available to the public once submitted to CMS. The
specialty society suggested that certain stakeholders in the
marketplace are often able to identify the individual practice
submitting the invoice through this process and that such public
revelation of the propriety pricing information may have major
implications for the provider in future price negotiations and service
lines in local markets for any practitioner volunteering such
information.
The AMA RUC expressed a shared concern with CMS about pricing
information submitted as supporting documentation for the ultrasound
room packages and stated that it will work with medical specialty
societies to provide paid invoices as soon as possible. The AMA RUC
also noted that it will work with the specialties to ensure that paid
invoices, rather than quotes, are submitted to CMS. Several commenters
objected to CMS' suggestion that a newspaper article might more
accurately reflect typical resource costs than an invoice.
Response: We appreciate the response of the AMA RUC to these
concerns. We also appreciate that in many cases the staff of medical
specialty societies may have difficulty obtaining paid invoices.
However, we believe the difficulty in obtaining invoices due to market
sensitivity does not negate or lessen the critical importance of using
accurate pricing information in establishing direct PE inputs. We
believe it is likely that the pricing information would be less market
sensitive if the information served to confirm the assumptions we
already display in the direct PE input database. We appreciate the
concerns shared by the AMA RUC's and we continue to seek the best means
to identify typical resource costs associated with disposable supplies
and medical equipment. While we believe that a copy of a paid invoice
is the minimal amount of necessary information for pricing a disposable
supply or medical equipment input, we reiterate our concerns that, even
when proffered, a sole paid invoice is not necessarily the optimal
source for identifying typical resource costs. We agree with commenters
that information a manufacturer provides the news media is not
necessarily accurate. However, when such information stands in stark
contrast to single invoices, we believe it is imperative to attempt to
reconcile that information to identify the best available information
regarding the typical cost. We will continue to consider the
perspectives offered by these commenters in developing future proposals
regarding the pricing of individual items and equipment packages.
(2) New Equipment Inputs and Price Updates
Ultrasound Unit, portable, breast procedures. The AMA RUC
recommended that a new direct PE input, ``ultrasound unit, portable,
breast procedures,'' be created for breast procedures that are
performed in a surgeon's office and where ultrasound imaging is
included in the code descriptor. These services are described by CPT
codes 19105 (Ablation, cryosurgical, of fibroadenoma, including
ultrasound guidance, each fibroadenoma), 19296 (Placement of
radiotherapy afterloading expandable catheter (single or multichannel)
into the breast for interstitial radioelement application following
partial mastectomy, includes imaging guidance; on date separate from
partial mastectomy), and 19298 (Placement of radiotherapy afterloading
brachytherapy catheters (multiple tube and button type) into the breast
for interstitial radioelement application following (at the time of or
subsequent to) partial mastectomy, includes imaging guidance). As we
noted in the proposed rule, we are creating this input. The pricing
information submitted for this item is a paid invoice and two price
quotes. As we have previously stated, we believe that copies of paid
invoices are more likely to reflect actual resource costs associated
with equipment and supply items than quotes or other information.
Therefore, we proposed a price of $33,930, which reflects the price
displayed on the submitted copy of the paid invoice. We are not using
the quotes as we do not believe that quotes provide reliable
information about the prices that are actually paid for medical
equipment. We did not receive any additional information regarding the
price for this equipment item. Therefore the CY 2014 direct PE input
database reflects the price as proposed.
Endoscopic Ultrasound Processor. The AMA RUC recommended creating a
new direct PE input called ``endoscopic ultrasound processor,'' for use
in furnishing the service described by CPT code 31620 (Endobronchial
ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic
intervention(s) (List
[[Page 74251]]
separately in addition to code for primary procedure[s])). We created
this equipment item to use as an input in the direct PE input database.
The price associated with the ``endoscopic ultrasound processor'' is
$59,925, which reflects the price documented on the copy of the paid
invoice submitted with the recommendation. We did not receive any
additional information regarding the price for this equipment item.
Therefore the CY 2014 direct PE input database reflects the price as
proposed.
Bronchofibervideoscope. The AMA RUC recommended creating a new
direct PE input called ``Bronchofibervideoscope,'' for use in
furnishing the service described by CPT code 31620 (Endobronchial
ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic
intervention(s) (List separately in addition to code for primary
procedure[s])). We created this new equipment item to use as an input
in the direct PE input database. However, this item had no price
associated with it in the proposed direct PE input database because we
did not receive any information that would allow us to price the item
accurately. Consequently, we sought copies of paid invoices for this
equipment item in the CY 2014 proposed rule so that we could price the
item accurately in the future.
Comment: One commenter reported that the current sales price for
the bronchofibervideoscope ranges from $30,000-$50,000. The commenter
provided an invoice for the equipment that reflected a price of
$35,200.
Response: Based on the submission of the invoice information, we
have updated the direct PE input database to reflect a price of $35,200
for the Bronchofibervideoscope (ER093).
Endoscope, ultrasound probe, drive (ES015). The AMA RUC forwarded
pricing information to us regarding the existing input called
``endoscope, ultrasound probe, drive'' (ES015), including a copy of a
paid invoice. Based on this information, we proposed to change the
price associated with ES015 to $13,256.25, which reflects the price
documented on the submitted copy of the paid invoice. We did not
receive any additional information regarding the price for this
equipment item. Therefore, we the CY 2014 direct PE input database
reflects the price as proposed.
(2) Ultrasound Equipment Input Recommendations for Particular Services
The AMA RUC made recommendations regarding the typical ultrasound
items used in furnishing particular services. In general, the AMA RUC
recommended that the existing equipment items accurately described the
typical equipment used in furnishing particular services. However, for
some CPT codes the AMA RUC recommended changing the associated
equipment inputs that appear in the direct PE input database. Based on
our review of these recommendations, we generally agreed with the AMA
RUC regarding these recommended changes, and the recommended changes
are reflected in the direct PE input database. Table 10 displays the
codes with changes to ultrasound equipment. However, for certain codes
we did not agree with the recommendations of the AMA RUC. The following
paragraphs address the changes we proposed that differ from the
recommendations of the AMA RUC.
For a series of cardiovascular services that include ultrasound
technology, the AMA RUC recommended removing certain equipment items
and replacing those items with a new item called ``room, ultrasound,
cardiovascular.'' As we described in the preceding paragraphs, we did
not propose to create the ``room, ultrasound, cardiovascular'' and
therefore did not propose to add this ``room'' as an input for these
services. However, we noted that the newly recommended equipment
package incorporates many of the same kinds of items as the currently
existing ``room, ultrasound, vascular'' (EL016). We agreed with the AMA
RUC's suggestion that the existing equipment inputs for the relevant
services listed in Table 10 do not reflect typical resource costs of
furnishing the services. We believed that, pending our further
consideration of the ultrasound ``room'' equipment packages, it would
be appropriate to use the existing ``room, ultrasound, vascular''
(EL016) as a proxy for resource costs for these services.
Comment: Several commenters urged CMS to accept the AMA RUC's
recommendations. Most of these commenters suggested that if CMS were
not to accept the AMA RUC's recommendation to create the new
``cardiovascular ultrasound room'' for CY 2014, then the inputs for the
existing ``room, ultrasound, vascular'' (EL016) should be used. A few
commenters representing some of the practitioners who furnish some of
these services objected to the change in equipment inputs based on
their assertion that the members of their specialty societies typically
use more resource intensive equipment than reflected in the AMA RUC
recommendations. One of these commenters suggested that the CPT codes
for fetal echocardiography (CPT codes 76825, 76826, 78627, and 78628)
previously included the same equipment items as the other
echocardiography codes with equipment updates. This commenter suggested
that the equipment for these codes should be updated to correspond with
the equipment for other, similar services.
Response: As we noted in the proposed rule, we believe that the
issue of equipment room packages should be addressed in future
rulemaking. Based on these comments, we are finalizing the use of the
existing ``room, ultrasound, vascular'' (EL016) as a proxy for resource
costs for these services pending future consideration of equipment room
packages. We note that the AMA RUC based its recommendation on
information obtained from the medical specialty societies that
represent the specialty of the practitioners who furnish the majority
of allowed services for each of these codes using recent Medicare
claims data. We examined the comments we received objecting to the
finalization of the AMA RUC-recommended equipment recommendations and,
in each case, confirmed that the commenters did not represent the
practitioners who typically furnish each service according to the
Medicare claims data. In the case of the fetal echocardiography codes,
we agree with the commenter's suggestion that the equipment for these
codes should correspond with the equipment for the similar services,
especially since the AMA RUC recommended replacing these items for all
other codes in the direct PE inputs database. Based on that review, we
remain confident that our proposal is appropriate and we are finalizing
the changes in the ultrasound equipment items as proposed, with the
exception of updating the equipment items for fetal echocardiography to
be consistent with other echocardiography services. These changes are
displayed in Table 10 and incorporated in the CY 2014 direct PE input
database.
In the case of CPT code 76942 (Ultrasonic guidance for needle
placement (for example, biopsy, aspiration, injection, localization
device), imaging supervision and interpretation), we agreed with the
AMA RUC's recommendation to replace the current equipment input of the
``room, ultrasound, general'' (EL015) with ``ultrasound unit,
portable'' (EQ250). We note that this service is typically reported
with other codes that describe the needle placement procedures and that
the recommended change in equipment from a room to a
[[Page 74252]]
portable device reflects a change in the typical kinds of procedures
reported with this image guidance service. Given this change, we
believe that it is appropriate to reconsider the procedure time
assumption currently used in establishing the direct PE inputs for this
code, which is 45 minutes. We reviewed the services reported with CPT
code 76942 to identify the most common procedures furnished with this
image guidance. The code most frequently reported with CPT code 76942
is CPT 20610 (Arthrocentesis, aspiration and/or injection; major joint
or bursa (for example, shoulder, hip, knee joint, subacromial bursa).
The assumed procedure time for this service is five minutes. The
procedure time assumptions for the vast majority of other procedures
frequently reported with CPT code 76942 range from 5 to 20 minutes.
Therefore, in addition to proposing the recommended change in equipment
inputs associated with the code, we proposed to change the procedure
time assumption used in establishing direct PE inputs for the service
from 45 to 10 minutes, based on our analysis of 30 needle placement
procedures most frequently reported with CPT code 76942. We noted that
this reduced the clinical labor and equipment minutes associated with
the code from 58 to 23 minutes.
Comment: Several commenters noted that the AMA RUC is planning to
conduct surveys and review the assumptions regarding the code and that
CMS will be in a better position to make more accurate determinations
if it waits for that data from the AMA RUC. One commenter stated that
CMS should not make a change in the direct PE input database based on
information in the Medicare claims data without input from the medical
specialty societies whose members furnish and report the ultrasound
guidance as described with CPT code 76942 and that a recommendation
from the AMA RUC may provide better data than the information contained
on Medicare claims.
Response: We appreciate the partnership of the AMA RUC in the
misvalued code initiative, but as a general principle, we do not
believe that we should refrain from making appropriate changes to code
values solely because the AMA RUC is planning to review a service in
the future. In some cases, we believe that we should examine claims
information and other sources of data and make proposals regarding the
appropriate inputs used to develop the amount Medicare pays for PFS
services. We believe that notice and comment rulemaking itself provides
a means for the public, including medical specialty societies and the
AMA RUC, to respond substantively to proposed changes in resource
inputs for particular services. Furthermore, in cases like this one, we
do not believe that the information reflected in the Medicare claims
data is subjective or open to differing interpretations.
Comment: Several commenters, including the AMA RUC, pointed out
that CPT code 76942 includes supervision and interpretation, which
represents both time and work that is separate from the surgical code
and that the additional time included in the direct PE inputs may
reflect time in addition to the base procedure.
Response: We appreciate the response of the AMA RUC and others in
pointing out concerns with our assumptions. We note that the proposed
clinical labor service period of 23 minutes includes the 10 minutes of
intra-service time in addition to 2 minutes for preparing the room,
equipment, and supplies, 3 minutes for preparing and positioning the
patient, 3 minutes for cleaning the room, and 5 minutes for processing
images, completing data sheet, and presenting images and data to the
interpreting physician. We did not receive information from any
commenters suggesting that the time allocated for these tasks was
inadequate. Therefore, we are finalizing our adjustment to the clinical
labor minutes associated with this code, as proposed.
Table 10--Codes With Changes to Ultrasound Equipment for CY 2014
----------------------------------------------------------------------------------------------------------------
CY 2014
CPT code Descriptor CY 2013 CMS CY 2013 equipment equipment CMS CY 2014 equipment
equipment code description code description
----------------------------------------------------------------------------------------------------------------
19105........... Cryosurg ablate fa EQ250 ultrasound unit, NEW ultrasound unit,
each. portable. portable, breast
procedures.
19296........... Place po breast EL015 room, ultrasound, NEW ultrasound unit,
cath for rad. general. portable, breast
procedures.
19298........... Place breast rad EL015 room, ultrasound, NEW ultrasound unit,
tube/caths. general. portable, breast
procedures.
--------------------------------------
31620........... Endobronchial us n/a NEW Bronchofibervideos
add-on. cope.
n/a NEW Endoscopic
ultrasound
processor.
--------------------------------------
52649........... Prostate laser EQ255 ultrasound, EQ250 ultrasound unit,
enucleation. noninvasive portable.
bladder scanner w-
cart.
76376........... 3d render w/o EL015 room, ultrasound, Remove input.
postprocess. general.
76775........... Us exam abdo back EL015 room, ultrasound, EQ250 ultrasound unit,
wall lim. general. portable.
76820........... Umbilical artery EQ249 ultrasound color EL015 room, ultrasound,
echo. doppler, general.
transducers and
vaginal probe.
76825........... Echo exam of fetal EQ254 ultrasound, EL016 room, ultrasound,
heart. echocardiography vascular.
w-4 transducers
(Sequoia C256).
EQ252 ultrasound,
echocardiography
analyzer software
(ProSolv).
76826........... Echo exam of fetal EQ254 ultrasound, EL016 room, ultrasound,
heart. echocardiography vascular.
w-4 transducers
(Sequoia C256).
EQ252 ultrasound,
echocardiography
analyzer software
(ProSolv).
76827........... Echo exam of fetal EQ254 ultrasound, EL016 room, ultrasound,
heart. echocardiography vascular.
w-4 transducers
(Sequoia C256).
[[Page 74253]]
76828........... Echo exam of fetal EQ254 ultrasound, EL016 room, ultrasound,
heart. echocardiography vascular.
w-4 transducers
(Sequoia C256).
76857........... Us exam pelvic EL015 room, ultrasound, EQ250 ultrasound unit,
limited. general. portable.
76870........... Us exam scrotum... EL015 room, ultrasound, EQ250 ultrasound unit,
general. portable.
76872........... Us transrectal.... EL015 room, ultrasound, EQ250 ultrasound unit,
general. portable.
76942........... Echo guide for EL015 room, ultrasound, EQ250 ultrasound unit,
biopsy. general. portable.
93303........... Echo guide for EQ253 ultrasound, EL016 room, ultrasound,
biopsy. echocardiography vascular.
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
EQ252 ultrasound,
echocardiography
analyzer software
(ProSolv).
93304........... Echo transthoracic EQ252 ultrasound, EL016 room, ultrasound,
echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93306........... Tte w/doppler EQ253 ultrasound, EL016 room, ultrasound,
complete. echocardiography vascular.
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
EQ252 ultrasound,
echocardiography
analyzer software
(ProSolv).
93307........... Tte w/o doppler EQ252 ultrasound, EL016 room, ultrasound,
complete. echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93308........... Tte f-up or lmtd.. EQ252 ultrasound, EL016 room, ultrasound,
echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93312........... Echo EQ253 ultrasound, EL016 room, ultrasound,
transesophageal. echocardiography vascular.
digital
acquisition (Novo
Microsonics,
TomTec).
EQ252 ultrasound,
echocardiography
analyzer software
(ProSolv).
EQ256 ultrasound,
transducer (TEE
Omniplane II).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93314........... Echo EQ254 ultrasound, EL016 room, ultrasound,
transesophageal. echocardiography vascular.
w-4 transducers
(Sequoia C256).
EQ256 ultrasound,
transducer (TEE
Omniplane II).
EQ252 ultrasound,
echocardiography
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
93320........... Doppler echo exam EQ252 ultrasound, EL016 room, ultrasound,
heart. echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93321........... Doppler echo exam EQ252 ultrasound, EL016 room, ultrasound,
heart. echocardiography vascular.
analyzer software
(ProSolv).
[[Page 74254]]
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93325........... Doppler color flow EQ252 ultrasound, EL016 room, ultrasound,
add-on. echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93350........... Stress tte only... EQ252 ultrasound, EL016 room, ultrasound,
echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93351........... Stress tte EQ254 ultrasound, EL016 room, ultrasound,
complete. echocardiography vascular.
w-4 transducers
(Sequoia C256).
93980........... Penile vascular EL015 room, ultrasound, EQ249 ultrasound color
study. general. doppler,
transducers and
vaginal probe.
93981........... Penile vascular EL015 room, ultrasound, EQ249 ultrasound color
study. general. doppler,
transducers and
vaginal probe.
----------------------------------------------------------------------------------------------------------------
B. Misvalued Services
1. Valuing Services Under the PFS
Section 1848(c) of the Act requires the Secretary to determine
relative values for physicians' services based on three components:
work, PE, and malpractice. Section 1848(c)(1)(A) of the Act defines the
work component to include ``the portion of the resources used in
furnishing the service that reflects physician time and intensity in
furnishing the service.'' In addition, section 1848(c)(2)(C)(i) of the
Act specifies that ``the Secretary shall determine a number of work
relative value units (RVUs) for the service based on the relative
resources incorporating physician time and intensity required in
furnishing the service.'' Section 1848(c)(1)(B) of the Act defines the
PE component as ``the portion of the resources used in furnishing the
service that reflects the general categories of expenses (such as
office rent and wages of personnel, but excluding malpractice expenses)
comprising practice expenses.'' (See section I.B.1.b. for more detail
on the development of the PE component.) Section 1848(c)(1)(C) of the
Act defines the malpractice component as ``the portion of the resources
used in furnishing the service that reflects malpractice expenses in
furnishing the service.'' Sections 1848 (c)(2)(C)(ii) and (iii) of the
Act specify that PE and malpractice RVUs shall be determined based on
the relative PE/malpractice resources involved in furnishing the
service.
Section 1848(c)(2)(B) of the Act directs the Secretary to conduct a
periodic review, not less often than every 5 years, of the RVUs
established under the PFS. Section 3134(a) of the Affordable Care Act
added a new section 1848(c)(2)(K) to the Act, which requires the
Secretary to periodically identify potentially misvalued services using
certain criteria and to review and make appropriate adjustments to the
relative values for those services. Section 3134(a) of the Affordable
Care Act also added a new section 1848(c)(2)(L) to the Act, which
requires the Secretary to develop a process to validate the RVUs of
certain potentially misvalued codes under the PFS, identified using the
same criteria used to identify potentially misvalued codes, and to make
appropriate adjustments.
As discussed in section II.B.1. of this final rule with comment
period, each year we develop and propose appropriate adjustments to the
RVUs, taking into account the recommendations provided by the American
Medical Association/Specialty Society Relative Value Scale Update
Committee (AMA RUC), the Medicare Payment Advisory Commission (MedPAC),
and others. For many years, the AMA RUC has provided us with
recommendations on the appropriate relative values for new, revised,
and potentially misvalued PFS services. We review these recommendations
on a code-by-code basis and consider these recommendations in
conjunction with analyses of other data, such as claims data, to inform
the decision-making process as authorized by the law. We may also
consider analyses of physician time, work RVUs, or direct PE inputs
using other data sources, such as Department of Veteran Affairs (VA),
National Surgical Quality Improvement Program (NSQIP), the Society for
Thoracic Surgeons (STS) National Database, and the Physician Quality
Reporting System (PQRS) databases. In addition to considering the most
recently available data, we also assess the results of physician
surveys and specialty recommendations submitted to us by the AMA RUC.
We conduct a clinical review to assess the appropriate RVUs in the
context of contemporary medical practice. We note that section
1848(c)(2)(A)(ii) of the Act authorizes the use of extrapolation and
other techniques to determine the RVUs for physicians' services for
which specific data are not available in addition to taking into
account the results of consultations with organizations representing
physicians. In accordance with section 1848(c) of the Act, we determine
appropriate adjustments to the RVUs, explain the basis of these
adjustments, and respond to public comments in the PFS proposed and
final rules.
[[Page 74255]]
2. Identifying, Reviewing, and Validating the RVUs of Potentially
Misvalued Services
a. Background
In its March 2006 Report to the Congress, MedPAC noted that
``misvalued services can distort the price signals for physicians'
services as well as for other health care services that physicians
order, such as hospital services.'' In that same report MedPAC
postulated that physicians' services under the PFS can become misvalued
over time. MedPAC stated, ``when a new service is added to the
physician fee schedule, it may be assigned a relatively high value
because of the time, technical skill, and psychological stress that are
often required to furnish that service. Over time, the work required
for certain services would be expected to decline as physicians become
more familiar with the service and more efficient in furnishing it.''
We believe services can also become overvalued when PEs decline. This
can happen when the costs of equipment and supplies fall, or when
equipment is used more frequently than is estimated in the PE
methodology, reducing its cost per use. Likewise, services can become
undervalued when physician work increases or PEs rise. In the ensuing
years since MedPAC's 2006 report, additional groups of potentially
misvalued services have been identified by the Congress, CMS, MedPAC,
the AMA RUC, and other stakeholders.
In recent years, CMS and the AMA RUC have taken increasingly
significant steps to identify and address potentially misvalued codes.
As MedPAC noted in its March 2009 Report to Congress, in the
intervening years since MedPAC made the initial recommendations, ``CMS
and the AMA RUC have taken several steps to improve the review
process.'' Most recently, section 1848(c)(2)(K)(ii) of the Act (as
added by section 3134(a) of the Affordable Care Act) directed the
Secretary to specifically examine, as determined appropriate,
potentially misvalued services in the following seven categories:
Codes and families of codes for which there has been the
fastest growth;
Codes and families of codes that have experienced
substantial changes in PEs;
Codes that are recently established for new technologies
or services;
Multiple codes that are frequently billed in conjunction
with furnishing a single service;
Codes with low relative values, particularly those that
are often billed multiple times for a single treatment;
Codes which have not been subject to review since the
implementation of the RBRVS (the so-called `Harvard-valued codes'); and
Other codes determined to be appropriate by the Secretary.
Section 1848(c)(2)(K)(iii) of the Act also specifies that the
Secretary may use existing processes to receive recommendations on the
review and appropriate adjustment of potentially misvalued services. In
addition, the Secretary may conduct surveys, other data collection
activities, studies, or other analyses, as the Secretary determines to
be appropriate, to facilitate the review and appropriate adjustment of
potentially misvalued services. This section also authorizes the use of
analytic contractors to identify and analyze potentially misvalued
codes, conduct surveys or collect data, and make recommendations on the
review and appropriate adjustment of potentially misvalued services.
Additionally, this section provides that the Secretary may coordinate
the review and adjustment of any RVU with the periodic review described
in section 1848(c)(2)(B) of the Act. Finally, section
1848(c)(2)(K)(iii)(V) of the Act specifies that the Secretary may make
appropriate coding revisions (including using existing processes for
consideration of coding changes) that may include consolidation of
individual services into bundled codes for payment under the physician
fee schedule.
b. Progress in Identifying and Reviewing Potentially Misvalued Codes
To fulfill our statutory mandate, we have identified and reviewed
numerous potentially misvalued codes in all seven of the categories
specified in section 1848(c)(2)(K)(ii) of the Act, and we plan to
continue our work examining potentially misvalued codes in these areas
over the upcoming years. In the current process, we identify
potentially misvalued codes for review, and request recommendations
from the AMA RUC and other public commenters on revised work RVUs and
direct PE inputs for those codes. The AMA RUC, through its own
processes, also identifies potentially misvalued codes for review.
Through our public nomination process for potentially misvalued codes
established in the CY 2012 PFS final rule with comment period, other
individuals and stakeholder groups submit nominations for review of
potentially misvalued codes as well.
Since CY 2009, as a part of the annual potentially misvalued code
review and Five-Year Review process, we have reviewed more than 1,000
potentially misvalued codes to refine work RVUs and direct PE inputs.
We have adopted appropriate work RVUs and direct PE inputs for these
services as a result of these reviews. A more detailed discussion of
the extensive prior reviews of potentially misvalued codes is included
in the CY 2012 PFS final rule with comment period (76 FR 73052 through
73055). In the CY 2012 PFS proposed rule, we proposed to identify and
review potentially misvalued codes in the category of ``Other codes
determined to be appropriate by the Secretary,'' referring to a list of
the highest PFS expenditure services, by specialty, that had not been
recently reviewed (76 FR 73059 through 73068).
In the CY 2012 final rule with comment period, we finalized our
policy to consolidate the review of physician work and PE at the same
time (76 FR 73055 through 73958), and established a process for the
annual public nomination of potentially misvalued services.
One of the priority categories for review of potentially misvalued
codes is services that have not been subject to review since the
implementation of the PFS (the so-called ``Harvard-valued codes''). In
the CY 2009 PFS proposed rule, we requested that the AMA RUC engage in
an ongoing effort to review the remaining Harvard-valued codes,
focusing first on the high-volume, low intensity codes (73 FR 38589).
For the Fourth Five-Year Review (76 FR 32410), we requested that the
AMA RUC review services that have not been reviewed since the original
implementation of the PFS with annual utilization greater than 30,000
(Harvard-valued--Utilization > 30,000). In the CY 2013 final rule with
comment period, we identified for review the potentially misvalued
codes for Harvard-valued services with annual allowed charges that
total at least $10,000,000 (Harvard-valued--Allowed charges
>=$10,000,000).
In addition to the Harvard-valued codes, in the same rule we
finalized for review a list of potentially misvalued codes that have
stand-alone PE (these are codes with clinical labor procedure time
assumptions not connected or dependent on physician time assumptions;
see 77 FR 68918 for detailed information).
c. Validating RVUs of Potentially Misvalued Codes
In addition to identifying and reviewing potentially misvalued
codes, section 3134(a) of the Affordable Care Act added section
1848(c)(2)(L) of the Act, which specifies that the Secretary shall
establish a formal process to validate RVUs under the PFS. The
validation process may include
[[Page 74256]]
validation of work elements (such as time, mental effort and
professional judgment, technical skill and physical effort, and stress
due to risk) involved with furnishing a service and may include
validation of the pre-, post-, and intra-service components of work.
The Secretary is directed, as part of the validation, to validate a
sampling of the work RVUs of codes identified through any of the seven
categories of potentially misvalued codes specified by section
1848(c)(2)(K)(ii) of the Act. Furthermore, the Secretary may conduct
the validation using methods similar to those used to review
potentially misvalued codes, including conducting surveys, other data
collection activities, studies, or other analyses as the Secretary
determines to be appropriate to facilitate the validation of RVUs of
services.
In the CY 2011 PFS proposed rule (75 FR 40068) and CY 2012 PFS
proposed rule (76 FR 42790), we solicited public comments on possible
approaches, methodologies, and data sources that we should consider for
a validation process. A summary of the comments along with our
responses are included in the CY 2011 PFS final rule with comment
period (75 FR 73217) and the CY 2012 PFS final rule with comment period
(73054 through 73055).
As we indicated in the CY 2014 PFS proposed rule (78 FR 43304), we
have entered into two contracts with outside entities to develop
validation models for RVUs. During a 2-year project, the RAND
Corporation will use available data to build a validation model to
predict work RVUs and the individual components of work RVUs, time and
intensity. The model design will be informed by the statistical
methodologies and approach used to develop the initial work RVUs and to
identify potentially misvalued procedures under current CMS and AMA RUC
processes. RAND will use a representative set of CMS-provided codes to
test the model. RAND will consult with a technical expert panel on
model design issues and the test results.
The second contract is with the Urban Institute. Given the central
role of time in establishing work RVUs and the concerns that have been
raised about the current time values, a key focus of the project is
collecting data from several practices for selected services. The data
will be used to develop time estimates. Urban Institute will use a
variety of approaches to develop objective time estimates, depending on
the type of service, which will be a very resource-intensive part of
the project. Objective time estimates will be compared to the current
time values used in the fee schedule. The project team will then
convene groups of physicians from a range of specialties to review the
new time data and their potential implications for work and the ratio
of work to time.
The research being performed under these two contracts continues.
For additional information, please visit our Web site (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/RVUs-Validation-Model.pdf).
3. CY 2014 Identification and Review of Potentially Misvalued Services
a. Public Nomination of Potentially Misvalued Codes
The public and stakeholders may nominate potentially misvalued
codes for review by submitting the code with supporting documentation
during the 60-day public comment period following the release of the
annual PFS final rule with comment period under a process we finalized
in the CY 2012 PFS final rule with comment period (76 FR 73058).
Supporting documentation for codes nominated for the annual review of
potentially misvalued codes may include the following:
Documentation in the peer-reviewed medical literature or
other reliable data that there have been changes in physician work due
to one or more of the following: technique; knowledge and technology;
patient population; site-of-service; length of hospital stay; and
physician time.
An anomalous relationship between the code being proposed
for review and other codes.
Evidence that technology has changed physician work, that
is, diffusion of technology.
Analysis of other data on time and effort measures, such
as operating room logs or national and other representative databases.
Evidence that incorrect assumptions were made in the
previous valuation of the service, such as a misleading vignette,
survey, or flawed crosswalk assumptions in a previous evaluation.
Prices for certain high cost supplies or other direct PE
inputs that are used to determine PE RVUs are inaccurate and do not
reflect current information.
Analyses of physician time, work RVU, or direct PE inputs
using other data sources (for example, Department of Veteran Affairs
(VA) National Surgical Quality Improvement Program (NSQIP), the Society
for Thoracic Surgeons (STS) National Database, and the Physician
Quality Reporting System (PQRS) databases).
National surveys of physician time and intensity from
professional and management societies and organizations, such as
hospital associations.
After we receive the nominated codes during the 60-day comment
period following the release of the annual PFS final rule with comment
period, we evaluate the supporting documentation and assess whether the
nominated codes appear to be potentially misvalued codes appropriate
for review under the annual process. In the following year's PFS
proposed rule, we publish the list of nominated codes and indicate
whether we are proposing each nominated code as a potentially misvalued
code. We encourage the public to submit nominations for potentially
misvalued codes during the comment period for this CY 2014 PFS final
rule with comment period.
We did not receive any public nominations of codes for
consideration as potentially misvalued codes in response to the CY 2013
final rule with comment period. As a result, we did not propose any
publicly nominated potentially misvalued codes in the CY 2014 proposed
rule.
b. Potentially Misvalued Codes
i. Contractor Medical Director Identified Potentially Misvalued Codes
We began considering additional ways to broaden participation in
the process of identifying potentially misvalued codes; we solicited
the input of Medicare Administrative Contractor medical directors
(CMDs) in making suggestions for codes to consider proposing as
potentially misvalued codes.
In the proposed rule, we noted several reasons why we believed that
CMD input would be valuable in developing our proposal. As a group,
CMDs represent a variety of medical specialties, which makes them a
diverse group of physicians capable of providing opinions across the
vast scope of services covered under the PFS. They are on the front
line of administering the Medicare program, with their offices often
serving as the first point of contact for practitioners with questions
regarding coverage, coding and claims processing. CMDs spend a
significant amount of time communicating directly with practitioners
and the health care industry discussing more than just the broad
aspects of the Medicare program but also engaging in and facilitating
specific discussions around individual services. Through their
development of evidence-based local coverage determinations (LCDs),
CMDs also have
[[Page 74257]]
experience developing policy based on research.
Comment: Many commenters supported our seeking input from the CMDs
in developing our proposal for codes to be considered as potentially
misvalued codes, while others expressed concern about using input from
CMDs. Some asked for details on the process that the CMDs used to
identify codes and some questioned whether CMDs possess the specialty-
related expertise to determine if a service is misvalued when that
service is not generally performed by a CMD's designated specialty. In
addition, several commenters believe that the identification of
misvalued codes (in addition to review and revision of those codes)
should be carried out through the AMA RUC process with input from the
medical community. These commenters oppose any effort by CMS to
unilaterally change code values.
Response: The commenters are correct in noting that CMDs do not
represent all specialties. We would note that in their role as CMDs,
they do work on issues involving all specialties. Moreover, their role
in this process was simply to assist us in identifying codes that we
could consider proposing as potentially misvalued codes. After our
evaluation, we proposed them as potentially misvalued codes in the CY
2014 proposed rule and sought public comment. Thus the affected
specialties and other stakeholders had the opportunity to provide us
with public comments as to whether or not these codes should be
evaluated as potentially misvalued. If, following our consideration of
public comments, we determine that these codes are potentially
misvalued, the AMA RUC and others will have further opportunity to
submit information and public comment about the appropriate value of
the codes before we would determine the codes are in fact misvalued and
make changes to the values.
Given the importance of ensuring that codes are appropriately
valued, we believe it is appropriate to call upon the experience of
CMDs in developing our proposal. Accordingly, we will proceed as we
proposed in the CY 2014 proposed rule to consider the codes identified
by CMDs as potentially misvalued codes.
In consultation with our CMDs, the following lists of codes in
Tables 11 and 12 were identified as potentially misvalued in the CY
2014 proposed rule.
Table 11--Codes Proposed as Potentially Misvalued Identified in
Consultation With CMDs
------------------------------------------------------------------------
CPT code Short descriptor
------------------------------------------------------------------------
17311............................ Mohs 1 stage h/n/hf/g.
17313............................ Mohs 1 stage t/a/l.
21800............................ Treatment of rib fracture.
22305............................ Closed tx spine process fx.
27193............................ Treat pelvic ring fracture.
33960............................ External circulation assist.
33961............................ External circulation assist, each
subsequent day.
47560............................ Laparoscopy w/cholangio.
47562............................ Laparoscopic cholecystectomy.
47563............................ Laparo cholecystectomy/graph.
55845............................ Extensive prostate surgery.
55866............................ Laparo radical prostatectomy.
64566............................ Neuroeltrd stim post tibial.
76942............................ Echo guide for biopsy.
------------------------------------------------------------------------
CPT codes 17311 (Mohs micrographic technique, including removal of
all gross tumor, surgical excision of tissue specimens, mapping, color
coding of specimens, microscopic examination of specimens by the
surgeon, and histpathologic preparation including routine stain(s) (for
example, hematoxylin and eosin, toluidine blue), head, neck, hands,
feet genitalia, or any location with surgery directly involving muscle,
cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5
tissue blocks) and 17313 (Mohs micrographic technique, including
removal of all gross tumor, surgical excision of tissue specimens,
mapping, color coding of specimens, microscopic examination of
specimens by the surgeon, and histopathologic preparation including
routine stains(s) (for example, hematoxylin and eosin, toluidine blue),
of the trunk, arms, or legs; first stage, up to 5 tissue blocks) were
proposed as potentially misvalued codes because we believe that these
codes may be overvalued based on CMD comments suggesting excessive
utilization.
Comment: All commenting on CPT codes 17311 and 17313 stated that
these codes were being reviewed by the AMA RUC in 2013, and two
suggested that we accept the AMA RUC recommended work values (6.2 and
5.56 respectively) in the 2014 PFS final rule with comment period. One
commenter asserted that these codes were not misvalued and should be
removed from consideration as potentially misvalued but did not supply
any information to support this view.
Response: The commenters are correct that the codes were under
review by the AMA RUC. Since the publication of the proposed rule, we
have received recommendations from the AMA RUC for these codes. Rather
than finalizing them as potentially misvalued codes, since we have the
AMA RUC recommendations we are proposing interim final values for these
codes per our usual process. (See section II.E.3.a.i.) These values are
open for comment during the comment period for this final rule.
CPT codes 21800 (Closed treatment of rib fracture, uncomplicated,
each), 22305 (Closed treatment of vertebral process fracture(s)) and
27193 (Closed treatment of pelvic ring fracture, dislocation, diastasis
or subluxation, without manipulation) were proposed for review as
potentially misvalued codes.
Comment: We received no comments on these codes.
Response: We are finalizing our proposal to review these codes as
potentially misvalued codes.
CPT codes 33960 (Prolonged extracorporeal circulation for
cardiopulmonary insufficiency; initial day) and 33961 (Prolonged
extracorporeal circulation for cardiopulmonary insufficiency; each
subsequent day) were proposed for review because the service was
originally valued when it was used primarily in premature neonates; but
the service is now being furnished to adults with severe influenza,
pneumonia and respiratory distress syndrome. We also noted in the
proposed rule that, while the code currently includes 523 minutes of
total physician time with 133 minutes of intraservice time, physicians
are not typically furnishing the service over that entire time
interval; rather, hospital-employed pump technicians are furnishing
much of the work.
Comment: We received no comments on these codes.
Response: We are finalizing our proposal to review these codes as
potentially misvalued codes.
CPT codes 47560 (Laparoscopy, surgical; with guided transhepatic
cholangiography, without biopsy), 47562 (Laparoscopy, surgical;
cholecystectomy) and 47563 (Laparoscopy, surgical; cholecystectomy with
cholangiography) were proposed as potentially misvalued because the
more extensive code (CPT 47560) has lower work RVUs than the less
extensive codes (CPT 47562 and CPT 47563).
Comment: We received a comment suggesting that these codes were not
potentially misvalued and urging us not to finalize our proposal,
stating that 47562 and 47563 describe more complex surgical procedures
and both have a 090-day global period while 47560 has a 000-day global
period.
[[Page 74258]]
Response: We acknowledge that the codes have different global
periods, but believe that questions remain about how these codes should
be valued. Therefore, we are finalizing our proposal to review these
codes as potentially misvalued codes.
CPT codes 55845 (Prostatectomy, retropubic radical, with or without
nerve sparing; with bilateral pelvic lymphadenectomy, including
external iliac, hypogastric, and obturator nodes) and 55866
(Laparoscopy, surgical prostatectomy, retropubic radial, including
nerve sparing, includes robotic assistance, when performed) were
proposed as potentially misvalued because the RVUs for the laparoscopic
procedure (CPT 55866) are higher than those for the open procedure (CPT
55845) and we believe that, in general, a laparoscopic procedure would
not require greater resources than the open procedure.
Comment: A few comments suggested that these codes were not
potentially misvalued because the laparoscopic code (CPT 55866) does
require a higher level of work than the open procedure (CPT 55845) so
the codes are in the appropriate rank order. One commenter stated that
they had submitted an action plan for the review of these codes at the
October 2013 AMA RUC meeting, and suggested that we defer any action on
these codes until the AMA RUC review process is complete. Another
commenter agreed that they were potentially misvalued saying that we
should pay the same rate for both codes.
Response: Although most of the commenters indicated that it was
appropriate that RVUs be higher for CPT code 55866 (laparoscopic
procedure) than for CPT code 55845 (open procedure), we believe that
there is enough question about how these codes should be valued that we
are finalizing the proposal to review these codes as potentially
misvalued codes. We note that we consider AMA RUC recommendations
through our usual review of potentially misvalued codes.
We proposed CPT 64566 (Posterior tibial neurostimulation,
percutaneous needle electrode, single treatment, includes programming)
as a potentially misvalued code because the current valuation is based
on the procedure being furnished by a physician, but we think that the
procedure typically is furnished by auxiliary personnel with physician
supervision (rather than by a physician).
Comment: We received a few comments stating that this code is not
misvalued and urged us not to finalize our proposal. One commenter
disagrees that CPT code 64566 is potentially misvalued and stated that
the current work RVU of 0.60 is appropriate and should be maintained.
Response: We believe that further review is needed to determine if
this procedure is typically performed by the physician, or the
auxiliary personnel with physician supervision. Therefore, we are
finalizing our proposal to review the codes described above as
potentially misvalued codes.
We proposed CPT code 76942 (Ultrasonic guidance for needle
placement (for example, biopsy, aspiration, injection, localization
device), imaging supervision and interpretation) as a potentially
misvalued code because of the high frequency with which it is billed
with CPT code 20610 (Arthrocentesis, aspiration and/or injection; major
joint or bursa (for example, shoulder, hip, knee joint, subacromial
bursa). As we noted in the proposed rule, we are concerned about
potential overutilization of these codes and it was suggested that the
payment for CPT code 76942 and CPT code 20610 should be bundled to
reduce the incentive for providers to always provide and bill
separately for ultrasound guidance.
We also noted in the proposed rule that we were proposing to revise
the direct PE inputs for CPT code 76942 because claims data shows that
the procedure time assumption for CPT code 76942 is longer than that
for the typical procedure with which the code is billed (CPT code
20610). The direct PE inputs and procedure time for CPT code 76942 are
addressed in detail in section II.B.4.f. of this final rule with
comment period. We further explained in the proposed rule that the
discrepancy in procedure times and the resulting potentially inaccurate
payment raises a fundamental concern regarding the incentive to furnish
ultrasound guidance.
Comment: We received a comment saying that this code is
undervalued, several comments indicating that the reduction of time and
other inputs would be inappropriate and some comments suggesting that
we should delay action until the AMA RUC can review and provide its
recommendation.
Response: Based on the diversity of the comments received about the
valuation of this code, we are finalizing our proposal to review it as
a potentially misvalued code. This action is consistent with the
comment recommending that we delay action until the AMA RUC acts
because we routinely consider AMA RUC recommendations through our usual
review of potentially misvalued codes. Thus, we would seek the AMA RUC
recommendation before re-valuing.
As we noted in the proposed rule that given our concerns with CPT
code 76942, we have similar concerns with other codes for ultrasound
guidance. Accordingly, we proposed the following additional ultrasound
guidance codes as potentially misvalued.
Table 12--Ultrasound Guidance Codes Proposed as Potentially Misvalued
------------------------------------------------------------------------
CPT code Short descriptor
------------------------------------------------------------------------
76930............................ Echo guide cardiocentesis.
76932............................ Echo guide for heart biopsy.
76936............................ Echo guide for artery repair.
76940............................ US guide tissue ablation.
76948............................ Echo guide ova aspiration.
76950............................ Echo guidance radiotherapy.
76965............................ Echo guidance radiotherapy.
------------------------------------------------------------------------
Comment: We received some comments asking us not to treat 76930,
76932, and 76936 as potentially misvalued codes stating that these
codes are not misvalued but without providing information to support
the contention. One commenter stated that 76936 should be removed from
the list because it is not an image guidance technique used to
supplement a surgical procedure.
Response: We agree that code 76936 is not a code used to supplement
a surgical procedure and therefore does not raise the concerns we
discussed in the proposed rule. Accordingly, it will not be included on
the list of potentially misvalued codes. The comments on codes 76930
and 76932 provided insufficient information to persuade us that these
codes should not be considered potentially misvalued. Given that the
identification of a code as potentially misvalued merely assures that
the current values are evaluated to determine whether changes are
warranted, we are finalizing our proposal to consider codes 76930 and
76932 as potentially misvalued.
In summary, the following codes are finalized as potentially
misvalued codes.
Table 13--Potentially Misvalued CPT Codes
------------------------------------------------------------------------
CPT code Short descriptor
------------------------------------------------------------------------
21800............................ Treatment of rib fracture.
22305............................ Closed tx spine process fx.
27193............................ Treat pelvic ring fracture.
33960............................ External circulation assist.
33961............................ External circulation assist, each
subsequent day.
47560............................ Laparoscopy w/cholangio.
[[Page 74259]]
47562............................ Laparoscopic cholecystectomy.
47563............................ Laparo cholecystectomy/graph.
55845............................ Extensive prostate surgery.
55866............................ Laparo radical prostatectomy.
64566............................ Neuroeltrd stim post tibial.
76930............................ Echo guide cardiocentesis.
76932............................ Echo guide for heart biopsy.
76940............................ US guide tissue ablation.
76942............................ Echo guide for biopsy.
76948............................ Echo guide ova aspiration.
76950............................ Echo guidance radiotherapy.
76965............................ Echo guidance radiotherapy.
------------------------------------------------------------------------
We will accept public nominations of potentially misvalued codes
with supporting documentation as described in section II.C.3.a. of this
final rule with comment period in the CY 2015 proposed rule.
ii. Number of Visits and Physician Time in Selected Global Surgical
Packages
In the CY 2013 proposed rule, we sought comments on methods of
obtaining accurate and current data on E/M services furnished as part
of a global surgical package. Commenters provided a variety of
suggestions including setting the all surgical services to a 0-day
global period, requiring all E/M services to be separately billed,
validating the global surgical packages with the hospital Diagnosis-
Related Group length of stay data, and setting auditable documentation
standards for post-operative E/M services. In addition to the broader
comments, the AMA RUC noted that many surgical procedures did not have
the correct hospital and discharge day management services in the
global period, resulting in incorrect times in the time file. The AMA
RUC submitted post-operative visits and times for the services that we
had displayed with zero visits in the CMS time file with the CY 2013
proposed rule. The AMA RUC suggested that the errors may have resulted
from the inadvertent removal of the visits from the time file in 2007.
We responded to this comment in the CY 2013 final rule with comment
period by saying that we would review this file and, if appropriate,
propose modifications. We noted in the CY 2013 final rule with comment
period that if time had been removed from the physician time file
inadvertently, it would have resulted in a small impact on the indirect
allocation of PE at the specialty level, but it would not have affected
the physician work RVUs or direct PE inputs for these services. It
would have a small impact on the indirect allocation of PE at the
specialty level, which we would review when we explore this potential
time file change.
After extensive review, we believe that the data were deleted from
the time file due to an inadvertent error as noted by the AMA RUC. To
correct this inadvertent error, in the CY2014 proposed rule, we
proposed to replace the missing post-operative hospital E/M visit
information and time for the 117 codes that were identified by the AMA
RUC and displayed in Table 14. Thus, we believe this correction will
populate the physician time file with data that, absent the inadvertent
error, would have been present in the time file.
Table 14--Global Surgical Package Visits and Physician Time Changes
----------------------------------------------------------------------------------------------------------------
Visits included in Global Package \1\ CY 2013 CY 2014
CPT code Short descriptor ------------------------------------------------ physician physician
99231 99232 99238 99291 time time
----------------------------------------------------------------------------------------------------------------
19368............... Breast 4.00 .......... 1.00 .......... 712.00 770.00
reconstruction.
19369............... Breast 3.00 .......... 1.00 .......... 657.00 690.00
reconstruction.
20100............... Explore wound neck 2.00 .......... 1.00 .......... 218.00 266.00
20816............... Replantation digit 5.00 .......... 1.00 .......... 671.00 697.00
complete.
20822............... Replantation digit 3.00 .......... 1.00 .......... 587.00 590.00
complete.
20824............... Replantation thumb 5.00 .......... 1.00 .......... 646.00 690.00
complete.
20827............... Replantation thumb 4.00 .......... 1.00 .......... 610.00 625.00
complete.
20838............... Replantation foot 8.00 .......... 1.00 .......... 887.00 986.00
complete.
20955............... Fibula bone graft 6.00 .......... 1.00 1.00 867.00 957.00
microvasc.
20969............... Bone/skin graft 8.00 .......... 1.00 .......... 1018.00 1048.00
microvasc.
20970............... Bone/skin graft 8.00 .......... 1.00 .......... 958.00 988.00
iliac crest.
20973............... Bone/skin graft 5.00 .......... 1.00 .......... 1018.00 988.00
great toe.
21139............... Reduction of 1.00 .......... 1.00 .......... 400.00 466.00
forehead.
21151............... Reconstruct 2.00 .......... 1.00 1.00 567.00 686.00
midface lefort.
21154............... Reconstruct 2.50 .......... 1.00 1.50 664.00 853.00
midface lefort.
21155............... Reconstruct 2.00 .......... 1.00 2.00 754.00 939.00
midface lefort.
21175............... Reconstruct orbit/ .......... 1.00 1.00 2.00 549.00 767.00
forehead.
21182............... Reconstruct .......... 1.00 1.00 2.00 619.00 856.00
cranial bone.
21188............... Reconstruction of 1.00 .......... 1.00 .......... 512.00 572.00
midface.
22100............... Remove part of 2.00 .......... 1.00 .......... 397.00 372.00
neck vertebra.
22101............... Remove part thorax 3.00 .......... 1.00 .......... 392.00 387.00
vertebra.
22110............... Remove part of 6.00 .......... 1.00 .......... 437.00 479.00
neck vertebra.
22112............... Remove part thorax 6.50 .......... 1.00 .......... 507.00 530.00
vertebra.
22114............... Remove part lumbar 6.50 .......... 1.00 .......... 517.00 530.00
vertebra.
22210............... Revision of neck 7.00 .......... 1.00 .......... 585.00 609.00
spine.
22212............... Revision of thorax 7.00 .......... 1.00 .......... 610.00 640.00
spine.
22214............... Revision of lumbar 7.00 .......... 1.00 .......... 585.00 624.00
spine.
22220............... Revision of neck 6.50 .......... 1.00 .......... 565.00 585.00
spine.
22222............... Revision of thorax 7.50 .......... 1.00 .......... 630.00 651.00
spine.
22224............... Revision of lumbar 7.50 .......... 1.00 .......... 620.00 666.00
spine.
22315............... Treat spine 1.00 .......... 1.00 .......... 257.00 252.00
fracture.
22325............... Treat spine 5.50 .......... 1.00 .......... 504.00 528.00
fracture.
22326............... Treat neck spine 5.50 .......... 1.00 .......... 452.00 480.00
fracture.
22327............... Treat thorax spine 9.00 .......... 1.00 .......... 505.00 604.00
fracture.
22548............... Neck spine fusion. 8.00 .......... 1.00 1.00 532.00 673.00
22556............... Thorax spine 3.00 .......... 1.00 1.00 525.00 557.00
fusion.
22558............... Lumbar spine 2.00 .......... 1.00 1.00 502.00 525.00
fusion.
[[Page 74260]]
22590............... Spine & skull 3.00 .......... 1.00 .......... 532.00 501.00
spinal fusion.
22595............... Neck spinal fusion 6.00 .......... 1.00 .......... 492.00 521.00
22600............... Neck spine fusion. 6.00 .......... 1.00 .......... 437.00 490.00
22610............... Thorax spine 7.50 .......... 1.00 .......... 468.00 549.00
fusion.
22630............... Lumbar spine 3.00 .......... 1.00 .......... 501.00 487.00
fusion.
22800............... Fusion of spine... 7.00 .......... 1.00 .......... 517.00 571.00
22802............... Fusion of spine... 4.00 .......... 1.00 .......... 552.00 538.00
22804............... Fusion of spine... 5.00 .......... 1.00 .......... 630.00 595.00
22808............... Fusion of spine... 5.00 .......... 1.00 .......... 553.00 530.00
22810............... Fusion of spine... 5.00 .......... 1.00 .......... 613.00 595.00
22812............... Fusion of spine... 7.50 .......... 1.00 .......... 666.00 700.00
31582............... Revision of larynx 8.00 .......... 1.00 .......... 489.00 654.00
32650............... Thoracoscopy w/ 2.00 .......... 1.00 .......... 322.00 290.00
pleurodesis.
32656............... Thoracoscopy w/ 3.00 .......... 1.00 .......... 419.00 377.00
pleurectomy.
32658............... Thoracoscopy w/sac 1.00 .......... 1.00 .......... 362.00 330.00
fb remove.
32659............... Thoracoscopy w/sac 2.00 .......... 1.00 .......... 414.00 357.00
drainage.
32661............... Thoracoscopy w/ 1.00 .......... 1.00 .......... 342.00 300.00
pericard exc.
32664............... Thoracoscopy w/th 1.00 .......... 1.00 .......... 362.00 330.00
nrv exc.
32820............... Reconstruct 3.50 .......... 1.00 4.50 631.00 854.00
injured chest.
33236............... Remove electrode/ 4.00 .......... 1.00 .......... 258.00 346.00
thoracotomy.
33237............... Remove electrode/ 5.00 .......... 1.00 .......... 378.00 456.00
thoracotomy.
33238............... Remove electrode/ 5.00 .......... 1.00 .......... 379.00 472.00
thoracotomy.
33243............... Remove eltrd/ 5.00 .......... 1.00 .......... 504.00 537.00
thoracotomy.
33321............... Repair major 8.00 .......... 1.00 .......... 751.00 754.00
vessel.
33332............... Insert major 8.00 .......... 1.00 .......... 601.00 604.00
vessel graft.
33401............... Valvuloplasty open 8.00 .......... 1.00 .......... 830.00 661.00
33403............... Valvuloplasty w/cp 8.00 .......... 1.00 .......... 890.00 638.00
bypass.
33417............... Repair of aortic 2.50 .......... 1.00 2.50 740.00 750.00
valve.
33472............... Revision of 0.50 .......... 1.00 4.50 665.00 780.00
pulmonary valve.
33502............... Coronary artery 2.50 .......... 1.00 2.50 710.00 688.00
correction.
33503............... Coronary artery 5.50 .......... 1.00 2.50 890.00 838.00
graft.
33504............... Coronary artery 4.50 .......... 1.00 2.50 740.00 789.00
graft.
33600............... Closure of valve.. 6.00 .......... 1.00 .......... 800.00 628.00
33602............... Closure of valve.. 6.00 .......... 1.00 .......... 770.00 628.00
33606............... Anastomosis/artery- 8.00 .......... 1.00 .......... 860.00 728.00
aorta.
33608............... Repair anomaly w/ 5.00 .......... 1.00 .......... 800.00 668.00
conduit.
33690............... Reinforce 2.50 .......... 1.00 2.50 620.00 636.00
pulmonary artery.
33702............... Repair of heart 0.50 .......... 1.00 3.50 663.00 751.00
defects.
33722............... Repair of heart 5.00 .......... 1.00 .......... 770.00 608.00
defect.
33732............... Repair heart-vein 5.00 .......... 1.00 .......... 710.00 578.00
defect.
33735............... Revision of heart 2.50 .......... 1.00 3.50 740.00 770.00
chamber.
33736............... Revision of heart 5.00 .......... 1.00 .......... 710.00 548.00
chamber.
33750............... Major vessel shunt 2.00 .......... 1.00 3.00 680.00 722.00
33764............... Major vessel shunt 1.50 .......... 1.00 3.50 710.00 750.00
& graft.
33767............... Major vessel shunt 5.00 .......... 1.00 .......... 800.00 608.00
33774............... Repair great 0.50 .......... 1.00 6.50 845.00 998.00
vessels defect.
33788............... Revision of 2.50 .......... 1.00 2.50 770.00 736.00
pulmonary artery.
33802............... Repair vessel 2.50 .......... 1.00 1.50 558.00 556.00
defect.
33803............... Repair vessel 2.50 .......... 1.00 1.50 618.00 586.00
defect.
33820............... Revise major 1.00 .......... 1.00 1.00 430.00 414.00
vessel.
33824............... Revise major 0.50 .......... 1.00 2.50 588.00 615.00
vessel.
33840............... Remove aorta 1.50 .......... 1.00 2.50 588.00 639.00
constriction.
33845............... Remove aorta 1.00 .......... 1.00 3.00 710.00 726.00
constriction.
33851............... Remove aorta 2.00 .......... 1.00 3.00 603.00 700.00
constriction.
33852............... Repair septal 2.00 .......... 1.00 3.00 663.00 719.00
defect.
33853............... Repair septal 8.00 .......... 1.00 .......... 800.00 668.00
defect.
33917............... Repair pulmonary 5.00 .......... 1.00 .......... 740.00 608.00
artery.
33920............... Repair pulmonary 6.00 .......... 1.00 .......... 800.00 658.00
atresia.
33922............... Transect pulmonary 5.00 .......... 1.00 .......... 618.00 546.00
artery.
33974............... Remove intra- 1.00 .......... 1.00 .......... 406.00 314.00
aortic balloon.
34502............... Reconstruct vena 6.00 .......... 1.00 .......... 793.00 741.00
cava.
35091............... Repair defect of 11.00 .......... 1.00 2.00 597.00 790.00
artery.
35694............... Arterial 2.00 .......... 1.00 .......... 468.00 456.00
transposition.
35901............... Excision graft 4.00 .......... 1.00 .......... 484.00 482.00
neck.
35903............... Excision graft 3.00 .......... 1.00 .......... 408.00 416.00
extremity.
47135............... Transplantation of 23.00 .......... 1.00 .......... 1501.00 1345.00
liver.
47136............... Transplantation of 28.00 .......... 1.00 .......... 1301.00 1329.00
liver.
49422............... Remove tunneled ip 1.00 .......... 1.00 .......... 154.00 182.00
cath.
49429............... Removal of shunt.. 6.00 .......... 1.00 .......... 249.00 317.00
50320............... Remove kidney 4.00 .......... 1.00 .......... 480.00 524.00
living donor.
[[Page 74261]]
50845............... Appendico- 5.00 .......... 1.00 .......... 685.00 613.00
vesicostomy.
56632............... Extensive vulva 7.00 .......... 1.00 .......... 835.00 683.00
surgery.
60520............... Removal of thymus 2.00 .......... 1.00 2.00 406.00 474.00
gland.
60521............... Removal of thymus 5.00 .......... 1.00 .......... 457.00 445.00
gland.
60522............... Removal of thymus 7.00 .......... 1.00 .......... 525.00 533.00
gland.
61557............... Incise skull/ 3.00 .......... 1.00 .......... 529.00 510.00
sutures.
63700............... Repair of spinal 3.00 .......... 1.00 .......... 399.00 401.00
herniation.
63702............... Repair of spinal 3.00 .......... 1.00 .......... 469.00 463.00
herniation.
63704............... Repair of spinal 8.00 .......... 1.00 .......... 534.00 609.00
herniation.
63706............... Repair of spinal 8.00 .......... 1.00 .......... 602.00 679.00
herniation.
----------------------------------------------------------------------------------------------------------------
\1\ We note that in the CY 2014 proposed rule, this table displayed only whole numbers of visits, although the
actual time file and our ratesetting calculations use data to two places beyond the decimal point.
iii. Codes With Higher Total Medicare Payments in Office Than in
Hospital or ASC
In the CY 2014 proposed rule with comment period, we proposed to
address nearly 200 codes that we believe to have misvalued resource
inputs. These are codes for which the total PFS payment when furnished
in an office or other nonfacility setting would exceed the total
Medicare payment (the combined payment to the facility and the
professional) when the service is furnished in a facility, either a
hospital outpatient department or an ASC.
For services furnished in a facility setting we would generally
expect the combined payment to the facility and the practitioner to
exceed the PFS payment made to the professional when the service is
furnished in the nonfacility setting. This payment differential is
expected because it reflects the greater costs we would expect to be
incurred by facilities relative to physicians furnishing services in
offices and other non-facility settings. These greater costs are due to
higher overhead resulting from differences in regulatory requirements
and for facilities, such as hospitals, maintaining the capacity to
furnish services 24 hours per day and 7 days per week. However, when we
analyzed such payments, we identified nearly 300 codes that would
result in greater Medicare payment in the nonfacility setting than in
the facility setting. We believe these anomalous site-of-service
payment differentials are the result of inaccurate resource input data
used to establish rates under the PFS.
We proposed to address these misvalued codes by refining the PE
methodology to limit the nonfacility PE RVUs for individual codes so
that the total nonfacility PFS payment amount would not exceed the
total combined payment under the PFS and the OPPS (or the ASC payment
system) when the service is furnished in the facility setting.
Section II.B.3 discusses the comment received on this misvalued
code proposal and our response to these comments.
4. Multiple Procedure Payment Reduction Policy
Medicare has long employed multiple procedure payment reduction
(MPPR) policies to adjust payment to more appropriately reflect reduced
resources involved with furnishing services that are frequently
furnished together. Under these policies, we reduce payment for the
second and subsequent services within the same MPPR category furnished
in the same session or same day. These payment reductions reflect
efficiencies that typically occur in either the PE or professional work
or both when services are furnished together. With the exception of a
few codes that are always reported with another code, the PFS values
services independently to recognize relative resources involved when
the service is the only one furnished in a session. Although some of
our MPPR policies precede the Affordable Care Act, MPPRs can address
the fourth category of potentially misvalued codes identified in
section 1848(c)(2)(K) of the Act, as added by the Affordable Care Act,
which is ``multiple codes that are frequently billed in conjunction
with furnishing a single service'' (see 75 FR 73216). The following
sections describe the history of MPPRs and the services currently
covered by MPPRs.
a. Background
Medicare has a longstanding policy to reduce payment by 50 percent
for the second and subsequent surgical procedures furnished to the same
beneficiary by a single physician or physicians in the same group
practice on the same day, largely based on the presence of efficiencies
in the PE and pre- and post-surgical physician work. Effective January
1, 1995, the MPPR policy, with this same percentage reduction, was
extended to nuclear medicine diagnostic procedures (CPT codes 78306,
78320, 78802, 78803, 78806, and 78807). In the CY 1995 PFS final rule
with comment period (59 FR 63410), we indicated that we would consider
applying the policy to other diagnostic tests in the future.
Consistent with recommendations of MedPAC in its March 2005 Report
to the Congress on Medicare Payment Policy, for CY 2006 PFS, we
extended the MPPR policy to the TC of certain diagnostic imaging
procedures furnished on contiguous areas of the body in a single
session (70 FR 70261). This MPPR policy recognizes that for the second
and subsequent imaging procedures furnished in the same session, there
are some efficiencies in clinical labor, supplies, and equipment time.
In particular, certain clinical labor activities and supplies are not
duplicated for subsequent imaging services in the same session and,
because equipment time and indirect costs are allocated based on
clinical labor time, adjustment to those figures is appropriate as
well.
The imaging MPPR policy originally applied to computed tomography
(CT) and computed tomographic angiography (CTA), magnetic resonance
imaging (MRI) and magnetic resonance angiography (MRA), and ultrasound
services within 11 families of codes based on imaging modality and body
region, and only applied to procedures furnished in a single session
involving contiguous body areas within a family of codes. Additionally,
this MPPR policy originally applied to TC-only services and to the TC
of global services, but not to professional component (PC) services.
[[Page 74262]]
There have been several revisions to this policy since it was
originally adopted. Under the current imaging MPPR policy, full payment
is made for the TC of the highest paid procedure, and payment for the
TC is reduced by 50 percent for each additional procedure subject to
this MPPR policy. We originally planned to phase in the imaging MPPR
policy over a 2-year period, with a 25 percent reduction in CY 2006 and
a 50 percent reduction in CY 2007 (70 FR 70263). However, section
5102(b) of the Deficit Reduction Act of 2005 (DRA) (Pub. L. 109-171,
enacted on December 20, 2006) amended the statute to place a cap on the
PFS payment amount for most imaging procedures at the amount paid under
the hospital OPPS. In view of this new OPPS payment cap, we decided in
the CY 2006 PFS final rule with comment period that it would be prudent
to retain the imaging MPPR at 25 percent while we continued to examine
the appropriate payment levels (71 FR 69659). The DRA also exempted
reduced expenditures attributable to the imaging MPPR policy from the
PFS budget neutrality provision. Effective July 1, 2010, section
1848(b)(4)(C) of the Act increased the MPPR on the TC of imaging
services under the policy established in the CY 2006 PFS final rule
with comment period from 25 to 50 percent. Section 1848(c)(2)(B)(v)(IV)
of the Act exempted the reduced expenditures attributable to this
further change from the PFS budget neutrality provision.
In the July 2009 U.S. Government Accountability Office (GAO) report
entitled, Medicare Physician Payments: Fees Could Better Reflect
Efficiencies Achieved when Services are Provided Together, the GAO
recommended that we take further steps to ensure that fees for services
paid under the PFS reflect efficiencies that occur when services are
furnished by the same physician to the same beneficiary on the same
day. The GAO report recommended the following: (1) Expanding the
existing imaging MPPR policy for certain services to the PC to reflect
efficiencies in physician work for certain imaging services; and (2)
expanding the MPPR to reflect PE efficiencies that occur when certain
nonsurgical, nonimaging services are furnished together. The GAO report
also encouraged us to focus on service pairs that have the most impact
on Medicare spending.
In its March 2010 report, MedPAC noted its concerns about
mispricing of services under the PFS. MedPAC indicated that it would
explore whether expanding the unit of payment through packaging or
bundling would improve payment accuracy and encourage more efficient
use of services. In the CY 2009 and CY 2010 PFS proposed rules (73 FR
38586 and 74 FR 33554, respectively), we stated that we planned to
analyze nonsurgical services commonly furnished together (for example,
60 to 75 percent of the time) to assess whether an expansion of the
MPPR policy could be warranted. MedPAC encouraged us to consider
duplicative physician work, as well as PE, in any expansion of the MPPR
policy.
Section 1848(c)(2)(K) of the Act specifies that the Secretary shall
identify potentially misvalued codes by examining multiple codes that
are frequently billed in conjunction with furnishing a single service,
and review and make appropriate adjustments to their relative values.
As a first step in applying this provision, in the CY 2010 final rule
with comment period, we implemented a limited expansion of the imaging
MPPR policy to additional combinations of imaging services.
Effective January 1, 2011, the imaging MPPR applies regardless of
code family; that is, the policy applies to multiple imaging services
furnished within the same family of codes or across families. This
policy is consistent with the standard PFS MPPR policy for surgical
procedures that does not group procedures by body region. The current
imaging MPPR policy applies to CT and CTA, MRI and MRA, and ultrasound
procedures furnished to the same beneficiary in the same session,
regardless of the imaging modality, and is not limited to contiguous
body areas.
As we noted in the CY 2011 PFS final rule with comment period (75
FR 73228), although section 1848(c)(2)(B)(v)(VI) of the Act specifies
that reduced expenditures attributable to the increase in the imaging
MPPR from 25 to 50 percent (effective for fee schedules established
beginning with 2010 and for services furnished on or after July 1,
2010) are excluded from the PFS budget neutrality adjustment, it does
not apply to reduced expenditures attributable to our policy change
regarding additional code combinations across code families
(noncontiguous body areas) that are subject to budget neutrality under
the PFS. The complete list of codes subject to the CY 2011 MPPR policy
for diagnostic imaging services is included in Addendum F.
As a further step in applying the provisions of section
1848(c)(2)(K) of the Act, on January 1, 2011, we implemented an MPPR
for therapy services. The MPPR applies to separately payable ``always
therapy'' services, that is, services that are only paid by Medicare
when furnished under a therapy plan of care. As we explained in the CY
2011 PFS final rule with comment period (75 FR 73232), the therapy MPPR
does not apply to contractor-priced codes, bundled codes, or add-on
codes.
This MPPR for therapy services was first proposed in the CY 2011
proposed rule (75 FR 44075) as a 50 percent payment reduction to the PE
component of the second and subsequent therapy services for multiple
``always therapy'' services furnished to a single beneficiary in a
single day. It applies to services furnished by an individual or group
practice or ``incident to'' a physician's service. However, in response
to public comments, in the CY 2011 PFS final rule with comment period
(75 FR 73232), we adopted a 25 percent payment reduction to the PE
component of the second and subsequent therapy services for multiple
``always therapy'' services furnished to a single beneficiary in a
single day.
Subsequent to publication of the CY 2011 PFS final rule with
comment period, section 3 of the Physician Payment and Therapy Relief
Act of 2010 (PPTRA) (Pub. L. 111-286) revised the payment reduction
percentage from 25 percent to 20 percent for therapy services for which
payment is made under a fee schedule under section 1848 of the Act
(which are services furnished in office settings, or non-institutional
services). The payment reduction percentage remained at 25 percent for
therapy services furnished in institutional settings. Section 4 of the
PPTRA exempted the reduced expenditures attributable to the therapy
MPPR policy from the PFS budget neutrality provision. Section 633 of
the ATRA revised the reduction to 50 percent of the PE component for
all settings, effective April 1, 2013. Therefore, full payment is made
for the service or unit with the highest PE and payment for the PE
component for the second and subsequent procedures or additional units
of the same service is reduced by 50 percent for both institutional and
non-institutional services.
This MPPR policy applies to multiple units of the same therapy
service, as well as to multiple different ``always therapy'' services,
when furnished to the same beneficiary on the same day. The MPPR
applies when multiple therapy services are billed on the same date of
service for one beneficiary by the same practitioner or facility under
the same National Provider Identifier (NPI), regardless of whether the
services are furnished in one therapy discipline or multiple
disciplines, including physical
[[Page 74263]]
therapy, occupational therapy, or speech-language pathology.
The MPPR policy applies in all settings where outpatient therapy
services are paid under Part B. This includes both services that are
furnished in the office setting and paid under the PFS, as well as
institutional services that are furnished by outpatient hospitals, home
health agencies, comprehensive outpatient rehabilitation facilities
(CORFs), and other entities that are paid for outpatient therapy
services at rates based on the PFS.
In its June 2011 Report to Congress, MedPAC highlighted continued
growth in ancillary services subject to the in-office ancillary
services exception. The in-office ancillary exception to the physician
self-referral prohibition in section 1877 of the Act, also known as the
Stark law, allows physicians to refer Medicare beneficiaries to their
own group practices for designated health services, including imaging,
radiation therapy, home health care, clinical laboratory tests, and
physical therapy, if certain conditions are met. MedPAC recommended
that we curb overutilization by applying a MPPR to the PC of diagnostic
imaging services furnished by the same practitioner in the same
session. As noted above, the GAO already had made a similar
recommendation in its July 2009 report.
In continuing to apply the provisions of section 1848(c)(2)(K) of
the Act regarding potentially misvalued codes that result from
``multiple codes that are frequently billed in conjunction with
furnishing a single service,'' in the CY 2012 final rule (76 FR 73071),
we expanded the MPPR to the PC of Advanced Imaging Services (CT, MRI,
and Ultrasound), that is, the same list of codes to which the MPPR on
the TC of advanced imaging already applied. Thus, this MPPR policy now
applies to the PC and the TC of certain diagnostic imaging codes.
Specifically, we expanded the payment reduction currently applied to
the TC to apply also to the PC of the second and subsequent advanced
imaging services furnished by the same physician (or by two or more
physicians in the same group practice) to the same beneficiary in the
same session on the same day. However, in response to public comments,
in the CY 2012 PFS final rule with comment period, we adopted a 25
percent payment reduction to the PC component of the second and
subsequent imaging services.
Under this policy, full payment is made for the PC of the highest
paid advanced imaging service, and payment is reduced by 25 percent for
the PC for each additional advanced imaging service furnished to the
same beneficiary in the same session. This policy was based on the
expected efficiencies in furnishing multiple services in the same
session due to duplication of physician work, primarily in the pre- and
post-service periods, but with some efficiencies in the intraservice
period.
This policy is consistent with the statutory requirement for the
Secretary to identify, review, and adjust the relative values of
potentially misvalued services under the PFS as specified by section
1848(c)(2)(K) of the Act. This policy is also consistent with our
longstanding policies on surgical and nuclear medicine diagnostic
procedures, under which we apply a 50 percent payment reduction to
second and subsequent procedures. Furthermore, it was responsive to
continued concerns about significant growth in imaging spending, and to
MedPAC (March 2010 and June 2011) and GAO (July 2009) recommendations
regarding the expansion of MPPR policies under the PFS to account for
additional efficiencies.
In the CY 2013 final rule (77 FR 68933), we expanded the MPPR to
the TC of certain cardiovascular and ophthalmology diagnostic tests.
Although we proposed a 25 percent reduction for both diagnostic
cardiovascular and ophthalmology services, we adopted a 20 percent
reduction for ophthalmology services in the final rule with comment
period (77 FR 68941) in response to public comments. For diagnostic
cardiovascular services, full payment is made for the procedure with
the highest TC payment, and payment is reduced by 25 percent for the TC
for each additional procedure furnished to the same patient on the same
day. For diagnostic ophthalmology services, full payment is made for
the procedure with the highest TC payment, and payment is reduced by 20
percent for the TC for each additional procedure furnished to the same
patient on the same day.
We did not propose and are not adopting any new MPPR policies for
CY 2014. However, we continue to look at expanding the MPPR based on
efficiencies when multiple procedures are furnished together.
The complete list of services subject to the MPPRs on diagnostic
imaging services, therapy services, diagnostic cardiovascular services
and diagnostic ophthalmology services is shown in Addenda F, H, I, and
J. We note that Addenda H, which lists services subject to the MPPR on
therapy services, contains four new CPT codes. Specifically, CPT code
92521 (Evaluation of speech fluency), 92522 (Evaluate speech sound
production), 92523 (Speech sound language comprehension) and 92524
(Behavioral and qualitative analysis of voice and resonance) are being
added to the list. These codes replace CPT code 92506 (Speech/hearing
evaluation) for CY 2014. Accordingly, CPT 92506 has been deleted from
Addenda H. Like CPT 92506, these new codes are ``always therapy''
services that are only paid by Medicare when furnished under a therapy
plan of care. Thus, like CPT 92506, they are subject to the MPPR for
therapy services. They have been added to the list of services subject
to the MPPR on therapy services on an interim final basis, and are open
to public comment on this final rule with comment period.
C. Malpractice RVUs
Section 1848(c) of the Act requires that each service paid under
the PFS be composed of three components: work, PE, and malpractice.
From 1992 to 1999, malpractice RVUs were charge-based, using weighted
specialty-specific malpractice expense percentages and 1991 average
allowed charges. Malpractice RVUs for new codes after 1991 were
extrapolated from similar existing codes or as a percentage of the
corresponding work RVU. Section 4505(f) of the BBA, which amended
section 1848(c) of the Act, required us to implement resource-based
malpractice RVUs for services furnished beginning in 2000. Therefore,
initial implementation of resource-based malpractice RVUs occurred in
2000.
The statute also requires that we review and, if necessary, adjust
RVUs no less often than every 5 years. The first review and
corresponding update of resource-based malpractice RVUs was addressed
in the CY 2005 PFS final rule with comment period (69 FR 66263). Minor
modifications to the methodology were addressed in the CY 2006 PFS
final rule with comment period (70 FR 70153). In the CY 2010 PFS final
rule with comment period, we implemented the second review and
corresponding update of malpractice RVUs. For a discussion of the
second review and update of malpractice RVUs, see the CY 2010 PFS
proposed rule (74 FR 33537) and final rule with comment period (74 FR
61758).
As explained in the CY 2011 PFS final rule with comment period (75
FR 73208), malpractice RVUs for new codes, revised codes and codes with
revised work RVUs (new/revised codes) effective before the next five-
year review of malpractice RVUs (for example, effective CY 2011 through
CY 2014,
[[Page 74264]]
assuming that the next review of malpractice RVUs occurs for CY 2015)
are determined either by a direct crosswalk from a similar source code
or by a modified crosswalk to account for differences in work RVUs
between the new/revised code and the source code. For the modified
crosswalk approach, we adjust (or ``scale'') the malpractice RVU for
the new/revised code to reflect the difference in work RVU between the
source code and the new/revised work value (or, if greater, the
clinical labor portion of the PE RVU) for the new code. For example, if
the proposed work RVU for a revised code is 10 percent higher than the
work RVU for its source code, the malpractice RVU for the revised code
would be increased by 10 percent over the source code malpractice RVU.
This approach presumes the same risk factor for the new/revised code
and source code but uses the work RVU for the new/revised code to
adjust for the difference in risk attributable to the variation in work
between the two services.
For CY 2014, we use this approach for determining malpractice RVUs
for new/revised codes. A list of new/revised codes and the malpractice
crosswalks used to determine their malpractice RVUs are in Sections
II.E.2.c and 3.c in this final rule with comment period. The CY 2014
malpractice RVUs for interim final codes are being implemented in the
CY 2014 PFS final rule with comment period. These RVUs are subject to
public comment. After considering public comments, they will then be
finalized in the CY 2015 PFS final rule with comment period.
D. Medicare Economic Index (MEI)
1. Revising of the Medicare Economic Index (MEI)
a. Background
The Medicare Economic Index (MEI) is authorized under section
1842(b)(3) of the Act, which states that prevailing charge levels
beginning after June 30, 1973 may not exceed the level from the
previous year except to the extent that the Secretary finds, on the
basis of appropriate economic index data, that such a higher level is
justified by year-to-year economic changes. Beginning July 1, 1975, and
continuing through today, the MEI has met this requirement by
reflecting the weighted-average annual price change for various inputs
involved in furnishing physicians' services. The MEI is a fixed-weight
input price index, with an adjustment for the change in economy-wide,
private nonfarm business multifactor productivity. This index is
comprised of two broad categories: (1) physicians' own time; and (2)
physicians' practice expense (PE).
The current general form of the MEI was described in the November
25, 1992 Federal Register (57 FR 55896) and was based in part on the
recommendations of a Congressionally-mandated meeting of experts held
in March 1987. Since that time, the MEI has been updated or revised on
four instances. First, the MEI was rebased in 1998 (63 FR 58845), which
moved the cost structure of the index from 1992 data to 1996 data.
Second, the methodology for the productivity adjustment was revised in
the CY 2003 PFS final rule with comment period (67 FR 80019) to reflect
the percentage change in the 10-year moving average of economy-wide
private nonfarm business multifactor productivity. Third, the MEI was
rebased in 2003 (68 FR 63239), which moved the cost structure of the
index from 1996 data to 2000 data. Fourth, the MEI was rebased in 2011
(75 FR 73262), which moved the cost structure of the index from 2000
data to 2006 data.
The terms ``rebasing'' and ``revising,'' while often used
interchangeably, actually denote different activities. Rebasing refers
to moving the base year for the structure of costs of a price index,
while revising relates to other types of changes such as changing data
sources, cost categories, or price proxies used in the price index. For
CY 2014, we proposed to revise the MEI based on the recommendations of
the MEI Technical Advisory Panel (TAP). We did not propose to rebase
the MEI and will continue to use the data from 2006 to estimate the
cost weights, since these are the most recently available, relevant,
and complete data we have available to develop these weights.
b. MEI Technical Advisory Panel (TAP) Recommendations
The MEI-TAP was convened to conduct a technical review of the MEI,
including the inputs, input weights, price-measurement proxies, and
productivity adjustment. After considering these issues, the MEI-TAP
was asked to assess the relevance and accuracy of inputs relative to
current physician practices. The MEI-TAP's analysis and recommendations
were to be considered in future rulemaking to ensure that the MEI
accurately and appropriately meets its intended statutory purpose.
The MEI-TAP consisted of five members and held three meetings in
2012: May 21; June 25; and July 11. It produced eight findings and 13
recommendations for consideration by CMS. Background on the MEI-TAP
members, meeting transcripts for all three meetings, and the MEI-TAP's
final report, including all findings and recommendations, are available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/FACA/MEITAP.html. We have determined, as noted in the proposed rule, that it
is possible to implement some of the recommendations immediately, while
more in-depth research is required to address several of the other
recommendations.
For CY 2014, we proposed to implement 10 of the 13 recommendations
made by the MEI-TAP. The remaining recommendations require more in-
depth research, and we will continue evaluating these three
recommendations and will propose any further changes to the MEI in
future rulemaking. The CY 2014 changes only involve revising the MEI
categories, cost shares, and price proxies. Again, we did not propose
to rebase the MEI for CY 2014 since the MEI-TAP concluded that there is
not a newer, reliable, or ongoing source of data to maintain the MEI.
c. Overview of Revisions
The MEI was last rebased and revised in the CY 2011 PFS final rule
with comment period (75 FR 73262--73275). The current base year for the
MEI is 2006, which means that the cost weights in the index reflect
physicians' expenses in 2006. The details of the methodology used to
determine the 2006 cost shares were provided in the CY 2011 PFS
proposed rule and finalized in the CY 2011 PFS final rule with comment
period (75 FR 40087 and 75 FR 73262, respectively). For CY 2014 we
proposed to make the following revisions to the 2006-based MEI:
(1) Reclassify and revise certain cost categories:
Reclassify expenses for non-physician clinical personnel
that can bill independently from non-physician compensation to
physician compensation.
Revise the physician wage and benefit split so that the
cost weights are more in line with the definitions of the price proxies
used for each category.
Add an additional subcategory under non-physician
compensation for health-related workers.
Create a new cost category called ``All Other Professional
Services'' that includes expenses covered in the current MEI
categories: ``All Other Services'' and ``Other Professional Expenses.''
The ``All Other Professional Services'' category would be further
disaggregated into appropriate occupational subcategories.
Create an aggregate cost category called ``Miscellaneous
Office Expenses''
[[Page 74265]]
that would include the expenses for ``Rubber and Plastics,''
``Chemicals,'' ``All Other Products,'' and ``Paper.''
(2) Revise price proxies:
Revise the price proxy for physician wages and salaries
from the Average Hourly Earnings (AHE) for the Total Private Nonfarm
Economy for Production and Nonsupervisory Workers to the ECI for Wages
and Salaries, Professional and Related Occupations, Private Industry.
Revise the price proxy for physician benefits from the ECI
for Benefits for the Total Private Industry to the ECI for Benefits,
Professional and Related Occupations, Private Industry.
Use the ECI for Wages and Salaries and the ECI for
Benefits of Hospital, Civilian workers (private industry) as the price
proxies for the new category of non-physician health-related workers.
Use ECIs to proxy the Professional Services occupational
subcategories that reflect the type of professional services purchased
by physicians' offices.
Revise the price proxy for the fixed capital category from
the CPI for Owners' Equivalent Rent of Residences to the PPI for
Lessors of Nonresidential Buildings (NAICS 53112).
d. Revising Expense Categories in the MEI
We did not propose any changes in the methodology for estimating
the cost shares as finalized in the CY 2011 PFS final rule with comment
period (75 FR 73263-73267). For CY 2014, we proposed to revise the
classification of certain expenses within the 2006-based MEI. The
details of the proposed revisions and the MEI-TAP recommendation that
is the impetus for each of the revisions can be found in the CY 2014
PFS proposed rule (78 FR 43312-43316). The following sections summarize
the proposed revisions to the cost weights for CY 2014.
(1) Overall MEI Cost Weights.
Table 15 lists the set of mutually exclusive and exhaustive cost
categories and weights that were proposed for CY 2014. A comparison of
the proposed revised MEI cost categories and cost shares to the 2006-
based MEI cost categories and cost shares as finalized in the CY 2011
PFS final rule can be found at 78 FR 43312-43313.
Based on the proposed revisions to the MEI for CY 2014, the
proposed physician compensation cost weight under the revised MEI is
2.600 percentage points higher than the physician compensation weight
in the current MEI. This change occurs because of the reclassification
of expenses for non-physician clinical staff that can bill
independently from non-physician compensation to physician
compensation. This change lowers the PE cost weight by 2.600 percent as
well, all of which comes from a lower weight for non-physician
compensation. The remaining MEI cost weights are unchanged.
The proposed revised MEI includes four new detailed cost categories
and two new sub-aggregate cost categories. The new detailed cost
categories are:
Health-related, non-physician wages and salaries.
Professional, scientific, and technical services.
Administrative support and waste management services.
All other services.
The new sub-aggregate categories are:
Non-health, non-physician wages.
Miscellaneous office expenses.
The proposed revised MEI excludes two sub-aggregate categories that
were included in the current 2006-based MEI. The sub-aggregate
categories removed are:
Office expenses.
Drugs & supplies.
Table 15--Revised 2006 MEI Cost Categories and, Weights
[Revised MEI (2006=100), CY2014]
------------------------------------------------------------------------
Revised
Revised cost category weights
(percent)
------------------------------------------------------------------------
Physician Compensation.................................. 50.866
Wages and Salaries.................................. 43.641
Benefits............................................ 7.225
Practice Expense........................................ 49.134
Non-physician compensation.......................... 16.553
Non-physician wages................................. 11.885
Non-health, non-physician wages................. 7.249
Professional and Related.................... 0.800
Management.................................. 1.529
Clerical.................................... 4.720
Services.................................... 0.200
Health related, non-physician wages............. 4.636
Non-physician benefits.............................. 4.668
Other Practice Expense.............................. 32.581
Utilities....................................... 1.266
Miscellaneous Office Expenses................... 2.478
Chemicals................................... 0.723
Paper....................................... 0.656
Rubber & Plastics........................... 0.598
All other products.......................... 0.500
Telephone....................................... 1.501
Postage......................................... 0.898
All Other professional services................. 8.095
Professional, scientific, & technical 2.592
services...................................
Administrative support & waste management... 3.052
All other services.......................... 2.451
Capital......................................... 10.310
Fixed Capital............................... 8.957
Moveable Capital............................ 1.353
Professional Liability Insurance................ 4.295
Medical Equipment............................... 1.978
[[Page 74266]]
Medical supplies................................ 1.760
Total MEI........................................... 100.000
------------------------------------------------------------------------
* The term (2006=100) refers to the base year of the MEI.
(2) Physician Compensation (Own Time)
The component of the MEI that reflects the physician's own time is
represented by the net income portion of business receipts. The 2006
cost weight associated with the physician's own time (otherwise
referred to as the Physician's Compensation cost weight) is based on
2006 AMA PPIS data for mean physician net income (physician
compensation) for self-employed physicians and for the selected self-
employed specialties. Expenses for employed physician compensation are
combined with expenses for self-employed physician compensation to
obtain an aggregate Physician Compensation cost weight. Based on this
methodology, the Physician Compensation cost weight in the current MEI
is 48.266 percent. For CY 2014, we proposed to reclassify the expenses
for non-physician practitioners that can bill independently from the
non-physician cost category in the MEI to the physician compensation
cost category for several reasons:
These types of practitioners furnish services that are
similar to those furnished by physicians.
If billing independently, these practitioners would be
paid at a percentage of the physicians' services or in certain cases at
the same rate as physicians.
The expenses related to the work components for the RVUs
would include work from clinical staff that can bill independently.
Therefore, it would improve consistency with the RVU payments to
include these expenses as physician compensation in the MEI.
The effect of moving the expenses related to clinical staff that
can bill independently is to increase the physician compensation cost
share by 2.600 percentage points and to reduce the non-physician
compensation cost share by the same amount. The physician compensation
cost share for the proposed revised MEI is 50.866 percent compared to
the physician compensation cost share of 48.266 percent in the current
MEI.
Within the physician compensation cost weight, the MEI includes a
separate weight for wages and salaries and a separate weight for
benefits. Under the current 2006-based MEI, the ratio for wages and
salaries, and benefits was calculated using data from the PPIS.
Based on MEI-TAP recommendation 3.1 we proposed to revise the wage
and benefit split used for physician compensation. Specifically, we
proposed to apply the distribution from the Statistics of Income (SOI)
data to both self-employed and employed physician compensation. In
reviewing the detailed AMA PPIS survey questions, it was clear that
self-employed physician benefits were mainly comprised of insurance
costs while other benefits such as physician retirement, paid leave,
and payroll taxes were likely included in physician wages and salaries.
By definition, the price proxy used for physician benefits, which
is an Employment Cost Index (ECI) concept, includes retirement savings.
Thus, using the AMA PPIS data produced a definitional inconsistency
between the cost weight and the price proxy. Therefore, we proposed to
use the data on wages and salaries, and employee benefits from the SOI
data for Offices of Physicians and Dentists for partnerships and
corporations for both self-employed and employed physicians. From the
SOI data, benefit expenses were estimated by summing the partnership
data for retirement plans and employee benefit programs with
corporation data for pension, profit-sharing plans and employee benefit
programs. For 2006, the split between wages and salaries, and benefits
was 85.8 percent and 14.2 percent, respectively. Retirement/pension
plans account for about 60 percent of total benefits. The SOI data do
not classify paid leave and supplemental pay as a benefit.
Combining the impact of classifying compensation for non-physicians
that can bill independently as physician compensation with the use of
the SOI data, the physician wages and salary cost share in the revised
MEI is lower than the current MEI by 0.240 percentage points. These two
methodological changes result in an increase in the physician benefit
cost share in the revised MEI of 2.839 percentage points. As a result,
the proposed physician wages and salary cost share for the revised MEI
is 43.641 percent and the proposed physician benefit cost share for the
revised MEI is 7.225 percent.
(3) Physician's Practice Expenses
To determine the PE cost weights, we use mean expense data from the
2006 PPIS survey. The derivation of the weights and categories for
practice expenses is the same as finalized in the CY 2011 PFS final
rule with comment period (75 FR 73264-73267), except where noted below.
(a) Non-Physician Employee Compensation
For CY 2014 we proposed to exclude the expenses related to non-
physician clinical staff that can bill independently from this cost
category. Moving the expenses related to the clinical staff that can
bill independently out of non-physician compensation costs decreases
the share by 2.600 percentage points. The non-physician compensation
cost share for the revised MEI is 16.553 percent compared to the
current physician compensation cost share of 19.153 percent.
We are further proposed to use the same method as finalized in the
CY 2011 PFS final rule to split the non-physician compensation between
wages and benefits. For reference, we use 2006 BLS Employer Costs for
Employee Compensation (ECEC) data for the Health Care and Social
Assistance (private industry). Data for 2006 in the ECEC for Health
Care and Social Assistance indicate that wages and benefits are 71.8
percent and 28.2 percent of compensation, respectively. The non-
physician wage and benefit cost shares for the revised MEI are 11.885
percent and 4.668 percent, respectively.
The current 2006-based MEI further disaggregated the non-physician
wages into four occupational subcategories, the details of this method
can be found in the CY 2011 PFS final rule with comment period (75 FR
73264-73265). Based on the MEI-TAP
[[Page 74267]]
Recommendation 4.4, the Panel recommended the disaggregation of the
non-physician compensation costs to include an additional category for
health-related workers. The exact recommendation can be found at 78 FR
43314.
We proposed to implement this recommendation using expenses
reported on the AMA PPIS for non-physician, non-health-related workers.
The survey question asks for the expenses for: ``non-clinical personnel
involved primarily in administrative, secretarial or clerical
activities (Including transcriptionists, medical records personnel,
receptionists, schedulers and billing staff, coding staff, information
technology staff, and custodial personnel).'' Using this method, the
proposed non-physician, non-health-related wage cost share for the
revised MEI is 7.249 percent.
For wage costs of non-physician, health-related workers, the survey
question asks for the expenses for: ``other clinical staff, including
RNs, LPNs, physicists, lab technicians, x-ray technicians, medical
assistants, and other clinical personnel who cannot independently
bill.'' Using this method, the proposed non-physician, health-related
wage cost share for the revised MEI is 4.636 percent. Together the non-
health and health-related, non-physician wage costs sum to be equal to
the total non-physician wage share in the revised MEI of 11.885
percent.
We further proposed to disaggregate the non-physician, non-health-
related wage cost weight of 7.249 percent into four occupational
subcategories. The methodology is similar to that finalized in the CY
2011 PFS final rule with comment period (75 FR 73264), in that we are
using 2006 Current Population Survey (CPS) data and 2006 BLS
Occupational Employment Statistics (OES) data to develop cost weights
for wages for non-physician, non-health-related occupational groups. We
determined total annual earnings for offices of physicians using
employment data from the CPS and mean annual earnings from the OES. To
arrive at a distribution for these separate occupational categories
(Professional & Related (P&R) workers, Managers, Clerical workers, and
Service workers), we determined annual earnings for each using the
Standard Occupational Classification (SOC) system. We then determined
the overall share of the total for each. The proposed occupational
distribution in the revised MEI is presented in Table 16. The
comparison between the proposed revised distribution of non-physician
payroll expense by occupational group to the prior comparison can be
found in the CY 2014 PFS proposed rule at 78 FR43315.
Table 16--Percent Distribution of Non-Physician Payroll Expense by
Occupational Group: Revised 2006-Based MEI
[Revised MEI (2006=100)]
------------------------------------------------------------------------
Revised weight (percent) Revised Cost Category
------------------------------------------------------------------------
16.553........................... Non-physician compensation.
11.885........................... Non-physician wages.
7.249............................ Non-health, non-phys. wages.
0.800............................ Professional and Related.
1.529............................ Management.
4.720............................ Clerical.
0.200............................ Services.
4.636............................ Health related, non-phys. wages.
4.668............................ Non-physician benefits.
------------------------------------------------------------------------
The health-related workers were previously included mainly in the
Professional and Technical and Service Categories. The proposed
reclassifications allow for health-related workers to be proxied by a
health-specific ECI rather than an ECI for more general occupations.
(b) Other Practice Expense
The remaining expenses in the MEI are categorized as Other Practice
Expenses. In the current 2006-based MEI we had classified other PEs in
one of the following subcategories: Office Expenses; Drugs and
Supplies; and All Other Professional Expenses. For CY 2014, we proposed
to disaggregate these expenses in a way consistent with the MEI-TAP's
recommendations, as detailed below.
We rely on the 2006 AMA PPIS data to determine the cost share for
Other Practice Expenses. These expenses are the total of office
expenses, medical supplies, medical equipment, Professional Liability
Insurance (PLI), and all other professional expenses.
For the revised 2006-based MEI, we disaggregate Other Practice
Expenses into 15 detailed subcategories as shown in Table 17.
Table 17--Revised Cost Categories for Other Practice Expense
------------------------------------------------------------------------
Revised weight
Revised cost category (percent)
------------------------------------------------------------------------
Other Practice Expense.................................. 32.581
Utilities........................................... 1.266
Miscellaneous Office Expenses....................... 2.478
Chemicals....................................... 0.723
Paper........................................... 0.656
Rubber & Plastics............................... 0.598
All other products.............................. 0.500
Telephone........................................... 1.501
Postage............................................. 0.898
All Other professional services..................... 8.095
Professional, Scientific, and Tech. Services.... 2.592
Administrative support & waste mgmt............. 3.052
All Other Services.............................. 2.451
Capital............................................. 10.310
Fixed........................................... 8.957
Moveable........................................ 1.353
Professional Liability Insurance.................... 4.295
Medical Equipment................................... 1.978
Medical supplies.................................... 1.760%
------------------------------------------------------------------------
[[Page 74268]]
For most of these categories, we use the same method as finalized
in the CY 2011 PFS final rule with comment period to estimate the cost
shares. In particular, the cost shares for the following categories are
derived directly from expense data reported on the 2006 AMA PPIS: PLI;
Medical Equipment; and Medical Supplies. In each case, the cost shares
remain the same as in the current MEI. Additionally, we continue to use
the Bureau of Economic Analysis (BEA) 2002-Benchmark I/O data aged to
2006 to determine the cost weights for other expenses not collected
directly from the AMA PPIS. The BEA 2002-Benchmark I/O data can be
accessed at the following link: http://www.bea.gov/industry/io_benchmark.htm#2002data
The derivation of the cost weight for each of the detailed
categories under Other Practice Expenses is provided in 78 FR 43315-
43316. The following categories had no revisions proposed to the cost
share weight and therefore reflect the same cost share weight as
finalized in the CY 2011 final rule: Utilities, Telephone, Postage,
Fixed Capital, Moveable Capital, PLI, Medical Equipment, and Medical
Supplies. The following section provides a review of the categories for
which we proposed revisions to the cost categories and cost share
weights (Miscellaneous Office Expenses, and All Other Services).
Miscellaneous Office Expenses: Based on MEI-TAP
recommendation 3.4 we proposed to include an aggregate category of
detailed office expenses that were stand-alone categories in the
current 2006-based MEI. During the CY 2011 PFS proposed rule comment
period, several commenters expressed confusion as to the relevance of
these categories to their practice costs. The MEI-TAP discussed the
degree of granularity needed in both the calculation and reporting of
the MEI. The MEI-TAP concluded that it might be prudent to collapse
some of the non-labor PE categories with other categories for
presentation purposes.
All Other Professional Services: Based on MEI-
TAP recommendation 3.3, we proposed to combine the All Other Services
cost weight and All Other Professional Expenses into a single cost
category. The proposed weight for the All Other Professional Services
category is 8.095 percent, which is the sum of the current MEI weight
for All Other Services (3.581 percent) and All Other Professional
Expenses (4.513 percent), and is more in line with the GPCI Purchased
Services index as finalized in the CY2012 PFS final rule with comment
period (76 FR 73085).--
We then proposed to further disaggregate the 8.095 percent of
expenses into more detail based on the BEA I-O data, allowing for
specific cost weights for services such as contract billing services,
accounting, and legal services. We considered various levels of
aggregation; however, in considering the level of aggregation, the
available corresponding price proxies had to be considered. Given the
price proxies that are available from the BLS Employment Cost Indexes
(ECI), we proposed to disaggregate these expenses into three
categories:
NAICS 54 (Professional, Scientific, and Technical
Services): The Professional, Scientific, and Technical Services sector
comprises establishments that specialize in performing professional,
scientific, and technical activities for others. These activities
require a high degree of expertise and training. The establishments in
this sector specialize according to expertise and provide these
services to clients in a variety of industries, including but not
limited to: legal advice and representation; accounting, and payroll
services; computer services; management consulting services; and
advertising services and have a 2.592 percent weight.
NAICS 56 (Administrative and Support and Waste Management
and Remediation Services): The Administrative and Support and Waste
Management and Remediation Services sector comprises establishments
performing routine support activities for the day-to-day operations of
other organizations. The establishments in this sector specialize in
one or more of these support activities and provide these services to
clients in a variety of industries including but not limited to: office
administration; temporary help services; security services; cleaning
and janitorial services; and trash collection services. These services
have a 3.052 percent weight.
All Other Services, a residual category of these expenses:
The residual All Other Services cost category is mostly comprised of
expenses associated with service occupations, including but not limited
to: lab and blood specimen transport; catering and food services;
collection company services; and dry cleaning services and have a 2.451
percent weight.
2. Selection of Price Proxies for Use in the MEI
After developing the cost category weights for the revised 2006-
based MEI, we reviewed all the price proxies based on the
recommendations from the MEI-TAP. As was the case in the development of
the current 2006-based MEI, most of the proxy measures we considered
are based on BLS data and are grouped into one of the following four
categories:
Producer Price Indices (PPIs): PPIs measure
price changes for goods sold in markets other than retail markets.
These fixed-weight indexes are measures of price change at the
intermediate or final stage of production. They are the preferred
proxies for physician purchases as these prices appropriately reflect
the product's first commercial transaction.
Consumer Price Indices (CPIs): CPIs measure
change in the prices of final goods and services bought by consumers.
Like the PPIs, they are fixed weight indexes. Since they may not
represent the price changes faced by producers, CPIs are used if there
are no appropriate PPIs or if the particular expenditure category is
likely to contain purchases made at the final point of sale.
Employment Cost Indices (ECIs) for Wages &
Salaries: These ECIs measure the rate of change in employee wage rates
per hour worked. These fixed-weight indexes are not affected by
employment shifts among industries or occupations and thus, measure
only the pure rate of change in wages.
Employment Cost Indices (ECIs) for Employee
Benefits: These ECIs measure the rate of change in employer costs of
employee benefits, such as the employer's share of Social Security
taxes, pension and other retirement plans, insurance benefits (life,
health, disability, and accident), and paid leave. Like ECIs for wages
& salaries, the ECIs for employee benefits are not affected by
employment shifts among industries or occupations.
When choosing wage and price proxies for each expense category, we
evaluate the strengths and weaknesses of each proxy variable using the
following four criteria.
Relevance: The price proxy should appropriately
represent price changes for specific goods or services within the
expense category. Relevance may encompass judgments about relative
efficiency of the market generating the price and wage increases.
Reliability: If the potential proxy demonstrates
a high sampling variability, or inexplicable erratic patterns over
time, its viability as an appropriate price proxy is greatly
diminished. Notably, low sampling variability can conflict with
relevance--since the more specifically a price variable is defined (in
terms of service, commodity, or geographic area), the
[[Page 74269]]
higher the possibility of high sampling variability. A well-established
time series is also preferred.
Timeliness of actual published data: For greater
granularity and the need to be as timely as possible, we prefer monthly
and quarterly data to annual data.
Public availability: For transparency, we prefer
to use data sources that are publicly available.
The price proxy selection for every category in the proposed
revised MEI is detailed in 78 FR 43316-43319. Below we discuss the
price and wage proxies for each cost category in the proposed revised
MEI.
a. Physician Compensation (Physician's Own Time)
(1) Physician Wages and Salaries
Based on recommendations from the MEI-TAP, we proposed to use the
ECI for Wages and Salaries for Professional and Related Occupations
(Private Industry) (BLS series code CIU2020000120000I) to measure price
growth of this category in the revised 2006-based MEI. The current
2006-based MEI used Average Hourly Earnings (AHE) for Production and
Non-Supervisory Employees for the Private Nonfarm Economy.
The MEI-TAP had two recommendations concerning the price proxy for
physician Wages and Salaries. The first recommendation from the MEI-TAP
was Recommendation 4.1, which stated that: ``. . . OACT revise the
price proxy associated with Physician Wages and Salaries from an
Average Hourly Earnings concept to an Employment Cost Index concept.''
AHEs are calculated by dividing gross payrolls for wages and salaries
by total hours. The AHE proxy was representative of actual changes in
hourly earnings for the nonfarm business economy, including shifts in
employment mix. The recommended alternative, the ECI concept, measures
the rate of change in employee wage rates per hour worked. ECIs measure
the pure rate of change in wages by industry and/or occupation and are
not affected by shifts in employment mix across industries and
occupations. The MEI-TAP believed that the ECI concept better reflected
physician wage trends compared to the AHE concept.
The second recommendation related to the price proxy for physician
wages and salaries was Recommendation 4.2, which stated that:
``CMS revise the price proxy associated with changes in Physician
Wages and Salaries to use the Employment Cost Index for Wages and
Salaries, Professional and Related, Private Industry. The Panel
believes this change would maintain consistency with the guidance
provided in the 1972 Senate Finance Committee report titled `Social
Security Amendments of 1972,' which stated that the index should
reflect changes in practice expenses and `general earnings.' In the
event this change would be determined not to meet the legal requirement
that the index reflect ``general earnings,'' the Panel recommended
replacing the current proxy with the Employment Cost Index for Wages
and Salaries, All Workers, Private Industry.'' The Panel believed this
change would maintain consistency with the guidance provided in the
1972 Senate Finance Committee report titled ``Social Security
Amendments of 1972,'' which stated that the index should reflect
changes in practice expenses and ``general earnings.'' \2\
---------------------------------------------------------------------------
\2\ U.S. Senate, Committee on Finance, Social Security
Amendments of 1972. ``Report of the Committee on Finance United
States Senate to Accompany H.R. 1,'' September 26, 1972, p. 191.
---------------------------------------------------------------------------
We agree that switching the proxy to the ECI for Wages and Salaries
for Professional and Related Occupations would be consistent with the
authority provided in the statute and reflect a wage trend more
consistent with other professionals that receive advanced training.
Additionally, we believe the ECI is a more appropriate concept than the
AHE because it can isolate wage trends without being impacted by the
change in the mix of employment.
(2) Physician Benefits
The MEI-TAP states in Recommendation 4.3 that, ``. . . any change
in the price proxy for Physician Wages and Salaries be accompanied by
the selection and incorporation of a Physician Benefits price proxy
that is consistent with the Physician Wages and Salaries price proxy.''
We proposed to use the ECI for Benefits for Professional and Related
Occupations (Private Industry) to measure price growth of this category
in the revised 2006-based MEI. The ECI for Benefits for Professional
and Related Occupations is derived using BLS's Total Compensation for
Professional and Related Occupations (BLS series ID CIU2010000120000I)
and the relative importance of wages and salaries within total
compensation. We believe this series is technically appropriate because
it better reflects the benefit trends for professionals requiring
advanced training. The current 2006-based MEI market basket used the
ECI for Total Benefits for the Total Private Industry.
b. Practice Expense
(1) Non-Physician Employee Compensation
(a) Non-Physician Wages and Salaries
(i) Non-Physician, Non-Health-Related Wages and Salaries
Professional and Related: We proposed to continue using
the ECI for Wages and Salaries for Professional and Related Occupation
(Private Industry) (BLS series code CIU2020000120000I) to measure the
price growth of this cost category.
Management: We proposed to continue using the ECI for
Wages and Salaries for Management, Business, and Financial (Private
Industry) (BLS series code CIU2020000110000I) to measure the price
growth of this cost category.
Clerical: We proposed to continue using the ECI for Wages
and Salaries for Office and Administrative Support (Private Industry)
(BLS series code CIU2020000220000I) to measure the price growth of this
cost category. This is the same proxy used in the current 2006-based
MEI.
Services: We proposed to continue using the ECI for Wages
and Salaries for Service Occupations (Private Industry) (BLS series
code CIU2020000300000I) to measure the price growth of this cost
category.
(ii) Non-Physician, Health-Related Wages and Salaries
In Recommendation 4.4, the MEI-TAP ``. . . recommend[ed] the
disaggregation of the Non-Physician Compensation costs to include an
additional category for health-related workers. This disaggregation
would allow for health-related workers to be separated from non-health-
related workers. CMS should rely directly on PPIS data to estimate the
health-related non-physician compensation cost weights. The non-health,
non-physician wages should be further disaggregated based on the
Current Population Survey and Occupational Employment Statistics data.
The new health-related cost category should be proxied by the ECI,
Wages and Salaries, Hospital (NAICS 622), which has an occupational mix
that is reasonably close to that in physicians' offices. The Non-
Physician Benefit category should be proxied by a composite benefit
index reflecting the same relative occupation weights as the non-
physician wages.'' We proposed to use the ECI for Wages and Salaries
for Hospital Workers (Private Industry) (BLS series code
CIU2026220000000I) to measure the price growth of this cost category in
the final revised 2006-based MEI. The ECI for Hospital workers has
[[Page 74270]]
an occupational mix that approximates that in physicians' offices. This
cost category was not broken out separately in the current 2006-based
MEI.
(b) Non-Physician Benefits
We proposed to continue using a composite ECI for non-physician
employee benefits in the revised 2006-based MEI. However, we also
proposed to expand the number of occupations from four to five by
adding detail on Non-Physician Health-Related Benefits. The weights and
price proxies for the composite benefits index will be revised to
reflect the addition of the new category. Table 18 lists the five ECI
series and corresponding weights used to construct the revised
composite benefit index for non-physician employees in the revised
2006-based MEI.
Table 18--CMS Composite Price Index for Non-Physician Employee Benefits
in the Revised 2006-Based MEI
------------------------------------------------------------------------
2006 Weight
ECI Series (%)
------------------------------------------------------------------------
Benefits for Professional and Related Occupation 7
(Private Industry).....................................
Benefits for Management, Business, and Financial 12
(Private Industry).....................................
Benefits for Office and Administrative Support (Private 40
Industry)..............................................
Benefits for Service Occupations (Private Industry)..... 2
Benefits for Hospital Workers (Private Industry)........ 39
------------------------------------------------------------------------
(3) Other Practice Expense
(a) All Other Professional Services
As discussed previously, MEI-TAP Recommendation 3.3 was that:
``. . . OACT create a new cost category entitled Professional
Services that should consist of the All Other Services cost category
(and its respective weight) and the Other Professional Expenses cost
category (and its respective weight). The Panel further recommends that
this category be disaggregated into appropriate occupational categories
consistent with the relevant price proxies.'' We are proposed to
implement this recommendation in the revised 2006-based MEI using a
cost category titled ``All Other Professional Services.'' Likewise, the
MEI-TAP stated in Recommendation 4.7 that ``. . . price changes
associated with the Professional Services category be proxied by an
appropriate blend of Employment Cost Indexes that reflect the types of
professional services purchased by physician offices.'' We agree with
this recommendation and proposed to use the following price proxies for
each of the new occupational categories:
Professional, Scientific, and Technical Services: We
proposed to use the ECI for Total Compensation for Professional,
Scientific, and Technical Services (Private Industry) (BLS series code
CIU2015400000000I) to measure the price growth of this cost category.
This cost category was not broken out separately in the current 2006-
based MEI.
Administrative and Support Services: We proposed to use
the ECI for Total Compensation for Administrative, Support, Waste
Management, and Remediation Services (Private Industry) (BLS series
code CIU2015600000000I) to measure the price growth of this cost
category. This cost category was not broken out separately in the
current 2006-based MEI.
All Other Services: We proposed to use the ECI for
Compensation for Service Occupations (Private Industry) (BLS series
code CIU2010000300000I) to measure the price growth of this cost
category.
(b) Miscellaneous Office Expenses
Chemicals: We proposed to continue using the PPI for Other
Basic Organic Chemical Manufacturing (BLS series code
PCU32519-32519) to measure the price growth of this cost
category.
Paper: We proposed to continue using the PPI for Converted
Paper and Paperboard (BLS series code WPU0915) to measure the
price growth of this cost category.
Rubber & Plastics: We proposed to continue using the PPI
for Rubber and Plastic Products (BLS series code WPU07) to
measure the price growth of this cost category.
All Other Products: We proposed to continue using the CPI-
U for All Products less Food and Energy (BLS series code
CUUR0000SA0L1E) to measure the price growth of this cost category.
Utilities: We proposed to continue using the CPI for Fuel
and Utilities (BLS series code CUUR0000SAH2) to measure the price
growth of this cost category.
Telephone: We proposed to continue using the CPI for
Telephone Services (BLS series code CUUR0000SEED) to measure the price
growth of this cost category.
Postage: We proposed to continue using the CPI for Postage
(BLS series code CUUR0000SEEC01) to measure the price growth of this
cost category.
Fixed Capital: In Recommendation 4.5, ``The Panel
recommends using the Producer Price Index for Lessors of Nonresidential
Buildings (NAICS 53112) for the MEI Fixed Capital cost category as it
represents the types of fixed capital expenses most likely faced by
physicians. The MEI-TAP noted the volatility in the index, which is
greater than the Consumer Price Index for Owners' Equivalent Rent of
Residences. This relative volatility merits ongoing monitoring and
evaluation of alternatives.'' We are proposed to use the PPI for
Lessors of Nonresidential Buildings (BLS series code PCU531120531120)
to measure the price growth of this cost category in the revised 2006-
based MEI. The current 2006-based MEI used the CPI for Owner's
Equivalent Rent. We believe the PPI for Lessors of Nonresidential
Buildings is more appropriate as fixed capital expenses in physician
offices should be more congruent with trends in business office space
costs than residential costs.
Moveable Capital: In Recommendation 4.6, the MEI-TAP
states that ``. . . CMS conduct research into and identify a more
appropriate price proxy for Moveable Capital expenses. In particular,
the MEI-TAP believes it is important that a proxy reflect price changes
in the types of non-medical equipment purchased in the production of
physicians' services, as well as the price changes associated with
Information and Communication Technology expenses (including both
hardware and software).'' We intend to continue to investigate possible
data sources that could be used to proxy the physician expenses related
to moveable capital in more detail. However, we proposed to continue
using the PPI for Machinery and Equipment (series code WPU11) to
measure the price growth of this cost category in the revised 2006-
based MEI.
[[Page 74271]]
Professional Liability Insurance: Unlike the other price
proxies based on data from BLS and other public sources, the proxy for
PLI is based on data collected directly by CMS from a sample of
commercial insurance carriers. The MEI-TAP discussed the methodology of
the CMS PLI index, as well as considered alternative data sources for
the PLI price proxy, including information available from BLS and
through state insurance commissioners. MEI-TAP Finding 4.3 states:
``The Panel finds the CMS-constructed professional liability
insurance price index used to proxy changes in professional liability
insurance premiums in the MEI represents the best currently available
method for its intended purpose. The Panel also believes the pricing
patterns of commercial carriers, as measured by the CMS PLI index, are
influenced by the same driving forces as those observable in policies
underwritten by physician-owned insurance entities; thus, the Panel
believes the current index appropriately reflects the price changes in
premiums throughout the industry.'' Given this MEI-TAP finding, we
proposed to continue using the CMS Physician PLI index to measure the
price growth of this cost category in the revised 2006-based MEI.
Medical Equipment: We proposed to continue using the PPI
for Medical Instruments and Equipment (BLS series code WPU1562) as the
price proxy for this category.
Medical Materials and Supplies: We proposed to continue
using a blended index comprised of a 50/50 blend of the PPI for
Surgical Appliances (BLS series code WPU156301) and the CPI-U for
Medical Equipment and Supplies (BLS series code CUUR0000SEMG).
Table 19--Revised 2006-Based MEI Cost Categories, Weights, and Price
Proxies
------------------------------------------------------------------------
2006 weight
Cost category (percent) Price proxy
------------------------------------------------------------------------
Total MEI.................... 100.000 .........................
Physician Compensation....... 50.866 .........................
Wages and Salaries....... 43.641 ECI--Wages and salaries--
Professional and Related
(Private).
Benefits................. 7.225 ECI--Benefits--Profession
al and Related
(Private).
Practice Expense............. 49.134 .........................
Non-physician 16.553 .........................
Compensation.
Non-physician Wages...... 11.885 .........................
Non-health, non- 7.249 .........................
physician wages.
Professional and 0.800 ECI--Wages And Salaries--
Related. Professional and Related
(Private).
Management........... 1.529 ECI--Wages And Salaries--
Management, Business,
and Financial (Private).
Clerical............. 4.720 ECI--Wages And Salaries--
Office and Admin.
Support (Private).
Services............. 0.200 ECI--Wages And Salaries--
Service Occupations
(Private).
Health related, non- 4.636 ECI--Wages and Salaries--
phys. Wages. Hospital (Private).
Non-physician Benefits... 4.668 Composite Benefit Index.
Other Practice Expense....... 32.581 .........................
Miscellaneous Office 2.478 .........................
Expenses.
Chemicals............ 0.723 PPI--Other Basic Organic
Chemical Manufacturing.
Paper................ 0.656 PPI--Converted Paper and
Paperboard.
Rubber and Plastics.. 0.598 PPI--Rubber and Plastic
Products.
All other products... 0.500 CPI--All Items Less Food
And Energy.
Telephone................ 1.501 CPI--Telephone.
Postage.................. 0.898 CPI--Postage.
All Other 8.095 .........................
Professional
Services.
Prof., Scientific, 2.592 ECI--Compensation--Prof.,
and Tech. Svcs. Scientific, and
Technical (Private).
Admin. and Support 3.052 ECI--Compensation--Admin.
Services. , Support, Waste
Management (Private).
All Other Services... 2.451 ECI--Compensation--Servic
e Occupations (Private).
Capital.............. .............. .........................
Fixed Capital........ 8.957 PPI--Lessors of
Nonresidential
Buildings.
Moveable Capital..... 1.353 PPI--Machinery and
Equipment.
Professional Liability 4.295 CMS--Professional
Insurance. Liability Phys. Prem.
Survey.
Medical Equipment........ 1.978 PPI--Medical Instruments
and Equipment.
Medical Supplies......... 1.760 Composite--PPI Surgical
Appliances & CPI-U
Medical Supplies.
------------------------------------------------------------------------
3. Productivity Adjustment to the MEI
The MEI has been adjusted for changes in productivity since its
inception. In the CY 2003 PFS final rule with comment period (67 FR
80019), we implemented a change in the way the MEI was adjusted to
account for changes in productivity. The MEI used for the 2003
physician payment update incorporated changes in the 10-year moving
average of private nonfarm business (economy-wide) multifactor
productivity that were applied to the entire index. Previously, the
index incorporated changes in productivity by adjusting the labor
portions of the index by the 10-year moving average of economy-wide
private nonfarm business labor productivity.
The MEI-TAP was asked to review this approach. In Finding 5.1,
``[t]he Panel reviewed the basis for the current economy-wide
multifactor productivity adjustment (Private Nonfarm Business
Multifactor Productivity) in the MEI and finds such an adjustment
continues to be appropriate. This adjustment prevents `double counting'
of the effects of productivity improvements, which would otherwise be
reflected in both (i) the increase in compensation and other input
price proxies underlying the MEI, and (ii) the growth in the number of
physician services performed per unit of input resources, which results
from advances in productivity by individual physician practices.''
Based on the MEI-TAP's finding, we proposed to continue to use the
current method for adjusting the full MEI for multifactor productivity
in the revised 2006-based MEI. As described in the CY 2003 PFS final
rule with comment period, we believe this adjustment is appropriate
because it explicitly reflects the productivity gains associated with
all inputs (both labor and non-labor).
[[Page 74272]]
We believe that using the 10-year moving average percent change in
economy-wide multifactor productivity is appropriate for deriving a
stable measure that helps alleviate the influence that the peak (or a
trough) of a business cycle may have on the measure. The adjustment
will be based on the latest available historical economy-wide nonfarm
business multifactor productivity data as measured and published by
BLS.
4. Results of Revisions on the MEI Update
Table 20 shows the average calendar year percent change from CY
2005 to CY 2013 for both the revised 2006-based MEI and the current
2006-based MEI, both excluding the productivity adjustment. The average
annual percent change in the revised 2006-based MEI is 0.1 percent
lower than the current 2006-based MEI over the 2005-2013 period. On an
annual basis over this period, the differences vary by up to plus or
minus 0.7 percentage point. In the two most recent years (CY 2012 and
CY 2013), the annual percent change in the revised 2006-based MEI was
within 0.1 percentage point of the percent change in the current 2006-
based MEI. The majority of these differences over the historical period
can be attributed to the revised price proxy for physician wages and
salaries and benefits and the revised price proxy for fixed capital.
Table 20--Annual Percent Change in the Revised 2006-Based MEI, Not
Including Productivity Adjustment and the Current 2006-Based MEI, Not
Including Productivity Adjustment *
------------------------------------------------------------------------
Revised Current
2006-based 2006-based
Update year MEI excl. MEI, excl.
MFP MFP
------------------------------------------------------------------------
CY 2005....................................... 3.8 3.1
CY 2006....................................... 4.0 3.3
CY 2007....................................... 3.2 3.2
CY 2008....................................... 3.2 3.4
CY 2009....................................... 2.9 3.1
CY 2010....................................... 2.4 2.8
CY 2011....................................... 0.9 1.6
CY 2012....................................... 1.7 1.8
CY 2013....................................... 1.7 1.8
Avg. Change for CYs 2005-2013................. 2.6 2.7
------------------------------------------------------------------------
* Update year based on historical data through the second quarter of the
prior calendar year. For example, the 2014 update is based on
historical data through the second quarter 2013, prior to the MFP
adjustment.
5. Summary of Comments and the Associated Responses
Comment: Many commenters appreciate the efforts of CMS to implement
the recommendations of the MEI-TAP. They agree with the MEI-TAP's
analysis and recommendations and believe these changes successfully
bring the ``market basket'' of MEI inputs up to date and improve the
accuracy of the index going forward. Nearly all commenters supported
the following proposals:
The increase in the physician benefits cost weight in
order to ensure consistency with the benefits price proxy.
The use of professional workers' earnings as the price
proxy for the physician compensation portion of the index.
Specifically, the price proxies for physician wages would change from
general economy-wide earnings to a wages index for ``Professional and
related occupations'' and the price proxy for physician benefits would
be changed from general economy-wide benefits to a benefit index for
``Professional and related occupations.''
The use of commercial rent data for the fixed capital
price proxy, replacing the CPI residential rent proxy.
The creation of a health sector wage category within the
index.
The creation of an ``all other professional services''
category, encompassing purchased services such as contract billing,
legal, and accounting services.
Response: We agree with the commenters that implementing the TAP
recommendations identified above improve the accuracy of the index.
Comment: Several commenters concur with the proposal to reclassify
expenses for non-physician clinical personnel that can bill
independently from non-physician compensation to physician
compensation. They agree with the proposal based on the reasons CMS
outlines and because this policy is more consistent with how services
by non-physician practitioners are treated in the resource-based
relative value scale (RBRVS).
Response: We appreciate the commenters support for the decision to
reclassify expenses related to non-physician clinical personnel that
can bill independently from non-physician compensation to physician
compensation. We also agree with the commenter that classifying the
expenses with physician compensation is more consistent with how
services by non-physician practitioners are treated in the RBRVS since
services related to direct patient care from non-physician
practitioners are reported with the work component in the RBRVS
methodology. We also believe that non-physician practitioners will
continue to perform services that are direct substitutes for services
furnished by physicians, such as office visits.
Comment: Many commenters believe that it is not technically
appropriate to reclassify all expenses for non-physician clinical
personnel that can bill independently from non-physician compensation
to physician compensation. They note that the MEI-TAP recommended that
the OACT consider ``the extent to which those who can bill
independently actually do so.'' They also note that non-physician
clinical personnel often spend much of their time on activities other
than providing services that are billed independently. They suggested
that only the portion of the time the non-physician clinical personnel
spend providing services that are billed independently should be
reclassified to physician compensation. They believe that the increase
in the physician compensation cost share by 2.600 percentage points,
and the reduction in non-physician compensation by the same amount, is
too high. The commenters encourage CMS to conduct real analysis of the
time spent on activities that are billed independently prior to
implementing this re-allocation of costs.
Response: We understand that non-physician clinical personnel may
spend some of their time on activities other than providing services
that are billed independently. We would note that physicians also spend
some of their time on work that is not direct patient care. We proposed
to only reclassify the expenses related to the non-physician clinical
personnel that can bill independently; that is, we are not
reclassifying the expenses for non-physician clinical personnel that
cannot bill independently. We believe that the increase in physician
compensation is technically correct.
The commenters suggested that the non-physician clinical staff that
can bill independently spend much of their time on activities other
than providing services that are billed separately; however, the
commenters did not provide any evidence to support this claim. Based on
part B claims data we have found that nurse practitioners and physician
assistants bill Medicare for the same top HCPCS codes as other primary
care specialties, including office/outpatient visits, subsequent
hospital care, emergency department visits, and nursing facility care
subsequent visits. Based on this, we do
[[Page 74273]]
not believe further analysis is needed to conclude that the non-
physician practitioners that can bill independently are furnishing
services that are substitutes for services furnished by physicians. As
such, we continue to believe that it is appropriate to classify their
costs in the physician compensation category.
Comment: A few commenters suggested that multiple states preclude
non-physicians from practicing and billing independently and therefore
the reclassification of expenses for these services would affect those
states differently than the states where non-physician practitioners
are allowed to practice and bill independently.
Response: We understand that state laws governing the practice
rules for non-physician practitioners can vary by State; however, we do
not believe that this is relevant to the decision to include in the
physician compensation cost category the expenses for non-physician
practitioners that can independently bill under Medicare. These
expenses were collected on the AMA PPIS where we expect that physicians
would have reported the expenses that coincided with the state laws for
non-physician clinical staff for the state in which they practiced. For
a state in which the laws do not permit non-physician practitioners to
bill independently, the expenses would have been allocated to the
category for clinical staff that cannot bill independently.
Comment: Several commenters questioned the implementation of the
MEI-TAP recommendation concerning payroll for non-physician personnel.
The commenters stated that the recommendation was more nuanced than we
had conveyed and that it only directed CMS to evaluate making the
change. The commenters suggested that the recommendation required CMS
to consider several factors including but not limited to, the statutory
definition of ``physician'' as it relates to the recommended change;
how time for non-physician practitioners is currently treated in the
PFS RVU methodology; whether there is evidence these non-physician
practitioners do not spend the majority of their time providing
``physicians' services;'' and the extent to which these practitioners
actually do bill independently for the services they furnish.
Response: When evaluating the MEI-TAP recommendation 3.2 and
formulating our proposal, we did consider the specific factors that the
MEI-TAP included in the recommendation to reclassify the expenses
related to non-physician clinical staff that can bill Medicare
independently. However, we disagree with the commenters' interpretation
that the recommendation intended CMS to only evaluate making the
change. We believe that the intent of all of the recommendations of the
MEI-TAP was for CMS to evaluate the recommendations and propose and
implement those changes as soon as possible.
As we indicated in the proposed rule, there are several reasons for
our proposal to reclassify these expenses which were: (1) These types
of practitioners furnish services that are similar to those furnished
by physicians; (2) if billing independently, these practitioners would
be paid at a percentage of the physicians' services or in certain cases
at the same rate as physicians; and (3) the expenses related to the
work components for the RVUs would include work from clinical staff
that can bill independently. Therefore, it would improve consistency
with the RVU payments to include these expenses as physician
compensation in the MEI.
In response to this comment, we explain further our consideration
of each of the factors as follows:
First, we do not believe the definition of physician under current
law limits CMS' ability to make the proposed change in the MEI. No
provisions of the Social Security Act address the classification of
costs in the MEI. The goal of the MEI is to appropriately estimate the
change in the input prices of the goods and services used to furnish
physician services over time. Therefore, we believe that classifying
costs for those non-physician practitioners that can bill independently
with physician compensation is the most technically appropriate
classification, given their role in the healthcare delivery system
today. We believe that since non-physician practitioners (NPPs) who
bill independently furnish services that substitute for physician work
and that the salary costs for these types of providers would grow at a
similar rate to those of physicians, it is appropriate to classify
these expenses within the physician compensation component of the MEI.
Second, the expenses for non-physician practitioners that can
independently bill are reflected in the physician work component in the
PFS RVU methodology since their services are substituting for physician
work. Expenses for other clinical staff, including RNs, LPNs,
physicists, lab technicians, x-ray technicians, medical assistants, and
other clinical personnel who cannot independently bill are reported in
the PE component in the RVU methodology.
Third, we have found no evidence that these types of providers do
not spend the majority of their time performing ``physicians'
services,'' as defined under the PFS. We looked at 2012 claims data for
the nurse practitioners (NPs) (specialty code 50) and physician
assistants (PAs) (specialty code 97) and compared their top Part B
HCPCS codes reported on claims to the top Part B HCPCS codes reported
on claims of the following three physician specialties: General
Practice (specialty code 01), Family Practice (specialty code 08), and
Internal Medicine (specialty code 11). We found that 7 out of the 10
top HCPCS codes for PAs and NPs are the same as those reported for
physicians in General Practice, Family Practice, and/or Internal
Medicine. HCPCS code 99213 and 99214 (both codes for office/outpatient
visits) were the top two HCPCS codes for all five specialties listed.
Approximately 40 percent of claims for PAs and 50 percent of claims for
NPs were for HCPCS codes that were also submitted by one of the three
primary care specialties (general practice, family practice, and
internal medicine). Based on this Medicare claims analysis, we believe
that these types of non-physician practitioners do spend the majority
of their time performing ``physicians' services.''
Fourth, we believe that non-physician practitioners who are able to
bill independently actually do so in the majority of circumstances
where it is financially beneficial for the practice as a whole. We
understand that different states may have different rules on how non-
physician practitioners are permitted to furnish physician services;
but, in general, if the non-physician practitioner can independently
bill, particularly if the reimbursement for the service is similar to
or the same as that provided to a physician, they usually do so. We
reviewed data on mean annual wages published in the May 2012
Occupational Employment Survey (OES) (http://www.bls.gov/oes/current/oes_stru.htm), and found that wages for PAs and NPs are significantly
higher than RNs and LPNs/LVNs. Specifically, the mean annual wages for
OES Category 29-1071 ``Physician Assistants'' is $92,460 and for OES
Category 29-1171 ``Nurse Practitioners'' it is $91,450 whereas for OES
Category 29-1141 ``Registered Nurses'' it is $67,930 and for OES
Category 29-2061 ``Licensed Practical and Licensed Vocational Nurses''
it is $42,400. In addition, wages for PAs and NPs are also
significantly higher than
[[Page 74274]]
technologist and technician wages. Select technologist and technician
wages are OES Category 29-2051 ``Dietetic Technicians'' at $28,680, OES
Category 29-2052 ``Pharmacy Technicians'' at $30,430, OES Category 29-
2053 ``Psychiatric Technicians'' at $33,140, OES Category 29-2054
``Respiratory Therapy Technicians'' $47,510, and OES Category 29-2055
``Surgical Technologists'' at $43,480. Given the significantly higher
wages for PAs and NPs, we believe it makes economic sense for PAs and
NPs to furnish and bill for ``physicians' services'' to the extent
permitted by law rather than to serve as clinical staff members who
only furnish services incident to a physician's services.
Comment: One commenter believes that the MEI is intended to be a
reflection of physician compensation and physician expenses, and that
it must conform to the definitions of ``physician'' and ``physicians'
services,'' which includes affirmation of the distinct definitions of
physician and nurse practitioner. The commenter claims the reasons for
our proposal fail to account for this foundational distinction between
physicians and ``physicians' services'' as opposed to other types of
practitioners and their services. The commenter believes that to lump
the two definitions together, which is what we are doing, is not
justifiable and in excess of authority.
Response: We disagree with the commenter that classifying the non-
physician independent billers' expenses in the same category as the
physician expenses ``is not justifiable and in excess of authority.''
The definition of physician that exists under current law does not
limit CMS' ability to make this change in the MEI. As mentioned
previously, no provisions of the Social Security Act address the
classification of costs in the MEI. We believe that since non-physician
practitioners that bill independently serve as substitutes for
physician work, and the growth in the salary costs for these types of
providers would grow at a similar rate to physicians, then classifying
the expenses related to non-physician practitioners that bill
independently with physician compensation is the most technically
appropriate classification, given their role in the healthcare delivery
system today.
Comment: It is unclear to several commenters why the productivity
assumptions for physicians are twice that used for the hospital
outpatient department and ambulatory surgery centers. Although they
understood that these are two different calculations, they found it
hard to imagine that individual physicians would have twice the
capability of increasing productivity than would facilities. They note
that all of the productivity adjustments should be based on 10-year
averages of private non-farm business multifactor productivity growth,
but the OPPS and ASC adjustments, are about half the MEI adjustment for
CY 2014.
Response: The productivity adjustments included in the MEI and
those that apply to ASCs and HOPDs are based on the 10-year moving
average of economy-wide private nonfarm business multifactor
productivity (MFP). The differences in the MFP adjustments between the
ASC and HOPD payment systems and the PFS are the result of differences
between the applicable statutes and the time period for which the
adjustment is calculated.
MEI updates have been based on the latest historical data at the
time of rulemaking since its inception. For the CY 2014 rule, the
proposed MEI update of 0.7 percent includes an MFP adjustment of 0.9
percent, which is based on BLS data through 2011 that represents the
latest historical data available at the time of rulemaking. The
proposed MFP adjustment is based on the 10-year moving average of
annual MFP growth from 2002-2011; and we would note that the annual MFP
growth over the 2002-2004 time period was historically high.
The ASC and HOPD MFP adjustments, on the other hand, are required
by law to be based on forecasts for the appropriate payment period, in
this case through CY 2014. The forecasts of the MFP are completed by
IHS Global Insight, Inc. (IGI). Accordingly, the MFP adjustment
applicable to ASCs and HOPDs is based on the 10-year moving average of
annual MFP growth from 2005-2014. A complete description of the
methodology used to calculate the MFP for the MEI can be found in the
CY 2012 PFS final rule with comment period (76 FR 73300).
Comment: One commenter disagrees with CMS' assessment that there is
not a reliable, ongoing source of data from which to index cost data.
CMS is currently basing the MEI on 2006 data yet it accepted and has
now fully transitioned the results of the Physician Practice
Information Survey (PPIS) as of 2013. The data from PPIS was developed
based on practice costs in 2008. They questioned why the data currently
available would be any less reliable than was used the previous three
times that CMS rebased the MEI. In fact, they claim that the PPIS data
should be more reliable. The commenter acknowledges that data developed
by the MGMA are derived primarily from large urban and suburban
practices and do not adequately capture costs from small and solo
practitioners who do not enjoy the same economies of scale and practice
efficiencies afforded to larger groups. However, the commenter would
support another updated survey of practice costs similar to PPIS that
would also include any elements included within the MEI that were not
previously captured. The commenter suggests that if the time and
resources are going to go into such a study, the survey should include
and be used to update all physician practice expenses.
Response: We believe the commenter misunderstood our statement. We
do believe the AMA PPIS is a reliable data source; however, the PPIS is
not an ongoing data source that is published regularly, such as the
IPPS, SNF, and HHA cost reports. The 2006 AMA PPIS data were used to
determine nine expenditure weights in the 2006-based MEI: physicians'
earnings, physicians' benefits, employed physician payroll, non-
physician compensation, office expenses, PLI, medical equipment,
medical supplies, and other professional expenses. It continues to be
the data source used in the CY 2014 proposed revisions to the MEI. At
this time, the AMA is no longer conducting the PPIS survey.
We concur with the commenter's points regarding the issues
pertaining to the MGMA data and also appreciate the commenter's support
of conducting another practice cost survey similar to the PPIS. We will
be looking into viable options for updating the MEI cost weights going
forward.
Comment: Several commenters appreciated the efforts by CMS to
convene the MEI-TAP, and urged the agency to continue work on the
remaining issues the MEI-TAP identified including consideration of
whether: (1) using self-employed physician data for the MEI cost
weights continues to be the most appropriate approach; (2) additional
data sources could allow more frequent updates to the MEI's cost
categories and their respective weights; and (3) there is a more
appropriate price proxy for Moveable Capital expenses. The commenter
noted that CMS plans to continue to investigate these three issues and
the commenter looks forward to working with CMS in that effort.
Response: We will continue to investigate possible options for the
three remaining MEI-TAP recommendations as they require additional
research regarding possible data sources. Any further changes to the
MEI, in response to MEI-TAP recommendations, will be
[[Page 74275]]
made through future notice and comment rulemaking.
Comment: One commenter noted that although the MEI-TAP recommended
a number of data sources that could be considered to rebase the MEI, it
was unable to identify a reliable, ongoing source of data to do so. The
commenter recommended that CMS consider a sample cost reporting method
rather than a survey similar to the American Medical Association's
(AMA) Physician Practice Information Survey (PPIS) that took place
between 2007 and 2008. The commenter noted that the PPIS was
extraordinarily expensive for the AMA and was plagued by low response
rates. In addition, the commenter noted that the disputed PPIS results
led to significant payment reductions for cardiology. The commenter
notes that CMS is already considering efforts to establish a cost
report for provider-based clinics. The commenter suggests that this
effort could be coupled with a sample of private practice clinics in
order to better measure the MEI.
Response: We thank the commenter for the suggestion. We will be
investigating possible data sources to use for the purpose of rebasing
the MEI in the future. Our research will include the evaluation of
multiple potential data sources including a sampling of clinics and/or
physicians subject to agency resources. If reliable cost report data is
collected for provider-based clinics in the future then we will analyze
and consider its possible use at that time. We remind the commenter
that any new study or survey we conduct would require approval through
OMB's standard survey and auditing process (see ``Standards and
Guidelines for Statistical Surveys'' http://www.whitehouse.gov/sites/default/files/omb/assets/omb/inforeg/statpolicy/standards_stat_surveys.pdf and ``Guidance on Agency Survey and Statistical Information
Collections'' http://www.whitehouse.gov/sites/default/files/omb/assets/omb/inforeg/pmc_survey_guidance_2006.pdf).
Comment: One commenter strongly supports the continued monitoring
of physician productivity growth as it compares to economy-wide growth.
The commenter notes that medical practices have been subjected to a
number of regulatory requirements in recent years that likely impacted
their productivity. To ensure compliance with these regulatory
requirements, physicians often must take actions that reduce practice
productivity, including hiring additional office staff, retaining
attorneys for legal and regulatory compliance, and contracting with
accountants and billing companies to ensure proper processing of
claims. Monitoring of physician productivity growth is necessary to
determine if the continued use of economy-wide productivity growth in
the MEI is appropriate.
Response: At the June 25, 2012 MEI-TAP meeting, we presented
estimates of physician-specific productivity from 1983 to 2010. These
estimates used a resource-based methodology similar to that used by
Charles Fisher to estimate physician office productivity from 1983-2004
as published in the Winter 2007 Health Care Financing Review. The MEI-
TAP had the following finding regarding the physician-specific
productivity estimates:
Finding 5.2: The Panel finds the measures of growth in physician-
specific productivity are of interest for the purpose of comparing the
structure of price increases for physician services versus other
sectors of the economy. The Panel does not recommend using a physician-
specific measure, but does believe that continued monitoring is
appropriate. Use of physician-specific productivity growth to adjust
economy-wide compensation growth in the MEI could introduce
inconsistencies in the calculation of the MEI that could distort the
results. The Panel concludes it is appropriate to continue to require
that the accounting identity between input price growth, output price
growth, and the productivity adjustment be maintained (as is
approximated by the current version of the index).
Per the MEI-TAP's recommendation, we will continue to monitor
trends in physician productivity on a periodic basis and how those
trends move relative to economy-wide productivity.
Comment: A few commenters noted that it will remain difficult for
practicing clinicians to reconcile changes in the MEI with their own
practice cost increases. The projected increase in the proposed MEI for
2014 is just 0.7 percent, but this amount has been reduced by economy-
wide productivity growth of 0.9 percent. Excluding the productivity
adjustment, inflation for medical practices is projected to be 1.6
percent for 2014. In addition, as is the case with any price index,
this amount does not take into account any change in the quantity of
inputs (for example, changes in the number of staff that practices
employ).
Response: We believe the MEI is the most technically appropriate
index available to measure the price growth of inputs involved in
furnishing physician services. We agree that the updates of the MEI do
not take into account any change in the quantity of inputs, since it is
not a cost index. The MEI-TAP was asked to consider whether the index
should continue to be a fixed-weight, Laspeyres-type index. The MEI-TAP
concluded that there is not sufficient evidence that the proportions of
costs represented by the index's inputs vary enough over short periods
of time, nor was there a consistently updated data source available, to
warrant or support a change from using the Laspeyres formulation.
Comment: One commenter believes that a driving flaw in the PE GPCI
is the rent input and its weighting. The commenter indicates the
proposed rule's CY 2014 cost share weight of 10.223 percent is not
representative of the office rent cost share weights of other
physicians. It is also not representative of what the MGMA's cost
survey data seems to indicate is the national office rent cost weight.
Response: As stated in the proposed rule, the PE GPCI office rent
portion (10.223 percent) includes the revised 2006-based MEI cost
weights for fixed capital (reflecting the expenses for rent,
depreciation on medical buildings and mortgage interest) and utilities.
The methodology for determining the fixed capital cost weight (8.957
percent) and utilities cost weight (1.266) is described in the CY 2011
PFS final rule (75 FR 73265).
We believe the weights produced from the methodology are
technically appropriate as it is based on the 2006 AMA PPIS data and
other government data for NAICS 621A00 (Offices of physicians,
dentists, and other health practitioners). We realize that although
individual practice experience may vary, the MEI cost shares must
reflect the cost structure of the average physician office.
Comment: One commenter supported the AMA's call for MEI recognition
of the cost/staffing implications of ever-increasing private and
governmental regulations upon medical practices.
Response: We believe the commenter is expressing that during the
course of our future research into alternative data sources on
physician expenses that we should try to find a data source that would
measure the increased costs that regulations compliance imposes on
physicians practice expenses (for example, additional staffing or costs
associated with moving to more technically advanced record-keeping such
as electronic health records (EHRs)). If we are able to identify an
appropriate data source for physician expenses that is updated and
published on a regular basis, then the associated costs will be
reflected in the relative shares of the various cost categories. In
order to determine cost shares for a year
[[Page 74276]]
later than 2006 we would need an alternative data source that is
reliable, representative, and collected on a more consistent, regular
basis.
Comment: One commenter claimed that the BEA Input-Output (I-O)
tables categorize cost components differently than do medical
practices; that CMS' actuarial conclusions are difficult to follow; and
the industry wide I-O tables do not appear to comport with MGMA cost
survey findings for medical practices. The commenter also stated that
BEA I-O tables seem more focused on and designed to address how the
offices of healthcare professionals utilize products in various
national industries for purposes of assessing the productivity of those
industries rather than to measure cost components of a medical
practice. In that regard, the commenter asserts that the use of the I-O
tables in developing GPCI cost share weights seems not to be an apples-
to-apples relationship.
Response: We disagree with the commenter's claim that the BEA I-O
tables are only to be used for purposes of assessing productivity of
those industries rather than to measure cost components. As stated on
the BEA Web site (http://www.bea.gov/scb/pdf/2007/10%20October/1007_benchmark_io.pdf), the BEA I-O data are based on the highest quality
source data available. They provide an accurate and comprehensive
picture of the inner workings of the economy, showing relationships
among more than 400 industries and commodities. They facilitate the
study of economic activity by providing a highly-detailed look at
inter-industry activity. They also provide the detail that is essential
in determining the quantity weights for price indexes such as the
producer price index that is compiled by the Bureau of Labor Statistics
(BLS). Therefore, our use of the BEA I-O data to derive the detailed
cost weights for the MEI (and by extension the GPCI weights) is
consistent with definition of and uses of the I-O data, as stated by
BEA.
We would also note that CMS' examination of the MGMA cost data
requested by the MEI-TAP found that the data: (1) reflected only group
practice data (practices with greater than three physicians) rather
than data for self-employed physician practices; (2) reflected more IDS
and hospital-owned practices than physician-owned practices; (3) are
not geographically representative; they are underrepresented in high-
cost areas (NY, NJ, CA) and overrepresented in lower cost areas, such
as the southern U.S.; and (4) are skewed toward primary care
specialties relative to the universe of physician specialties.
Additionally, the MGMA data are not publicly available. The BEA I-O
data, on the other hand are based on detailed data from the
quinquennial economic censuses that are conducted by the Bureau of the
Census and show how industries interact at the detailed level;
specifically, they show how approximately 500 industries provide input
to, and use output from, each other to produce gross domestic product.
The data we used in the construction of the MEI are representative of
the entire broader industry as defined by NAICS 621A00, Offices of
Physicians, Dentists and Other Health Professionals; and therefore we
believe it is the most technically appropriate data source available to
use to further disaggregate practice expenses within the MEI.
Comment: One commenter is concerned with CMS' proposal to use the
Employment Cost Index (ECI) for Wages and Salaries for Hospital Workers
(Private Industry) as a price proxy for Non-physician, Health-related
staff compensation. The commenter does not agree with CMS' reasoning
that the ECI for Hospital Workers has an occupational mix that is
reasonably close to the occupational mix in physicians' offices. The
commenter stated that they do not currently have an alternative price
proxy suggestion.
Response: The purpose of the disaggregation of the Non-Physician
Compensation costs to include an additional category for health-related
workers was to be able to more accurately reflect the price inflation
associated with these workers. There are limited health-related ECIs
available. During the MEI-TAP discussions on July 11, 2012, this
limitation was discussed (http://www.cms.gov/Regulations-and-Guidance/Guidance/FACA/MEITAP.html ).
We continue to believe that the ECI for Wages and Salaries for
Hospital Workers (Private Industry) is the most technically appropriate
proxy for the compensation price inflation faced by non-physician,
health related staff in physician offices as this ECI reflects the
highest proportion of health-related staff (as measured by the
Occupational Employment Statistics data) compared to other ECIs. Should
the commenter have alternative price proxy suggestions, we will
consider them in future rulemaking.
Comment: Several commenters agree with the proposed change in the
price proxy for Fixed Capital, since it represents the types of fixed
capital expenses most likely faced by physicians.
Response: We agree with the commenters that the price proxy
proposed for Fixed Capital is more representative of the types of fixed
capital expenses faced by physicians.
6. Final CY 2014 Revisions to the MEI
In general, most commenters supported all of the proposed changes
to the index. The one area where there was concern from commenters was
with the proposal to reclassify expenses for non-physician
practitioners that can independently bill from non-physician
compensation to physician compensation. Based on the public comments,
we did not find any reason to reconsider our proposal, nor did we find
any compelling technical reason that we should not implement this
revision to the MEI. Therefore, we are finalizing our proposal to
reclassify these expenses from non-physician compensation to physician
compensation in the MEI. The effect of moving the expenses related to
clinical staff that can bill independently to physician compensation
category is to increase the physician compensation cost share by 2.600
percentage points and reduce non-physician compensation costs by the
same amount. The revisions we are finalizing include:
Reclassifying expenses for non-physician clinical
personnel that can bill independently from non-physician compensation
to physician compensation.
Revising the physician wage and benefit split so that the
cost weights are more in line with the definitions of the price proxies
used for each category.
Adding an additional subcategory under non-physician
compensation for health-related workers.
Creating a new cost category called ``All Other
Professional Services'' that includes expenses covered in the current
MEI categories: ``All Other Services'' and ``Other Professional
Expenses.'' And further disaggregating the ``All Other Professional
Services'' category into appropriate occupational subcategories.
Creating an aggregate cost category called ``Miscellaneous
Office Expenses'' that would include the expenses for ``Rubber and
Plastics,'' ``Chemicals,'' ``All Other Products,'' and ``Paper.''
Revising the price proxy for physician wages and salaries
from the Average Hourly Earnings (AHE) for the Total Private Nonfarm
Economy for Production and Nonsupervisory Workers to the ECI for Wages
and Salaries, Professional and Related Occupations, Private Industry.
[[Page 74277]]
Revising the price proxy for physician benefits from the
ECI for Benefits for the Total Private Industry to the ECI for
Benefits, Professional and Related Occupations, Private Industry.
Using the ECI for Wages and Salaries and the ECI for
Benefits of Hospital, Civilian workers (private industry) as the price
proxies for the new category of non-physician health-related workers.
Using ECIs to proxy the Professional Services occupational
subcategories that reflect the type of professional services purchased
by physicians' offices.
Revising the price proxy for the fixed capital category
from the CPI for Owners' Equivalent Rent of Residences to the PPI for
Lessors of Nonresidential Buildings (NAICS 53112).
Table 21 shows the final revised 2006-based MEI update for CY 2014
PFS, which is an increase of 0.8 percent. The CY 2014 MEI update would
be the same if using the current 2006-based MEI. This update is based
on historical data through the second quarter of 2013.
Table 21--Annual Percent Change in the CY 2014 Revised 2006-Based MEI
and the Current 2006-Based MEI *
------------------------------------------------------------------------
Final
revised Current
Update year 2006-based 2006-based
MEI MEI
------------------------------------------------------------------------
CY 2014....................................... 0.8 0.8
------------------------------------------------------------------------
* Based on historical data through the 2nd quarter 2013.
For the productivity adjustment, the 10-year moving average percent
change adjustment for CY 2014 is 0.9 percent, which is based on the
most historical data available from BLS at the time of the final rule,
and reflects annual MFP estimates through 2012.
Table 22 shows the Cost Categories, Price Proxies, Cost Share
Weights and the CY 2014 percent changes for each category in the
revised 2006-based MEI. This table summarizes all of the final
revisions to the MEI for CY 2014.
Table 22--Annual Percent Change in the Revised MEI for CY 2014
[All categories] \1\
----------------------------------------------------------------------------------------------------------------
2006 Final
revised cost CY14 update
Revised cost category Revised price proxy weight \2\ (percent) \5\
(percent)
----------------------------------------------------------------------------------------------------------------
MEI........................................... ................................ 100.000 0.8
MFP........................................... 10-yr moving average of Private N/A 0.9
Nonfarm Business Multifactor
Productivity.
MEI without productivity adjustment........... 100.000 1.7
Physician Compensation \3\.................... 50.866 1.9
Wages and Salaries........................ ECI--Wages and salaries-- 43.641 1.9
Professional and Related
(private).
Benefits.................................. ECI--Benefits--Professional and 7.225 2.2
Related (private).
Practice Expense.............................. 49.134 1.4
Non-physician compensation................ 16.553 1.7
Non-physician wages....................... 11.885 1.7
Non-health, non-physician wages........... 7.249 1.8
Professional & Related.................... ECI--Wages And Salaries-- 0.800 1.9
Professional and Related
(Private).
Management................................ ECI--Wages And Salaries-- 1.529 1.8
Management, Business, and
Financial (Private).
Clerical.................................. ECI--Wages And Salaries--Office 4.720 1.8
and Administrative Support
(Private).
Services.................................. ECI--Wages And Salaries--Service 0.200 1.5
Occupations (Private).
Health related, non-physician wages....... ECI--Wages and Salaries - 4.636 1.4
Hospital (civilian).
Non-physician benefits.................... Composite Benefit Index......... 4.668 1.9
Other Practice Expense.................... 32.581 1.2
Utilities................................. CPI Fuels and Utilities......... 1.266 0.7
Miscellaneous Office Expenses............. 2.478 0.3
Chemicals............................. Other Basic Organic Chemical 0.723 -1.2
Manufacturing PPI325190.
Paper................................. PPI for converted paper......... 0.656 1.1
Rubber & Plastics..................... PPI for rubber and plastics..... 0.598 0.5
All other products.................... CPI--All Items Less Food And 0.500 1.9
Energy.
Telephone................................. CPI for Telephone............... 1.501 0.0
Postage................................... CPI for Postage................. 0.898 4.9
All Other Professional Services........... 8.095 1.8
Professional, Scientific, and Tech. ECI--Compensation: Prof. 2.592 1.7
Services. scientific, tech.
Administrative and support & waste.... ECI--Compensation Administrative 3.052 1.9
All Other Services.................... ECI Compensation: Services 2.451 1.6
Occupations.
Capital................................... 10.310 0.7
Fixed................................. PPI for Lessors of 8.957 0.7
nonresidential buildings.
Moveable.............................. PPI for Machinery and Equipment. 1.353 0.7
Professional Liability Insurance\4\....... CMS--Prof. Liability. Phys. 4.295 1.5
Prem. Survey.
Medical Equipment......................... PPI--Med. Inst. & Equip......... 1.978 1.2
[[Page 74278]]
Medical supplies.......................... Composite--PPI Surg. Appl. & 1.760 1.0
CPIU Med. Supplies. (CY2006).
----------------------------------------------------------------------------------------------------------------
\1\ The estimates are based upon the latest available Bureau of Labor Statistics data on the 10-year moving
average of BLS private nonfarm business multifactor productivity published on July 19, 2013 http://www.bls.gov/news.release/prod3.nr0.htm
\2\ The weights shown for the MEI components are the 2006 base-year weights, which may not sum to subtotals or
totals because of rounding. The MEI is a fixed-weight, Laspeyres input price index whose category weights
indicate the distribution of expenditures among the inputs to physicians' services for CY 2006. To determine
the MEI level for a given year, the price proxy level for each component is multiplied by its 2006 weight. The
sum of these products (weights multiplied by the price index levels) yields the composite MEI level for a
given year. The annual percent change in the MEI levels is an estimate of price change over time for a fixed
market basket of inputs to physicians' services.
\3\ The measures of Productivity, Average Hourly Earnings, Employment Cost Indexes, as well as the various
Producer and Consumer Price Indexes can be found on the Bureau of Labor Statistics (BLS) Web site at http://stats.bls.gov.
\4\ Derived from a CMS survey of several major commercial insurers.
\5\ Based on historical data through the 2nd quarter 2013. N/A Productivity is factored into the MEI as a
subtraction from the total index growth rate; therefore, no explicit weight exists for productivity in the
MEI.
E. Establishing RVUs for CY 2014
Section 1848(c)(2)(B) of the Act requires that we review RVUs for
physicians' services no less often than every 5 years. Under section
1848(c)(2)(K) of the Act (as added by section 3134 of the Affordable
Care Act), we are required to identify and revise RVUs for services
identified as potentially misvalued. To facilitate the review and
appropriate adjustment of potentially misvalued services, section
1848(c)(2)(K)(iii) specifies that the Secretary may use existing
processes to receive recommendations; conduct surveys, other data
collection activities, studies, or other analyses as the Secretary
determined to be appropriate; and use analytic contractors to identify
and analyze potentially misvalued services, conduct surveys or collect
data. In accordance with section 1848(c)(2)(K)(iii) of the Act, we
identify potentially misvalued codes, and develop and propose
appropriate adjustments to the RVUs, taking into account the
recommendations provided by the AMA RUC, the Medicare Payment Advisory
Commission (MedPAC), and other public commenters.
For many years, the AMA RUC has provided CMS with recommendations
on the appropriate relative values for PFS services. Over the past
several years, CMS and the AMA RUC have identified and reviewed a
number of potentially misvalued codes on an annual basis, based on
various identification screens for codes at risk for being misvalued.
This annual review of work RVUs and direct PE inputs for potentially
misvalued codes was further bolstered by the Affordable Care Act
mandate to examine potentially misvalued codes, with an emphasis on the
following categories specified in section 1848(c)(2)(K)(ii) of the Act
(as added by section 3134 of the Affordable Care Act):
Codes and families of codes for which there has been the
fastest growth.
Codes or families of codes that have experienced
substantial changes in practice expenses.
Codes that are recently established for new technologies
or services.
Multiple codes that are frequently billed in conjunction
with furnishing a single service.
Codes with low relative values, particularly those that
are often billed multiple times for a single treatment.
Codes which have not been subject to review since the
implementation of the RBRVS (the ``Harvard-valued'' codes).
Other codes determined to be appropriate by the Secretary.
In addition to providing recommendations to CMS for work RVUs, the
AMA RUC's Practice Expense Subcommittee reviews, and then the AMA RUC
recommends, direct PE inputs (clinical labor, disposable supplies, and
medical equipment) for individual services. To guide the establishment
of malpractice RVUs for new and revised codes before each Five-Year
Review of Malpractice, the AMA RUC also provides malpractice crosswalk
recommendations, that is, ``source'' codes with a similar specialty mix
of practitioners furnishing the source code and the new/revised code.
CMS reviews the AMA RUC recommendations on a code-by-code basis.
For AMA RUC recommendations regarding physician work RVUs, after
conducting a clinical review of the codes, we determine whether we
agree with the recommended work RVUs for a service (that is, whether we
agree the AMA RUC recommended valuation is accurate). If we disagree,
we determine an alternative value that better reflects our estimate of
the physician work for the service.
Because of the timing of the CPT Editorial Panel decisions, the AMA
RUC recommendations, and our rulemaking cycle, we publish these work
RVUs in the PFS final rule with comment period as interim final values,
subject to public comment. Similarly, we assess the AMA RUC's
recommendations for direct PE inputs and malpractice crosswalks, and
establish interim final direct PE inputs and malpractice RVUs, which
are also subject to comment. We note that the main aspect of our PE
valuation that is open for public comment for a new, revised, or
potentially misvalued code is the direct PE inputs and not the other
elements of the PE valuation methodology, such as the indirect cost
allocation methodology, that also contribute to establishing the PE
RVUs for a code. The public comment period on the PFS final rule with
comment period remains open for 60 days after the rule is issued.
In the interval between closure of the comment period and the
subsequent year's PFS final rule with comment period, we consider all
of the public comments on the interim final work, PE, and malpractice
RVUs for the new, revised, and potentially misvalued codes and the
results of the refinement panel, if applicable. Finally, we address the
interim final work and malpractice RVUs and interim final direct PE
inputs by providing a summary of the public comments and our responses
to those comments, including a discussion of any changes to the interim
final work or malpractice RVUs or direct PE inputs, in the following
year's PFS final rule with comment period. We then typically finalize
the direct PE inputs and the
[[Page 74279]]
work, PE, and malpractice RVUs for the service in that year's PFS final
rule with comment period, unless we determine it would be more
appropriate to continue their interim final status for another year and
solicit further public comment.
1. Methodology
We conducted a review of each code identified in this section and
reviewed the current work RVU, if one exists, the AMA RUC-recommended
work RVUs, intensity, and time to furnish the preservice, intraservice,
and postservice activities, as well as other components of the service
that contribute to the value. Our review generally includes, but is not
limited to, a review of information provided by the AMA RUC, Health
Care Professionals Advisory Committee (HCPAC), and other public
commenters, medical literature, and comparative databases, as well as a
comparison with other codes within the Medicare PFS, consultation with
other physicians and health care professionals within CMS and the
federal government. We also assessed the methodology and data used to
develop the recommendations submitted to us by the AMA RUC and other
public commenters and the rationale for the recommendations. As we
noted in the CY 2011 PFS final rule with comment period (75 FR 73328
through 73329), there are a variety of methodologies and approaches
used to develop work RVUs, including survey data, building blocks,
crosswalk to key reference or similar codes, and magnitude estimation.
When referring to a survey, unless otherwise noted, we mean the surveys
conducted by specialty societies as part of the formal AMA RUC process.
The building block methodology is used to construct, or deconstruct,
the work RVU for a CPT code based on component pieces of the code.
Components used in the building block approach may include preservice,
intraservice, or postservice time and post-procedure visits. When
referring to a bundled CPT code, the components could be the CPT codes
that make up the bundled code. Magnitude estimation refers to a
methodology for valuing physician work that determines the appropriate
work RVU for a service by gauging the total amount of physician work
for that service relative to the physician work for similar service
across the physician fee schedule without explicitly valuing the
components of that work.
The PFS incorporates cross-specialty and cross-organ system
relativity. Valuing services requires an assessment of relative value
and takes into account the clinical intensity and time required to
furnish a service. In selecting which methodological approach will best
determine the appropriate value for a service, we consider the current
and recommended work and time values, as well as the intensity of the
service, all relative to other services.
Several years ago, to aid in the development of preservice time
recommendations for new and revised CPT codes, the AMA RUC created
standardized preservice time packages. The packages include preservice
evaluation time, preservice positioning time, and preservice scrub,
dress and wait time. Currently there are six preservice time packages
for services typically furnished in the facility setting, reflecting
the different combinations of straightforward or difficult procedure,
straightforward or difficult patient, and without or with sedation/
anesthesia. Currently there are two preservice time packages for
services typically furnished in the nonfacility setting, reflecting
procedures without and with sedation/anesthesia care.
We have developed several standard building block methodologies to
appropriately value services when they have common billing patterns. In
cases where a service is typically furnished to a beneficiary on the
same day as an evaluation and management (E/M) service, we believe that
there is overlap between the two services in some of the activities
furnished during the preservice evaluation and postservice time. We
believe that at least one-third of the physician time in both the
preservice evaluation and postservice period is duplicative of work
furnished during the E/M visit. Accordingly, in cases where we believe
that the AMA RUC has not adequately accounted for the overlapping
activities in the recommended work RVU and/or times, we adjust the work
RVU and/or times to account for the overlap. The work RVU for a service
is the product of the time involved in furnishing the service times the
intensity of the work. Preservice evaluation time and postservice time
both have a long-established intensity of work per unit of time (IWPUT)
of 0.0224, which means that 1 minute of preservice evaluation or
postservice time equates to 0.0224 of a work RVU. Therefore, in many
cases when we remove 2 minutes of preservice time and 2 minutes of
postservice time from a procedure to account for the overlap with the
same day E/M service, we also remove a work RVU of 0.09 (4 minutes x
0.0224 IWPUT) if we do not believe the overlap in time has already been
accounted for in the work RVU. We continue to believe this adjustment
is appropriate. The AMA RUC has recognized this valuation policy and,
in many cases, addresses the overlap in time and work when a service is
typically provided on the same day as an E/M service.
2. Responding to CY 2013 Interim Final RVUs and CY 2014 Proposed RVUs
In this section, we address the interim final values published in
the CY 2013 PFS final rule with comment period, as subsequently
corrected in the correction notice (78 FR 48996), and the proposed
values published in the CY 2014 PFS proposed rule. We discuss the
results of the CY 2013 refinement panel for CY 2013 interim final codes
the panel reviewed, respond to public comments received on specific
interim final and proposed RVUs and direct PE inputs, and address the
other new, revised, or potentially misvalued codes with interim final
or proposed values. The direct PE inputs are listed in a file called
``CY 2014 PFS Direct PE Inputs,'' available on the CMS Web site under
downloads for the CY 2014 PFS final rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The final CY
2014 work, PE, and malpractice RVUs are in Addendum B of a file called
``CY 2014 PFS Addenda,'' available on the CMS Web site under downloads
for the CY 2014 PFS final rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
(a) Finalizing CY 2013 Interim Final Work RVUs for CY 2014
(i) Refinement Panel
(1) Refinement Panel Process
As discussed in the 1993 PFS final rule with comment period (57 FR
55938), we adopted a refinement panel process to assist us in reviewing
the public comments on CPT codes with interim final work RVUs for a
year and in developing final work values for the subsequent year. We
decided the panel would be comprised of a multispecialty group of
physicians who would review and discuss the work involved in each
procedure under review, and then each panel member would individually
rate the work of the procedure. We believed establishing the panel with
a multispecialty group would balance the interests of the specialty
societies who commented on the work RVUs with the budgetary and
redistributive effects that could occur if we accepted extensive
increases in work RVUs across a broad range of services. Depending on
the
[[Page 74280]]
number and range of codes that are subject to refinement in a given
year, we establish refinement panels with representatives from four
groups of physicians: Clinicians representing the specialty identified
with the procedures in question; physicians with practices in related
specialties; primary care physicians; and contractor medical directors
(CMDs). Typical panels have included 8 to 10 physicians across the four
groups.
Following the addition of section 1848(c)(2)(K) to the Act by
Section 3134 of the Affordable Care Act, which required the Secretary
periodically to review potentially misvalued codes and make appropriate
adjustments to the RVUs, we reassessed the refinement panel process. As
detailed in the CY 2011 PFS final rule with comment period (75 FR
73306), we believed that the refinement panel process may provide an
opportunity to review and discuss the proposed and interim final work
RVUs with a clinically diverse group of experts, who then provide
informed recommendations. Therefore, we indicated that we would
continue the refinement process, but with administrative modification
and clarification. We also noted that we would continue using the
established composition that includes representatives from the four
groups of physicians--clinicians representing the specialty identified
with the procedures in question, physicians with practices in related
specialties, primary care physicians, and CMDs.
At that time, we made a change in how we calculated refinement
panel results. The basis of the refinement panel process is that,
following discussion of the information but without an attempt to reach
a consensus, each member of the panel submits an independent rating to
CMS. Historically, the refinement panel's recommendation to change a
work value or to retain the interim final value had hinged solely on
the outcome of a statistical test on the ratings (an F-test of panel
ratings among the groups of participants). Over time, we found the
statistical test used to evaluate the RVU ratings of individual panel
members became less reliable as the physicians in each group tended to
select a previously discussed value, rather than developing a unique
value, thereby reducing the observed variability needed to conduct a
robust statistical test. In addition, reliance on values developed
using the F-test also occasionally resulted in rank order anomalies
among services (that is, a more complex procedure is assigned lower
RVUs than a less complex procedure). As a result, we eliminated the use
of the statistical F-test and instead used the median work value of the
individual panel members' ratings. We said that this approach would
simplify the refinement process administratively, while providing a
result that reflects the summary opinion of the panel members based on
a commonly used measure of central tendency that is not significantly
affected by outlier values.
At the same time, we clarified that we have the final authority to
set the work RVUs, including making adjustments to the work RVUs
resulting from the refinement process, and that we will make such
adjustments if warranted by policy concerns (75 FR 73307).
As we continue to strive to make the refinement panel process as
effective and efficient as possible, we would like to remind readers
that the refinement panels are not intended to review every code for
which we did not accept the AMA RUC-recommended work RVUs. Rather, the
refinement panels are designed for situations where there is new
information available that might provide a reason for a change in work
values and for which a multispecialty panel of physicians might provide
input that would assist us in making work RVU decisions. To facilitate
the selection of services for the refinement panels, we would like to
remind specialty societies seeking reconsideration of interim final
work RVUs, including consideration by a refinement panel, to
specifically state in their public comments that they are requesting
refinement panel review. Furthermore, we have asked commenters
requesting refinement panel review to submit sufficient new information
concerning the clinical aspects of the work assigned for a service to
indicate that referral to the refinement panel is warranted (57 FR
55917).
We note that most of the information presented during the last
several refinement panel discussions has been duplicative of the
information provided to the AMA RUC during its development of
recommendations. As detailed in section II.E.1. of this final rule with
comment period, we consider information and recommendations from the
AMA RUC when assigning proposed and interim final RVUs to services.
Thus, if the only information that a commenter has to present is
information already considered by the AMA RUC, referral to a refinement
panel is not appropriate. To facilitate selection of codes for
refinement, we request that commenters seeking refinement panel review
of work RVUs submit supporting information that has not already been
considered the AMA RUC in creating recommended work RVUs or by CMS in
assigning proposed and interim final work RVUs. We can make best use of
our resources as well as those of the specialties involved and
physician volunteers by avoiding duplicative consideration of
information by the AMA RUC, CMS, and a refinement panel. To achieve
this goal, CMS will continue to critically evaluate the need to refer
codes to refinement panels in future years, specifically considering
any new information provided by commenters.
(2) CY 2013 Interim Final Work RVUs Considered by the Refinement Panel
We referred to the CY 2013 refinement panel 12 CPT codes with CY
2013 interim final work values for which we received a request for
refinement that met the requirements described above. For these 12 CPT
codes, all commenters requested increased work RVUs. For ease of
discussion, we will be referring to these services as ``refinement
codes.'' Consistent with the process described above, we convened a
multi-specialty panel of physicians to assist us in the review of the
information submitted to support increased work RVUs. The panel was
moderated by our physician advisors, and consisted of the following
voting members:
One to two clinicians representing the commenting
organization.
One to two primary care clinicians nominated by the
American Academy of Family Physicians and the American College of
Physicians.
Four Contractor Medical Directors (CMDs).
One to two clinicians with practices in related
specialties, who were expected to have knowledge of the services under
review.
The panel process was designed to capture each participant's
independent judgment and his or her clinical experience which informed
and drove the discussion of the refinement code during the refinement
panel proceedings. Following the discussion, each voting participant
rated the physician work of the refinement code and submitted those
ratings to CMS directly and confidentially. We note that not all voting
participants voted for every CPT code. There was no attempt to achieve
consensus among the panel members. As finalized in the CY 2011 PFS
final rule with comment period (75 FR 73307), we calculated the median
value for each service based upon the individual ratings that were
submitted to CMS by panel participants.
[[Page 74281]]
Table 23 presents information on the work RVUs for the codes
considered by the refinement panel, including the refinement panel
ratings and the final CY 2014 work RVUs. In section II.E.2.a.ii., we
discuss each of the individual codes reviewed by the refinement panel.
Table 23--Codes Reviewed by the 2013 Multi-Specialty Refinement Panel
----------------------------------------------------------------------------------------------------------------
CY 2013 AMA RUC/HCPAC Refinement
HCPCS code Short descriptor interim final recommended panel median CY 2014 work
work RVU work RVU rating RVU
----------------------------------------------------------------------------------------------------------------
35475................. Angioplasty, arterial... 5.75 6.60 6.60 6.60
35476................. Angioplasty, venous..... 4.71 5.10 5.10 5.10
93655................. Arrhythmia ablation add- 7.50 9.00 9.00 7.50
on.
93657................. Afibablation add-on..... 7.50 10.00 10.00 7.50
95886................. EMG extremity add-on.... 0.70 0.92 0.92 0.86
95887................. EMG non-extremity add-on 0.47 0.73 0.73 0.71
95908................. Nerve conduction 1.25 1.37 1.37 1.25
studies; 3-4 studies.
95909................. Nerve conduction 1.50 1.77 1.77 1.50
studies; 5-6 studies.
95910................. Nerve conduction 2.00 2.80 2.80 2.00
studies; 7-8 studies.
95911................. Nerve conduction 2.50 3.34 3.34 2.50
studies; 9-10 studies.
92912................. Nerve conduction 3.00 4.00 4.00 3.00
studies; 11-12 studies.
95913................. Nerve conduction 3.56 4.20 4.20 3.56
studies; 13 or more
studies.
----------------------------------------------------------------------------------------------------------------
(ii) Code-Specific Issues
Table 24 of this final rule with comment period lists all codes
that had a CY 2013 interim final work value. This chart provides the CY
2013 work RVUs, the CY 2014 work RVUs and indicates whether we are
finalizing the CY 2014 work RVUs. If there is no work RVUs listed, a
letter indicates the relevant PFS procedure status indicator. A list of
the PFS procedure status indicators can be found in Addendum A. If the
CY 2014 Action column indicates that the CY 2014 values are interim
final, public comments on these values will be accepted during the
public comment period on this final rule with comment period. The
comprehensive list of all CY 2014 RVUs is in Addendum B to this final
rule with comment period, which is contained in the ``CY 2014 PFS
Addenda'' available on the CMS Web site under downloads for the CY 2014
PFS final rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The comprehensive list of all CY 2013 values
is in Addendum B to the CY 2013 Correction Notice which is contained in
the ``CMS-1590-CN Addenda,'' available on the CMS Web site under
downloads for the CY 2013 correction notice at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The time values for all codes are
listed in a file called ``CY 2014 PFS Physician Time,'' available on
the CMS Web site under downloads for the CY 2014 PFS final rule with
comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
Table 24--Codes With CY 2013 Interim Final Work Values
----------------------------------------------------------------------------------------------------------------
CY 2013 CY 2014
HCPCS code Long descriptor work RVU work RVU CY 2014 action
----------------------------------------------------------------------------------------------------------------
10120..................... Incision and removal of 1.22 1.22 Finalize.
foreign body, subcutaneous
tissues; simple.
11055..................... Paring or cutting of benign 0.35 0.35 Finalize.
hyperkeratotic lesion (eg,
corn or callus); single
lesion.
11056..................... Paring or cutting of benign 0.50 0.50 Finalize.
hyperkeratotic lesion (eg,
corn or callus); 2 to 4
lesions.
11057..................... Paring or cutting of benign 0.65 0.65 Finalize.
hyperkeratotic lesion (eg,
corn or callus); more than 4
lesions.
11300..................... Shaving of epidermal or dermal 0.60 0.60 Finalize.
lesion, single lesion, trunk,
arms or legs; lesion diameter
0.5 cm or less.
11301..................... Shaving of epidermal or dermal 0.90 0.90 Finalize.
lesion, single lesion, trunk,
arms or legs; lesion diameter
0.6 to 1.0 cm.
11302..................... Shaving of epidermal or dermal 1.05 1.05 Finalize.
lesion, single lesion, trunk,
arms or legs; lesion diameter
1.1 to 2.0 cm.
11303..................... Shaving of epidermal or dermal 1.25 1.25 Finalize.
lesion, single lesion, trunk,
arms or legs; lesion diameter
over 2.0 cm.
11305..................... Shaving of epidermal or dermal 0.80 0.80 Finalize.
lesion, single lesion, scalp,
neck, hands, feet, genitalia;
lesion diameter 0.5 cm or
less.
11306..................... Shaving of epidermal or dermal 0.96 0.96 Finalize.
lesion, single lesion, scalp,
neck, hands, feet, genitalia;
lesion diameter 0.6 to 1.0 cm.
11307..................... Shaving of epidermal or dermal 1.20 1.20 Finalize.
lesion, single lesion, scalp,
neck, hands, feet, genitalia;
lesion diameter 1.1 to 2.0 cm.
11308..................... Shaving of epidermal or dermal 1.46 1.46 Finalize.
lesion, single lesion, scalp,
neck, hands, feet, genitalia;
lesion diameter over 2.0 cm.
11310..................... Shaving of epidermal or dermal 0.80 0.80 Finalize.
lesion, single lesion, face,
ears, eyelids, nose, lips,
mucous membrane; lesion
diameter 0.5 cm or less.
11311..................... Shaving of epidermal or dermal 1.10 1.10 Finalize.
lesion, single lesion, face,
ears, eyelids, nose, lips,
mucous membrane; lesion
diameter 0.6 to 1.0 cm.
[[Page 74282]]
11312..................... Shaving of epidermal or dermal 1.30 1.30 Finalize.
lesion, single lesion, face,
ears, eyelids, nose, lips,
mucous membrane; lesion
diameter 1.1 to 2.0 cm.
11313..................... Shaving of epidermal or dermal 1.68 1.68 Finalize.
lesion, single lesion, face,
ears, eyelids, nose, lips,
mucous membrane; lesion
diameter over 2.0 cm.
11719..................... Trimming of nondystrophic 0.17 0.17 Finalize.
nails, any number.
12035..................... Repair, intermediate, wounds 3.50 3.50 Finalize.
of scalp, axillae, trunk and/
or extremities (excluding
hands and feet); 12.6 cm to
20.0 cm.
12036..................... Repair, intermediate, wounds 4.23 4.23 Finalize.
of scalp, axillae, trunk and/
or extremities (excluding
hands and feet); 20.1 cm to
30.0 cm.
12037..................... Repair, intermediate, wounds 5.00 5.00 Finalize.
of scalp, axillae, trunk and/
or extremities (excluding
hands and feet); over 30.0 cm.
12045..................... Repair, intermediate, wounds 3.75 3.75 Finalize.
of neck, hands, feet and/or
external genitalia; 12.6 cm
to 20.0 cm.
12046..................... Repair, intermediate, wounds 4.30 4.30 Finalize.
of neck, hands, feet and/or
external genitalia; 20.1 cm
to 30.0 cm.
12047..................... Repair, intermediate, wounds 4.95 4.95 Finalize.
of neck, hands, feet and/or
external genitalia; over 30.0
cm.
12055..................... Repair, intermediate, wounds 4.50 4.50 Finalize.
of face, ears, eyelids, nose,
lips and/or mucous membranes;
12.6 cm to 20.0 cm.
12056..................... Repair, intermediate, wounds 5.30 5.30 Finalize.
of face, ears, eyelids, nose,
lips and/or mucous membranes;
20.1 cm to 30.0 cm.
12057..................... Repair, intermediate, wounds 6.00 6.00 Finalize.
of face, ears, eyelids, nose,
lips and/or mucous membranes;
over 30.0 cm.
13100..................... Repair, complex, trunk; 1.1 cm 3.00 3.00 Finalize.
to 2.5 cm.
13101..................... Repair, complex, trunk; 2.6 cm 3.50 3.50 Finalize.
to 7.5 cm.
13102..................... Repair, complex, trunk; each 1.24 1.24 Finalize.
additional 5 cm or less (list
separately in addition to
code for primary procedure).
13120..................... Repair, complex, scalp, arms, 3.23 3.23 Finalize.
and/or legs; 1.1 cm to 2.5 cm.
13121..................... Repair, complex, scalp, arms, 4.00 4.00 Finalize.
and/or legs; 2.6 cm to 7.5 cm.
13122..................... Repair, complex, scalp, arms, 1.44 1.44 Finalize.
and/or legs; each additional
5 cm or less (list separately
in addition to code for
primary procedure).
13131..................... Repair, complex, forehead, 3.73 3.73 Finalize.
cheeks, chin, mouth, neck,
axillae, genitalia, hands and/
or feet; 1.1 cm to 2.5 cm.
13132..................... Repair, complex, forehead, 4.78 4.78 Finalize.
cheeks, chin, mouth, neck,
axillae, genitalia, hands and/
or feet; 2.6 cm to 7.5 cm.
13133..................... Repair, complex, forehead, 2.19 2.19 Finalize.
cheeks, chin, mouth, neck,
axillae, genitalia, hands and/
or feet; each additional 5 cm
or less (list separately in
addition to code for primary
procedure).
13150..................... Repair, complex, eyelids, 3.58 D D.
nose, ears and/or lips; 1.0
cm or less.
13151..................... Repair, complex, eyelids, 4.34 4.34 Finalize.
nose, ears and/or lips; 1.1
cm to 2.5 cm.
13152..................... Repair, complex, eyelids, 4.90 5.34 Finalize.
nose, ears and/or lips; 2.6
cm to 7.5 cm.
13153..................... Repair, complex, eyelids, 2.38 2.38 Finalize.
nose, ears and/or lips; each
additional 5 cm or less (list
separately in addition to
code for primary procedure).
20985..................... Computer-assisted surgical 2.50 2.50 Finalize.
navigational procedure for
musculoskeletal procedures,
image-less (list separately
in addition to code for
primary procedure).
22586..................... Arthrodesis, pre-sacral 28.12 28.12 Finalize.
interbody technique,
including disc space
preparation, discectomy, with
posterior instrumentation,
with image guidance, includes
bone graft when performed, l5-
s1 interspace.
23350..................... Injection procedure for 1.00 1.00 Finalize.
shoulder arthrography or
enhanced ct/mri shoulder
arthrography.
23331..................... Removal of foreign body, 7.63 D D.
shoulder; deep (eg, neer
hemiarthroplasty removal).
23332..................... Removal of foreign body, 12.37 D D.
shoulder; complicated (eg,
total shoulder).
23472..................... Arthroplasty, glenohumeral 22.13 22.13 Finalize.
joint; total shoulder
(glenoid and proximal humeral
replacement (eg, total
shoulder)).
23473..................... Revision of total shoulder 25.00 25.00 Finalize.
arthroplasty, including
allograft when performed;
humeral or glenoid component.
23474..................... Revision of total shoulder 27.21 27.21 Finalize.
arthroplasty, including
allograft when performed;
humeral and glenoid component.
23600..................... Closed treatment of proximal 3.00 3.00 Interim Final.
humeral (surgical or
anatomical neck) fracture;
without manipulation.
24160..................... Implant removal; elbow joint.. 8.00 18.63 Interim Final.
24363..................... Arthroplasty, elbow; with 22.00 22.00 Finalize.
distal humerus and proximal
ulnar prosthetic replacement
(eg, total elbow).
24370..................... Revision of total elbow 23.55 23.55 Finalize.
arthroplasty, including
allograft when performed;
humeral or ulnar component.
24371..................... Revision of total elbow 27.50 27.50 Finalize.
arthroplasty, including
allograft when performed;
humeral and ulnar component.
28470..................... Closed treatment of metatarsal 2.03 2.03 Interim Final.
fracture; without
manipulation, each.
29075..................... Application, cast; elbow to 0.77 0.77 Interim Final.
finger (short arm).
29581..................... Application of multi-layer 0.25 0.25 Interim Final.
compression system; leg
(below knee), including ankle
and foot.
[[Page 74283]]
29582..................... Application of multi-layer 0.35 0.35 Interim Final.
compression system; thigh and
leg, including ankle and
foot, when performed.
29583..................... Application of multi-layer 0.25 0.25 Interim Final.
compression system; upper arm
and forearm.
29584..................... Application of multi-layer 0.35 0.35 Interim Final.
compression system; upper
arm, forearm, hand, and
fingers.
29824..................... Arthroscopy, shoulder, 8.98 8.98 Interim Final.
surgical; distal
claviculectomy including
distal articular surface
(mumford procedure).
29826..................... Arthroscopy, shoulder, 3.00 3.00 Interim Final.
surgical; decompression of
subacromial space with
partial acromioplasty, with
coracoacromial ligament (ie,
arch) release, when performed
(list separately in addition
to code for primary
procedure).
29827..................... Arthroscopy, shoulder, 15.59 15.59 Finalize.
surgical; with rotator cuff
repair.
29828..................... Arthroscopy, shoulder, 13.16 13.16 Finalize.
surgical; biceps tenodesis.
31231..................... Nasal endoscopy, diagnostic, 1.10 1.10 Finalize.
unilateral or bilateral
(separate procedure).
31647..................... Bronchoscopy, rigid or 4.40 4.40 Finalize.
flexible, including
fluoroscopic guidance, when
performed; with balloon
occlusion, when performed,
assessment of air leak,
airway sizing, and insertion
of bronchial valve(s),
initial lobe.
31648..................... Bronchoscopy, rigid or 4.20 4.20 Finalize.
flexible, including
fluoroscopic guidance, when
performed; with removal of
bronchial valve(s), initial
lobe.
31649..................... Bronchoscopy, rigid or 1.44 1.44 Finalize.
flexible, including
fluoroscopic guidance, when
performed; with removal of
bronchial valve(s), each
additional lobe (list
separately in addition to
code for primary procedure).
31651..................... Bronchoscopy, rigid or 1.58 1.58 Finalize.
flexible, including
fluoroscopic guidance, when
performed; with balloon
occlusion, when performed,
assessment of air leak,
airway sizing, and insertion
of bronchial valve(s), each
additional lobe (list
separately in addition to
code for primary
procedure[s]).
31660..................... Bronchoscopy, rigid or 4.25 4.25 Finalize.
flexible, including
fluoroscopic guidance, when
performed; with bronchial
thermoplasty, 1 lobe.
31661..................... Bronchoscopy, rigid or 4.50 4.50 Finalize.
flexible, including
fluoroscopic guidance, when
performed; with bronchial
thermoplasty, 2 or more lobes.
32440..................... Removal of lung, pneumonectomy 27.28 27.28 Finalize.
32480..................... Removal of lung, other than 25.82 25.82 Finalize.
pneumonectomy; single lobe
(lobectomy).
32482..................... Removal of lung, other than 27.44 27.44 Finalize.
pneumonectomy; 2 lobes
(bilobectomy).
32491..................... Removal of lung, other than 25.24 25.24 Finalize.
pneumonectomy; with resection-
plication of emphysematous
lung(s) (bullous or non-
bullous) for lung volume
reduction, sternal split or
transthoracic approach,
includes any pleural
procedure, when performed.
32551..................... Tube thoracostomy, includes 3.29 3.29 Finalize.
connection to drainage system
(eg, water seal), when
performed, open (separate
procedure).
32554..................... Thoracentesis, needle or 1.82 1.82 Finalize.
catheter, aspiration of the
pleural space; without
imaging guidance.
32555..................... Thoracentesis, needle or 2.27 2.27 Finalize.
catheter, aspiration of the
pleural space; with imaging
guidance.
32556..................... Pleural drainage, 2.50 2.50 Finalize.
percutaneous, with insertion
of indwelling catheter;
without imaging guidance.
32557..................... Pleural drainage, 3.12 3.12 Finalize.
percutaneous, with insertion
of indwelling catheter; with
imaging guidance.
32663..................... Thoracoscopy, surgical; with 24.64 24.64 Finalize.
lobectomy (single lobe).
32668..................... Thoracoscopy, surgical; with 3.00 3.00 Finalize.
diagnostic wedge resection
followed by anatomic lung
resection (list separately in
addition to code for primary
procedure).
32669..................... Thoracoscopy, surgical; with 23.53 23.53 Finalize.
removal of a single lung
segment (segmentectomy).
32670..................... Thoracoscopy, surgical; with 28.52 28.52 Finalize.
removal of two lobes
(bilobectomy).
32671..................... Thoracoscopy, surgical; with 31.92 31.92 Finalize.
removal of lung
(pneumonectomy).
32672..................... Thoracoscopy, surgical; with 27.00 27.00 Finalize.
resection-plication for
emphysematous lung (bullous
or non-bullous) for lung
volume reduction (lvrs),
unilateral includes any
pleural procedure, when
performed.
32673..................... Thoracoscopy, surgical; with 21.13 21.13 Finalize.
resection of thymus,
unilateral or bilateral.
32701..................... Thoracic target(s) delineation 4.18 4.18 Finalize.
for stereotactic body
radiation therapy (srs/sbrt),
(photon or particle beam),
entire course of treatment.
33361..................... Transcatheter aortic valve 25.13 25.13 Finalize.
replacement (tavr/tavi) with
prosthetic valve;
percutaneous femoral artery
approach.
33362..................... Transcatheter aortic valve 27.52 27.52 Finalize.
replacement (tavr/tavi) with
prosthetic valve; open
femoral artery approach.
33363..................... Transcatheter aortic valve 28.50 28.50 Finalize.
replacement (tavr/tavi) with
prosthetic valve; open
axillary artery approach.
33364..................... Transcatheter aortic valve 30.00 30.00 Finalize.
replacement (tavr/tavi) with
prosthetic valve; open iliac
artery approach.
33365..................... Transcatheter aortic valve 33.12 33.12 Finalize.
replacement (tavr/tavi) with
prosthetic valve; transaortic
approach (eg, median
sternotomy, mediastinotomy).
[[Page 74284]]
33367..................... Transcatheter aortic valve 11.88 11.88 Finalize.
replacement (tavr/tavi) with
prosthetic valve;
cardiopulmonary bypass
support with percutaneous
peripheral arterial and
venous cannulation (eg,
femoral vessels) (list
separately in addition to
code for primary procedure).
33368..................... Transcatheter aortic valve 14.39 14.39 Finalize.
replacement (tavr/tavi) with
prosthetic valve;
cardiopulmonary bypass
support with open peripheral
arterial and venous
cannulation (eg, femoral,
iliac, axillary vessels)
(list separately in addition
to code for primary
procedure).
33369..................... Transcatheter aortic valve 19.00 19.00 Finalize.
replacement (tavr/tavi) with
prosthetic valve;
cardiopulmonary bypass
support with central arterial
and venous cannulation (eg,
aorta, right atrium,
pulmonary artery) (list
separately in addition to
code for primary procedure).
33405..................... Replacement, aortic valve, 41.32 41.32 Finalize.
with cardiopulmonary bypass;
with prosthetic valve other
than homograft or stentless
valve.
33430..................... Replacement, mitral valve, 50.93 50.93 Finalize.
with cardiopulmonary bypass.
33533..................... Coronary artery bypass, using 33.75 33.75 Finalize.
arterial graft(s); single
arterial graft.
33990..................... Insertion of ventricular 8.15 8.15 Finalize.
assist device, percutaneous
including radiological
supervision and
interpretation; arterial
access only.
33991..................... Insertion of ventricular 11.88 11.88 Finalize.
assist device, percutaneous
including radiological
supervision and
interpretation; both arterial
and venous access, with
transseptal puncture.
33992..................... Removal of percutaneous 4.00 4.00 Finalize.
ventricular assist device at
separate and distinct session
from insertion.
33993..................... Repositioning of percutaneous 3.51 3.51 Finalize.
ventricular assist device
with imaging guidance at
separate and distinct session
from insertion.
35475..................... Transluminal balloon 5.75 6.60 Finalize.
angioplasty, percutaneous;
brachiocephalic trunk or
branches, each vessel.
35476..................... Transluminal balloon 4.71 5.10 Finalize.
angioplasty, percutaneous;
venous.
36221..................... Non-selective catheter 4.17 4.17 Finalize.
placement, thoracic aorta,
with angiography of the
extracranial carotid,
vertebral, and/or
intracranial vessels,
unilateral or bilateral, and
all associated radiological
supervision and
interpretation, includes
angiography of the
cervicocerebral arch, when
performed.
36222..................... Selective catheter placement, 5.53 5.53 Finalize.
common carotid or innominate
artery, unilateral, any
approach, with angiography of
the ipsilateral extracranial
carotid circulation and all
associated radiological
supervision and
interpretation, includes
angiography of the
cervicocerebral arch, when
performed.
36223..................... Selective catheter placement, 6.00 6.00 Finalize.
common carotid or innominate
artery, unilateral, any
approach, with angiography of
the ipsilateral intracranial
carotid circulation and all
associated radiological
supervision and
interpretation, includes
angiography of the
extracranial carotid and
cervicocerebral arch, when
performed.
36224..................... Selective catheter placement, 6.50 6.50 Finalize.
internal carotid artery,
unilateral, with angiography
of the ipsilateral
intracranial carotid
circulation and all
associated radiological
supervision and
interpretation, includes
angiography of the
extracranial carotid and
cervicocerebral arch, when
performed.
36225..................... Selective catheter placement, 6.00 6.00 Finalize.
subclavian or innominate
artery, unilateral, with
angiography of the
ipsilateral vertebral
circulation and all
associated radiological
supervision and
interpretation, includes
angiography of the
cervicocerebral arch, when
performed.
36226..................... Selective catheter placement, 6.50 6.50 Finalize.
vertebral artery, unilateral,
with angiography of the
ipsilateral vertebral
circulation and all
associated radiological
supervision and
interpretation, includes
angiography of the
cervicocerebral arch, when
performed.
36227..................... Selective catheter placement, 2.09 2.09 Finalize.
external carotid artery,
unilateral, with angiography
of the ipsilateral external
carotid circulation and all
associated radiological
supervision and
interpretation (list
separately in addition to
code for primary procedure).
36228..................... Selective catheter placement, 4.25 4.25 Finalize.
each intracranial branch of
the internal carotid or
vertebral arteries,
unilateral, with angiography
of the selected vessel
circulation and all
associated radiological
supervision and
interpretation (eg, middle
cerebral artery, posterior
inferior cerebellar artery)
(list separately in addition
to code for primary
procedure).
37197..................... Transcatheter retrieval, 6.29 6.29 Finalize.
percutaneous, of
intravascular foreign body
(eg, fractured venous or
arterial catheter), includes
radiological supervision and
interpretation, and imaging
guidance (ultrasound or
fluoroscopy), when performed.
37211..................... Transcatheter therapy, 8.00 8.00 Finalize.
arterial infusion for
thrombolysis other than
coronary, any method,
including radiological
supervision and
interpretation, initial
treatment day.
37212..................... Transcatheter therapy, venous 7.06 7.06 Finalize.
infusion for thrombolysis,
any method, including
radiological supervision and
interpretation, initial
treatment day.
37213..................... Transcatheter therapy, 5.00 5.00 Finalize.
arterial or venous infusion
for thrombolysis other than
coronary, any method,
including radiological
supervision and
interpretation, continued
treatment on subsequent day
during course of thrombolytic
therapy, including follow-up
catheter contrast injection,
position change, or exchange,
when performed.
[[Page 74285]]
37214..................... Transcatheter therapy, 2.74 2.74 Finalize.
arterial or venous infusion
for thrombolysis other than
coronary, any method,
including radiological
supervision and
interpretation, continued
treatment on subsequent day
during course of thrombolytic
therapy, including follow-up
catheter contrast injection,
position change, or exchange,
when performed.
38240..................... Hematopoietic progenitor cell 3.00 4.00 Finalize.
(hpc); allogeneic
transplantation per donor.
38241..................... Hematopoietic progenitor cell 3.00 3.00 Finalize.
(hpc); autologous
transplantation.
38242..................... Allogeneic lymphocyte 2.11 2.11 Finalize.
infusions.
38243..................... Hematopoietic progenitor cell 2.13 2.13 Finalize.
(hpc); hpc boost.
40490..................... Biopsy of lip................. 1.22 1.22 Finalize.
43206..................... Esophagoscopy, rigid or C 2.39 Interim Final.
flexible; with optical
endomicroscopy.
43252..................... Upper gastrointestinal C 3.06 Interim Final.
endoscopy including
esophagus, stomach, and
either the duodenum and/or
jejunum as appropriate; with
optical endomicroscopy.
44705..................... Preparation of fecal I I Finalize.
microbiota for instillation,
including assessment of donor
specimen.
45330..................... Sigmoidoscopy, flexible; 0.96 0.96 Finalize.
diagnostic, with or without
collection of specimen(s) by
brushing or washing (separate
procedure).
47562..................... Laparoscopy, surgical; 10.47 10.47 Finalize.
cholecystectomy.
47563..................... Laparoscopy, surgical; 11.47 11.47 Finalize.
cholecystectomy with
cholangiography.
47600..................... Cholecystectomy............... 17.48 17.48 Finalize.
47605..................... Cholecystectomy; with 18.48 18.48 Finalize.
cholangiography.
49505..................... Repair initial inguinal 7.96 7.96 Finalize.
hernia, age 5 years or older;
reducible.
50590..................... Lithotripsy, extracorporeal 9.77 9.77 Finalize.
shock wave.
52214..................... Cystourethroscopy, with 3.50 3.50 Finalize.
fulguration (including
cryosurgery or laser surgery)
of trigone, bladder neck,
prostatic fossa, urethra, or
periurethral glands.
52224..................... Cystourethroscopy, with 4.05 4.05 Finalize.
fulguration (including
cryosurgery or laser surgery)
or treatment of minor (less
than 0.5 cm) lesion(s) with
or without biopsy.
52234..................... Cystourethroscopy, with 4.62 4.62 Finalize.
fulguration (including
cryosurgery or laser surgery)
and/or resection of; small
bladder tumor(s) (0.5 up to
2.0 cm).
52235..................... Cystourethroscopy, with 5.44 5.44 Finalize.
fulguration (including
cryosurgery or laser surgery)
and/or resection of; medium
bladder tumor(s) (2.0 to 5.0
cm).
52240..................... Cystourethroscopy, with 7.50 7.50 Finalize.
fulguration (including
cryosurgery or laser surgery)
and/or resection of; large
bladder tumor(s).
52287..................... Cystourethroscopy, with 3.20 3.20 Finalize.
injection(s) for
chemodenervation of the
bladder.
52351..................... Cystourethroscopy, with 5.75 5.75 Finalize.
ureteroscopy and/or
pyeloscopy; diagnostic.
52352..................... Cystourethroscopy, with 6.75 6.75 Finalize.
ureteroscopy and/or
pyeloscopy; with removal or
manipulation of calculus
(ureteral catheterization is
included).
52353..................... Cystourethroscopy, with 7.50 7.50 Finalize.
ureteroscopy and/or
pyeloscopy; with lithotripsy
(ureteral catheterization is
included).
52354..................... Cystourethroscopy, with 8.00 8.00 Finalize.
ureteroscopy and/or
pyeloscopy; with biopsy and/
or fulguration of ureteral or
renal pelvic lesion.
52355..................... Cystourethroscopy, with 9.00 9.00 Finalize.
ureteroscopy and/or
pyeloscopy; with resection of
ureteral or renal pelvic
tumor.
53850..................... Transurethral destruction of 10.08 10.08 Finalize.
prostate tissue; by microwave
thermotherapy.
60520..................... Thymectomy, partial or total; 17.16 17.16 Finalize.
transcervical approach
(separate procedure).
60521..................... Thymectomy, partial or total; 19.18 19.18 Finalize.
sternal split or
transthoracic approach,
without radical mediastinal
dissection (separate
procedure).
60522..................... Thymectomy, partial or total; 23.48 23.48 Finalize.
sternal split or
transthoracic approach, with
radical mediastinal
dissection (separate
procedure).
64450..................... Injection, anesthetic agent; 0.75 0.75 Finalize.
other peripheral nerve or
branch.
64612..................... Chemodenervation of muscle(s); 1.41 1.41 Finalize.
muscle(s) innervated by
facial nerve, unilateral (eg,
for blepharospasm, hemifacial
spasm).
64613..................... Chemodenervation of muscle(s); 2.01 D D.
neck muscle(s) (eg, for
spasmodic torticollis,
spasmodic dysphonia).
64614..................... Chemodenervation of muscle(s); 2.20 D D.
extremity and/or trunk
muscle(s) (eg, for dystonia,
cerebral palsy, multiple
sclerosis).
64615..................... Chemodenervation of muscle(s); 1.85 1.85 Finalize.
muscle(s) innervated by
facial, trigeminal, cervical
spinal and accessory nerves,
bilateral (eg, for chronic
migraine).
64640..................... Destruction by neurolytic 1.23 1.23 Finalize.
agent; other peripheral nerve
or branch.
65222..................... Removal of foreign body, 0.84 0.84 Finalize.
external eye; corneal, with
slit lamp.
65800..................... Paracentesis of anterior 1.53 1.53 Finalize.
chamber of eye (separate
procedure); with removal of
aqueous.
66982..................... Extracapsular cataract removal 11.08 11.08 Finalize.
with insertion of intraocular
lens prosthesis (1-stage
procedure), manual or
mechanical technique (eg,
irrigation and aspiration or
phacoemulsification),
complex, requiring devices or
techniques not generally used
in routine cataract surgery
(eg, iris expansion device,
suture support for
intraocular lens, or primary
posterior capsulorrhexis) or
performed on patients in the
amblyogenic developmental
stage.
66984..................... Extracapsular cataract removal 8.52 8.52 Finalize.
with insertion of intraocular
lens prosthesis (1 stage
procedure), manual or
mechanical technique (eg,
irrigation and aspiration or
phacoemulsification).
67028..................... Intravitreal injection of a 1.44 1.44 Finalize.
pharmacologic agent (separate
procedure).
[[Page 74286]]
67810..................... Incisional biopsy of eyelid 1.18 1.18 Finalize.
skin including lid margin.
68200..................... Subconjunctival injection..... 0.49 0.49 Finalize.
69200..................... Removal foreign body from 0.77 0.77 Finalize.
external auditory canal;
without general anesthesia.
69433..................... Tympanostomy (requiring 1.57 1.57 Finalize.
insertion of ventilating
tube), local or topical
anesthesia.
72040..................... Radiologic examination, spine, 0.22 0.22 Finalize.
cervical; 3 views or less.
72050..................... Radiologic examination, spine, 0.31 0.31 Finalize.
cervical; 4 or 5 views.
72052..................... Radiologic examination, spine, 0.36 0.36 Finalize.
cervical; 6 or more views.
72191..................... Computed tomographic 1.81 1.81 Interim Final.
angiography, pelvis, with
contrast material(s),
including noncontrast images,
if performed, and image
postprocessing.
73221..................... Magnetic resonance (eg, 1.35 1.35 Finalize.
proton) imaging, any joint of
upper extremity; without
contrast material(s).
73721..................... Magnetic resonance (eg, 1.35 1.35 Finalize.
proton) imaging, any joint of
lower extremity; without
contrast material.
74170..................... Computed tomography, abdomen; 1.40 1.40 Finalize.
without contrast material,
followed by contrast
material(s) and further
sections.
74174..................... Computed tomographic 2.20 2.20 Finalize.
angiography, abdomen and
pelvis, with contrast
material(s), including
noncontrast images, if
performed, and image
postprocessing.
74175..................... Computed tomographic 1.90 1.90 Finalize.
angiography, abdomen, with
contrast material(s),
including noncontrast images,
if performed, and image
postprocessing.
74247..................... Radiological examination, 0.69 0.69 Finalize.
gastrointestinal tract,
upper, air contrast, with
specific high density barium,
effervescent agent, with or
without glucagon; with or
without delayed films, with
kub.
74280..................... Radiologic examination, colon; 0.99 0.99 Finalize.
air contrast with specific
high density barium, with or
without glucagon.
74400..................... Urography (pyelography), 0.49 0.49 Finalize.
intravenous, with or without
kub, with or without
tomography.
75896-26.................. Transcatheter therapy, 1.31 1.31 Interim Final.
infusion, other than for
thrombolysis, radiological
supervision and
interpretation.
75896-TC.................. Transcatheter therapy, C C Interim Final.
infusion, other than for
thrombolysis, radiological
supervision and
interpretation.
75898-26.................. Angiography through existing 1.65 1.65 Interim Final.
catheter for follow-up study
for transcatheter therapy,
embolization or infusion,
other than for thrombolysis.
75898-TC.................. Angiography through existing C C Interim Final.
catheter for follow-up study
for transcatheter therapy,
embolization or infusion,
other than for thrombolysis.
76830..................... Ultrasound, transvaginal...... 0.69 0.69 Finalize.
76872..................... Ultrasound, transrectal....... 0.69 0.69 Finalize.
77001..................... Fluoroscopic guidance for 0.38 0.38 Interim Final.
central venous access device
placement, replacement
(catheter only or complete),
or removal (includes
fluoroscopic guidance for
vascular access and catheter
manipulation, any necessary
contrast injections through
access site or catheter with
related venography radiologic
supervision and
interpretation, and
radiographic documentation of
final catheter position)
(list separately in addition
to code for primary
procedure).
77002..................... Fluoroscopic guidance for 0.54 0.54 Interim Final.
needle placement (eg, biopsy,
aspiration, injection,
localization device).
77003..................... Fluoroscopic guidance and 0.60 0.60 Interim Final.
localization of needle or
catheter tip for spine or
paraspinous diagnostic or
therapeutic injection
procedures (epidural or
subarachnoid).
77080..................... Dual-energy x-ray 0.20 0.20 Finalize.
absorptiometry (dxa), bone
density study, 1 or more
sites; axial skeleton (eg,
hips, pelvis, spine).
77082..................... Dual-energy x-ray 0.17 0.17 Finalize.
absorptiometry (dxa), bone
density study, 1 or more
sites; vertebral fracture
assessment.
77301..................... Intensity modulated 7.99 7.99 Finalize.
radiotherapy plan, including
dose-volume histograms for
target and critical structure
partial tolerance
specifications.
78012..................... Thyroid uptake, single or 0.19 0.19 Finalize.
multiple quantitative
measurement(s) (including
stimulation, suppression, or
discharge, when performed).
78013..................... Thyroid imaging (including 0.37 0.37 Finalize.
vascular flow, when
performed).
78014..................... Thyroid imaging (including 0.50 0.50 Finalize.
vascular flow, when
performed); with single or
multiple uptake(s)
quantitative measurement(s)
(including stimulation,
suppression, or discharge,
when performed).
78070..................... Parathyroid planar imaging 0.80 0.80 Finalize.
(including subtraction, when
performed).
78071..................... Parathyroid planar imaging 1.20 1.20 Finalize.
(including subtraction, when
performed); with tomographic
(spect).
78072..................... Parathyroid planar imaging 1.60 1.60 Finalize.
(including subtraction, when
performed); with tomographic
(spect), and concurrently
acquired computed tomography
(ct) for anatomical
localization.
78278..................... Acute gastrointestinal blood 0.99 0.99 Finalize.
loss imaging.
78472..................... Cardiac blood pool imaging, 0.98 0.98 Finalize.
gated equilibrium; planar,
single study at rest or
stress (exercise and/or
pharmacologic), wall motion
study plus ejection fraction,
with or without additional
quantitative processing.
[[Page 74287]]
86153..................... Cell enumeration using 0.69 0.69 Finalize.
immunologic selection and
identification in fluid
specimen (eg, circulating
tumor cells in blood);
physician interpretation and
report, when required.
88120..................... Cytopathology, in situ 1.20 1.20 Interim Final.
hybridization (eg, fish),
urinary tract specimen with
morphometric analysis, 3-5
molecular probes, each
specimen; manual.
88121..................... Cytopathology, in situ 1.00 1.00 Interim Final.
hybridization (eg, fish),
urinary tract specimen with
morphometric analysis, 3-5
molecular probes, each
specimen; using computer-
assisted technology.
88312..................... Special stain including 0.54 0.54 Finalize.
interpretation and report;
group i for microorganisms
(eg, acid fast, methenamine
silver).
88365..................... In situ hybridization (eg, 1.20 1.20 Interim Final.
fish), each probe.
88367..................... Morphometric analysis, in situ 1.30 1.30 Interim Final.
hybridization (quantitative
or semi-quantitative) each
probe; using computer-
assisted technology.
88368..................... Morphometric analysis, in situ 1.40 1.40 Interim Final.
hybridization (quantitative
or semi-quantitative) each
probe; manual.
88375..................... Optical endomicroscopic C I Interim Final.
image(s), interpretation and
report, real-time or
referred, each endoscopic
session.
90785..................... Interactive complexity (list 0.11 0.33 Interim Final.
separately in addition to the
code for primary procedure).
90791..................... Psychiatric diagnostic 2.80 3.00 Interim Final.
evaluation.
90792..................... Psychiatric diagnostic 2.96 3.25 Interim Final.
evaluation with medical
services.
90832..................... Psychotherapy, 30 minutes with 1.25 1.50 Interim Final.
patient and/or family member.
90833..................... Psychotherapy, 30 minutes with 0.98 1.50 Interim Final.
patient and/or family member
when performed with an
evaluation and management
service (list separately in
addition to the code for
primary procedure).
90834..................... Psychotherapy, 45 minutes with 1.89 2.00 Interim Final.
patient and/or family member.
90836..................... Psychotherapy, 45 minutes with 1.60 1.90 Interim Final.
patient and/or family member
when performed with an
evaluation and management
service (list separately in
addition to the code for
primary procedure).
90837..................... Psychotherapy, 60 minutes with 2.83 3.00 Interim Final.
patient and/or family member.
90838..................... Psychotherapy, 60 minutes with 2.56 2.50 Interim Final.
patient and/or family member
when performed with an
evaluation and management
service (list separately in
addition to the code for
primary procedure).
90839..................... Psychotherapy for crisis; C 3.13 Interim Final.
first 60 minutes.
90840..................... Psychotherapy for crisis; each C 1.50 Interim Final.
additional 30 minutes (list
separately in addition to
code for primary service).
90845..................... Psychoanalysis................ 1.79 2.10 Interim Final.
90846..................... Family psychotherapy (without 1.83 2.40 Interim Final.
the patient present).
90847..................... Family psychotherapy (conjoint 2.21 2.50 Interim Final.
psychotherapy) (with patient
present).
90853..................... Group psychotherapy (other 0.59 0.59 Interim Final.
than of a multiple-family
group).
90863..................... Pharmacologic management, I I Interim Final.
including prescription and
review of medication, when
performed with psychotherapy
services (list separately in
addition to the code for
primary procedure).
91112..................... Gastrointestinal transit and 2.10 2.10 Finalize.
pressure measurement, stomach
through colon, wireless
capsule, with interpretation
and report.
92083..................... Visual field examination, 0.50 0.50 Finalize.
unilateral or bilateral, with
interpretation and report;
extended examination (eg,
goldmann visual fields with
at least 3 isopters plotted
and static determination
within the central 30[iexcl],
or quantitative, automated
threshold perimetry, octopus
program g-1, 32 or 42,
humphrey visual field
analyzer full threshold
programs 30-2, 24-2, or 30/60-
2).
92100..................... Serial tonometry (separate 0.61 0.61 Finalize.
procedure) with multiple
measurements of intraocular
pressure over an extended
time period with
interpretation and report,
same day (eg, diurnal curve
or medical treatment of acute
elevation of intraocular
pressure).
92235..................... Fluorescein angiography 0.81 0.81 Finalize.
(includes multiframe imaging)
with interpretation and
report.
92286..................... Anterior segment imaging with 0.40 0.40 Finalize.
interpretation and report;
with specular microscopy and
endothelial cell analysis.
92920..................... Percutaneous transluminal 10.10 10.10 Finalize.
coronary angioplasty; single
major coronary artery or
branch.
92921..................... Percutaneous transluminal B B Finalize.
coronary angioplasty; each
additional branch of a major
coronary artery (list
separately in addition to
code for primary procedure).
92924..................... Percutaneous transluminal 11.99 11.99 Finalize.
coronary atherectomy, with
coronary angioplasty when
performed; single major
coronary artery or branch.
92925..................... Percutaneous transluminal B B Finalize.
coronary atherectomy, with
coronary angioplasty when
performed; each additional
branch of a major coronary
artery (list separately in
addition to code for primary
procedure).
92928..................... Percutaneous transcatheter 11.21 11.21 Finalize.
placement of intracoronary
stent(s), with coronary
angioplasty when performed;
single major coronary artery
or branch.
92929..................... Percutaneous transcatheter B B Finalize.
placement of intracoronary
stent(s), with coronary
angioplasty when performed;
each additional branch of a
major coronary artery (list
separately in addition to
code for primary procedure).
[[Page 74288]]
92933..................... Percutaneous transluminal 12.54 12.54 Finalize.
coronary atherectomy, with
intracoronary stent, with
coronary angioplasty when
performed; single major
coronary artery or branch.
92934..................... Percutaneous transluminal B B Finalize.
coronary atherectomy, with
intracoronary stent, with
coronary angioplasty when
performed; each additional
branch of a major coronary
artery (list separately in
addition to code for primary
procedure).
92937..................... Percutaneous transluminal 11.20 11.20 Finalize.
revascularization of or
through coronary artery
bypass graft (internal
mammary, free arterial,
venous), any combination of
intracoronary stent,
atherectomy and angioplasty,
including distal protection
when performed; single vessel.
92938..................... Percutaneous transluminal B B Finalize.
revascularization of or
through coronary artery
bypass graft (internal
mammary, free arterial,
venous), any combination of
intracoronary stent,
atherectomy and angioplasty,
including distal protection
when performed; each
additional branch subtended
by the bypass graft (list
separately in addition to
code for primary procedure).
92941..................... Percutaneous transluminal 12.56 12.56 Finalize.
revascularization of acute
total/subtotal occlusion
during acute myocardial
infarction, coronary artery
or coronary artery bypass
graft, any combination of
intracoronary stent,
atherectomy and angioplasty,
including aspiration
thrombectomy when performed,
single vessel.
92943..................... Percutaneous transluminal 12.56 12.56 Finalize.
revascularization of chronic
total occlusion, coronary
artery, coronary artery
branch, or coronary artery
bypass graft, any combination
of intracoronary stent,
atherectomy and angioplasty;
single vessel.
92944..................... Percutaneous transluminal B B Finalize.
revascularization of chronic
total occlusion, coronary
artery, coronary artery
branch, or coronary artery
bypass graft, any combination
of intracoronary stent,
atherectomy and angioplasty;
each additional coronary
artery, coronary artery
branch, or bypass graft (list
separately in addition to
code for primary procedure).
93015..................... Cardiovascular stress test 0.75 0.75 Finalize.
using maximal or submaximal
treadmill or bicycle
exercise, continuous
electrocardiographic
monitoring, and/or
pharmacological stress; with
supervision, interpretation
and report.
93016..................... Cardiovascular stress test 0.45 0.45 Finalize.
using maximal or submaximal
treadmill or bicycle
exercise, continuous
electrocardiographic
monitoring, and/or
pharmacological stress;
supervision only, without
interpretation and report.
93018..................... Cardiovascular stress test 0.30 0.30 Finalize.
using maximal or submaximal
treadmill or bicycle
exercise, continuous
electrocardiographic
monitoring, and/or
pharmacological stress;
interpretation and report
only.
93308..................... Echocardiography, 0.53 0.53 Finalize.
transthoracic, real-time with
image documentation (2d),
includes m-mode recording,
when performed, follow-up or
limited study.
93653..................... Comprehensive 15.00 15.00 Finalize.
electrophysiologic evaluation
including insertion and
repositioning of multiple
electrode catheters with
induction or attempted
induction of an arrhythmia
with right atrial pacing and
recording, right ventricular
pacing and recording, his
recording with intracardiac
catheter ablation of
arrhythmogenic focus; with
treatment of supraventricular
tachycardia by ablation of
fast or slow atrioventricular
pathway, accessory
atrioventricular connection,
cavo-tricuspid isthmus or
other single atrial focus or
source of atrial re-entry.
93654..................... Comprehensive 20.00 20.00 Finalize.
electrophysiologic evaluation
including insertion and
repositioning of multiple
electrode catheters with
induction or attempted
induction of an arrhythmia
with right atrial pacing and
recording, right ventricular
pacing and recording, his
recording with intracardiac
catheter ablation of
arrhythmogenic focus; with
treatment of ventricular
tachycardia or focus of
ventricular ectopy including
intracardiac
electrophysiologic 3d
mapping, when performed, and
left ventricular pacing and
recording, when performed.
93655..................... Intracardiac catheter ablation 7.50 7.50 Finalize.
of a discrete mechanism of
arrhythmia which is distinct
from the primary ablated
mechanism, including repeat
diagnostic maneuvers, to
treat a spontaneous or
induced arrhythmia (list
separately in addition to
code for primary procedure).
93656..................... Comprehensive 20.02 20.02 Finalize.
electrophysiologic evaluation
including transseptal
catheterizations, insertion
and repositioning of multiple
electrode catheters with
induction or attempted
induction of an arrhythmia
with atrial recording and
pacing, when possible, right
ventricular pacing and
recording, his bundle
recording with intracardiac
catheter ablation of
arrhythmogenic focus, with
treatment of atrial
fibrillation by ablation by
pulmonary vein isolation.
93657..................... Additional linear or focal 7.50 7.50 Finalize.
intracardiac catheter
ablation of the left or right
atrium for treatment of
atrial fibrillation remaining
after completion of pulmonary
vein isolation (list
separately in addition to
code for primary procedure).
93925..................... Duplex scan of lower extremity 0.80 0.80 Finalize.
arteries or arterial bypass
grafts; complete bilateral
study.
93926..................... Duplex scan of lower extremity 0.50 0.50 Finalize.
arteries or arterial bypass
grafts; unilateral or limited
study.
93970..................... Duplex scan of extremity veins 0.70 0.70 Finalize.
including responses to
compression and other
maneuvers; complete bilateral
study.
[[Page 74289]]
93971..................... Duplex scan of extremity veins 0.45 0.45 Finalize.
including responses to
compression and other
maneuvers; unilateral or
limited study.
95017..................... Allergy testing, any 0.07 0.07 Finalize.
combination of percutaneous
(scratch, puncture, prick)
and intracutaneous
(intradermal), sequential and
incremental, with venoms,
immediate type reaction,
including test interpretation
and report, specify number of
tests.
95018..................... Allergy testing, any 0.14 0.14 Finalize.
combination of percutaneous
(scratch, puncture, prick)
and intracutaneous
(intradermal), sequential and
incremental, with drugs or
biologicals, immediate type
reaction, including test
interpretation and report,
specify number of tests.
95076..................... Ingestion challenge test 1.50 1.50 Finalize.
(sequential and incremental
ingestion of test items, eg,
food, drug or other
substance); initial 120
minutes of testing.
95079..................... Ingestion challenge test 1.38 1.38 Finalize.
(sequential and incremental
ingestion of test items, eg,
food, drug or other
substance); each additional
60 minutes of testing (list
separately in addition to
code for primary procedure).
95782..................... Polysomnography; younger than 2.60 2.60 Finalize.
6 years, sleep staging with 4
or more additional parameters
of sleep, attended by a
technologist.
95783..................... Polysomnography; younger than 2.83 2.83 Finalize.
6 years, sleep staging with 4
or more additional parameters
of sleep, with initiation of
continuous positive airway
pressure therapy or bi-level
ventilation, attended by a
technologist.
95860..................... Needle electromyography; 1 0.96 0.96 Finalize.
extremity with or without
related paraspinal areas.
95861..................... Needle electromyography; 2 1.54 1.54 Finalize.
extremities with or without
related paraspinal areas.
95863..................... Needle electromyography; 3 1.87 1.87 Finalize.
extremities with or without
related paraspinal areas.
95864..................... Needle electromyography; 4 1.99 1.99 Finalize.
extremities with or without
related paraspinal areas.
95865..................... Needle electromyography; 1.57 1.57 Finalize.
larynx.
95866..................... Needle electromyography; 1.25 1.25 Finalize.
hemidiaphragm.
95867..................... Needle electromyography; 0.79 0.79 Finalize.
cranial nerve supplied
muscle(s), unilateral.
95868..................... Needle electromyography; 1.18 1.18 Finalize.
cranial nerve supplied
muscles, bilateral.
95869..................... Needle electromyography; 0.37 0.37 Finalize.
thoracic paraspinal muscles
(excluding t1 or t12).
95870..................... Needle electromyography; 0.37 0.37 Finalize.
limited study of muscles in 1
extremity or non-limb (axial)
muscles (unilateral or
bilateral), other than
thoracic paraspinal, cranial
nerve supplied muscles, or
sphincters.
95885..................... Needle electromyography, each 0.35 0.35 Finalize.
extremity, with related
paraspinal areas, when
performed, done with nerve
conduction, amplitude and
latency/velocity study;
limited (list separately in
addition to code for primary
procedure).
95886..................... Needle electromyography, each 0.70 0.86 Finalize.
extremity, with related
paraspinal areas, when
performed, done with nerve
conduction, amplitude and
latency/velocity study;
complete, five or more
muscles studied, innervated
by three or more nerves or
four or more spinal levels
(list separately in addition
to code for primary
procedure).
95887..................... Needle electromyography, non- 0.47 0.71 Finalize.
extremity (cranial nerve
supplied or axial) muscle(s)
done with nerve conduction,
amplitude and latency/
velocity study (list
separately in addition to
code for primary procedure).
95905..................... Motor and/or sensory nerve 0.05 0.05 Finalize.
conduction, using
preconfigured electrode
array(s), amplitude and
latency/velocity study, each
limb, includes f-wave study
when performed, with
interpretation and report.
95907..................... Nerve conduction studies; 1-2 1.00 1.00 Finalize.
studies.
95908..................... Nerve conduction studies; 3-4 1.25 1.25 Finalize.
studies.
95909..................... Nerve conduction studies; 5-6 1.50 1.50 Finalize.
studies.
95910..................... Nerve conduction studies; 7-8 2.00 2.00 Finalize.
studies.
95911..................... Nerve conduction studies; 9-10 2.50 2.50 Finalize.
studies.
95912..................... Nerve conduction studies; 11- 3.00 3.00 Finalize.
12 studies.
95913..................... Nerve conduction studies; 13 3.56 3.56 Finalize.
or more studies.
95921..................... Testing of autonomic nervous 0.90 0.90 Finalize.
system function; cardiovagal
innervation (parasympathetic
function), including 2 or
more of the following: Heart
rate response to deep
breathing with recorded r-r
interval, valsalva ratio, and
30:15 ratio.
95922..................... Testing of autonomic nervous 0.96 0.96 Finalize.
system function; vasomotor
adrenergic innervation
(sympathetic adrenergic
function), including beat-to-
beat blood pressure and r-r
interval changes during
valsalva maneuver and at
least 5 minutes of passive
tilt.
95923..................... Testing of autonomic nervous 0.90 0.90 Finalize.
system function; sudomotor,
including 1 or more of the
following: Quantitative
sudomotor axon reflex test
(qsart), silastic sweat
imprint, thermoregulatory
sweat test, and changes in
sympathetic skin potential.
95924..................... Testing of autonomic nervous 1.73 1.73 Finalize.
system function; combined
parasympathetic and
sympathetic adrenergic
function testing with at
least 5 minutes of passive
tilt.
95925..................... Short-latency somatosensory 0.54 0.54 Finalize.
evoked potential study,
stimulation of any/all
peripheral nerves or skin
sites, recording from the
central nervous system; in
upper limbs.
95926..................... Short-latency somatosensory 0.54 0.54 Finalize.
evoked potential study,
stimulation of any/all
peripheral nerves or skin
sites, recording from the
central nervous system; in
lower limbs.
95928..................... Central motor evoked potential 1.50 1.50 Interim Final.
study (transcranial motor
stimulation); upper limbs.
95929..................... Central motor evoked potential 1.50 1.50 Interim Final.
study (transcranial motor
stimulation); lower limbs.
[[Page 74290]]
95938..................... Short-latency somatosensory 0.86 0.86 Finalize.
evoked potential study,
stimulation of any/all
peripheral nerves or skin
sites, recording from the
central nervous system; in
upper and lower limbs.
95939..................... Central motor evoked potential 2.25 2.25 Finalize.
study (transcranial motor
stimulation); in upper and
lower limbs.
95940..................... Continuous intraoperative 0.60 0.60 Finalize.
neurophysiology monitoring in
the operating room, one on
one monitoring requiring
personal attendance, each 15
minutes (list separately in
addition to code for primary
procedure).
95941..................... Continuous intraoperative I I Finalize.
neurophysiology monitoring,
from outside the operating
room (remote or nearby) or
for monitoring of more than
one case while in the
operating room, per hour
(list separately in addition
to code for primary
procedure).
95943..................... Simultaneous, independent, C C Finalize.
quantitative measures of both
parasympathetic function and
sympathetic function, based
on time-frequency analysis of
heart rate variability
concurrent with time-
frequency analysis of
continuous respiratory
activity, with mean heart
rate and blood pressure
measures, during rest, paced
(deep) breathing, valsalva
maneuvers, and head-up
postural change.
96920..................... Laser treatment for 1.15 1.15 Finalize.
inflammatory skin disease
(psoriasis); total area less
than 250 sq cm.
96921..................... Laser treatment for 1.30 1.30 Finalize.
inflammatory skin disease
(psoriasis); 250 sq cm to 500
sq cm..
96922..................... Laser treatment for 2.10 2.10 Finalize.
inflammatory skin disease
(psoriasis); over 500 sq cm.
97150..................... Therapeutic procedure(s), 0.65 0.29 Finalize.
group (2 or more individuals).
99485..................... Supervision by a control B B Finalize.
physician of interfacility
transport care of the
critically ill or critically
injured pediatric patient, 24
months of age or younger,
includes two-way
communication with transport
team before transport, at the
referring facility and during
the transport, including data
interpretation and report;
first 30 minutes.
99486..................... Supervision by a control B B Finalize.
physician of interfacility
transport care of the
critically ill or critically
injured pediatric patient, 24
months of age or younger,
includes two-way
communication with transport
team before transport, at the
referring facility and during
the transport, including data
interpretation and report;
each additional 30 minutes
(list separately in addition
to code for primary
procedure).
99487..................... Complex chronic care B B Finalize.
coordination services; first
hour of clinical staff time
directed by a physician or
other qualified health care
professional with no face-to-
face visit, per calendar
month.
99488..................... Complex chronic care B B Finalize.
coordination services; first
hour of clinical staff time
directed by a physician or
other qualified health care
professional with one face-to-
face visit, per calendar
month.
99489..................... Complex chronic care B B Finalize.
coordination services; each
additional 30 minutes of
clinical staff time directed
by a physician or other
qualified health care
professional, per calendar
month (list separately in
addition to code for primary
procedure).
99495..................... Transitional care management 2.11 2.11 Finalize.
services with the following
required elements:
Communication (direct
contact, telephone,
electronic) with the patient
and/or caregiver within 2
business days of discharge
medical decision making of at
least moderate complexity
during the service period
face-to-face visit, within 14
calendar days of discharge.
99496..................... Transitional care management 3.05 3.05 Finalize.
services with the following
required elements:
Communication (direct
contact, telephone,
electronic) with the patient
and/or caregiver within 2
business days of discharge
medical decision making of
high complexity during the
service period face-to-face
visit, within 7 calendar days
of discharge (do not report
90951-90970, 98960-98962,
98966-98969, 99071, 99078,
99080, 99090, 99091, 99339,
99340, 99358, 99359, 99363,
99364, 99366-99368, 99374-
99380, 99441-99444, 99487-
99489, 99605-99607 when
performed during the service
time of codes 99495 or 99496).
G0127..................... Trimming of dystrophic nails, 0.17 0.17 Finalize.
any number.
G0416..................... Surgical pathology, gross and 3.09 3.09 Finalize.
microscopic examinations for
prostate needle biopsy, any
method, 10-20 specimens.
G0452..................... Molecular pathology procedure; 0.37 0.37 Finalize.
physician interpretation and
report.
G0453..................... Continuous intraoperative 0.5 0.6 Finalize.
neurophysiology monitoring,
from outside the operating
room (remote or nearby), per
patient, (attention directed
exclusively to one patient)
each 15 minutes (list in
addition to primary
procedure).
G0455..................... Preparation with instillation 0.97 1.34 Finalize.
of fecal microbiota by any
method, including assessment
of donor specimen.
G0456..................... Negative pressure wound C C Finalize.
therapy, (e.g. vacuum
assisted drainage collection)
using a mechanically-powered
device, not durable medical
equipment, including
provision of cartridge and
dressing(s), topical
application(s), wound
assessment, and instructions
for ongoing care, per
session; total wounds(s)
surface area less than or
equal to 50 square
centimeters.
[[Page 74291]]
G0457..................... Negative pressure wound C C Finalize.
therapy, (e.g. vacuum
assisted drainage collection)
using a mechanically-powered
device, not durable medical
equipment, including
provision of cartridge and
dressing(s), topical
application(s), wound
assessment, and instructions
for ongoing care, per
session; total wounds(s)
surface area greater than 50
square centimeters.
----------------------------------------------------------------------------------------------------------------
In the following section, we discuss all codes for which we
received a comment on the CY 2013 interim final work value or time
during the comment period for the CY 2013 final rule with comment
period or codes for which we are modifying the work RVU or time. If a
code in Table 24 is not discussed in this section, we did not receive
any comments on that code and are finalizing the CY 2013 interim final
value.
(1) Integumentary System: Skin, Subcutaneous, and Accessory Structures
(CPT Code 10120)
As detailed in the CY 2013 final rule with comment period, CPT code
10120 had previously been identified as potentially misvalued using the
Harvard-valued utilization over 30,000 screen. We assigned an interim
final work RVU of 1.22 for CY 2013, which was slightly less than the
AMA RUC-recommended value of 1.25. The AMA RUC recommendation was based
upon survey results; however, we believed an RVU of 1.25 overstated the
work of this procedure because some of the activities furnished during
the postservice period of the procedure code overlapped with the E/M
visit. The AMA RUC appropriately accounted for the overlap with the E/M
visit in its recommendation of preservice time, but we believed the
recommendation failed to account for the overlap in the postservice
time. To account for this overlap, we used our standard methodology as
described above. As noted in the CY 2013 final rule with comment
period, we refined the time to equal 3 minutes in the postservice
physician time for CPT code 10120 for CY 2013.
Comment: Commenters urged us to use the AMA RUC-recommended work
value of 1.25 RVUs and postservice physician time of 5 minutes for CPT
code 10120. Commenters stated that the AMA RUC conducted extensive
review of Medicare claims data for services billed together and after
discussing the potential overlap and explicitly determined physician
time recommendations that did not include overlap with an E/M service.
Since in their view, there was no overlap between the physician time
and the E/M service, they recommended that we value the code as
recommended by the AMA RUC.
Response: After re-review, we maintain that some of the activities
conducted during the postservice time of the procedure code and the E/M
visit overlap and, therefore, should not be counted twice in developing
the procedure's work value. We continue to believe that the recommended
postservice time should be reduced by one-third to account for this
overlap. To calculate the time, we reduced the survey's median
postservice time of 5 minutes by one-third, resulting in a reduction
from 5 minutes to 3 minutes. As such, we also continue to believe that
a work RVU of 1.22 accurately reflects the work of the service relative
to similar services. Therefore, we are finalizing a work RVU of 1.22
for CPT code 10120 and the time refinement as established for CY 2014.
(2) Integumentary System: Skin, Subcutaneous, and Accessory Structures
(CPT Codes 11302, 11306, 11310, 11311, 11312, and 11313)
For these codes, as we discussed in the CY 2013 final rule with
comment period, we set the work RVUs at the survey's 25th percentile
work RVUs as we believed this reflected the appropriate relativity of
the services both within this family as well as relative to other PFS
services. As noted in the CY 2013 final rule with comment period, our
interim final values differed from the AMA RUC recommendation for CPT
codes 11302, 11306, 11310, 11311, 11312 and11313.
Comment: Commenters expressed disappointment with our CY 2013
interim final values for CPT codes 11302, 11306, 11310, 11311, 11312,
and 11313, but without providing reasons to support a higher value.
Response: We continue to believe that the survey's 25th percentile
RVUs accurately reflect the work of these procedures relative to each
other and relative to other procedures. Therefore, for CY 2014 we are
finalizing the CY 2013 interim final work RVU values for CPT codes
11302, 11306, 11310, 11311, 11312 and 11313.
(3) Integumentary System: Repair (Closure) (CPT Codes 13132, 13150,
11351, and 13152)
For CY 2013, we received new recommendations from the AMA RUC for
the complex wound repair family, including CPT codes 13132, 13150,
13151, and 13152. As we described in the CY 2013 final rule with
comment period, we assigned CY 2013 interim final work RVUs consistent
with AMA RUC recommendations for all the codes in this complex wound
repair family, except CPT codes 13150 and 13152, as discussed below. We
assigned the following CY 2013 interim final work RVUs: 4.78 for CPT
code 13132, 3.58 for CPT code 13150, 4.34 for CPT code 13151 and 2.38
for CPT code 13153.
Comment: Commenters agreed with our interim final work RVUs of 4.78
for CPT code 13132 and 4.34 for CPT code 13151 and thanked us for
accepting the AMA RUC-recommendations.
Response: We are finalizing work RVUs for CY 2014 of 4.78 for CPT
code 13132 and 4.34 for CPT code 13151.
The AMA RUC did not provide a recommendation for CPT code 13150 for
CY 2013 with the other codes in the family because it was expecting
that code to be deleted for CY 2014. As we noted in the CY 2013 final
rule with comment period, we believed it was appropriate to reduce the
work RVU of CPT code 13150 proportionate to the reductions in work RVUs
that the AMA RUC recommended and we adopted for other services in the
family, so that we maintained appropriate proportionate rank order for
CY 2013. For the 12 other CPT codes in the family, their CY 2012 work
RVUs were reduced, on average, by 7 percent for CY 2013. Applying that
reduction to the work RVU of CPT code 13150 resulted in a CY 2013 work
RVU of 3.58. We believed that value appropriately reflected the work
associated with the procedure and we assigned a CY 2013 interim final
work RVU of 3.58 to CPT code 13150. This code will be deleted effective
January 1, 2014.
[[Page 74292]]
As we noted in the CY 2013 final rule with comment period, after
reviewing CPT code 13152, we believed that the AMA RUC-recommended work
RVU of 5.34 was too high relative to similar CPT code 13132, which had
an AMA RUC-recommended work RVU of 4.78, and CPT code 13151, which had
an AMA RUC-recommended work RVU of 4.34. We believed that the survey's
25th percentile work RVU of 4.90 more appropriately reflected the
relative work involved in furnishing the service. Therefore, we
assigned a CY 2013 interim final work RVU of 4.90 for CPT code 13152.
Comment: Commenters disagreed with our relative comparison of CPT
code 13152 to CPT codes 13132 and 13151. Commenters stated that the AMA
RUC determined that the survey's 25th percentile work RVU of 4.90 was
too low for CPT code 13152 and would cause a rank order anomaly when
compared to the less intense CPT code 13132. One commenter cited the
detailed rationale that they presented to the AMA RUC explaining how
CPT code 13152 was more intense and complex to perform than CPT code
13132. Furthermore, commenters supported the AMA RUC-recommended direct
crosswalk of CPT code 13152 to CPT code 36571, which has a work RVU of
5.34. Commenters requested that we use the AMA RUC-recommended work RVU
of 5.34 for CPT code 13152.
Response: Based on comments received, we re-reviewed CPT code 13152
and agree based on the complexity and intensity of the service that CPT
code 13152 is more appropriately directly crosswalked to CPT code 36571
which has a work RVU of 5.34. Therefore, we are finalizing the AMA RUC-
recommended work RVU of 5.34 to CPT code 13152 for CY 2014.
(4) Arthrocentesis (CPT Code 20605)
In the CY 2013 final rule with comment period, we revised the
direct PE inputs for CPT code 20605 (Arthrocentesis, aspiration and/or
injection; intermediate joint or bursa (eg, temporomandibular,
acromioclavicular, wrist, elbow or ankle, olecranon bursa)) and valued
the code on an interim final basis for CY 2013. We had revised the work
RVU for this code in CY 2012. In CY 2012, when we revised the work RVU,
we established a value of 0.68 (76 FR 73209). However, in CY 2013 due
to a data entry error, a work RVU of 0.98 was used for CPT 20605.
Subsequent to the publication of the proposed rule, a stakeholder
alerted us to a work RVU discrepancy for this code. The values
displayed in Addenda B and C of the CY 2013 final rule with comment
period reflect this error. In this final rule with comment period we
are making a technical correction to the work RVU, revising it to 0.68,
which is the work value we established in CY 2012.
(5) Musculoskeletal System: Spine (Vertebral Column) (CPT Code 22586)
CPT code 22586 was created by the CPT Editorial Panel effective
January 1, CY 2013. As we noted in the CY 2013 final rule with comment
period, after clinical review of CPT code 22586, we believed that a
work RVU of 28.12 accurately accounted for the work associated with the
service and assigned this as the CY 2013 interim final value. The AMA
RUC did not provide a recommendation on this service because the
specialty societies that would have needed to conduct a survey as part
of the AMA RUC process declined to do so. We also noted that a
specialty society that does not participate in the AMA RUC conducted a
survey of its members, who furnish this service, regarding the work and
time associated with this procedure and submitted a work RVU
recommendation to CMS.
In the CY 2013 final rule with comment period we noted that in
determining the appropriate value for this new CPT code, we reviewed
the survey results and recommendations submitted to us, literature on
the procedure, and Medicare claims data. Ultimately, we used a building
block approach to value CPT code 22586. As we stated in the CY 2013
final rule with comment period, we valued CPT 22586 using CPT code
22558 as a reference service. CPT code 22558 is a similar procedure
except that it does not include additional grafting, instrumentation,
and fixation that are included in CPT code 22586. To assess the
appropriate relative work increase from unbundled CPT code 22558 to the
new bundled CPT code 22586, we used Medicare claims data to assess
which grafting, instrumentation, and fixation services were commonly
billed with CPT code 22558. Using these data we created a utilization-
weighted work RVU for the grafting component of CPT code 22586, the
instrumentation component of the 22586, and the fixation component of
22586. Adding these work RVUs to those of CPT code 22558 created a work
RVU of 28.12, which we assigned as the CY 2013 interim final work RVU
for CPT code 22586.
Additionally, as detailed in the CY 2013 final rule with comment
period, after reviewing the physician time and post-operative visits
for similar services, we concluded that this service includes 40
minutes of preservice evaluation time, 20 minutes of preservice
positioning time, 20 minutes of preservice scrub, dress and wait time,
180 minutes of intraservice time, and 30 minutes of immediate
postservice time. In the post-operative period, we believed that this
service typically includes 2 CPT code 99231 visits, 1 CPT code 99323
visit, 1 CPT code 99238 visit, and 4 CPT code 99213 visits.
Comment: A commenter opposed our use of the building block
methodology to value CPT code 22586, noting that we had used a
methodology that digressed from our current standards for valuing
procedures. Additionally, the commenter disagreed with our use of data
from a specialty society that does not participate in the AMA RUC.
Response: To properly value this service without an AMA RUC
recommendation, we believe that our evaluation of survey results,
recommendations, literature, and Medicare claims data is crucial.
Additionally, as we stated in the methodology section above and in
previous final rules with comment periods, we believe the building
block methodology is an appropriate approach to develop RVUs. We
continue to believe the methodology used to develop the CY 2013 interim
final work RVU using CPT code 22588 as the base reference is suitable
for this code. Furthermore, we believe that the interim final work RVU
accurately reflects the work of the typical case and reflects the
appropriate incremental difference in work between CPT code 22588 and
new CPT code 22586. Therefore, we are finalizing a work RVU of 28.12
for CPT code 22586 for CY 2014.
(6) Elbow Implant Removal (CPT Code 24160)
As detailed in the CY 2013 final rule with comment period, we
maintained the current work value for CPT code 24160 based upon the AMA
RUC recommendation. We received an AMA RUC recommendation for a work
RVU of 18.63 based upon a revised CPT code description for this code.
We agree with the AMA RUC recommendation and are assigning a CY 2014
interim final work RVU of 18.63 to CPT code 24160.
As detailed in the CY 2013 final rule with comment period, in
response to comments we received in response to the CY 2012 final rule
with comment period, we referred CPT code 29581 to the CY 2012 multi-
specialty refinement panel for further review. The refinement panel
median work RVU for CPT code 29581 was 0.50. Typically, we finalize the
work values for CPT codes after reviewing the results of the refinement
[[Page 74293]]
panel. However, for CY 2012 we assigned interim RVUs for CPT codes
29581, 29582, 29583, and 29584 and requested additional information,
with the intention of re-reviewing the services for CY 2013 with the
new information we had received, and setting interim final values at
that time. After consideration of the public comments, refinement panel
median value, and our clinical review, we continued to believe that a
work RVU of 0.25 was appropriate for CPT code 29581. We recognized that
CPT code 29581 received only editorial changes in CY 2012; however, we
continued to believe the HCPAC-reviewed codes 29582, 29583, and 29584
describe similar services. While the services are performed by
different specialties, they do involve similar work. Therefore, we
continued to believe that crosswalking CPT code 29581 to CPT codes
29582, 29583 and 29584 was appropriate and that the resulting work RVU
accurately reflected the work associated with the service. Accordingly,
on an interim final basis for CY 2013, we assigned a work RVU of 0.25
to CPT code 29581; a work RVU of 0.35 to CPT code 29582; a work RVU of
0.25 to CPT code 29583; and a work RVU of 0.35 to CPT code 29584.
Comment: Commenters disagreed with our crosswalk of CPT 29581 to
CPT codes 29582, 29583, and 29584. Commenters stated that it was
incorrect to compare CPT code 29581 to the other codes in the family
because the typical patient for CPT 29581, a patient with a
recalcitrant venous ulcer, is entirely different and more complex than
the typical patient for the other codes, and as a result, CPT 29581 is
a more intense and time-consuming service. Therefore, commenters
requested that we use the AMA RUC-recommended work RVU of 0.60 for CPT
code 29581.
Response: After re-review of CPT code 29581, we maintain that a
crosswalk to CPT codes 29582, 29583, and 29584 is appropriate because
the services involve similar work and as such, should be valued
relative to one another. Even though the typical patient for CPT code
29581 may be different than CPT codes 29582, 29583, and 29584, the work
associated with the service is not necessarily different. Accordingly,
we continue to believe that our recommended value accurately reflects
the work of the procedure and are finalizing a work RVU of 0.25 for CPT
code 29581 for CY 2014.
(8) Respiratory System: Accessory Sinuses (CPT Code 31231)
Previously, CPT code 31231 was identified for review because it was
on the multispecialty points of comparison list. We assigned a CY 2013
interim final work RVU of 1.10 to CPT code 31231, which was the
survey's 25th percentile value and the AMA RUC recommendation. We
believed that some of the activities furnished during the preservice
and postservice period of the procedure code and the E/M visit
overlapped and, therefore, should not be counted twice in developing
the procedure's work value. Although we believed the AMA RUC
appropriately accounted for this overlap in its recommendation of
preservice time, we believed they did not account for the overlap in
the postservice time. To account for this overlap, we reduced the
postservice time by one-third. Specifically, we reduced the postservice
time from 5 minutes to 3 minutes.
Comment: Although commenters supported the use of the AMA RUC-
recommended work RVU, they overwhelmingly disagreed with lowering the
postservice time for CPT code 31231. Commenters stated that the AMA RUC
valued CPT code 31231 through significant review of Medicare claims
data for services billed together and deliberations on potential
overlap, and determined physician time recommendations that did not
include overlap with an E/M service. The commenters stated that none of
the post-time allocated to this code overlapped with the E/M service.
Therefore, commenters requested our acceptance of the AMA RUC-
recommended postservice physician time of 5 minutes.
Response: After re-review, we maintain that some of the activities
conducted during the postservice time of the procedure code and the E/M
visit overlap and, therefore, should not be counted twice in developing
the procedure's work value. To account for this overlap, we used our
standard methodology as described above. Therefore, we are finalizing a
refinement of postservice time and a work RVU of 1.10 for CPT code
31231 for CY 2014.
(9) Respiratory System: Trachea and Bronchi (CPT Codes 31647, 31648,
31649 and 31651)
Effective January 1, 2013, the CPT Editorial Panel created CPT
codes 31647, 31648, 31649, and 31651 to replace 0250T, 0251T; and CPT
codes 31660 and 31661 to replace 0276T and 0277T. As we noted in the CY
2013 final rule with comment period when we valued these codes for the
first time, we assigned a work RVU of 4.40 to CPT code 31647; a work
RVU of 4.20 to CPT code 31648; and a work RVU of 1.58 to CPT code 31651
on an interim final basis for CY 2013, based upon the AMA RUC
recommendations for these codes.
Comment: Commenters agreed with our interim final work for these
codes and thanked us for accepting the AMA RUC recommendations.
Response: We are finalizing work RVUs of 4.40 for CPT code 31647,
4.20 for CPT code 31648 and 1.58 for CPT code 31651 for CY 2014.
As we noted in the CY 2013 final rule with comment period, after
clinical review, we did not agree with the AMA RUC-recommended work RVU
of 2.00 for CPT code 31649. Since CPT code 31647 had a higher work RVU
than CPT code 31648, we believed that to maintain the appropriate
relativity between the services, the add-on code associated with CPT
code 31647 (CPT code 31651) should have a higher RVU than the add-on
code associated with CPT code 31648 (CPT code 31649). We believed that
by valuing CPT code 31649 at the survey's 25th percentile work RVU of
1.44, the services were placed in the appropriate rank order.
Therefore, we assigned a CY 2013 interim final work RVU of 1.44 to CPT
code 31649.
Comment: Commenters urged us to use the AMA RUC-recommended work
value of 2.00 for CPT code 31649 and requested that we refer the code
to the refinement panel. They noted that proper relativity would have
CPT code 31649 ranked higher than CPT code 31651 due to the fact that
valve removal requires greater physician intensity and complexity
compared to insertion.
Response: After evaluation of the request for refinement, we
determined that the criteria for the request for refinement were not
met and, as a result, we did not refer CPT code 31649 to the CY 2013
multi-specialty refinement panel for further review.
After re-review of the work RVUs for CPT code 31649 in light of the
comments submitted, we maintain that our approach in valuing this
procedure is appropriate. Additionally, during clinical re-review we
examined in great detail the physician intensity and complexity
involved in CPT code 31649 and believe that the survey's 25th
percentile work RVU of 1.44 adequately captures these factors.
Furthermore, we believe that the CY 2013 interim final work RVU
accurately reflects the work of the typical case and reflects the
appropriate incremental difference in work with CPT code 31651.
Therefore, we are finalizing a work RVU of 1.44 for CPT code 31649 for
CY 2014.
[[Page 74294]]
(10) Respiratory System: Lungs and Pleura (CPT Codes 32551 and 32557)
We assigned CPT code 32551 a CY 2013 interim final work RVU of
3.29. As we noted in the CY 2013 final rule with comment period, we did
not believe that the 0.21 work RVU increase recommended by the AMA RUC
based upon the survey's 25th percentile work RVU of 3.50 was warranted
for this service, especially considering the substantial reduction in
recommended physician time. Additionally, as we noted in the CY 2013
interim final rule with comment period, we believed that a work RVU of
3.29 placed this service in the appropriate rank order with the other
similar CPT codes reviewed for CY 2013.
Comment: A commenter stated CPT code 32551 should have been
assigned a higher work value than we assigned in CY 2013 and requested
that we use the AMA RUC-recommended work value for the service. The
commenter also pointed out that the work RVU value for 32551 was
reduced a few years ago to account for the vast number of percutaneous
catheter insertions billed with this code. Because the percutaneous
placed catheters, which involve less work, have since been given their
own code set, the commenter stated that the open chest tube insertion
would be the only procedure for which CPT code 32551 could be used. As
such, the commenter believed that if we accepted the idea that a
``properly valued code can be split into less complex and intense
(percutaneous catheter insertion) with lesser value and more complex
and intense (32551, open thoracostomy) of greater value, [we] would
have an appropriate rationale for accepting the RUC recommendations
(25th percentile of the survey, 3.50 RVW) for 32551.''
Response: After review of the comments, we continue to believe that
an increase in work RVU for CPT code 32551 is inappropriate, especially
considering the substantial reduction in the AMA RUC-recommended
physician time. Moreover, we believe that the work RVU of 3.29
accurately reflects the work of the typical case of this service.
Therefore, we are finalizing a work RVU of 3.29 for CPT code 32551 for
CY 2014.
As detailed in the CY 2013 final rule with comment period, CPT code
32557 was created as part of a coding restructure for this family. This
code was assigned a CY 2013 interim final work RVU of 3.12 because we
believed the AMA RUC-recommended work RVU of 3.62 overstated the
difference between this code and CPT code 32556, which had an AMA RUC-
recommended work RVU of 2.50. The specialty societies that surveyed CPT
code 32556 recommended to the AMA RUC a work RVU of 3.00 for CPT code
32556 and a work RVU of 3.62 for CPT code 32557. We believed this
difference of 0.62 in work RVUs between the two codes more accurately
captured the relative difference between the services. Therefore, since
we assigned CPT code 32556 a CY 2013 interim final work RVU of 2.50, we
believed a work RVU of 3.12 reflected the appropriate difference
between CPT codes 32556 and 32557 and appropriately reflected the work
of CPT code 32557.
Additionally, in CY 2013, we refined the AMA RUC-recommended
preservice evaluation time from 15 minutes to 13 minutes for CPT code
32557 to match the preservice evaluation time of CPT code 32556.
Comment: Commenters stated that we did not comprehend the
relationship between the base code, CPT code 32556, without imaging,
and CPT code 32557, with imaging, and the significant clinical
differences in providing the services. Commenters disagreed with the
way we determined the work RVU for CPT 32557 and stated that a better
alternative for valuing CPT code 32557 would have been to add the value
of CT guidance (1.19) to the non-image guided code (CPT code 32556 at
2.50 RVUs) to achieve the AMA RUC-recommended work RVU of 3.62.
Therefore, commenters requested our use of the AMA RUC-recommended work
value of 3.62 for CPT code 32557 and refinement panel review of the
code.
Response: After evaluation of the request for refinement, we
determined that the criteria for the request for refinement were not
met and, as a result, we did not refer CPT code 32557 to the CY 2013
multi-specialty refinement panel for further review.
After re-review of CPT code 32557, we maintain that our approach in
valuing this procedure is appropriate since the AMA RUC-recommended
work RVU of 3.62 overstates the difference between CPT codes 32556 and
32557. We continue to believe that the difference in work RVUs
presented to the AMA RUC by the specialty societies that surveyed CPT
code 32557 is more appropriate in order to maintain relativity among
the codes. Therefore, we are finalizing the refinement to time and the
work RVU of 3.12 for CPT code 32557 for CY 2014.
(11) Respiratory System: Lungs and Pleura (CPT Codes 32663, 32668,
32669, 32670, 32671, 32672, and 32673)
The CPT Editorial Panel reviewed the lung resection family of codes
and deleted 8 codes, revised 5 codes, and created 18 new codes for CY
2012. As detailed in the CY 2012 final rule with comment period, during
our review for the CY 2012 PFS final rule with comment period, we were
concerned with the varying differentials in the AMA RUC-recommended
work RVUs and times between some of the open surgery lung resection
codes and their endoscopic analogs. Rather than assign alternate
interim final RVUs and times in this large restructured family of
codes, we accepted the AMA RUC recommendations on an interim basis for
CY 2012 and requested that the AMA RUC re-review the surgical services
along with their endoscopic analogs.
In the CY 2012 PFS final rule with comment period we made this
request. However, there was an inadvertent typographical error in our
request, in that we referred to ``open heart surgery analogs'' instead
of just ``open surgery analogs'' for each code. For example, we stated,
``For CPT code 32663 (Thoracoscopy, surgical; with lobectomy (single
lobe)), the AMA RUC recommended a work RVU of 24.64. Upon clinical
review, we have determined that it is most appropriate to accept the
AMA RUC-recommended work RVU of 24.64 on a provisional basis, pending
review of the open heart surgery analogs, in this case CPT code 32480.
We are requesting the AMA RUC look at the incremental difference in
RVUs and times between the open and laparoscopic surgeries and
recommend a consistent valuation of RVUs and time for CPT code 32663
and other services within this family with this same issue.
Accordingly, we are assigning a work RVU of 24.64 for CPT code 32663 on
an interim basis for CY 2012'' (76 FR 73195). During the comment period
on the CY 2012 final rule with comment period, the affected specialty
societies and the AMA RUC responded to our request noting that the
codes were not open heart surgery codes.
In the CY 2013 final rule with comment period, we acknowledged that
our request would have been more clear if we had referred to ``open
surgery codes'' instead of ``open heart surgery codes'' and if we had
written ``endoscopic procedures'' instead of ``laparoscopic
surgeries.'' With this clarification, we re-requested public comment on
the appropriate work RVUs and time values for CPT codes 32663 and
32668-32673. For CY 2013, we maintained the following CY 2012 interim
final values for these services as shown in Table 24.
Comment: A commenter stated that there was no apparent correlation
[[Page 74295]]
between the endoscopic and open variations of the procedures and added
that no further effort was needed to determine differences between the
two approaches because ``any such relationship would be spurious at
best.'' The commenter also stated that additional ``exercises to
establish consistent differences in work value according to surgical
approach (when such relationships actually do not exist for clinical
reasons)'' are unnecessary.
Response: We continue to believe that our request for additional
information on the relationship between open and endoscopic procedures
was warranted. Because we received no additional information on this
family, as requested, we are finalizing our CY 2013 interim final
values for this family.
(12) Cardiovascular System: Heart and Pericardium (CPT Codes 33361,
33362, 33363, 33364, 33365, 33367, 33368, 33405, 33430, and 33533)
As detailed in the CY 2013 final rule with comment period, the CPT
Editorial Panel deleted four Category III codes (0256T through 0259T)
and created nine CPT codes (33361 through 33369) to report
transcatheter aortic valve replacement (TAVR) procedures for CY 2012.
Like their predecessor Category III codes (0256T-0259T), the new
Category I CPT codes 33361 through 33365 require the work of an
interventional cardiologist and cardiothoracic surgeon to jointly
participate in the intra-operative technical aspects of TAVR as co-
surgeons. Claims processing instructions for the Coverage with Evidence
Development (CED) (CR 7897 transmittal 2552) requires each physician to
bill with modifier -62 indicating that the co-surgery payment applies.
In this situation, Medicare pays each co-surgeon 62.5 percent of the
fee schedule amount. The three add-on cardiopulmonary bypass support
services (CPT codes 33367, 33368, and 33369) are only reported by the
cardiothoracic surgeon; therefore the AMA RUC-recommended work RVUs for
those services reflected only the work of one physician. The AMA RUC-
recommended work RVUs for each of the co-surgery CPT codes (33361
through 33365) reflect the combined work of both physicians without any
adjustment to reflect the co-surgery payment policy. As we noted in the
CY 2013 final rule with comment period, we considered whether it was
appropriate to continue our co-surgery payment policy at 62.5 percent
of the physician fee schedule amount for each physician for these codes
if the work value reflected 100 percent of the work for two physicians.
Ultimately, we decided to set the work RVU values to reflect the total
work of the procedures, and to continue to follow our co-surgery
payment policy, which allows the services to be billed by two
physicians in part because this was part of the payment policy
established with the CED decision.
As we noted in the CY 2013 final rule with comment period, after
clinical review of CPT code 33361, we believed that the survey's 25th
percentile work RVU of 25.13 appropriately captured the total work of
the service. The AMA RUC recommended the survey's median work RVU of
29.50. Regarding physician time, for CPT 33361, as well as CPT codes
33362 through 33364, we believed 45 minutes of preservice evaluation
time, which was the survey median time, was more consistent with the
work of this service than the AMA RUC-recommended preservice evaluation
time of 50 minutes. Accordingly, we assigned a work RVU of 25.13 to CPT
code 33361, with a refinement of 45 minutes of preservice evaluation
time, on an interim final basis for CY 2013.
As we explained in the CY 2013 interim final rule with comment
period, after clinical review of CPT code 33362, we believed that the
survey's 25th percentile work RVU of 27.52 appropriately captured the
total work of the service and assigned an interim final work RVU of
27.52. The AMA RUC recommended the survey median work RVU of 32.00. As
with CPT code 33361, we believed 45 minutes of preservice evaluation
time was more appropriate for this service than the AMA RUC recommended
preservice evaluation time of 50 minutes. We therefore refined the
preservice evaluation time to 45 minutes.
As we noted in the CY 2013 interim final rule with comment period,
after clinical review of CPT code 33363, we believed that the survey's
25th percentile work RVU of 28.50 appropriately captured the total work
of the service and assigned an interim final work RVU of 28.50. The AMA
RUC recommended the survey median work RVU of 33.00. As with CPT codes
33361 and 33362, we believed 45 minutes of preservice evaluation time
was more appropriate for this service than the AMA RUC recommended time
of 50 minutes and we therefore refined the preservice evaluation time
to 45 minutes.
As we noted in the CY 2013 final rule with comment period, after
clinical review of CPT code 33364, we believed that the survey's 25th
percentile work RVU of 30.00 more appropriately captured the total work
of the service than the AMA RUC-recommended survey median work RVU of
34.87, and therefore, we established an interim final work RVU of
30.00. As with CPT codes 33361-33363, we also believed 45 minutes of
preservice evaluation time was more appropriate for this service than
the AMA RUC-recommended time of 50 minutes, and therefore, we refined
the preservice evaluation time 45 minutes.
As we noted in the CY 2013 final rule with comment period, after
clinical review of CPT code 33365, we believed a work RVU of 33.12
accurately reflected the work associated with this service rather than
the survey's median work RVU of 37.50. We determined that the work
associated with this service was similar to reference CPT code 33410,
which has a work RVU of 46.41 and has a 90-day global period that
includes inpatient hospital and office visits. Because CPT code 33365
had a 0-day global period that does not include post-operative visits,
we calculated the value of the pre-operative and post-operative visits
in the global period of CPT code 33410, which totaled 13.29 work RVUs,
and subtracted that from the total work RVU of 46.41 for CPT code 33410
to determine the appropriate work RVU for CPT code 33365. With regard
to time, we used the 50 minutes of preservice evaluation time because
we believed that the procedure described by CPT code 33365 involves
more preservice evaluation time than 33410 since it was performed by
surgically opening the chest via median sternotomy. Accordingly, we
assigned an interim final work RVU of 33.12 for CPT code 33365 for CY
2013.
Comment: Commenters disagreed with our use of the 25th percentile
survey values for CPT codes 33361-33365 rather than the AMA RUC-
recommended median survey values. Commenters stated that our valuation
of CPT code 33365 was arbitrary and resulted in considerably
undervalued work RVUs. They also asserted that our interim final work
RVUs produced rank order anomalies, were inconsistent with the high
level of intensity and complexity necessitated by the procedures, and
undervalued the procedures for each physician. Additionally, commenters
provided examples comparing the AMA RUC recommendations and the interim
final work RVUs for CPT codes 33361-33365 to other codes that were
recently valued. In providing the examples, commenters made an effort
to demonstrate that, by comparing CPT codes 33361-33365 to active
comparable CPT codes and through proration of the physician time, it
was apparent that the work RVUs for
[[Page 74296]]
CPT codes 33361-33365 should be increased. Commenters therefore
requested we use the AMA RUC-recommended work values of 29.50 for CPT
code 33361, 32.00 for CPT code 33362, 33.00 for CPT code 33363, 34.87
for CPT code 33364 and 37.50 for CPT code 33365 and submit the code
series to the refinement panel for review.
Response: After evaluation of the request for refinement, we
determined that the criteria for the request for refinement were not
met and, as a result, we did not refer CPT codes 33361-33365 to the CY
2013 multi-specialty refinement panel for further review.
After consideration of the comments on CPT codes 33361-33365, we
maintain that our approach in valuing these procedures is appropriate.
We believe that the AMA RUC-recommended work RVUs overstate the
intensity and physician time in this family. We also believe that
setting the work RVU values of these services to reflect the total work
of the procedures is appropriate. This decision is also consistent with
our co-surgery payment policy, which allows the services to be billed
by two physicians. While many commenters objected to this rationale, we
believe that their comparisons of CPT codes 33361-33365, services that
require the work of two physicians, to codes where only one physician
is performing the work are inappropriate. We continue to believe that
the interim final work RVUs that we established in the CY 2013 final
rule with comment period accurately reflect the work of the typical
case of this service. Therefore, for CY 2014, we are finalizing the
interim final work RVUs for CPT codes 33361-33365. We are also
finalizing the following refinements to time for CY 2014: 45 minutes of
preservice evaluation for CPT codes 33361-33364; and 50 minutes of
preservice evaluation for CPT code 33365.
Comment: Commenters specifically agreed with our interim final work
RVUs of 11.88 for CPT code 33367 and 14.39 to CPT code 33368 and
thanked us for using the AMA RUC recommendations.
Response: We are finalizing the work RVUs of 11.88 to CPT code
33367 and 14.39 to CPT code 33368 for CY 2014.
As detailed in the CY 2013 final rule with comment period, CPT
codes 33405, 33430, and 33533 were previously identified as potentially
misvalued through the high expenditure procedure code screen. When
reviewing the services, the specialty society utilized data from the
Society of Thoracic Surgeons (STS) National Adult Cardiac Database in
developing recommended times and work RVUs for CPT codes 33405, 33430
and 33533 rather than conducting a survey of work and time. After
reviewing the mean procedure times for the services in the STS database
alongside other information relating to the value of the services, the
AMA RUC concluded that CPT codes 33405 and 33430 were appropriately
valued and, accordingly, the CY 2012 RVUs of 41.32 for CPT code 33405,
and 50.93 for CPT code 33430 should be maintained, and that the work
associated with CPT code 33553 had increased since the service was last
reviewed. The AMA RUC recommended a work RVU of 34.98 for CPT code
33533, which is a direct crosswalk to CPT code 33510.
As we noted in the CY 2013 final rule with comment period (77 FR
69049), we believed the STS database, which captures outcome data in
addition to time and visit data, is a useful resource in the valuation
of services. However, we remain interested in additional data from the
STS database that might help provide context to the reported
information. The AMA RUC recommendations on the services showed only
the STS database mean time for CPT codes 33405, 33430, and 33533. We
noted in the CY 2013 final rule with comment period that we were
interested in seeing the distribution of times for the 25th percentile,
median, and 75th percentile values, in addition to any other
information STS believed would be relevant to the valuation of the
services. For CY 2013, we assigned interim final work RVUs for the
services, pending receipt of additional time data. Specifically, we
maintained the CY 2012 work RVU values of 41.32 for CPT code 33405;
50.93 for CPT code 33430; and 33.75 for CPT code 33533.
Comment: STS requested a higher work value of CPT code 33533 and
also disagreed with the AMA RUC recommendation. In its opinion, ``the
RUC recommendation is not consistent with the process and alters the
intensity of 33533 contrary to the RUC rationale.'' In contrast, the
AMA RUC stated that the AMA RUC work value recommendation was most
appropriate and asked that we submit the code for refinement panel
review.
In response to our request for additional information regarding
times from the STS database, all commenters declined to provide further
information, stating that sufficient time data and explanations for the
methodology associated with utilization of the database were provided
to both the AMA RUC and CMS. STS further expressed its disinterest in
providing additional information by noting that the supplementary data
that we requested, the median or 25th percentile statistical
descriptors, would ``systematically exclude known physician work from
consideration in code valuation, and if utilized would result in
undervaluation relative to the remainder of the Physician Fee
Schedule.''
Response: After evaluation of the request for refinement, we
determined that the criteria for the request for refinement were not
met and, as a result, we did not refer CPT code 33533 to the CY 2013
multi-specialty refinement panel for further review.
After re-review of CPT codes 33405, 33430 and 33533, we maintain
that our approach in valuing these procedures is appropriate. In the CY
2013 final rule with comment period, we expressed our concern with the
data derived from the STS database and our desire to receive additional
information regarding the distribution of times and varying RVUs, for
the 25th percentile, median, and 75th percentile values, in order to
better value the services. We did not receive additional information
from either STS or the AMA RUC regarding these procedures. In the
absence of this information, we continue to believe that the CY 2013
interim final work RVUs for CPT codes 33405, 33430 and 33533 reflect
the work of the typical case of these services. Therefore, we are
finalizing the work RVUs of 41.32 for CPT code 33405, 50.93 for CPT
code 33430 and 33.75 for CPT code 33533 for CY 2014.
(13) Cardiovascular System: Arteries and Veins (CPT Codes 35475, 35476,
36221-36227)
In the CY 2013 final rule with comment period, after clinical
review of CPT code 35475, we established a work RVU of 5.75 to
appropriately capture the work of the service. The AMA RUC, rather than
using the survey, used a building block approach based on comparison
CPT code 37224, which has a work RVU of 9.00, and recommended a work
RVU of 6.60. The AMA RUC acknowledged that CPT code 35475 was typically
reported with other services. We determined that the appropriate
crosswalk for this code was CPT code 37220, which has a work RVU of
8.15. After accounting for overlap with other services, we determined
that a work RVU of 5.75 was appropriate for the service. Accordingly,
we assigned a work RVU of 5.75 to CPT code 35475 on an interim final
basis for CY 2013.
After clinical review of CPT code 35476, we assigned a work RVU of
4.71 to the service in the CY 2013 final rule with comment period. The
AMA RUC
[[Page 74297]]
had recommended a work RVU of 5.10, based on the survey's 25th
percentile value. We determined that the work associated with CPT code
35476 was similar in terms of physician time and intensity to CPT code
37191, which had a work RVU of 4.71. We believed the work RVU of 4.71
appropriately captured the relative difference between the service and
CPT code 35475. Therefore, we assigned a work RVU of 4.71 for CPT code
35476 on an interim final basis for CY 2013.
Comment: Commenters universally disagreed with our reference codes
for CPT codes 35475 and 35476. They stated that our comparison of CPT
code 35475 to CPT code 37224 did not fully consider intensity or
complexity of CPT code 35475, such as the need for a physician to
perform catheter manipulation or traverse multiple vessels. They also
stated that our comparison of CPT code 35476 to CPT code 37220 was
inappropriate because the latter procedure was related to a service in
a lower flow vein and, thus, using this crosswalk did not account for
the service's work intensity or complexity, including the risk
associated with angioplasty. Commenters believed that the comparison
codes utilized by the AMA RUC in its recommended valuation, CPT codes
37224 and 37220, had a more comparable level of difficulty to CPT codes
35475 and 35476, respectively, than the codes we used. Additionally,
commenters were concerned on a broader policy basis that the interim
final values would compromise both the vascular access care provided to
chronic kidney disease patients and specialty programs. For those
reasons, commenters requested our use of the AMA RUC-recommended work
RVUs of 6.60 for CPT code 35475 and 5.10 for CPT code 35476 and
refinement panel review of the codes.
Response: We referred CPT codes 35475 and 35476 to the CY 2013
multi-specialty refinement panel for further consideration because the
requirements for refinement panel review were met. The refinement panel
median work RVU for CPT codes 35475 and 35476 were 6.60 and 5.10,
respectively. After reevaluation, we are finalizing work RVUs of 6.60
for CPT code 35475 and 5.10 for CPT code 35476, based upon the
refinement panel median.
In the CY 2013 final rule with comment period we assigned CPT code
36221 an interim final work RVU of 4.17 and refined the postservice to
30 minutes. The AMA RUC recommended a work RVU of 4.51 and a
postservice time of 40 minutes using a direct crosswalk to the two
component codes being bundled, CPT code 32600, which has a work RVU of
3.02, and CPT code 75650, which has a work RVU of 1.49. As we noted in
the CY 2013 final rule with comment period, we believed that that there
were efficiencies gained when services were bundled and that
crosswalking to the work RVU of CPT code 32550, which had a work RVU of
4.17, appropriately accounted for the physician time and intensity with
CPT code 36221. Additionally, we believed that the survey's postservice
time of 30 minutes more accurately accounted for the time involved in
furnishing the service than the AMA RUC-recommended postservice time of
40 minutes.
In the CY 2013 final rule with comment period we noted that after
clinical review of CPT code 36222, we believed the survey 25th
percentile work RVU of 5.53 appropriately captured the work of the
service, particularly the efficiencies when two services were bundled
together. The AMA RUC recommended the survey median work RVU of 6.00.
Like CPT code 36221, we believed the survey's postservice time of 30
minutes was more appropriate than the AMA RUC-recommended postservice
time of 40 minutes. We assigned a work RVU of 5.53 with refinement to
time for CPT code 36222 as interim final for CY 2013.
In the CY 2013 final rule, we noted that after clinical review of
CPT code 36223, we assigned an interim final work RVU value of 6.00,
the survey's 25th percentile value, because we believed it
appropriately captured the work of the service, particularly
efficiencies when two services were bundled together. The AMA RUC
reviewed the survey results, and after a comparison to similar CPT
codes, recommended a work RVU of 6.50. Like many other codes in the
family, we believed the survey's postservice time of 30 minutes was
more appropriate than the AMA RUC-recommended time of 40 minutes and
refined the time accordingly.
In the CY 2013 final rule, we noted that after clinical review of
CPT code 36224, we believed a work RVU of 6.50, the survey's 25th
percentile value, appropriately captured the work of the service,
particularly, efficiencies when two services were bundled together. We
believed 30 minutes of postservice time more appropriately accounted
for the work of the service. The AMA RUC reviewed the survey results,
and after a comparison to similar CPT codes, recommended a value of
7.55 and a postservice time of 40 minutes for CPT code 36224.
Accordingly, we assigned a work RVU of 6.50 with refinement to time for
CPT code 36224 as interim final for CY 2013.
In the CY 2013 final rule, we noted that after clinical review of
CPT code 36225, we believed it should be valued the same as the CPT
code 36223, which was assigned an interim final work RVU of 6.00.
Comparable to CPT code 36223, we also believed 30 minutes of
postservice time more appropriately accounted for the work of the
service and refined the time accordingly. The AMA RUC reviewed the
survey results and recommended the survey's median work RVU of 6.50 and
a postservice time of 40 minutes for CPT code 36225.
In the CY 2013 final rule (77 FR 69051), we noted that after
clinical review of CPT code 36226, we believed it should be valued the
same as CPT code 36224, which was assigned work RVU of 6.50. Comparable
to CPT code 36224, we believed 30 minutes of postservice time more
appropriately accounted for the work of the service. The AMA RUC
reviewed the survey results, and after a comparison to similar CPT
codes, recommended a value of 7.55 and a postservice time of 40 minutes
for CPT code 36226. We assigned a work RVU of 6.50 with refinement to
time for CPT code 36226 as interim final for CY 2013.
In the CY 2013 final rule, we noted that after clinical review of
CPT code 36227, we determined that efficiencies were gained when
services were bundled, and identified a work RVU of 2.09 for the
service. A 2.09 work RVU reflected the application of a very
conservative estimate of 10 percent for the work efficiencies that we
expected to occur when multiple component codes were bundled together
to the sum of the work RVUs for the component codes. The AMA RUC
reviewed the survey results, and after a comparison to similar CPT
codes, recommended a value of 2.32 for CPT code 36227. The AMA RUC used
a direct crosswalk to the two component codes being bundled, CPT code
36218, which has a work RVU of 1.01, and CPT code 75660, which has a
work RVU of 1.31. We assigned a CY 2013 interim final work RVU of 2.09.
Comment: Commenters stated that the AMA RUC-recommended work RVUs
captured all of the efficiencies that were achieved by bundling the
services and that our conclusion that these codes values should further
be lowered was unsupported and would produce rank order anomalies among
intervention services. Some stated that for CPT codes 36222, 36223,
36224, 36225 and 36226, the AMA RUC-recommended values represented a
considerable savings to the Medicare system. Commenters
[[Page 74298]]
acknowledged that it may be true that efficiencies occur when surgical
codes are bundled with other surgical codes or radiologic supervision
and interpretation (S&I) codes are bundled with other S&I codes.
However, commenters stated that CPT codes 36221 and 36227 reflects the
bundling of surgical codes with S&I codes and, that since the
activities of surgical codes and S&I codes are, by definition,
separate, they disagreed that efficiencies should be assumed.
Furthermore, commenters stated that it was incorrect for us to directly
crosswalk to other procedures, such as CPT codes 32550, 36251 and
36253, which are easier in nature and entail less risk and less image
interpretation, when more parallel crosswalks existed. As such,
commenters supported the direct crosswalks and the following
recommended work RVUs provided by the AMA RUC: 4.51 for CPT code 36221,
6.00 for CPT code 36222, 6.50 for CPT code 36223, 7.55 for CPT code
36224, 6.50 for CPT code 36225, 7.55 for CPT code 36226 and 2.32 for
CPT code 36227 and requested refinement panel review of the codes.
Response: After evaluation of the request for refinement, we
determined that the criteria for the request for refinement were not
met and, as a result, we did not refer the codes to the CY 2013 multi-
specialty refinement panel for further review.
After re-review of CPT codes 36221-36227, we maintain that the
recommended direct crosswalks for these services are appropriate
because the codes involve similar work and, as such, should be valued
relative to one another. We also disagree with the commenters that
efficiencies do not occur when surgical codes and S&I codes are
bundled. Therefore, we are finalizing the CY 2013 interim final values
for CY 2014 for CPT codes 36221-36227. We are also finalizing the
postservice time refinement of 30 minutes to CPT codes 36221-36226 for
CY 2014.
(14) Cardiovascular System: Arteries and Veins (CPT Codes 37197 and
37214)
As we noted in the CY 2013 final rule with comment period, we
crosswalked the physician time and intensity of CPT code 36247 to CPT
code 37197, resulting in a CY 2013 interim final work RVU of 6.29 for
CPT code 37197. The AMA RUC had recommended a work RVU of 6.72 for CPT
code 37197.
For the CY 2013 final rule with comment period, we assigned an
interim final work RVU of 2.74 to CPT code 37214. In making its
recommendation, the AMA RUC reviewed the survey results, and after a
comparison to similar CPT codes, recommended a work RVU of 3.04 to CPT
code 37214. After clinical review, we determined that there were
efficiencies gained when services were bundled and ultimately used a
very conservative estimate of 10 percent for the work efficiencies we
expected to occur when multiple component codes were bundled.
Specifically, we decreased the AMA RUC-recommended work RVU value of
3.04 by 10 percent to produce the work RVU value of 2.74, which we
assigned as the CY 2103 an interim final work RVU for CPT code 37214.
Comment: Commenters disagreed with these interim final values and
suggested that we finalize the AMA RUC-recommended work RVUs of 6.72
for CPT code 37197 and 3.04 for CPT code 37214 because the services are
more intense and complex than accounted for by the CY 2013 interim
final values. Additionally, several commenters alerted us to our
oversight in not providing a written rationale for our work RVU values
for CPT codes 37197 and 37214 and as result, requested a technical
correction.
Response: The commenters are correct that we did not include a
rationale to explain how we reached the interim final work values for
these codes in the CY 2013 final rule with comment period. However,
Table 30 ``Work RVUs for CY 2013 New, Revised and Potentially Misvalued
Codes'' in the CY 2013 final rule with comment period clearly
identified the interim final values being assigned to these codes. It
also included the AMA RUC recommendations, denoted whether we agreed
with the AMA RUC recommendations, and indicated whether we refined the
times recommended by the AMA RUC.
Based upon the comments received, we re-reviewed CPT codes 37197
and 37214. Based upon our review, we believe that directly crosswalking
CPT code 37197 to CPT code 36247 and reducing CPT code 37214 by a
conservative 10 percent to account for efficiencies gained when
services are bundled are appropriate to establish values for these
services and produce RVUs that fully reflect the typical work and
intensity of the procedures. Therefore, we are finalizing the work RVU
of 6.29 for CPT code 37197 and 2.74 for CPT code 37214 for CY 2014.
(15) Hemic and Lymphatic System: General (CPT Codes 38240 and 38241)
In the CY 2013 final rule, we noted that after review, we believed
CPT code 38240 should have the same work RVU as CPT code 38241 because
the two services involved the same amount of work. The AMA RUC
recommended a work RVU of 4.00 for CPT code 38240 and 3.00 for CPT code
38241. On an interim final basis for CY 2013 we assigned CPT code 38240
a work RVU of 3.00 and agreed with the AMA RUC recommendation of 3.00
for CPT code 38241.
Comment: Commenters specifically opposed our comparison of work for
CPT code 38240 to CPT code 38241, stating that CPT code 38240 was much
more complicated, intense and time consuming than CPT code 38241 and,
as a result, should have a higher work RVU. Commenters also indicated
that CPT 38240 has become more difficult to perform in recent years.
Therefore, commenters requested that we use the AMA RUC-recommended
work RVU of 4.00 for CPT code 38240 and maintain the interim final
value of RVU of 3.00 for CPT code 38241. Commenters asked that both
codes be referred to the refinement panel.
Response: After evaluation of the request for refinement, we
determined that the criteria for the request for refinement were not
met and, as a result, we did not refer CPT codes 38240 and 38241 to the
CY 2013 multi-specialty refinement panel for further review.
Based on comments received, we re-reviewed the codes and agree that
CPT code 38240 is a more involved and intense procedure than CPT code
38241 and as a result, should have a higher RVU valuation for work than
the CY 2013 interim final work RVU. Therefore, we are finalizing the
AMA RUC-recommended work RVU for 4.00 to CPT code 38240 and 3.00 for
CPT code 38241 for CY 2014.
(16) Digestive System: Lips (CPT Code 40490)
As detailed in the CY 2013 final rule with comment period, we
assigned an interim final work RVU of 1.22 to CPT code 40490, as
recommended by the AMA RUC.
Comment: Commenters agreed and expressed appreciation with our use
of the AMA RUC-recommended value.
Response: We are finalizing a work RVU of 1.22 for CPT code 40490
for CY 2014.
(17) Gastrointestinal (GI) Endoscopy (CPT Codes 43206 and 43252)
As detailed in the CY 2013 final rule with comment period, CPT
codes 43206 and 43252 were contractor priced on an interim final basis.
As part of its review of all gastrointestinal endoscopy codes, we
received recommendations from the
[[Page 74299]]
AMA RUC for a work RVU of 2.39 for CPT code 43206 and 3.06 for CPT code
43252. Based upon these recommendations we have the data necessary to
establish RVUs and so are assigning CY 2014 interim final work RVUs of
2.39 for CPT code 43206 and 3.06 for CPT code 43252.
As detailed in the CY 2013 final rule with comment period, we
assigned an interim final work RVU of 3.20 to CPT code 52287 as
recommended by the AMA RUC.
Comment: A specialty association disagreed with our use of the AMA
RUC work RVU recommendation for CPT code 52287. The commenter supported
the survey's use of CPT code 51715 as the key reference code for this
service, but stated that CPT code 52287 should have, at a minimum, the
same RVU as CPT code 51715 because CPT code 52287 requires more
injections and, as a result, a higher level of technical skill and more
time. Therefore, the commenter requested that we accept a work RVU
recommendation of 3.79 for CPT code 52287.
Response: After re-review of CPT code 52287, we maintain that our
interim final value based upon the AMA RUC recommendation is
appropriate. We note that the key reference service CPT code 51715 has
more intraservice time (45 minutes) than CPT code 52287 (21 minutes),
contrary to the commenter's assertion. We continue to believe that a
RVU of 3.20 accurately and fully captures the work required for this
service. Therefore, we are finalizing a work RVU of 3.20 for CPT code
52287 for CY 2014.
(19) Urinary System: Bladder (CPT Code 52353)
We assigned a CY 2013 interim final work RVU of 7.50 for CPT code
52353. As detailed in the CY 2013 final rule with comment period, after
clinical review, we determined that the survey's 25th percentile work
RVU represented a more appropriate incremental difference over the base
code, CPT code 52351, than the AMA RUC-recommended work RVU of 7.88.
Additionally, we believed the survey 25th percentile work RVU more
appropriately accounted for the significant reduction in intraservice
time from the current value.
Comment: Commenters objected to our reduction in the work RVU from
the CY 2012 value and stated that we should use the AMA RUC-recommended
work RVU of 7.88. Commenters said that the skills, effort, and time of
CPT 52353 were more intense than those of CPT code 52351 and our value
did not provide the fully warranted differential between the two codes.
Additionally, commenters initially requested refinement panel review of
CPT code 52353, but later withdrew their request.
Response: Based on comments received, we re-reviewed CPT code 52353
and continue to believe that our interim final work value is
appropriate. We maintain that the survey's 25th percentile work RVU
appropriately accounts for the work of this service, especially given
the significant reduction in intraservice time and the lack of evidence
that the intensity of this procedure has increased. We also believe
that the interim final work value appropriately provides an incremental
difference over the base CPT code 52351. For these reasons, we are
finalizing a work RVU of 7.50 to CPT code 52353 for CY 2014.
(20) Nervous System: Extracranial Nerves, Peripheral Nerves, and
Autonomic Nervous System (CPT Code 64615)
The CPT Editorial Panel created CPT code 64615 effective January 1,
2013. The AMA RUC recommended a work RVU of 1.85 and we agreed with the
recommendation.
The AMA RUC also requested a decrease in the global period from 10
days to 0 days. As we noted in the CY 2013 final rule, we assigned CPT
64615 a global period of 10 days to maintain consistency within the
family of codes.
Comment: Commenters stated that the assigned 10-day global period
was not appropriate because there are no E/M post-operative visits
related to the service, and accordingly, a 0-day global period would
correctly reflect the work involved in, and valuation of, the service.
Additionally, commenters noted that the 10-day global period was
inconsistent with the 0-day global period we adopted for other services
within the family. Commenters requested that we accept the AMA RUC-
recommended global period of 0 days.
Response: Based on comments received, we re-reviewed CPT code 64615
and continue to believe that a 10-day global period is appropriate.
Given that most of the other services within this family of CPT codes
also have 10-day global periods, we continue to believe that a 10-day
global period is appropriate for CPT code 64615. Furthermore, while
there are other chemodenerveration codes in other areas of the body
that do have 0-day global periods, we continue to believe that a 10-day
global period for CPT code 64615 is appropriate in this anatomical
region. Therefore, we are finalizing the work RVU of 1.85 for CPT code
64615, with a 10-day global period, for CY 2014.
(21) Eye and Ocular Adnexa: Eyeball (CPT Code 65222)
CPT code 65222 was identified as potentially misvalued under the
Harvard-valued utilization over 30,000 screen. As we noted in the CY
2013 final rule with comment period, we assigned a work RVU of 0.84 to
CPT code 65222, as well as a refinement to the AMA RUC-recommended
time. Medicare claims data from 2011 indicated that CPT code 65222 was
typically furnished to the beneficiary on the same day as an E/M visit.
We believed that some of the activities furnished during the preservice
and postservice period overlapped with the E/M visit. We did not
believe that the AMA RUC appropriately accounted for this overlap in
its recommendation of preservice and postservice time. To account for
this overlap, we reduced the AMA RUC-recommended preservice evaluation
time by one-third, from 7 minutes to 5 minutes, and the AMA RUC-
recommended postservice time by one-third, from 5 minutes to 3 minutes.
We believed that 5 minutes of preservice evaluation time and 3 minutes
of postservice time accurately reflected the time involved in
furnishing the preservice and postservice work of the procedure, and
that those times were well-aligned with similar services.
Comment: Commenters disagreed with our work RVU and time refinement
for CPT code 65222, stating that they were arbitrary in nature and
based on an incorrect assumption that the overlap between the E/M visit
and the preservice and postservice periods were not properly accounted
for in the AMA RUC recommendation. Commenters stated that the AMA RUC
did take the overlap into consideration and correctly accounted for it
through a decrease in the preservice time from the specialty society
survey determined time of 13 minutes to 7 minutes. Therefore,
commenters requested that we accept the AMA RUC recommendation of a
0.93 work RVU with 7 minutes of preservice time and 5 minutes of
postservice time.
Response: Based on comments received, we re-reviewed CPT code 65222
and continue to believe that our interim final work RVU of 0.84 is
appropriate. We maintain that the AMA RUC did not fully account for the
fact that some of the activities furnished during the preservice and
postservice period of the procedure code overlap with those for the E/M
visit, making the preservice time reductions recommended by the AMA RUC
[[Page 74300]]
insufficient. As such, we continue to believe that 5 minutes of
preservice evaluation time and 3 minutes of postservice time accurately
reflect the physician time involved in furnishing the preservice and
postservice work of this procedure, and that these times are well-
aligned with similar services. Therefore, we are finalizing a work RVU
of 0.84 to CPT code 65222 with 5 minutes of preservice evaluation time
and 3 minutes of postservice, for CY 2014.
(22) Eye and Ocular Adnexa: Ocular Adnexa (CPT Code 67810)
CPT code 67810 was identified as potentially misvalued under the
Harvard-valued utilization over 30,000 screen. On an interim final
basis for CY 2013, we assigned the AMA RUC-recommended work RVU of 1.18
to CPT code 67810, with a refinement to the AMA RUC-recommended time.
As we noted in the CY 2013 final rule with comment period, Medicare
claims data from CY 2011 indicated that CPT code 67810 was typically
furnished to the beneficiary on the same day as an E/M visit. We noted
that that some of the activities furnished during the preservice and
postservice period of the procedure code and the E/M visit overlapped
and that although the AMA RUC appropriately accounted for this overlap
in its recommendation of preservice time, its recommendation for
postservice time was high relative to similar services performed on the
same day as an E/M service. To better account for the overlap in the
postservice period, and to value the service relative to similar
services, we reduced the AMA RUC-recommended postservice time for this
procedure by one-third, from 5 minutes to 3 minutes.
Comment: Commenters believed that our time refinement for CPT code
67810 was unsubstantiated and that we were incorrect in assuming that
the overlap between the E/M visit and the postservice period was not
appropriately accounted for in the AMA RUC recommendation. Commenters
suggested that the AMA RUC did take the overlap into consideration and
appropriately accounted for it by lowering the time recommendations by
nearly 50 percent. Therefore, commenters requested that we accept the
AMA RUC-recommended postservice time of 5 minutes for CPT code 67810.
Response: Based on comments received, we re-reviewed CPT code 67810
and continue to believe that our interim final work RVU of 1.18 and our
time refinement is appropriate. We maintain that the AMA RUC did not
fully account for the fact that some of the activities furnished during
the postservice period of the procedure code overlap with the E/M visit
and that the AMA RUC's time refinements were insufficient. As such, we
continue to believe that 3 minutes of postservice time accurately
reflects the physician time involved in furnishing the postservice work
of this procedure, and that this time is well-aligned with that for
similar services. Therefore, we are finalizing a work RVU of 1.18 to
CPT code 67810 with 3 minutes of postservice time for CY 2014.
(23) Eye and Ocular Adnexa: Conjunctiva (CPT Code 68200)
CPT code 68200 was identified as potentially misvalued under the
Harvard-valued utilization over 30,000 screen. On an interim final
basis for CY 2013, we assigned a work RVU of 0.49 to CPT code 68200,
with a refinement to the AMA RUC-recommended time. As we noted in the
CY 2013 final rule with comment period, Medicare claims data from CY
2011 indicated that CPT code 68200 was typically furnished to the
beneficiary on the same day as an E/M visit. We believed that some of
the activities furnished during the preservice and postservice period
of the procedure code overlapped with the E/M visit. We believed that
the AMA RUC appropriately accounted for this overlap in its
recommendation of preservice time, but did not adequately account for
the overlap in the postservice time. To better account for the overlap
in postservice time, we reduced the AMA RUC-recommended postservice
time for this procedure by one-third, from 5 minutes to 3 minutes.
After reviewing CPT code 68200 and assessing the overlap in time and
work, we agreed with the AMA RUC-recommended work RVU of 0.49 for CY
2013.
Comment: Commenters believed that our time refinement for CPT code
68200 was unsupported and that we assumed incorrectly that the overlap
between the E/M visit and the postservice period was not appropriately
accounted for in the AMA RUC recommendation. Commenters suggested that
the AMA RUC did take the overlap into consideration and completely
accounted for it by lowering the preservice time recommendation.
Therefore, commenters request that we accept the AMA RUC-recommended
postservice time of 5 minutes postservice for CPT code 68200.
Response: After reviewing the comments, we continue to believe that
our refinement of the recommended time is appropriate. We maintain that
the AMA RUC did not fully account for the fact that some of the
activities furnished during the postservice period of the procedure
code overlap with the E/M visit and that the AMA RUC-recommended time
refinements were insufficient. As such, we continue to believe that 3
minutes of postservice time accurately reflects the time involved in
furnishing the postservice work of this procedure, and that this time
is well-aligned with similar services. Therefore, we are finalizing a
work RVU of 0.49 for CPT code 68200 with 3 minutes of postservice time,
for CY 2014.
(24) Eye and Ocular Adnexa: Conjunctiva (CPT Code 69200)
CPT code 69200 was identified as potentially misvalued under the
Harvard-valued utilization over 30,000 screen. On an interim final
basis for CY 2013, we assigned a work RVU of 0.77 to CPT code 69200, as
well as refining to the AMA RUC-recommended time. In the CY 2013 final
rule, we noted that Medicare claims data from 2011 indicated that CPT
code 69200 was typically furnished to the beneficiary on the same day
as an E/M visit and that some of the activities furnished during the
preservice and postservice period of the procedure code overlapped with
the E/M visit. To account for this overlap, we removed one-third of the
preservice evaluation time from the preservice time package, reducing
the preservice evaluation time from 7 minutes to 5 minutes.
Additionally, we reduced the AMA RUC-recommended postservice time for
this procedure by one-third, from 5 minutes to 3 minutes. After
reviewing CPT code 69200 and assessing the overlap in time and work, we
agreed with the AMA RUC-recommended work RVU of 0.77 for CY 2013.
Comment: A commenter thanked us for our acceptance of the AMA RUC-
recommended work for CPT code 69200.
Response: For CY 2014, we are finalizing the interim final work RVU
and time for this code.
(25) Eye and Ocular Adnexa: Conjunctiva (CPT Code 69433)
As detailed in the CY 2013 final rule with comment period, we
assigned an interim final work RVU of 1.57 to CPT code 69433; which the
AMA RUC had recommended.
Comment: A commenter thanked us for our acceptance of the AMA RUC
recommendation.
Response: We are finalizing our interim final work RVU for CY 2014.
[[Page 74301]]
(26) Computed Tomographic (CT) Angiography (CPT Code 72191)
As detailed in the CY 2013 final rule with comment period, CPT code
72191 was assigned a CY 2013 interim final work RVU of 1.81, consistent
with the AMA RUC recommendation.
As detailed in this final rule with comment period, based upon the
AMA RUC recommendations, we are establishing interim final values for
codes within the CT angiography family. To allow for contemporaneous
public comment on this entire family of codes, we are maintaining the
CY 2013 work value for CPT code 72191 as interim final for CY 2014.
(27) Radiologic Guidance: Fluoroscopic Guidance (CPT Codes 77001, 77002
and 77003)
As detailed in the CY 2013 final rule with comment period, CPT
codes 77001, 77002 and 77003 were assigned CY 2013 interim final work
RVUs of 0.38, 0.54 and 0.60, respectively, based upon AMA RUC
recommendations. We received AMA RUC recommendations for work RVUs of
0.38 for CPT code 77001, 0.54 for CPT code 77002 and 0.60 for CPT code
77003.
We agree with the AMA RUC-recommended values but are concerned that
the recommended intraservice times for all three codes are generally
higher than the procedure codes with which they are typically billed.
For example, CPT code 77002 has 15 minutes of intraservice time and CPT
code 20610 (Arthrocentesis, aspiration and/or injection; major joint or
bursa (eg, shoulder, hip, knee joint, subacromial bursa)) has an
intraservice time of only 5 minutes. We are requesting additional
public comment and input from the AMA RUC and other stakeholders
regarding the appropriate relationship between the intraservice time
associated with fluoroscopic guidance and the intraservice time of the
procedure codes with which they are typically billed. Therefore, for CY
2014 we are assigning CY 2014 interim final work RVUs of 0.38 to CPT
code 77001, 0.54 to CPT code 77002 and 0.60 to CPT code 77003.
(28) Radiology (CPT Codes 75896 and 75898)
CPT code 75896 was identified as potentially misvalued through the
codes reported together 75 percent or more screen. As we noted in the
CY 2013 final rule with comment period, the AMA RUC intended to survey
and review CPT codes 75896 and 75898 for CY 2014 as part of their work
on bundling thrombolysis codes. The AMA RUC recommended contractor
pricing these two services for CY 2014. However, since we had
established a national payment rate for the professional component of
these services and only the technical component of the services was
contractor priced at that time, we maintained the national price on the
professional component and continued contractor pricing for the
technical component for these codes on an interim final basis for CY
2013.
We did not receive any comments on these codes nor did we receive
any recommendations from the AMA RUC. As we anticipate receiving AMA
RUC recommendations for these codes, we are maintaining the current
pricing on an interim final basis for CY 2014.
(29) Pathology (CPT Codes 88120, 88121, 88365, 88367, and 88368)
The CPT Editorial Panel created CPT 88120 and 88121 effective for
CY 2011. In the CY 2012 PFS final rule with comment period, we assigned
interim final work RVUs of 1.20 and 1.00 to CPT codes 88120 and 88121,
respectively. We maintained the 2012 work RVUs for 88120 and 88121 as
interim final for CY 2013. Additionally, we expressed concern about
potential payment disparities between these codes and similar codes,
CPT codes 88365, 88367 and 88368, and asked the AMA RUC to review the
work and PE for these codes to ensure the appropriate relativity
between the two sets of services. Since the AMA RUC is reviewing CPT
codes 88365, 88367, and 88368, we are establishing CY 2014 interim
final work RVUs of 1.20 for CPT code 88365, 1.30 for CPT code 88367,
and 1.40 for CPT code 88368 for CY 2014.
Comment: A commenter stated that it was appropriate to reaffirm the
values for 88120 and 88121.
Response: For the reasons stated above, we are assigning CY 2014
interim final work RVUs of 1.20 and 1.00 to CPT codes 88120 and 88121,
respectively.
(30) Optical Endomicroscopy (CPT Code 88375)
As detailed in the CY 2013 final rule with comment period, CPT code
88375 was assigned an interim final PFS procedure status of C
(Contractors price the code. Contractors establish RVUs and payment
amounts for these services.). We received a recommendation from the AMA
RUC for a work RVU of 1.08 for CPT code 88375.
CPT code 88375 provides a code for reporting the pathology service
when one is required to assist in the procedure. The AMA RUC
recommended an intraservice time of 25 minutes and a work RVU of 1.08
for CPT code 88375. Based on our analysis of this recommendation, we
believe that the typical optical endomicroscopy case will involve only
the endoscopist, and CPT codes 43206 and 43253 are valued to reflect
this. Accordingly, we believe a separate payment for CPT code 88375
would result in double payment for a portion of the overall optical
endomicroscopy service. Therefore, we are assigning a PFS procedure
status of I (Not valid for Medicare purposes. Medicare uses another
code for the reporting of and the payment for these services) to CPT
code 88375. In the unusual situation that a pathologist is requested to
assist an endoscopist in optical endomicroscopy, we would expect the
pathologist to report other codes more appropriate to the service (e.g.
CPT code 88392 Pathology consultation during surgery).
(31) Psychiatry (CPT Codes 90785, 90791, 90792, 90832, 90833, 90834,
90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90853 and
90863)
For CY 2013, the CPT Editorial Panel restructured the psychiatry/
psychotherapy CPT codes allowing for separate reporting of E/M codes,
eliminating the site-of-service differential, creating codes for
crisis, and creating a series of add-on psychotherapy codes to describe
interactive complexity and medication management. The AMA RUC
recommended values for all of the codes in this family except CPT codes
90785 (add-on for interactive complexity), 90839 (psychotherapy for
crisis, first 60 minutes), 90840 (each additional 30 minutes) and 90863
(pharmacologic management, when performed with psychotherapy) which
were the AMA RUC recommended to be contractor priced. In establishing
CY 2013 values for the psychitry codes, our general approach was to
maintain the CY 2012 values for the services or adopt values that
approximated the CY 2012 values after adjusting for differences in code
structure between CY 2012 and 2013, for all psychiatry/psychotherapy
services on an interim final basis. We noted in the CY 2013 final rule
with comment period that we intended to review the values for all the
codes in the family once the survey process was complete and we had
recommendations for all the codes. This would allow for a comprehensive
review of the values for the full code set that would ensure more
accurate valuation and proper relativity. The CY 2013 interim values
for this family can be found in Table 24.
We have now received AMA RUC recommendations for all of the codes
in the family and are establishing CY 2014
[[Page 74302]]
interim final work RVUs based on these recommendations. The CY 2014
interim work values displayed in Table 24 correspond with the AMA RUC
recommended values, with the exception of CPT code 90863, which has
been assigned a PFS procedure status of I (Not valid for Medicare
purposes. Medicare uses another code for the reporting of and the
payment for these services). These recommendations, which are now
complete, have provided us with a comprehensive set of information
regarding revisions to the overall relative resource costs for these
services. This is consistent with the approach we described in the CY
2013 PFS final rule with comment period (77 FR 69060-69063). Because of
the changes for this relativity new code set, we are establishing these
values on an interim final basis.
Comment: Several commenters urged CMS to use the AMA RUC-
recommended values for CY 2013 and questioned why CMS chose instead to
adopt a general approach of maintaining the CY 2012 values for the
services. These commenters noted that CMS has previously adopted
interim final values for only a portion of new codes in a family,
pending subsequent valuation of other codes in the family. Other
commenters questioned the logic of maintaining preexisting values for
these services since the new set of codes resulted from the
identification of these services as potentially misvalued several years
ago. Other commenters pointed out that the general approach to valuing
the codes resulted in anomalous values. Several other commenters
suggested alternative work values for the codes with and without
corresponding AMA RUC recommendations.
Response: We appreciate commenters' concerns regarding the
appropriate valuation of this family of codes. We also acknowledge that
commenters accurately point out that, in some cases, we have previously
established new interim values for new codes when related codes have
not been simultaneously reviewed. However, as we explained in the CY
2013 final rule with comment period (77 FR 69060), the CY 2013 changes
for this family of codes consisted of a new structure that allowed for
the separate reporting of E/M codes, the elimination of the site-of-
service differential, the establishment of CPT codes for crisis, and
the creation of a series of add-on CPT codes to psychotherapy to
describe interactive complexity and medication management. We believed
that the unusual complexity of these coding changes and the magnitude
of their impacts among the affected specialties that furnish these
services necessitated a comprehensive review of the potential impact of
the changes prior to adopting significant changes in overall value. We
also acknowledge that maintaining overall value for services between
calendar years with coding changes presents extensive challenges that
often result in anomalous values between individual codes. Since we are
establishing new interim final work RVUs for the codes in this family
for CY 2014 based on the recommendations of the AMA RUC, we believe
that commenters' concerns regarding our approach to CY 2013 have been
largely been mitigated for CY 2014. We note that the interim final CY
2014 work RVUs for all of these services are open for comment and we
will respond to comments regarding these values in the CY 2015 PFS
final rule with comment period.
Comment: Several commenters stated that it was difficult for health
care professionals that furnish these services to implement use of the
new CPT codes for Medicare payment with only a few months' notice given
the technology involved in claims systems. Other commenters suggested
that CMS should revise CPT code descriptors for codes to conform to
Medicare policies.
Response: We appreciate the concern regarding insufficient time to
adopt new codes. Although we would prefer for the new, revised and
deleted codes to be released in time to appear in PFS proposed
rulemaking, the timing of the annual release of the new codes set is
completely under the control of the CPT Editorial Panel. We note that
CMS does not have the authority to alter CPT code descriptors.
Comment: Several commenters supported CMS's decision to assign CPT
code 90863 with a PFS procedure status indicator of I (Not valid for
Medicare purposes. Medicare uses another code for the reporting of and
the payment for these services) for CY 2013 and encouraged CMS to
maintain that status for CY 2014.
Response: We appreciate commenters' support for this assignment. We
understand from our past meetings with stakeholders that the ability to
prescribe medicine is predicated upon first providing evaluation and
management (E/M) services. Although clinical psychologists have been
granted prescriptive privileges in Louisiana and New Mexico, we do not
believe that they are n authorized under their state scope of practice
to furnish the full range of traditional E/M services. As a result, we
believe that clinical psychologists continue to be precluded from
billing Medicare for pharmacologic management services under CPT code
90863 because pharmacologic management services require some knowledge
and ability to furnish E/M services, as some stakeholders have
indicated. Even though clinical psychologists in Louisiana and New
Mexico have been granted prescriptive privileges, clinical
psychologists overall remain unlicensed and unauthorized by their state
to furnish E/M services. Accordingly, on an interim final basis for CY
2014, for CPT code 90863, we are maintaining a PFS procedure status
indicator of I (Not valid for Medicare purposes. Medicare uses another
code for the reporting of and the payment for these services.).
(32) Cardiovascular: Therapeutic Services and Procedures (CPT Codes
92920, 92921, 92924, 92925, 92928, and 92929)
The CPT Editorial Panel created 13 new percutaneous coronary
intervention (PCI) CPT codes for CY 2013 (92920, 92921, 92924, 92925,
92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, and 92944) to
replace the 6 existing codes, which resulted in a greater level of
granularity.
As detailed in the CY 2013 final rule with comment period, we
believed that the CPT-established unbundling of the placement of
branch-level stents may encourage increased placement of stents. To
eliminate that incentive, on an interim final basis for CY 2013, we
rebundled the work associated with the placement of a stent in an
arterial branch into the base code for the placement of a stent in an
artery. Accordingly, for CY 2013 we bundled each new add-on code into
its base code. Specifically, we bundled the work of CPT code 92921 into
CPT code 92920, the work of CPT code 92925 into CPT code 92924, the
work of CPT code 92929 into CPT code 92928, the work of CPT code 92934
into CPT code 92933, the work of CPT code 92938 into CPT code 92937;
and the work of CPT code 92944 into CPT code 92943.
In the CY 2013 final rule with comment period we explained how we
established the work RVUs for the new bundled codes. For each code, we
used the AMA RUC-recommended utilization crosswalk to determine what
percentage of the base code utilization would be billed with the add-on
code, and added that percentage of the AMA RUC-recommended work RVU for
the add-on code to the AMA RUC-recommended work RVU for the base code.
Based on this methodology, we assigned the following CY 2013 interim
final work RVUs: 10.10 to CPT code 92920, 11.99
[[Page 74303]]
to CPT code 92924, 11.21 to CPT code 92928, 12.54 to CPT code 92933,
11.20 to CPT code 92937, and 12.56 to CPT code 92943.
On an interim final basis for CY 2013, add-on CPT codes 92921,
92925, 92929, 92934, 92938, and 92944 were assigned a PFS procedure
status indicator of B (Bundled code. Payments for covered services are
always bundled into payment for other services, which are not
specified. If RVUs are shown, they are not used for Medicare payment.
If these services are covered, payment for them is subsumed by the
payment for the services to which they are bundled.) Therefore, these
codes were not separately payable.
As detailed in the CY 2013 final rule with comment period, we did
not use this methodology to establish a work RVU for CPT code 92941,
which did not have a specific corresponding add-on code. After
reviewing the service alongside the other services in the family, we
believed CPT code 92941 had the same work as CPT code 92943. As we
stated above, we assigned a work RVU of 12.56 to CPT code 92943.
Therefore, on an interim final basis for CY 2013 we assigned a work RVU
of 12.56 to CPT code 92941 with the AMA RUC-recommended intraservice
time of 70 minutes.
Comment: Commenters disagreed with our bundling of codes into their
respective base codes. Commenters stated that we negated the work of
the CPT Editorial Panel, specialty societies, and the AMA RUC by
further bundling already bundled codes for PCI services. They indicated
that the additional bundling of payment for these codes generated a
substantial disconnect between the coding guidelines detailed in the
CPT manual and the use of the codes under the Medicare system, causing
great uncertainty and confusion. Additionally, commenters stated that
the decreases in PCI were of serious concern because it would drive
physicians from private practice. Therefore, commenters requested we
adopt the CPT Editorial Panel coding construct and the AMA RUC-
recommended values for all of the PCI codes. Furthermore, commenters
requested that we publish the values for the bundled codes, even though
they were not recognized for separate payment by Medicare, so that
third-party carriers who depend on the PFS to determine payment rates
can develop payment policies that conform to the CPT Editorial Panel's
coding decisions.
Response: After re-review, we maintain that our valuation and
bundling of codes into their respective base codes is appropriate. We
continue to believe that the revised CPT coding structure represents a
trend toward creating greater granularity in codes that describe the
most intense and difficult work. Specifically for this code family, we
continue to believe that making separate Medicare payment for unbundled
codes that describe the placement of branch-level stents may encourage
increased placement of stents in a fee-for-service system. To eliminate
that incentive while maintaining an appropriate reflection of the
resources involved in furnishing these services, we continue to believe
that rebundling the work associated with the placement of a stent in an
arterial branch into the base code for the placement of a stent in an
artery is appropriate and consistent with the prior coding structure.
Therefore, we are finalizing work RVU values of 10.10 for CPT code
92920, 11.99 for CPT code 92924 and 11.21 for CPT 92928 and a PFS
procedure status indicator of B (Bundled code. Payments for covered
services are always bundled into payment for other services, which are
not specified. If RVUs are shown, they are not used for Medicare
payment. If these services are covered, payment for them is subsumed by
the payment for the services to which they are bundled for CPT codes
92921, 92925 and 92929 for CY 2014. We are also finalizing for CY 2014
a work RVU of 12.56 for CPT code 92941, with the AMA RUC-recommended
intraservice time of 70 minutes.
(33) Cardiovascular: Intracardiac Electrophysiological Procedures/
Studies (CPT Codes 93655 and 93657)
Previously, CPT codes 93651 and 93652 were identified as
potentially misvalued through the codes reported together 75 percent or
more screen. Upon reviewing these codes, the CPT Editorial Panel
deleted CPT codes 93651 and 93652 and and replaced them with new CPT
codes 93653 through 93657 effective January 1, 2013.
As detailed in CY 2013 final rule with comment period, we believed
these codes had a similar level of intensity to CPT codes 93653, 93654,
and 93656, which were all valued at 5.00 RVUs per 1 hour of
intraservice time. Therefore, for CY 2013 we assigned a work RVU of
7.50 to CPT codes 93655 and 93657, which have 90 minutes of
intraservice time. The AMA RUC recommended a work RVU of 9.00 for CPT
code 93655 and a work RVU of 10.00 for CPT code 93657.
Comment: Commenters disagreed with the incremental value
methodology for CPT codes 93655 and 93657, stating that our approach
did not accurately account for the intensity of these services. They
stated that CPT codes 93655 and 93657 are more intense and complex
procedures than CPT codes 93653, 93654, and 93656 because patients who
require the services have widespread refractory disease, requiring
additional technical skill and time. Therefore, commenters requested we
use the AMA RUC-recommended work RVUs of 9.0 for CPT code 93655 and
10.0 for CPT code 93657. In addition, one commenter requested that we
refer these codes to the refinement panel.
Response: After reviewing the request for refinement, we agreed
that CPT codes 93655 and 93657 met the requirements for refinement and
referred the codes to the CY 2013 multi-specialty refinement panel for
further review. The refinement panel median work RVU for CPT codes
93655 and 93657 are 9.00, and 10.00 respectively. Following the
refinement panel meeting, we again reviewed the work involved in this
code and continue to believe that the two services involve a very
similar level of intensity to CPT codes 93653, 93654, and 93656, which
are all valued at 5.00 RVUs per 1 hour of intraservice time. We
continue to believe that this is the appropriate value for CPT codes
93655 and 93657 because we believe these services contain the same
amount of work as the base codes, CPT codes 93653, 93654, and 93656.
Therefore, we are finalizing a work RVU of 7.50 for CPT codes 93655 and
93657 for CY 2014.
(34) Noninvasive Vascular Diagnostic Studies: Extremity Arterial
Studies (Including Digits) (CPT Codes 93925 and 93926)
Previously, CPT codes 93925 and 93926 were identified by the AMA
RUC as potentially misvalued and we received AMA RUC recommendations
for CY 2013.
After reviewing CPT codes 93925 and 93926, we believed that the
survey's 25th percentile work RVUs of 0.80 for CPT code 93925 and 0.50
for CPT code 93926 accurately accounted for the work involved in
furnishing the services and appropriately captured the increase in work
since the services were last valued and assigned these as interim final
work RVUs for CY 2013. As we noted in the CY 2013 final rule with
comment period, we believed that the AMA RUC-recommended survey median
work RVUs of 0.90 for CPT code 93925 and 0.70 for CPT code 93926
overstated the increase in work for the services and that the RVUs were
too high relative to similar services. Regarding physician time, we
refined the AMA RUC-
[[Page 74304]]
recommended preservice and postservice times from 5 minutes to 3
minutes to align with similar services, specifically CPT codes 93922
and 93923.
Comment: All commenters disagreed with our work valuation and some
commenters also disagreed with our time refinements for CPT codes 93925
and 93926. One commenter stated that the work RVUs for CPT codes 93925
and 93926 should be increased because the work associated with the
services has changed and also argued that our valuations were arbitrary
in nature and unsupported. Two commenters noted that the AMA RUC-
recommended work RVUs of 0.90 for CPT code 93925 and 0.70 for CPT code
93926 were supported by relativity comparisons to CPT codes 93306,
73700, 76776 and 76817 and according the CY 2013 interim final work RVU
values were too low. Additionally, two commenters disagreed with our
time refinements for CPT codes 93925 and 93926 from the survey's median
to the survey's 25th percentile values. One commenter specifically
disagreed with our use of CPT codes 93922 and 93923 as reference codes
for time refinements because they stated ``physiologic studies do not
require artery-by-artery inch-by-inch assessment of femoral and tibial
arteries, as do the duplex exams'' and as such, are not appropriate
codes for comparison. They added that CPT codes 93925 and 93926 require
more time for proper performance of the exam and interpretation of
results. All commenters suggested acceptance of the AMA RUC
recommendations. One commenter also requested refinement panel review
of the codes.
Response: After evaluation of the request for refinement, we
determined that the criteria for the request for refinement were not
met and, as a result, we did not refer CPT codes 93925 and 93926 to the
CY 2013 multi-specialty refinement panel for further review.
After reviewing the comments, we maintain that our valuation is
appropriate. We continue to believe that that the survey's 25th
percentile work RVUs of 0.80 for CPT code 93925, and 0.50 for CPT code
93926 accurately account for the work involved in furnishing these
services and appropriately captures the increase in work since these
services were last valued. Additionally, we continue to believe that a
refinement to the AMA RUC-recommended time is appropriate to align the
times with those associated with CPT codes 93922 and 93923 that
describe similar services. Therefore, we are finalizing a work RVU of
0.80 to CPT code 93925 and a work RVU of 0.50 to CPT code 93926, with 3
minutes of preservice and postservice time for CY 2014.
(35) Neurology and Neuromuscular Procedures: Sleep Medicine Testing
(CPT Codes 95782 and 95783)
The CPT Editorial Panel created new CPT codes 95782 and 95783,
effective January 1, 2013, to describe the work involved in pediatric
polysomnography for children 5 years of age or younger. For CY 2013, we
assigned an interim final work RVU of 2.60 to CPT code 95782 and a work
RVU of 2.83 to CPT code 95783. As we noted in the CY 2013 final rule
with comment period, we assigned these values after we reviewed CPT
codes 95782 and 95783 and determined that the survey's 25th percentile
work RVUs of 2.60 for CPT code 95782 and 2.83 for CPT code 95783
appropriately reflected the work involved in furnishing the services.
The AMA RUC recommended the survey's median work RVUs of 3.00 for CPT
code 95782 and 3.20 for CPT code 95783.
Comment: Commenters disagreed with our valuation of CPT codes 95782
and 95783, stating that the services should have received a greater
valuation explaining that it is more difficult to perform sleep studies
on children than adults, and more work is required to obtain an
accurate polysomnogram due to children's greater need for attention
and, in some cases, even mild sedation. Additionally, commenters noted
that the work involved in the interpretation of data supported a higher
work RVU. Therefore, commenters requested that we use the AMA RUC-
recommended work RVU of 3.00 for CPT code 95782 and 3.20 for CPT code
95783.
Response: After consideration of comments and re-reviewing of CPT
codes 95782 and 95783, we maintain that our valuation is appropriate.
We continue to believe that that the survey's 25th percentile work RVUs
of 2.60 for CPT code 95782 and 2.83 for CPT code 95783 accurately
accounts for the work involved in furnishing these services. Therefore,
we are finalizing a work RVU of 2.60 for CPT code 95782 and 2.83 for
CPT code 95783, for CY 2014.
(36) Neurology and Neuromuscular Procedures: Electromyography and Nerve
Conduction Tests (CPT Codes 95885, 95886, and 95887)
CPT codes 95860, 95861, 95863, and 95864 were previously identified
as potentially misvalued through the codes reported together 75 percent
or more screen. The relevant specialty societies submitted a code
change proposal to the CPT Editorial Panel to bundle the services
commonly reported together. In response, the CPT created three add-on
codes (CPT codes 95885, 95886, and 95887) and seven new codes (CPT
codes 95907 through 95913) that bundled the work of multiple nerve
conduction studies into each individual code.
We agreed with the AMA RUC recommendation for CPT code 95885 and
assigned a CY 2013 interim final work RVU of 0.35. After review, we
determined that CPT codes 95886 and 95887 involved the same level of
work intensity as CPT code 95885. To determine the appropriate RVU for
CPT codes 95886 and 95887, we increased the work RVUs of CPT codes
95886 and 95887 proportionate to the differences in times from CPT code
95885. Therefore, we assigned an interim final work RVU of 0.70 to CPT
code 95886 and of 0.47 to CPT code 95887 for CY 2013 as compared to the
AMA RUC-recommended 0.92 and 0.73, respectively.
Comment: Commenters indicated that we utilized a flawed building
block approach in valuing CPT codes 95886 and 95887 because the
methodology did not take into account precise distinctions within each
service and inaccurately assumed that the codes had identical intensity
and complexity. Commenters supported the AMA RUC-recommended values
developed using magnitude estimation saying that the methodology was
more precise due to its use of data derived from multiple factors like
physician time, intensity and work value estimates. Additionally,
commenters noted that we failed to distinguish the increasing intensity
and complexity involved as additional nerve conductions were performed.
Therefore, commenters requested our use of the AMA RUC-recommended work
RVU of 0.92 for CPT code 95886 and 0.73 for CPT code 95887 and
refinement panel review of the codes.
Response: After reviewing the request for refinement, we agreed
that CPT codes 95886 and 95887 met the requirements for refinement and
referred the codes to the CY 2013 multi-specialty refinement panel for
further review. The refinement panel median work RVUs for CPT codes
95886 and 95887 were respectively, 0.92 and 0.73. Following the
refinement panel meeting, we again reviewed the work involved in these
codes and agreed with the panel that these codes were more intense and
complex than reflected in the CY 2013 interim final values and, as
such, warranted a higher work RVU. While we agree that work RVUs for
CPT codes 95886 and 95887 should be increased, based on our clinical
review, we conclude that the refinement panel's
[[Page 74305]]
suggested values overstate the work involved in these procedures.
We believe that the work for CPT code 95886 is similar to the work
performed when five or more muscles are examined in one extremity, as
described by CPT code 95860, which has a work RVU of 0.96. However, CPT
code 95886 is an add-on code to nerve conduction studies. Therefore, as
we have previously valued services that overlap with another CPT code,
we applied a 10% reduction to the work RVU of CPT code 95860 to
determine a work RVU of 0.86 for CPT code 95886. Similarly, in our
valuation of CPT code 95887, we believe that the work for the code is
similar to the work performed when cranial nerve supplied muscles are
examined, as described by CPT code 95867, which has a work RVU of 0.79.
However, CPT code 95887 is an add-on code to nerve conduction studies.
Therefore, as we have previously valued services that overlap with
another code, we applied a 10 percent reduction to the work RVU of CPT
code 95867 to determine a work RVU of 0.79 for CPT code 95887. For CY
2014, we are finalizing a work RVU of 0.86 for CPT code 95886 and 0.71
for CPT code 95887.
(37) Neurology and Neuromuscular Procedures: Electromyography and Nerve
Conduction Tests (CPT Codes 95908, 95909, 95910, 95911, 95912, and
95913)
In our CY 2013 review, we did not accept the AMA RUC-recommended
values for CPT codes 95908, 95909, 95910, 95911, 95912, and 95913. For
those codes, we found that the progression of the survey's 25th
percentile work RVUs and survey's median times appropriately reflected
the relativity of the services and valued the codes accordingly. CPT
code 95908 was an exception to this, as we believed the survey's 25th
percentile work RVU was too low relative to other fee schedule
services. Therefore, we assigned the following work RVUs for CY 2013:
1.00 to CPT code 95907, 1.25 to CPT code 95908, 1.50 to CPT code 95909,
2.00 to CPT code 95910, 2.50 to CPT code 95911, 3.00 to CPT code 95912,
and 3.56 to CPT code 95913.
Additionally, we refined the AMA RUC-recommended intraservice time
for CPT code 95908 from 25 minutes to the survey's median time of 22
minutes and for CPT code 95909 from 35 minutes to the survey's median
time of 30 minutes, so that all the CPT codes in the series were valued
using the survey's median intraservice time.
Comment: Commenters disagreed with our valuation of CPT codes
95908, 95909, 95910, 95911, 95912, and 95913. Commenters opposed the
interim final values for the codes because they believed the intensity
and complexity of the procedures increased as more nerve conductions
were performed and as a result, believed that the valuations should be
higher. Additionally, commenters believe that because no significant
changes in the efficiencies of the test had occurred, in terms of time
and cost related to performance, that our changes in the valuations
were unjustified. Therefore, commenters requested that we accept the
AMA RUC-recommended work RVUs for all of these codes and requested
refinement panel review. Lastly, commenters also suggested that if the
interim final values were to be finalized, that their implementation be
staggered to limit the adverse impacts that the values would have on
health care access.
Response: After reviewing the request for refinement, we agreed
that CPT codes 95908, 95909, 95910, 95911, 95912, and 95913 met the
requirements for refinement and referred the codes to the CY 2013
multi-specialty refinement panel for further review. The refinement
panel median work RVUs were: 1.37 for CPT code 95908, 1.77 for CPT code
95909, 2.80 for CPT code 95910, 3.34 for CPT code 95911, 4.00 for CPT
code 95912, and 4.20 for CPT code 95913. Following the refinement panel
meeting, we again reviewed the work involved in these codes and
continue to believe that the progression of the survey's 25th
percentile work RVUs and survey median times for these codes
appropriately reflect the relativity of these codes. CPT code 95908 was
an exception to this approach because we believe that the survey's 25th
percentile work RVU is too low relative to other fee schedule services.
We also note that we do not believe that the results of the survey
support the notion that the intensity and complexity of the procedures
increases as more nerve conductions are performed. Instead, we believe
that the incremental differences reflected in the survey correspond
with the incremental differences in our CY 2013 interim final values.
Therefore, we are finalizing the CY 2013 interim final work RVUs and
time refinements for CPT codes 95908, 95909, 95910, 95911, 95912, and
95913 for CY 2014. With regard to the comment that our rates would
impede access to these critical services, we are unaware of data that
shows that access has declined.
(38) Evoked Potentials (CPT Codes 95928 and 95929)
As detailed in the CY 2013 final rule with comment period, CPT
codes 95928 and 95929 were each assigned a CY 2013 interim final work
RVU of 1.50. Subsequently, the AMA RUC recommended intraservice time
for these codes based on only 19 of the 28 survey responses. As a
result, the AMA RUC recommendations included an intraservice time of 40
minutes with which we do not agree. When based on all 28 survey
responses, the intraservice time is 33 minutes. We agree with the AMA
RUC recommended preservice and postservice times because they are
consistent across all 28 survey responses. Therefore, for CY 2014, we
are refining the preservice time, intraservice and postservice times
for CPT codes 95928 and 95929 to 15 minutes, 33 minutes and 10 minutes,
respectively. We are assigning CY 2014 interim final work RVUs of 1.50
to CPT codes 95928 and 95929, based upon the AMA RUC recommendations,
and are seeking public input on the time of the codes.
(39) Neurology and Neuromuscular Procedures: Intraoperative
Neurophysiology (CPT Codes 95940 and 95941 and HCPCS Code G0453)
Effective January 1, 2013, the CPT Editorial Panel deleted CPT code
95920 and replaced it with CPT codes 95940 for continuous
intraoperative neurophysiology monitoring in the operating room
requiring personal attendance and 95941 for continuous intraoperative
neurophysiology monitoring from outside the operating room (remote or
nearby). Prior to CY 2013, the Medicare PFS paid for remote monitoring
billed under CPT code 95920, which was used for both in-person and
remote monitoring. For CY 2013, we created HCPCS code G0453 to be used
for Medicare purposes instead of CPT code 95941. Unlike CPT code 95941,
HCPCS code G0453 can be billed only for undivided attention by the
monitoring physician to a single beneficiary, not for the monitoring of
multiple beneficiaries simultaneously. Since G0453 was used for remote
monitoring of Medicare beneficiaries, CPT code 95941 was assigned a PFS
procedure status indicator of I (Not valid for Medicare purposes.
Medicare uses another code for the reporting of and the payment for
these services.
As detailed in the CY 2013 final rule with comment period, after
reviewing CPT code 95940, we agreed with the AMA RUC that a work RVU of
0.60 accurately accounted for the work involved in furnishing the
procedure. Also, we agreed with the AMA RUC that a work RVU of 2.00
accurately accounted for the work involved in furnishing 60 minutes of
continuous
[[Page 74306]]
intraoperative neurophysiology monitoring from outside the operating
room. Accordingly, we assigned a work RVU of 0.50 to HCPCS code G0453,
which described 15 minutes of monitoring from outside the operating
room, on an interim final basis for CY 2013.
Comment: Commenters disagreed with our valuation of CPT codes
95940, 95941 and G0453. Commenters opposed the one-on-one patient to
physician model that our recommendations proposed. Commenters stated
the following: G0453 was contradictory to current provider models; the
accessibility of IONM services would be lowered; surgeons would be
deprived of advantageous services; qualified level of professional
supervision would be reduced; hospitals would suffer increased
overheard costs; and GO453 inappropriately assessed the services.
Therefore, commenters requested we withdraw HCPCS code G0453 and
validate CPT codes 95940 and 95941 together, through acceptance of the
AMA RUC-recommended work RVUs of 0.60 for CPT code 95940 and 2.00 for
CPT code 95941.
Another commenter suggested we value CPT code 95941 at 0.5 of CPT
95940 although a rationale for that valuation was not provided. Several
other commenters requested we increase the work value of G0453 so that
it was equal to the work RVU assigned to CPT code 95940 because they
believed the physician time and effort for both services was the same.
The majority of commenters suggested we value the concurrent monitoring
of up to 4 patients by a neurologist with the creation of additional G
codes for the remote monitoring of 2, 3 or 4 patients.
Response: Based on comments received, we re-reviewed CPT codes
95940, 95941 and HCPCS code G0453 and agree that based on the
comparable nature of the work between CPT code 95940 and HCPCS code
G0453, that G0453 should be valued equally to CPT code 95940.
Therefore, we are finalizing a work RVU of 0.60 to CPT code 95940
and 0.60 to HCPCS code G0453 for CY 2014. We are also finalizing a PFS
procedure status indicator of I (Not valid for Medicare purposes.
Medicare uses another code for the reporting of and the payment for
these services) to CPT code 95941 for CY 2014, because for Medicare
purposes, HCPCS code G0453 will continue to be used instead of CPT code
95941. Although we considered commenters' suggestions to value
concurrent monitoring of up to 3 or 4 patients by a neurologist with
the creation of additional G-codes for the remote monitoring of 2, 3 or
4 patients, creation of these G codes would allow billing for more than
60 minutes of work during a 60 minute time period. We continue to
believe that HCPCS code G0453 adequately accounts for the relative
resources involved when the physician monitors a Medicare beneficiary,
while it precludes inaccurate payment in cases where multiple patients
are being monitored simultaneously. Therefore, we will maintain the
current code descriptor for HCPCS code G0453.
Comment: Some commenters suggested we create mechanisms for
practitioners to report the professional and technical components
separately for CPT codes 95940 and HCPCS code G0453. One of these
commenters suggested that creating separate technical component payment
for the PFS would allow hospitals to approximate the relative resource
costs associated with the technical component of the service.
Response: It is our understanding that these services are nearly
always furnished to beneficiaries in facility settings. Therefore,
Medicare would not make payments through the PFS that account for the
clinical labor, disposable supplies, or medical equipment involved in
furnishing the service. Instead, these resource costs would be included
in the payment Medicare makes to the facility through other payment
mechanisms. Therefore, we do not believe it would be appropriate to
create separate payment rates for the professional and technical
component of these services.
(40) Neurology System: Autonomic Function Tests (CPT Code 95943)
As detailed in the CY 2013 final rule with comment period, we
assigned a PFS procedure status of C to CPT code 95943, pursuant to the
AMA RUC recommendation. (Contractors price the code. Contractors
establish RVUs and payment amounts for these services.) The AMA RUC
believes that a PFS procedure status of ``C'' was appropriate because
they did not have sufficient information for making a specific work RVU
recommendation.
Comment: Commenters opposed contractor pricing of CPT code 95943
because the other autonomic nervous system testing codes have national
work RVUs and payment rates. Commenters suggested we crosswalk CPT code
95943 to CPT code 95924 due to the procedures' similarity in total
work.
Response: We continue to believe that a PFS procedure status of C
(Contractors price the code. Contractors establish RVUs and payment
amounts for these services.) is appropriate for CPT code 95943. We do
not believe that the commenters provided sufficient data to value the
service. Therefore, we are finalizing a Contractor Pricing procedure
status to CPT code 95943 for CY 2014.
(41) Inpatient Neonatal Intensive Care Services and Pediatric and
Neonatal Critical Care Services: Pediatric Critical Care Patient
Transport (CPT Codes 99485 and 99486)
For CY 2013, he CPT editorial panel created CPT codes 99485 and
99486, to describe the non-face-to-face services provided by physician
to supervise interfacility care of critically ill or critically injured
pediatric patients.
As detailed in the CY 2013 final rule with comment period, we
reviewed CPT codes 99485 and 99486 and believed the services should be
bundled into other services and not be separately payable. We believed
the services were similar to CPT code 99288, which is also bundled on
the PFS. The AMA RUC recommended a work RVU of 1.50 for CPT code 99485
and a work RVU of 1.30 for CPT code 99486. On an interim final basis
for CY 2013, we assigned CPT codes 99485 and 99486 a PFS procedure
status indicator of B (Payments for covered services are always bundled
into payment for other services, which are not specified. If RVUs are
shown, they are not used for Medicare payment. If these services are
covered, payment for them is subsumed by the payment for the services
to which they are bundled).
Comment: Commenters disagreed with our assignment of CPT codes
99485 and 99486 as bundled codes. They stated that that classification
puts pediatric physicians at a disadvantage since the majority of non-
Medicare payers will commonly bundle the codes as well. Commenters
strongly recommended that we adopt status indicator A (Active) or, at
the very least, status indicator N (Noncovered Service) for CPT codes
99485 and 99486.
Response: We continue to believe that CPT codes 99485 and 99486 are
similar to CPT code 99288 and, like CPT code 99288, involve work that
is already considered in the valuation of other services. Therefore, we
do not believe that these services should be separately payable.
Therefore, we are finalizing a PFS procedure status of B (Payments for
covered services are always bundled into payment for other services,
which are not specified. If RVUs are shown, they are not used for
Medicare payment. If these services are covered, payment for them is
subsumed by the payment for the services to which they are
[[Page 74307]]
bundled) to CPT codes 99485 and 99486 for CY 2014.
(42) Molecular Pathology (HCPCS Code G0452)
As detailed in the CY 2013 final rule with comment period, one of
the molecular pathology CPT codes that was deleted by CPT for CY 2012
was payable on the PFS: CPT code 83912-26. To replace this CPT code, we
created HCPCS code G0452 to describe medically necessary interpretation
and written report of a molecular pathology test, above and beyond the
report of laboratory results. We reviewed the work associated with this
procedure and we believed it was appropriate to directly crosswalk the
work RVUs and times of CPT code 83912-26 to HCPCS code G0452, because
we did not believe the coding change reflected a change in the service
or in the resources involved in furnishing the service. Accordingly, we
assigned a work RVU of 0.37, with 5 minutes of preservice time, 10
minutes of intraservice time, and 5 minutes of postservice time to
HCPCS code G0452 on an interim final basis for CY 2013.
Comment: Commenters disagreed with our valuation of HCPCS code
G0452. Commenters expressed concern about the creation of a single
HCPCS G-code to distinguish work related to a considerable number of
procedures with changing relative values recommended by the AMA RUC.
Response: The decision to pay for molecular pathology codes under
the CLFS required the creation of a new code for the interpretation and
reporting services by pathologists on the PFS. We continue to believe
that the creation of HCPCS code G0452 was appropriate to describe
medically necessary interpretation and written report of a molecular
pathology test, above and beyond the report of laboratory results. We
also believe that this single HCPCS code is sufficient to capture the
work involved in any of the numerous molecular pathology codes.
Additionally, the professional component-only HCPCS G-code is a
``clinical laboratory interpretation service,'' which is one of the
current categories of PFS pathology services under the definition of
physician pathology services at Sec. 415.130(b)(4). Therefore, we are
finalizing a work RVU of 0.37 to HCPCS code G0452.
(43) Digestive System: Intestines (Except Rectum) (CPT Code G0455)
For CY 2013, we created HCPCS code G0455 to be used for Medicare
purposes instead of CPT code 44705. HCPCS code G0455 will be used to
bundle the preparation and instillation of microbiota. CPT code 44705
was assigned a PFS procedure status indicator of I (Not valid for
Medicare purposes).
After reviewing the preparation and instillation work associated
with this procedure, we believed that CPT code 99213 was an appropriate
crosswalk for the work and time of HCPCS code G0455. Therefore, on an
interim final basis for CY 2013, we assigned a work RVU of 0.97 to
HCPCS code G0455.
Comment: Commenters disagreed with our valuation of HCPCS code
G0455. Commenters opposed the interim final work RVU because they
believed extensive work was required for the preparation of the
microbiota, to determine if a patient was an appropriate candidate for
fecal donation. Commenters believed that our work RVU valuation failed
to distinguish between varying clinical circumstances for the use of
this code. Commenters also suggested that we should consider coverage
of more than one donor specimen screening when clinically suitable.
Response: After review, we agree with the commenters that the
interim final work RVU of 0.97 undervalues this service. We believe
that bundling the work RVU and physician time of CPT code 80500, a lab
pathology consultation, with CPT code 99213 more appropriately values
this work. Therefore, we are finalizing a work RVU of 1.34 and an
intraservice time of 28 minutes for HCPCS code G0455.
b. Finalizing CY 2013 Interim Direct PE Inputs
(i) Background and Methodology
On an annual basis, the AMA RUC provides CMS with recommendations
regarding direct PE inputs, including clinical labor, disposable
supplies, and medical equipment, for new, revised, and potentially
misvalued codes. We review the AMA RUC-recommended direct PE inputs on
a code-by-code basis. When we determine that the AMA RUC
recommendations appropriately estimate the direct PE inputs required
for the typical service and reflect our payment policies, we use those
direct PE inputs to value a service. If not, we refine the PE inputs to
better reflect our estimate of the PE resources required for the
service. We also confirm whether CPT codes should have facility and/or
nonfacility direct PE inputs and refine the inputs accordingly.
In the CY 2013 PFS final rule with comment period (77 FR 69072), we
addressed the general nature of some of our common refinements to the
AMA RUC-recommended direct PE inputs as well as the reasons for
refinements to particular inputs. In the following subsections, we
respond to the comments we received regarding common refinements we
made based on established principles or policies. Following those
discussions, we summarize and respond to comments received regarding
other refinements to particular codes.
We note that the interim final direct PE inputs for CY 2013 that
are being finalized for CY 2014 are displayed in the final CY 2014
direct PE input database, available on the CMS Web site under the
downloads for the CY 2014 PFS final rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The inputs displayed there have also
been used in developing the CY 2014 PE RVUs as displayed in Addendum B
of this final rule with comment period.
(ii) Common Refinements
(1) Equipment Time
Prior to CY 2010, the AMA RUC did not generally provide CMS with
recommendations regarding equipment time inputs. In CY 2010, in the
interest of ensuring the greatest possible degree of accuracy in
allocating equipment minutes, we requested that the AMA RUC provide
equipment times along with the other direct PE recommendations, and we
provided the AMA RUC with general guidelines regarding appropriate
equipment time inputs. We continue to appreciate the AMA RUC's
willingness to provide us with these additional inputs as part of its
direct PE recommendations.
In general, the equipment time inputs correspond to the service
period portion of the clinical labor times. We have clarified this
principle, indicating that we consider equipment time as the times
within the intraservice period when a clinician is using the piece of
equipment plus any additional time that the piece of equipment is not
available for use for another patient due to its use during the
designated procedure. For services in which we allocate cleaning time
to portable equipment items, we do not include that time for the
remaining equipment items as they are available for use for other
patients during that time. In addition, when a piece of equipment is
typically used during any additional visits included in a service's
global period, the equipment time would also reflect that use.
We believe that certain highly technical pieces of equipment and
equipment rooms are less likely to be
[[Page 74308]]
used during all of the preservice or postservice tasks performed by
clinical labor staff on the day of the procedure (the clinical labor
service period) and are typically available for other patients even
when one member of clinical staff may be occupied with a preservice or
postservice task related to the procedure.
Some commenters have repeatedly objected to our rationale for
refinement of equipment minutes on this basis. We acknowledge the
comments we received that reiterate those objections to this rationale
and refer readers to our extensive discussion regarding those
objections in the CY 2012 PFS final rule with comment period (76 FR
73182). In the following paragraphs we address new comments on this
policy.
Comment: Several commenters pointed out that technician time is
independent of physician time for some procedures so that equipment
time should not be altered based on changes in physician intraservice
time.
Response: The estimated time it takes for a practitioner or
clinical staff to furnish a procedure is an important factor used in
determining the appropriate direct PE input values used in developing
nonfacility PE RVUs. For many services, the physician intraservice time
serves as the basis for allocating the appropriate number of minutes
within the service period to account for the time used in furnishing
the service to the patient. In the case of many services, the number of
physician intraservice minutes, or occasionally a particular proportion
thereof, is allocated to both the clinical staff that assist the
practitioner in furnishing the service and to the equipment used by
either the practitioner or the staff in furnishing the service. This
allocation reflects only the time the beneficiary receives treatment
and does not include resources used immediately prior to or following
the service. Additional minutes are often allocated to both clinical
labor and equipment resources to account for the time used for
necessary preparatory tasks immediately preceding the procedure or
tasks typically performed immediately following it. For these services,
we routinely adjust the minutes assigned to the direct PE inputs so
that they correspond with the procedure time assumptions displayed in
the physician time file that are used in determining work RVUs and
allocating indirect PE values.
The commenters accurately point out that for a significant number
of services, especially diagnostic tests, the procedure time
assumptions used in determining direct PE inputs are distinct from, and
therefore not dependent on, physician intraservice time assumptions.
For these services, we do not make refinements to the direct PE inputs
based on changes to estimated physician intraservice times.
Comment: Several commenters asked that CMS identify what
constitutes a highly technical piece of equipment.
Response: During our review of all recommended direct PE inputs, we
consider whether or not particular equipment items would typically be
used in the most efficient manner possible. In making this
determination, we consider such items as the degree of specificity of a
piece of equipment, which may influence whether the equipment item is
likely to be stored in the same room in which the clinical staff greets
and gowns, obtains vitals, or provides education to a patient prior to
the procedure itself. We also consider the level of portability
(including the level of difficulty involved in cleaning the equipment
item) to determine whether an item could be easily transferred between
rooms before or after a given procedure. We also examine the prices for
the particular equipment items to determine whether the equipment is
likely to be located in the same room used for all the tasks undertaken
by clinical staff prior to and following the procedure. For each
service, on a case-by-case basis, we look at the description provided
in the AMA RUC recommendation and consider the overlap of the equipment
item's level of specificity, portability, and cost; and, consistent
with the review of other recommended direct PE inputs, make the
determination of whether the recommended equipment items are highly
technical.
(2) Standard Tasks and Minutes for Clinical Labor Tasks
In general, the preservice, service period, and postservice
clinical labor minutes associated with clinical labor inputs in the
direct PE input database reflect the sum of particular tasks described
in the information that accompanies the recommended direct PE inputs,
``PE worksheets.'' For most of these described tasks, there are a
standardized number of minutes, depending on the type of procedure, its
typical setting, its global period, and the other procedures with which
it is typically reported. At times, the AMA RUC recommends a number of
minutes either greater than or less than the time typically allotted
for certain tasks. In those cases, CMS clinical staff reviews the
deviations from the standards to determine their clinical
appropriateness. Where the AMA RUC-recommended exceptions are not
accepted, we refine the interim final direct PE inputs to match the
standard times for those tasks. In addition, in cases when a service is
typically billed with an E/M, we remove the preservice clinical labor
tasks so that the inputs are not duplicative and reflect the resource
costs of furnishing the typical service.
In general, clinical labor tasks fall into one of the categories on
the PE worksheets. In cases where tasks cannot be attributed to an
existing category, the tasks are labeled ``other clinical activity.''
In these instances, CMS clinical staff reviews these tasks to determine
whether they are similar to tasks delineated for other services under
the PFS. For those tasks that do not meet this criterion, we do not
accept those clinical labor tasks as direct inputs.
Comment: Several commenters objected to CMS's refinement to
recommended clinical labor minutes to meet these standards in cases
where the recommendation included information suggesting that the
service requires specialized clinical labor tasks, especially relating
to quality assurance documentation, that are not typically included on
the PE worksheets.
Response: Although we appreciate the importance of quality
assurance and other tasks, we note that the nonfacility direct PE
inputs include an estimated number of clinical labor minutes for most
codes developed based on an extensive, standard list of clinical labor
tasks such as ``prepare equipment,'' and ``prepare and position
patient.'' We believe that quality assurance documentation tasks for
services across the PFS are already accounted for in the overall
estimate of clinical labor time. We do not believe that it would serve
the relativity of the direct PE input database were additional minutes
added for each clinical task that could be discretely described for
every code and thus are not making any changes based upon this comment.
(3) Equipment Minutes for Film Equipment Inputs
In general, the equipment time allocated to film equipment, such as
``film processor, dry, laser'' (ED024), ``film processor, wet''
(ED025), and ``film alternator (motorized film viewbox)'' (ER029),
corresponds to the clinical labor task ``hang and process film.''
Comment: Several commenters argued that the film equipment should
be allocated for the entire service period.
Response: We believe that the film equipment, when used, is
typically only used during the time associated with
[[Page 74309]]
certain clinical labor tasks, and is otherwise generally available for
use in furnishing services to other patients. In reviewing these
equipment inputs in the direct PE input database, we note that this
equipment is generally not allocated for the full number of minutes of
the clinical labor service period. Because we do not believe that this
equipment would be in use during periods other than during particular
clinical labor tasks, and to maintain relativity, we are finalizing the
CY 2013 direct PE inputs based on this general principle.
(4) Film Inputs as a Proxy for Digital Imaging Inputs
Comment: A few commenters objected to our refinement of certain
film inputs including eliminating VHS video system and tapes, and
reducing the number of films for several procedures. Commenters also
stated that the film processor was a necessary input for several
procedures from which it was removed.
Response: As stated in the CY 2013 PFS final rule with comment
period (77 FR 69029), a variety of imaging services across the PFS
include direct PE inputs that reflect film-based technology instead of
digital technology. We believe that for imaging services, digital
technology is more typical than film technology. However, stakeholders,
including the AMA RUC, have recommended that we continue to use film
technology inputs as a proxy for digital until digital inputs for all
imaging services can be considered. In response to these
recommendations, we have maintained inputs for film-based technology as
proxy inputs while this review occurs. In the case of new, revised, and
potentially misvalued codes, we have accepted the recommended proxy
inputs to the extent that the recommended proxy inputs are those that
are usually associated with imaging codes. However, we have not
accepted recommended inputs that are not usually included in other
imaging services. We have reviewed the recommended inclusion of the
film processor and, upon additional review, noted that the item is
routinely included in other imaging codes. Therefore, we are including
that item in the direct PE input database. We anticipate updating all
of the associated inputs in future rulemaking. After consideration of
comments received, we are finalizing the direct PE inputs in accordance
with this general principle with the additional refinement of inserting
the film processor for relevant codes.
(iii) Code-Specific Direct PE Inputs
We note that we received many comments objecting to refinements
made based on CMS clinical review (including our determination that
certain recommended items were duplicative of others already included
with the service), statutory requirements, or established principles
and policies under the PFS. We note that for many of our refinements,
the medical specialty societies that represent the practitioners who
furnish the service objected to most of these refinements for the
general reasons described above or for the reasons we respond to in the
``background and methodology'' portion of this section. Below, we
respond to comments in which commenters address specific CPT/HCPCS
codes and provide rationale for their objections to our refinements in
the form of new information supporting the inclusion of the items and/
or times requested. When discussing these refinements, rather than
listing all refinements made for each service, we discuss only the
specific refinements that meet these criteria. We indicate the presence
of other refinements by noting ``among other refinements'' after
delineating the specific refinements for a particular service or group
of services. For those comments that stated that an item was
``necessary for the service'' and no additional rationale or evidence
was provided, we conducted further review to determine whether the
inputs as refined were appropriate and concluded that the inputs as
refined were indeed appropriate.
Further, in the CY 2013 PFS correction notice (78 FR 48996), we
addressed several technical and typographical errors that respond to
comments received. We do not repeat those comments nor provide our
responses for those items here.
(1) Cross-Family Comments
Comment: We received comments regarding refinements to equipment
times for many procedures, in which commenters indicated that the
equipment time for the procedure should include the time that the
equipment is unavailable for other patients, including while preparing
equipment, positioning the patient, assisting the physician, and
cleaning the room.
Response: As stated above, we agree with commenters that the
equipment time should include the times within the intraservice period
when a clinician is using the piece of equipment plus any additional
time the piece of equipment is not available for use for another
patient due to its use during the designated procedure. We believe that
some of these commenters are suggesting that we should allocate the
full number of clinical labor minutes included in the service period to
the equipment items. However, as we have explained, the clinical labor
service period includes minutes based on some clinical labor tasks
associated with preservice and postservice activities that we do not
believe typically preclude equipment items from being used in
furnishing services to other patients because these activities
typically occur in other rooms.
The equipment times allocated to the CPT codes in Table 25 already
include the full intraservice time the equipment is typically used in
furnishing the service, plus additional minutes to reflect time that
the equipment is unavailable for use in furnishing services to other
patients.
Table 25--Equipment Inputs That Include Appropriate Clinical Labor Tasks
About Which Comments Were Received
------------------------------------------------------------------------
CPT code Equipment items
------------------------------------------------------------------------
50590................................... EQ175.
52214................................... all items.
52224................................... all items.
72040................................... EL012.
72050................................... EL012.
72052................................... EL012.
72192................................... EL007.
72193................................... EL007.
72194................................... EL007.
73221................................... EL008.
73721................................... EL008.
74150................................... EL007.
74160................................... EL007.
74170................................... EL007.
74175................................... EL007.
74177................................... EL007.
74178................................... EL007.
77301................................... ER005.
78012................................... ER063.
78013................................... ER032.
78014................................... EF010, ER063.
78070................................... ER032.
78071................................... ER032.
93925................................... EL016.
93926................................... EL016.
93970................................... EL016.
------------------------------------------------------------------------
Comment: Some commenters stated that selected items added to
various CPT codes during clinical review by CMS were not typical. In
Table 26, we list those services and items identified by commenters as
atypical for the service. For each of these items, we note whether we
maintained our refinement or removed the input based on commenter
recommendation. In general,
[[Page 74310]]
we have accepted the comments to remove the items, except when we
believed that doing so would deviate from our standard policies.
Specifically, as we discuss above, we are maintaining standard times
for clinical labor tasks; these include 10 minutes for ``clean surgical
instrument package'' for CPT codes 11301-11313, the time for ``Assist
physician in performing procedure'' to conform to physician time for
CPT code 13150, and the equipment minutes used exclusively for the
patient for ``lane, screening (oph)'' (EL006) for CPT codes 92081,
92082, and 92083.
Table 26--Items Identified as Not Typical by Commenters
--------------------------------------------------------------------------------------------------------------------------------------------------------
CMS code Labor activity (if AMA RUC CMS Commenter CMS decision/
CPT code/ code range CMS code description applicable) recommendation refinement recommendation rationale
--------------------------------------------------------------------------------------------------------------------------------------------------------
11301-11313......... L037D............ RN/LPN/MTA......... Clean Surgical 1 10 1 Maintain
Instrument refinement/
Package. Standard Time.
13150............... L037D............ RN/LPN/MTA......... Assist physician 20 26 20 Maintain
in performing refinement/
procedure. Standard Time.
32554............... SA067............ tray, shave prep... .................. 0 1 0 Removed.
SB001............ cap, surgical...... .................. 0 2 0 Removed.
SB039............ shoe covers, .................. 0 2 0 Removed.
surgical.
32556............... SA044............ pack, moderate .................. 0 1 0 Removed.
sedation.
SA067............ tray, shave prep... .................. 0 1 0 Removed.
SB001............ cap, surgical...... .................. 0 2 0 Removed.
SB039............ shoe covers, .................. 0 2 0 Removed.
surgical.
SC010............ closed flush .................. 0 1 0 Removed.
system,
angiography.
SH065............ sodium chloride .................. 0 1 0 Removed.
0.9% flush syringe.
SH069............ sodium chloride .................. 0 1 0 Removed.
0.9% irrigation
(500-1000 ml uou).
32557............... SB027............ gown, staff, .................. 0 1 0 Removed.
impervious.
SG078............ tape, surgical .................. 0 25 0 Removed.
occlusive 1 in
(Blenderm).
67810............... SB011............ drape, sterile, .................. 0 1 0 Removed.
fenestrated 16 in
x 29 in.
72192............... SK076............ slide sleeve (photo .................. 0 1 0 Removed.
slides).
SK098............ film, x-ray, laser .................. 0 8 4 Removed.
print.
72193............... SH065............ sodium chloride .................. 0 15 1 Removed.
0.9% flush syringe.
SK076............ slide sleeve (photo .................. 0 1 0 Removed.
slides).
74150............... SK076............ slide sleeve (photo .................. 0 1 0 Removed.
slides).
SK098............ film, x-ray, laser .................. 0 8 4 Removed.
print.
74160............... SH065............ sodium chloride .................. 0 15 1 Removed.
0.9% flush syringe.
74170............... SH065............ sodium chloride .................. 0 15 1 Removed.
0.9% flush syringe.
92081............... EL006............ lane, screening .................. 12 17 12 Maintain
(oph). refinement/
Standard Time.
92082............... EL006............ lane, screening .................. 22 27 22 Maintain
(oph). refinement/
Standard Time.
92083............... EL006............ lane, screening .................. 32 37 32 Maintain
(oph). refinement/
Standard Time.
[[Page 74311]]
93017............... L051A............ RN................. Complete 0 4 0 Removed.
diagnostic forms,
lab & X-ray
requisitions.
--------------------------------------------------------------------------------------------------------------------------------------------------------
(2) Integumentary System: Skin, Subcutaneous, and Accessory Structures
(CPT Codes 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308,
11310, 11311, 11312, 11313)
In establishing interim final direct PE inputs for CY 2013, CMS
refined the AMA RUC's recommendation for CPT codes 11300 (Shaving of
epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion
diameter 0.5 cm or less), 11301 (Shaving of epidermal or dermal lesion,
single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm),
11302 (Shaving of epidermal or dermal lesion, single lesion, trunk,
arms or legs; lesion diameter 1.1 to 2.0 cm), 11303 (Shaving of
epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion
diameter over 2.0 cm), 11305 (Shaving of epidermal or dermal lesion,
single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5
cm or less), 11306 (Shaving of epidermal or dermal lesion, single
lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0
cm), 11307 (Shaving of epidermal or dermal lesion, single lesion,
scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm),
11308 (Shaving of epidermal or dermal lesion, single lesion, scalp,
neck, hands, feet, genitalia; lesion diameter over 2.0 cm), 11310
(Shaving of epidermal or dermal lesion, single lesion, face, ears,
eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less),
11311 (Shaving of epidermal or dermal lesion, single lesion, face,
ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0
cm), 11312 (Shaving of epidermal or dermal lesion, single lesion, face,
ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0
cm), and 11313 (Shaving of epidermal or dermal lesion, single lesion,
face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over
2.0 cm) by removing ``electrocautery-hyfrecator, up to 45 watts''
(EQ110), and ``cover, probe (cryosurgery)'' (SB003), among other
refinements.
Comment: Commenters noted that there is an ``inherent and
persistent risk of bleeding'' during these procedures, and that the
electrocautery-hyfrecator needs to be readily available to prevent
excessive blood loss and is typically included in the surgical field.
These commenters explained that the item, ``cover, probe
(cryosurgery)'' is the generic sterile sheath that covers the
electrocautery-hyfrecator pen-handle and cable, and therefore required
to be used with the electrocautery-hyfrecator.
Response: In our clinical review, we reviewed the work vignettes
for these procedures, which did not include the use of the
electrocautery-hyfrecator as a part of the procedure. Although we
acknowledge that the electrocautery-hyfrecator needs to be readily
available during the procedure, we note that ``standby'' equipment, or
items that are not used in the typical case, are considered indirect
costs. For further discussion of this issue, we refer readers to our
discussion of ``standby'' equipment in the CY 2001 PFS proposed rule
(65 FR 44187). With regard to the ``cover, probe (cryosurgery)'', this
item is a disposable supply that would only be used with each patient
if the electrocautery-hyfrecator is in the sterile field during all
procedures. We do not have information to suggest that the
electrocautery-hyfrecator is typically in the sterile field, so we are
not including the supply item ``cover, probe (cryosurgery)'' in the
direct PE database for this service. After consideration of the
comments received, we are finalizing the CY 2013 interim final direct
PE inputs for 11300-11313 as established.
(3) Integumentary System: Repair (Closure) (CPT Codes 13100, 13101,
13102, 13120, 13121, 13122, 13131, 13132, 13133, 13152, and 13153)
In establishing interim final direct PE inputs for CY 2013, CMS
refined the AMA RUC's recommendations for CPT codes 13100 (Repair,
complex, trunk; 1.1 cm to 2.5 cm), 13101 (Repair, complex, trunk; 2.6
cm to 7.5 cm), 13102 (Repair, complex, trunk; each additional 5 cm or
less (list separately in addition to code for primary procedure)),
13120 (Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm),
13121 (Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm),
13122 (Repair, complex, scalp, arms, and/or legs; each additional 5 cm
or less (list separately in addition to code for primary procedure)),
13131 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae,
genitalia, hands and/or feet; 1.1 cm to 2.5 cm), 13132 (Repair,
complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands
and/or feet; 2.6 cm to 7.5 cm), 13133 (Repair, complex, forehead,
cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each
additional 5 cm or less (list separately in addition to code for
primary procedure)), 13150 (Repair, complex, eyelids, nose, ears and/or
lips; 1.0 cm or less), 13151 (Repair, complex, eyelids, nose, ears and/
or lips; 1.1 cm to 2.5 cm), 13152 (Repair, complex, eyelids, nose, ears
and/or lips; 2.6 cm to 7.5 cm), and 13153 (Repair, complex, eyelids,
nose, ears and/or lips; each additional 5 cm or less (list separately
in addition to code for primary procedure)) by removing duplicative
items, among other refinements.
Comment: A few commenters argued that the majority of procedures
reported using CPT codes 13100, 13101, 13120, 13121, 13131, 13132,
13150, 13151, and 13153 are furnished under local anesthesia, delivered
by subcutaneous injection, and therefore typically require ``needle,
18-27g'' (SC029). Commenters also pointed out that the second ``gown,
staff, impervious'' (SB027) and ``mask, surgical'' (SB033) are not
duplicative, but required, because an assistant at surgery is allowed
for these surgeries in some cases, and OSHA requirements mandate that
health care workers be protected from blood exposure. Commenters stated
that they did not believe these procedures could be furnished without
these inputs.
Response: Based on the rationale provided by commenters, we agree
that the needle should be included as a direct PE input for this family
of codes. However, we continue to believe that a second gown and mask
are not typical because our claims data show that an assistant at
surgery is rarely, if ever, used for these services.
After consideration of the comments received, we are finalizing the
CY 2013 interim final direct PE inputs for 13100-13153 with the
additional refinement of incorporating the ``needle, 18-27g''
[[Page 74312]]
(SC029) as recommended by commenters.
(4) Integumentary System: Nails (CPT Code 11719)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC recommendation for CPT code 11719 by adjusting the
times allocated for clinical labor tasks as follows: ``Provide
preservice education/obtain consent'' from 2 minutes to 1 minute,
``Greet patient, provide gowning, assure appropriate medical records
are available'' from 3 minutes to 1 minute, ``Prepare room, equipment,
supplies'' from 2 minutes to 1 minute, and ``Clean room/equipment by
physician staff'' from 3 minutes to 1 minute, among other refinements.
Comment: A commenter objected to our refinements to this clinical
labor task, and argued that one minute of ``provide preservice
education/obtain consent'' is inadequate to review the advanced
beneficiary notice (ABN) and answer patient questions. This commenter
also objected to our decreasing the number of minutes associated with
the other clinical labor activities to below the AMA-RUC recommended
standard minutes.
Response: We believe that the time assigned to ``provide preservice
education/obtain consent'' appropriately reflects the resources
required in furnishing the typical procedure and thus are not making
the change requested, particularly since five minutes of preservice
physician time are also included for the service. We also would not
expect an ABN to be provided in the typical case. We agree with
commenters that we should allocate the standard number of minutes for
the remaining clinical labor activities and have adjusted the direct PE
database accordingly.
Comment: One commenter suggested that it was typical to position a
patient in a power table/chair in lieu of an exam table when furnishing
this service.
Response: CMS clinical staff reviewed CPT code 11719 in the context
of this comment. We do not believe that it is typical that a power
table/chair would be used for these procedures. After considering the
comments received, we are finalizing the CY 2013 interim final direct
PE inputs for CPT code 11719 as established, with the exception of
increasing the minutes assigned to clinical labor activities to the
standard number of minutes.
(5) Arthrocentesis (CPT Codes 20600, 20605, 20610)
In establishing direct PE inputs for CY 2013, we refined the AMA
RUC's recommendations for CPT codes 20600 (Arthrocentesis, aspiration
and/or injection; small joint or bursa (eg, fingers, toes), 20605
(Arthrocentesis, aspiration and/or injection; intermediate joint or
bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle,
olecranon bursa)), and 20610 (Arthrocentesis, aspiration and/or
injection; major joint or bursa (eg, shoulder, hip, knee joint,
subacromial bursa)) by removing the minutes associated with the
clinical labor activity ``discharge day management'' and replacing
these minutes with ``conduct phone calls/call in prescriptions'' in the
facility setting.
Comment: Commenters requested clarification as to whether the time
allocated for ``conduct phone calls/call in prescriptions'' is limited
to the facility setting or is also included in the non-facility
setting.
Response: The AMA RUC recommendation included ``conduct phone
calls/call in prescriptions'' in the nonfacility setting and we did not
refine this recommendation. Therefore, this activity is included in the
inputs for the nonfacility setting as well.
Comment: One commenter suggested it was typical for a physician to
position a patient in a power table/chair in lieu of an exam table when
furnishing 20600 and 20605.
Response: Our clinical staff reviewed CPT codes 20600 and 20605 in
the context of this comment. We do not believe that it is typical that
a power table/chair would be used for these procedures. After
considering the comments received, we are finalizing the CY 2013
interim final direct PE inputs for CPT codes 20600, 20605, and 20610 as
established.
(6) Respiratory System: Accessory Sinuses (CPT Code 31231)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT code 31231 (Nasal
endoscopy, diagnostic, unilateral or bilateral (separate procedure)) by
removing the second ``endoscope, rigid, sinoscopy'' (ES013) from the
inputs for the service, refining the equipment time to reflect typical
use exclusive to the patient, and removing the time allocated to
preservice clinical labor tasks, among other refinements.
Comment: A commenter disagreed with our removal of the second
endoscope, arguing that the second scope is medically necessary because
the first scope (zero degree rigid scope) does not allow visualizing
above or behind all the normal structures of the nasal vault such as
superior turbinate and the frontal recess. The second scope (for
example, a 30, 45 or 70 degree scope) is used more than 51 percent of
the time.
Response: We agree with the commenter that the second scope is used
in the typical case, and based on this comment; we are adding the
second scope to the direct PE inputs for the service.
Comment: A commenter disagreed with our refinements to the
equipment time for this service, and stated that the entire clinical
labor service period time of 63 minutes, and at a minimum, 43 minutes,
should be allocated to all equipment used in this procedure.
Response: In general, for equipment that we do not consider to be
highly technical, we allocate the entire service period time, with the
exception of the time allocated for cleaning of other, portable pieces
of equipment. Therefore, we agree with the commenter that the equipment
times should be modified, but do not agree with the commenter that 63
minutes should be allocated. Instead, we are modifying the time
allocated for the equipment in this procedure by assigning 53 minutes
to the instrument pack to reflect the intraservice time other than
cleaning of the scopes, 48 minutes to the scopes to reflect the
intraservice time other than the cleaning of the instrument pack, and
38 minutes to the remaining equipment items, which reflects the entire
intraservice clinical labor time except for the time allocated for
cleaning the portable equipment items instrument pack and scope.
Comment: Commenters argued that the preservice clinical labor tasks
included in the RUC recommendation should have been maintained in this
procedure.
Response: This procedure is typically billed with an E/M service,
and the preservice tasks are already included as direct PE inputs for
the E/M services. Therefore, we believe that including these items
again in CPT 31231 would be duplicative.
After consideration of public comments, we are finalizing the CY
2013 interim final direct PE inputs for 31231 as established with the
additional refinements of adding in the second scope as an equipment
item and adjusting the equipment times as discussed above.
(7) Respiratory System: Lungs and Pleura (CPT Codes 32554, 32555, and
32557)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT codes 32554 (Removal of
fluid from chest cavity), 32555 (Removal of fluid from
[[Page 74313]]
chest cavity with imaging guidance), and 32557 (Removal of fluid from
chest cavity with insertion of indwelling catheter and imaging
guidance), by inserting supply item ``kit, pleural catheter insertion''
(SA077) and refining the equipment times to reflect the typical use
exclusive to the patient.
Comment: Commenters indicated that a tunneled catheter is not used
during this procedure, so that the pleural catheter insertion kit is
not an accurate supply item to use as the thoracentesis kit (SA113).
The commenter also pointed out that the price of the thoracentesis kit
that appears in the direct PE input database appeared to be
inaccurately priced at $260.59. The commenter pointed out that the
price listed in the database reflects an invoice that includes ten
units, so that the accurate price for the items is $26.06.
Response: Based on the information provided by commenters, we agree
that supply item ``Kit, thoracentesis'' (SA113) would be more
appropriate than ``kit, pleural catheter insertion'' (SA077) and we
agree that the correct price for the item is $26.06. We have updated
this price in the direct PE input database accordingly.
Comment: Commenters stated that the time allocated to equipment
items ``room, ultrasound, general'' (EL015) and ``room, CT'' (EL007),
as well as ``light, exam'' (EQ168) should reflect the time for tasks
during which the room is not available to other patients; specifically,
for CPT code 32555, 33 minutes should be assigned to EL015, and for CPT
code 32557, 45 minutes should be assigned to EL007 and EQ168.
Response: We agree with commenters that it is consistent with our
stated policy to allocate time for highly technical equipment for
preparing the room, positioning the patient, acquiring images, and
cleaning the room. Therefore, for CPT code 32555, we are assigning 33
minutes to ``room, ultrasound, general'' (EL015), and for CPT code
32557, we are assigning 45 minutes to ``room, CT'' (EL007) and ``light,
exam'' (EQ168).
After reviewing the public comments received, we are finalizing the
CY 2013 interim final direct PE inputs for CPT codes 32554, 32555, and
32557 as established with the additional refinements of including and
updating the price of the ``kit, thoracentesis'' (SA113) supply item
and adjusting the equipment times as commenters recommended.
(8) Cardiovascular System: Heart and Pericardium (CPT Codes 33361,
33362, 33363, 33364, 33365, and 33405)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT codes 33361, 33362, 33363,
33364, and 33365 by refining the time allocated to clinical labor tasks
in the preservice and postservice periods to be consistent with the
standards for adjusted 000-day global services.
Comment: Commenters stated that these services are furnished in a
facility setting, requiring a fully equipped operating room or hybrid
suite. The commenter detailed the various clinical labor tasks that are
needed for these procedures, and noted that the requirements are
similar to those of 90-day global procedures.
Response: We agree with commenters that it would be appropriate to
allocate the standard 90-day global clinical labor inputs for these
services. After consideration of public comments, we are finalizing the
CY 2013 interim final direct PE inputs for CPT codes 33361-33365 as
established, with the additional refinement of replacing the current
times for clinical labor tasks with those of the standard 90-day global
inputs.
We also refined the direct PE inputs for CPT code 33405 by removing
the clinical labor activity, ``Additional coordination between multiple
specialties for complex procedures (tests, meds, scheduling, etc.)
prior to patient arrival at site of service.''
Comment: A commenter stated that inclusion of the time allocated
for this additional coordination activity is consistent with other
major surgical procedures, and that removing it would create an anomaly
with other cardiac procedures.
Response: We do not agree that it is appropriate to include these
``additional coordination'' tasks as inputs to this procedure. We thank
the commenter for bringing to our attention the potential anomaly
created by having this activity included in other procedures and will
consider any relativity issues regarding clinical labor preservice
minutes allocated for other procedures in future rulemaking. After
consideration of the comments received, we are finalizing the CY 2013
direct PE inputs for CPT code 33405 as established.
(9) Cardiovascular System: Arteries and Veins (CPT Codes 36221, 36222,
36223, 36224, 36225, 36226, 36227, 36228, and 37197)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT codes 36221 (Insertion of
catheter into chest aorta for diagnosis or treatment), 36222 (Insertion
of catheter into neck artery for diagnosis or treatment), 36223
(Insertion of catheter into neck artery for diagnosis or treatment),
36224 (Insertion of catheter into neck artery for diagnosis or
treatment), 36225 (Insertion of catheter into chest artery for
diagnosis or treatment), 36226 (Insertion of catheter into chest artery
for diagnosis or treatment), and 36227 (Insertion of catheter into neck
artery for diagnosis or treatment) by substituting equipment item
``table, instrument, mobile'' (EF027) for equipment item ``Stretcher''
(EF018), refining equipment time to reflect typical use exclusive to
the patient for equipment items ``room, angiography'' (EL011),
``contrast media warmer'' (EQ088), and ``film alternator (motorized
film viewbox)'' (ER029), and removing the recommended minutes based on
the clinical labor task described as ``image post processing'' from CPT
code 36221, among other refinements.
Comment: Commenters stated that they believed that the removal of
the stretcher was an error because a stretcher is necessary for these
cerebral angiography codes and requested that the stretcher be included
as an input for these procedures.
Response: We do not agree with commenters that it is appropriate to
include a stretcher for this family of codes. The inclusion of a
stretcher is not consistent with the AMA RUC-recommended standardized
nonfacility direct PE inputs that account for moderate sedation as
typically furnished as a part of such service, which we used as the
basis for proposing and finalizing a standard package of direct PE
inputs for moderate sedation during CY 2012 rulemaking. For further
discussion of this issue, we refer readers to the CY 2012 PFS rule (76
FR 73044).
Comment: Commenters stated the CMS refinement for equipment minutes
was inappropriate, and that the equipment time for ``room,
angiography'' (EL011), ``contrast media warmer'' (EQ088), and ``film
alternator (motorized film viewbox)'' (ER029) should include the
clinical labor tasks of ``prepare room,'' ``prepare and position
patient,'' ``sedate patient,'' ``assist physician/acquire images,'' and
``clean room.'' Specifically, commenters requested that we adjust the
time for all equipment items as follows: 49 minutes for CPT code 36221,
59 minutes for CPT code 36222, 64 minutes for CPT code 36223, 69
minutes for CPT code 36224,
[[Page 74314]]
64 minutes for CPT code 36225, and 69 minutes for CPT code 36226.
Response: We agree with commenters that the time allocated to the
equipment should account for these tasks. We are adjusting the
equipment times for ``room, angiography'' (EL011), ``contrast media
warmer'' (EQ088), and ``film alternator (motorized film viewbox)''
(ER029) to those identified by the commenters and described above.
Comment: A commenter noted that ``image post processing'' often
appears as a clinical labor task activity on the PE worksheet and that
the task is integral to patient care for the services described by
these codes. Commenters requested that we include these clinical labor
tasks for these procedures.
Response: Upon further review of similar codes, we agree with the
commenter that it is consistent with other services in this family to
include clinical labor minutes based on the ``image post processing''
task. After consideration of public comments, we are finalizing the CY
2013 interim final direct PE inputs for CPT codes 36221-36227 as
established with the additional refinements of the adjusted equipment
and clinical labor times noted above.
We also refined the AMA RUC's recommendation for direct PE inputs
for CPT code 36228 (Insertion of catheter into neck artery for
diagnosis or treatment) by removing 1 minute of clinical labor time,
based on the task called ``prepare room, equipment, and supplies,'' and
1 minute for ``assisting with fluoroscopy/image acquisition.'' We also
refined the recommendation by not including the supply item ``syringe,
5-6 ml'' (SC075).
Comment: Commenters stated that the additional minute for ``prepare
room, equipment, and supplies'' is necessary for this add-on code. They
also requested that we adjust the time for acquiring images as well.
Commenters also stated that the syringe is necessary to safely inject
micro-catheters and should be included.
Response: We do not agree with commenters that an additional minute
should be added to the clinical labor time for this add-on code to
account for additional time to ``prepare the room, equipment, and
supplies.'' As we stated in the CY 2013 PFS final rule with comment
period (77 FR 68933), we believe that preparing the room would not
typically be duplicated when furnishing a subsequent procedure to the
same patient on the same day, and we believe that the standard number
of minutes allocated on the basis of the clinical labor task accounts
for the typical amount time spent preparing the items for the primary
procedure, regardless of whether or not a separate code is reported for
some cases. However, based on the commenters' explanation, we agree
that an additional minute for image acquisition is typical when the
add-on code is reported. We also agree that the syringe is necessary
for this procedure.
After reviewing public comments received, we are finalizing the CY
2013 direct PE inputs for CPT code 36228 as established with the
additional refinements to the clinical labor and supply items noted
above.
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT code 37197 (Retrieval of
intravascular foreign body) by removing equipment items ``ultrasound
unit, portable'' (EQ250) and ``contrast media warmer'' (EQ088), and
supply items ``sheath-cover, sterile, 96in x 6in (transducer)''
(SB048), ``catheter, (Glide)'' (SD147), ``guidewire, Amplatz wire 260
cm'' (SD252), and ``sodium chloride 0.9% flush syringe'' (SH065).
Comment: Commenters indicated that the portable ultrasound unit is
necessary to gain vascular access, the contrast media warmer is
necessary for the procedure, and the supply items we refined from the
AMA RUC recommendation are also required for the procedures since the
foreign body cannot be removed without these items.
Response: We do not agree that the portable ultrasound unit should
be included as a direct PE input for this procedure. The CPT
description of this code states that either fluoroscopy or ultrasound
is used; the angiography room accounts for the resources associated
with fluoroscopy. When fluoroscopy is used, these resources are
appropriately accounted for. In the event that a portable ultrasound
unit is used in place of fluoroscopy, the resource costs would be
significantly overestimated, since a portable ultrasound unit is far
less expensive than the angiography room. Therefore, we continue to
believe that the PE inputs adequately account for the resource costs
used for imaging in this procedure. We also continue to believe that
the supply items we refined from the AMA RUC recommendation are
duplicative since the inputs for this service already include supply
items that are used for removing the foreign body during the procedure.
We agree with commenters that the contrast media warmer should be
included in the procedure, and are including this equipment item as a
direct PE input for this service.
After consideration of these comments, we are finalizing the CY
2013 interim final direct PE inputs for CPT code 37197 as established
with the additional refinement of adding the equipment item ``contrast
media warmer'' (EQ088), as noted above.
(10) Digestive System: Intestines (Except Rectum) (CPT Code 44705 and
HCPCS Code G0455)
In establishing interim final direct PE inputs for CY 2013, CMS
crosswalked the inputs from 44705 (Prepare fecal microbiota for
instillation, including assessment of donor specimen) to G0455
(Preparation with instillation of fecal microbiota by any method,
including assessment of donor specimen), and incorporated a minimum
multi-specialty visit pack (SA048) and an additional 17 minutes of
clinical labor time in the service period based on the amount of time
allocated for clinical labor tasks in the direct PE inputs for E/M
services. In the CY 2013 final rule with comment period, we noted that
Medicare would only pay for the preparation of the donor specimen if
the specimen is ultimately used for the treatment of a beneficiary.
Accordingly, we bundled preparation and instillation into a HCPCS code,
G0455, to be used for Medicare beneficiaries instead of the new CPT
code 44705 (Preparation of fecal microbiota for instillation, including
assessment of donor specimen), which we assigned a PFS procedure status
indicator of I (Not valid for Medicare purposes). G0455 includes both
the work of preparation and instillation of the microbiota.
Comment: A commenter asserted that CMS listed G0455 as having a PE
RVU of 2.48 without explaining how this value was derived.
Response: In the CY 2013 PFS final rule with comment period (77 FR
69073), we described how we established the direct PE inputs for G0455.
Specifically, we stated that we used the AMA RUC-recommended
nonfacility PE inputs for CPT code 44705, in addition to 17 minutes of
clinical labor time and a ``minimum multi-specialty visit pack''
(SA048), to account for both the preparation and instillation. The PE
RVU of 2.48 results from the standard methodology outlined in PFS rules
in the section entitled ``Resource-Based Practice Expense (PE) Relative
Value Units (RVUs)'' (see, for example, 77 FR 68899). After
consideration of the public comment, we are finalizing the interim
final direct PE inputs for HCPCS code G0455 as established.
(11) Digestive System: Biliary Tract (CPT Codes 47600 and 47605)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA
[[Page 74315]]
RUC's recommendation for CPT codes 47600 (Removal of gallbladder) and
47605 (Removal of gallbladder with X-ray study of bile ducts) by
replacing the supply item ``pack, post-op incision care (suture &
staple)'' (SA053) with supply item ``pack, post-op incision care
(suture)'' (SA054).
Comment: Commenters stated that although sutures and staples are
sometimes both used, at a minimum, staples are used in this procedure.
Therefore, commenters requested that, as a minimum, we include the
staple removal pack.
Response: We agree with the commenters that the staple removal pack
(SA052) should be included instead of the suture pack. After
consideration of these comments, we are finalizing the CY 2013 interim
final direct PE inputs for CPT codes 47600 and 47605 as established,
with the additional refinement of substituting the staple removal pack
(SA052) for the suture removal pack (SA054).
(12) Urinary System: Bladder (CPT Codes 52214, 52224, and 52287)
In establishing the interim final direct practice expense inputs
for CY 2013 for CPT code 52214, we refined the AMA RUC recommendation
to remove supply items ``drape-towel, sterile, 18in x 26in'' (SB019),''
``lidocaine 1%-2% inj (Xylocaine)'' (SH047), and ``penis clamp.''
Comment: Commenters indicated that the supply item ``drape-towel,
sterile, 18in x 26in,'' is used on the instrument table and that the
supply item ``lidocaine 1%-2% inj (Xylocaine)'' (SH047), is used to
instill into the bladder as a numbing agent. Commenters also indicated
that the item ``penis clamp'' is required to keep the lidocaine in the
penile urethra.
Response: We agree with commenters that the drape towel and
lidocaine should be included in this procedure. However, we do not
agree that the reusable penis clamp, even when typically used, should
be included in the direct PE input database for this procedure. Since
the item is reusable, the resource cost associated with the item is not
considered to be a direct PE supply input. Given the price associated
with the item, the cost per minute over several years of useful life
becomes negligible relative to the other costs accounted for in the PE
methodology. We refer readers to a discussion of equipment items under
$500 in the NPRM for CY 2005 (69 FR 47494). We note that including such
items as equipment in the direct PE input database would not impact the
PE RVU values.
In establishing the interim final direct practice expense inputs
for CY 2013, we refined the AMA RUC recommendation for CPT code 52224
by adjusting the equipment time for ``fiberscope, flexible,
cystoscopy'' (ES018) to 94 minutes, adjusting the clinical labor
activity ``prepare biopsy specimen'' to 2 minutes, and adjusting the
quantity of the supply item ``gloves, sterile'' (SB024) to 1 pair, and
``cup, biopsy-specimen sterile 4oz'' (SL036) to 3, among other
refinements.
Comment: Commenters stated that the time for this equipment item
should include all standard tasks, in addition to the cleaning of the
scope. Commenters also noted that, depending upon the number of
biopsies, the preparation of the specimen can take more than 2 minutes,
that a minimum of 3 pairs of gloves are required, and that biopsy
specimens are submitted in several containers.
Response: We re-examined the time for the fiberscope and agree with
commenters that the time should include all time associated with
standard tasks and cleaning the scope. We are therefore adjusting the
time for this equipment item to 97 minutes. We continue to believe that
2 minutes represents the typical time required to prepare the specimen
and are not adjusting the time. We agree with commenters that more than
1 pair of gloves may be required; however, since a biopsy is not
required in all cases, we believe that 2 pairs of gloves accounts for
the resources used in furnishing the typical service. Finally, we
continue to believe that 3 containers represent the typical resources
used in furnishing this procedure given the small size of the lesions.
After considering the comments received, we are finalizing the CY 2013
interim final direct PE inputs for CPT code 52224 as established with
the additional refinement of adjusting the equipment time to account
for cleaning the scope, and adding one pair of gloves, as noted above.
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT code 52287 by adjusting
the time for the clinical labor activity ``assist physician in
performing procedure'' from 20 minutes to 21 minutes to conform to the
physician intraservice time, and refining the equipment time to reflect
the typical use exclusive to the patient.
Comment: The AMA RUC stated that its original submission to CMS
contained 21 minutes for this clinical labor activity. Another
commenter noted that the times allocated to preservice clinical labor
tasks were missing in the nonfacility setting. Another commenter stated
that the equipment time should include the time for all of the standard
clinical labor tasks.
Response: We note that the AMA RUC and CMS agree on the appropriate
number of minutes to assign to the clinical labor service period to
account for ``assist physician.'' Regarding the preservice clinical
labor tasks, we note that the AMA RUC did not recommend preservice
clinical labor time for these tasks in the nonfacility setting, and
that such inputs are not standard for 000-day global services. With
respect to equipment time, we agree with commenters that the equipment
time for all equipment in this procedure should include time for all of
the standard clinical labor tasks, with the exception of the time
allocated for cleaning of the scope. The times for the equipment items
included in CPT code 52287 already include all of these tasks, with the
exception of ``fiberscope, flexible, cystoscopy'' (ES018). We are
adjusting time for the scope from 76 to 78 minutes to align the
equipment time with that of the standard clinical labor tasks.
After considering the comments received, we are finalizing the CY
2013 interim final direct PE inputs for CPT code 52287 as established
with the additional refinement of adjusting the equipment time as noted
above.
(13) Transurethral Destruction of Prostate Tissue (CPT Code 53850)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT code 53850 by refining
equipment time to reflect typical use exclusive to the patient.
Comment: A commenter stated that the equipment time should include
the time for all of the standard clinical labor tasks.
Response: We agree with the commenter that the equipment time for
all equipment in this procedure should include time for all of the
standard clinical labor tasks, and we are allocating the entire service
period of 99 minutes for ``stretcher, endoscopy'' (EF020), ``table,
instrument, mobile'' (EF027), ``TUMT system control unit'' (EQ037), and
``ultrasound unit, portable'' (EQ250), which are used during the
service period only. In addition, we are allocating 169 minutes for
items used during both the service period and postservice period, which
are ``table, power'' (EF031) and ``light, exam'' (EQ168), to account
for both the service period and postservice period.
We also refined the AMA recommendation for this code by not
assigning additional clinical labor
[[Page 74316]]
minutes for non-standard clinical labor tasks described as ``setup
ultrasound probe,'' ``setup TUMT machine,'' and ``clean TUMT machine.''
Comment: The same commenter also stated that the clinical labor
tasks were necessary because extra time was required.
Response: We do not agree that the time for these clinical labor
tasks is reflective of typical resource costs involved in furnishing
the service. For this procedure the assigned clinical labor time
already includes the standard number of minutes for set-up and clean-
up, and the commenter provided no information justifying a deviation
from these standard times for this procedure.
Comment: A commenter stated that there is no preservice clinical
staff time assigned for the nonfacility, and that the clinical labor
time should account for tasks such as ``setting up the room,''
``greeting patient,'' and ``position patient prior to the procedure.''
Response: The clinical labor tasks referred to by the commenter are
tasks generally included in service period activities; the preservice
clinical staff time that is included when the procedure is done in the
facility includes scheduling and coordination services that are unique
to procedures furnished in facility settings. The service period time
for this procedure includes minutes allocated for clinical labor tasks
such as ``greet patient,'' ``provide gowning,'' ``ensure appropriate
medical records are available,'' and ``prepare and position patient.''
Therefore, we are not making a change at this time and are finalizing
the CY 2013 interim final direct PE inputs for CPT code 53850,
including the clinical labor tasks, as established.
(14) Nervous System: Extracranial Nerves, Peripheral Nerves, and
Autonomic Nervous System (CPT Code 64615)
In establishing interim final direct PE inputs for CY 2013, we
accepted the AMA RUC's recommendation for CPT code 64615 (Injection of
chemical for destruction of facial and neck nerve muscles).
Comment: A commenter questioned why this service had only 3 minutes
of postservice clinical labor time, while other codes in the family
have 27 or 30 minutes.
Response: The apparent discrepancy between CPT code 64615 and the
other codes in the family results because CPT 64615 does not have any
post-operative visits in the global period while the other codes in the
family have post-operative visits. Specifically, the 30 minutes of
postservice clinical labor time in 64612 are allocated specifically for
the post-operative visits. After consideration of public comment, we
are finalizing the CY 2013 interim final direct PE inputs for CPT code
64615 as established.
(15) Diagnostic Radiology: Abdomen and Pelvis (CPT Codes 72191, 72192,
72193, 72194, 74150, 74160, 74170, 74175, 74176, 74177, 74178)
In establishing interim final direct PE inputs for CY 2013, we
reviewed the direct PE inputs for all of the abdomen, pelvis, and
abdomen/pelvis combined CT codes. For each set of codes, we established
a common set of disposable supplies and medical equipment. We
established clinical labor minutes that reflect the fundamental
assumption that the component codes should include a base number of
minutes for particular tasks, and that the number of minutes in the
combined codes should reflect efficiencies that occur when the regions
are examined together. Among other refinements, we adjusted the
intraservice time for CPT codes 72194, 74160, and 74177 by 2 minutes, 4
minutes, and 6 minutes respectively.
Comment: Commenters stated that more information was required about
from where CMS decreased the minutes from the service period for CPT
codes 72194, 74160, and 74177.
Response: We refined the minutes in the service period such that
the aggregate number of clinical labor minutes reflected in the direct
PE input database and used to develop PE RVUs was consistent within
this family of codes. We believe that the aggregate clinical labor time
in each clinical service period (preservice period, service period, and
postservice period) or aggregate number of minutes for particular
equipment items that reflects the total typical resource use is more
important than the minutes associated with each clinical labor task,
which are a tool used by the AMA RUC to develop their recommendations.
We hope that in reviewing future services, commenters consider the
aggregate clinical labor time as well, recognizing that it is the
aggregate time that ultimately has implications for payment. Finally,
we welcome comments that address the appropriateness of the number of
clinical labor minutes in each service period and the number of
equipment minutes for each service.
In this refinement process, we also removed supply item ``needle,
18-27g'' (SC029) and replaced it with ``needle, 14-20g, biopsy''
(SC025) for CPT codes 72193, 72194, 74160, and 74170.
Comment: Commenters stated that the biopsy needle (SC025) was not
appropriate for these services, and that supply item ``needle, 18-27g''
(SC029) would be more appropriate. In addition, commenters noted that
the ``film processor'' (ED024) is in use during a portion of the
service.
Response: We agree with commenters that the ``needle, 18-28g''
(SC029) is more appropriate for these services, and that the film
processor should be included for these codes. We are adjusting the
direct PE inputs to include the needle and film processor in CPT codes
72193, 72194, 74160, and 74170.
In refining the direct PE inputs, we also substituted a radiologic
technologist for a CT technologist for CPT codes 72191 and 74175, and
removed the clinical labor time for ``Retrieve prior appropriate
imaging exams and hang for MD review, verify orders, review the chart
to incorporate relevant clinical information'' from 72191, 74170, and
74175.
Comment: Commenters stated that a CT technologist was the typical
clinical labor type for these CT procedures. Commenters also objected
to the removal of recommended minutes based on the clinical labor
activity ``Retrieve prior appropriate imaging exams and hang for MD
review, verify orders, review the chart to incorporate relevant
clinical information'' from CPT codes 72191, 74170, and 74175, and to
the reduction of preservice and intraservice clinical labor time in
this family of codes.
Response: Based on the information provided by commenters, we agree
that CPT codes 72191 and 74175 should include a CT technologist rather
than a radiologic technologist for CPT codes 72191 and 74175 because
the CT technologist is typical. However, we do not agree that the
clinical labor time should be changed per the commenters' request, as
we continue to believe that these tasks are already captured in the
preservice clinical labor time. We refer readers to the CY 2013 PFS
final rule with comment period (77 FR 69073) for a discussion of the
development of a standard allocation of inputs for these families of
codes.
For CPT code 72191, we refined the time for equipment item ``room,
CT'' (EL007) to 40 minutes.
Comment: Commenters stated that the CT room time for should be at
least 43 minutes to include time for cleaning the room.
Response: We agree with commenters that the time for the CT room
should be 43 minutes to include the standard clinical labor tasks for
highly technical equipment, including cleaning the room.
[[Page 74317]]
After considering the comments received, we are finalizing the CY
2013 interim final direct PE inputs for CPT codes 72193, 72194, 73221,
73721, 74150, 74160, 74170, 74175, 74176, and 74177 as established with
the additional refinements of the supply item, changes to clinical
labor staff type, and equipment time noted above.
(16) Diagnostic Ultrasound: Transvaginal and Transrectal Ultrasound
(CPT Codes 76830 and 76872)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT code 76830 by removing the
equipment item ``room, ultrasound, general'' (EL015) and replacing it
with individual items including a portable ultrasound unit.
Comment: A commenter noted that a panel of obstetrician/
gynecologists, a specialty that frequently furnishes this service,
indicated that a dedicated ultrasound room was used.
Response: Based on the comments we received, we agree that it would
be more appropriate to allocate a general ultrasound room for this
procedure rather than a portable ultrasound unit and accompanying
items. We are including the ultrasound room as a direct PE input for
CPT code 76830.
In refining the inputs for CPT code 76830, we also removed ``film
alternator (motorized film viewbox)'' (ER029), ``Surgilube lubricating
jelly'' (SJ033), and ``film processor, dry, laser'' (ED024).
Comment: Another commenter stated that the film alternator and
Surgilube lubricating jelly are required; however, the specialty that
most frequently furnishes the service stated that they did not use
either of these items.
Response: We continue to believe that neither the film alternator
nor the lubricating jelly should be included for this service as, and
after considering the comments from the specialty that most frequently
furnishes the service, we agree that these are not used in the typical
case.
After considering the comments received, we are finalizing the CY
2013 interim final direct PE inputs for CPT code 76830 as established
with the additional refinement of allocating a general ultrasound room
and removing individual inputs related to a portable ultrasound unit.
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT code 76872 by adjusting
the equipment time to reflect the typical use exclusive to the patient,
and removing clinical labor tasks, ``obtain vital signs,'' and
``prepare ultrasound probe'' from the preservice period; removing
``obtain vital signs'' from the service period; and removing supply
items ``drape, sterile, for Mayo stand'' (SB012), ``iv tubing
(extension)'' (SC019), ``lidocaine 2% jelly, topical (Xylocaine)''
(SH048), ``alcohol isopropyl 70%'' (SJ001), ``lubricating jelly (K-Y)
(5gm uou)'' (SJ032), ``glutaraldehyde 3.4% (Cidex, Maxicide,
Wavicide)'' (SM018), ``glutaraldehyde test strips (Cidex, Metrex)''
(SM019), and ``sanitizing cloth-wipe (surface, instruments,
equipment)'' (SM022).
Comment: Commenters indicated that the equipment time allocated for
this procedure should be 68 minutes to reflect the time that the
equipment is unavailable for other patients.
Response: We agree with commenters that the equipment time for all
equipment in this procedure should include time for all of the standard
clinical labor tasks in the service period, so we are allocating 42
minutes for those equipment items.
Comment: Commenters noted that it is necessary to obtain vital
signs prior to the service, and that the supplies were necessary for a
variety of purposes outlined in the comment.
Response: We do not agree that it is necessary to obtain vital
signs in the preservice period in order to determine if the patient
becomes hypotensive during the service period, but agree that obtaining
vital signs in the service period is necessary. We note that we have
standard setup times for equipment and do not generally allocate
separate time for preparing individual pieces of equipment. After
considering the information provided by the commenters, we are
persuaded that the supplies that were removed are necessary for the
procedure. Therefore, we are including 3 additional minutes in the
service period and reinstating the supplies that we removed from the
procedure in establishing interim final direct PE inputs.
After considering comments received, we are finalizing the CY 2013
interim final direct PE inputs for CPT code 76872 as established with
the additional refinement of adjusting equipment time and incorporating
supply items as noted above.
(17) Radiation Oncology: Medical Radiation Physics, Dosimetry,
Treatment Devices, and Special Services (CPT Code 77301)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT code 77301 by removing
equipment item ``computer system, record and verify'' from the service,
adjusting the equipment time for ``treatment planning system, IMRT
(Corvus w-Peregrine 3D Monte Carlo)'' from 376 to 330, among other
refinements previously discussed in the context of our discussion of
general refinements.
Comment: Commenters indicated that the minutes used for the
computer system are not captured elsewhere and should be included in
the service, and that there is physician time independent of clinical
staff time for the treatment planning system.
Response: The computer system was not previously an input for this
service, and the commenter did not provide sufficient information or
evidence for us to conclude that there should be a change. We also note
that this service has both a technical and professional component; the
professional component has no inputs, and the equipment time associated
with the physician time is not appropriately placed in the technical
component. Thus, the equipment time is allocated for the technical
component only.
After considering public comments, we are finalizing the CY 2013
interim final direct PE inputs for CPT code 77301 as established.
(18) Nuclear Medicine: Diagnostic (CPT Code 78072)
In establishing interim final direct PE inputs for CY 2013, we were
unable to price the new equipment item ``gamma camera system, single-
dual head SPECT/CT'' for CPT code 78072 (Parathyroid planar imaging
(including subtraction, when performed); with tomographic (SPECT), and
concurrently acquired computed tomography (CT) for anatomical
localization)) since we did not receive any paid invoices. Because the
cost of the item that we were unable to price is disproportionately
large relative to the costs reflected by remainder of the recommended
direct PE inputs, we contractor priced the technical component of the
code for CY 2013, on an interim basis, until the newly recommended
equipment item could be appropriately priced.
Comment: A commenter indicated that it would provide necessary
documentation so that CMS can establish a price for the new SPECT/CT
equipment item associated with CPT code 78072. We received 4 paid
invoices for the SPECT/CT equipment.
Response: Out of the four invoices we received, we were only able
to use one of them to price the equipment because the other three
included training and other costs as part of the overall equipment
price. Since training and these other costs are not considered part of
the price of the equipment in the
[[Page 74318]]
current PE methodology, we are unable to use invoices when these items
are not separately priced on the invoice. Based on the invoice that met
our criteria, this equipment is priced at $600,272. We are assigning 92
minutes based on our standard allocation for highly technical
equipment, to include ``prepare room, prepare and position patient,
administer radiopharmaceutical, acquire images, complete diagnostic
forms, and clean room.'' After reviewing the comments received, we are
establishing interim final direct PE inputs for CPT code 78082 and,
rather than contractor price the code as we did in 2013, we are pricing
this code under the PFS on an interim final basis for CY 2014.
(19) Pathology and Laboratory: Chemistry (CPT Code 86153)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT code 86153 (Cell
enumeration using immunologic selection and identification in fluid
specimen (eg, circulating tumor cells in blood)) by valuing the service
without direct practice expense inputs.
Comment: Commenters requested that we include direct PE inputs for
CPT code 86153, explaining that in the majority of cases, CPT code
86152 is submitted without an accompanying 86153 code. Commenters noted
that there are clinical labor tasks furnished by a laboratory
technician for this service.
Response: CPT code 86153 is a professional component-only CPT code
that is a ``clinical laboratory interpretation service,'' which is one
of the current categories of PFS physician pathology services. For this
category of services, only services billed with a ``26'' modifier may
be paid under the PFS; the technical component of these services is
paid under the Clinical Lab Fee Schedule (CLFS). Generally, under the
PFS, RVUs for services billed with a ``26'' modifier do not include
direct PE inputs, since the development of the RVUs for such codes
incorporate all associated direct PE inputs in the RVUs for the
technical component of the service. When the corresponding laboratory
service is billed under the CLFS, the payment accounts for the resource
costs involved in furnishing the laboratory service, including the
kinds of costs described by the items in the direct PE input database.
In addition, we do not believe that it would serve appropriate
relativity to include direct PE inputs for professional component
services only when the corresponding technical component payment is
made through a different Medicare payment system. After consideration
of public comment, we are finalizing our CY 2013 interim final
valuation of this service as established.
(20) Pathology and Laboratory: Surgical Pathology (CPT Codes 88300,
88302, 88304, 88305, 88307, 88309)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT codes 88300, 88302, 88304,
88305, 88307, and 88309 (Surgical Pathology, Levels I through VI), by
not including new supply items ``specimen, solvent, and formalin
disposal cost,'' and ``courier transportation costs'' and new equipment
items called ``equipment maintenance cost,'' ``Copath System with
maintenance contract,'' and ``Copath software.'' We stated in the CY
2013 final rule with comment period that we would consider additional
information from commenters regarding whether the Copath computer
system and associated software should be considered a direct cost as
medical equipment associated with furnishing the technical component of
these surgical pathology services. We stated that we were especially
interested in understanding the clinical functionality of the equipment
in relation to the services being furnished. We also sought additional
public comment regarding the appropriate assumptions regarding the
direct PE inputs for these services, as well as independent evidence
regarding the appropriate number of blocks to assume as typical for
each of these services. We requested public comment regarding the
appropriate number of blocks and urged the AMA RUC and interested
medical specialty societies to provide corroborating, independent
evidence that the number of blocks assumed in the current direct PE
input recommendations is typical prior to finalizing the direct PE
inputs for these services.
Comment: Commenters generally rejected the notion that the items
CMS did not accept for this family of codes are indirect costs and
asked for a basis for CMS's statement that disposal costs are accounted
for in the indirect PE allocation. A commenter asserted that it is
extremely rare for CMS to not accept direct PE inputs recommended by
the AMA RUC.
Response: As we noted above and in the CY 2014 PFS proposed rule
(78 FR 43292), within the PE methodology all costs other than clinical
labor, disposable supplies, and medical equipment are considered
indirect costs. We note that we frequently refine direct PE
recommendations from the AMA RUC and address these refinements through
rulemaking. Below, we respond to the specific statements by commenters
regarding particular items not accepted as direct inputs.
Comment: Commenters stated that specimen, solvent, and formalin
disposal costs are variable costs that can be allocated to individual
specimens, and noted that these costs are not captured in surveys of
indirect costs used for the PFS. Commenters asserted that these costs
are proportional to the number of specimens processed each day, and are
directly attributable to each case by specimen size and the number of
tissue blocks associated with that specimen. Commenters pointed to
several items in the direct PE database that they believed were
anomalous to the specimen, solvent, and formalin disposal costs that we
did not accept.
Response: In the CY 2014 PFS proposed rule (78 FR 43293), we
addressed the items in the direct PE database brought to our attention
by the commenters. There, we clarified that we believe that a
disposable supply is one that is attributable, in its entirety, to an
individual patient for a particular service. We clarified that we
believe that supply costs related to specimen disposal attributable to
individual services may be appropriately categorized as disposable
supplies, but that specimen disposal costs related to an allocated
portion of service contracts that cannot be attributed to individual
services should not be incorporated into the direct PE input database
as disposable supplies. As we address in section II.B. of this final
rule, all costs other than clinical labor, disposable supplies, and
medical equipment should be considered indirect costs in order to
maintain relativity within the PE methodology. We believe that there
are a wide range of costs allocable to individual services that are
appropriately considered part of indirect cost categories for purposes
of the PE methodology.
Comment: Commenters argued that courier transportation costs are
directly allocable to individual beneficiary specimens, and represent a
significant practice expense. One commenter stated, ``Although more
than one specimen may be included in a courier run, still there is a
cost per specimen'' and asserted that the indirect PE costs allocated
to CPT code 88305 do not adequately account for the sizeable expense of
couriers.
Response: Again, we maintain that all costs other than clinical
labor, disposable supplies, and medical equipment should be considered
indirect costs to maintain relativity within the PE methodology. In
addition
[[Page 74319]]
to not meeting that criterion to be considered direct PE, the commenter
pointed out that more than one specimen may be included in a courier
run, so that the cost of courier services does not meet the additional
criterion of being ``attributable, in its entirety, to an individual
patient for a particular service.'' We acknowledge the commenters'
concern that the indirect costs allocated to CPT code 88305 may not
equate to the indirect costs associated for every instance a service
described by that code is furnished. However, we note that the practice
expense methodology is applied consistently throughout the fee
schedule, and that the nature of indirect costs is such that the costs
allocated to an individual procedure are an estimate of the relative
costs associated with the typical procedure reported with a particular
code, and are not intended to account for those costs on a line item
basis for each instance the code is reported.
Comment: Commenters argued that the maintenance costs are in fact
variable costs in that the costs are proportional to specimen volume.
Commenters acknowledged the 5% equipment maintenance factor that is
figured into the costs of equipment inputs to the PE methodology, but
argued that pathology laboratories have several equipment items that
require more frequent maintenance (in the range of 10%-12%). Commenters
requested that we establish specialty-specific maintenance factors.
Response: We believe that the nature of many equipment items across
the fee schedule is such that the required maintenance would relate, at
least in part, to the volume of procedures furnished using the
equipment. We note that the established PE methodology does not
generally account for either additional costs incurred or efficiencies
gained when services are furnished in atypical volumes. The equipment
maintenance factor is intended to represent the typical cost per minute
associated with a particular piece of equipment. At this time, our PE
methodology does not accommodate equipment maintenance factors that
vary by specialty.
Comment: Commenters provided descriptions of the CoPath system,
indicating that the system provides procedure support that assists labs
with specimen management and tracking, report generation, record
storage, workflow automation, management reporting and quality
assurance functions and support. Commenters stated that the CoPath
system is a stand-alone system that must be interfaced with the main
electronic health care record system, and is unique to pathology and
only used by pathology. The CoPath system is required for labs to
assign each specimen its unique identifier and associate it with other
specimens from the same patient, as well as track the course of the
entire process.
Commenters also explained that the CoPath system is an advanced
pathology information management system for storing and reporting
pathology information and accommodates clinical disciplines including
surgical pathology, cytology, histology, and autopsy. CoPath manages
the integrity of specimen accession and processing, and provides
patient history review, pathology text entry, support for diagnostic
coding using the CAP SNOMED database, report generation, case review
and sign out, and retrieval for subsequent purposes. It also assists in
inputting blocks and interfaces with cassette and slide labelers,
querying database for cases, patient histories, and reducing workload.
Commenters compared the Picture Archiving and Communication System
(PACS) system for radiologists to the CoPath or equivalent system for
pathology.
One commenter argued that the clerical and administrative
functionality support by a laboratory information system is immaterial
to the direct costs associated with its more prominent utility as the
clinical information infrastructure for anatomic pathology
laboratories.
Response: We asked for comments to help with our understanding of
the clinical functionality of the equipment in relation to the services
being furnished. We appreciate the explanations provided, as well as
the comparison to the PACS system for radiologists. Based on our review
of the comments received, we understand that this information
management system is used for a variety of administrative and clerical
functions, as well as clinical support functions. Tools that facilitate
the similar functionality for other services, such as the cognitive
work involved in the professional component, are considered indirect
costs under the PFS. For instance, across services furnished by a range
of physician specialties, many items that support clinical decision-
making are considered indirect costs, irrespective of their utility and
are not included in the PE methodology as direct costs. Instead, they
are part of the indirect category of resource costs. As a general
principle, for this reason, we do not believe that information
management systems are appropriately characterized as direct costs.
Furthermore, we believe that the relativity within the PE
methodology would be undermined by including these kinds of items as
medical equipment only for particular kinds of services. We believe
that, were we to reconsider the categorization of clinical information
systems for this particular kind of service, it would be necessary to
reconsider the categorization of resource costs of other clinical
information systems used across PFS services. Therefore, we continue to
believe that the CoPath system is best characterized as an indirect
cost that is captured in the indirect cost allocation.
Comment: One commenter suggested that the labor cost of the
histotechnologist is closer to 50 cents per minute, rather than the 37
cents per minute used in the PE direct inputs database.
Response: We did not change the labor cost for histotechnologists
in the CY 2013 final rule with comment period. We note, however, that
the prices associated with the labor codes derive from data from the
Bureau of Labor Statistics, and we will consider the appropriate time
to update all labor category costs in the PE direct inputs database for
future rulemaking.
Comment: Commenters disputed the assertion that there is a
``typical'' case for CPT code 88305, given that there are wide
variations in the types of tissues being biopsied.
Response: Under the PFS, services are priced based on the typical
case. We continue to seek the best information regarding the inputs
involved in furnishing the typical case.
Comment: Commenters expressed concern that CMS asked the AMA RUC to
review CPT code 88305 based on the assertion of a single stakeholder
that the clinical vignette used to identify the PE inputs was not
typical.
Response: As indicated in section II.C.2 of this final rule with
comment period, we note that we generally do not identify a code as
potentially misvalued solely on the basis of individual assertions. On
the contrary, when stakeholders bring information to our attention, it
is subject to internal review to determine whether the code would
appropriately be proposed as a potentially misvalued code, and we offer
the public the opportunity to comment prior to finalizing a code as
potentially misvalued. We followed our standard process in evaluating
CPT code 88305 as potentially misvalued and reached the conclusion that
it was appropriate the refer the service to the AMA RUC. Therefore, we
do not agree
[[Page 74320]]
with commenters that we asked the AMA RUC to review this service based
solely on information provided by a single stakeholder.
Comment: Some commenters provided information regarding the number
of blocks that is typical for 88305. An association representing
pathologists argued that there is no typical case for 88305, and
provided several vignettes to illustrate the variation based on the
type of tissue being biopsied. The association also presented findings
from one data collection effort involving several specialty societies
that suggested that the typical number of blocks may be as high as
four. However, the association supported the AMA RUC's recommendation
of two blocks as most likely to represent the typical case. Other
commenters indicated that a review of hundreds of cases from multiple
institutions indicated that the typical, or average, case of 88305
requires one block, not two, and that 92% of cases including pathology,
skin pathology, surgical pathology, urologic pathology, cell blocks,
and bone marrow cases required one block. Another medical specialty
indicated that more than two slide-blocks are routinely required, and
requested the use of a modifier for 88305 for those services that
routinely require more than two slide-blocks. Another commenter
requested that we stratify payment based on the number of blocks.
Another commenter suggested that the AMA RUC's recommended number of
clinical labor minutes for 88305 underestimates the amount of clinical
labor time associated with the typical service described by the code.
Response: Based on the wide range of views expressed in comments,
it is difficult to determine the appropriate number of blocks to use in
establishing direct PE inputs for CPT code 88305. At this time, because
we do not have strong evidence to conclude that a change should be
made, are maintaining these values. However, we will continue to seek
better information to permit consideration of the appropriate number of
blocks, and the appropriate direct PE inputs for this code. We are not
establishing a modifier to differentiate the number of blocks since
there is not a current billing mechanism to make adjustments based on
the number of blocks used when a code is reported.
Comment: One commenter argued that the practice expense RVU for CPT
code 88305 is insufficient for a tissue exam with two blocks and
certainly insufficient for those exams that require more than the two
blocks and slides than are accounted for in the AMA RUC's vignette. The
commenter argued that even though many tissue biopsies may use an
average of two blocks, the valuation of this service does not account
for the many kinds of biopsies that use more than two blocks. Another
commenter argued that the payment will no longer allow ``profits'' for
1-2 block specimens to offset the ``losses'' from specimens that
require a larger number of blocks.
Response: We acknowledge the commenter's concern that the valuation
of this service is based on two blocks when some services require a
greater number of blocks. However, this circumstance is not
inconsistent with the established PE methodology, which accounts for
the relative resources involved in furnishing a typical case for a
particular HCPCS code. We acknowledge that there are cases that use
higher than typical resources, and that there are also cases that use
lower than typical resources. As a general principle, we do not believe
that the direct inputs associated with a particular PFS service should
be established or maintained to result in payment rates that might
offset outlier cases for that service or support practice expenses for
practitioners who furnish lower-paid services.
Furthermore, we note that we continue to receive feedback regarding
the appropriate coding and code descriptors for surgical pathology for
the prostate needle biopsy services. We believe that revising the code
descriptors to ensure that all prostate needle biopsy services with 10
or more specimens are described by the G-codes may facilitate broader
consensus regarding the typical resource costs for 88305. Therefore,
for clarity, we are revising the CY 2014 descriptors for these HCPCS
codes to include the phrase ``any method'' following ``sampling.''
The revised HCPCS code descriptors for microscopic examination for
prostate biopsy are as follows: G0416 (Surgical pathology, gross and
microscopic examination for prostate needle biopsies, any method; 10-20
specimens), G0417 (Surgical pathology, gross and microscopic
examination for prostate needle biopsies, any method; 21-40 specimens),
G0418 (Surgical pathology, gross and microscopic examination for
prostate needle biopsies, any method; 41-60 specimens) and G0419
(Surgical pathology, gross and microscopic examination for prostate
needle biopsies, any method; greater than 60 specimens).
After consideration of public comments received, we are finalizing
the CY 2013 interim final direct PE inputs for CPT codes 88300-88309 as
established.
(21) Pathology and Laboratory: Cytopathology (CPT Codes 88120 and
88121)
In the PFS final rule with comment period, we addressed comments
from stakeholders who suggested that CMS increase the price of the
supply ``UroVysion test kit'' (SA105) by building in an ``efficiency
factor'' to account for the kits that are purchased by practitioners
and used in tests that fail. The stakeholders provided documentation
suggesting that a certain failure rate is inherent in the procedure.
We indicated that the prices associated with supply inputs in the
direct PE input database reflect the price per unit of each supply.
Since the current PE methodology relies on the inputs for each service
reflecting the typical direct practice expense costs for each service,
and the supply costs for the failed tests are not used in furnishing
PFS services, we do not believe that the methodology accommodates a
failure rate in allocating the cost of disposable medical supplies.
Therefore, we did not adjust the price input for ``UroVysion test kit''
(SA105) in the direct PE input database.
Comment: Commenters disagreed with our decision, stating that these
are valid expenses and that the inherent failure rate is commonly due
to factors beyond the control of the laboratory or quality of
equipment. Further, commenters pointed out that these costs are not
reflected in overhead costs, and should therefore be included in direct
practice expense inputs.
Response: Because the current PE methodology relies on the inputs
used in furnishing each service, reflecting the typical direct practice
expense costs for each service, we continue to believe that the price
of the supply kit should not reflect any failure rate. After
consideration of public comment, we are finalizing the CY 2013 interim
final direct PE inputs for CPT codes 88120 and 88121 as established.
(22) Immunotherapy Injections (CPT Codes 95115 and 95117)
In establishing interim final direct PE inputs for CPT codes 95115
and 95117, we refined the AMA RUC's recommendation by removing
equipment item ``refrigerator, vaccine, commercial grade, w-alarm
lock.''
Comment: Commenters indicated that injectable materials need to be
refrigerated, and thus the refrigerator should be included for this
service.
Response: As previously noted, equipment that is used for multiple
[[Page 74321]]
procedures at once is considered an indirect cost. In future
rulemaking, we anticipate reviewing our files for consistency across
practice expense inputs in this regard. After consideration of comments
received, we are finalizing the CY 2013 interim final direct practice
expense inputs for CPT codes 95115 and 95117 as established.
(23) Neurology and Neuromuscular Procedures: Intraoperative
Neurophysiology (CPT Codes 95940, 95941 and HCPCS Code G0453)
In establishing payment for intraoperative neurophysiology (95940
and G0453) for CY 2013, we did not accept the AMA RUC direct PE input
recommendations, since we do not believe that these services are
furnished to patients outside of facility settings.
Comment: A commenter noted that hospitals previously owned all of
the equipment and supplies and employed the technicians for
intraoperative monitoring. The commenter asserted that, currently,
hospitals often use ``mobile services'' to furnish these monitoring
procedures, and thus there should be technical component RVUs for these
services.
Response: The structure of monitoring businesses and the
arrangements made with hospitals are not a factor in determining the
inputs typical to a particular service. Since this service is furnished
in a facility, we have not included direct PE inputs for this service.
We continue to believe that this service should be priced without
direct PE inputs because when a service is furnished in the facility
setting, the equipment, supplies, and labor costs of the service are
considered in the calculation of Medicare payments made to the facility
through other Medicare payment systems. After consideration of comments
received, we are finalizing the CY 2013 interim final direct PE inputs
for 95940 and G0453 as established.
(24) Neurology and Neuromuscular Procedures: Sleep Medicine Testing
(CPT Codes 95782, 95783)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT codes 95782
(Polysomnography, younger than 6 years, 4 or more) and 95783
(Polysomnography, younger than 6 years, w/cpap) by reducing time
associated with ``Measure and mark head and face. Apply and secure
electrodes to head and face. Check impedances. Reapply electrodes as
needed'' and ``apply recording devices'' and removing equipment item
``crib'' for use in these services. We stated that we did not believe a
crib would typically be used in this service, and we incorporated the
bedroom furniture including a hospital bed and a reclining chair as
typical equipment for this service.
Comment: Commenters disagreed, stating that it takes additional
time to perform these clinical labor tasks for a child, and that we
should assign 30 minutes to the ``measure and mark head and face'' task
and 25 minutes to the ``apply recording devices'' task. Commenters also
indicated that the crib is used in the typical case, while the parent
uses the hospital bed to remain close to the child. We also received a
paid invoice for the equipment item ``crib.''
Response: After additional clinical review, we agree with
commenters' explanation that the additional clinical labor minutes are
required when furnishing these services to children. Therefore, we are
allocating an additional 5 minutes for each of these tasks, so that 25
minutes are allocated based on the clinical labor task called ``Measure
and mark head and face. Apply and secure electrodes to head and face.
Check impedances. Reapply electrodes as needed'' and 20 minutes are
allocated for the task ``apply recording devices.'' Based on the
information provided by commenters, we agree that the equipment item
``crib'' should be included for CPT codes 95782 and 95783. We are
pricing the equipment item ``crib'' at $3,900 based on the invoice
received. After consideration of the comments received, we are
finalizing the CY 2013 interim final direct PE inputs for 95782 and
95783 as established with the additional refinement of adjusting the
clinical labor time and incorporating the ``crib'' discussed above.
(25) Neurology and Neuromuscular Procedures: Electromyography and Nerve
Conduction Tests (CPT Codes 95907, 95908, 95909, 95910, 95911, 95912,
95913, and 95861)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT code 95861 by adjusting
the time for the clinical labor activity ``assist physician in
performing procedure'' from 19 minutes to 29 minutes to conform to
physician time.
Comment: Commenters brought to our attention that this refinement
was inaccurate, in that the AMA RUC recommendation included 29 minutes
for this labor activity.
Response: We agree with commenters that this refinement was
inaccurate and acknowledge the administrative discrepancy in the
refinement table. We note that this had no impact on payment rates,
since there was no corresponding discrepancy in the direct PE input
database. After considering comments received, we are finalizing the CY
2013 interim final direct PE inputs for CPT code 95861 as established.
We also refined the AMA RUC's recommendation for CPT codes 95907,
95908, 95909, 95910, 95911, 95912, and 95913 by substituting non-
sterile gauze for sterile gauze, and removing surgical tape and
electrode gel.
Comment: Commenters indicated that sterile gauze is required
because the skin is cleansed before the procedure with vigorous
scrubbing that often can produce minor bleeding, and that tape is
required because the electrodes may not stick well when testing
patients who have used lotions or creams prior to testing. Finally, the
electrode gel is required to maximize conductivity, especially in
patients who have used lotions or creams prior to testing.
Response: We agree with commenters that the sterile gauze and tape
should be included for this service. However, since the disposable
electrode pack includes pre-gelled electrodes, we do not believe it is
typical that electrode gel is also used in this procedure. After
consideration of public comments, we are finalizing the CY 2013 interim
final direct practice expense inputs for CPT codes 95907--95913 as
established, with the additional refinement of including the sterile
gauze and tape.
(26) Neurology and Neuromuscular Procedures: Autonomic Function Testing
(CPT Codes 95921, 95922, 95923, and 95924)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT codes 95921 and 95922 by
removing the preservice clinical labor tasks, and adjusting the
monitoring time following the procedure from 5 to 2 minutes for 95921,
95922, 95923, and 95924.
Comment: Commenters stated that the patient requires assistance
following the tests; therefore, additional time for monitoring the
patient is necessary and should be added to the number of clinical
labor minutes in the service period.
Response: CMS clinical staff reviewed the information presented by
commenters and found no evidence that 2 minutes did not represent the
typical resources involved in furnishing the service for CPT codes
95921, 95922, 95923, and 95924.
In refining CPT codes 95921, 95922, 95923, and 95924, we refined
the
[[Page 74322]]
equipment time to reflect the typical use exclusive to the patient.
Comment: Commenters stated that extra time was required for the
equipment so that the patient can lie still after the procedure to
ensure that there are not negative side effects due to fluctuations in
blood pressure.
Response: We agree with commenters' justification for allocating
additional equipment minutes to account for the time that the patient
is laying still after the procedure.
In refining CPT code 95923, we refined the clinical labor activity
``assist physician'' to 45 minutes.
Comment: Commenters stated that an additional 10 minutes of
``assist physician'' time was needed to assist the patient out of the
machine and into the shower, since patients are extremely sweaty after
the procedure.
Response: Assisting patients following the procedure is not part of
the ``assist physician'' labor activity. Since this clinical labor
activity was not specified in the AMA RUC recommendation, we do not
believe this activity typically takes additional time over that already
allotted to the procedure. After considering public comments received,
we are finalizing the CY 2013 interim final direct practice expense
inputs for CPT codes 95921--95924 as established.
(27) Special Dermatological Procedures (CPT Codes 96920, 96921, 96922)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC's recommendation for CPT codes 96920, 96921, and
96922 by decreasing the time allocated to clinical labor activity
``monitor patient following service/check tubes, monitors, drains''
from 3 minutes to 1 minutes, and clinical labor activity ``clean room/
equipment by physician staff'' from 3 minutes to 2 minutes.
Comment: Commenters objected to CMS's refinement of clinical labor
tasks below the standard number of minutes allocated for these tasks.
Response: We agree with commenters that the standard number of AMA
RUC-recommended minutes should be allocated for these tasks. After
considering public comments received, we are finalizing the CY 2013
interim final direct practice expense inputs for CPT codes 96920,
96921, and 96922 with the additional refinement of adjusting the times
allocated for the clinical labor activities noted above.
(28) Psychiatry (CPT Codes 90791, 90832, 90834, and 90837)
As we addressed in the CY 2013 PFS final rule (77 FR 69075), the
AMA RUC submitted direct PE input recommendations in the revised set of
codes that describe psychotherapy services. These recommendations
included significant reductions to the direct PE inputs associated with
the predecessor codes. For most of the new codes, we accepted these
recommended reductions in direct practice expense. This was consistent
with our general approach of maintaining the existing values for these
services given that many practitioners who furnished these services
prior to CY 2013 would report concurrent medical evaluation and
management services (which have practice expense values that will
offset the differences in total PE values between the new and old
psychotherapy codes). However, for practitioners who do not furnish
medical E/M services, there were no corresponding PE value increases to
offset the recommended reductions. Therefore, instead of accepting the
recommended direct PE inputs for the new CPT codes that describe
services primarily furnished by practitioners who do not also report
medical E/M services, for CY 2013, we crosswalked the 2012 PE RVUs from
the predecessor codes. This crosswalk used the CY 2012 year fully-
implemented PE RVUs established for CPT codes 90791 (Psychiatric
diagnostic evaluation), 90832 (Psychotherapy, 30 minutes with patient
and/or family member), 90834 (Psychotherapy, 45 minutes with patient
and/or family member), and 90837 (Psychotherapy, 60 minutes with
patient and/or family member).
Comment: Several commenters pointed out that by crosswalking the PE
RVUs from predecessor codes, CMS created a rank order anomaly for CPT
codes 90791 (Psychiatric diagnostic evaluation) and 90792 (Psychiatric
diagnostic evaluation with medical services). These commenters urged
CMS to issue a technical correction for CY 2013 and accept the AMA-RUC
recommended inputs in developing PE RVUs for these services for CY
2014.
Response: We appreciate the commenters' concerns regarding rank
order anomalies for these services. However, as we explained in
establishing the interim final values for CY 2013, we believed that it
was important to maintain approximate overall value for the family of
services for the specialties involved, pending valuation of the whole
set of codes for CY 2014. Now that we have considered the full family
of codes for CY 2014 including the additional work RVUs, we agree with
the commenters and believe that the AMA RUC- recommended direct PE
inputs for the whole family of codes can be implemented. Given the
significant change in PE RVUs and in the context of the whole family of
services, the direct PE inputs for these services will be interim final
and subject to comment for CY 2014.
Comment: In a comment to the CY 2014 proposed PFS rule, one
commenter argued that the crosswalked PE RVUs for these services should
be maintained due to the negative impact of the PE methodology on
certain specialties, especially clinical psychologists. This commenter
also suggested that the reductions in PE RVUs that would result from
implementing the AMA RUC recommended direct PE inputs for CY 2014 would
fully offset any increases in work RVUs for these services.
Response: We do not agree that the reductions in PE RVUs that
result from the AMA RUC-recommended inputs fully offset the increases
in overall payment for these services that results from CMS' adoption
of the AMA RUC-recommended work RVUs for most of the codes in this
family. However, we will consider the commenter's concerns regarding
the effect of the PE methodology for specialties like clinical
psychologists for future rulemaking.
(29) Transitional Care Management Services (CPT Codes 99495, 99496)
In establishing interim final direct PE inputs for CY 2013, we
refined the AMA RUC recommendation by incorporating the clinical labor
inputs for dedicated non-face-to-face care management tasks as facility
inputs in addition to increasing clinical labor minutes for 99496.
Comment: The AMA RUC disagreed with CMS's refinement to include
clinical labor minutes in the facility setting based on the assertion
that the non-face-to-face care management tasks are critical to the
codes and cannot be separated from the care coordination delivered by
the clinical staff in the non-facility setting. The AMA RUC also
suggested that several medical specialty societies also disagreed with
the refinement to include clinical labor minutes in the facility
setting, while one specialty society agreed with our refinement.
Response: After considering the rationale of the AMA RUC, we agree
that only non-facility direct PE inputs should be included for these
services. Therefore, we are finalizing the CY 2013 interim final direct
PE inputs for 99495 and 99496 as established with the additional
refinement of removing the facility direct PE inputs.
[[Page 74323]]
c. Finalizing CY 2013 Interim and Proposed Malpractice Crosswalks for
CY 2014
In accordance with our malpractice methodology, we adjusted the
malpractice RVUs for the CY 2013 new/revised codes for the difference
in work RVUs (or, if greater, the clinical labor portion of the PE
RVUs) between the source codes and the new/revised codes to reflect the
specific risk-of-service for the new/revised codes. The interim final
malpractice crosswalks were listed in Table 75 of the CY 2013 PFS final
rule with comment period.
We received no comments on the CY 2013 interim final malpractice
crosswalks and are finalizing them without modification for CY 2014.
The malpractices RVUs for these services are reflected in Addendum B of
this CY 2014 PFS final rule with comment period.
Consistent with past practice when the MEI has been rebased or
revised we proposed to make adjustments to ensure that estimates of the
aggregate CY 2014 PFS payments for work, PE and malpractice are in
proportion to the weights for these categories in the revised MEI. As
discussed in the II.A., the MEI is being revised for CY 2014, the PE
and malpractice RVUs, and the CF are being adjusted accordingly. For
more information on this, see section II.B. We received no comments
specifically on the adjustment to malpractice RVUs.
d. Other New, Revised or Potentially Misvalued Codes With CY 2013
Interim Final RVUs Not Specifically Discussed in the CY 2014 Final Rule
With Comment Period
For all other new, revised, or potentially misvalued codes with CY
2013 interim final RVUs that are not specifically discussed in this CY
2014 PFS final rule with comment period, we are finalizing for CY 2014,
without modification, the CY 2013 interim final or CY 2014 proposed
work RVUs, malpractice crosswalks, and direct PE inputs. Unless
otherwise indicated, we agreed with the time values recommended by the
AMA RUC or HCPAC for all codes addressed in this section. The time
values for all codes are listed in a file called ``CY 2014 PFS
Physician Time,'' available on the CMS Web site under downloads for the
CY 2014 PFS final rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
3. Establishing CY 2014 Interim Final RVUs
a. Establishing CY 2014 Interim Final Work RVUs
Table 27 contains the CY 2014 interim final work RVUs for all codes
for which we received AMA RUC recommendations for CY 2014 and new G-
codes created for CY 2014. These values are subject to public comment
in this final rule with comment period. Codes for which work RVUs are
not applicable have the appropriate PFS procedure status indicator in
the relevant column. A description of all PFS procedure status
indicators can be found in Addendum A. The column labeled ``CMS Time
Refinement'' indicates for each code whether we refined the time values
recommended by the AMA RUC or HCPAC.
The RVUs and other payment information for all CY 2014 payable
codes are available in Addendum B. The RVUs and other payment
information regarding all codes subject to public comment in this final
rule with comment period are available in Addendum C. All addenda are
available on the CMS Web site under downloads for the CY 2014 PFS final
rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The time values for all CY 2014 codes are listed in a
file called ``CY 2014 PFS Physician Time,'' available on the CMS Web
site under downloads for the CY 2014 PFS final rule with comment period
at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
Table 27--Interim Final Work RVUs for New/Revised/Potentially Misvalued Codes
----------------------------------------------------------------------------------------------------------------
AMA RUC/HCPAC
HCPCS code Long descriptor CY 2013 work RVU recommended CY 2014 work CMS time
work RVU RVU refinement
----------------------------------------------------------------------------------------------------------------
10030............. Image-guided fluid New.............. 3.00 3.00 No.
collection drainage
by catheter (eg,
abscess, hematoma,
seroma, lymphocele,
cyst), soft tissue
(eg, extremity,
abdominal wall,
neck), percutaneous.
17000............. Destruction (eg, laser 0.65............. 0.61 0.61 No.
surgery,
electrosurgery,
cryosurgery,
chemosurgery,
surgical
curettement),
premalignant lesions
(eg, actinic
keratoses); first
lesion.
17003............. Destruction (eg, laser 0.07............. 0.04 0.04 No.
surgery,
electrosurgery,
cryosurgery,
chemosurgery,
surgical
curettement),
premalignant lesions
(eg, actinic
keratoses); second
through 14 lesions,
each (list separately
in addition to code
for first lesion).
17004............. Destruction (eg, laser 1.85............. 1.37 1.37 No.
surgery,
electrosurgery,
cryosurgery,
chemosurgery,
surgical
curettement),
premalignant lesions
(eg, actinic
keratoses), 15 or
more lesions.
17311............. Mohs micrographic 6.20............. 6.20 6.20 No.
technique, including
removal of all gross
tumor, surgical
excision of tissue
specimens, mapping,
color coding of
specimens,
microscopic
examination of
specimens by the
surgeon, and
histopathologic
preparation including
routine stain(s) (eg,
hematoxylin and
eosin, toluidine
blue), head, neck,
hands, feet,
genitalia, or any
location with surgery
directly involving
muscle, cartilage,
bone, tendon, major
nerves, or vessels;
first stage, up to 5
tissue blocks.
[[Page 74324]]
17312............. Mohs micrographic 3.30............. 3.30 3.30 No.
technique, including
removal of all gross
tumor, surgical
excision of tissue
specimens, mapping,
color coding of
specimens,
microscopic
examination of
specimens by the
surgeon, and
histopathologic
preparation including
routine stain(s) (eg,
hematoxylin and
eosin, toluidine
blue), head, neck,
hands, feet,
genitalia, or any
location with surgery
directly involving
muscle, cartilage,
bone, tendon, major
nerves, or vessels;
each additional stage
after the first
stage, up to 5 tissue
blocks (list
separately in
addition to code for
primary procedure).
17313............. Mohs micrographic 5.56............. 5.56 5.56 No.
technique, including
removal of all gross
tumor, surgical
excision of tissue
specimens, mapping,
color coding of
specimens,
microscopic
examination of
specimens by the
surgeon, and
histopathologic
preparation including
routine stain(s) (eg,
hematoxylin and
eosin, toluidine
blue), of the trunk,
arms, or legs; first
stage, up to 5 tissue
blocks.
17314............. Mohs micrographic 3.06............. 3.06 3.06 No.
technique, including
removal of all gross
tumor, surgical
excision of tissue
specimens, mapping,
color coding of
specimens,
microscopic
examination of
specimens by the
surgeon, and
histopathologic
preparation including
routine stain(s) (eg,
hematoxylin and
eosin, toluidine
blue), of the trunk,
arms, or legs; each
additional stage
after the first
stage, up to 5 tissue
blocks (list
separately in
addition to code for
primary procedure).
17315............. Mohs micrographic 0.87............. 0.87 0.87 No.
technique, including
removal of all gross
tumor, surgical
excision of tissue
specimens, mapping,
color coding of
specimens,
microscopic
examination of
specimens by the
surgeon, and
histopathologic
preparation including
routine stain(s) (eg,
hematoxylin and
eosin, toluidine
blue), each
additional block
after the first 5
tissue blocks, any
stage (list
separately in
addition to code for
primary procedure).
19081............. Biopsy, breast, with New.............. 3.29 3.29 No.
placement of breast
localization
device(s) (eg, clip,
metallic pellet),
when performed, and
imaging of the biopsy
specimen, when
performed,
percutaneous; first
lesion, including
stereotactic guidance.
19082............. Biopsy, breast, with New.............. 1.65 1.65 No.
placement of breast
localization
device(s) (eg, clip,
metallic pellet),
when performed, and
imaging of the biopsy
specimen, when
performed,
percutaneous; each
additional lesion,
including
stereotactic guidance
(list separately in
addition to code for
primary procedure).
19083............. Biopsy, breast, with New.............. 3.10 3.10 No.
placement of breast
localization
device(s) (eg, clip,
metallic pellet),
when performed, and
imaging of the biopsy
specimen, when
performed,
percutaneous; first
lesion, including
ultrasound guidance.
19084............. Biopsy, breast, with New.............. 1.55 1.55 No.
placement of breast
localization
device(s) (eg, clip,
metallic pellet),
when performed, and
imaging of the biopsy
specimen, when
performed,
percutaneous; each
additional lesion,
including ultrasound
guidance (list
separately in
addition to code for
primary procedure).
19085............. Biopsy, breast, with New.............. 3.64 3.64 No.
placement of breast
localization
device(s) (eg, clip,
metallic pellet),
when performed, and
imaging of the biopsy
specimen, when
performed,
percutaneous; first
lesion, including
magnetic resonance
guidance.
19086............. Biopsy, breast, with New.............. 1.82 1.82 No.
placement of breast
localization
device(s) (eg, clip,
metallic pellet),
when performed, and
imaging of the biopsy
specimen, when
performed,
percutaneous; each
additional lesion,
including magnetic
resonance guidance
(list separately in
addition to code for
primary procedure).
19281............. Placement of breast New.............. 2.00 2.00 No.
localization
device(s) (eg, clip,
metallic pellet, wire/
needle, radioactive
seeds), percutaneous;
first lesion,
including
mammographic guidance.
19282............. Placement of breast New.............. 1.00 1.00 No.
localization
device(s) (eg, clip,
metallic pellet, wire/
needle, radioactive
seeds), percutaneous;
each additional
lesion, including
mammographic guidance
(list separately in
addition to code for
primary procedure).
19283............. Placement of breast New.............. 2.00 2.00 No.
localization
device(s) (eg, clip,
metallic pellet, wire/
needle, radioactive
seeds), percutaneous;
first lesion,
including
stereotactic guidance.
[[Page 74325]]
19284............. Placement of breast New.............. 1.00 1.00 No.
localization
device(s) (eg, clip,
metallic pellet, wire/
needle, radioactive
seeds), percutaneous;
each additional
lesion, including
stereotactic guidance
(list separately in
addition to code for
primary procedure).
19285............. Placement of breast New.............. 1.70 1.70 No.
localization
device(s) (eg, clip,
metallic pellet, wire/
needle, radioactive
seeds), percutaneous;
first lesion,
including ultrasound
guidance.
19286............. Placement of breast New.............. 0.85 0.85 Yes.
localization
device(s) (eg, clip,
metallic pellet, wire/
needle, radioactive
seeds), percutaneous;
each additional
lesion, including
ultrasound guidance
(list separately in
addition to code for
primary procedure).
19287............. Placement of breast New.............. 3.02 2.55 No.
localization
device(s) (eg clip,
metallic pellet, wire/
needle, radioactive
seeds), percutaneous;
first lesion,
including magnetic
resonance guidance.
19288............. Placement of breast New.............. 1.51 1.28 No.
localization
device(s) (eg clip,
metallic pellet, wire/
needle, radioactive
seeds), percutaneous;
each additional
lesion, including
magnetic resonance
guidance (list
separately in
addition to code for
primary procedure).
23333............. Removal of foreign New.............. 6.00 6.00 No.
body, shoulder; deep
(subfascial or
intramuscular).
23334............. Removal of prosthesis, New.............. 18.89 15.50 No.
includes debridement
and synovectomy when
performed; humeral or
glenoid component.
23335............. Removal of prosthesis, New.............. 22.13 19.00 No.
includes debridement
and synovectomy when
performed; humeral
and glenoid
components (eg, total
shoulder).
24164............. Removal of prosthesis, 6.43............. 10.00 10.00 No.
includes debridement
and synovectomy when
performed; radial
head.
27130............. Arthroplasty, 21.79............ 19.60 20.72 Yes.
acetabular and
proximal femoral
prosthetic
replacement (total
hip arthroplasty),
with or without
autograft or
allograft.
27236............. Open treatment of 17.61............ 17.61 17.61 Yes.
femoral fracture,
proximal end, neck,
internal fixation or
prosthetic
replacement.
27446............. Arthroplasty, knee, 16.38............ 17.48 17.48 No.
condyle and plateau;
medial or lateral
compartment.
27447............. Arthroplasty, knee, 23.25............ 19.60 20.72 Yes.
condyle and plateau;
medial and lateral
compartments with or
without patella
resurfacing (total
knee arthroplasty).
31237............. Nasal/sinus endoscopy, 2.98............. 2.60 2.60 No.
surgical; with
biopsy, polypectomy
or debridement
(separate procedure).
31238............. Nasal/sinus endoscopy, 3.26............. 2.74 2.74 No.
surgical; with
control of nasal
hemorrhage.
31239............. Nasal/sinus endoscopy, 9.33............. 9.04 9.04 No.
surgical; with
dacryocystorhinostomy.
31240............. Nasal/sinus endoscopy, 2.61............. 2.61 2.61 No.
surgical; with concha
bullosa resection.
33282............. Implantation of 4.80............. 3.50 3.50 No.
patient-activated
cardiac event
recorder.
33284............. Removal of an 3.14............. 3.00 3.00 No.
implantable, patient-
activated cardiac
event recorder.
33366............. Transcatheter aortic New.............. 40.00 35.88 No.
valve replacement
(tavr/tavi) with
prosthetic valve;
transapical exposure
(eg, left
thoracotomy).
34841............. Endovascular repair of New.............. C C N/A.
visceral aorta (eg,
aneurysm,
pseudoaneurysm,
dissection,
penetrating ulcer,
intramural hematoma,
or traumatic
disruption) by
deployment of a
fenestrated visceral
aortic endograft and
all associated
radiological
supervision and
interpretation,
including target zone
angioplasty, when
performed; including
one visceral artery
endoprosthesis
(superior mesenteric,
celiac or renal
artery).
34842............. Endovascular repair of New.............. C C N/A.
visceral aorta (eg,
aneurysm,
pseudoaneurysm,
dissection,
penetrating ulcer,
intramural hematoma,
or traumatic
disruption) by
deployment of a
fenestrated visceral
aortic endograft and
all associated
radiological
supervision and
interpretation,
including target zone
angioplasty, when
performed; including
two visceral artery
endoprostheses
(superior mesenteric,
celiac and/or renal
artery[s]).
[[Page 74326]]
34843............. Endovascular repair of New.............. C C N/A.
visceral aorta (eg,
aneurysm,
pseudoaneurysm,
dissection,
penetrating ulcer,
intramural hematoma,
or traumatic
disruption) by
deployment of a
fenestrated visceral
aortic endograft and
all associated
radiological
supervision and
interpretation,
including target zone
angioplasty, when
performed; including
three visceral artery
endoprostheses
(superior mesenteric,
celiac and/or renal
artery[s]).
34844............. Endovascular repair of New.............. C C N/A.
visceral aorta (eg,
aneurysm,
pseudoaneurysm,
dissection,
penetrating ulcer,
intramural hematoma,
or traumatic
disruption) by
deployment of a
fenestrated visceral
aortic endograft and
all associated
radiological
supervision and
interpretation,
including target zone
angioplasty, when
performed; including
four or more visceral
artery endoprostheses
(superior mesenteric,
celiac and/or renal
artery[s]).
34845............. Endovascular repair of New.............. C C N/A.
visceral aorta and
infrarenal abdominal
aorta (eg, aneurysm,
pseudoaneurysm,
dissection,
penetrating ulcer,
intramural hematoma,
or traumatic
disruption) with a
fenestrated visceral
aortic endograft and
concomitant unibody
or modular infrarenal
aortic endograft and
all associated
radiological
supervision and
interpretation,
including target zone
angioplasty, when
performed; including
one visceral artery
endoprosthesis
(superior mesenteric,
celiac or renal
artery).
34846............. Endovascular repair of New.............. C C N/A.
visceral aorta and
infrarenal abdominal
aorta (eg, aneurysm,
pseudoaneurysm,
dissection,
penetrating ulcer,
intramural hematoma,
or traumatic
disruption) with a
fenestrated visceral
aortic endograft and
concomitant unibody
or modular infrarenal
aortic endograft and
all associated
radiological
supervision and
interpretation,
including target zone
angioplasty, when
performed; including
two visceral artery
endoprostheses
(superior mesenteric,
celiac and/or renal
artery[s]).
34847............. Endovascular repair of New.............. C C N/A.
visceral aorta and
infrarenal abdominal
aorta (eg, aneurysm,
pseudoaneurysm,
dissection,
penetrating ulcer,
intramural hematoma,
or traumatic
disruption) with a
fenestrated visceral
aortic endograft and
concomitant unibody
or modular infrarenal
aortic endograft and
all associated
radiological
supervision and
interpretation,
including target zone
angioplasty, when
performed; including
three visceral artery
endoprostheses
(superior mesenteric,
celiac and/or renal
artery[s]).
34848............. Endovascular repair of New.............. C C N/A.
visceral aorta and
infrarenal abdominal
aorta (eg, aneurysm,
pseudoaneurysm,
dissection,
penetrating ulcer,
intramural hematoma,
or traumatic
disruption) with a
fenestrated visceral
aortic endograft and
concomitant unibody
or modular infrarenal
aortic endograft and
all associated
radiological
supervision and
interpretation,
including target zone
angioplasty, when
performed; including
four or more visceral
artery endoprostheses
(superior mesenteric,
celiac and/or renal
artery[s]).
35301............. Thromboendarterectomy, 19.61............ 21.16 21.16 No.
including patch
graft, if performed;
carotid, vertebral,
subclavian, by neck
incision.
36245............. Selective catheter 4.67............. 4.90 4.90 No.
placement, arterial
system; each first
order abdominal,
pelvic, or lower
extremity artery
branch, within a
vascular family.
37217............. Transcatheter New.............. 22.00 20.38 No.
placement of an
intravascular
stent(s),
intrathoracic common
carotid artery or
innominate artery by
retrograde treatment,
via open ipsilateral
cervical carotid
artery exposure,
including
angioplasty, when
performed, and
radiological
supervision and
interpretation.
37236............. Transcatheter New.............. 9.00 9.00 No.
placement of an
intravascular
stent(s) (except
lower extremity,
cervical carotid,
extracranial
vertebral or
intrathoracic
carotid,
intracranial, or
coronary), open or
percutaneous,
including
radiological
supervision and
interpretation and
including all
angioplasty within
the same vessel, when
performed; initial
artery.
[[Page 74327]]
37237............. Transcatheter New.............. 4.25 4.25 No.
placement of an
intravascular
stent(s) (except
lower extremity,
cervical carotid,
extracranial
vertebral or
intrathoracic
carotid,
intracranial, or
coronary), open or
percutaneous,
including
radiological
supervision and
interpretation and
including all
angioplasty within
the same vessel, when
performed; each
additional artery
(list separately in
addition to code for
primary procedure).
37238............. Transcatheter New.............. 6.29 6.29 No.
placement of an
intravascular
stent(s), open or
percutaneous,
including
radiological
supervision and
interpretation and
including angioplasty
within the same
vessel, when
performed; initial
vein.
37239............. Transcatheter New.............. 3.34 2.97 No.
placement of an
intravascular
stent(s), open or
percutaneous,
including
radiological
supervision and
interpretation and
including angioplasty
within the same
vessel, when
performed; each
additional vein (list
separately in
addition to code for
primary procedure).
37241............. Vascular embolization New.............. 9.00 9.00 No.
or occlusion,
inclusive of all
radiological
supervision and
interpretation,
intraprocedural
roadmapping, and
imaging guidance
necessary to complete
the intervention;
venous, other than
hemorrhage (eg,
congenital or
acquired venous
malformations, venous
and capillary
hemangiomas, varices,
varicoceles).
37242............. Vascular embolization New.............. 11.98 10.05 No.
or occlusion,
inclusive of all
radiological
supervision and
interpretation,
intraprocedural
roadmapping, and
imaging guidance
necessary to complete
the intervention;
arterial, other than
hemorrhage or tumor
(eg, congenital or
acquired arterial
malformations,
arteriovenous
malformations,
arteriovenous
fistulas, aneurysms,
pseudoaneurysms).
37243............. Vascular embolization New.............. 14.00 11.99 No.
or occlusion,
inclusive of all
radiological
supervision and
interpretation,
intraprocedural
roadmapping, and
imaging guidance
necessary to complete
the intervention; for
tumors, organ
ischemia, or
infarction.
37244............. Vascular embolization New.............. 14.00 14.00 No.
or occlusion,
inclusive of all
radiological
supervision and
interpretation,
intraprocedural
roadmapping, and
imaging guidance
necessary to complete
the intervention; for
arterial or venous
hemorrhage or
lymphatic
extravasation.
43191............. Esophagoscopy, rigid, New.............. 2.78 2.00 No.
transoral;
diagnostic, including
collection of
specimen(s) by
brushing or washing
when performed
(separate procedure).
43192............. Esophagoscopy, rigid, New.............. 3.21 2.45 No.
transoral; with
directed submucosal
injection(s), any
substance.
43193............. Esophagoscopy, rigid, New.............. 3.36 3.00 No.
transoral; with
biopsy, single or
multiple.
43194............. Esophagoscopy, rigid, New.............. 3.99 3.00 No.
transoral; with
removal of foreign
body.
43195............. Esophagoscopy, rigid, New.............. 3.21 3.00 No.
transoral; with
balloon dilation
(less than 30 mm
diameter).
43196............. Esophagoscopy, rigid, New.............. 3.36 3.30 No.
transoral; with
insertion of guide
wire followed by
dilation over guide
wire.
43197............. Esophagoscopy, New.............. 1.59 1.48 Yes.
flexible, transnasal;
diagnostic, includes
collection of
specimen(s) by
brushing or washing
when performed
(separate procedure).
43198............. Esophagoscopy, New.............. 1.89 1.78 Yes.
flexible, transnasal;
with biopsy, single
or multiple.
43200............. Esophagoscopy, 1.59............. 1.59 1.50 No.
flexible, transoral;
diagnostic, including
collection of
specimen(s) by
brushing or washing,
when performed
(separate procedure).
43201............. Esophagoscopy, 2.09............. 1.90 1.80 No.
flexible, transoral;
with directed
submucosal
injection(s), any
substance.
43202............. Esophagoscopy, 1.89............. 1.89 1.80 No.
flexible, transoral;
with biopsy, single
or multiple.
43204............. Esophagoscopy, 3.76............. 2.89 2.40 No.
flexible, transoral;
with injection
sclerosis of
esophageal varices.
43205............. Esophagoscopy, 3.78............. 3.00 2.51 No.
flexible, transoral;
with band ligation of
esophageal varices.
43211............. Esophagoscopy, New.............. 4.58 4.21 No.
flexible, transoral;
with endoscopic
mucosal resection.
43212............. Esophagoscopy, New.............. 3.73 3.38 No.
flexible, transoral;
with placement of
endoscopic stent
(includes pre- and
post-dilation and
guide wire passage,
when performed).
[[Page 74328]]
43213............. Esophagoscopy, New.............. 5.00 4.73 No.
flexible, transoral;
with dilation of
esophagus, by balloon
or dilator,
retrograde (includes
fluoroscopic
guidance, when
performed).
43214............. Esophagoscopy, New.............. 3.78 3.38 No.
flexible, transoral;
with dilation of
esophagus with
balloon (30 mm
diameter or larger)
(includes
fluoroscopic
guidance, when
performed).
43215............. Esophagoscopy, 2.60............. 2.60 2.51 No.
flexible, transoral;
with removal of
foreign body.
43216............. Esophagoscopy, 2.40............. 2.40 2.40 No.
flexible, transoral;
with removal of
tumor(s), polyp(s),
or other lesion(s) by
hot biopsy forceps or
bipolar cautery.
43217............. Esophagoscopy, 2.90............. 2.90 2.90 No.
flexible, transoral;
with removal of
tumor(s), polyp(s),
or other lesion(s) by
snare technique.
43220............. Esophagoscopy, 2.10............. 2.10 2.10 No.
flexible, transoral;
with transendoscopic
balloon dilation
(less than 30 mm
diameter).
43226............. Esophagoscopy, 2.34............. 2.34 2.34 No.
flexible, transoral;
with insertion of
guide wire followed
by passage of
dilator(s) over guide
wire.
43227............. Esophagoscopy, 3.59............. 3.26 2.99 No.
flexible, transoral;
with control of
bleeding, any method.
43229............. Esophagoscopy, New.............. 3.72 3.54 No.
flexible, transoral;
with ablation of
tumor(s), polyp(s),
or other lesion(s)
(includes pre- and
post-dilation and
guide wire passage,
when performed).
43231............. Esophagoscopy, 3.19............. 3.19 2.90 No.
flexible, transoral;
with endoscopic
ultrasound
examination.
43232............. Esophagoscopy, 4.47............. 3.83 3.54 No.
flexible, transoral;
with transendoscopic
ultrasound-guided
intramural or
transmural fine
needle aspiration/
biopsy(s).
43233............. Esophagogastroduodenos New.............. 4.45 4.05 No.
copy, flexible,
transoral; with
dilation of esophagus
with balloon (30 mm
diameter or larger)
(includes
fluoroscopic
guidance, when
performed).
43235............. Esophagogastroduodenos 2.39............. 2.26 2.17 No.
copy, flexible,
transoral;
diagnostic, including
collection of
specimen(s) by
brushing or washing,
when performed
(separate procedure).
43236............. Esophagogastroduodenos 2.92............. 2.57 2.47 No.
copy, flexible,
transoral; with
directed submucosal
injection(s), any
substance.
43237............. Esophagogastroduodenos 3.98............. 3.85 3.57 No.
copy, flexible,
transoral; with
endoscopic ultrasound
examination limited
to the esophagus,
stomach or duodenum,
and adjacent
structures.
43238............. Esophagogastroduodenos 5.02............. 4.50 4.11 No.
copy, flexible,
transoral; with
transendoscopic
ultrasound-guided
intramural or
transmural fine
needle aspiration/
biopsy(s), esophagus
(includes endoscopic
ultrasound
examination limited
to the esophagus,
stomach or duodenum,
and adjacent
structures).
43239............. Esophagogastroduodenos 2.87............. 2.56 2.47 No.
copy, flexible,
transoral; with
biopsy, single or
multiple.
43240............. Esophagogastroduodenos 6.85............. 7.25 7.25 No.
copy, flexible,
transoral; with
transmural drainage
of pseudocyst
(includes placement
of transmural
drainage catheter[s]/
stent[s], when
performed, and
endoscopic
ultrasound, when
performed).
43241............. Esophagogastroduodenos 2.59............. 2.59 2.59 No.
copy, flexible,
transoral; with
insertion of
intraluminal tube or
catheter.
43242............. Esophagogastroduodenos 7.30............. 5.39 4.68 No.
copy, flexible,
transoral; with
transendoscopic
ultrasound-guided
intramural or
transmural fine
needle aspiration/
biopsy(s) (includes
endoscopic ultrasound
examination of the
esophagus, stomach,
and either the
duodenum or a
surgically altered
stomach where the
jejunum is examined
distal to the
anastomosis).
43243............. Esophagogastroduodenos 4.56............. 4.37 4.37 No.
copy, flexible,
transoral; with
injection sclerosis
of esophageal/gastric
varices.
43244............. Esophagogastroduodenos 5.04............. 4.50 4.50 No.
copy, flexible,
transoral; with band
ligation of
esophageal/gastric
varices.
43245............. Esophagogastroduodenos 3.18............. 3.18 3.18 No.
copy, flexible,
transoral; with
dilation of gastric/
duodenal stricture(s)
(eg, balloon, bougie).
43246............. Esophagogastroduodenos 4.32............. 4.32 3.66 No.
copy, flexible,
transoral; with
directed placement of
percutaneous
gastrostomy tube.
43247............. Esophagogastroduodenos 3.38............. 3.27 3.18 No.
copy, flexible,
transoral; with
removal of foreign
body.
[[Page 74329]]
43248............. Esophagogastroduodenos 3.15............. 3.01 3.01 No.
copy, flexible,
transoral; with
insertion of guide
wire followed by
passage of dilator(s)
through esophagus
over guide wire.
43249............. Esophagogastroduodenos 2.90............. 2.77 2.77 No.
copy, flexible,
transoral; with
transendoscopic
balloon dilation of
esophagus (less than
30 mm diameter).
43250............. Esophagogastroduodenos 3.20............. 3.07 3.07 No.
copy, flexible,
transoral; with
removal of tumor(s),
polyp(s), or other
lesion(s) by hot
biopsy forceps or
bipolar cautery.
43251............. Esophagogastroduodenos 3.69............. 3.57 3.57 No.
copy, flexible,
transoral; with
removal of tumor(s),
polyp(s), or other
lesion(s) by snare
technique.
43253............. Esophagogastroduodenos New.............. 5.39 4.68 No.
copy, flexible,
transoral; with
transendoscopic
ultrasound-guided
transmural injection
of diagnostic or
therapeutic
substance(s) (eg,
anesthetic,
neurolytic agent) or
fiducial marker(s)
(includes endoscopic
ultrasound
examination of the
esophagus, stomach,
and either the
duodenum or a
surgically altered
stomach where the
jejunum is examined
distal to the
anastomosis).
43254............. Esophagogastroduodenos New.............. 5.25 4.88 No.
copy, flexible,
transoral; with
endoscopic mucosal
resection.
43255............. Esophagogastroduodenos 4.81............. 4.20 3.66 No.
copy, flexible,
transoral; with
control of bleeding,
any method.
43257............. Esophagogastroduodenos 5.50............. 4.25 4.11 No.
copy, flexible,
transoral; with
delivery of thermal
energy to the muscle
of lower esophageal
sphincter and/or
gastric cardia, for
treatment of
gastroesophageal
reflux disease.
43259............. Esophagogastroduodenos 5.19............. 4.74 4.14 No.
copy, flexible,
transoral; with
endoscopic ultrasound
examination,
including the
esophagus, stomach,
and either the
duodenum or a
surgically altered
stomach where the
jejunum is examined
distal to the
anastomosis.
43260............. Endoscopic retrograde 5.95............. 5.95 5.95 No.
cholangiopancreatogra
phy (ercp);
diagnostic, including
collection of
specimen(s) by
brushing or washing,
when performed
(separate procedure).
43261............. Endoscopic retrograde 6.26............. 6.25 6.25 No.
cholangiopancreatogra
phy (ercp); with
biopsy, single or
multiple.
43262............. Endoscopic retrograde 7.38............. 6.60 6.60 No.
cholangiopancreatogra
phy (ercp); with
sphincterotomy/
papillotomy.
43263............. Endoscopic retrograde 7.28............. 7.28 6.60 No.
cholangiopancreatogra
phy (ercp); with
pressure measurement
of sphincter of oddi.
43264............. Endoscopic retrograde 8.89............. 6.73 6.73 No.
cholangiopancreatogra
phy (ercp); with
removal of calculi/
debris from biliary/
pancreatic duct(s).
43265............. Endoscopic retrograde 10.00............ 8.03 8.03 No.
cholangiopancreatogra
phy (ercp); with
destruction of
calculi, any method
(eg, mechanical,
electrohydraulic,
lithotripsy).
43266............. Esophagogastroduodenos New.............. 4.40 4.05 No.
copy, flexible,
transoral; with
placement of
endoscopic stent
(includes pre- and
post-dilation and
guide wire passage,
when performed).
43270............. Esophagogastroduodenos New.............. 4.39 4.21 No.
copy, flexible,
transoral; with
ablation of tumor(s),
polyp(s), or other
lesion(s) (includes
pre- and post-
dilation and guide
wire passage, when
performed).
43273............. Endoscopic cannulation 2.24............. 2.24 2.24 No.
of papilla with
direct visualization
of pancreatic/common
bile duct(s) (list
separately in
addition to code(s)
for primary
procedure).
43274............. Endoscopic retrograde New.............. 8.74 8.48 No.
cholangiopancreatogra
phy (ercp); with
placement of
endoscopic stent into
biliary or pancreatic
duct, including pre-
and post-dilation and
guide wire passage,
when performed,
including
sphincterotomy, when
performed, each stent.
43275............. Endoscopic retrograde New.............. 6.96 6.96 No.
cholangiopancreatogra
phy (ercp); with
removal of foreign
body(s) or stent(s)
from biliary/
pancreatic duct(s).
43276............. Endoscopic retrograde New.............. 9.10 8.84 No.
cholangiopancreatogra
phy (ercp); with
removal and exchange
of stent(s), biliary
or pancreatic duct,
including pre- and
post-dilation and
guide wire passage,
when performed,
including
sphincterotomy, when
performed, each stent
exchanged.
[[Page 74330]]
43277............. Endoscopic retrograde New.............. 7.11 7.00 No.
cholangiopancreatogra
phy (ercp); with
trans-endoscopic
balloon dilation of
biliary/pancreatic
duct(s) or of ampulla
(sphincteroplasty),
including
sphincterotomy, when
performed, each duct.
43278............. Endoscopic retrograde New.............. 8.08 7.99 No.
cholangiopancreatogra
phy (ercp); with
ablation of tumor(s),
polyp(s), or other
lesion(s), including
pre- and post-
dilation and guide
wire passage, when
performed.
43450............. Dilation of esophagus, 1.38............. 1.38 1.38 No.
by unguided sound or
bougie, single or
multiple passes.
43453............. Dilation of esophagus, 1.51............. 1.51 1.51 No.
over guide wire.
49405............. Image-guided fluid New.............. 4.25 4.25 No.
collection drainage
by catheter (eg,
abscess, hematoma,
seroma, lymphocele,
cyst); visceral (eg,
kidney, liver,
spleen, lung/
mediastinum),
percutaneous.
49406............. Image-guided fluid New.............. 4.25 4.25 No.
collection drainage
by catheter (eg,
abscess, hematoma,
seroma, lymphocele,
cyst); peritoneal or
retroperitoneal,
percutaneous.
49407............. Image-guided fluid New.............. 4.50 4.50 No.
collection drainage
by catheter (eg,
abscess, hematoma,
seroma, lymphocele,
cyst); peritoneal or
retroperitoneal,
transvaginal or
transrectal.
50360............. Renal 40.90............ 40.90 39.88 No.
allotransplantation,
implantation of
graft; without
recipient nephrectomy.
52332............. Cystourethroscopy, 2.82............. 2.82 2.82 No.
with insertion of
indwelling ureteral
stent (eg, gibbons or
double-j type).
52356............. Cystourethroscopy, New.............. 8.00 8.00 No.
with ureteroscopy and/
or pyeloscopy; with
lithotripsy including
insertion of
indwelling ureteral
stent (eg, gibbons or
double-j type).
62310............. Injection(s), of 1.91............. 1.68 1.18 No.
diagnostic or
therapeutic
substance(s)
(including
anesthetic,
antispasmodic,
opioid, steroid,
other solution), not
including neurolytic
substances, including
needle or catheter
placement, includes
contrast for
localization when
performed, epidural
or subarachnoid;
cervical or thoracic.
62311............. Injection(s), of 1.54............. 1.54 1.17 No.
diagnostic or
therapeutic
substance(s)
(including
anesthetic,
antispasmodic,
opioid, steroid,
other solution), not
including neurolytic
substances, including
needle or catheter
placement, includes
contrast for
localization when
performed, epidural
or subarachnoid;
lumbar or sacral
(caudal).
62318............. Injection(s), 2.04............. 2.04 1.54 No.
including indwelling
catheter placement,
continuous infusion
or intermittent
bolus, of diagnostic
or therapeutic
substance(s)
(including
anesthetic,
antispasmodic,
opioid, steroid,
other solution), not
including neurolytic
substances, includes
contrast for
localization when
performed, epidural
or subarachnoid;
cervical or thoracic.
62319............. Injection(s), 1.87............. 1.87 1.50 No.
including indwelling
catheter placement,
continuous infusion
or intermittent
bolus, of diagnostic
or therapeutic
substance(s)
(including
anesthetic,
antispasmodic,
opioid, steroid,
other solution), not
including neurolytic
substances, includes
contrast for
localization when
performed, epidural
or subarachnoid;
lumbar or sacral
(caudal).
63047............. Laminectomy, 15.37............ 15.37 15.37 No.
facetectomy and
foraminotomy
(unilateral or
bilateral with
decompression of
spinal cord, cauda
equina and/or nerve
root[s], [eg, spinal
or lateral recess
stenosis]), single
vertebral segment;
lumbar.
63048............. Laminectomy, 3.47............. 3.47 3.47 No.
facetectomy and
foraminotomy
(unilateral or
bilateral with
decompression of
spinal cord, cauda
equina and/or nerve
root[s], [eg, spinal
or lateral recess
stenosis]), single
vertebral segment;
each additional
segment, cervical,
thoracic, or lumbar
(list separately in
addition to code for
primary procedure).
64616............. Chemodenervation of New.............. 1.79 1.53 No.
muscle(s); neck
muscle(s), excluding
muscles of the
larynx, unilateral
(eg, for cervical
dystonia, spasmodic
torticollis).
64617............. Chemodenervation of New.............. 2.06 1.90 No.
muscle(s); larynx,
unilateral,
percutaneous (eg, for
spasmodic dysphonia),
includes guidance by
needle
electromyography,
when performed.
64642............. Chemodenervation of New.............. 1.65 1.65 No.
one extremity; 1-4
muscle(s).
[[Page 74331]]
64643............. Chemodenervation of New.............. 1.32 1.22 No.
one extremity; each
additional extremity,
1-4 muscle(s) (list
separately in
addition to code for
primary procedure).
64644............. Chemodenervation of New.............. 1.82 1.82 No.
one extremity; 5 or
more muscle(s).
64645............. Chemodenervation of New.............. 1.52 1.39 No.
one extremity; each
additional extremity,
5 or more muscle(s)
(list separately in
addition to code for
primary procedure).
64646............. Chemodenervation of New.............. 1.80 1.80 No.
trunk muscle(s); 1-5
muscle(s).
64647............. Chemodenervation of New.............. 2.11 2.11 No.
trunk muscle(s); 6 or
more muscle(s).
66183............. Insertion of anterior New.............. 13.20 13.20 No.
segment aqueous
drainage device,
without extraocular
reservoir, external
approach.
67914............. Repair of ectropion; 3.75............. 3.75 3.75 No.
suture.
67915............. Repair of ectropion; 3.26............. 2.03 2.03 No.
thermocauterization.
67916............. Repair of ectropion; 5.48............. 5.48 5.48 No.
excision tarsal wedge.
67917............. Repair of ectropion; 6.19............. 5.93 5.93 No.
extensive (eg, tarsal
strip operations).
67921............. Repair of entropion; 3.47............. 3.47 3.47 No.
suture.
67922............. Repair of entropion; 3.14............. 2.03 2.03 No.
thermocauterization.
67923............. Repair of entropion; 6.05............. 5.48 5.48 No.
excision tarsal wedge.
67924............. Repair of entropion; 5.93............. 5.93 5.93 No.
extensive (eg, tarsal
strip or
capsulopalpebral
fascia repairs
operation).
69210............. Removal impacted 0.61............. 0.58 0.61 No.
cerumen requiring
instrumentation,
unilateral.
70450............. Computed tomography, 0.85............. 0.85 0.85 No.
head or brain;
without contrast
material.
70460............. Computed tomography, 1.13............. 1.13 1.13 No.
head or brain; with
contrast material(s).
70551............. Magnetic resonance 1.48............. 1.48 1.48 No.
(eg, proton) imaging,
brain (including
brain stem); without
contrast material.
70552............. Magnetic resonance 1.78............. 1.78 1.78 No.
(eg, proton) imaging,
brain (including
brain stem); with
contrast material(s).
70553............. Magnetic resonance 2.36............. 2.36 2.29 No.
(eg, proton) imaging,
brain (including
brain stem); without
contrast material,
followed by contrast
material(s) and
further sequences.
72141............. Magnetic resonance 1.60............. 1.48 1.48 No.
(eg, proton) imaging,
spinal canal and
contents, cervical;
without contrast
material.
72142............. Magnetic resonance 1.92............. 1.78 1.78 No.
(eg, proton) imaging,
spinal canal and
contents, cervical;
with contrast
material(s).
72146............. Magnetic resonance 1.60............. 1.48 1.48 No.
(eg, proton) imaging,
spinal canal and
contents, thoracic;
without contrast
material.
72147............. Magnetic resonance 1.92............. 1.78 1.78 No.
(eg, proton) imaging,
spinal canal and
contents, thoracic;
with contrast
material(s).
72148............. Magnetic resonance 1.48............. 1.48 1.48 No.
(eg, proton) imaging,
spinal canal and
contents, lumbar;
without contrast
material.
72149............. Magnetic resonance 1.78............. 1.78 1.78 No.
(eg, proton) imaging,
spinal canal and
contents, lumbar;
with contrast
material(s).
72156............. Magnetic resonance 2.57............. 2.29 2.29 No.
(eg, proton) imaging,
spinal canal and
contents, without
contrast material,
followed by contrast
material(s) and
further sequences;
cervical.
72157............. Magnetic resonance 2.57............. 2.29 2.29 No.
(eg, proton) imaging,
spinal canal and
contents, without
contrast material,
followed by contrast
material(s) and
further sequences;
thoracic.
72158............. Magnetic resonance 2.36............. 2.29 2.29 No.
(eg, proton) imaging,
spinal canal and
contents, without
contrast material,
followed by contrast
material(s) and
further sequences;
lumbar.
77280............. Therapeutic radiology 0.70............. 0.70 0.70 No.
simulation-aided
field setting; simple.
77285............. Therapeutic radiology 1.05............. 1.05 1.05 No.
simulation-aided
field setting;
intermediate.
77290............. Therapeutic radiology 1.56............. 1.56 1.56 No.
simulation-aided
field setting;
complex.
77293............. Respiratory motion New.............. 2.00 2.00 No.
management simulation
(list separately in
addition to code for
primary procedure).
77295............. 3-dimensional 4.56............. 4.29 4.29 No.
radiotherapy plan,
including dose-volume
histograms.
81161............. Dmd (dystrophin) (eg, New.............. 1.85 X N/A
duchenne/becker
muscular dystrophy)
deletion analysis,
and duplication
analysis, if
performed.
88112............. Cytopathology, 1.18............. 0.56 0.56 No.
selective cellular
enhancement technique
with interpretation
(eg, liquid based
slide preparation
method), except
cervical or vaginal.
[[Page 74332]]
88342............. Immunohistochemistry 0.85............. 0.60 I N/A
or
immunocytochemistry,
each separately
identifiable antibody
per block, cytologic
preparation, or
hematologic smear;
first separately
identifiable antibody
per slide.
88343............. Immunohistochemistry New.............. 0.24 I N/A
or
immunocytochemistry,
each separately
identifiable antibody
per block, cytologic
preparation, or
hematologic smear;
each additional
separately
identifiable antibody
per slide (list
separately in
addition to code for
primary procedure).
92521............. Evaluation of speech New.............. 1.75 1.75 No.
fluency (eg,
stuttering,
cluttering).
92522............. Evaluation of speech New.............. 1.50 1.50 No.
sound production (eg,
articulation,
phonological process,
apraxia, dysarthria).
92523............. Evaluation of speech New.............. 3.36 3.00 No.
sound production (eg,
articulation,
phonological process,
apraxia, dysarthria);
with evaluation of
language
comprehension and
expression (eg,
receptive and
expressive language).
92524............. Behavioral and New.............. 1.75 1.50 No.
qualitative analysis
of voice and
resonance.
93000............. Electrocardiogram, 0.17............. 0.17 0.17 No.
routine ecg with at
least 12 leads; with
interpretation and
report.
93010............. Electrocardiogram, 0.17............. 0.17 0.17 No.
routine ecg with at
least 12 leads;
interpretation and
report only.
93582............. Percutaneous New.............. 14.00 12.56 No.
transcatheter closure
of patent ductus
arteriosus.
93583............. Percutaneous New.............. 14.00 14.00 No.
transcatheter septal
reduction therapy
(eg, alcohol septal
ablation) including
temporary pacemaker
insertion when
performed.
93880............. Duplex scan of 0.60............. 0.80 0.60 No.
extracranial
arteries; complete
bilateral study.
93882............. Duplex scan of 0.40............. 0.50 0.40 No.
extracranial
arteries; unilateral
or limited study.
95816............. Electroencephalogram 1.08............. 1.08 1.08 No.
(eeg); including
recording awake and
drowsy.
95819............. Electroencephalogram 1.08............. 1.08 1.08 No.
(eeg); including
recording awake and
asleep.
95822............. Electroencephalogram 1.08............. 1.08 1.08 No.
(eeg); recording in
coma or sleep only.
96365............. Intravenous infusion, 0.21............. 0.21 0.21 No.
for therapy,
prophylaxis, or
diagnosis (specify
substance or drug);
initial, up to 1 hour.
96366............. Intravenous infusion, 0.18............. 0.18 0.18 No.
for therapy,
prophylaxis, or
diagnosis (specify
substance or drug);
each additional hour
(list separately in
addition to code for
primary procedure).
96367............. Intravenous infusion, 0.19............. 0.19 0.19 No.
for therapy,
prophylaxis, or
diagnosis (specify
substance or drug);
additional sequential
infusion of a new
drug/substance, up to
1 hour (list
separately in
addition to code for
primary procedure).
96368............. Intravenous infusion, 0.17............. 0.17 0.17 No.
for therapy,
prophylaxis, or
diagnosis (specify
substance or drug);
concurrent infusion
(list separately in
addition to code for
primary procedure).
96413............. Chemotherapy 0.28............. 0.28 0.28 No.
administration,
intravenous infusion
technique; up to 1
hour, single or
initial substance/
drug.
96415............. Chemotherapy 0.19............. 0.19 0.19 No.
administration,
intravenous infusion
technique; each
additional hour (list
separately in
addition to code for
primary procedure).
96417............. Chemotherapy 0.21............. 0.21 0.21 No.
administration,
intravenous infusion
technique; each
additional sequential
infusion (different
substance/drug), up
to 1 hour (list
separately in
addition to code for
primary procedure).
97610............. Low frequency, non- New.............. C C N/A
contact, non-thermal
ultrasound, including
topical
application(s), when
performed, wound
assessment, and
instruction(s) for
ongoing care, per day.
98940............. Chiropractic 0.45............. 0.46 0.46 No.
manipulative
treatment (cmt);
spinal, 1-2 regions.
98941............. Chiropractic 0.65............. 0.71 0.71 No.
manipulative
treatment (cmt);
spinal, 3-4 regions.
98942............. Chiropractic 0.87............. 0.96 0.96 No.
manipulative
treatment (cmt);
spinal, 5 regions.
99446............. Interprofessional New.............. 0.35 B No.
telephone/internet
assessment and
management service
provided by a
consultative
physician including a
verbal and written
report to the
patient's treating/
requesting physician
or other qualified
health care
professional; 5-10
minutes of medical
consultative
discussion and review.
99447............. Interprofessional New.............. 0.70 B No.
telephone/internet
assessment and
management service
provided by a
consultative
physician including a
verbal and written
report to the
patient's treating/
requesting physician
or other qualified
health care
professional; 11-20
minutes of medical
consultative
discussion and review.
[[Page 74333]]
99448............. Interprofessional New.............. 1.05 B No.
telephone/internet
assessment and
management service
provided by a
consultative
physician including a
verbal and written
report to the
patient's treating/
requesting physician
or other qualified
health care
professional; 21-30
minutes of medical
consultative
discussion and review.
99449............. Interprofessional New.............. 1.40 B No.
telephone/internet
assessment and
management service
provided by a
consultative
physician including a
verbal and written
report to the
patient's treating/
requesting physician
or other qualified
health care
professional; 31
minutes or more of
medical consultative
discussion and review.
99481............. Total body systemic New.............. C C N/A
hypothermia in a
critically ill
neonate per day (list
separately in
addition to code for
primary procedure).
99482............. Selective head New.............. C C N/A
hypothermia in a
critically ill
neonate per day (list
separately in
addition to code for
primary procedure).
G0461............. Immunohistochemistry New.............. N/A 0.60 No.
or
immunocytochemistry,
per specimen; first
separately
identifiable antibody.
G0462............. Immunohistochemistry New.............. N/A 0.24 No.
or
immunocytochemistry,
per specimen; each
additional separately
identifiable antibody
(List separately in
addition to code for
primary procedure).
----------------------------------------------------------------------------------------------------------------
As previously discussed in section III.E.2 of this final rule with
comment period, each year, the AMA RUC and HCPAC, along with other
public commenters, provide us with recommendations regarding physician
work values for new, revised, and potentially misvalued CPT codes. This
section discusses codes for which the interim final work RVU or time
values assigned for CY 2014 vary from those recommended by the AMA RUC.
It also discusses work RVU and time values for new and revised HCPCS G-
codes.
i. Code Specific Issues
(1) Breast Biopsy (CPT Codes 19081, 19082, 19083, 19084, 19085, 19086,
19281, 19282, 19283, 19284, 19285, 19286, 19287, and 19288)
The AMA RUC identified several breast intervention codes as
potentially misvalued using the codes reported together 75 percent or
more screen as potentially misvalued. For CY 2014, the CPT Editorial
Panel created 14 new codes, CPT codes 19081 through 19288, to describe
breast biopsy and placement of breast localization devices.
We are establishing the AMA RUC-recommended values as CY 2014
interim final values for all of the breast biopsy codes with the
exception of CPT code 19287 and its add-on CPT code, 19288. We believe
that the work RVU recommended by the AMA RUC for CPT code 19287 would
create a rank order anomaly with other codes in the family. To avoid
this anomaly, we are assigning a CY 2014 interim final work RVU of
2.55, which is between the 25th percentile and the median work RVU in
the survey. In determining how to value this service, we examined the
work RVU relationship among the breast biopsy codes as established by
the AMA RUC and believed those to be correct. We used those
relationships to establish the value for CPT code 19287. We believe
that using this work value creates the appropriate relativity with
other codes in the family.
To value CPT code 19288, we followed the same procedure used by the
AMA RUC in making its recommendation for the add-on codes, which was to
value add-on services at 50 percent of the applicable base code value,
resulting in a work RVU of 1.28 for CPT code 19288.
We received public input suggesting that when one of these
procedures is performed without mammography guidance, mammography is
commonly performed afterwards to confirm appropriate placement. We seek
public input as to whether or not post-procedure mammography is
commonly furnished with breast biopsy and marker placement, and if so,
whether the services should be bundled together.
Finally, we note that the physician intraservice time for CPT code
19286, which is an add-on code, is 19 minutes, which is higher than the
15 minutes of intraservice time for its base code, CPT code 19285.
Therefore we are reducing the intraservice time for CPT code 19286 to
the survey 25th percentile value of 14 minutes.
(2) Shoulder Prosthesis Removal (CPT Codes 23333, 23334, and 23335)
Three new codes, CPT codes 23333, 23334 and 23335, were created to
replace CPT codes 23331 (removal of foreign body, shoulder; deep (eg,
Neer hemiarthroplasty removal)) and 23332 (removal of foreign body,
shoulder; complicated (eg, total shoulder)).
We are establishing a CY 2014 interim final work RVU of 6.00 for
CPT code 23333, as recommended by the AMA RUC.
The AMA RUC recommended a work RVU of 18.89 for CPT code 23334
based on a crosswalk to the work value of CPT code 27269 (Open
treatment of femoral fracture, proximal end, head, includes internal
fixation, when performed). The code currently reported for this
service, CPT code 23331, has a work RVU of 7.63. Recognizing that more
physician time is involved with CPT code 23334 than CPT code 23331 and
that the technique for removal of prosthesis may have changed since its
last valuation, we still do not believe that the work has more than
doubled for this service. Therefore, instead of assigning a work RVU of
18.89, we are assigning CPT 23334 a CY 2014 interim final work RVU of
15.50, based upon the 25th percentile of the survey. We believe this
more appropriately reflects the work required to furnish this service.
Similarly, we believe that the 25th percentile of the survey also
provides the appropriate work RVU for CPT code 23335. The AMA RUC
recommended a work RVU of 22.13 based on a crosswalk to the CY 2013
interim final value of
[[Page 74334]]
CPT code 23472 (Arthroplasty, glenohumeral joint; total shoulder
(glenoid and proximal humeral replacement (eg, total shoulder))). CPT
code 23332 is currently billed for the work of new CPT code 23335 and
has a work RVU of 12.37. Although the physician time for CPT code 23335
has increased from that of the predecessor code, CPT code 22332, and
the technique for removal of prosthesis may have changed, we do not
believe that the work has almost doubled for this service. Therefore,
we are assigning a work RVU of 19.00 based upon the 25th percentile
work RVU in the survey. We believe this appropriately reflects the work
required to perform this service.
(3) Hip and Knee Replacement (CPT Codes 27130, 27236, 27446 and 27447)
CPT codes CY 27130, 27446 and 27447 were identified as potentially
misvalued codes under the CMS high expenditure procedural code screen
in the CY 2012 final rule with comment period. The AMA RUC reviewed the
family of codes for hip and knee replacement (CPT codes 27130, 27236,
27446 and 27447) and provided us with recommendations for work RVUs and
physician time for these services for CY 2014. We are establishing the
AMA RUC-recommended values of 17.61 and 17.48 a CY 2014 interim final
work RVUs for CPT codes 27236 and 27446, respectively.
For CPT codes 27130 and 27447, we are establishing work RVUs that
vary from those recommended by the AMA RUC. In addition to the
recommendation we received from the AMA RUC, we received alternative
recommendations and input regarding appropriate values for codes within
this family from the relevant specialty societies. These societies
raised several objections to the AMA RUC's recommended values,
including the inconsistent data sources used for determining the time
for this recommendation relative to its last recommendation in 2005,
concerns regarding the thoroughness of the AMA RUC's review of the
services, and questions regarding the appropriate number of visits
estimated to be furnished within the global period for the codes.
We have examined the information presented by the specialty
societies and the AMA RUC regarding these services and we share
concerns raised by stakeholders regarding the appropriate valuation of
these services, especially related to using the most accurate data
source available for determining the intraservice time involved in
furnishing PFS services. Specifically, there appears to be significant
variation between the time values estimated through a survey versus
those collected through specialty databases. However, we also note that
the AMA RUC, in making its recommendation, acknowledged that there has
been a change in the source for time estimates since these services
were previously valued.
We note that one source of disagreement regarding the appropriate
valuation of these services result from differing views as to the
postoperative visits that typically occur in the global period for both
of these procedures. The AMA RUC recommended including three inpatient
postoperative visits (2 CPT code 99231 and one CPT code 99232), one
discharge day management visit (99238), and three outpatient
postoperative office visits (1 CPT code 99212 and 2 CPT code 99213) in
the global periods for both CPT codes 27130 and 27447. The specialty
societies agreed with the number of visits included in the AMA RUC
recommendation, but contended that the visits were not assigned to the
appropriate level. Specifically, the specialty societies believe that
the three inpatient postoperative visits should be 1 CPT code 99231 and
2 CPT code 99232. Similarly, the specialty societies indicated that the
three outpatient postoperative visits should all be CPT code 99213. The
visits recommended by the specialty societies would result in greater
resources in the global period and thus higher work values.
The divergent recommendations from the specialty societies and the
AMA RUC regarding the accuracy of the estimates of time for these
services, including both the source of time estimates for the procedure
itself as well as the inpatient and outpatient visits included in the
global periods for these codes, lead us to take a cautious approach in
valuing these services.
We agree with the AMA RUC's recommendation to value CPT codes 27130
and 27447 equally so we are establishing the same CY 2014 interim final
work RVUs for these two procedures. However, based upon the information
that we have at this time, we believe it is also appropriate to modify
the AMA RUC-recommended RVU to reflect the visits in the global period
as recommended by the specialty societies. This change results in a
1.12 work RVU increase for the visits in the global period. We added
the additional work to the AMA RUC-recommended work RVU of 19.60 for
CPT codes 27130 and 27447, resulting in an interim final work RVU of
20.72 for both services.
To finalize values for these services for CY 2015, we seek public
comment regarding not only the appropriate work RVUs for these
services, but also the most appropriate reconciliation for the
conflicting information regarding time values for these services as
presented to us by the physician community. We are also interested in
public comment on the use of specialty databases as compared to surveys
for determining time values. We are especially interested in potential
sources of objective data regarding procedure times and levels of
visits furnished during the global periods for the services described
by these codes.
(4) Transcatheter Aortic Valve Replacement (TAVR) (CPT Code 33366)
For the CY 2013 final rule with comment period, we reviewed and
valued several codes within the transcatheter aortic valve replacement
(TAVR) family including CPT Codes 33361 (transcatheter aortic valve
replacement (tavr/tavi) with prosthetic valve; percutaneous femoral
artery approach), 33362 (transcatheter aortic valve replacement (tavr/
tavi) with prosthetic valve; open femoral artery approach), 33363
(transcatheter aortic valve replacement (tavr/tavi) with prosthetic
valve; open axillary artery approach), 33364 (transcatheter aortic
valve replacement (tavr/tavi) with prosthetic valve; open iliac artery
approach) and 33365 (transcatheter aortic valve replacement (tavr/tavi)
with prosthetic valve; transaortic approach (eg, median sternotomy,
mediastinotomy)). For these codes, we finalized the CY 2013 interim
final values for CY 2014 (see section II.E.2.a.ii.) For CY 2014, CPT
created a new code in the TAVR family, CPT code 33366, (Trcath replace
aortic value).
The AMA RUC has recommended the median survey value RVU of 40.00
for CPT Code 33366. After review, we believe that a work RVU of 35.88,
which is between the survey's 25th percentile of 30.00 and the median
of 40.00, accurately reflects the work associated with this service.
The median intraservice time from the survey for CPT code 33365 is 180
minutes and for CPT code 33366 is 195. Using a ratio between the times
for these procedures we determined the current work RVU of 33.12 for
CPT code 33365 results in the work RVU of 35.88 for CPT code 33366. We
believe that an RVU of 35.88 more appropriately reflects the work
required to perform CPT code 33366 and maintains appropriate relativity
among these five codes. We are establishing a CY 2014 interim final
work RVU of 35.88 for CPT code 33366.
[[Page 74335]]
(5) Retrograde Treatment Open Carotid Stent (CPT Code 37217)
The CPT Editorial Panel created CPT Code 37217, effective January
1, 2014. The AMA RUC recommended a work RVU of 22.00, the median from
the survey, and an intraservice time of 120 minutes.
The AMA RUC identified CPT Code 37215 (Transcatheter placement of
intravascular stent(s), cervical carotid artery, percutaneous; with
distal embolic protection), which has an RVU of 19.68, as the key
reference code for CPT code 37217. For its recommendations, the AMA RUC
also compared CPT code 37217 to CPT Code 35301 (thromboendarterectomy,
including patch graft, if performed; carotid, vertebral, subclavian, by
neck incision), which has a work RVU of 19.61, and CPT code 35606
(Bypass graft, with other than vein; carotid-subclavian), which has a
work RVU of 22.46.
In our review, we used the same comparison codes for CPT code 37217
as the AMA RUC used in valuing CPT code 37217. To assess the work RVUs
for CPT code 37217 relative to CPT code 35606, we compared the AMA RUC-
recommended work RVUs after removing the inpatient and outpatient
visits in each code's 90-day global period, resulting in work RVUs of
15.39 and 15.85, respectively. Although these RVUs are similar, the
intraservice times are not. CPT code 35606 has an intraservice time of
145 minutes compared with 120 minutes for CPT code 37217. To address
the variation in intraservice times, we calculated a work RVU for CPT
code 37217 that results in its work RVU having the same relationship to
its time as does CPT code 35606. This results in a work RVU of 13.12
for the intraservice time. Adding back the RVUs for the visits results
in a total work RVU of 19.73. This value, along with the RVUs of the
other comparison codes used by the AMA RUC (CPT codes 37215 and 35301),
supports our decision to establish a CY 2014 interim final work RVU of
20.38, the 25th percentile of the survey. We believe that this work RVU
of 20.38 more accurately reflects the work involved and maintains
relatively among the other codes involving similar work.
(6) Transcatheter Placement Intravascular Stent (CPT Code 37236, 37237,
37238, and 37239)
For CY 2014, the CPT Editorial Panel deleted four intravascular
stent placement codes and created four new bundled codes, CPT codes
37236, 37237, 37238, and 37239.
We agreed with the AMA RUC recommendations for all of the codes in
the family except CPT code 37239. The AMA RUC recommended a work RVU of
3.34 for CPT code 37239, which they crosswalked to the work value of
35686 (Creation of distal arteriovenous fistula during lower extremity
bypass surgery (non-hemodialysis) (List separately in addition to code
for primary procedure)). CPT code 37239 is the add-on code to 37238 for
placement of an intravascular stent in each additional vein. The AMA
RUC valued placement of a stent in the initial artery (CPT code 37236)
at 9.0 work RVUs and its corresponding add-on code (37237) for
placement of a stent in an additional artery at 4.25 work RVUs. After
review, we believe that the ratio of the work of placement of the
initial stent and additional stents would be the same regardless of
whether the stent is placed in an artery or a vein, and that the
appropriate ratio is found in the AMA RUC-recommended work RVUs of CPT
codes 37236 and 37237. To determine the work RVU for CPT code 37239, we
applied that ratio to the AMA RUC-recommended work RVU of 6.29 for CPT
code 37238. Therefore, we are assigning an interim final work RVU of
2.97 to CPT code 37239 for CY 2014.
(7) Embolization and Occlusion Procedures (CPT Codes 37241, 37242,
37243, and 37244)
For CY 2014, the CPT Editorial Panel deleted CPT code 37204
(transcatheter occlusion or embolization (eg, for tumor destruction, to
achieve hemostasis, to occlude a vascular malformation), percutaneous,
any method, non-central nervous system, non-head or neck)) and created
four new bundled codes to describe embolization and occlusion
procedures, CPT codes 37241, 37242, 37423, and 37244.
We agreed with the AMA RUC recommendations for CPT codes 37241 and
37244. However, we disagree with the AMA RUC-recommended work RVU of
11.98 for CPT code 37242. The AMA RUC recommended a direct crosswalk to
CPT code 34833 (Open iliac artery exposure with creation of conduit for
delivery of aortic or iliac endovascular prosthesis, by abdominal or
retroperitoneal incision, unilateral) because of the similarity in
intraservice time. The service described by CPT code 37242 was
previously reported using CPT codes 37204 (Transcatheter occlusion or
embolization (eg, for tumor destruction, to achieve hemostasis, to
occlude a vascular malformation), percutaneous, any method, non-central
nervous system, non-head or neck, 75894 (Transcatheter therapy,
embolization, any method, radiological supervision and interpretation),
and 75898 (Angiography through existing catheter for follow-up study
for transcatheter therapy, embolization or infusion, other than for
thrombolysis). The intraservice time for CPT code 37204 is 240 minutes
and the work RVU is 18.11. The AMA RUC-recommended intraservice time
for CPT code 37242 is 100 minutes. We believe that the AMA RUC-
recommended work RVU does not adequately consider the substantial
decrease in intraservice time for CPT code 37242 as compared to CPT
code 37204. Therefore, we believe that the survey's 25th percentile
work RVU of 10.05 is consistent with the decreases in intraservice time
and more appropriately reflects the work of this procedure.
We also disagree with the AMA RUC-recommended work RVU of 14.00 for
CPT code 37243, which the AMA RUC crosswalked from CPT code 37244,
which has a work RVU of 14.00. The AMA RUC stated that work RVU of CPT
codes 37243 and 37244 should be the same despite a 30-minute
intraservice time difference between the codes because the work of CPT
code 37244 (recommended intraservice time of 90 minutes) was more
intense than CPT code 37243 (recommended intraservice time of 120
minutes). This service was previously reported using CPT codes 37204,
75894 and 75898; or 37210 (Uterine fibroid embolization (UFE,
embolization of the uterine arteries to treat uterine fibroids,
leiomyoma), percutaneous approach inclusive of vascular access, vessel
selection, embolization, and all radiological supervision and
interpretation, intraprocedural roadmapping, and imaging guidance
necessary to complete the procedure). The current intraservice time for
CPT code 37204 is 240 minutes and the work RVU is 18.11. The current
intraservice time for CPT code 37210 is 90 minutes and the work RVU is
10.60. The AMA RUC-recommended intraservice time for 37243 is 120
minutes. We do not believe that the AMA RUC-recommended work RVU
adequately considers the substantial decrease in intraservice time for
CPT code 37243 as compared to CPT code 37204. We also note that the AMA
recognized that CPT code 37243 is less intense than CPT code 37244.
Therefore, we believe that the survey's 25th percentile work RVU of
11.99 more appropriately reflects the work required to perform this
service.
[[Page 74336]]
(8a) Gastrointestinal (GI) Endoscopy (CPT Codes 43191-43453)
In CY 2011, numerous esophagoscopy codes were identified as
potentially misvalued because they were on the CMS multi-specialty
points of comparison list. For CY 2014, the CPT Editorial Panel revised
the code sets for these services. The AMA RUC submitted recommendations
for 65 codes that describe esophagoscopy, esophagogastroduodenoscopy
(EGD), and endoscopic retrograde cholangiopancreatography (ERCP) of the
esophagus, stomach, duodenum, and pancreas/gall bladder.
In valuing this revised set of codes, we note that the AMA RUC
recommendations included information demonstrating significant overall
reduction in time resources associated with furnishing these services.
In the absence of information supporting an increase in intensity, we
would expect that the work RVUs would decrease if there are reductions
in time. However, the AMA RUC-recommended work RVUs do not reflect
overall reductions in work RVUs proportionate to the reductions in
time. Therefore, we questioned the recommended work RVUs unless the
recommendations included information indicating that the intensity of
the work had increased.
We note that in assigning values that maintain the appropriate
relativity throughout the PFS, it is extremely important to review a
family of services together and we aim to address recommendations
regarding potentially misvalued codes in the first possible rulemaking
cycle. Therefore, we are establishing interim final values for these
codes for CY 2014 although we do not have the AMA RUC recommendations
for the remaining lower GI tract codes. We expect to receive these
recommendations in time to include them in the CY 2015 final rule with
comment period. At that time, we may revise the interim final values
established in this final rule with comment period to address any
family relativity issues that may arise once we have more complete
information for the entire family.
The AMA RUC used a number of methodologies in valuing these codes.
These include accepting survey medians or 25th percentiles,
crosswalking to other codes, and calculating work RVUs using the
building block methodology. These are reviewed in section II.E.1.
above. The AMA RUC also made extensive use of a methodology that uses
the incremental difference in codes to determine values for many of
these services. This methodology, which we call the incremental
difference methodology, uses a base code or other comparable code and
considers what the difference should be between that code and another
code by comparing the differentials to those for other similar codes.
Many of the procedures described within the esophagoscopy subfamily
have identical counterparts in the esophagogastroduodenoscopy (EGD)
subfamily. For instance, the base esophagoscopy CPT code 43200 is
described as ``Esophagoscopy, flexible, transoral; diagnostic,
including collection of specimen(s) by brushing or washing when
performed.'' The base EGD CPT code 43235 is described as
``Esophagogastroduodenoscopy, flexible, transoral; diagnostic, with
collection of specimen(s) by brushing or washing, when performed.'' In
valuing other codes within both subfamilies, the AMA RUC frequently
used the difference between these two base codes as an increment for
measuring the difference in work involved in doing a similar procedure
utilizing esophagoscopy versus utilizing EGD. For example, the EGD CPT
code 43239 includes a biopsy in addition to the base diagnostic EGD CPT
code 43235. The AMA RUC valued this by adding the incremental
difference in the base esophagoscopy code over the base EGD CPT code to
the value it recommended for the esophagoscopy biopsy, CPT code 43202.
With some variations, the AMA RUC extensively used this incremental
difference methodology in valuing subfamilies of codes. We have made
use of similar methodologies, in addition to the methodologies listed
above, in establishing work RVUs for codes in this family. We have also
made use of an additional methodology not typically utilized by the AMA
RUC. As noted above in this section, we believe that the significant
decreases in intraservice and total times for these services should
result in corresponding changes to the work RVUs for the services. In
keeping with this principle, we chose, in some cases, to decrement the
work RVUs for particular codes in direct proportion to the decrement in
time. For example, for a CPT code with a current work RVU of 4.00 and
an intraservice time of 20 minutes that decreases to 15 minutes
following the survey, we might have reconciled the 25 percent reduction
in overall time by reducing the work RVU to 3.00, a reduction of 25
percent.
(8b) Esophagoscopy
The rigid and flexible esophagoscopy services are currently
combined into one code, but under the new coding structure the services
are separated into rigid transoral, flexible transnasal and flexible
transoral procedure CPT codes.
(8c) Rigid Transoral Esophagoscopy
To determine the interim final values for the rigid transoral
esophagoscopy codes, CPT codes 43191, 43192, 43193, 43194, 43195, and
43196, we considered the AMA RUC-recommended intraservice times and
found that the surveys showed that half of the rigid transoral
esophagoscopy codes had 30 minutes of intraservice time and a work RVU
survey low of 3.00, a ratio of 1 RVU per 10 minutes (1 work RVU/10
minutes). This ratio was further supported by the relationship between
the CY 2013 work value of 1.59 RVUs for CPT code 43200 (Esophagoscopy,
rigid or flexible; diagnostic, with or without collection of
specimen(s) by brushing or washing (separate procedure)) and its
intraservice time of 15 minutes. Based upon the 1 work RVU/10 minutes
ratio, we are establishing CY 2014 interim final work RVU of 2.00 for
CPT code 43191, 3.00 for CPT code 43193, 3.00 for CPT code 43194, 3.00
for CPT code 43195, and 3.30 for CPT code 43196.
For CPT code 43192, the 1 work RVU/10 minute ratio resulted in a
value that was less than the survey low, and thus did not appear to
work appropriately for this procedure. Therefore, we are establishing a
CY 2014 interim final work RVU for CPT code 43192 of 2.45 based upon
the survey low.
(8d) Flexible Transnasal Esophagoscopy
In recommending work RVUs for the two CPT codes 43197 and 43198,
which describe flexible transnasal services, the AMA RUC recommended
the same work RVUs as it recommended for the corresponding flexible
transoral CPT codes (43200 and 43202). We believe these recommendations
overstate the work involved in the transnasal codes since, unlike the
transoral codes, they are not typically furnished with moderate
sedation. Therefore, to value CPT code 43197 and 43198, we removed 2
minutes of the pre-scrub, dress and wait preservice time from the
calculation of the work RVUs that we are establishing for CY 2014 for
CPT codes 43200 and 43202. We are establishing CY 2014 interim final
values of 1.48 for CPT code 43197 and 1.78 for CPT code 43198.
(8e) Flexible Transoral Esophagoscopy
We established values for CPT codes 43216 through 43226 based on
the AMA RUC recommendations.
We used CPT code 43200 as the base code for evaluating all the
flexible esophagoscopy services. The CY 2013
[[Page 74337]]
code descriptor for 43200 includes both flexible and rigid
esophagoscopy, while for CY 2014, the descriptor has been revised to
include only flexible esophagoscopy. Despite this change in the code
descriptor for CY 2014, the AMA RUC-recommended maintaining a work RVU
of 1.59 for this code. However, we believe that the rigid
esophagoscopy, described by the new CPT code 43191, is a more difficult
procedure and by removing the rigid service from CPT code 43200 the
intensity of services described by the revised CPT code 43200 are lower
than the intensity of services described by the existing code. To
establish an appropriate interim final value for the new code, we
followed the 1 work RVU per 10 minutes of intraservice time methodology
described above resulting in an interim final work RVU of 1.50 for the
service. This interim final work RVU valuation is further supported by
the AMA RUC's recommendation that would decrease total time from 55
minutes to 52 minutes.
We believe that the work value difference between CPT code 43200
and 43202 as recommended by the AMA RUC is correct. Therefore, we added
the difference in the AMA RUC recommended values for CPT codes 43200
and 43202, 0.30 RVUs, to CPT code 43200, resulting in a work RVU of
1.80 for CPT codes 43201. We note that the resulting difference between
43200 and 43201 of 0.30 RVUs is also similar to the 0.31 difference
between the values the AMA RUC recommended for these two codes.
We also believe that the work involved in CPT code 43201 is similar
to the work involved in CPT code 43202. Accordingly we are establishing
a CY 2014 interim final work RVU of 1.80.
For CPT code 43204, the AMA RUC recommended a work RVU of 2.89. We
believe that this code is similar to CPT code 43201 in that both codes
involve injections in the esophagus. However, CPT code 43204 has 20
minutes of intraservice time compared to 15 minutes for CPT code 43201.
Applying this increase in intraservice time to the work RVU that we are
establishing for CPT code 43201 results in a work RVU of 2.40 for this
code. The AMA RUC recommended a work RVU of 3.00 for CPT code 43205, an
increment of 0.11 RVUs over its recommended value for CPT code 43204.
Both of these codes involve treatment of esophageal varices. We agree
with that increment and are adding that to our CY 2014 interim final
work RVU for CPT code 43204 of 2.40 to arrive at a CY 2014 interim
final work RVU of 2.51 for CPT code 43205.
In establishing interim final work RVUs for CPT code 43211, we
followed the methodology used by the AMA RUC to develop its
recommendation. The AMA RUC decreased the work RVU of the corresponding
esophagogastroduodenoscopy (EGD for mucosal resection), CPT code 43254,
by the difference between the base esophagoscopy code 43200 and the
base EGD code 43235, which is 0.67 RVU. Reducing our CY 2014 interim
final work RVU of 4.88 for CPT code 43254 by this difference results in
a CY 2014 interim final work RVU of 4.21 for CPT code 43211.
Since CPT code 43212 has almost identical times and intensities as
CPT code 43214, we crosswalked the work RVU from our CY 2014 interim
final work RVU of 3.38.
In valuing CPT code 43213, we believe it is comparable to CPT code
43200, but has intraservice time of 45 minutes, while CPT code 43200
has only 20 minutes. We are establishing a CY 2014 interim final work
RVU of 4.73, which is based upon the difference in intraservice time
between the two codes.
CPT code 43214 is esophageal dilatation using fluoroscopic
guidance. We believe that the service described by CPT code 43214 is
similar in intensity and intraservice time to CPT code 31622
(Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when
performed; diagnostic, with cell washing, when performed (separate
procedure)), another endoscopic code using fluoroscopic guidance.
However, CPT code 43214 includes an endoscopic dilation in addition to
the fluoroscopic guided endoscopy. Therefore, we added the incremental
increase between the work RVU of the esophagoscopy base code for
dilation without fluoroscopic guidance, CPT code 43220, and the base
code to the work RVU for CPT code 31622 and are establishing a CY 2014
interim final work RVU of 3.38 for CPT code 43214.
We believe that the time and work for CPT 43215 are identical to
those for CPT code 43205. Therefore, we crosswalked the work RVU for
CPT code 43215 to CPT code 43205, and are establishing a CY 2014
interim final work RVU of 2.51.
For current CPT code 43227, the survey reflected a decrease in
intraservice time from the current, 36 minutes to 30 minutes. The AMA
RUC recommended a small decrease in RVUs, but not one that was
proportionate to the difference in intraservice time. Therefore, we
decreased the current work RVU proportionate to the decrease in
intraservice time, resulting in a CY 2014 interim final work RVU of
2.99.
CPT code 43231 is a basic esophagoscopy procedure done with
endoscopic ultrasound. We disagree with the AMA RUC recommendation to
maintain the current work RVU of 3.19, despite a decrease in
intraservice time. Instead, we used the work RVU of another endoscopic
code using endoscopic ultrasound to value the incremental difference in
work between this service and the esophagoscopy base code. CPT code
31620 (Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic
or therapeutic intervention(s) (List separately in addition to code for
primary procedure[s])) is an add-on code for EBUS to other bronchoscopy
codes, with a current work RVU of 1.40. We added this EBUS work RUV to
the work RVU of base esophagoscopy code 43200 and are establishing a CY
2014 interim final work RVU of 2.90.
For CPT code 43232, we believe that the work value difference
between CPT code 43231 and 43232 as recommended by the AMA RUC is
correct. We added that difference of 0.64 work RVUs to our CY 2014
interim final work RVU for CPT code 43231 to arrive at our CY 2014
interim final work RVU of 3.54 for CPT code 43232.
CPT code 43229 has similar times and intensity to CPT code 43232
and therefore, we directly crosswalked the work value of CPT code 43229
to CPT code 43232, resulting in a CY 2014 interim final work RVU of
3.54.
(8f) Esophagogastroduodenoscopy (EGD)
Various EGD codes were identified as potentially misvalued through
the multi-specialty point of comparison, high expenditures, and fastest
growing screens. The AMA RUC recommended values for all EGD codes. We
agreed with the AMA RUC recommended values and are establishing CY 2014
interim final work RVUs for CPT codes 43240, 43241, 43243, 43244,
43245, 43248, 43249, 43250, and 43251 based on its recommendations.
In reviewing the base EGD code, CPT code 43235, we determined that
we agreed with the AMA RUC's recommended work RVU difference between
this EGD base code and the esophagoscopy base code, CPT 43200. We
applied this difference to our CY 2014 interim final work RVU of 1.50
for CPT code 43200 and are establishing a CY 2014 interim final RVU of
2.17 for CPT code 43235.
CPT code 43233 is an identical procedure to CPT code 43214 except
that it uses EGD rather than esophagoscopy. We added the
[[Page 74338]]
additional work RVU of furnishing an EGD as compared to an
esophagoscopy to our CY 2014 interim final work RVU of 3.38 for CPT
code 43214, resulting in a CY 2014 interim final work RVU of 4.05 for
CPT 43233.
CPT code 43236 is the EGD equivalent of the esophagoscopy CPT code
43201. In valuing CPT code 43236, the AMA RUC used the incremental
difference methodology using CPT codes 43200 and 43201 and added that
difference to its recommended work value for CPT code 43235 to arrive
at its recommended RVU of 2.57 for CPT code 43236. We used the same
methodology but instead of using the AMA RUC recommended work RVU for
CPT code 43235, we used our CY 2014 interim final value of 2.17 for CPT
code 43235. We are establishing a CY 2014 interim final work RVU of
2.47 for CPT code 43236.
CPT code 43237 is the EGD equivalent to the esophagoscopy CPT code
43231. We do not believe that the AMA RUC-recommended work RVU
adequately accounts for the 20 percent decrease from current time to
the AMA RUC-recommended intraservice time. Therefore, we applied an
incremental difference methodology as discussed above for CPT code
43233. We used the comparable esophagoscopy code 43231 and added its CY
2014 interim final work RVUs to the incremental value of a base EGD
over the base esophagoscopy, resulting in a CY 2014 interim final work
RVU of 3.57 for CPT code 43237.
CPT code 43238 is the EGD equivalent to the esophagoscopy CPT code
43232. We valued this code similarly to CPT code 43237 using the
incremental difference approach. We do not believe that the AMA RUC
recommended RVU adequately accounts for the 36 percent decrease in
intraservice time. We used the CY 2014 interim final work RVU for the
comparable esophagoscopy CPT code 43232 and added that to that the
incremental work RVU of an EGD over esophagoscopy, resulting in a CY
2014 interim final work RVU of 4.11 for CPT code 43238.
CPT code 43239 is the EGD equivalent to the esophagoscopy CPT code
43202 and we used the incremental difference methodology described
above. We do not believe that the AMA RUC recommended RVU adequately
accounts for the 56 percent decrease in intraservice time. We used the
CY 2014 interim final work RVU for the comparable esophagoscopy code
43202 and added that to the incremental work RVU value of an EGD over
esophagoscopy, resulting in a work RVU of 2.47, which we are
establishing as the CY 2014 interim final work RVU for CPT code 43239.
CPT code 43242 is an equivalent service to CPT code 43238 except
that CPT code 43242 includes diagnostic services in a surgically
altered GI tract. The AMA RUC recommendation used a methodology that
took the increment between CPT code 43238 and CPT code 43237, which is
an ultrasound examination of a gastrointestinal (GI) tract that has not
been surgically altered. The AMA RUC then applied that difference in
its recommended work RVUs for these two codes to CPT code 43259, which
is an ultrasound of a GI tract that has been surgically altered. We
agree with that methodology but instead applied our CY 2014 interim
final work RVUs for those codes. Accordingly, we are establishing a CY
2014 interim final RVU of 4.68 for CPT code 43242.
In valuing CPT code 43246, we note that the work and time are very
similar to CPT code 43255. Therefore, we directly crosswalked the
service to the CY 2014 interim final work RVU of CPT code 43255 and are
establishing a CY 2014 interim final value of 3.66.
CPT code 43247 is the EGD equivalent to the esophagoscopy CPT code
43215. In valuing this code, the AMA RUC applied the increment between
CPT code 43200 and 43215 to the EGD base CPT code 43235 to arrive at
its recommended RVU of 3.27. We agree with this methodology but applied
the values we have established for these codes, resulting in a work RVU
of 3.18 for CPT code 43247.
In valuing CPT code 43253, the AMA RUC applied the same methodology
as it used in valuing CPT code 43242, resulting in a recommended RVU of
5.39. We agree with that methodology, but instead of using the AMA RUC-
recommended values, we are using our CY 2014 interim final work RVUs.
We are establishing a CY 2014 interim final work RVU of 4.68 for CPT
code 43253.
CPT code 43254 is the EGD equivalent to the esophagoscopy CPT code
43211. The AMA RUC-recommended a work RVU of the survey's 25th
percentile of 5.25. We believe that this overstates the work involved
in this code and that the incremental methodology used by the AMA RUC
for many of these codes is more appropriate. Thus, we applied the
incremental difference methodology between the base EGD and
esophagoscopy codes to the equivalent esophagoscopy CPT code 43211 and
are establishing a CY 2014 interim final RVU of 4.88.
CPT code 43255 is the EGD equivalent to the esophagoscopy CPT code
43227. We do not believe that the AMA RUC-recommended 13 percent work
RVU decrease adequately accounts for the 44 percent decrease in
intraservice time. Therefore, we applied the incremental difference
methodology, using our CY 2014 interim final values and the comparable
esophagoscopy code, CPT code 43227. We are establishing a CY 2014
interim final work RVU of 3.66 for CPT code 43255.
CPT code 43257 is a CY 2013 code for which the AMA RUC recommended
the survey's 25th percentile. We note that the service has an identical
intraservice time and similar intensity to CPT code 43238. Thus, we
directly crosswalked the work RVU from CPT code 43238 to CPT code
43257. We are establishing a CY 2014 interim final work RVU of 4.11 for
CPT code 43257, which is consistent with the 25 percent reduction from
current intraservice time.
In valuing CPT code 43259, the AMA RUC recommended the survey's
25th percentile RVU of 4.74. We disagree with that value and note that
the intraservice time has decreased 35 percent and the total time has
decreased 20 percent. Applying the intraservice time decrease to the CY
2013 work RVU would result in an RVU of 3.38. We believe that value
does not maintain the appropriate rank order with the other EGD codes.
Adjusting the current RVU to account for the reduction in total time
results in a work RVU of 4.14. We believe that this work RVU more
accurately values the work involved in this service. Thus, we are
establishing a CY 2014 interim final RVU of 4.14 for this code.
CPT code 43266 is the EGD equivalent to the esophagoscopy CPT code
43212. In valuing CPT code 43266, the AMA RUC recommended the survey's
25th percentile RVU of 4.40, higher than the current value of 4.34 even
though the intraservice time decreased from 45 minutes to 40 minutes.
We disagree with this recommended work RVU. Therefore, we used the
incremental difference methodology and added the difference in work
RVUs between the base esophagoscopy code and the base EGD code to the
equivalent esophagoscopy CPT code 43212 for an RVU of 4.05. Thus, we
are establishing a CY 2014 interim final work RVU of 4.05 for CPT code
43266.
CPT code 43270 is the EGD equivalent to the esophagoscopy CPT code
43229. The AMA RUC recommended the survey's 25th percentile work RVU of
4.39. We disagree with this value and believe that utilizing the
incremental difference methodology more accurately determines the
appropriate work for this service. For CPT code 43270, we added the
difference in work RVUs between the base EGD code over the base
[[Page 74339]]
esophagoscopy code to our CY 2014 interim final work RVU for CPT 43229,
resulting in a work RVU of 4.21. Thus, we are establishing a CY 2014
interim final value of 4.21 for CPT code 43270.
(8g) Endoscopic Retrograde Cholangiopancreatography
In CY 2011, several endoscopic retrograde cholangiopancreatography
(ERCP) codes were identified by CMS through the multi-specialty points
of comparison screen. The AMA RUC provided recommendations for seven
current codes and five new codes. CPT codes 43260-43265 and 43273-43278
were reviewed. We agreed with the AMA RUC-recommended values for CPT
codes 43260, 43261, 43262, 43264, 43265, 43273, 43275, and 43277 as
shown on Table 27.
The AMA RUC recommended that the work RVU for CPT code 43263 be
maintained at its current RVU of 7.28 in spite of a 25 percent decrease
to its recommended intraservice time for this code. This code has
identical times to CPT code 43262 for which the AMA RUC recommended a
decrease in the work RVU from its current value of 7.38 to 6.60,
consistent with the decrease in time. We believe that this reduction
more accurately reflects the work involved in this code, so we
crosswalked the work RVU for CPT code 43263 to CPT code 43262. We are
establishing a CY 2014 interim final work RVU of 6.60 for CPT code
43263.
CPT code 43274 is a new code involving stent placement and
sphincterotomy. The AMA RUC valued this code by adding the increment of
a sphincterotomy and stent placement to the work RVU of the base ERCP,
CPT code 43260, resulting in an AMA RUC-recommended work RVU of 8.74.
We agree with this methodology, except we have used our CY 2014 interim
final work RVUs. We are establishing an interim final RVU of 8.48 for
CPT code 43274.
CPT code 43276 is a new code without previous physician times to
compare that involves the removal and replacement of a stent. The AMA
RUC developed its recommendation using the incremental difference
methodology. It determined the incremental work RVU associated with
removing a foreign body by comparing CPT code 43215 to the base
esophagoscopy code, CPT code 43200. It also determined the incremental
value of placing a stent with esophagoscopy, CPT code 43212, over the
base esophagoscopy, CPT code 43200. By adding these two increments to
the work RVU of the ERCP base code, CPT code 43260, the AMA recommended
a work RVU for CPT code 43276 of 9.10. The median survey value was 9.88
and the survey's 25th percentile was 6.95. The combination of 60
minutes of intraservice time with an RVU of 9.10 is not comparable with
other ERCP codes. For CPT code 43274, for example, the AMA RUC
recommended 68 minutes intraservice time and a work RVU of 8.74. We
accepted the AMA RUC recommendations for CPT code 43265 of 78 minutes
intraservice time and a work RVU of 8.03. Both CPT codes 43262 and
43263 have intraservice times of 60 minutes and a CY 2014 interim final
work RVU of 6.60. Based on these comparisons, we believe that the AMA
RUC recommendation for this code of 9.10 is inconsistent with the RVUs
assigned to codes that describe similar services with similar
intraservice times. Therefore, we are using the incremental difference
methodology to arrive at the appropriate work RVU. CPT code 43275
describes the removal of a stent using ERCP. We used CPT code 43275
with a CY 2014 interim final work RVU of 6.96 and added the incremental
difference of placing a stent utilizing esophagoscopy, CPT code 43212,
over the base esophagoscopy code CPT code 43200. We believe that this
valuation approach results in values that are more consistent with
other codes in this family than the AMA RUC recommendation. We are
establishing a CY 2014 interim final RVU of 8.84 for CPT code 43276.
CPT code 43277 is a new code for CY 2014, which describes ERCP with
dilation and if furnished, sphincterotomy. The AMA RUC recommended a
work RVU of 7.11 RVU. The AMA RUC determined this value using an
incremental approach. Specifically, the work RVU for dilation was
calculated as the difference between the esophagoscopy dilation code
(CPT code 43220) and the esophagoscopy base code, CPT code 43200, and
the sphincterotomy work RVU was calculated as the difference between
the base ERCP code, CPT 43260, and the ERCP sphincterotomy code, CPT
code 43262. By adding these two values to the work RVU of CPT code
43260, the AMA RUC calculated its recommended work RVU of 7.11. The
survey's 25th percentile is 7.00.
Currently, ERCP sphincterotomy is billed using a single code, CPT
code 43262, and duct dilation using ERCP is currently billed using CPT
code 43271. Adding together the current work RVUs for these two codes
results in a RVU of 8.81. The total combined intraservice time for
these two codes is 90 minutes. Since the new CPT code 43277 has an
intraservice time of only 70 minutes, we applied the percentage
decrease in time to the current combined work RVU for CPT 43262 and
43271 of 8.81, resulting in a work RVU of 6.85. Although this value
reflects a proportional reduction in intraservice time between the
current codes and the time presumed for the AMA RUC recommendation, we
believe that a work RVU of 6.85 does not adequately reflect the
intensity of this service and are therefore establishing an interim
final RVU for CPT code of 43277 of 7.00, which is the survey's 25th
percentile.
CPT code 43278 is a new code involving lesion ablation. The AMA RUC
valued this code by adding the incremental work RVU difference between
the base esophagoscopy code and the esophagoscopy ablation code, CPT
code 43229, to the base ERCP code, resulting in a RVU of 8.08. We agree
with this methodology. However, using our CY 2014 interim final values
we are establishing a CY 2014 interim final work RVU of 7.99.
(8h) Dilation of Esophagus
We agree with the AMA RUC recommended values for the dilation of
the esophagus, CPT codes 43450 and 43453, as shown on Table 27.
(9) Transplantation of Kidney (CPT Code 50360)
We received an AMA RUC work RVU recommendation of 40.90 for CPT
code 50360 which included an increase in the service's intraservice
time, from 183 minutes to 210 minutes. We also note that there is a
significant decrease in the number of AMA RUC-recommended visits in the
global period for this procedure.
In CY 2006, the work RVU for CPT 50360 was 31.48. In CY 2007 and CY
2010, the work RVUs for all services with global periods, including CPT
code 50360, were increased to take into account increases in the work
RVUs for E/M services. These changes resulted in the current work RVU
for CPT code 50360 of 40.90. We note that this increase was based on an
assumption of 32 visits in the global period. Based upon information
that we now have, it appears that an assumption of 10 visits may have
been more appropriate. If we had used an assumption of 10 visits when
adding E/M services in 2007 and 2010, the current work RVU would be
34.68.
In determining a CY 2014 interim final work RVU, we began with the
34.68 work RVU value. The AMA RUC recommended a 14.75 percent increase
in intraservice time, from 183 min to 210 min. Applying this ratio to
the refined base work RVU of 34.68 results
[[Page 74340]]
in a new base work RVU of 39.80. Adding the changes in work RVU
resulting from the changes in the preservice and postservice times
recommended by the AMA RUC results in an interim final work RVU of
39.88 for CPT code 50360.
(10) Spinal Injections (CPT Codes 62310, 62311, 62318, and 62319)
For CY 2014, we received AMA RUC recommendations for CPT codes
62310, 62311, 62318, and 62319. Although the AMA RUC recommendations
show a significant reduction in intraservice and total times for the
family, the recommended work RVUs do not reflect a similar decrease.
For CPT code 62310, we disagree with the work RVU of 1.68
recommended by the AMA RUC because the reduction from the current work
is not comparable to the 63 percent reduction in time being recommended
by the AMA RUC. We, however, agree that the methodology used by the AMA
RUC to develop a recommendation was appropriate. Using this
methodology, we calculated the difference in the AMA RUC
recommendations for CPT 62310 and 62318 and subtracted this from our CY
2014 interim work RVU for CPT 62318, which results in a work RVU of
1.18, which we are establishing as the CY 2014 interim final work RVU
for CPT code 62310.
The AMA RUC recommended maintaining the current work RVU for CPT
code 62311 of 1.54 even though its recommended intraservice time
decreased 50 percent. We disagreed with this approach.To determine the
CY 2014 interim final work RVU we subtracted the difference between the
AMA RUC-recommended work RVUs of 62311 and 62319 from our CY 2014
interim final work RVU for CPT code 62319. We believe that the
resultant work RVU of 1.17 is a better approximation of the work
involved in CPT code 62311.
CPT code 62318 currently has an intraservice time of 20 minutes and
a work RVU of 2.04. The intraservice time reduced by 25 percent but the
AMA RUC recommended no change in the work RVU. The low value of the
survey is 1.54, which is consistent with the reduction in intraservice
time. Therefore, we are establishing an interim final RVU for CPT code
62318 of 1.54.
The AMA RUC recommended a 50 percent decrease in intraservice time
for CPT 62319 but no change in the work RVU. Similar to the CPT code
62318, we believe the low value of 1.50 more accurately represents the
work involved in the code and the significant reduction in intraservice
time.
(11) Laminectomy (CPT Codes 63047 and 63048)
We identified CPT code 63047 through the high expenditure procedure
code screen. For CY 2014, we received AMA RUC recommendations on CPT
codes 63047 and 63048.
In reviewing the AMA RUC recommendations for these codes, we
determined that to appropriately value these codes, we need to consider
the other two codes in this family: CPT codes 63045 (Laminectomy,
facetectomy and foraminotomy (unilateral or bilateral with
decompression of spinal cord, cauda equina and/or nerve root[s], [eg,
spinal or lateral recess stenosis]), single vertebral segment;
cervical) and 63046 (Laminectomy, facetectomy and foraminotomy
(unilateral or bilateral with decompression of spinal cord, cauda
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]),
single vertebral segment; thoracic). Since the AMA RUC did not submit
recommendations for these codes, we are valuing CPT codes 63047 and
63048 on an interim final basis for CY 2014 at work RVUs of 15.37 and
3.47, respectively, based upon the AMA RUC recommendations. We note
that expect to review these values in concert with the AMA RUC
recommendations for CPT codes 63045 and 63046.
(12) Chemodenervation of Neck Muscles (CPT Codes 64616 and 64617)
For CY 2014, we received AMA RUC recommendations for two new
chemodenervation codes, CPT codes 64616 and 64617, which replace CPT
code 64613 (chemodenervation of muscle(s); neck muscle(s) (eg, for
spasmodic torticollis, spasmodic dysphonia)). We disagree with the AMA
RUC-recommended work RVUs of 1.79 for CPT code 64616 and 2.06 for CPT
code 64617. We do not think that these recommended values account for
the absence of the outpatient visit that was included in the
predecessor code, CPT 64613. To adjust for this, we subtracted the 0.48
work RVUs associated with the outpatient visit from the 2.01 work RVU
of the predecessor code, CPT code 64613; resulting in a work RVU of
1.53, which we are assigning as an interim final value for CPT 64616.
CPT code 64617 is chemodenervation of the larynx and includes EMG
guidance when furnished. The EMG guidance CPT code 95874 (Needle
electromyography for guidance in conjunction with chemodenervation
(List separately in addition to code for primary procedure)) has a work
RVU of 0.37. To calculate the work RVU for CPT 64617 we added the work
RVU for CPT 95874, EMG guidance, to the 1.53 work RVU for CPT 64616,
which results in a work RVU of 1.90.
Therefore, on an interim final basis for CY 2014, we are assigning
a work RVU of 1.53 to CPT code 64616 and 1.90 to CPT code 64617.
(13) Chemodenervation of Extremity or Trunk Muscles (CPT Codes 64642,
64643, 64644, 64645, and 64647)
For CY 2014, the CPT Editorial Panel created six new codes to more
precisely describe chemodenervation of extremity and trunk muscles. We
assigned CY 2014 interim final work RVUs for four of these CPT codes
(64642, 64644, 64646 and 64647), based upon the AMA RUC
recommendations.
CPT Codes 64643 and 64645 are add-on codes to CPT codes 64642 and
64644, respectively. We disagree with the AMA RUC-recommended work RVUs
of 1.32 for CPT code 64643 and 1.52 for CPT code 64645. We agree with
the AMA RUC that the intraservice times for each base code and its add-
on code should be the same. However, the AMA RUC-recommendations for
the add-on codes contain 19 minutes less time than the base codes
because of decreased preservice and post-times in the add-on codes.
Therefore, we are adjusting the add-on codes by subtracting the RVUs
equal to 19 minutes of preservice and postservice from the AMA RUC
recommended work RVU for each base code to account for the decrease in
time for performing the add-on service. Using the methodology outlined
above, we are assigning a CY 2014 interim final work RVU for CPT code
64643 of 1.22 and a work RVU for CPT code 64645 of 1.39.
We are basing the global period for these codes on their
predecessor code, CPT code 64614 (chemodenervation of muscle(s);
extremity and/or trunk muscle(s) (eg, for dystonia, cerebral palsy,
multiple sclerosis)), which is being deleted for CY 2014. Therefore, we
are assigning these codes a 010-day global period.
(14) Cerumen Removal (CPT Code 69210)
This code was reviewed as a potentially misvalued code pursuant to
the CMS high expenditure screen. The CPT Editorial Panel changed the
code descriptor for removal of impacted cerumen from ``1 or both ears''
to ``unilateral,'' effective January 1, 2014. The AMA RUC recommended a
work RVU for this code of 0.58. In its recommendation to the AMA RUC,
the specialty society stated that there was
[[Page 74341]]
no information to determine how often the service was performed
unilaterally but asserted, and the AMA RUC agreed, that the service was
performed bilaterally 10 percent of the time. In determining its
recommendation, the AMA RUC applied work neutrality to the current work
RVU of 0.61 to arrive at the recommended work RVU of 0.58 based upon
the assertion that the code that was previously only reported once if
furnished bilaterally, would now be reported for two units, due the
descriptor change.
We disagree with the assumption by the AMA RUC that the procedure
will be furnished in both ears only 10 percent of the time as the
physiologic processes that create cerumen impaction likely would affect
both ears. Given this, we will continue to allow only one unit of CPT
69210 to be billed when furnished bilaterally. We do not believe the
AMA RUC's recommended value reflects this and therefore, we will
maintain the CY 2013 work value of 0.61 for CPT code 69210 when the
service is furnished.
(15) MRI Brain (CPT Code 70551, 70552, 70553, 72141, 72142, 72146,
72147, 72148, 72149, 72156, 72157, and 72158)
For CY 2014, the AMA RUC reviewed the family of magnetic resonance
imaging (MRI) for the brain (CPT codes 70551, 70552, and 70553) and the
family for MRI for the spine (CPT codes 72141, 72142, 72146, 72147,
72148, 72149, 72156, 72157, and 72158). We are assigning the AMA RUC-
recommended work RVUs as CY 2014 interim final values for all of these
codes except for CPT code 70553.
The AMA RUC found that the codes in these two families required a
similar amount of work and valued the codes with similar work
identically, except for CPT code 70553, which is the MRI code for brain
imaging. CPT code 70553 is brain imaging without contrast followed by
brain imaging with contrast. The AMA RUC recommended that the work RVU
for this code remain at its current value of 2.36, while recommending
that the work RVUs of CPT codes 72156, 72157 and 72158 be decreased to
2.29. These three codes are similar to CPT code 70553 in that they
identify MRI services without contrast followed by contrast for the
three sections of the spine--cervical, thoracic and lumbar. We agree
with the AMA RUC that the work is similar for the two families of codes
and that the codes should be valued accordingly. The AMA RUC-
recommended value for CPT code 70553 is not consistent with the
determination that these codes require a similar amount of work.
Therefore, we are assigning a CY 2014 interim final work RVU of 2.29 to
CPT code 70553.
(16) Molecular Pathology (CPT Code 81161)
The AMA RUC submitted a recommended value for CPT code 81161, a
newly created molecular pathology code, for CY 2014. Consistent with
our policy established in the CY 2013 final rule with comment period
that molecular pathology codes are paid under the CLFS as lab tests,
rather than under the PFS as physician services, we are assigning CPT
code 81161, a PFS procedure status indicator of X (Statutory exclusion
(not within definition of `physician service' for physician fee
schedule payment purposes. Physician Fee Schedule does not allow
payment, but perhaps another Medicare Fee Schedule does)). (77 FR
68994-69002). As explained in the CY 2013 final rule with comment
period, HCPCS code G0452 can be used under the PFS by a physician to
bill for medically necessary interpretation and written report of a
molecular pathology test, above and beyond the report of laboratory
results.
(17) Immunohistochemistry (CPT Codes 88342 and 88343)
The CPT Editorial Panel revised the existing immunohistochemistry
code, CPT code 88342 and created a new add-on code 88343 for CY 2014.
Current coding requirements only allow CPT code 88342 to be billed once
per specimen for each antibody, but the revised CPT codes and
descriptors would allow the reporting of multiple units for each slide
and each block per antibody (88342 for the first antibody and 88343 for
subsequent antibodies). We believe that this coding would encourage
overutilization by allowing multiple blocks and slides to be billed.
To avoid this incentive, we are creating G0461
(Immunohistochemistry or immunocytochemistry, per specimen; first
single or multiplex antibody stain) and G0462 (Immunohistochemistry or
immunocytochemistry, per specimen; each additional single or multiplex
antibody stain (List separately in addition to code for primary
procedure)) to ensure that the services are only reported once for each
antibody per specimen. We believe this will result in appropriate
values for these services without creating incentives for
overutilization.
We examined the AMA RUC recommendations for work RVUs CPT codes
88342 and 88343 in order to determine whether it would be appropriate
to use these recommendations as the basis for establishing work RVUs
for the new G-codes. To determine whether the AMA RUC-recommended work
RVUs were appropriate for use in valuing the new G-codes, we examined
whether the change in descriptors between the CPT and G-codes would
change the underlying assumptions regarding the physician work and
resource costs of the typical services described by the codes. We note
that the existing CPT code 88342 is to be reported per specimen, per
antibody. To crosswalk the utilization for the service described by the
current CPT code 88342 to the new CPT coding structure, the AMA RUC
recommended that 90 percent of the utilization previously reported with
CPT code 88342 would continue to be reported with as a single unit of
88342 and that 10 percent of the utilization previously reported with
CPT code 88342 would be reported with the new add-on code, CPT code
88343. It seems clear, then, that in recommending values for the new
services, the AMA RUC did not anticipate that any additional services
would be reported despite the new descriptors that would allow for
units to be reported for each block and each slide for each antibody.
Therefore, we assume that the AMA RUC's recommended work RVUs and
direct PE inputs for the new CPT codes were also developed with the
assumption that the typical case would continue to be one unit reported
per specimen, per antibody. Since the descriptors for the G-codes we
are adopting in lieu of the new and revised CPT codes make explicit
what appears to be the premise underlying the AMA RUC-recommended
values for these services, we believe it is appropriate to use the AMA
RUC recommendations for CPT codes 88342 and 88343 as the basis for
establishing interim final work RVUs and direct PE inputs for the new
G-codes for CY 2014.
Therefore, we are assigning an interim final work RVU of 0.60 for
code G0461, which is the AMA RUC recommendation for CPT code 88342; and
we are assigning an interim final work RVU of 0.24 for code G0462,
which is the AMA RUC recommendation for CPT code 88343.
(18) Psychiatry (CPT Code 90863)
For CY 2013, the CPT Editorial Panel restructured the psychiatry/
psychotherapy CPT codes allowing for separate reporting of E/M codes,
eliminating the site-of-service differential, creation of CPT codes for
crisis, and a series of add-on CPT codes to psychotherapy to describe
interactive complexity and medication management. In CY 2013, the AMA
RUC
[[Page 74342]]
provided us with recommendations for the majority, but not all, of the
updated psychiatry/psychotherapy CPT codes. Due to the absence of AMA
RUC recommendations for the entire family, we established interim final
values for the codes based on a general approach of maintaining the
previous values for the services, or as close to the previous values as
possible, pending our receipt of recommended values for all codes in
the new structure in CY 2014. See section II.E.2.a.ii.(25) of this
final rule with comment period for a discussion of the finalization of
the CY 2013 interim final RVUs.
For CY 2014, we received the outstanding AMA RUC recommendations
for the psychiatry/psychotherapy CPT code family. We are establishing
interim final work RVUs for CPT codes 90785, 90839, and 90840 based
upon the AMA RUC's recommended work RVUs.
We are assigning CPT code 90863 a PFS procedure status indicator of
I (Not valid for Medicare purposes. Medicare uses another code for the
reporting of and the payment for these services.). The CPT Editorial
Panel created CPT add-on code 90863 to describe medication management
by a nonphysician when furnished with psychotherapy. As detailed in the
CY 2013 final rule with comment period, clinical psychologists are
precluded from billing Medicare for pharmacologic management services
under CPT code 90863 because pharmacologic management services require
some knowledge and ability to perform evaluation and management
services, as some stakeholders acknowledged.
(19) Speech Evaluation (CPT Codes 92521, 92522, 92523, and 92524)
For CY 2014, the CPT Editorial Panel replaced CPT code 92506
(evaluation of speech, language, voice, communication, and/or auditory
processing) with four new speech evaluation codes, CPT codes 92521,
92522, 92523, and 92524, to more accurately describe speech-language
pathology evaluation services.
We are assigning CY 2014 interim final work RVUs of 1.75 and 1.50
for CPT codes 92521 and 92522, respectively, as the HCPAC recommended.
For CPT code 92523, we disagree with the HCPAC-recommended work RVU
of 3.36. In arguing that this service should have a higher work RVU
than the survey median of 1.86, the affected specialty society stated
that its survey results were faulty for this CPT code because surveyees
did not consider all the work necessary to perform the service. We
believe that the appropriate value for 60 minutes of work for the
speech evaluation codes is reflected in CPT code 92522, for which the
HCPAC recommended 1.50 RVUs. Because the intraservice time for CPT code
92523 is twice that for CPT code 92522, we are assigning a work RVU of
3.0 to CPT code 92523.
Similarly, since CPT codes 92524 and 92522 have identical
intraservice time recommendations and similar descriptions of work we
believe that the work RVU for CPT code 92524 should be the same as the
work RVU for CPT code 95922. Therefore, we are assigning a work RVU of
1.50 to CPT code 92524.
Additionally, it is important to note that these codes are defined
as ``always therapy'' services, regardless of the type of practitioner
who performs them. As a result, CPT codes 92521, 92522, 92523 and 92524
always require a therapy modifier (GP, GO, or GN). Also, as noted in
Addendum H, these codes will be subject to the therapy MPPR.
In accordance with longstanding Medicare policy, we also note that
in general, we would expect that only one evaluation code would be
billed for a therapy episode of care.
(20) Cardiovascular: Cardiac Catheterization (93582)
For CY 2014, we reviewed new CPT code 93582. Although the AMA RUC
compared this code to CPT code 92941 (percutaneous transluminal
revascularization of acute total/subtotal occlusion during acute
myocardial infarction, coronary artery or coronary), which has a work
RVU of 12.56 and 70 minutes of intraservice time, it recommended a work
RVU of 14.00, the survey's 25th percentile. We agree with the AMA RUC
that CPT code 92941 is an appropriate comparison code and believe that
due to the similarity in intensity and time that the codes should be
valued with the same work RVU. Therefore, we are assigning an interim
final work RVU of 12.56 to CPT code 93582 for CY 2014.
(21) Duplex Scans (CPT Codes 93880, 93882, 93925, 93926, 93930, 93931,
93970, 93971, 93975, 93976, 93978 and 93979)
CPT Code 93880 was identified as a high expenditure procedure code
and referred to the AMA RUC for review. As part of its recommendations,
the AMA RUC included recommendations for CPT code 93882. The AMA RUC
recommended an increase in the work RVUs for 92880 and 92882 from 0.60
and 0.40 to 0.80 and 0.50, respectively.
In the 2013 PFS final rule with comment period, we reviewed 93925
(Duplex scan of lower extremity arteries or arterial bypass grafts;
complete bilateral study) and 93926 (Duplex scan of lower extremity
arteries or arterial bypass grafts; unilateral or limited study), which
were identified by the AMA RUC as potentially misvalued because the
time and PE inputs for these services were Harvard valued and these
services have utilization of 500,000 service per year. We disagreed
with the respective AMA RUC-recommended work RVUs of 0.90 and 0.70 and
established interim final values of 0.80 and 0.50 instead.
We believe the AMA RUC-recommended values for these two sets of
codes do not maintain the appropriate relative values within the family
of duplex scans. In addition to these four codes, there are several
other duplex scan codes that may fit within this family, including CPT
codes: 93880 (Duplex scan of extracranial arteries; complete bilateral
study), 93882 (Duplex scan of extracranial arteries; unilateral or
limited study), 93925 (Duplex scan of lower extremity arteries or
arterial bypass grafts; complete bilateral study), 93926 (Duplex scan
of lower extremity arteries or arterial bypass grafts; unilateral or
limited study), 93930 (Duplex scan of upper extremity arteries or
arterial bypass grafts; complete bilateral study), 93931 (Duplex scan
of upper extremity arteries or arterial bypass grafts; unilateral or
limited study), 93970 (Duplex scan of extremity veins including
responses to compression and other maneuvers; complete bilateral
study), 93971 (Duplex scan of extremity veins including responses to
compression and other maneuvers; unilateral or limited study), 93975
(Duplex scan of arterial inflow and venous outflow of abdominal,
pelvic, scrotal contents and/or retroperitoneal organs; complete
study), 93976 (Duplex scan of arterial inflow and venous outflow of
abdominal, pelvic, scrotal contents and/or retroperitoneal organs;
limited study), 93978 (Duplex scan of aorta, inferior vena cava, iliac
vasculature, or bypass grafts; complete study) and 93979 (Duplex scan
of aorta, inferior vena cava, iliac vasculature, or bypass grafts;
unilateral or limited study).
We are concerned that the AMA RUC-recommended values for 93880 and
93882, as well as our interim final values for 93925 and 93926, do not
maintain the appropriate relativity within this family and we are
referring the entire family to the AMA RUC to assess relativity among
the codes and then recommend appropriate work RVUs. We also request
that the AMA RUC consider CPT codes 93886
[[Page 74343]]
(Transcranial Doppler study of the intracranial arteries; complete
study) and 93888 (Transcranial Doppler study of the intracranial
arteries; limited study) in conjunction with the duplex scan codes in
order to assess the relativity between and among these codes.
Therefore, we will maintain the CY 2013 RVUs for CPT codes 93880
and 93882 on an interim final basis until we receive further
recommendations from the AMA RUC
(22) Ultrasonic Wound Assessment (CPT Code 97610)
For CY 2014, the AMA RUC reviewed new CPT code 97610. We are
contractor pricing this code for CY 2014 as recommended by the AMA RUC.
Although the code will be contractor priced, we are designating this
service as a ``sometimes therapy'' service. Like other ``sometimes
therapy'' codes, when a therapist furnishes this service all outpatient
therapy policies apply.
(23) Interprofessional Telephone Consultative Services (CPT Code 99446,
99447, 99448, and 99449)
For CY 2014, the CPT Editorial Panel created CPT codes 99446-99449
to describe telephone/internet consultative services. The AMA RUC-
recommended work RVUs for these codes. Medicare pays for telephone
consultations about a beneficiary services as a part of other services
furnished to the beneficiary. Therefore, for CY 2014 we are assigning
CPT codes 99446, 99447, 99448, and 99449 a PFS procedure status
indicator of B (Bundled code. Payments for covered services are always
bundled into payment for other services, which are not specified. If
RVUs are shown, they are not used for Medicare payment. If these
services are covered, payment for them is subsumed by the payment for
the services to which they are bundled (for example, a telephone call
from a hospital nurse regarding care of a patient).)
b. Establishing Interim Final Direct PE RVUs for CY 2014
i. Background and Methodology
The AMA RUC provides CMS with recommendations regarding direct PE
inputs, including clinical labor, supplies, and equipment, for new,
revised, and potentially misvalued codes. We review the AMA RUC-
recommended direct PE inputs on a code-by-code basis, including the
recommended facility PE inputs and/or nonfacility PE inputs. This
review is informed by both our clinical assessment of the typical
resource requirements for furnishing the service and our intention to
maintain the principles of accuracy and relativity in the database. We
determine whether we agree with the AMA RUC's recommended direct PE
inputs for a service or, if we disagree, we refine the PE inputs to
represent inputs that better reflect our estimate of the PE resources
required to furnish the service in the facility and/or nonfacility
settings. We also confirm that CPT codes should have facility and/or
nonfacility direct PE inputs and make changes based on our clinical
judgment and any PFS payment policies that would apply to the code.
We have accepted for CY 2014, as interim final and without
refinement, the direct PE inputs based on the recommendations submitted
by the AMA RUC for the codes listed in Table 28. For the remainder of
the AMA RUC's direct PE recommendations, we have accepted the PE
recommendations submitted by the AMA RUC as interim final, but with
refinements. These codes and the refinements to their direct PE inputs
are listed in Table 29.
We note that the final CY 2014 PFS direct PE input database
reflects the refined direct PE inputs that we are adopting on an
interim final basis for CY 2014. That database is available under
downloads for the CY 2014 PFS final rule with comment period on the CMS
Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. We also
note that the PE RVUs displayed in Addenda B and C reflect the interim
final values and policies described in this section. All PE RVUs
adopted on an interim final basis for CY 2014 are included in Addendum
C and are open for comment in this final rule with comment period.
ii. Common Refinements
Table 29 details our refinements of the AMA RUC's direct PE
recommendations at the code-specific level. In this section, we discuss
the general nature of some common refinements and the reasons for
particular refinements.
(a) Changes in Physician Time
Some direct PE inputs are directly affected by revisions in
physician time described in section II.E.3.a. of this final rule with
comment period. We note that for many codes, changes in the
intraservice portions of the physician time and changes in the number
or level of postoperative visits included in the global periods result
in corresponding changes to direct PE inputs. We also note that, for a
significant number of services, especially diagnostic tests, the
procedure time assumptions used in determining direct PE inputs are
distinct from, and therefore not dependent on, physician intraservice
time assumptions. For these services, we do not make refinements to the
direct PE inputs based on changes to estimated physician intraservice
times.
Changes in Intraservice Physician Time in the Nonfacility Setting.
For most codes valued in the nonfacility setting, a portion of the
clinical labor time allocated to the intraservice period reflects
minutes assigned for assisting the physician with the procedure. To the
extent that we are refining the times associated with the intraservice
portion of such procedures, we have adjusted the corresponding
intraservice clinical labor minutes in the nonfacility setting.
For equipment associated with the intraservice period in the
nonfacility setting, we generally allocate time based on the typical
number of minutes a piece of equipment is being used, and therefore,
not available for use with another patient during that period. In
general, we allocate these minutes based on the description of typical
clinical labor activities. To the extent that we are making changes in
the clinical labor times associated with the intraservice portion of
procedures, we have adjusted the corresponding equipment minutes
associated with the codes.
Changes in the Number or Level of Postoperative Office Visits in
the Global Period. For codes valued with postservice physician office
visits during a global period, most of the clinical labor time
allocated to the postservice period reflects a standard number of
minutes allocated for each of those visits. To the extent that we are
refining the number or level of postoperative visits, we have modified
the clinical staff time in the postservice period to reflect the
change. For codes valued with postservice physician office visits
during a global period, we allocate standard equipment for each of
those visits. To the extent that we are making a change in the number
or level of postoperative visits associated with a code, we have
adjusted the corresponding equipment minutes. For codes valued with
postservice physician office visits during a global period, a certain
number of supply items are allocated for each of those office visits.
To the extent that we are making a change in the number of
postoperative visits, we have adjusted the corresponding supply item
quantities associated with the codes. We note that many supply items
associated with postservice physician office visits are allocated for
each office visit (for
[[Page 74344]]
example, a minimum multi-specialty visit pack (SA048) in the CY 2014
direct PE input database). For these supply items, the quantities in
the direct PE input database should reflect the number of office visits
associated with the code's global period. However, some supply items
are associated with postservice physician office visits but are only
allocated once during the global period because they are typically used
during only one of the postservice office visits (for example, pack,
post-op incision care (suture) (SA054) in the direct PE input
database). For these supply items, the quantities in the direct PE
input database reflect that single quantity.
These refinements are reflected in the final CY 2014 PFS direct PE
input database and detailed in Table 29.
(b) Equipment Minutes
In general, the equipment time inputs reflect the sum of the times
within the intraservice period when a clinician is using the piece of
equipment, plus any additional time the piece of equipment is not
available for use for another patient due to its use during the
designated procedure. While some services include equipment that is
typically unavailable during the entire clinical labor service period,
certain highly technical pieces of equipment and equipment rooms are
less likely to be used by a clinician for all tasks associated with a
service, and therefore, are typically available for other patients
during the preservice and postservice components of the service period.
We adjust those equipment times accordingly. We refer interested
stakeholders to our extensive discussion of these policies in the CY
2012 PFS final rule with comment period (76 FR 73182-73183) and in
section II.E.2.b. of this final rule with comment period. We are
refining the CY 2014 AMA RUC direct PE recommendations to conform to
these equipment time policies. These refinements are reflected in the
final CY 2013 PFS direct PE input database and detailed in Table 29.
(c) Moderate Sedation Inputs
In the CY 2012 PFS final rule (76 FR 73043-73049), we finalized a
standard package of direct PE inputs for services where moderate
sedation is considered inherent in the procedure. We are refining the
CY 2014 AMA RUC direct PE recommendations to conform to these policies.
These refinements are reflected in the final CY 2013 PFS direct PE
input database and detailed in Table 29.
(d) Standard Minutes for Clinical Labor Tasks
In general, the preservice, service period, and postservice
clinical labor minutes associated with clinical labor inputs in the
direct PE input database reflect the sum of particular tasks described
in the information that accompanies the recommended direct PE inputs on
``PE worksheets.'' For most of these described tasks, there are a
standardized number of minutes, depending on the type of procedure, its
typical setting, its global period, and the other procedures with which
it is typically reported. At times, the AMA RUC recommends a number of
minutes either greater than or less than the time typically allotted
for certain tasks. In those cases, CMS clinical staff reviews the
deviations from the standards to assess whether they are clinically
appropriate. Where the AMA RUC-recommended exceptions are not accepted,
we refine the interim final direct PE inputs to match the standard
times for those tasks. In addition, in cases when a service is
typically billed with an E/M, we remove the preservice clinical labor
tasks so that the inputs are not duplicative and reflect the resource
costs of furnishing the typical service.
In some cases the AMA RUC recommendations include additional
minutes described by a category called ``other clinical activity,'' or
through the addition of clinical labor tasks that are different from
those previously included as standard. In these instances, CMS clinical
staff reviews the tasks as described in the recommendation to determine
whether they are already incorporated into the total number of minutes
based on the standard tasks. Additionally, CMS reviews these tasks in
the context of the kinds of tasks delineated for other services under
the PFS. For those tasks that are duplicative or not separately
incorporated for other services, we do not accept those additional
clinical labor tasks as direct inputs. These refinements are reflected
in the final CY 2013 PFS direct PE input database and detailed in Table
29.
(e) New Supply and Equipment Items
The AMA RUC generally recommends the use of supply and equipment
items that already exist in the direct PE input database for new,
revised, and potentially misvalued codes. Some recommendations include
supply or equipment items that are not currently in the direct PE input
database. In these cases, the AMA RUC has historically recommended a
new item be created and has facilitated CMS's pricing of that item by
working with the specialty societies to provide sales invoices to us.
We received invoices for several new supply and equipment items for
CY 2014. We have accepted the majority of these items and added them to
the direct PE input database. However, in many cases we cannot
adequately price a newly recommended item due to inadequate
information. In some cases, no supporting information regarding the
price of the item has been included in the recommendation to create a
new item. In other cases, the supporting information does not
demonstrate that the item has been purchased at the listed price (for
example, price quotes instead of paid invoices). In cases where the
information provided allowed us to identify clinically appropriate
proxy items, we have used currently existing items as proxies for the
newly recommended items. In other cases, we have included the item in
the direct PE input database without an associated price. While
including the item without an associated price means that the item does
not contribute to the calculation of the PE RVU for particular
services, it facilitates our ability to incorporate a price once we are
able to do so.
(f) Recommended Items That Are Not Direct PE Inputs
In some cases, the recommended direct PE inputs included items that
are not clinical labor, disposable supplies, or medical equipment
resources. We have addressed these kinds of recommendations in previous
rulemaking and in sections II.E.2.b. and II.B.4.a. of this final rule
with comment period. Refinements to adjust for these recommended inputs
are reflected in the final CY 2013 PFS direct PE input database and
detailed in Table 29.
iii. Code-Specific Refinements
(a) Breast Biopsy (CPT Codes 19085, 19086, 19287, and 19288)
The AMA RUC submitted recommended direct PE inputs for CPT codes
19085, 19086, 19287, 19288, including suggestions to create new PE
inputs for items called ``20MM handpiece--MR,'' ``vacuum line
assembly,'' ``introducer localization set (trocar),'' and ``tissue
filter.'' CMS clinical staff reviewed these recommended items and
concluded that each of these items serve redundant clinical purposes
with other biopsy supplies already included as direct PE inputs for the
codes. Similarly, CMS clinical staff reviewed three newly recommended
equipment items described as ``breast biopsy software,'' ``breast
biopsy device (coil),'' and
[[Page 74345]]
``lateral grid,'' and determined that these items serve clinical
functions to similar items already included in MR room equipment
package (EL008). Therefore, we did not create new direct PE inputs for
these seven items. These refinements, as well as other applicable
standard and common refinements for these codes, are reflected in the
final CY 2014 PFS direct PE input database and detailed in Table 29.
(b) Esophagoscopy, Esophagogastroduodenoscopy and Endoscopic Retrograde
Cholangiopancreatography (CPT Codes 43270, 43229, and 43198)
For CY 2014, the CPT Editorial Panel revised the set of codes that
describe esophagoscopy, esophagogastroduodenoscopy (EGD) and endoscopic
retrograde cholangiopancreatography (ERCP). These revisions included
the addition and deletion of several codes and the development of new
guidelines and coding instructions. The AMA RUC provided CMS with
recommended direct PE inputs for these services.
For two codes within this family, CPT codes 43270 and 43229, the
AMA RUC recommended including the supply item called ``kit, probe,
radiofrequency, XIi-enhanced RF probe'' (SA100) as a proxy for an RF
ablation catheter, as well as a new recommended equipment item called
``radiofrequency generator (Angiodynamics).'' The AMA RUC did not
provide additional information regarding what portion of the RF
ablation catheter might be reusable. Additionally, the recommendation
did not provide information regarding why the supply item SA100 that is
priced at $2,695 would be an appropriate proxy for the RF ablation
catheter. The CY 2013 codes that would be used to report these services
do not include these or similar items, so we believe that it would not
be appropriate to assume such a significant increase in resource costs
without more detail regarding the item for which the recommended input
would serve as a proxy. We note that in previous rulemaking (77 FR
69031) we have addressed recommendations for other codes that also
suggested using this expensive disposable supply as a proxy input. For
these other services, we created a proxy equipment item instead of a
proxy supply item, pending the submission of additional information
regarding the newly recommended item.
We also note that the AMA RUC recommendation did not include
adequate information that would allow us to price the newly recommended
item called ``'radiofrequency generator (Angiodynamics).'' To
incorporate the best estimate of resource costs for these items for
these new codes for CY 2014, we followed the precedents set in previous
rulemaking and created a new equipment item to serve as a proxy for the
``RF ablation catheter,'' and used a currently existing radiofrequency
generator equipment item (EQ214) as a proxy item pending the submission
of additional information regarding these items.
For another new code in the family, CPT code 43198, the AMA RUC
recommended including a disposable supply item called ``endoscopic
biopsy forceps'' (SD066). However, additional information included with
the recommendation suggested that a reusable biopsy forceps is
typically used in furnishing the service. Therefore, we did not
incorporate the disposable forceps in the direct PE input database.
These refinements, as well as other applicable standard and common
refinements for these codes, are reflected in the final CY 2014 PFS
direct PE input database and detailed in Table 29.
(c) Dilation of Esophagus (CPT Codes 43450 and 43453)
The AMA RUC recommended direct PE input updates for CTP codes 43450
and 43453. The recommendation included a new item listed as a supply
called ``esophageal bougies.'' We note that we did not receive an
invoice or additional description of this item and, based on CMS
clinical staff clinical review, we believe the functionality of this
kind of item can be accomplished through the use of a reusable piece of
equipment. Therefore, we created a new equipment item called
``esophageal bougies, set, reusable.'' Once we receive appropriate
pricing information regarding the new item, we will update the price in
the direct PE input database. This refinement and other applicable
standard and common refinements for these codes are reflected in the
final CY 2014 PFS direct PE input database and detailed in Table 29.
(d) MRI of Brain (CPT Codes 70551, 70552, and 70553)
The AMA RUC recommended updated direct PE inputs for a series of
codes that describe magnetic resonance imaging (MRI) of the brain. We
note the AMA RUC recommended that the typical length of time it takes
for the MRI technician to acquire images is equal to the time it took
in 2002, when the PE inputs for the codes were last evaluated.
When reviewing the direct PE inputs for this code, CMS clinical
staff concluded that there should be no significant difference between
the assumed time to acquire images for MRI of the brain and MRI of the
spine; therefore, we have adjusted the direct PE inputs accordingly.
This refinement and other applicable standard and common refinements
for these codes are reflected in the final CY 2014 PFS direct PE input
database and detailed in Table 29.
(e) Selective Catheter Placement (CPT Codes 36245 and 75726)
The AMA RUC submitted new direct PE inputs for CPT code 36245
(Selective catheter placement, arterial system; each first order
abdominal, pelvic, or lower extremity artery branch, within a vascular
family). We have reviewed the recommended direct PE inputs for this
service and made the applicable standard and common refinements which
are reflected in the final CY 2014 PFS direct PE input database and
detailed in Table 29. However, we note that the review of CPT code
36245 was initiated based on the identification of the code through two
misvalued code screens. One of these was the screen that identifies
codes reported together at least 75 percent of the time. As the RUC
noted in its recommendation, CPT 36245 may be reported with a number of
different radiologic supervision and interpretation codes including
75726 (Angiography, visceral, selective or supraselective (with or
without flush aortogram), radiological supervision and interpretation).
The AMA RUC recommendation stated that, because these code combinations
were valued as individual component codes, no potential for duplication
of physician work exists. The recommended direct PE inputs for CPT
36245 did not address whether or not the direct PE inputs for CPT code
75726 should be updated given that it is typically reported with CPT
code 36245.
The current direct PE inputs for 75726 include 73 clinical labor
minutes for ``assist physician in performing procedure.'' This time
matches the precise number of minutes assumed for the same task for CPT
code 36245 in the existing direct PE inputs. The AMA RUC has
recommended changing the amount of time considered typical for that
task from 73 minutes to 45 minutes and we are accepting that change,
without refinement, on an interim final basis for CY 2014. Given that
these codes are typically reported together and the underlying
procedure time assumption used in valuing 75726 is dependent on the
assumed times for 36245, we believe it is appropriate to make a
corresponding change to 75726
[[Page 74346]]
on an interim final basis to reflect the best estimate of resources for
these services which are frequently furnished together. This change is
reflected in the final CY 2014 PFS direct PE input database and
detailed in Table 29.
(g) Respiratory Motion Management Simulation (CPT Code 77293)
The AMA RUC submitted direct PE inputs recommendations for CPT code
77293 (Respiratory motion management simulation). Among these was the
recommendation to create a new equipment item called ``virtual
simulation package.'' However, the information that accompanied the
recommendation included a price quote for the new item instead of a
copy of paid invoice. We believe that the currently existing item
``radiation virtual simulation system'' (ER057) will serve as an
appropriate proxy for the new item pending our receipt of additional
information regarding the newly recommended item. This refinement and
other applicable standard and common refinements for these codes are
reflected in the final CY 2014 PFS direct PE input database and
detailed in Table 29.
(h) Stereotactic Body Radiation Therapy (CPT Code 77373)
The AMA RUC recommended updated direct PE inputs for CPT code 77373
(Stereotactic body radiation therapy, treatment delivery, per fraction
to 1 or more lesions, including image guidance, entire course not to
exceed 5 fractions). We note that we previously established final
direct PE inputs for this code in the CY 2013 PFS final rule with
comment period (77 FR 68922) in response to direct PE inputs we
proposed in the CY 2013 PFS proposed rule (77 FR 44743). In finalizing
the direct PE inputs for this code, we explained that we were including
the equipment item called ``radiation treatment vault'' (ER056) based
on public comment, and noting that we had questions regarding whether
the item is appropriately categorized as equipment within the
established PE methodology. The AMA RUC recommendations did not include
the ``radiation treatment vault'' (ER056) for CPT 77373. Because we
intend to address that issue in future rulemaking, we believe that we
should continue to include the item as a direct PE input for CY 2014.
This refinement and other applicable standard and common refinements
for these codes are reflected in the final CY 2014 PFS direct PE input
database and detailed in Table 29.
(i) Immunohistochemistry (CPT Codes 88342 and 88343 and HCPCS Codes
G0461 and G0462
The AMA RUC recommended direct PE inputs for revised CPT code 88342
and new CPT code 88343. We direct the reader to section II.E.3 of this
final rule with comment period. There, we discuss our decision for CY
2014 to use HCPCS codes G0461 and G0462 for Medicare services instead
of reporting the CPT codes describing immunohistochemistry services and
to use the AMA RUC recommended values for the CPT codes in establishing
interim final values for the HCPCS codes. We based the interim final
direct PE inputs for G0461 and G0462 on the recommended inputs for CPT
codes 88342 and 88343, therefore the standard and common refinements to
the recommended direct PE inputs for these CPT codes are detailed in
Table 29 as the inputs for G0461 and G0462. Likewise, the interim final
direct PE inputs for G0461 and G0462 appear in the final CY 2014 PFS
direct PE input database.
(j) Anogenital Examination With Colposcopic Magnification in Childhood
for Suspected Trauma (CPT Code 99170)
The AMA RUC recommended updated direct PE inputs for CPT code
99170. As part of that recommendation, the AMA RUC recommended that we
create a new clinical labor type called ``Child Life Specialist'' to be
included in the direct PE input database for this particular service.
The recommendation also contained additional information that might
facilitate the development of an appropriate cost/minute for this new
clinical labor type. After reviewing that information, we conclude that
the resource costs for the new clinical labor type are very similar to
the costs associated with the existing nurse blend clinical labor type
(L037D). Therefore, we have created a new clinical labor category
called ``Child Life Specialist'' (L037E) with a rate per minute
crosswalked from the existing labor type L037D.
We also note that the direct PE input recommendation for this code
did not conform to the usual format. The PE worksheet included minutes
for the new clinical labor type but instead of assigning minutes to
specified clinical labor tasks, the worksheet referenced a narrative
description of the tasks for the clinical labor type in the preservice,
intra-, and postservice periods. This format did not limit our clinical
staff from reviewing the recommendation, but it does not allow us to
display refinements for particular tasks in Table 29. Instead, the
refinements to the recommended aggregate number of minutes for each
time component appear in the table along with other applicable standard
and common refinements to the recommended direct PE inputs.
Table 28--CY 2014 Interim Final Codes With Direct PE Input
Recommendations Accepted Without Refinement
------------------------------------------------------------------------
CPT code CPT code description
------------------------------------------------------------------------
17003............................ Destruct premalg les 2-14.
17311............................ Mohs 1 stage h/n/hf/g.
17312............................ Mohs addl stage.
17313............................ Mohs 1 stage t/a/l.
17314............................ Mohs addl stage t/a/l.
17315............................ Mohs surg addl block.
19081............................ Bx breast 1st lesion strtctc.
19082............................ Bx breast add lesion strtctc.
19083............................ Bx breast 1st lesion us imag.
19084............................ Bx breast add lesion us imag.
19283............................ Perq dev breast 1st strtctc.
19284............................ Perq dev breast add strtctc.
19285............................ Perq dev breast 1st us imag.
23333............................ Remove shoulder fb deep.
23334............................ Shoulder prosthesis removal.
23335............................ Shoulder prosthesis removal.
24160............................ Remove elbow joint implant.
24164............................ Remove radius head implant.
27130............................ Total hip arthroplasty.
27236............................ Treat thigh fracture.
27446............................ Revision of knee joint.
27447............................ Total knee arthroplasty.
27466............................ Lengthening of thigh bone.
31239............................ Nasal/sinus endoscopy surg.
31240............................ Nasal/sinus endoscopy surg.
33282............................ Implant pat-active ht record.
33284............................ Remove pat-active ht record.
35301............................ Rechanneling of artery.
37217............................ Stent placemt retro carotid.
37239............................ Open/perq place stent ea add.
43191............................ Esophagoscopy rigid trnso dx.
43192............................ Esophagoscp rig trnso inject.
43193............................ Esophagoscp rig trnso biopsy.
43194............................ Esophagoscp rig trnso rem fb.
43195............................ Esophagoscopy rigid balloon.
43196............................ Esophagoscp guide wire dilat.
43204............................ Esoph scope w/sclerosis inj.
43205............................ Esophagus endoscopy/ligation.
43211............................ Esophagoscop mucosal resect.
43212............................ Esophagoscop stent placement.
43214............................ Esophagosc dilate balloon 30.
43233............................ Egd balloon dil esoph30 mm/>.
43237............................ Endoscopic us exam esoph.
43238............................ Egd us fine needle bx/aspir.
43240............................ Egd w/transmural drain cyst.
43241............................ Egd tube/cath insertion.
43242............................ Egd us fine needle bx/aspir.
43243............................ Egd injection varices.
43244............................ Egd varices ligation.
43246............................ Egd place gastrostomy tube.
43251............................ Egd remove lesion snare.
43253............................ Egd us transmural injxn/mark.
43254............................ Egd endo mucosal resection.
43257............................ Egd w/thrml txmnt gerd.
43259............................ Egd us exam duodenum/jejunum.
43260............................ Ercp w/specimen collection.
43261............................ Endo cholangiopancreatograph.
43262............................ Endo cholangiopancreatograph.
[[Page 74347]]
43263............................ Ercp sphincter pressure meas.
43264............................ Ercp remove duct calculi.
43265............................ Ercp lithotripsy calculi.
43266............................ Egd endoscopic stent place.
43273............................ Endoscopic pancreatoscopy.
43274............................ Ercp duct stent placement.
43275............................ Ercp remove forgn body duct.
43276............................ Ercp stent exchange w/dilate.
43277............................ Ercp ea duct/ampulla dilate.
43278............................ Ercp lesion ablate w/dilate.
50360............................ Transplantation of kidney.
52356............................ Cysto/uretero w/lithotripsy.
62310............................ Inject spine cerv/thoracic.
62311............................ Inject spine lumbar/sacral.
62318............................ Inject spine w/cath crv/thrc.
62319............................ Inject spine w/cath lmb/scrl.
63047............................ Remove spine lamina 1 lmbr.
63048............................ Remove spinal lamina add-on.
64643............................ Chemodenerv 1 extrem 1-4 ea.
64645............................ Chemodenerv 1 extrem 5/> ea.
66183............................ Insert ant drainage device.
69210............................ Remove impacted ear wax uni.
77001............................ Fluoroguide for vein device.
77002............................ Needle localization by xray.
77003............................ Fluoroguide for spine inject.
77280............................ Set radiation therapy field.
77285............................ Set radiation therapy field.
77290............................ Set radiation therapy field.
77295............................ 3-d radiotherapy plan.
77301............................ Radiotherapy dose plan imrt.
77336............................ Radiation physics consult.
77338............................ Design mlc device for imrt.
77372............................ Srs linear based.
88112............................ Cytopath cell enhance tech.
90839............................ Psytx crisis initial 60 min.
90840............................ Psytx crisis ea addl 30 min.
90875............................ Psychophysiological therapy.
91065............................ Breath hydrogen/methane test.
92521............................ Evaluation of speech fluency.
92522............................ Evaluate speech production.
92523............................ Speech sound lang comprehen.
92524............................ Behavral qualit analys voice.
93000............................ Electrocardiogram complete.
93005............................ Electrocardiogram tracing.
93010............................ Electrocardiogram report.
95928............................ C motor evoked uppr limbs.
95929............................ C motor evoked lwr limbs.
96365............................ Ther/proph/diag iv inf init.
96366............................ Ther/proph/diag iv inf addon.
96367............................ Tx/proph/dg addl seq iv inf.
96368............................ Ther/diag concurrent inf.
96413............................ Chemo iv infusion 1 hr.
96415............................ Chemo iv infusion addl hr.
96417............................ Chemo iv infus each addl seq.
98940............................ Chiropract manj 1-2 regions.
98941............................ Chiropract manj 3-4 regions.
98942............................ Chiropractic manj 5 regions.
98943............................ Chiropract manj xtrspinl 1/>.
------------------------------------------------------------------------
Table 29--CY 2014 Interim Final Codes With Direct PE Input Recommendations Accepted With Refinements
--------------------------------------------------------------------------------------------------------------------------------------------------------
RUC
recommendation CMS
HCPCS code HCPCS code Input code Input code Non-fac/fac Labor activity (if or current Refinement Comment
description description applicable) value (min or (min or
qty) qty)
--------------------------------------------------------------------------------------------------------------------------------------------------------
10030......... Guide cathet fluid EF018 stretcher......... NF .................. 120 0 Non-standard input
drainage. for Moderate
Sedation.
EF027 table, instrument, NF .................. 159 152 Standard input for
mobile. Moderate
Sedation.
EQ011 ECG, 3-channel NF .................. 159 152 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 159 152 Standard input for
Moderate
Sedation.
L037D RN/LPN/MTA........ NF Circulating 8 7 Conforms to
throughout proportionate
procedure (25%). allocation of
intraservice time
among clinical
labor types.
17000......... Destruct premalg ED004 camera, digital (6 NF .................. 22 13 Refined equipment
lesion. mexapixel). time to conform
to changes in
clinical labor
time.
EF031 table, power...... NF .................. 46 40 Refined equipment
time to conform
to changes in
clinical labor
time.
EQ093 cryosurgery NF .................. 22 13 Refined equipment
equipment (for time to conform
liquid nitrogen). to changes in
clinical labor
time.
EQ168 light, exam....... NF .................. 46 40 Refined equipment
time to conform
to changes in
clinical labor
time.
SA048 pack, minimum NF .................. 1 2 CMS clinical
multi-specialty review.
visit.
SA048 pack, minimum F .................. 0 1 CMS clinical
multi-specialty review.
visit.
17004......... Destroy premal ED004 camera, digital (6 NF .................. 41 30 Refined equipment
lesions 15/>. mexapixel). time to conform
to changes in
clinical labor
time.
EQ093 cryosurgery NF .................. 41 30 Refined equipment
equipment (for time to conform
liquid nitrogen). to changes in
clinical labor
time.
SA048 pack, minimum NF .................. 1 2 CMS clinical
multi-specialty review.
visit.
[[Page 74348]]
SA048 pack, minimum F .................. 0 1 CMS clinical
multi-specialty review.
visit.
19085......... Bx breast 1st S 20MM handpiece--MR NF .................. 1 0 CMS clinical
lesion mr imag. review;
functionality of
items redundant
with other direct
PE inputs.
S vacuum line NF .................. 1 0 CMS clinical
assembly. review;
functionality of
items redundant
with other direct
PE inputs.
S introducer NF .................. 1 0 CMS clinical
localization set review;
(trocar). functionality of
items redundant
with other direct
PE inputs.
S tissue filter..... NF .................. 1 0 CMS clinical
review;
functionality of
items redundant
with other direct
PE inputs.
E breast biopsy NF .................. 54 0 CMS clinical
software. review;
functionality of
items redundant
with other direct
PE inputs.
E breast biopsy NF .................. 54 0 CMS clinical
device (coil). review;
functionality of
items redundant
with other direct
PE inputs.
E lateral grid...... NF .................. 54 0 CMS clinical
review;
functionality of
items redundant
with other direct
PE inputs.
19086......... Bx breast add S 20MM handpiece--MR NF .................. 1 0 CMS clinical
lesion mr imag. review;
functionality of
items redundant
with other direct
PE inputs.
S vacuum line NF .................. 1 0 CMS clinical
assembly. review;
functionality of
items redundant
with other direct
PE inputs.
S introducer NF .................. 1 0 CMS clinical
localization set review;
(trocar). functionality of
items redundant
with other direct
PE inputs.
S tissue filter..... NF .................. 1 0 CMS clinical
review;
functionality of
items redundant
with other direct
PE inputs.
E breast biopsy NF .................. 43 0 CMS clinical
software. review;
functionality of
items redundant
with other direct
PE inputs.
E breast biopsy NF .................. 43 0 CMS clinical
device (coil). review;
functionality of
items redundant
with other direct
PE inputs.
E lateral grid...... NF .................. 43 0 CMS clinical
review;
functionality of
items redundant
with other direct
PE inputs.
19281......... Perq device breast ED025 film processor, NF .................. 9 5 Refined equipment
1st imag. wet. time to conform
to changes in
clinical labor
time.
ER029 film alternator NF .................. 9 5 CMS clinical
(motorized film review.
viewbox).
L043A Mammography NF Process images, 9 5 CMS clinical
Technologist. complete data review.
sheet, present
images and data
to the
interpreting
physician.
19282......... Perq device breast ED025 film processor, NF .................. 9 5 Refined equipment
ea imag. wet. time to conform
to changes in
clinical labor
time.
[[Page 74349]]
ER029 film alternator NF .................. 9 5 Refined equipment
(motorized film time to conform
viewbox). to changes in
clinical labor
time.
L043A Mammography NF Other Clinical 9 5 CMS clinical
Technologist. Activity review.
(Service).
19286......... Perq dev breast add L043A Mammography NF Assist physician 19 14 Conforming to
us imag. Technologist. in performing physician time.
procedure.
19287......... Perq dev breast 1st S 20MM handpiece--MR NF .................. 1 0 CMS clinical
mr guide. review;
functionality of
items redundant
with other direct
PE inputs.
S vacuum line NF .................. 1 0 CMS clinical
assembly. review;
functionality of
items redundant
with other direct
PE inputs.
S introducer NF .................. 1 0 CMS clinical
localization set review;
(trocar). functionality of
items redundant
with other direct
PE inputs.
S tissue filter..... NF .................. 1 0 CMS clinical
review;
functionality of
items redundant
with other direct
PE inputs.
E breast biopsy NF .................. 46 0 CMS clinical
software. review;
functionality of
items redundant
with other direct
PE inputs.
E breast biopsy NF .................. 46 0 CMS clinical
device (coil). review;
functionality of
items redundant
with other direct
PE inputs.
E lateral grid...... NF .................. 46 0 CMS clinical
review;
functionality of
items redundant
with other direct
PE inputs.
19288......... Perq dev breast add S 20MM handpiece--MR NF .................. 1 0 CMS clinical
mr guide. review;
functionality of
items redundant
with other direct
PE inputs.
S vacuum line NF .................. 1 0 CMS clinical
assembly. review;
functionality of
items redundant
with other direct
PE inputs.
S introducer NF .................. 1 0 CMS clinical
localization set review;
(trocar). functionality of
items redundant
with other direct
PE inputs.
S tissue filter..... NF .................. 1 0 CMS clinical
review;
functionality of
items redundant
with other direct
PE inputs.
E breast biopsy NF .................. 35 0 CMS clinical
software. review;
functionality of
items redundant
with other direct
PE inputs.
E breast biopsy NF .................. 35 0 CMS clinical
device (coil). review;
functionality of
items redundant
with other direct
PE inputs.
E lateral grid...... NF .................. 35 0 CMS clinical
review;
functionality of
items redundant
with other direct
PE inputs.
23333......... Remove shoulder fb EF031 table, power...... F .................. 90 63 Refined equipment
deep. time to conform
to changes in
clinical labor
time.
EQ168 light, exam....... F .................. 90 63 Refined equipment
time to conform
to changes in
clinical labor
time.
L037D RN/LPN/MTA........ F Total Office Visit 90 63 Conforming to
Time. physician time.
SA048 pack, minimum F .................. 3 2 Conforming to
multi-specialty physician time.
visit.
[[Page 74350]]
27130......... Total hip L037D RN/LPN/MTA........ F Post Service 99 108 Conforming to
arthroplasty. Period. physician time.
EF031 table, power...... F .................. 99 108 Refined equipment
time to conform
to changes in
clinical labor
time.
27447......... Total knee L037D RN/LPN/MTA........ F Post Service 99 108 Conforming to
arthroplasty. Period. physician time.
EF031 table, power...... F .................. 99 108 Refined equipment
time to conform
to changes in
clinical labor
time.
31237......... Nasal/sinus L037D RN/LPN/MTA........ NF Monitor pt. 15 5 CMS clinical
endoscopy surg. following service/ review.
check tubes,
monitors, drains.
31238......... Nasal/sinus L037D RN/LPN/MTA........ NF Monitor pt. 15 5 CMS clinical
endoscopy surg. following service/ review.
check tubes,
monitors, drains.
33366......... Trcath replace L037D RN/LPN/MTA........ F Coordinate pre- 40 20 CMS clinical
aortic valve. surgery services. review;
refinement
reflects standard
preservice times.
36245......... Ins cath abd/l-ext EF018 stretcher......... NF .................. 240 0 Non-standard input
art 1st. for Moderate
Sedation.
37236......... Open/perq place EF018 stretcher......... NF .................. 240 0 Non-standard input
stent 1st. for Moderate
Sedation.
EF027 table, instrument, NF .................. 347 332 Standard input for
mobile. Moderate
Sedation.
EQ011 ECG, 3-channel NF .................. 347 332 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 347 332 Standard input for
Moderate
Sedation.
S Balloon expandable NF .................. 1 0 CMS clinical
review; input
already exists.
SD152 catheter, balloon, NF .................. 0 1 CMS clinical
PTA. review; input
already exists.
37237......... Open/perq place S Balloon expandable NF .................. 1 0 CMS clinical
stent ea add. review; input
already exists.
SD152 catheter, balloon, NF .................. 0 1 CMS clinical
PTA. review; input
already exists.
37238......... Open/perq place EF018 stretcher......... NF .................. 180 0 Non-standard input
stent same. for Moderate
Sedation.
EF027 table, instrument, NF .................. 257 302 Standard input for
mobile. Moderate
Sedation.
EQ011 ECG, 3-channel NF .................. 257 302 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 257 302 Standard input for
Moderate
Sedation.
37241......... Vasc embolize/ EF018 stretcher......... NF .................. 180 0 Non-standard input
occlude venous. for Moderate
Sedation.
EF027 table, instrument, NF .................. 287 272 Standard input for
mobile. Moderate
Sedation.
EQ011 ECG, 3-channel NF .................. 287 272 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 287 272 Standard input for
Moderate
Sedation.
L037D RN/LPN/MTA........ NF Circulating 23 22 Conforms to
throughout proportionate
procedure (25%). allocation of
intraservice time
among clinical
labor types.
37242......... Vasc embolize/ EF018 stretcher......... NF .................. 240 0 Non-standard input
occlude artery. for Moderate
Sedation.
EF027 table, instrument, NF .................. 357 342 Standard input for
mobile. Moderate
Sedation.
EQ011 ECG, 3-channel NF .................. 357 342 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 357 342 Standard input for
Moderate
Sedation.
37243......... Vasc embolize/ EF018 stretcher......... NF .................. 240 0 Non-standard input
occlude organ. for Moderate
Sedation.
[[Page 74351]]
EF027 table, instrument, NF .................. 377 362 Standard input for
mobile. Moderate
Sedation.
EQ011 ECG, 3-channel NF .................. 377 362 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 377 362 Standard input for
Moderate
Sedation.
37244......... Vasc embolize/ EF018 stretcher......... NF .................. 240 0 Non-standard input
occlude bleed. for Moderate
Sedation.
EF027 table, instrument, NF .................. 347 332 Standard input for
mobile. Moderate
Sedation.
EQ011 ECG, 3-channel NF .................. 347 332 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 347 332 Standard input for
Moderate
Sedation.
L037D RN/LPN/MTA........ NF Circulating 23 22 Conforms to
throughout proportionate
procedure (25%). allocation of
intraservice time
among clinical
labor types.
43197......... Esophagoscopy flex ED036 video printer, NF .................. 15 39 Refined equipment
dx brush. color (Sony time to conform
medical grade). to established
policies for
technical
equipment.
EF008 chair with NF .................. 15 39 Refined equipment
headrest, exam, time to conform
reclining. to established
policies for
technical
equipment.
EF015 mayo stand........ NF .................. 15 39 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ170 light, fiberoptic NF .................. 15 39 Refined equipment
headlight w- time to conform
source. to established
policies for
technical
equipment.
EQ234 suction and NF .................. 15 39 Refined equipment
pressure cabinet, time to conform
ENT (SMR). to established
policies for
technical
equipment.
ER095 transnasal NF .................. 15 66 Refined equipment
esophagoscope 80K time to conform
series. to established
policies for
technical
equipment.
ES026 video add-on NF .................. 15 39 Refined equipment
camera system w- time to conform
monitor to established
(endoscopy). policies for
technical
equipment.
ES031 video system, NF .................. 15 39 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
L026A Medical/Technical NF Clean Surgical 10 0 Standardized time
Assistant. Instrument input; surgical
Package. instrument
package not
included.
43198......... Esophagosc flex ED036 video printer, NF .................. 20 46 Refined equipment
trnsn biopsy. color (Sony time to conform
medical grade). to established
policies for
technical
equipment.
EF008 chair with NF .................. 20 46 Refined equipment
headrest, exam, time to conform
reclining. to established
policies for
technical
equipment.
[[Page 74352]]
EF015 mayo stand........ NF .................. 20 46 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ170 light, fiberoptic NF .................. 20 46 Refined equipment
headlight w- time to conform
source. to established
policies for
technical
equipment.
EQ234 suction and NF .................. 20 46 Refined equipment
pressure cabinet, time to conform
ENT (SMR). to established
policies for
technical
equipment.
ER095 transnasal NF .................. 20 73 Refined equipment
esophagoscope 80K time to conform
series. to established
policies for
technical
equipment.
ES026 video add-on NF .................. 20 46 Refined equipment
camera system w- time to conform
monitor to established
(endoscopy). policies for
technical
equipment.
ES031 video system, NF .................. 20 46 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
L026A Medical/Technical NF Clean Surgical 10 0 Standardized time
Assistant. Instrument input.
Package.
SD066 endoscopic biopsy NF .................. 1 0 CMS clinical
forceps. review.
43200......... Esophagoscopy EF018 stretcher......... NF .................. 73 0 Non-standard input
flexible brush. for Moderate
Sedation.
EF027 table, instrument, NF .................. 29 77 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 29 43 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 52 77 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 52 77 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 29 43 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 29 43 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 59 70 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43201......... Esoph scope w/ EF018 stretcher......... NF .................. 76 0 Non-standard input
submucous inj. for Moderate
Sedation.
EF027 table, instrument, NF .................. 32 80 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 32 46 Refined equipment
time to conform
to changes in
clinical labor
time.
EQ011 ECG, 3-channel NF .................. 55 80 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
[[Page 74353]]
EQ032 IV infusion pump.. NF .................. 55 80 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 32 46 Refined equipment
(Gomco). time to conform
to changes in
clinical labor
time.
ES031 video system, NF .................. 32 46 Refined equipment
endoscopy time to conform
(processor, to changes in
digital capture, clinical labor
monitor, printer, time.
cart).
ES034 videoscope, NF .................. 62 73 Refined equipment
gastroscopy. time to conform
to changes in
clinical labor
time.
L037D RN/LPN/MTA........ NF Assist physician 18 15 Conforming to
in performing physician time.
procedure.
L051A RN................ NF Monitor patient 18 15 Conforming to
during Moderate physician time.
Sedation.
SC079 needle, NF .................. 1 0 CMS clinical
micropigmentation review.
(tattoo).
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
SL035 cup, biopsy- NF .................. 1 0 CMS clinical
specimen non- review.
sterile 4 oz.
43202......... Esophagoscopy flex EF018 stretcher......... NF .................. 78 0 Non-standard input
biopsy. for Moderate
Sedation.
EF027 table, instrument, NF .................. 34 82 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 34 48 Refined equipment
time to conform
to changes in
clinical labor
time.
EQ011 ECG, 3-channel NF .................. 57 82 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 57 82 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 34 48 Refined equipment
(Gomco). time to conform
to changes in
clinical labor
time.
ES031 video system, NF .................. 34 48 Refined equipment
endoscopy time to conform
(processor, to changes in
digital capture, clinical labor
monitor, printer, time.
cart).
ES034 videoscope, NF .................. 64 75 Refined equipment
gastroscopy. time to conform
to changes in
clinical labor
time.
L037D RN/LPN/MTA........ NF Assist physician 20 15 Conforming to
in performing physician time.
procedure.
L051A RN................ NF Monitor patient 20 15 Conforming to
during Moderate physician time.
Sedation.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43206......... Esoph optical EF018 stretcher......... NF .................. 91 0 Non-standard input
endomicroscopy. for Moderate
Sedation.
EF027 table, instrument, NF .................. 47 92 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 47 61 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 70 92 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 70 92 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 47 61 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
[[Page 74354]]
EQ355 optical NF .................. 77 61 Refined equipment
endomicroscope time to conform
processor unit to established
system. policies for
technical
equipment.
ES031 video system, NF .................. 47 61 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 77 88 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43213......... Esophagoscopy retro EF018 stretcher......... NF .................. 103 0 Non-standard input
balloon. for Moderate
Sedation.
EF027 table, instrument, NF .................. 59 107 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 59 73 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 82 107 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 82 107 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 59 73 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 59 73 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 89 100 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
43215......... Esophagoscopy flex EF018 stretcher......... NF .................. 78 0 Non-standard input
remove fb. for Moderate
Sedation.
EF027 table, instrument, NF .................. 34 82 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 34 48 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 57 82 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 57 82 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 34 48 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 34 48 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
[[Page 74355]]
ES034 videoscope, NF .................. 64 75 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43216......... Esophagoscopy EF018 stretcher......... NF .................. 80 0 Non-standard input
lesion removal. for Moderate
Sedation.
EF027 table, instrument, NF .................. 36 84 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 36 50 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 59 84 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 59 84 Standard input for
Moderate
Sedation.
EQ113 electrosurgical NF .................. 36 50 Refined equipment
generator, time to conform
gastrocautery. to established
policies for
technical
equipment.
EQ235 suction machine NF .................. 36 50 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 36 50 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 66 77 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43217......... Esophagoscopy snare EF018 stretcher......... NF .................. 88 0 Non-standard input
les remv. for Moderate
Sedation.
EF027 table, instrument, NF .................. 44 92 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 44 58 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 67 92 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 67 92 Standard input for
Moderate
Sedation.
EQ113 electrosurgical NF .................. 44 58 Refined equipment
generator, time to conform
gastrocautery. to established
policies for
technical
equipment.
EQ235 suction machine NF .................. 44 58 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 44 58 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 74 85 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
[[Page 74356]]
43220......... Esophagoscopy EF018 stretcher......... NF .................. 78 0 Non-standard input
balloon <30mm. for Moderate
Sedation.
EF027 table, instrument, NF .................. 34 82 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 34 48 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 57 82 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 57 82 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 34 48 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 34 48 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 64 75 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
SD019 catheter, balloon, NF .................. SD205 SD019 Supply proxy
ureteral-GI change due to CMS
(strictures). clinical review.
SD090 guidewire, STIFF.. NF .................. 1 0 CMS clinical
review.
SL035 cup, biopsy- NF .................. 1 0 CMS clinical
specimen non- review.
sterile 4 oz.
43226......... Esoph endoscopy EF018 stretcher......... NF .................. 83 0 Non-standard input
dilation. for Moderate
Sedation.
EF027 table, instrument, NF .................. 39 87 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 39 53 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 62 87 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 62 87 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 39 53 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 39 53 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 69 80 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
L037D RN/LPN/MTA........ NF Clean Surgical 0 10 Standardized time
Instrument input.
Package.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
SL035 cup, biopsy- NF .................. 1 0 CMS clinical
specimen non- review.
sterile 4 oz.
43227......... Esophagoscopy EF018 stretcher......... NF .................. 88 0 Non-standard input
control bleed. for Moderate
Sedation.
EF027 table, instrument, NF .................. 44 92 Standard input for
mobile. Moderate
Sedation.
[[Page 74357]]
EF031 table, power...... NF .................. 44 58 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 67 92 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 67 92 Standard input for
Moderate
Sedation.
EQ113 electrosurgical NF .................. 44 58 Refined equipment
generator, time to conform
gastrocautery. to established
policies for
technical
equipment.
EQ235 suction machine NF .................. 44 58 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 44 58 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
............ videoscope, NF .................. 74 85 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43229......... Esophagoscopy EF018 stretcher......... NF .................. 103 0 Non-standard input
lesion ablate. for Moderate
Sedation.
EF027 table, instrument, NF .................. 59 107 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 59 73 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 82 107 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 82 107 Standard input for
Moderate
Sedation.
EQ113 electrosurgical NF .................. 59 73 Refined equipment
generator, time to conform
gastrocautery. to established
policies for
technical
equipment.
EQ214 radiofrequency NF .................. 59 73 CMS clinical
generator (NEURO). review; see
discussion in
section II.D.3.b.
of this final
rule.
EQ235 suction machine NF .................. 59 73 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
EQ356 kit, probe, NF .................. 0 73 CMS clinical
radiofrequency, review; see
XIi-enhanced RF discussion in
probe (proxy for section II.D.3.b.
catheter, RF of this final
ablation, rule.
endoscopic).
ES031 video system, NF .................. 59 73 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 89 100 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
[[Page 74358]]
SA100 kit, probe, NF .................. 1 0 CMS clinical
radiofrequency, review.
XIi-enhanced RF
probe.
43231......... Esophagoscop EF018 stretcher......... NF .................. 103 0 Non-standard input
ultrasound exam. for Moderate
Sedation.
EF027 table, instrument, NF .................. 59 107 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 59 73 Refined equipment
time to conform
to changes in
clinical labor
time.
EQ011 ECG, 3-channel NF .................. 82 107 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 82 107 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 59 73 Refined equipment
(Gomco). time to conform
to changes in
clinical labor
time.
ER094 endoscopic NF .................. 59 73 Refined equipment
ultrasound time to conform
processor. to changes in
clinical labor
time.
ES031 video system, NF .................. 59 73 Refined equipment
endoscopy time to conform
(processor, to changes in
digital capture, clinical labor
monitor, printer, time.
cart).
ES038 videoscope, NF .................. 89 100 Refined equipment
endoscopic time to conform
ultrasound. to changes in
clinical labor
time.
L037D RN/LPN/MTA........ NF Assist physician 45 30 Conforming to
in performing physician time.
procedure.
L051A RN................ NF Monitor patient 45 30 Conforming to
during Moderate physician time.
Sedation.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
SL035 cup, biopsy- NF .................. 1 0 CMS clinical
specimen non- review.
sterile 4 oz.
43232......... Esophagoscopy w/us EF018 stretcher......... NF .................. 118 0 Non-standard input
needle bx. for Moderate
Sedation.
EF027 table, instrument, NF .................. 74 122 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 74 88 Refined equipment
time to conform
to changes in
clinical labor
time.
EQ011 ECG, 3-channel NF .................. 97 122 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 97 122 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 74 88 Refined equipment
(Gomco). time to conform
to changes in
clinical labor
time.
ER094 endoscopic NF .................. 74 88 Refined equipment
ultrasound time to conform
processor. to changes in
clinical labor
time.
ES031 video system, NF .................. 74 88 Refined equipment
endoscopy time to conform
(processor, to changes in
digital capture, clinical labor
monitor, printer, time.
cart).
ES038 videoscope, NF .................. 104 115 Refined equipment
endoscopic time to conform
ultrasound. to changes in
clinical labor
time.
L037D RN/LPN/MTA........ NF Assist physician 60 45 Conforming to
in performing physician time.
procedure.
L051A RN................ NF Monitor patient 60 45 Conforming to
during Moderate physician time.
Sedation.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43235......... Egd diagnostic EF018 stretcher......... NF .................. 73 0 Non-standard input
brush wash. for Moderate
Sedation.
[[Page 74359]]
EF027 table, instrument, NF .................. 29 77 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 29 43 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 52 77 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 52 77 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 29 43 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 29 43 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 59 70 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43236......... Uppr gi scope w/ EF018 stretcher......... NF .................. 78 0 Non-standard input
submuc inj. for Moderate
Sedation.
EF027 table, instrument, NF .................. 34 82 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 34 48 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 57 82 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 57 82 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 34 48 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 34 48 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 64 75 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43239......... Egd biopsy single/ EF018 stretcher......... NF .................. 73 0 Non-standard input
multiple. for Moderate
Sedation.
EF027 table, instrument, NF .................. 29 77 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 29 43 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 52 77 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 52 77 Standard input for
Moderate
Sedation.
[[Page 74360]]
EQ235 suction machine NF .................. 29 43 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 29 43 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 59 70 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43245......... Egd dilate EF018 stretcher......... NF .................. 81 0 Non-standard input
stricture. for Moderate
Sedation.
EF027 table, instrument, NF .................. 37 85 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 37 51 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 60 85 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 60 85 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 37 51 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 37 51 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 67 78 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43247......... Egd remove foreign EF018 stretcher......... NF .................. 88 0 Non-standard input
body. for Moderate
Sedation.
EF027 table, instrument, NF .................. 44 92 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 44 58 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 67 92 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 67 92 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 44 58 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 44 58 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 74 85 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
[[Page 74361]]
43248......... Egd guide wire EF018 stretcher......... NF .................. 78 0 Non-standard input
insertion. for Moderate
Sedation.
EF027 table, instrument, NF .................. 34 82 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 34 48 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 57 82 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 57 82 Standard input for
Moderate
Sedation.
EQ137 instrument pack, NF .................. 64 55 Refined equipment
basic ($500- time to conform
$1499). to established
policies for
technical
equipment.
EQ235 suction machine NF .................. 34 48 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 34 48 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 64 75 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43249......... Esoph egd dilation EF018 stretcher......... NF .................. 78 0 Non-standard input
<30 mm. for Moderate
Sedation.
EF027 table, instrument, NF .................. 34 82 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 34 48 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 57 82 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 57 82 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 34 48 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 34 48 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 64 75 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
SD090 guidewire, STIFF.. NF .................. 1 0 CMS clinical
review.
43250......... Egd cautery tumor EF018 stretcher......... NF .................. 78 0 Non-standard input
polyp. for Moderate
Sedation.
EF027 table, instrument, NF .................. 34 82 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 34 48 Refined equipment
time to conform
to established
policies for
technical
equipment.
[[Page 74362]]
EQ011 ECG, 3-channel NF .................. 57 82 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 57 82 Standard input for
Moderate
Sedation.
EQ113 electrosurgical NF .................. 34 48 Refined equipment
generator, time to conform
gastrocautery. to established
policies for
technical
equipment.
EQ235 suction machine NF .................. 34 48 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 34 48 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 64 75 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43251......... Egd remove lesion EF018 stretcher......... NF .................. 78 0 Non-standard input
snare. for Moderate
Sedation.
EF027 table, instrument, NF .................. 34 82 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 34 48 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 57 82 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 57 82 Standard input for
Moderate
Sedation.
EQ113 electrosurgical NF .................. 34 48 Refined equipment
generator, time to conform
gastrocautery. to established
policies for
technical
equipment.
EQ235 suction machine NF .................. 34 48 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 34 48 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 64 75 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43252......... Egd optical EF018 stretcher......... NF .................. 78 0 Non-standard input
endomicroscopy. for Moderate
Sedation.
EF027 table, instrument, NF .................. 34 92 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 34 61 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 70 92 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 57 92 Standard input for
Moderate
Sedation.
[[Page 74363]]
EQ235 suction machine NF .................. 34 61 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
EQ355 optical NF .................. 77 61 Refined equipment
endomicroscope time to conform
processor unit to established
system. policies for
technical
equipment.
ES031 video system, NF .................. 34 61 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 64 88 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43255......... Egd control EF018 stretcher......... NF .................. 88 0 Non-standard input
bleeding any. for Moderate
Sedation.
EF027 table, instrument, NF .................. 44 92 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 44 58 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 67 92 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 67 92 Standard input for
Moderate
Sedation.
EQ113 electrosurgical NF .................. 44 58 Refined equipment
generator, time to conform
gastrocautery. to established
policies for
technical
equipment.
EQ235 suction machine NF .................. 44 58 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
ES031 video system, NF .................. 44 58 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 74 85 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
43270......... Egd lesion ablation EF018 stretcher......... NF .................. 103 0 Non-standard input
for Moderate
Sedation.
EF027 table, instrument, NF .................. 82 107 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 59 73 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 82 107 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 82 107 Standard input for
Moderate
Sedation.
EQ113 electrosurgical NF .................. 59 73 Refined equipment
generator, time to conform
gastrocautery. to established
policies for
technical
equipment.
[[Page 74364]]
EQ214 radiofrequency NF .................. 59 73 CMS clinical
generator (NEURO). review; see
discussion in
section II.D.3.b.
of this final
rule.
EQ235 suction machine NF .................. 59 73 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
EQ356 kit, probe, NF .................. 0 73 CMS clinical
radiofrequency, review; see
XIi-enhanced RF discussion in
probe (proxy for section II.D.3.b.
catheter, RF of this final
ablation, rule.
endoscopic).
ES031 video system, NF .................. 59 73 Refined equipment
endoscopy time to conform
(processor, to established
digital capture, policies for
monitor, printer, technical
cart). equipment.
ES034 videoscope, NF .................. 89 100 Refined equipment
gastroscopy. time to conform
to established
policies for
technical
equipment.
SA100 kit, probe, NF .................. 1 0 CMS clinical
radiofrequency, review.
XIi-enhanced RF
probe.
SD009 canister, suction. NF .................. 2 1 CMS clinical
review.
SD090 guidewire, STIFF.. NF .................. 1 0 CMS clinical
review.
43450......... Dilate esophagus 1/ E Mobile stand, NF .................. 47 0 Non-standard input
mult pass. Vital Signs for Moderate
Monitor. Sedation.
EF014 light, surgical... NF .................. 24 36 Refined equipment
time to conform
to established
policies for
technical
equipment.
EF018 stretcher......... NF .................. 51 0 Non-standard input
for Moderate
Sedation.
EF027 table, instrument, NF .................. 24 77 Standard input for
mobile. Moderate
Sedation.
EF031 table, power...... NF .................. 24 36 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 47 77 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 47 77 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 24 36 Refined equipment
(Gomco). time to conform
to established
policies for
technical
equipment.
EQ357 esophageal NF .................. 0 36 CMS clinical
bougies, set, review; see
reusable. discussion in
section II.D.3.b.
of this final
rule.
ES005 endoscope NF .................. 15 0 CMS clinical
disinfector, review.
rigid or
fiberoptic, w-
cart.
43453......... Dilate esophagus... E Mobile stand, NF .................. 57 0 CMS clinical
Vital Signs review.
Monitor.
EF014 light, surgical... NF .................. 34 46 Refined equipment
time to conform
to changes in
clinical labor
time.
EF018 stretcher......... NF .................. 61 0 Non-standard input
for Moderate
Sedation.
EF027 table, instrument, NF .................. 34 87 Standard input for
mobile. Moderate
Sedation.
[[Page 74365]]
EF031 table, power...... NF .................. 34 46 Refined equipment
time to conform
to changes in
clinical labor
time.
EQ011 ECG, 3-channel NF .................. 57 87 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 57 87 Standard input for
Moderate
Sedation.
EQ235 suction machine NF .................. 34 46 Refined equipment
(Gomco). time to conform
to changes in
clinical labor
time.
ES005 endoscope NF .................. 15 0 CMS clinical
disinfector, review; an
rigid or endoscope is not
fiberoptic, w- included.
cart.
L037D RN/LPN/MTA........ NF Assist physician 25 20 Conforming to
in performing physician time.
procedure.
L051A RN................ NF Monitor patient 25 20 Conforming to
during Moderate physician time.
Sedation.
49405......... Image cath fluid EF018 stretcher......... NF .................. 120 0 Non-standard input
colxn visc. for Moderate
Sedation.
EF027 table, instrument, NF .................. 169 162 Standard input for
mobile. Moderate
Sedation.
EQ011 ECG, 3-channel NF .................. 169 162 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 169 162 Standard input for
Moderate
Sedation.
49406......... Image cath fluid EF018 stretcher......... NF .................. 120 0 Non-standard input
peri/retro. for Moderate
Sedation.
EF027 table, instrument, NF .................. 169 162 Standard input for
mobile. Moderate
Sedation.
EQ011 ECG, 3-channel NF .................. 169 162 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 169 162 Standard input for
Moderate
Sedation.
49407......... Image cath fluid EF018 stretcher......... NF .................. 120 0 Non-standard input
trns/vgnl. for Moderate
Sedation.
EF027 table, instrument, NF .................. 174 167 Standard input for
mobile. Moderate
Sedation.
EQ011 ECG, 3-channel NF .................. 174 167 Standard input for
(with SpO2, NIBP, Moderate
temp, resp). Sedation.
EQ032 IV infusion pump.. NF .................. 174 167 Standard input for
Moderate
Sedation.
63650......... Implant EF018 stretcher......... NF .................. 10 15 Refined equipment
neuroelectrodes. time to conform
to established
policies for
technical
equipment.
EF024 table, fluoroscopy NF .................. 60 84 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 60 84 Refined equipment
(with SpO2, NIBP, time to conform
temp, resp). to established
policies for
technical
equipment.
ER031 fluoroscopic NF .................. 60 69 Refined equipment
system, mobile C- time to conform
Arm. to established
policies for
technical
equipment.
L037D RN/LPN/MTA........ NF Clean Surgical 15 0 Standardized time
Instrument input.
Package.
SA043 pack, cleaning, NF .................. 1 0 CMS clinical
surgical review.
instruments.
64616......... Chemodenerv musc EF023 table, exam....... NF .................. 28 24 Refined equipment
neck dyston. time to conform
to changes in
clinical labor
time.
[[Page 74366]]
L037D RN/LPN/MTA........ NF Other Clinical 3 0 CMS clinical
Activity: review.
Complete botox
log.
L037D RN/LPN/MTA........ NF Assist physician 7 5 Conforming to
in performing physician time.
procedure.
64617......... Chemodener muscle EF023 table, exam....... NF .................. 30 33 Refined equipment
larynx emg. time to conform
to changes in
clinical labor
time.
EQ024 EMG-NCV-EP system, NF .................. 30 33 Refined equipment
8 channel. time to conform
to changes in
clinical labor
time.
64642......... Chemodenerv 1 EF023 table, exam....... NF .................. 44 38 Refined equipment
extremity 1-4. time to conform
to changes in
clinical labor
time.
L037D RN/LPN/MTA........ NF Other Clinical 3 0 CMS clinical
Activity: review.
Complete botox
log.
64644......... Chemodenerv 1 EF023 table, exam....... NF .................. 49 43 Refined equipment
extrem 5/> mus. time to conform
to established
policies for
technical
equipment.
L037D RN/LPN/MTA........ NF Other Clinical 3 0 CMS clinical
Activity: review.
Complete botox
log.
64646......... Chemodenerv trunk EF023 table, exam....... NF .................. 44 38 Refined equipment
musc 1-5. time to conform
to established
policies for
technical
equipment.
L037D RN/LPN/MTA........ NF Other Clinical 3 0 CMS clinical
Activity: review.
Complete botox
log.
64647......... Chemodenerv trunk EF023 table, exam....... NF .................. 49 43 Refined equipment
musc 6/>. time to conform
to established
policies for
technical
equipment.
L037D RN/LPN/MTA........ NF Other Clinical 3 0 CMS clinical
Activity: review.
Complete botox
log.
67914......... Repair eyelid EF015 mayo stand........ NF .................. 31 20 Refined equipment
defect. time to conform
to established
policies for
technical
equipment.
EL006 lane, screening NF .................. 121 110 Refined equipment
(oph). time to conform
to established
policies for
technical
equipment.
EQ114 electrosurgical NF .................. 31 20 Refined equipment
generator, up to time to conform
120 watts. to established
policies for
technical
equipment.
EQ138 instrument pack, NF .................. 43 20 Refined equipment
medium ($1500 and time to conform
up). to established
policies for
technical
equipment.
EQ176 loupes, standard, NF .................. 31 20 Refined equipment
up to 3.5x. time to conform
to established
policies for
technical
equipment.
L038A COMT/COT/RN/CST... NF Clean Surgical 15 10 Standardized time
Instrument input.
Package.
SC027 needle, 18-19g, NF .................. SB034 SC027 Supply/Equipment
filter. code correction.
SC057 syringe 5-6ml..... NF .................. SK057 SC057 Supply/Equipment
code correction.
67915......... Repair eyelid EF015 mayo stand........ NF .................. 21 10 Refined equipment
defect. time to conform
to established
policies for
technical
equipment.
[[Page 74367]]
EL006 lane, screening NF .................. 71 64 Refined equipment
(oph). time to conform
to established
policies for
technical
equipment.
EQ114 electrosurgical NF .................. 21 10 Refined equipment
generator, up to time to conform
120 watts. to established
policies for
technical
equipment.
EQ176 loupes, standard, NF .................. 21 10 Refined equipment
up to 3.5x. time to conform
to established
policies for
technical
equipment.
SB027 gown, staff, NF .................. SB034 SB027 Supply/Equipment
impervious. code correction.
SC057 syringe 5-6ml..... NF .................. SK057 SC057 Supply/Equipment
code correction.
67916......... Repair eyelid SB027 gown, staff, NF .................. SB034 SB027 Supply/Equipment
defect. impervious. code correction.
SC057 syringe 5-6ml..... NF .................. SK057 SC057 Supply/Equipment
code correction.
67917......... Repair eyelid SB027 gown, staff, NF .................. SB034 SB027 Supply/Equipment
defect. impervious. code correction.
SC057 syringe 5-6ml..... NF .................. SK057 SC057 Supply/Equipment
code correction.
67921......... Repair eyelid SB027 gown, staff, NF .................. SB034 SB027 Supply/Equipment
defect. impervious. code correction.
SC057 syringe 5-6ml..... NF .................. SK057 SC057 Supply/Equipment
code correction.
67922......... Repair eyelid SB027 gown, staff, NF .................. SB034 SB027 Supply/Equipment
defect. impervious. code correction.
SC057 syringe 5-6ml..... NF .................. SK057 SC057 Supply/Equipment
code correction.
67923......... Repair eyelid SB027 gown, staff, NF .................. SB034 SB027 Supply/Equipment
defect. impervious. code correction.
SC057 syringe 5-6ml..... NF .................. SK057 SC057 Supply/Equipment
code correction.
67924......... Repair eyelid SB027 gown, staff, NF .................. SB034 SB027 Supply/Equipment
defect. impervious. code correction.
SC057 syringe 5-6ml..... NF .................. SK057 SC057 Supply/Equipment
code correction.
70450......... Ct head/brain w/o ED024 film processor, NF .................. 15 4 Refined equipment
dye. dry, laser. time to conform
to established
policies for
technical
equipment.
EL007 room, CT.......... NF .................. 26 17 Refined equipment
time to conform
to established
policies for
technical
equipment.
ER029 film alternator NF .................. 15 4 Refined equipment
(motorized film time to conform
viewbox). to established
policies for
technical
equipment.
70460......... Ct head/brain w/dye ED024 film processor, NF .................. 15 4 Refined equipment
dry, laser. time to conform
to established
policies for
technical
equipment.
EL007 room, CT.......... NF .................. 34 24 Refined equipment
time to conform
to established
policies for
technical
equipment.
ER029 film alternator NF .................. 15 4 Refined equipment
(motorized film time to conform
viewbox). to established
policies for
technical
equipment.
[[Page 74368]]
70470......... Ct head/brain w/o & ED024 film processor, NF .................. 15 6 Refined equipment
w/dye. dry, laser. time to conform
to established
policies for
technical
equipment.
EL007 room, CT.......... NF .................. 42 30 Refined equipment
time to conform
to established
policies for
technical
equipment.
ER029 film alternator NF .................. 15 6 Refined equipment
(motorized film time to conform
viewbox). to established
policies for
technical
equipment.
70551......... Mri brain stem w/o EL008 room, MRI......... NF .................. 33 31 Refined equipment
dye. time to conform
to established
policies for
technical
equipment.
L047A MRI Technologist.. NF Other Clinical 8 3 CMS clinical
Activity: review.
Retrieve prior
appropriate
imaging exams and
hang for MD
review, verify
orders, review
the chart to
incorporate
relevant clinical
information and
confirm contrast
protocol with
interpreting MD.
L047A MRI Technologist.. NF Assist physician 30 20 CMS clinical
in performing review.
procedure.
L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
70552......... Mri brain stem w/ EL008 room, MRI......... NF .................. 47 45 Refined equipment
dye. time to conform
to established
policies for
technical
equipment.
L047A MRI Technologist.. NF Other Clinical 8 5 CMS clinical
Activity: review.
Retrieve prior
appropriate
imaging exams and
hang for MD
review, verify
orders, review
the chart to
incorporate
relevant clinical
information and
confirm contrast
protocol with
interpreting MD.
L047A MRI Technologist.. NF Obtain vital signs 0 3 CMS clinical
review.
L047A MRI Technologist.. NF Provide preservice 9 7 CMS clinical
education/obtain review.
consent.
L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
SG053 gauze, sterile 2in NF .................. 1 0 CMS clinical
x 2in. review.
SG089 tape, phix strips NF .................. 6 0 CMS clinical
(for nasal review.
catheter).
SJ043 povidone NF .................. 1 0 CMS clinical
swabsticks (3 review.
pack uou).
SJ053 swab-pad, alcohol. NF .................. 1 0 CMS clinical
review.
70553......... Mri brain stem w/o EL008 room, MRI......... NF .................. 57 53 Refined equipment
& w/dye. time to conform
to established
policies for
technical
equipment.
[[Page 74369]]
L047A MRI Technologist.. NF Other Clinical 8 5 CMS clinical
Activity: review.
Retrieve prior
appropriate
imaging exams and
hang for MD
review, verify
orders, review
the chart to
incorporate
relevant clinical
information and
confirm contrast
protocol with
interpreting MD.
L047A MRI Technologist.. NF Obtain vital signs 0 3 CMS clinical
review.
L047A MRI Technologist.. NF Provide preservice 9 7 CMS clinical
education/obtain review.
consent.
L047A MRI Technologist.. NF Assist physician 40 38 CMS clinical
in performing review.
procedure.
L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
SG053 gauze, sterile 2in NF .................. 1 0 CMS clinical
x 2in. review.
SG089 tape, phix strips NF .................. 6 0 CMS clinical
(for nasal review.
catheter).
SJ043 povidone NF .................. 1 0 CMS clinical
swabsticks (3 review.
pack uou).
SJ053 swab-pad, alcohol. NF .................. 1 0 CMS clinical
review.
72141......... Mri neck spine w/o L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
dye. Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
72142......... Mri neck spine w/ L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
dye. Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
72146......... Mri chest spine w/o L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
dye. Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
72147......... Mri chest spine w/ L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
dye. Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
72148......... Mri lumbar spine w/ L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
o dye. Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
72149......... Mri lumbar spine w/ L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
dye. Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
72156......... Mri neck spine w/o L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
& w/dye. Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
72157......... Mri chest spine w/o L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
& w/dye. Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
72158......... Mri lumbar spine w/ L047A MRI Technologist.. NF Other Clinical 2 0 CMS clinical
o & w/dye. Activity: Escort review.
patient from exam
room due to
magnetic
sensitivity.
74174......... Ct angio abd & pelv L046A CT Technologist... NF Other Clinical 25 20 CMS clinical
w/o & w/dye. Activity: Process review.
films, hang films
and review study
with interpreting
MD prior to
patient discharge.
75726......... Artery x-rays L041A Angio Technician.. NF Assist physician 73 45 CMS clinical
abdomen. in performing review.
procedure.
77280......... Set radiation E Virtual Simulation NF .................. 27 0 CMS clinical
therapy field. Package. review.
[[Page 74370]]
ER057 radiation virtual NF .................. 0 27 CMS clinical
simulation system. review;
inadequate
information to
price new items;
existing item
used as a proxy.
77285......... Set radiation E Virtual Simulation NF .................. 43 0 CMS clinical
therapy field. Package. review.
ER057 radiation virtual NF .................. 0 43 CMS clinical
simulation system. review;
inadequate
information to
price new items;
existing item
used as a proxy.
77290......... Set radiation E Virtual Simulation NF .................. 50 0 CMS clinical
therapy field. Package. review.
ER057 radiation virtual NF .................. 0 50 CMS clinical
simulation system. review;
inadequate
information to
price new items;
existing item
used as a proxy.
77293......... Respirator motion E Virtual Simulation NF .................. 40 0 CMS clinical
mgmt simul. Package. review.
E 4D Simulation NF .................. 40 0 CMS clinical
Package. review.
ER057 radiation virtual NF .................. 0 40 CMS clinical
simulation system. review;
inadequate
information to
price new items;
existing item
used as a proxy.
77373......... Sbrt delivery...... EQ211 pulse oximeter w- NF .................. 104 86 Refined equipment
printer. time to conform
to established
policies for
technical
equipment.
ER056 radiation NF .................. 0 86 See discussion in
treatment vault. section II.D.3.b.
of this final
rule.
ER083 SRS system, SBRT, NF .................. 104 86 Refined equipment
six systems, time to conform
average. to established
policies for
technical
equipment.
77600......... Hyperthermia EF015 mayo stand........ NF .................. 123 105 Refined equipment
treatment. time to conform
to established
policies for
technical
equipment.
ER035 hyperthermia NF .................. 123 105 Refined equipment
system, time to conform
ultrasound, to established
external. policies for
technical
equipment.
L037D RN/LPN/MTA........ NF Clean Scope....... 10 0 CMS clinical
review; catheters
included are
disposable
supplies and time
is already
included for
cleaning
equipment.
77785......... Hdr brachytx 1 E Emergency service NF .................. 46 0 Indirect practice
channel. container-safety expense.
kit.
EF021 table, NF .................. 46 42 Refined equipment
brachytherapy time to conform
treatment. to established
policies for
technical
equipment.
EQ292 Applicator Base NF .................. 46 42 Refined equipment
Plate. time to conform
to established
policies for
technical
equipment.
ER003 HDR Afterload NF .................. 46 42 Refined equipment
System, time to conform
Nucletron--Oldelf to established
t. policies for
technical
equipment.
[[Page 74371]]
ER028 electrometer, PC- NF .................. 46 42 Refined equipment
based, dual time to conform
channel. to established
policies for
technical
equipment.
ER054 radiation survey NF .................. 46 42 Refined equipment
meter. time to conform
to established
policies for
technical
equipment.
ER060 source, 10 Ci Ir NF .................. 46 42 Refined equipment
192. time to conform
to established
policies for
technical
equipment.
ER062 stirrups (for NF .................. 46 42 Refined equipment
brachytherapy time to conform
table). to established
policies for
technical
equipment.
ER073 Area Radiation NF .................. 46 42 Refined equipment
Monitor. time to conform
to established
policies for
technical
equipment.
77786......... Hdr brachytx 2-12 E Emergency service NF .................. 100 0 Indirect practice
channel. container-safety expense.
kit.
EF021 table, NF .................. 100 86 Refined equipment
brachytherapy time to conform
treatment. to established
policies for
technical
equipment.
EQ011 ECG, 3-channel NF .................. 100 86 Refined equipment
(with SpO2, NIBP, time to conform
temp, resp). to established
policies for
technical
equipment.
EQ292 Applicator Base NF .................. 100 86 Refined equipment
Plate. time to conform
to established
policies for
technical
equipment.
ER003 HDR Afterload NF .................. 100 86 Refined equipment
System, time to conform
Nucletron--Oldelf to established
t. policies for
technical
equipment.
ER028 electrometer, PC- NF .................. 100 86 Refined equipment
based, dual time to conform
channel. to established
policies for
technical
equipment.
ER054 radiation survey NF .................. 100 86 Refined equipment
meter. time to conform
to established
policies for
technical
equipment.
ER060 source, 10 Ci Ir NF .................. 100 86 Refined equipment
192. time to conform
to established
policies for
technical
equipment.
ER073 Area Radiation NF .................. 100 86 Refined equipment
Monitor. time to conform
to established
policies for
technical
equipment.
77787......... Hdr brachytx over E Emergency service NF .................. 162 0 Indirect practice
12 chan. container-safety expense.
kit.
EF021 table, NF .................. 162 137 Refined equipment
brachytherapy time to conform
treatment. to established
policies for
technical
equipment.
[[Page 74372]]
EQ011 ECG, 3-channel NF .................. 162 137 Refined equipment
(with SpO2, NIBP, time to conform
temp, resp). to established
policies for
technical
equipment.
EQ292 Applicator Base NF .................. 162 137 Refined equipment
Plate. time to conform
to established
policies for
technical
equipment.
ER003 HDR Afterload NF .................. 162 137 Refined equipment
System, time to conform
Nucletron--Oldelf to established
t. policies for
technical
equipment.
ER028 electrometer, PC- NF .................. 162 137 Refined equipment
based, dual time to conform
channel. to established
policies for
technical
equipment.
ER054 radiation survey NF .................. 162 137 Refined equipment
meter. time to conform
to established
policies for
technical
equipment.
ER060 source, 10 Ci Ir NF .................. 162 137 Refined equipment
192. time to conform
to established
policies for
technical
equipment.
ER062 stirrups (for NF .................. 162 137 Refined equipment
brachytherapy time to conform
table). to established
policies for
technical
equipment.
ER073 Area Radiation NF .................. 162 137 Refined equipment
Monitor. time to conform
to established
policies for
technical
equipment.
88112......... Cytopath cell E Laboratory NF .................. 2 0 Included in
enhance tech. Information equipment cost
System with per minute
maintenance calculation.
contract.
E Copath System NF .................. 2 0 Indirect practice
Software. expense.
L035A Lab Tech/ NF Order, restock, 0.5 0 CMS clinical
Histotechnologist. and distribute review.
specimen
containers with
requisition
forms..
L045A Cytotechnologist.. NF Perform screening 8 0 CMS clinical
function (where review.
applicable).
L045A Cytotechnologist.. NF A. Confirm patient 2 0 CMS clinical
ID, organize review.
work, verify and
review history.
L045A Cytotechnologist.. NF B: Enter screening 2 0 CMS clinical
diagnosis in review.
laboratory
information
system, complete
workload
recording logs,
manage any
relevant
utilization
review/quality
assurance
activities and
regulatory
compliance
documentation and
assemble and
deliver slides
with paperwork to
pathologist.
S Courier NF .................. 2.02 0 Indirect practice
transportation expense.
costs.
S Specimen, solvent, NF .................. 0.18 0 Indirect practice
and formalin expense.
disposal cost.
[[Page 74373]]
93880......... Extracranial bilat ED021 computer, desktop, NF .................. 68 51 Refined equipment
study. w-monitor. time to conform
to established
policies for
technical
equipment.
ED034 video SVHS VCR NF .................. 68 0 CMS clinical
(medical grade). review;
functionality of
items redundant
with other direct
PE inputs.
ED036 video printer, NF .................. 10 0 CMS clinical
color (Sony review;
medical grade). functionality of
items redundant
with other direct
PE inputs.
EL016 room, ultrasound, NF .................. 68 51 Refined equipment
vascular. time to conform
to established
policies for
technical
equipment.
93882......... Extracranial uni/ ED021 computer, desktop, NF .................. 44 29 Refined equipment
ltd study. w-monitor. time to conform
to established
policies for
technical
equipment.
ED034 video SVHS VCR NF .................. 44 0 CMS clinical
(medical grade). review;
functionality of
items redundant
with other direct
PE inputs.
ED036 video printer, NF .................. 10 0 CMS clinical
color (Sony review;
medical grade). functionality of
items redundant
with other direct
PE inputs.
EL016 room, ultrasound, NF .................. 44 29 Refined equipment
vascular. time to conform
to established
policies for
technical
equipment.
94667......... Chest wall EF023 table, exam....... NF .................. 1 35 Refined equipment
manipulation. time to conform
to changes in
clinical labor
time.
94668......... Chest wall EF023 table, exam....... NF .................. 1 33 Refined equipment
manipulation. time to conform
to changes in
clinical labor
time.
94669......... Mechanical chest EF023 table, exam....... NF .................. 1 45 Refined equipment
wall oscill. time to conform
to changes in
clinical labor
time.
95816......... Eeg awake and EQ330 EEG, digital, NF .................. 116 107 Refined equipment
drowsy. testing system time to conform
(computer to established
hardware, policies for
software & technical
camera). equipment.
95819......... Eeg awake and EQ330 EEG, digital, NF .................. 148 139 Refined equipment
asleep. testing system time to conform
(computer to established
hardware, policies for
software & technical
camera). equipment.
95822......... Eeg coma or sleep EQ330 EEG, digital, NF .................. 123 114 Refined equipment
only. testing system time to conform
(computer to established
hardware, policies for
software & technical
camera). equipment.
99170......... Anogenital exam ED005 camera, digital NF .................. 50 60 Refined equipment
child w imag. system, 12 time to conform
megapixel to established
(medical grade). policies for
technical
equipment.
ED021 computer, desktop, NF .................. 50 0 Indirect practice
w-monitor. expense.
EF015 mayo stand........ NF .................. 50 60 Refined equipment
time to conform
to established
policies for
technical
equipment.
[[Page 74374]]
EF031 table, power...... NF .................. 50 60 Refined equipment
time to conform
to established
policies for
technical
equipment.
EQ170 light, fiberoptic NF .................. 50 60 Refined equipment
headlight w- time to conform
source. to established
policies for
technical
equipment.
ES004 colposcope........ NF .................. 50 67 Refined equipment
time to conform
to established
policies for
technical
equipment.
L051A RN................ NF Coordinate pre- 0 3 CMS clinical
surgery services. review.
L051A RN................ NF Other Clinical 5 0 CMS clinical
Activity review.
(Preservice).
L051A RN................ NF Other Clinical 15 3 CMS clinical
Activity (Post review.
Service).
SA048 pack, minimum F .................. 1 0 Service period
multi-specialty supplies are not
visit. included in the
facility setting.
SB006 drape, non- F .................. 1 0 Service period
sterile, sheet supplies are not
40in x 60in. included in the
facility setting.
SB022 gloves, non- F .................. 1 0 Service period
sterile. supplies are not
included in the
facility setting.
SD118 specula, vaginal.. F .................. 1 0 Service period
supplies are not
included in the
facility setting.
SG008 applicator, cotton- F .................. 2 0 Service period
tipped, non- supplies are not
sterile 6in. included in the
facility setting.
SJ033 lubricating jelly F .................. 1 0 Service period
(Surgilube). supplies are not
included in the
facility setting.
SL146 tubed culture F .................. 2 0 Service period
media. supplies are not
included in the
facility setting.
SL157 cup, sterile, 8 oz F .................. 1 0 Service period
supplies are not
included in the
facility setting.
G0461......... Immunohistochemistr E Specimen, solvent, NF .................. 0.35 0 Indirect practice
y, initial and formalin expense.
antibody. disposal cost.
E Laboratory NF .................. 2 0 Included in
Information equipment cost
System with per minute
maintenance calculation.
contract.
E Copath System NF .................. 2 0 Indirect practice
Software. expense.
EP043 water bath, NF .................. 8 5 CMS clinical
general purpose review.
(lab).
ER041 microtome......... NF .................. 8 5 CMS clinical
review.
G0462......... Immunohistochemistr EP112 Benchmark ULTRA NF .................. 33 15 CMS clinical
y, subsequent automated slide review.
antibody. preparation
system.
SL489 UtraView Universal NF .................. 0.2 2 CMS clinical
Alkaline review.
Phosphatase Red
Detection Kit.
--------------------------------------------------------------------------------------------------------------------------------------------------------
c. Establishing CY 2014 Interim Final Malpractice RVUs
According to our malpractice methodology discussed in section II.C,
we are assigning malpractice RVUs for CY 2014 new, revised and
potentially misvalued codes by utilizing a crosswalk to a source code
with a similar malpractice risk. We have reviewed the AMA RUC
recommended malpractice source code crosswalks for CY 2014 new, revised
and potentially misvalued codes, and we are accepting all of them on an
interim final basis for CY 2014.
For CY 2014, we created two HCPCS G-codes. HCPCS code G0461
(Immunohistochemistry or immunocytochemistry, per specimen; first stain
with separately identifiable antibody(ies)) was created to replace CPT
code 88342 (immunohistochemistry or immunocytochemistry, each
separately identifiable antibody per block, cytologic preparation, or
hematologic
[[Page 74375]]
smear; first separately identifiable antibody per slide), which is
Invalid effective January 1, 2014. We believe CPT code 88342 has a
similar malpractice risk-of-service as HCPCS code G0461. Therefore, we
are assigning an interim final malpractice crosswalk of CPT code 88342
to HCPCS code G0461 on an interim final basis for CY 2014. HCPCS code
G0462 (Immunohistochemistry or immunocytochemistry, per specimen; each
additional stain with separately identifiable antibody(ies) (List
separately in addition to code for primary procedure) was created to
replace CPT code 88343 (immunohistochemistry or immunocytochemistry,
each separately identifiable antibody per block, cytologic preparation,
or hematologic smear; each additional separately identifiable antibody
per slide (list separately in addition to code for primary procedure),
which is invalid effective Janauary 1, 2014. We believe CPT code 88343
has a similar malpractice risk-of-service as HCPCS code G0462.
Therefore, we are assigning an interim final malpractice crosswalk of
CPT code 88343 to HCPCS code G0462 on an interim final basis for CY
2014.
Table 30 lists the adjusted CY 2013 and new/revised CY 2014 HCPCS
codes and their respective source codes used to set the interim final
CY 2014 malpractice RVUs. The malpractice RVUs for these services are
reflected in Addendum B of this CY 2014 PFS final rule with comment
period.
Consistent with past practice when the MEI has been rebased or
revised we proposed to make adjustments to ensure that estimates of the
aggregate CY 2014 PFS payments for work, PE and malpractice are in
proportion to the weights for these categories in the revised MEI. As
discussed in the II.B. and II.D., the MEI is being revised, the PE and
malpractice RVUs, and the CF are being adjusted accordingly. For more
information on this, see those sections. We received no comments
specifically on the adjustment to malpractice RVUs.
Table 30--Crosswalk for Establishing CY 2014 New/Revised/Potentially Misvalued Codes Malpractice RVUs
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
CY 2014 new, revised, or potentiallyMalpractice risk factor crosswalk HCPCS code
----------------------------------------------------------------------------------------------------------------
10030............................. Guide cathet fluid 37200................ transcatheter biopsy.
drainage.
13152............................. Cmplx rpr e/n/e/l 2.6-7.5 13152................ cmplx rpr e/n/e/l 2.6-7.5
cm. cm.
17000............................. Destruct premalg lesion... 17000................ destruct premalg lesion.
17003............................. Destruct premalg les 2-14. 17003................ destruct premalg les 2-
14.
17004............................. Destroy premal lesions 15/ 17004................ destroy premal lesions 15/
>. >.
17311............................. Mohs 1 stage h/n/hf/g..... 17311................ mohs 1 stage h/n/hf/g.
17312............................. Mohs addl stage........... 17312................ mohs addl stage.
17313............................. Mohs 1 stage t/a/l........ 17313................ mohs 1 stage t/a/l.
17314............................. Mohs addl stage t/a/l..... 17314................ mohs addl stage t/a/l.
17315............................. Mohs surg addl block...... 17315................ mohs surg addl block.
19081............................. Bx breast 1st Lesion 32553................ ins mark thor for rt
strtctc. perq.
19082............................. Bx breast add Lesion 64480................ inj foramen epidural add-
strtctc. on.
19083............................. Bx breast 1st Lesion US 32551................ insertion of chest tube.
imag.
19084............................. Bx breast add Lesion US 64480................ inj foramen epidural add-
imag. on.
19085............................. Bx breast 1st lesion mr 36565................ insert tunneled cv cath.
imag.
19086............................. Bx breast add lesion mr 76812................ ob us detailed addl
imag. fetus.
19281............................. Perq device breast 1st 50387................ change ext/int ureter
imag. stent.
19282............................. Perq device breast ea imag 76812................ ob us detailed addl
fetus.
19283............................. Perq dev breast 1st 50387................ change ext/int ureter
strtctc. stent.
19284............................. Perq dev breast add 76812................ ob us detailed addl
strtctc. fetus.
19285............................. Perq dev breast 1st us 36569................ insert picc cath.
imag.
19286............................. Perq dev breast add us 76812................ ob us detailed addl
imag. fetus.
19287............................. Perq dev breast 1st mr 32551................ insertion of chest tube.
guide.
19288............................. Perq dev breast add mr 76812................ ob us detailed addl
guide. fetus.
23333............................. Remove shoulder fb deep... 23472................ reconstruct shoulder
joint.
23334............................. Shoulder prosthesis 23472................ reconstruct shoulder
removal. joint.
23335............................. Shoulder prosthesis 23472................ reconstruct shoulder
removal. joint.
24160............................. Remove elbow joint implant 24363................ replace elbow joint.
24164............................. Remove radius head implant 23430................ repair biceps tendon.
27130............................. Total hip arthroplasty.... 27130................ total hip arthroplasty.
27236............................. Treat thigh fracture...... 27236................ treat thigh fracture.
27446............................. Revision of knee joint.... 27446................ revision of knee joint.
27447............................. Total knee arthroplasty... 27447................ total knee arthroplasty.
31237............................. Nasal/sinus endoscopy surg 31237................ nasal/sinus endoscopy
surg.
31238............................. Nasal/sinus endoscopy surg 31238................ nasal/sinus endoscopy
surg.
31239............................. Nasal/sinus endoscopy surg 31239................ nasal/sinus endoscopy
surg.
31240............................. Nasal/sinus endoscopy surg 31240................ nasal/sinus endoscopy
surg.
33282............................. Implant pat-active ht 33282................ implant pat-active ht
record. record.
33284............................. Remove pat-active ht 33284................ remove pat-active ht
record. record.
33366............................. Trcath replace aortic 33979................ insert intracorporeal
valve. device.
35301............................. Rechanneling of artery.... 35301................ rechanneling of artery.
35475............................. Repair arterial blockage.. 35475................ repair arterial blockage.
35476............................. Repair venous blockage.... 35476................ repair venous blockage.
36245............................. Ins cath abd/l-ext art 1st 36245................ ins cath abd/l-ext art
1st.
37217............................. Stent placemt retro 37660................ revision of major vein.
carotid.
37236............................. Open/perq place stent 1st. 36247................ ins cath abd/l-ext art
3rd.
37237............................. Open/perq place stent ea 37223................ iliac revasc w/stent add-
add. on.
37238............................. Open/perq place stent same 36247................ ins cath abd/l-ext art
3rd.
37239............................. Open/perq place stent ea 37223................ iliac revasc w/stent add-
add. on.
[[Page 74376]]
37241............................. Vasc embolize/occlude 37204................ transcatheter occlusion.
venous.
37242............................. Vasc embolize/occlude 37204................ transcatheter occlusion.
artery.
37243............................. Vasc embolize/occlude 37204................ transcatheter occlusion.
organ.
37244............................. Vasc embolize/occlude 37204................ transcatheter occlusion.
bleed.
38240............................. Transplt allo hct/donor... 38240................ transplt allo hct/donor.
43191............................. Esophagoscopy rigid trnso 31575................ diagnostic laryngoscopy.
dx.
43192............................. Esophagoscp rig trnso 31575................ diagnostic laryngoscopy.
inject.
43193............................. Esophagoscp rig trnso 31575................ diagnostic laryngoscopy.
biopsy.
43194............................. Esophagoscp rig trnso rem 31575................ diagnostic laryngoscopy.
fb.
43195............................. Esophagoscopy rigid 31575................ diagnostic laryngoscopy.
balloon.
43196............................. Esophagoscp guide wire 31638................ bronchoscopy revise
dilat. stent.
43197............................. Esophagoscopy flex dx 31575................ diagnostic laryngoscopy.
brush.
43198............................. Esophagosc flex trnsn 31575................ diagnostic laryngoscopy.
biopsy.
43200............................. Esophagoscopy flexible 43200................ esophagoscopy flexible
brush. brush.
43201............................. Esoph scope w/submucous 43201................ esoph scope w/submucous
inj. inj.
43202............................. Esophagoscopy flex biopsy. 43202................ esophagoscopy flex
biopsy.
43204............................. Esoph scope w/sclerosis 43204................ esoph scope w/sclerosis
inj. inj.
43205............................. Esophagus endoscopy/ 43205................ esophagus endoscopy/
ligation. ligation.
43206............................. Esoph optical 43200................ esophagoscopy flexible
endomicroscopy. brush.
43211............................. Esophagoscop mucosal 43201................ esoph scope w/submucous
resect. inj.
43212............................. Esophagoscop stent 43219................ esophagus endoscopy.
placement.
43213............................. Esophagoscopy retro 43456................ dilate esophagus.
balloon.
43214............................. Esophagosc dilate balloon 43458................ dilate esophagus.
30.
43215............................. Esophagoscopy flex remove 43215................ esophagoscopy flex remove
fb. fb.
43216............................. Esophagoscopy lesion 43216................ esophagoscopy lesion
removal. removal.
43217............................. Esophagoscopy snare les 43217................ esophagoscopy snare les
remv. remv.
43220............................. Esophagoscopy balloon 43220................ esophagoscopy balloon
<30mm. <30mm.
43226............................. Esoph endoscopy dilation.. 43226................ esoph endoscopy dilation.
43227............................. Esophagoscopy control 43227................ esophagoscopy control
bleed. bleed.
43229............................. Esophagoscopy lesion 43228................ esoph endoscopy ablation.
ablate.
43231............................. Esophagoscop ultrasound 43231................ esophagoscop ultrasound
exam. exam.
43232............................. Esophagoscopy w/us needle 43232................ esophagoscopy w/us needle
bx. bx.
43233............................. Egd balloon dil esoph30 mm/ 43271................ endo
>. cholangiopancreatograph.
43235............................. Egd diagnostic brush wash. 43235................ egd diagnostic brush
wash.
43236............................. Uppr gi scope w/submuc inj 43236................ uppr gi scope w/submuc
inj.
43237............................. Endoscopic us exam esoph.. 43237................ endoscopic us exam esoph.
43238............................. Egd us fine needle bx/ 43238................ egd us fine needle bx/
aspir. aspir.
43239............................. Egd biopsy single/multiple 43239................ egd biopsy single/
multiple.
43240............................. Egd w/transmural drain 43240................ egd w/transmural drain
cyst. cyst.
43241............................. Egd tube/cath insertion... 43241................ egd tube/cath insertion.
43242............................. Egd us fine needle bx/ 43242................ egd us fine needle bx/
aspir. aspir.
43243............................. Egd injection varices..... 43243................ egd injection varices.
43244............................. Egd varices ligation...... 43244................ egd varices ligation.
43245............................. Egd dilate stricture...... 43245................ egd dilate stricture.
43246............................. Egd place gastrostomy tube 43246................ egd place gastrostomy
tube.
43247............................. Egd remove foreign body... 43247................ egd remove foreign body.
43248............................. Egd guide wire insertion.. 43248................ egd guide wire insertion.
43249............................. Esoph egd dilation <30 mm. 43249................ esoph egd dilation <30
mm.
43250............................. Egd cautery tumor polyp... 43250................ egd cautery tumor polyp.
43251............................. Egd remove lesion snare... 43251................ egd remove lesion snare.
43252............................. Egd optical endomicroscopy 43200................ esophagoscopy flexible
brush.
43253............................. Egd us transmural injxn/ 43242................ egd us fine needle bx/
mark. aspir.
43254............................. Egd endo mucosal resection 43251................ egd remove lesion snare.
43255............................. Egd control bleeding any.. 43255................ egd control bleeding any.
43257............................. Egd w/thrml txmnt gerd.... 43257................ egd w/thrml txmnt gerd.
43259............................. Egd us exam duodenum/ 43259................ egd us exam duodenum/
jejunum. jejunum.
43260............................. Ercp w/specimen collection 43260................ ercp w/specimen
collection.
43261............................. Endo 43261................ endo
cholangiopancreatograph. cholangiopancreatograph.
43262............................. Endo 43262................ endo
cholangiopancreatograph. cholangiopancreatograph.
43263............................. Ercp sphincter pressure 43263................ ercp sphincter pressure
meas. meas.
43264............................. Ercp remove duct calculi.. 43264................ ercp remove duct calculi.
43265............................. Ercp lithotripsy calculi.. 43265................ ercp lithotripsy calculi.
43266............................. Egd endoscopic stent place 43256................ uppr gi endoscopy w/
stent.
43270............................. Egd lesion ablation....... 43258................ operative upper gi
endoscopy.
43273............................. Endoscopic pancreatoscopy. 43273................ endoscopic
pancreatoscopy.
43274............................. Ercp duct stent placement. 43268................ endo
cholangiopancreatograph.
43275............................. Ercp remove forgn body 43269................ endo
duct. cholangiopancreatograph.
43276............................. Ercp stent exchange w/ 43269................ endo
dilate. cholangiopancreatograph.
43277............................. Ercp ea duct/ampulla 43271................ endo
dilate. cholangiopancreatograph.
43278............................. Ercp lesion ablate w/ 43272................ endo
dilate. cholangiopancreatograph.
43450............................. Dilate esophagus 1/mult 43450................ dilate esophagus 1/mult
pass. pass.
43453............................. Dilate esophagus.......... 43453................ dilate esophagus.
49405............................. Image cath fluid colxn 37200................ transcatheter biopsy.
visc.
[[Page 74377]]
49406............................. Image cath fluid peri/ 37200................ transcatheter biopsy.
retro.
49407............................. Image cath fluid trns/vgnl 37200................ transcatheter biopsy.
50360............................. Transplantation of kidney. 50360................ transplantation of
kidney.
52332............................. Cystoscopy and treatment.. 52332................ cystoscopy and treatment.
52353............................. Cystouretero w/lithotripsy 52353................ cystouretero w/
lithotripsy.
52356............................. Cysto/uretero w/ 52353................ cystouretero w/
lithotripsy. lithotripsy.
62310............................. Inject spine cerv/thoracic 62310................ inject spine cerv/
thoracic.
62311............................. Inject spine lumbar/sacral 62311................ inject spine lumbar/
sacral.
62318............................. Inject spine w/cath crv/ 62318................ inject spine w/cath crv/
thrc. thrc.
62319............................. Inject spine w/cath lmb/ 62319................ inject spine w/cath lmb/
scrl. scrl.
63047............................. Remove spine lamina 1 lmbr 63047................ remove spine lamina 1
lmbr.
63048............................. Remove spinal lamina add- 63048................ remove spinal lamina add-
on. on.
63650............................. Implant neuroelectrodes... 63650................ implant neuroelectrodes.
64613............................. Destroy nerve neck muscle. 64613................ destroy nerve neck
muscle.
64614............................. Destroy nerve extrem musc. 64614................ destroy nerve extrem
musc.
64616............................. Chemodenerv musc neck 64613................ destroy nerve neck
dyston. muscle.
64617............................. Chemodener muscle larynx 31513................ injection into vocal
emg. cord.
64642............................. Chemodenerv 1 extremity 1- 64614................ destroy nerve extrem
4. musc.
64643............................. Chemodenerv 1 extrem 1-4 64614................ destroy nerve extrem
ea. musc.
64644............................. Chemodenerv 1 extrem 5/> 64614................ destroy nerve extrem
mus. musc.
64645............................. Chemodenerv 1 extrem 5/> 64614................ destroy nerve extrem
ea. musc.
64646............................. Chemodenerv trunk musc 1-5 64614................ destroy nerve extrem
musc.
64647............................. Chemodenerv trunk musc 6/> 64614................ destroy nerve extrem
musc.
66180............................. Implant eye shunt......... 66180................ implant eye shunt.
66183............................. Insert ant drainage device 65850................ incision of eye.
66185............................. Revise eye shunt.......... 66185................ revise eye shunt.
67255............................. Reinforce/graft eye wall.. 67255................ reinforce/graft eye wall.
67914............................. Repair eyelid defect...... 67914................ repair eyelid defect.
67915............................. Repair eyelid defect...... 67915................ repair eyelid defect.
67916............................. Repair eyelid defect...... 67916................ repair eyelid defect.
67917............................. Repair eyelid defect...... 67917................ repair eyelid defect.
67921............................. Repair eyelid defect...... 67921................ repair eyelid defect.
67922............................. Repair eyelid defect...... 67922................ repair eyelid defect.
67923............................. Repair eyelid defect...... 67923................ repair eyelid defect.
67924............................. Repair eyelid defect...... 67924................ repair eyelid defect.
69210............................. Remove impacted ear wax 69210................ remove impacted ear wax
uni. uni.
70450............................. Ct head/brain w/o dye..... 70450................ ct head/brain w/o dye.
70460............................. Ct head/brain w/dye....... 70460................ ct head/brain w/dye.
70551............................. Mri brain stem w/o dye.... 70551................ mri brain stem w/o dye.
70552............................. Mri brain stem w/dye...... 70552................ mri brain stem w/dye.
70553............................. Mri brain stem w/o & w/dye 70553................ mri brain stem w/o & w/
dye.
72141............................. Mri neck spine w/o dye.... 72141................ mri neck spine w/o dye.
72142............................. Mri neck spine w/dye...... 72142................ mri neck spine w/dye.
72146............................. Mri chest spine w/o dye... 72146................ mri chest spine w/o dye.
72147............................. Mri chest spine w/dye..... 72147................ mri chest spine w/dye.
72148............................. Mri lumbar spine w/o dye.. 72148................ mri lumbar spine w/o dye.
72149............................. Mri lumbar spine w/dye.... 72149................ mri lumbar spine w/dye.
72156............................. Mri neck spine w/o & w/dye 72156................ mri neck spine w/o & w/
dye.
72157............................. Mri chest spine w/o & w/ 72157................ mri chest spine w/o & w/
dye. dye.
72158............................. Mri lumbar spine w/o & w/ 72158................ mri lumbar spine w/o & w/
dye. dye.
72191............................. Ct angiograph pelv w/o&w/ 72191................ ct angiograph pelv w/o&w/
dye. dye.
74174............................. Ct angio abd&pelv w/o&w/ 74174................ ct angio abd&pelv w/o&w/
dye. dye.
74175............................. Ct angio abdom w/o & w/dye 74175................ ct angio abdom w/o & w/
dye.
77001............................. Fluoroguide for vein 77001................ fluoroguide for vein
device. device.
77002............................. Needle localization by 77002................ needle localization by
xray. xray.
77003............................. Fluoroguide for spine 77003................ fluoroguide for spine
inject. inject.
77280............................. Set radiation therapy 77280................ set radiation therapy
field. field.
77285............................. Set radiation therapy 77285................ set radiation therapy
field. field.
77290............................. Set radiation therapy 77290................ set radiation therapy
field. field.
77293............................. Respirator motion mgmt 77470................ special radiation
simul. treatment.
77295............................. 3-d radiotherapy plan..... 77295................ 3-d radiotherapy plan.
77301............................. Radiotherapy dose plan 77301................ radiotherapy dose plan
imrt. imrt.
77336............................. Radiation physics consult. 77336................ radiation physics
consult.
77338............................. Design mlc device for imrt 77338................ design mlc device for
imrt.
77372............................. Srs linear based.......... 77372................ srs linear based.
77373............................. Sbrt delivery............. 77373................ sbrt delivery.
77402............................. Radiation treatment 77402................ radiation treatment
delivery. delivery.
77403............................. Radiation treatment 77403................ radiation treatment
delivery. delivery.
77404............................. Radiation treatment 77404................ radiation treatment
delivery. delivery.
77406............................. Radiation treatment 77406................ radiation treatment
delivery. delivery.
77407............................. Radiation treatment 77407................ radiation treatment
delivery. delivery.
77408............................. Radiation treatment 77408................ radiation treatment
delivery. delivery.
77409............................. Radiation treatment 77409................ radiation treatment
delivery. delivery.
[[Page 74378]]
77411............................. Radiation treatment 77411................ radiation treatment
delivery. delivery.
77412............................. Radiation treatment 77412................ radiation treatment
delivery. delivery.
77413............................. Radiation treatment 77413................ radiation treatment
delivery. delivery.
77414............................. Radiation treatment 77414................ radiation treatment
delivery. delivery.
77416............................. Radiation treatment 77416................ radiation treatment
delivery. delivery.
77417............................. Radiology port film(s).... 77417................ radiology port film(s).
77600............................. Hyperthermia treatment.... 77600................ hyperthermia treatment.
77785............................. Hdr brachytx 1 channel.... 77785................ hdr brachytx 1 channel.
77786............................. Hdr brachytx 2-12 channel. 77786................ hdr brachytx 2-12
channel.
77787............................. Hdr brachytx over 12 chan. 77787................ hdr brachytx over 12
chan.
78072............................. Parathyrd planar w/ 78452................ ht muscle image spect
spect&ct. mult.
88112............................. Cytopath cell enhance tech 88112................ cytopath cell enhance
tech.
88365............................. Insitu hybridization 88365................ insitu hybridization
(fish). (fish).
88367............................. Insitu hybridization auto. 88367................ insitu hybridization
auto.
88368............................. Insitu hybridization 88368................ insitu hybridization
manual. manual.
90785............................. Psytx complex interactive. 90836................ psytx pt&/fam w/e&m 45
min.
90791............................. Psych diagnostic 90846................ family psytx w/o patient.
evaluation.
90792............................. Psych diag eval w/med 90846................ family psytx w/o patient.
srvcs.
90832............................. Psytx pt&/family 30 90846................ family psytx w/o patient.
minutes.
90833............................. Psytx pt&/fam w/e&m 30 min 90846................ family psytx w/o patient.
90834............................. Psytx pt&/family 45 90846................ family psytx w/o patient.
minutes.
90836............................. Psytx pt&/fam w/e&m 45 min 90846................ family psytx w/o patient.
90837............................. Psytx pt&/family 60 90846................ family psytx w/o patient.
minutes.
90838............................. Psytx pt&/fam w/e&m 60 min 90846................ family psytx w/o patient.
90839............................. Psytx crisis initial 60 90837................ psytx pt&/family 60
min. minutes.
90840............................. Psytx crisis ea addl 30 90833................ psytx pt&/fam w/e&m 30
min. min.
90845............................. Psychoanalysis............ 90845................ psychoanalysis.
90846............................. Family psytx w/o patient.. 90846................ family psytx w/o patient.
90847............................. Family psytx w/patient.... 90847................ family psytx w/patient.
90853............................. Group psychotherapy....... 90853................ group psychotherapy.
91065............................. Breath hydrogen/methane 91065................ breath hydrogen/methane
test. test.
92521............................. Evaluation of speech 96105................ assessment of aphasia.
fluency.
92522............................. Evaluate speech production 96105................ assessment of aphasia.
92523............................. Speech sound lang 96105................ assessment of aphasia.
comprehen.
92524............................. Behavral qualit analys 92520................ laryngeal function
voice. studies.
93000............................. Electrocardiogram complete 93000................ electrocardiogram
complete.
93005............................. Electrocardiogram tracing. 93005................ electrocardiogram
tracing.
93010............................. Electrocardiogram report.. 93010................ electrocardiogram report.
93582............................. Perq transcath closure pda 93580................ transcath closure of asd.
93583............................. Perq transcath septal 93580................ transcath closure of asd.
reduxn.
93880............................. Extracranial bilat study.. 93880................ extracranial bilat study.
93882............................. Extracranial uni/ltd study 93882................ extracranial uni/ltd
study.
94667............................. Chest wall manipulation... 94667................ chest wall manipulation.
94668............................. Chest wall manipulation... 94668................ chest wall manipulation.
94669............................. Mechanical chest wall 94668................ chest wall manipulation.
oscill.
95816............................. Eeg awake and drowsy...... 95816................ eeg awake and drowsy.
95819............................. Eeg awake and asleep...... 95819................ eeg awake and asleep.
95822............................. Eeg coma or sleep only.... 95822................ eeg coma or sleep only.
95886............................. Musc test done w/n test 95886................ musc test done w/n test
comp. comp.
95887............................. Musc tst done w/n tst 95887................ musc tst done w/n tst
nonext. nonext.
95928............................. C motor evoked uppr limbs. 95928................ c motor evoked uppr
limbs.
95929............................. C motor evoked lwr limbs.. 95929................ c motor evoked lwr limbs.
96365............................. Ther/proph/diag iv inf 96365................ ther/proph/diag iv inf
init. init.
96366............................. Ther/proph/diag iv inf 96366................ ther/proph/diag iv inf
addon. addon.
96367............................. Tx/proph/dg addl seq iv 96367................ tx/proph/dg addl seq iv
inf. inf.
96368............................. Ther/diag concurrent inf.. 96368................ ther/diag concurrent inf.
96413............................. Chemo iv infusion 1 hr.... 96413................ chemo iv infusion 1 hr.
96415............................. Chemo iv infusion addl hr. 96415................ chemo iv infusion addl
hr.
96417............................. Chemo iv infus each addl 96417................ chemo iv infus each addl
seq. seq.
98940............................. Chiropract manj 1-2 98940................ chiropract manj 1-2
regions. regions.
98941............................. Chiropract manj 3-4 98941................ chiropract manj 3-4
regions. regions.
98942............................. Chiropractic manj 5 98942................ chiropractic manj 5
regions. regions.
98943............................. Chiropract manj xtrspinl 1/ 98943................ chiropract manj xtrspinl
>. 1/>.
99170............................. Anogenital exam child w 99170................ anogenital exam child w
imag. imag.
70450 26.......................... Ct head/brain w/o dye..... 70450 26............. ct head/brain w/o dye.
70450 TC.......................... Ct head/brain w/o dye..... 70450 TC............. ct head/brain w/o dye.
70460 26.......................... Ct head/brain w/dye....... 70460 26............. ct head/brain w/dye.
70460 TC.......................... Ct head/brain w/dye....... 70460 TC............. ct head/brain w/dye.
70551 26.......................... Mri brain stem w/o dye.... 70551 26............. mri brain stem w/o dye.
70551 TC.......................... Mri brain stem w/o dye.... 70551 TC............. mri brain stem w/o dye.
70552 26.......................... Mri brain stem w/dye...... 70552 26............. mri brain stem w/dye.
70552 TC.......................... Mri brain stem w/dye...... 70552 TC............. mri brain stem w/dye.
70553 26.......................... Mri brain stem w/o & w/dye 70553 26............. mri brain stem w/o & w/
dye.
[[Page 74379]]
70553 TC.......................... Mri brain stem w/o & w/dye 70553 tc............. mri brain stem w/o & w/
dye.
72141 26.......................... Mri neck spine w/o dye.... 72141 26............. mri neck spine w/o dye.
72141 TC.......................... Mri neck spine w/o dye.... 72141 TC............. mri neck spine w/o dye.
72142 26.......................... Mri neck spine w/dye...... 72142 26............. mri neck spine w/dye.
72142 TC.......................... Mri neck spine w/dye...... 72142 TC............. mri neck spine w/dye.
72146 26.......................... Mri chest spine w/o dye... 72146 26............. mri chest spine w/o dye.
72146 TC.......................... Mri chest spine w/o dye... 72146 TC............. mri chest spine w/o dye.
72147 26.......................... Mri chest spine w/dye..... 72147 26............. mri chest spine w/dye.
72147 TC.......................... Mri chest spine w/dye..... 72147 TC............. mri chest spine w/dye.
72148 26.......................... Mri lumbar spine w/o dye.. 72148 26............. mri lumbar spine w/o dye.
72148 TC.......................... Mri lumbar spine w/o dye.. 72148 TC............. mri lumbar spine w/o dye.
72149 26.......................... Mri lumbar spine w/dye.... 72149 26............. mri lumbar spine w/dye.
72149 TC.......................... Mri lumbar spine w/dye.... 72149 TC............. mri lumbar spine w/dye.
72156 26.......................... Mri neck spine w/o & w/dye 72156 26............. mri neck spine w/o & w/
dye.
72156 TC.......................... Mri neck spine w/o & w/dye 72156 TC............. mri neck spine w/o & w/
dye.
72157 26.......................... Mri chest spine w/o & w/ 72157 26............. mri chest spine w/o & w/
dye. dye.
72157 TC.......................... Mri chest spine w/o & w/ 72157 TC............. mri chest spine w/o & w/
dye. dye.
72158 26.......................... Mri lumbar spine w/o & w/ 72158 26............. mri lumbar spine w/o & w/
dye. dye.
72158 TC.......................... Mri lumbar spine w/o & w/ 72158 TC............. mri lumbar spine w/o & w/
dye. dye.
72191 26.......................... Ct angiograph pelv w/o&w/ 72191 26............. ct angiograph pelv w/o&w/
dye. dye.
72191 TC.......................... Ct angiograph pelv w/o&w/ 72191 TC............. ct angiograph pelv w/o&w/
dye. dye.
74174 26.......................... Ct angio abd&pelv w/o&w/ 74174 26............. ct angio abd&pelv w/o&w/
dye. dye.
74174 TC.......................... Ct angio abd&pelv w/o&w/ 74174 TC............. ct angio abd&pelv w/o&w/
dye. dye.
74175 26.......................... Ct angio abdom w/o & w/dye 74175 26............. ct angio abdom w/o & w/
dye.
74175 TC.......................... Ct angio abdom w/o & w/dye 74175 TC............. ct angio abdom w/o & w/
dye.
77001 26.......................... Fluoroguide for vein 77001 26............. fluoroguide for vein
device. device.
77001 TC.......................... Fluoroguide for vein 77001 TC............. fluoroguide for vein
device. device.
77002 26.......................... Needle localization by 77002 26............. needle localization by
xray. xray.
77002 TC.......................... Needle localization by 77002 TC............. needle localization by
xray. xray.
77003 26.......................... Fluoroguide for spine 77003 26............. fluoroguide for spine
inject. inject.
77003 TC.......................... Fluoroguide for spine 77003 TC............. fluoroguide for spine
inject. inject.
77280 26.......................... Set radiation therapy 77280 26............. set radiation therapy
field. field.
77280 TC.......................... Set radiation therapy 77280 TC............. set radiation therapy
field. field.
77285 26.......................... Set radiation therapy 77285 26............. set radiation therapy
field. field.
77285 TC.......................... Set radiation therapy 77285 TC............. set radiation therapy
field. field.
77290 26.......................... Set radiation therapy 77290 26............. set radiation therapy
field. field.
77290 TC.......................... Set radiation therapy 77290 TC............. set radiation therapy
field. field.
77293 26.......................... Respirator motion mgmt 77470 26............. special radiation
simul. treatment.
77293 TC.......................... Respirator motion mgmt 77470 TC............. special radiation
simul. treatment.
77295 26.......................... 3-d radiotherapy plan..... 77295 26............. 3-d radiotherapy plan.
77295 TC.......................... 3-d radiotherapy plan..... 77295 TC............. 3-d radiotherapy plan.
77301 26.......................... Radiotherapy dose plan 77301 26............. radiotherapy dose plan
imrt. imrt.
77301 TC.......................... Radiotherapy dose plan 77301 TC............. radiotherapy dose plan
imrt. imrt.
77338 26.......................... Design mlc device for imrt 77338 26............. design mlc device for
imrt.
77338 TC.......................... Design mlc device for imrt 77338 TC............. design mlc device for
imrt.
77600 26.......................... Hyperthermia treatment.... 77600 26............. hyperthermia treatment.
77600 TC.......................... Hyperthermia treatment.... 77600 TC............. hyperthermia treatment.
77785 26.......................... Hdr brachytx 1 channel.... 77785 26............. hdr brachytx 1 channel.
77785 TC.......................... Hdr brachytx 1 channel.... 77785 TC............. hdr brachytx 1 channel.
77786 26.......................... Hdr brachytx 2-12 channel. 77786 26............. hdr brachytx 2-12
channel.
77786 TC.......................... Hdr brachytx 2-12 channel. 77786 TC............. hdr brachytx 2-12
channel.
77787 26.......................... Hdr brachytx over 12 chan. 77787 26............. hdr brachytx over 12
chan.
77787 TC.......................... Hdr brachytx over 12 chan. 77787 TC............. hdr brachytx over 12
chan.
88112 26.......................... Cytopath cell enhance tech 88112 26............. cytopath cell enhance
tech.
88112 TC.......................... Cytopath cell enhance tech 88112 TC............. cytopath cell enhance
tech.
88365 26.......................... Insitu hybridization 88365 26............. insitu hybridization
(fish). (fish).
88365 TC.......................... Insitu hybridization 88365 TC............. insitu hybridization
(fish). (fish).
88367 26.......................... Insitu hybridization auto. 88367 26............. insitu hybridization
auto.
88367 TC.......................... Insitu hybridization auto. 88367 TC............. insitu hybridization
auto.
88368 26.......................... Insitu hybridization 88368 26............. insitu hybridization
manual. manual.
88368 TC.......................... Insitu hybridization 88368 TC............. insitu hybridization
manual. manual.
91065 26.......................... Breath hydrogen/methane 91065 26............. breath hydrogen/methane
test. test.
91065 TC.......................... Breath hydrogen/methane 91065 TC............. breath hydrogen/methane
test. test.
93880 26.......................... Extracranial bilat study.. 93880 26............. extracranial bilat study.
93880 TC.......................... Extracranial bilat study.. 93880 TC............. extracranial bilat study.
93882 26.......................... Extracranial uni/ltd study 93882 26............. extracranial uni/ltd
study.
93882 TC.......................... Extracranial uni/ltd study 93882 TC............. extracranial uni/ltd
study.
95816 26.......................... Eeg awake and drowsy...... 95816 26............. eeg awake and drowsy.
95816 TC.......................... Eeg awake and drowsy...... 95816 TC............. eeg awake and drowsy.
95819 26.......................... Eeg awake and asleep...... 95819 26............. eeg awake and asleep.
95819 TC.......................... Eeg awake and asleep...... 95819 TC............. eeg awake and asleep.
95822 26.......................... Eeg coma or sleep only.... 95822 26............. eeg coma or sleep only.
95822 TC.......................... Eeg coma or sleep only.... 95822 TC............. eeg coma or sleep only.
[[Page 74380]]
95928 26.......................... C motor evoked uppr limbs. 95928 26............. c motor evoked uppr
limbs.
95928 TC.......................... C motor evoked uppr limbs. 95928 TC............. c motor evoked uppr
limbs.
95929 26.......................... C motor evoked lwr limbs.. 95929 26............. c motor evoked lwr limbs.
95929 TC.......................... C motor evoked lwr limbs.. 95929 TC............. c motor evoked lwr limbs.
G0453............................. Cont intraop neuro monitor 95920................ intraop nerve test add-
on.
G0455............................. Fecal microbiota prep 91065................ breath hydrogen/methane
instil. test.
G0461............................. Immunohistochemistry, init 88342................ immunohisto antibody
slide.
G0462............................. Immunohistochemistry, addl 88342................ immunohisto antibody
slide
----------------------------------------------------------------------------------------------------------------
F. Geographic Practice Cost Indices (GPCIs)
1. Background
Section 1848(e)(1)(A) of the Act requires us to develop separate
Geographic Practice Cost Indices (GPCIs) to measure resource cost
differences among localities compared to the national average for each
of the three fee schedule components (that is, work, PE, and MP). The
89 total PFS localities are discussed in section II.F.3. of this final
rule with comment period. Although requiring that the PE and MP GPCIs
reflect the full relative cost differences, section 1848(e)(1)(A)(iii)
of the Act requires that the work GPCIs reflect only one-quarter of the
relative cost differences compared to the national average. In
addition, section 1848(e)(1)(G) of the Act sets a permanent 1.5 work
GPCI floor for services furnished in Alaska beginning January 1, 2009,
and section 1848(e)(1)(I) of the Act sets a permanent 1.0 PE GPCI floor
for services furnished in frontier states (as defined in section
1848(e)(1)(I) of the Act) beginning January 1, 2011. Additionally,
section 1848(e)(1)(E) of the Act provided for a 1.0 floor for the work
GPCIs, which was set to expire at the end of 2012. Section 602 of the
ATRA amended the statute to extend the 1.0 floor for the work GPCIs
through CY 2013 (that is, for services furnished no later than December
31, 2013).
Section 1848(e)(1)(C) of the Act requires us to review and, if
necessary, adjust the GPCIs at least every 3 years. Section
1848(e)(1)(C) of the Act requires that ``if more than 1 year has
elapsed since the date of the last previous GPCI adjustment, the
adjustment to be applied in the first year of the next adjustment shall
be 1/2 of the adjustment that otherwise would be made.'' Therefore,
since the previous GPCI update was implemented in CY 2011 and CY 2012,
we proposed to phase in 1/2 of the latest GPCI adjustment in CY 2014.
We completed a review of the GPCIs and proposed new GPCIs, as well
as a revision to the cost share weights that correspond to all three
GPCIs in the CY 2014 proposed rule. We also calculated a corresponding
geographic adjustment factor (GAF) for each PFS locality. The GAFs are
a weighted composite of each area's work, PE and MP GPCIs using the
national GPCI cost share weights. Although the GAFs are not used in
computing the fee schedule payment for a specific service, we provide
them because they are useful in comparing overall areas costs and
payments. The actual effect on payment for any actual service will
deviate from the GAF to the extent that the proportions of work, PE and
MP RVUs for the service differ from those of the GAF.
As noted above, section 602 of the ATRA extended the 1.0 work GPCI
floor only through December 31, 2013. Therefore, the proposed CY 2014
work GPCIs and summarized GAFs do not reflect the 1.0 work floor.
However, as required by sections 1848(e)(1)(G) and 1848(e)(1)(I) of the
Act, the 1.5 work GPCI floor for Alaska and the 1.0 PE GPCI floor for
frontier states are permanent, and therefore, applicable in CY 2014
2. GPCI Update
As discussed in the CY 2014 PFS proposed rule (78 FR 43322), the
proposed updated GPCI values were calculated by a contractor to CMS.
There are three GPCIs (work, PE, and MP), and all GPCIs are calculated
through comparison to a national average for each type. Additionally,
each of the three GPCIs relies on its own data source(s) and
methodology for calculating its value as described below. Additional
information on the proposed CY 2014 GPCI update may be found in our
contractor's draft report, ``Draft Report on the CY 2014 Update of the
Geographic Practice Cost Index for the Medicare Physician Fee
Schedule,'' which is available on the CMS Web site. It is located under
the supporting documents section of the CY 2014 PFS proposed rule
located at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. Note:
Our contractor's final report and associated analysis will be posted on
the CMS Web site after publication of this final rule with comment
period (under the downloads section of the CY 2014 PFS final rule.
a. Work GPCIs
The physician work GPCIs are designed to reflect the relative costs
of physician labor by Medicare PFS locality. As required by statute,
the physician work GPCI reflects one quarter of the relative wage
differences for each locality compared to the national average.
To calculate the physician work GPCIs, we use wage data for seven
professional specialty occupation categories, adjusted to reflect one-
quarter of the relative cost differences for each locality compared to
the national average, as a proxy for physicians' wages. Physicians'
wages are not included in the occupation categories used in calculating
the work GPCI because Medicare payments are a key determinant of
physicians' earnings. Including physician wage data in calculating the
work GPCIs would potentially introduce some circularity to the
adjustment since Medicare payments typically contribute to or influence
physician wages. That is, including physicians' wages in the physician
work GPCIs would, in effect, make the indices, to some extent,
dependent upon Medicare payments.
The physician work GPCI updates in CYs 2001, 2003, 2005, and 2008
were based on professional earnings data from the 2000 Census. However,
for the CY 2011 GPCI update (75 FR 73252), the 2000 data were outdated
and wage and earnings data were not available from the more recent
Census because the ``long form'' was discontinued. Therefore, we used
the median hourly earnings from the 2006 through 2008 Bureau of Labor
Statistics (BLS) Occupational Employment Statistics (OES) wage data as
a replacement for the 2000 Census data. The BLS OES data meet several
criteria that we consider to be important for selecting a data source
for purposes of calculating
[[Page 74381]]
the GPCIs. For example, the BLS OES wage and employment data are
derived from a large sample size of approximately 200,000
establishments of varying sizes nationwide from every metropolitan area
and can be easily accessible to the public at no cost. Additionally,
the BLS OES is updated regularly, and includes a comprehensive set of
occupations and industries (for example, 800 occupations in 450
industries).
Because of its reliability, public availability, level of detail,
and national scope, we believe the BLS OES continues to be the most
appropriate source of wage and employment data for use in calculating
the work GPCIs (and as discussed in section II.F.2.b the employee wage
component and purchased services component of the PE GPCI). Therefore,
for the proposed CY 2014 GPCI update, we used updated BLS OES data
(2009 through 2011) as a replacement for the 2006 through 2008 data to
compute the work GPCIs.
b. Practice Expense GPCIs
The PE GPCIs are designed to measure the relative cost difference
in the mix of goods and services comprising practice expenses (not
including malpractice expenses) among the PFS localities as compared to
the national average of these costs. Whereas the physician work GPCIs
(and as discussed later in this section, the MP GPCIs) are comprised of
a single index, the PE GPCIs are comprised of four component indices
(employee wages; purchased services; office rent; and equipment,
supplies and other miscellaneous expenses). The employee wage index
component measures geographic variation in the cost of the kinds of
skilled and unskilled labor that would be directly employed by a
physician practice. Although the employee wage index adjusts for
geographic variation in the cost of labor employed directly by
physician practices, it does not account for geographic variation in
the cost of services that typically would be purchased from other
entities, such as law firms, accounting firms, information technology
consultants, building service managers, or any other third-party
vendor. The purchased services index component of the PE GPCI (which is
a separate index from employee wages) measures geographic variation in
the cost of contracted services that physician practices would
typically buy. (For more information on the development of the
purchased service index, we refer readers to the CY 2012 PFS final rule
with comment period (76 FR 73084 through 73085).) The office rent index
component of the PE GPCI measures relative geographic variation in the
cost of typical physician office rents. For the medical equipment,
supplies, and miscellaneous expenses component, we believe there is a
national market for these items such that there is not significant
geographic variation in costs. Therefore, the ``equipment, supplies and
other miscellaneous expense'' cost index component of the PE GPCI is
given a value of 1.000 for each PFS locality.
For the previous update to the GPCIs (implemented in CY 2011 and CY
2012) we used 2006 through 2008 BLS OES data to calculate the employee
wage and purchased services indices for the PE GPCI. As we discussed in
the proposed rule because of its reliability, public availability,
level of detail, and national scope, we continue to believe the BLS OES
is the most appropriate data source for collecting wage and employment
data. Therefore, in calculating the proposed CY 2014 GPCI update, we
used updated BLS OES data (2009 through 2011) as a replacement for the
2006 through 2008 data for purposes of calculating the employee wage
component and purchased service index of the PE GPCI.
Office Rent Index Discussion
Since the inception of the PFS, we have used residential rent data
(primarily the two-bedroom residential apartment rent data produced by
the Department of Housing and Urban Development (HUD) at the 50th
percentile) as the proxy to measure the relative cost difference in
physician office rents. As discussed in the CY 2012 PFS final rule with
comment period (76 FR 73084), we had concerns with the continued use of
the HUD rental data because the data were not updated frequently and
the Census ``long form,'' which was used to collect the necessary base
year rents for the HUD Fair Market Rent (FMR) data, was discontinued in
CY 2010 and would no longer be available for future updates. Therefore,
we examined the suitability of using 3-year (2006-2008) U.S. Census
Bureau American Community Survey (ACS) rental data as a proxy for
physician office rents to replace the HUD data. We determined that the
ACS is one of the largest nationally representative surveys of
household rents in the United States conducted annually by the U.S.
Census Bureau, sampling approximately 3 million addresses with a recent
response rate above 97 percent, and that it reports rental information
for residences at the county level. Given that the ACS rental data
provided a sufficient degree of reliability, is updated annually, and
was expected to be available for future updates, we used the 2006
through 2008 ACS 3-year residential rent data as a replacement for the
HUD data to create the office rent index for the CY 2012 PFS final rule
with comment (76 FR 73084). For all the same reasons that we used the
ACS data for the last GPCI update, we proposed to use updated ACS
residential rent data (2008 through 2010) to calculate the office rent
component of the PE GPCI. We noted in the proposed rule that when
responding to the ACS survey, individuals also report whether utilities
are included in their rent. Thus, the cost of utilities cannot be
separated from ``gross rents'' since some individuals monthly rent also
covers the cost of utilities. As discussed in section II.F.2.d., we
combined the cost weights for fixed capital and utilities when
assigning a proposed weight to the office rent component of the PE
GPCI.
For many years, we have received requests from stakeholders to use
commercial rent data instead of residential rent data to measure the
relative cost differences in physician office rent. Additionally, in a
report entitled ``Geographic Adjustment in Medicare Payment, Phase I:
Improving Accuracy,'' prepared for CMS under contract and released on
September 28, 2011, the Institute of Medicine recommended that ``a new
source of data should be developed to determine the variation in the
price of commercial office rent per square foot.'' The Institute of
Medicine report did not identify any new data source and did not
suggest how a new source of data might be developed. Because we could
not identify a reliable commercial rental data source that is available
on a national basis and includes data for non-metropolitan areas, we
continued to use residential rent data for the CY 2012 GPCI update.
For the CY 2014 GPCI update, we continued our efforts to identify a
reliable source of commercial rent data that could be used in
calculating the rent index. We could not identify a nationally
representative commercial rent data source that is available in the
public sector. However, we identified a proprietary commercial rent
data source that has potential for use in calculating the office rent
indices in future years. To that end, we are attempting to negotiate an
agreement with the proprietor to use the data for purposes of
calculating the office rent component of the PE GPCI.
One of the challenges of using a proprietary data source is our
ability to make information available to the public. When using
government data,
[[Page 74382]]
we are able to release all data for public consideration. However, when
using a proprietary data source, it is likely that restrictions will be
imposed on its use and our ability to disclose data. In such a
situation, those wishing to replicate our calculations based on
detailed data would also need to purchase the underlying proprietary
data. We also believe that, generally speaking, a proprietary ``for
profit'' data source is more susceptible to periodic changes in the
criteria used for data collection, including possible changes in the
data collected, the frequency at which the data is updated, changes in
ownership, and the potential for termination of the survey vehicle
entirely as changes are made to address economic pressures or
opportunities. As such, we cannot predict that a given proprietary data
source will be available in the format needed to develop office rent
indices in the future. Since we have not identified a nationally
representative commercial rent data source that is available in the
public sector, we believe it would be necessary to use a proprietary
data source for commercial office rent data. That is, in the absence of
using a proprietary data source, it is unlikely that we would be able
to use commercial rent data to calculate the office rent index
component of the PE GPCI. In the proposed rule we requested comments on
the use of a proprietary commercial rent data source as well as whether
there is a source for these data that is not proprietary.
c. Malpractice Expense (MP) GPCIs
The MP GPCIs measure the relative cost differences among PFS
localities for the purchase of professional liability insurance (PLI).
The MP GPCIs are calculated based on insurer rate filings of premium
data for $1 million to $3 million mature claims-made policies (policies
for claims made rather than services furnished during the policy term).
For the CY 2011 GPCI update (sixth update) we used 2006 and 2007
malpractice premium data (75 FR 73256). The proposed CY 2014 MP GPCI
update was developed using 2011 and 2012 premium data.
Additionally, for the past several GPCI updates, we were not able
to collect MP premium data from insurer rate filings for the Puerto
Rico payment locality. For the CY 2014 (seventh) GPCI update, we worked
directly with the Puerto Rico Insurance Commissioner and Institute of
Statistics to obtain data on MP insurance premiums that were used to
calculate an updated MP GPCI for Puerto Rico. We noted in the proposed
rule that using updated MP premium data would result in a 17 percent
increase in MP GPCI for the Puerto Rico payment locality under the
proposed fully phased-in seventh GPCI update, which would be effective
CY 2015.
d. GPCI Cost Share Weights
To determine the cost share weights for the proposed CY 2014 GPCIs,
we used the weights we proposed to use for the CY 2014 value for the
revised 2006-based MEI as discussed in section II.D. of this final rule
with comment period. As discussed in detail in that section, the MEI
was rebased and revised in the CY 2011 PFS final rule with comment
period (75 FR 73262 through 73277) to reflect the weighted-average
annual price change for various inputs needed to provide physicians'
services. We have historically updated the GPCI cost share weights to
make them consistent with the most recent update to the MEI, and
proposed to do so again for CY 2014. We would note that consistent with
this approach, in the CY 2011 proposed rule, the last time the MEI was
revised, we proposed to update the GPCI cost share weights to reflect
these revisions to the MEI. However, in response to public comments we
did not finalize the proposal in the CY 2011 PFS final rule with
comment period (75 FR 73258 and 73260), so that we could explore public
comments received suggesting the reallocation of labor related costs
from the medical equipment, supplies and miscellaneous component to the
employee compensation component and comments received on the cost share
weight for the rent index of the PE GPCI as well as to continue our
analysis of the cost share weights attributed to the PE GPCIs as
required by section 1848(e)(1)(H)(iv) of the Act.
In the CY 2012 PFS final rule (76 FR 73085 through 73086) we
addressed commenter concerns regarding the inclusion of the cost share
weight assigned to utilities within the office rent component of the PE
GPCI and to geographically adjust wage related industries contained
within the medical equipment, supplies and miscellaneous component of
the PE GPCI. As a result, to accurately capture the utility measurement
present in the ACS two bedroom gross rent data, the cost share weight
for utilities was combined with the fixed capital portion to form the
office rent index. Additionally, we developed a purchased service index
to geographically adjust the labor-related components of the ``All
Other Services'' and ``Other Professional Expenses'' categories of the
2006-based MEI market basket. Upon completing our analysis of the GPCI
cost share weights (as required by the Act) and addressing commenters'
concerns regarding the office rent and labor related industries
previously contained in the medical equipment, supplies and other
miscellaneous components of the PE GCPI, we updated the GPCI cost share
weights consistent with the weights established in the 2006-based MEI
in the CY 2012 PFS final rule (76 FR 73086).
The proposed revised 2006-based MEI cost share weights reflect our
actuaries' best estimate of the weights associated with each of the
various inputs needed to provide physicians' services. Use of the
current MEI cost share weights also provides consistency across the PFS
in the use of this data. Given that we have addressed previous
commenters' concerns about the allocation of labor related costs (as
discussed earlier in this section) and that we have completed our
analysis of the GPCI cost share weights (as required by the Act) we
proposed to adopt the weights we proposed to use for the revised 2006-
based MEI as the GPCI cost share weights for CY 2014.
Specifically, we proposed to change the cost share weights for the
work GPCI (as a percentage of the total) from 48.266 percent to 50.866
percent, and the cost share weight for the PE GPCI from 47.439 percent
to 44.839 percent. In addition we proposed to change the employee
compensation component of the PE GPCI from 19.153 to 16.553 percentage
points. The proposed cost share weights for the office rent component
(10.223 percent), purchased services component (8.095 percent), and the
medical equipment, supplies, and other miscellaneous expenses component
(9.968 percent) of the PE GPCI and the cost share weight for the MP
GPCI (4.295 percent) remained unchanged. A discussion of the specific
MEI cost centers and the respective weights used to calculate each GPCI
component (and subcomponent) is provided below.
(1) Work GPCIs
We proposed to adopt the proposed revised weight of 50.866 for the
physician compensation cost category as the proposed work GPCI cost
share weight.
(2) Practice Expense GPCIs
For the cost share weight for the PE GPCIs, we used the revised
2006-based MEI proposed weight for the PE category of 49.134 percent
minus the PLI category weight of 4.295 percent (because the relative
costs differences in malpractice expenses are measured by its own
GPCI). Therefore, the proposed cost share weight for the PE GPCIs is
44.839 percent.
[[Page 74383]]
(a) Employee Compensation
For the employee compensation portion of the PE GPCIs, we used the
proposed non-physician employee compensation category weight of 16.553
percent reflected in the revised 2006-based MEI.
(b) Office Rent
We set the PE GPCI office rent portion at 10.223 percent, which
includes the proposed revised 2006-based MEI cost weights for fixed
capital (reflecting the expenses for rent, depreciation on medical
buildings and mortgage interest) and utilities. As discussed previously
in this section, we proposed to use 2008-2010 ACS rental data as the
proxy for physician office rent. As mentioned previously, these data
represent a gross rent amount and include data on utility expenditures.
Since it is not possible to separate the utilities component of rent
for all ACS survey respondents, we combined these two components to
calculate office rent values that were used to calculate the office
rent index component of the proposed PE GPCI. For purposes of
consistency, we combined those two cost categories when assigning a
proposed weight to the office rent component.
(c) Purchased Services
As discussed in section II.A. of this final rule with comment
period, to be consistent with the purchased services index, we proposed
to combine the current MEI cost share weights for ``All Other
Services'' and ``Other Professional Expenses'' into a component called
``All Other Professional Services.'' The proposed weight for ``All
Other Professional Services'' is 8.095. As noted in the CY 2012 PFS
final rule with comment period (76 FR 73084), we only adjust for
locality cost differences of the labor-related share of the purchased
services index. We determined that only 5.011 percentage points of the
total 8.095 proposed weight are labor-related and, thus, would be
adjusted for locality cost differences (5.011 adjusted purchased
service + 3.084 non-adjusted purchased services = 8.095 total cost
share weight). Therefore, only 62 percent (5.011/8.095) of the
purchased service index is adjusted for geographic cost differences
while the remaining 38 percent (3.084/8.095) of the purchased service
index is not adjusted for geographic variation.
(d) Equipment, Supplies, and Other Miscellaneous Expenses
To calculate the medical equipment, supplies, and other
miscellaneous expenses component, we removed PLI (4.295 percentage
points), non-physician employee compensation (16.553 percentage
points), fixed capital/utilities (10.223 percentage points), and
purchased services (8.095 percentage points) from the total proposed PE
category weight (49.134 percent). Therefore, the proposed cost share
weight for the medical equipment, supplies, and other miscellaneous
expenses component is 9.968 percent (49.134 - (4.295 + 16.553 + 10.223
+ 8.095) = 9.968). As explained above, because we believe there is a
national market for these items, costs that fall within this component
of the PE GPCI are not adjusted for geographic variation.
(3) Malpractice GPCIs
We proposed to use the PLI weight of 4.295 percent for the MP GPCI
cost share weight. The proposed GPCI cost share weights for CY 2014 are
displayed in Table 31.
Table 31--Proposed Cost Share Weights for CY 2014 GPCI Update
------------------------------------------------------------------------
Current cost Proposed CY 2014
Expense category share weight cost share weight
(percent) (percent)
------------------------------------------------------------------------
Work.............................. 48.266 50.866
Practice Expense (less PLI)....... 47.439 44.839
- Employee Compensation....... 19.153 16.553
- Office Rent................. 10.223 10.223
- Purchased Services.......... 8.095 8.095
- Equipment, Supplies, Other.. 9.968 9.968
Malpractice Insurance............. 4.295 4.295
-------------------------------------
Total......................... 100.000 100.000
------------------------------------------------------------------------
e. PE GPCI Floor for Frontier States
Section 10324(c) of the Affordable Care Act added a new
subparagraph (I) under section 1848(e)(1) of the Act to establish a 1.0
PE GPCI floor for physicians' services furnished in frontier States
effective January 1, 2011. In accordance with section 1848(e)(1)(I) of
the Act, beginning in CY 2011, we applied a 1.0 PE GPCI floor for
physicians' services furnished in states determined to be frontier
states. In general, a frontier state is one in which at least 50
percent of the counties are ``frontier counties,'' which are those that
have a population per square mile of less than 6. For more information
on the criteria used to define a frontier state, we refer readers to
the FY 2011 Inpatient Prospective Payment System final rule (75 FR
50160 through 50161). There are no changes in the states identified as
``frontier states'' for CY 2014. The qualifying states are reflected in
Table 32. In accordance with the Act, we will apply a 1.0 PE GPCI floor
for these states in CY 2014.
Table 32--Frontier States Under Section 1848(E)(1)(I) of the Act
[As added by section 10324(c) of the Affordable Care Act]
----------------------------------------------------------------------------------------------------------------
Percent frontier
counties (relative to
State Total counties Frontier counties counties in the State)
(percent)
----------------------------------------------------------------------------------------------------------------
Montana.............................. 56 45 80
Wyoming.............................. 23 17 74
[[Page 74384]]
North Dakota......................... 53 36 68
Nevada............................... 17 11 65
South Dakota......................... 66 34 52
----------------------------------------------------------------------------------------------------------------
f. Proposed GPCI Update
As explained above, the periodic review and adjustment of GPCIs is
mandated by section 1848(e)(1)(C) of the Act. At each update, the
proposed GPCIs are published in the PFS proposed rule to provide an
opportunity for public comment and further revisions in response to
comments prior to implementation. The proposed CY 2014 updated GPCIs
for the first and second year of the 2-year transition, along with the
GAFs, were displayed in Addenda D and E to the CY 2014 proposed rule
available on the CMS Web site under the supporting documents section of
the CY 2014 PFS proposed rule Web page at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
3. Payment Locality Discussion
a. Background
The current PFS locality structure was developed and implemented in
1997. There are currently 89 total PFS localities; 34 localities are
statewide areas (that is, only one locality for the entire state).
There are 52 localities in the other 16 states, with 10 states having 2
localities, 2 states having 3 localities, 1 state having 4 localities,
and 3 states having 5 or more localities. The District of Columbia,
Maryland, and Virginia suburbs, Puerto Rico, and the Virgin Islands are
additional localities that make up the remainder of the total of 89
localities. The development of the current locality structure is
described in detail in the CY 1997 PFS proposed rule (61 FR 34615) and
the subsequent final rule with comment period (61 FR 59494).
Prior to 1992, Medicare payments for physicians' services were made
under the reasonable charge system. Payments were based on the charging
patterns of physicians. This resulted in large differences in payment
for physicians' services among types of services, geographic payment
areas, and physician specialties. Recognizing this, the Congress
replaced the reasonable charge system with the Medicare PFS in the
Omnibus Budget Reconciliation Act (OBRA) of 1989, and the PFS went into
effect January 1, 1992. Payments under the PFS are based on the
relative resources involved with furnishing services, and are adjusted
to account for geographic variations in resource costs as measured by
the GPCIs.
Payment localities originally were established under the reasonable
charge system by local Medicare carriers based on their knowledge of
local physician charging patterns and economic conditions. These
localities changed little between the inception of Medicare in 1967 and
the beginning of the PFS in 1992. Shortly after the PFS took effect,
CMS undertook a study in 1994 that culminated in a comprehensive
locality revision that was implemented in 1997 (61 FR 59494).
The revised locality structure reduced the number of localities
from 210 to the current 89, and the number of statewide localities
increased from 22 to 34. The revised localities were based on locality
resource cost differences as reflected by the GPCIs. For a full
discussion of the methodology, see the CY 1997 PFS final rule with
comment period (61 FR 59494). The current 89 fee schedule areas are
defined alternatively by state boundaries (for example, Wisconsin),
metropolitan areas (for example, Metropolitan St. Louis, MO), portions
of a metropolitan area (for example, Manhattan), or rest-of-state areas
that exclude metropolitan areas (for example, rest of Missouri). This
locality configuration is used to calculate the GPCIs that are in turn
used to calculate payments for physicians' services under the PFS.
As stated in the CY 2011 PFS final rule with comment period (75 FR
73261), we require that changes to the PFS locality structure be done
in a budget neutral manner within a state. For many years, before
making any locality changes, we have sought consensus from among the
professionals whose payments would be affected. In recent years, we
have also considered more comprehensive changes to locality
configuration. In 2008, we issued a draft comprehensive report
detailing four different locality configuration options (www.cms.gov/physicianfeesched/downloads/ReviewOfAltGPCIs.pdf). The alternative
locality configurations in the report are described below.
Option 1: CMS Core-Based Statistical Area (CBSA) Payment
Locality Configuration: CBSAs are a combination of Office of Management
and Budget (OMB's) Metropolitan Statistical Areas (MSAs) and
Micropolitan Statistical Areas. Under this option, MSAs would be
considered as urban CBSAs. Micropolitan Statistical Areas (as defined
by OMB) and rural areas would be considered as non-urban (rest of
state) CBSAs. This approach would be consistent with the areas used in
the Inpatient Prospective Payment System (IPPS) pre-reclassification
wage index, which is the hospital wage index for a geographic area
(CBSA or non-CBSA) calculated from submitted hospital cost report data
before statutory adjustments reconfigure, or ``reclassify'' a hospital
to an area other than its geographic location, to adjust payments for
differences in local resource costs in other Medicare payment systems.
Based on data used in the 2008 locality report, this option would
increase the number of PFS localities from 89 to 439.
Option 2: Separate High-Cost Counties from Existing
Localities (Separate Counties): Under this approach, higher cost
counties are removed from their existing locality structure, and they
would each be placed into their own locality. This option would
increase the number of PFS localities from 89 to 214, using a 5 percent
GAF differential to separate high-cost counties.
Option 3: Separate MSAs from Statewide Localities
(Separate MSAs): This option begins with statewide localities and
creates separate localities for higher cost MSAs (rather than removing
higher cost counties from their existing locality as described in
Option 2). This option would increase the number of PFS localities from
89 to 130, using a 5 percent GAF differential to separate high-cost
MSAs.
[[Page 74385]]
Option 4: Group Counties Within a State Into Locality
Tiers Based on Costs (Statewide Tiers): This option creates tiers of
counties (within each state) that may or may not be contiguous but
share similar practice costs. This option would increase the number of
PFS localities from 89 to 140, using a 5 percent GAF differential to
group similar counties into statewide tiers.
For a detailed discussion of the public comments on the
contractor's 2008 draft report detailing four different locality
configurations, we refer readers to the CY 2010 PFS proposed rule (74
FR 33534) and subsequent final rule with comment period (74 FR 61757).
There was no public consensus on the options, although a number of
commenters expressed support for Option 3 (separate MSAs from statewide
localities) because the commenters believed this alternative would
improve payment accuracy and could mitigate potential reductions to
rural areas compared to Option 1 (CMS CBSAs).
In response to some public comments regarding the third of the four
locality options, we had our contractor conduct an analysis of the
impacts that would result from the application of Option 3. Those
results were displayed in the final locality report released in 2011.
The final report, entitled ``Review of Alternative GPCI Payment
Locality Structures--Final Report,'' may be accessed directly from the
CMS Web site at www.cms.gov/PhysicianFeeSched/downloads/Alt_GPCI_Payment_Locality_Structures_Review.pdf.
Moreover, at our request, the Institute of Medicine conducted a
comprehensive empirical study of the Medicare GAFs established under
sections 1848(e) (PFS GPCI) and 1886(d)(3)(E) (IPPS hospital wage
index) of the Act. These adjustments are designed to ensure Medicare
payments reflect differences in input costs across geographic areas.
The first of the Institute of Medicine's two reports entitled,
``Geographic Adjustment in Medicare Payment, Phase I: Improving
Accuracy'' recommended that the same labor market definition should be
used for both the hospital wage index and the physician geographic
adjustment factor. Further, the Institute of Medicine recommended that
MSAs and statewide non-metropolitan statistical areas should serve as
the basis for defining these labor markets.
Under the Institute of Medicine's recommendations, MSAs would be
considered as urban CBSAs. Micropolitan Areas (as defined by the OMB)
and rural areas would be considered as non-urban (rest of state) CBSAs.
This approach would be consistent with the areas used in the IPPS pre-
reclassification wage index to make geographic payment adjustments in
other Medicare payment systems. For more information on the Institute
of Medicine's recommendations on the PFS locality structure, see the CY
2013 PFS final rule with comment period (77 FR 68949). We also provided
our technical analyses of the Institute of Medicine Phase I
recommendations in a report released on the PFS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
Additionally, the Phase I report can be accessed on the Institute
of Medicine's Web site at http://www.iom.edu/Reports/2011/Geographic-Adjustment-in-Medicare-Payment-Phase-I-Improving-Accuracy.aspx.
b. Institute of Medicine Phase II Report Discussion
The Institute of Medicine's second report, entitled ``Geographic
Adjustment in Medicare Payment--Phase II: Implications for Access,
Quality, and Efficiency'' was released July 17, 2012 and can be
accessed on the Institute of Medicine's Web site at http://www.iom.edu/Reports/2011/Geographic-Adjustment-in-Medicare-Payment-Phase-I-Improving-Accuracy.aspx.
The Phase II report evaluated the effects of geographic adjustment
factors (hospital wage index and GPCIs) on the distribution of the
health care workforce, quality of care, population health, and the
ability to provide efficient, high value care. The Institute of
Medicine's Phase II report also included an analysis of the impacts of
implementing its recommendations for accuracy in geographic adjustments
which include a CBSA-based locality structure under the PFS. The
Institute of Medicine analysis found that adopting a CBSA-based
locality structure under the PFS creates large changes in county GAF
values; for example, approximately half of all U.S. counties would
experience a payment reduction. The Institute of Medicine also found
that GPCIs calculated under a CBSA-based locality structure would
result in lower GAFs in rural areas (relative to the national average)
because the GPCI values for rural areas would no longer include
metropolitan practice costs within the current ``rest-of-state'' or
``statewide'' localities.
(1) Institute of Medicine Phase II Report Recommendations
The Institute of Medicine developed recommendations for improving
access to and quality of medical care. The recommendations included in
the Institute of Medicine's Phase II report are summarized as follows:
Recommendation 1: The Medicare program should develop and
apply policies that promote access to primary care services in
geographic areas where Medicare beneficiaries experience persistent
access problems.
Recommendation 2: The Medicare program should pay for
services that improve access to primary and specialty care for
beneficiaries in medically underserved urban and rural areas,
particularly telehealth technologies.
Recommendation 3: To promote access to appropriate and
efficient primary care services, the Medicare program should support
policies that would allow all qualified practitioners to practice to
the full extent of their educational preparation.
Recommendation 4: The Medicare program should reexamine
its policies that provide location-based adjustments for specific
groups of hospitals, and modify or discontinue them based on their
effectiveness in ensuring adequate access to appropriate care.
Recommendation 5: Congress should fund an independent
ongoing entity, such as the National Health Care Workforce Commission,
to support data collection, research, evaluations, and strategy
development, and make actionable recommendations about workforce
distribution, supply, and scope of practice.
Recommendation 6: Federal support should facilitate
independent external evaluations of ongoing workforce programs intended
to provide access to adequate health services for underserved
populations and Medicare beneficiaries. These programs include the
National Health Services Corps, Title VII and VIII programs under the
Public Health Service Act, and related programs intended to achieve
these goals.
(2) Institute of Medicine Phase II Report Conclusions
The Institute of Medicine committee concluded that geographic
payment adjustments under the PFS are not a strong determinant of
access problems and not an appropriate mechanism for improving the
distribution of the healthcare workforce, quality of care, population
health, and the ability to provide efficient, high value care.
Specifically, the Institute of Medicine
[[Page 74386]]
committee stated ``that there are wide discrepancies in access to and
quality of care across geographic areas particularly for racial and
ethnic minorities. However, the variations do not appear to be strongly
related to differences in or potential changes to fee for service
payment'' (Page. 6). The committee also concluded ``that Medicare
beneficiaries in some geographic pockets face persistent access and
quality problems, and many of these pockets are in medically
underserved rural and inner-city areas. However, geographic adjustment
of Medicare payment is not an appropriate approach for addressing
problems in the supply and distribution of the health care workforce.
The geographic variations in the distribution of physicians, nurses and
physician assistants, and local shortages that create access problems
for beneficiaries should be addressed through other means'' (Page 7).
Moreover, the committee concluded that ``geographic [payment]
adjustment is not an appropriate tool for achieving policy goals such
as improving quality of expanding the pool of providers available to
see Medicare beneficiaries'' (Page 9).
(3) CMS Summary Response to Institute of Medicine Phase II Report
The Institute of Medicine's Phase II report recommendations are
broad in scope, do not propose specific recommendations for making
changes to the GPCIs or PFS locality structure, or are beyond the
statutory authority of CMS.
We agree with the Institute of Medicine's assessment that many
counties would experience a payment reduction and that large payment
shifts would occur as a result of implementing a CBSA-based locality
configuration under the PFS. Based on our contractor's analysis, there
would be significant redistributive impacts if we were to implement a
policy that would reconfigure the PFS localities based on the Institute
of Medicine's CBSA-based locality recommendation. Many rural areas
would see substantial decreases in their corresponding GAF and GPCI
values as higher cost counties are removed from current ``rest of
state'' payment areas. Conversely, many urban areas, especially those
areas that are currently designated as ``rest of state'' but are
located within higher cost MSAs, would experience increases in their
applicable GPCIs and GAFs. That is, given that urban and rural areas
would no longer be grouped together (for example, as in the current 34
statewide localities), many rural areas would see a reduction in
payment under a CBSA-based locality configuration.
As noted earlier in this section, we are assessing a variety of
approaches to changing the locality structure under the PFS and will
continue to study options for revising the locality structure. However,
to fully assess the implications of proposing a nationwide locality
reconfiguration under the PFS, we must also assess and analyze the
operational changes necessary to implement a revised locality
structure. Given that all options under consideration (including the
Institute of Medicine's CBSA-based approach) would expand the number of
current localities and result in payment reductions to primarily rural
areas, presumably any nationwide locality reconfiguration could
potentially be transitioned over a number of years (to phase-in the
impact of payment reductions gradually, from year-to-year, instead of
all at once). As such, transitioning from the current locality
structure to a nationwide reconfigured locality structure would present
operational and administrative challenges that need to be identified
and addressed. Therefore, we have begun to assess the broad operational
changes that would be involved in implementing a nationwide locality
reconfiguration under the PFS. Accordingly, we believe that it would be
premature to make any statements about potential changes we would
consider making to the PFS localities at this time. Any changes to PFS
fee schedule areas would be made through future notice and comment
rulemaking.
The following is a summary of the comments we received regarding
our proposed CY 2014 GPCI update and summary response to the Institute
of Medicine's Phase II report recommendations.
Comment: A few commenters including a national medical association
and state medical society expressed support for using more current data
in calculating the GPCIs. Another commenter stated that the BLS OES
provides the best data for calculating the work GPCI and the employee
wage component and purchased service component of the PE GPCI.
Response: For the reasons outlined in the proposed rule, we agree
with the commenters.
Comment: One state medical association expressed support for our
proposal to use BLS OES data for calculating the geographic variation
in physician work. The commenter stated that the BLS OES includes a
large sample of data on wages and should be very reliable. However, the
commenter raised concerns about using multi-year averages of wages in
years that large demographic and economic changes may have occurred.
The commenter contends that because the BLS OES data are so robust,
using three-year averages is not necessary or appropriate. The
commenter suggested that GPCI updates based on BLS OES data should be
based on the most recent annual data available, rather than multi-year
averages.
Response: We agree with the commenter that the BLS OES data are a
reliable and robust source of wage and earnings data. The BLS OES wage
and earnings data released in any given year are aggregated using 6
semi-annual panels of data collected over 3 years (2 panels per year).
The BLS does not produce 1-year wage and earnings data. According to
the Occupational Employment Statistics Frequently Asked Questions:
``Significant reductions in sampling error can be achieved by taking
advantage of a full 3 years of data, covering 1.2 million
establishments and about 62 percent of the employment in the United
States. This feature is particularly important in improving the
reliability of estimates for detailed occupations in small geographical
areas. Combining multiple years of data is also necessary to obtain
full coverage of the largest establishments. In order to reduce
respondent burden, the OES survey samples these establishments with
virtual certainty only once every three years.'' We also note that the
BLS recognizes that labor costs change over time. To make the data from
all 6 semi-annual panels comparable, the OES program uses the
Employment Cost Index (ECI) to translate the occupation-level wages
from previous years into a wage number for the most recent year. The
Occupational Employment Statistics Frequently Asked Questions may be
accessed from the Bureau of Labor Statistics Web site at: http://www.bls.gov/oes/oes_ques.htm. As discussed above, the OES FAQs explain
that the use of multi-year averages improves reliability of the data
and reduces sampling error. We agree with this assessment, and
therefore, we will continue to use the BLS OES wage and earnings data
that reflect multi-year averaging.
Comment: A few commenters stated that the proposed GPCI update
results in lowering payment amounts to rural areas, which threatens
patient access to physician services, including treatments for complex
conditions such as cancer and lupus. Another commenter expressed
support for the elimination of all geographic adjustment factors under
[[Page 74387]]
the PFS. The commenter believes that lower GPCIs discourage physicians
and practitioners from practicing in rural and underserved areas.
Response: As discussed previously, section 1848(e)(1)(A) of the Act
requires us to develop separate GPCIs to measure resource cost
differences among localities compared to the national average for each
of the three fee schedule components. We do not have the authority to
eliminate geographic payment adjustments under the PFS. We note that
the GPCI values for many rural PFS areas, including many single state
localities (and rest of state localities), will increase as a result of
the CY 2014 GPCI update. However, because the statutory 1.0 work GPCI
floor expires at the end of CY 2013, beginning January 1, 2014, PFS
payment amounts will be calculated based upon the actual work GPCI for
the locality rather than using the 1.0 work GPCI floor (except in
Alaska where the statutory 1.5 work GPCI floor will continue to apply).
Accordingly, the summarized GAFs, provided as noted above for purposes
of illustration and comparison, demonstrate decreases in the work GPCIs
for these same PFS localities.
Comment: A few commenters requested an extension of the
statutorily-mandated 1.0 work GPCI floor, which expires on December 31,
2013.
Response: As discussed above, the 1.0 work GPCI floor is
established by statute and expires on December 31, 2013. We do not have
authority to extend the 1.0 work GPCI floor beyond December 31, 2013.
Comment: A few commenters urged us to reassess the professional
occupational categories used to determine the relative cost differences
in physician earnings for purposes of calculating the work GPCI. The
commenters believe that the current inputs do not adequately measure
the relative cost differences in physician salary across PFS
localities. The commenters also mentioned a recent report published by
MedPAC on the work GPCI, which recommended changes to the proxy
occupations used in calculating the work GPCI. The commenters stated
that the MedPAC study found that the data sources we currently rely
upon for determining the work GPCI bear no correlation to physician
earnings and that rural primary care physicians have higher wages than
their urban counterparts. One commenter suggested that we use actual
physician salaries (instead of proxy occupations) to determine the
relative differences in physician wages. Another commenter urged us to
modify the work GPCI to include ``reference occupations that will
accurately reflect the higher input costs of rural physician
earnings.''
Response: We appreciate the comments regarding the professional
occupations used to determine the relative cost differences in
physician earnings for purposes of calculating the work GPCI. As noted
previously in this section, physicians' wages are not included in the
occupation categories used in calculating the work GPCI because
Medicare payments are a key determinant of physicians' earnings.
Including physician wage data in calculating the work GPCIs would
potentially introduce some circularity to the adjustment since Medicare
payments typically contribute to or influence physician wages. In other
words, including physicians' wages in the physician work GPCIs would,
in effect, make the indices, to some extent, dependent upon Medicare
payments, which in turn are affected by the indices. Additionally, as
noted in the proposed rule the MedPAC was required by section 3004 of
the MCTRJCA to submit a report to the Congress by June 15, 2013,
assessing whether any adjustment under section 1848 of the Act to
distinguish the difference in work effort by geographic area is
appropriate and, if so, what that level should be and where it should
be applied. In the report, MedPAC was required to also assess the
impact of the work geographic adjustment under the Act, including the
extent to which the floor on such adjustment impacts access to care. We
also noted in the proposed rule that we did not have sufficient time to
review this report, which was issued on June 14, 2013, in order to take
the report into consideration for the proposed rule. We will be
assessing the findings and recommendations from the MedPAC report and,
and we will consider whether to make recommendations or proposals for
changes in future rulemaking.
Comment: Several commenters noted that they appreciated our efforts
to obtain more recent malpractice premium data from Puerto Rico for
purposes of calculating the MP GPCIs. The commenters stated that a MP
GPCI update for the Puerto Rico payment locality is long overdue.
Response: We agree with the commenters. By obtaining more recent
malpractice premium insurance data, we were able to calculate an
updated MP GPCI for the Puerto Rico payment locality using recent
market share and rate filings data, as we were able to do for most
other PFS localities.
Comment: One commenter stated that we did not use the most recent
ACS residential rent data available (2009 through 2011) when
calculating the rent index and encouraged us to use the most recent ACS
residential rent data if it does not decrease the PE GPCI for Puerto
Rico.
Response: We appreciate the commenter's suggestion to use 2009
through 2011 ACS data for the CY 2014 GPCI update. We note that there
was insufficient time between the release of the 2009 through 2011 ACS
data and the CY 2014 PFS proposed rule to allow us to use these data
for the calculation of the proposed office rent component of the PE
GPCI.
Comment: Many commenters requested an increase to the PE GPCI
values for the Puerto Rico payment locality. The commenters believe it
is necessary to increase payments to Puerto Rico to prevent the
continued exodus of physicians to the U.S. mainland, as well as to
maintain the quality of care, reflect inflation, and modernize
equipment and supplies in Puerto Rico. The commenters also argue that
doctors in Puerto Rico are required to provide the same services for
lower reimbursement than those practicing in the U.S. mainland).
One commenter acknowledged that the work, PE and malpractice GPCIs
for the Puerto Rico locality were increased as a result of the CY 2014
GPCI update, but noted that, even with the increases, Puerto Rico
continues to be the lowest paid PFS locality and that its ``neighboring
locality,'' the Virgin Islands, unjustifiably receives a MP GPCI and PE
GPCI of 1.0. The commenter also requested specific increases to the
proposed PE GPCI for the Puerto Rico locality, most notably the rent
component and medical equipment and supplies component, and referenced
a previous study entitled ``Cost of Medical Services in Puerto Rico,''
which included physician survey information on the costs of operating a
medical practice in Puerto Rico.
In addition, the same commenter stated that the methodology used to
determine the equipment and supplies component of the PE GPCI is unfair
to Puerto Rico. For example, the commenter noted that the medical
equipment and supplies component of the PE GPCI is currently not
adjusted for geographic cost differences; therefore all PFS localities
receive an index of 1.0 for the equipment and supplies component. The
commenter stated that medical equipment and supplies cost more in
Puerto Rico because of the higher cost of shipping, noting, for
example, that air and maritime shipping is more
[[Page 74388]]
expensive than ground shipping. Because Puerto Rico is dependent on air
and maritime shipping, the commenter believes that our presumption that
most medical equipment and supplies are sold through a national market
does not adequately capture the higher cost of shipping medical
equipment and medical supplies to the Puerto Rico locality. The
commenter urged us to increase the PE GPCI calculated for the Puerto
Rico locality, ``so that it is equal to, or more closely approximates,
the PE GPCI calculated for the state with the lowest PE GPCI (in this
case, West Virginia).''
Response: As noted previously in this section, we are required by
section 1848(e)(1)(A) of the Act to develop separate GPCIs to measure
relative resource cost differences among localities compared to the
national average for each of the three fee schedule components: work,
PE and MP expense and to update the GPCIs at least every 3 years. In
the CY 2014 PFS proposed rule, we proposed to update the GPCIs for each
Medicare PFS locality using updated data. For the CY 2014 GPCI update,
we calculated updated GPCIs for the Puerto Rico locality using the same
data sources and methodology as used for other PFS localities. To
calculate the work GPCI and the employee compensation and purchased
service components of the PE GPCI, we used 2009 through 2011 BLS OES
data. To calculate the office rent component of the PE GPCI we used
updated ACS data (2008 through 2010) as replacement for 2006 through
2008. With respect to the comment suggesting we assign the PE GPCI
calculated for West Virginia to the Puerto Rico payment locality, we
note that we are required to calculate GPCIs based upon the geographic
cost differences between a specific PFS payment locality and the
national average. As noted above, we have sufficient cost data to
calculate GPCI values specific to the Puerto Rico payment locality. It
would not be appropriate to assign a PE GPCI calculated for the West
Virginia payment locality (based on data specific to West Virginia) to
the Puerto Rico payment locality. Additionally, with respect to the
comment on the differential between the GPCI values assigned to the
Virgin Islands payment locality (as compared to the calculated GPCI
values for the Puerto Rico payment locality), we note that when a
locality has sufficient locality-specific data, we use those data to
calculate GPCI values according to the established methodology. Given
that there are sufficient locality-specific data for Puerto Rico, we
calculated the GPCI values for the Puerto Rico payment locality based
upon data from Puerto Rico.
As previously mentioned, we continue to believe that the BLS OES
and ACS are reliable data sources for measuring the relative cost
differences in wages and rents. In preparation for the CY 2014 GPCI
update, we reviewed the study previously submitted by stakeholders
entitled ``Cost of Medical Services in Puerto Rico.'' The study aimed
to analyze medical practice costs as well as physicians' perceptions of
cost trends in Puerto Rico. Broadly, many of the study's findings are
not directly relevant to the GPCIs because the study largely measured
increases in the cost of practicing medicine in the Puerto Rico
locality over time, but did not compare Puerto Rico cost trends to
those across other PFS localities. We note that updates to the GPCIs
are based upon changes in the relative costs of operating a medical
practice among all PFS localities and not changes in the costs within a
specific locality. Further, the survey methodology did not claim to be
representative of all physicians furnishing services in the Puerto Rico
payment locality. The physician responses do not appear to be weighted
to represent the population of physicians across the Puerto Rico
payment locality.
Moreover, the study claimed (as did many of the commenters) that
shipping and transportation expenses increase the cost of medical
equipment and supplies in Puerto Rico relative to the U.S. mainland. In
developing the proposed CY 2014 GPCI update, we evaluated the premise
that Puerto Rico physicians incur higher shipping costs when purchasing
medical equipment and supplies that should be reflected in the GPCIs.
At our request, our contractor attempted to locate data sources
specific to geographic variation in shipping costs for medical
equipment and supplies. However, there does not appear to be a
comprehensive national data source available. In light of the comment
that shipping costs are more expensive for the Puerto Rico payment
locality (and rural areas, as discussed later in this section by other
commenters) we are requesting specific information regarding potential
data sources for shipping costs for medical equipment and supplies that
are accessible to the public, available on a national basis for both
urban and rural areas, and updated regularly.
Comment: One commenter asserted that residential rents are an
inaccurate proxy for commercial (office) rents in Puerto Rico because
the residential rental market is less developed in Puerto Rico as
compared to the commercial rental market. The commenter noted that
Puerto Rico's residential rental market is largely skewed towards the
very low (and extremely low) end of the income scale. For example, the
commenter stated that 30 percent of renters in Puerto Rico are
subsidized by a HUD program, compared to a national average of about 12
percent. The commenter also mentioned that the ACS residential rent
data (which are used to calculate the office rent index) includes
utilities. The commenter stated that the cost of one utility,
electricity, in Puerto Rico, is more than double the national average.
However, the commenter believes the high cost of electricity and other
utilities that physicians in Puerto Rico incur is not adequately
captured in the ACS residential rental data, because nearly one third
of all the renters in Puerto Rico receive utility allowances and
therefore are not responsible for their utility costs.
Response: The ACS is designed to capture the total actual costs of
both rent and utilities (i.e. gross rent) regardless of whether either
or both are subsidized and regardless of whether utility costs are
included in rent or paid separately. According to the American
Community Survey and Puerto Rico Community Survey (PRCS) 2010 Subject
Definitions: ``Gross rent is the contract rent plus the estimated
average monthly cost of utilities (electricity, gas, and water and
sewer) and fuels (oils, coal, kerosene, wood, etc.) if these are paid
by the renter (or paid for the renter by someone else).'' (Page 17.)
The rent portion of gross rent is ``the monthly rent agreed to or
contracted for, regardless of any furnishings, utilities, fees, meals,
or services that may be included.'' (Page 15.) Contract rent data were
obtained from Housing Question 15a of the 2010 American Community
Survey and Puerto Rico Community Survey. Utility costs included in the
rent payment were also captured in this question while utility costs
paid separately from contract rent were obtained from a different set
of questions in the survey. For instance, according to the American
Community Survey and Puerto Rico Community Survey 2010 Subject
Definitions: ``The data on utility costs were obtained from Housing
Questions 11a through 11d in the 2010 American Community Survey. The
questions were asked of occupied housing units. The questions about
electricity and gas asked for the monthly costs, and the questions
about water/sewer and other fuels (oil, coal, wood,
[[Page 74389]]
kerosene, etc.) asked for the yearly costs. Costs are recorded if paid
by or billed to occupants, a welfare agency, relatives, or friends
[emphasis added]. Costs that are paid by landlords, included in the
rent payment, or included in condominium or cooperative fees are
excluded'' (Page 37). Therefore, it is correct to say the ACS estimates
of residential rent and utility costs account for subsidized utilities.
The American Community Survey and Puerto Rico Community Survey 2010
Subject Definitions publication may be accessed from the Bureau of
Census Web site at http://www.census.gov/acs/www/Downloads/data_documentation/SubjectDefinitions/2010_ACSSubjectDefinitions.pdf.
Comment: One commenter stated that ``our region's office rental
rates are, by GPCI measurement, supposedly only one-third of the
highest (cost) regions'' and that Medical Group Management Association
(MGMA) survey data do not support these findings. The commenter
requested that relative cost differences be accurately determined
before making any adjustment to the PE GPCI.
Response: We do not believe the MGMA rental information on
physician office rent is an adequate source for calculating the office
rent index component of the PE GPCI for the following reasons. First,
although MGMA invites about 11,000 medical practices to complete each
of the two surveys it conducts (cost survey and compensation survey),
the response rates for these surveys are typically below 20 percent and
responses primarily capture information for physician practices
operating in metropolitan areas. Second, in addition to the low
response rates, MGMA has uneven response rates across regions due to
the fact that MGMA relies on a convenience sample rather than a random
sample. For example, almost twice as many Colorado practices completed
the surveys compared to those in California; the survey also includes
more provider responses from Minnesota (ranked 21st in population) than
any other state. Finally, there are few observations for many small
states; in fact, ten states have fewer than 10 observations each.
For the reasons discussed above, we do not believe the MGMA survey
is a viable data source for determining the relative cost differences
in rents across PFS localities. As discussed previously in this
section, given its national representation, reliability, high response
rate and frequent updates we continue to believe that the ACS
residential rent data is the most appropriate data source available at
this time for purposes of calculating the rent index of the PE GPCI.
Comment: We received mixed comments regarding the potential use of
a proprietary commercial rent data source for purposes of calculating
the rent index of the PE GPCI. For instance, a few commenters stated
that we should continue to explore the possibility of using a
commercial rent data source (but did not comment specifically on the
potential use of proprietary data). One medical association stated that
it would be helpful if we could ``elucidate how incorporating the
commercial rent data would impact the practice expense GPCI and payment
rates in each Medicare payment locality.'' In contrast, three other
commenters did not support the use of a proprietary commercial rent
data source and urged us to continue using publicly available data. One
association suggested that we ``should use the most accurate publicly
available datasets to set the GPCI adjustments . . . because . . . it
is important for the public to have an opportunity to comment on
proposed changes, and they need access to information to provide
meaningful comments.'' Another commenter stated that there is not a
more reliable source of data for calculating physician office rents
(than the ACS residential rent data) and that the ACS data serve as a
reasonable proxy for the relative differences in rents across PFS
localities. The same commenter expressed concern about the cost to the
public of purchasing proprietary data and suggested that a commercial
rent data source might be used to validate relative cost differences
calculated from the ACS data (but not replace the ACS data).
Response: We appreciate the comments received on the potential use
of a proprietary commercial rent data source. In the event we make a
specific proposal to incorporate a commercial rent data source (either
proprietary or publicly available) for calculating the office rent
index of the PE GPCI, we would provide locality level impacts of such
proposal and the opportunity for public comment as afforded through the
rulemaking process.
Comment: A few commenters supported the continuation of the 1.0 PE
GPCI floor for frontier states.
Response: The 1.0 PE GPCI floor will continue to be applied for
states identified as ``frontier states'' in accordance with
1848(e)(1)(I) of the Act.
Comment: Two commenters stated that many rural areas that do not
fall within the statutory definition of a frontier state also face
challenges associated with patient access to ``physician-furnished
services.'' The commenters stated that, even if the 1.0 work GPCI floor
is extended, the updates to the PE GPCIs disadvantage rural providers,
most notably in the provision of drugs and biologicals administered in
a physician's office. The commenters assert that rural practices have
``low purchasing power'' (because of lower patient volumes) and higher
shipping costs (in comparison to urban areas). The same commenters
urged us to take into account the ``unique challenges faced by rural
physicians in non-designated frontier states'' and to fully recognize
the significant costs of providing health care in rural communities
when updating the GPCIs.
Response: We appreciate the comments received on the PE GPCI for
rural areas. As discussed previously in this section, we are required
to update the GPCIs at least every 3 years to reflect the relative cost
differences of operating a medical practice in each locality compared
to the national average costs. We do not have authority to apply the
1.0 PE GPCI floor to states that do not meet the statutory definition
of a frontier state. As discussed above in response to another
commenter, we are requesting specific information regarding potential
data sources for shipping costs for medical equipment and supplies--
especially sources that are publicly available, collect data nationally
with sufficient coverage in both urban and rural areas, and are updated
at regular intervals.
Comment: Several state medical associations strongly opposed the
proposed revised 2006-based MEI that moved compensation for
nonphysician practitioners from the practice expense category to the
physician compensation category, and the implications of that proposed
change for the GPCIs. Because of those concerns, the commenters
strongly objected to our proposal to update the GPCI cost share weights
to make them consistent with the most recent update to the MEI.
Additionally, the commenters expressed concern that the proposed
changes in cost share weights used in calculating updated GPCIs would
alone cause significant changes in CY 2014 PFS payment amounts.
Response: As discussed in section II.B. revisions to the MEI are
used to adjust the RVUs under the PFS so that the work RVUs and PE RVUs
(in the aggregate) are in the same proportions as in the MEI. We also
make the necessary adjustments to achieve budget neutrality for the
year under the PFS. A discussion of how our adoption of the proposed
MEI cost weight revisions affects the
[[Page 74390]]
adjustment of work RVUs and PE RVUs is provided in section II.B. of
this final rule with comment period.
With regard to the GPCIs, as noted in section II.F.2.d., we
historically have updated the GPCI cost share weights (and more
generally, as noted above, the RVUs under the PFS) to make them
consistent with the most recent update to the MEI because the MEI cost
share weights reflect our actuaries' best estimate of the weights
associated with each of the various inputs needed to provide physician
services. Use of the revised MEI weights for purposes of the GPCIs does
not represent a change to the data sources or methodology used to
calculate the GPCIs. For purposes of calculating GPCI values, the
revised MEI weights only result in changes to the relative weighting
within the PE GPCI (because there are no subcomponent cost share
weights for the work GPCI or malpractice GPCI). Since the MEI weight
only changed for the employee compensation subcomponent (for instance,
the MEI weights for office rent, purchased services and equipment and
supplies remained unchanged), the revised MEI affected the relative
weight of all PE subcomponents (as a percentage of total PE GPCI). In
other words, using the revised MEI cost share weights results in a
lower weight for the employee compensation component as a percentage of
the total PE GPCI and higher weights for office rents, purchased
services, and medical equipment and supplies as a percentage of the
total PE GPCI. Use of the revised MEI cost share weights has no
implications for calculating the work GPCI values or malpractice GPCI
values. Thus, we believe the comments on our proposal to adopt the
revised 2006-based MEI weights predominately reflect concerns about the
impact of the revised weights in terms of RVU redistribution and
conversion factor adjustment, which is discussed in section II.B.2.f.,
rather than on their use in the calculation of GPCI values. An analysis
isolating the impact of the changes in the subcomponent weighting of
the PE GPCIs is available on the CMS Web site under the supporting
documents section of the CY 2014 PFS final rule Web page at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
We note that the MEI cost share weights are also used to calculate
a geographic adjustment factor (GAF) for each PFS locality, weighting
each locality's GPCIs (work, PE, and MP) by the corresponding national
MEI cost share weight. However, as mentioned previously, we calculate
the GAFs for purposes of comparing the approximate aggregate geographic
payment adjustments among localities. The GAF is not used to calculate
the geographically adjusted payment amount for individual services.
Rather, the geographically adjusted payment amount is calculated by
applying the actual GPCI values (for work, PE and malpractice) for the
particular PFS locality to adjust the RVUs (for work, PE and MP) for a
specific service.
Comment: A few national medical associations requested that CMS
respond to the Institute of Medicine's ``Recommendation 3'' as
contained in its Phase II report. The commenters noted that the
Institute of Medicine recommended that the Medicare program should
support policies that would allow all qualified practitioners to
practice to the full extent of their educational preparation. The
commenters believe ``that there are numerous barriers in Medicare
regulations, procedures, and instructions that prevent nurse
practitioners and other health care providers from performing the full
range of services they are educated and clinically prepared to
deliver.'' However, the commenter did not provide specific examples as
part of their submitted comments on the CY 2014 PFS proposed rule.
Moreover, the commenter urged us to develop proposals to revise
Medicare regulations and policies to address the need for primary care,
including women's health and pediatric services, in underserved areas.
Response: The Institute of Medicine's Phase II report summary
analysis indicates: ``There are many inconsistencies in state laws
regarding scope of practice and many NPs are more likely to locate in
rural areas in states with more progressive, less restrictive
regulations.'' Additionally, the Institute of Medicine recommended that
``given the shortage of primary care providers in the United States and
specifically in rural areas, the committee agrees that it would be
reasonable to remove barriers in Medicare and state licensing language
so all qualified practitioners are able to practice to the full extent
of their educational preparation in providing needed services for
Medicare beneficiaries'' (Page 10). We did not include any proposals
based on this Institute of Medicine recommendation in the CY 2014 PFS
proposed rule. Therefore, we believe the comments relating to this
recommendation are beyond the scope of the CY 2014 PFS proposed rule.
Comment: We received several comments on the PFS locality structure
that were not within the scope of the CY 2014 proposed rule. For
example, several commenters requested a locality change for a specific
county. Another commenter requested that we consider the operational
impact of a locality reconfiguration on the provider community,
including non-physician practitioners, before making changes to the PFS
locality structure. Two state medical associations emphasized the need
to reform PFS localities, preferring an MSA-based approach. One
national association was opposed to locality changes resulting in
payment reductions to rural areas and a rural physician clinic
recommended that we do not make any changes to the PFS locality
structure because increasing the number of localities would lower
payments to rural physicians.
Response: We appreciate the suggestions for making revisions to the
PFS locality structure. As discussed above, we did not propose changes
to the PFS locality structure.
Result of Evaluation of Comments
After consideration of the public comments received on the CY 2014
GPCI update, we are finalizing the CY 2014 GPCI update as proposed.
Specifically, we are using updated BLS OES data (2009 through 2011) as
a replacement for 2006 through 2008 data for purposes of calculating
the work GPCI and the employee compensation component and purchased
services component of the PE GPCI. We are also using updated ACS data
(2008 through 2010) as a replacement for 2006 through 2008 data for
calculating the office rent component of the PE GPCI, and updated
malpractice premium data (2011 and 2012) as a replacement for 2006
through 2007 data to calculate the MP GPCI. We also note that we do not
adjust the medical equipment, supplies and other miscellaneous expenses
component of the PE GPCI because we continue to believe there is a
national market for these items such that there is not a significant
geographic variation in costs. However, in light of comments suggesting
that there are geographic differences in shipping costs for medical
equipment and supplies, we are requesting specific information
regarding potential data sources for these shipping costs--especially
sources that are publicly available, nationally representative with
sufficient coverage in both urban and rural areas, and updated at
regular intervals. Additionally, we are finalizing our proposal to
update the GPCI cost share weights consistent with the revised
[[Page 74391]]
2006-based MEI cost share weights finalized in section II.D. of this
final rule with comment period. As discussed above in response to
comments, use of the revised GPCI cost share weights changed the
weighting of the subcomponents within the PE GPCI (employee wages,
office rent, purchased services, and medical equipment and supplies).
The CY 2014 updated GPCIs and summarized GAFs by Medicare PFS
locality may be found in Addenda D and E to the CY 2014 final rule
available on the CMS Web site under the supporting documents section of
the CY 2014 proposed rule Web page at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
Additional information on the CY 2014 GPCI update may be found in
our contractor's report, ``Report on the CY 2014 Update of the
Geographic Practice Cost Index for the Medicare Physician Fee
Schedule,'' which is available on the CMS Web site. It is located under
the supporting documents section of the CY 2014 PFS final rule with
comment period located at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
G. Allowed Expenditures for Physicians' Services and the Sustainable
Growth Rate
1. Medicare Sustainable Growth Rate (SGR)
The SGR is an annual growth rate that applies to physicians'
services paid by Medicare. The use of the SGR is intended to control
growth in aggregate Medicare expenditures for physicians' services.
Payments for services are not withheld if the percentage increase in
actual expenditures exceeds the SGR. Rather, the PFS update, as
specified in section 1848(d)(4) of the Act, is adjusted based on a
comparison of allowed expenditures (determined using the SGR) and
actual expenditures. If actual expenditures exceed allowed
expenditures, the update is reduced. If actual expenditures are less
than allowed expenditures, the update is increased.
Section 1848(f)(2) of the Act specifies that the SGR for a year
(beginning with CY 2001) is equal to the product of the following four
factors:
(1) The estimated change in fees for physicians' services;
(2) The estimated change in the average number of Medicare fee-for-
service beneficiaries;
(3) The estimated projected growth in real Gross Domestic Product
per capita; and
(4) The estimated change in expenditures due to changes in statute
or regulations.
In general, section 1848(f)(3) of the Act requires us to determine
the SGRs for 3 different time periods], using the best data available
as of September 1 of each year. Under section 1848(f)(3) of the Act,
(beginning with the FY and CY 2000 SGRs) the SGR is estimated and
subsequently revised twice based on later data. (The Act also provides
for adjustments to be made to the SGRs for FY 1998 and FY 1999. See the
February 28, 2003 Federal Register (68 FR 9567) for a discussion of
these SGRs). Under section 1848(f)(3)(C)(ii) of the Act, there are no
further revisions to the SGR once it has been estimated and
subsequently revised in each of the 2 years following the preliminary
estimate. In this final rule with comment, we are making our
preliminary estimate of the CY 2014 SGR, a revision to the CY 2013 SGR,
and our final revision to the CY 2012 SGR.
a. Physicians' Services
Section 1848(f)(4)(A) of the Act defines the scope of physicians'
services covered by the SGR. The statute indicates that ``the term
`physicians' services' includes other items and services (such as
clinical diagnostic laboratory tests and radiology services), specified
by the Secretary, that are commonly performed or furnished by a
physician or in a physician's office, but does not include services
furnished to a Medicare+Choice plan enrollee.''
We published a definition of physicians' services for use in the
SGR in the November 1, 2001 Federal Register (66 FR 55316). We defined
physicians' services to include many of the medical and other health
services listed in section 1861(s) of the Act. Since that time, the
statute has been amended to add new Medicare benefits. As the statute
changed, we modified the definition of physicians' services for the SGR
to include the additional benefits added to the statute that meet the
criteria specified in section 1848(f)(4)(A).
As discussed in the CY 2010 PFS final rule with comment period (74
FR 61961), the statute provides the Secretary with clear discretion to
decide whether physician-administered drugs should be included or
excluded from the definition of ``physicians' services.'' Exercising
this discretion, we removed physician-administered drugs from the
definition of physicians' services in section 1848(f)(4)(A) of the Act
for purposes of computing the SGR and the levels of allowed
expenditures and actual expenditures beginning with CY 2010, and for
all subsequent years. Furthermore, in order to effectuate fully the
Secretary's policy decision to remove drugs from the definition of
physicians' services, we removed physician-administered drugs from the
calculation of allowed and actual expenditures for all prior years.
Thus, for purposes of determining allowed expenditures, actual
expenditures for all years, and SGRs beginning with CY 2010 and for all
subsequent years, we specified that physicians' services include the
following medical and other health services if bills for the items and
services are processed and paid by Medicare carriers (and those paid
through intermediaries where specified) or the equivalent services
processed by the Medicare Administrative Contractors:
Physicians' services.
Services and supplies furnished incident to physicians'
services, except for the expenditures for ``drugs and biologicals which
are not usually self-administered by the patient.''
Outpatient physical therapy services and outpatient
occupational therapy services,
Services of PAs, certified registered nurse anesthetists,
certified nurse midwives, clinical psychologists, clinical social
workers, nurse practitioners, and certified nurse specialists.
Screening tests for prostate cancer, colorectal cancer,
and glaucoma.
Screening mammography, screening pap smears, and screening
pelvic exams.
Diabetes outpatient self-management training (DSMT)
services.
Medical Nutrition Therapy (MNT) services.
Diagnostic x-ray tests, diagnostic laboratory tests, and
other diagnostic tests (including outpatient diagnostic laboratory
tests paid through intermediaries).
X-ray, radium, and radioactive isotope therapy.
Surgical dressings, splints, casts, and other devices used
for the reduction of fractures and dislocations.
Bone mass measurements.
An initial preventive physical exam.
Cardiovascular screening blood tests.
Diabetes screening tests.
Telehealth services.
Physician work and resources to establish and document the
need for a power mobility device.
Additional preventive services.
[[Page 74392]]
Pulmonary rehabilitation.
Cardiac rehabilitation.
Intensive cardiac rehabilitation.
Kidney disease education (KDE) services.
Personalized prevention plan services
b. Preliminary Estimate of the SGR for 2014
Our preliminary estimate of the CY 2014 SGR is -16.7 percent. We
first estimated the CY 2014 SGR in March 2013, and we made the estimate
available to the MedPAC and on our Web site. Table 33 shows the March
2013 estimate and our current estimates of the factors included in the
2014 SGR. The majority of the difference between the March estimate and
our current estimate of the CY 2014 SGR is explained by changes in
estimated enrollment after our March estimate was prepared. Estimates
of 2014 real per capita GDP are also higher than were included in our
March 2013 estimate of the SGR.
Table 33--CY 2014 SGR Calculation
----------------------------------------------------------------------------------------------------------------
Statutory factors March estimate Current estimate
----------------------------------------------------------------------------------------------------------------
Fees................................. 0.5 percent (1.005).......... 0.6 percent (1.006).
Enrollment........................... 4.5 percent (1.045).......... 2.2 percent (1.022).
Real per Capita GDP.................. 0.6 percent (1.006).......... 0.8 percent (1.008).
Law and Regulation................... -19.7 percent (0.803)........ -19.6 percent (0.804).
--------------------------------------------------------------------------
Total............................ -15.2 percent (0.848)........ -16.7 percent (0.833).
----------------------------------------------------------------------------------------------------------------
Note: Consistent with section 1848(f)(2) of the Act, the statutory factors are multiplied, not added, to produce
the total (that is, 1.006 x 1.022 x 1.008 x 0.804 = 0.833). A more detailed explanation of each figure is
provided in section II.G.1.e. of this final rule with comment period.
c. Revised Sustainable Growth Rate for CY 2013
Our current estimate of the CY 2013 SGR is 1.8 percent. Table 34
shows our preliminary estimate of the CY 2013 SGR, which was published
in the CY 2013 PFS final rule with comment period, and our current
estimate. The majority of the difference between the preliminary
estimate and our current estimate of the CY 2013 SGR is explained by
adjustments to reflect intervening legislative changes that have
occurred since publication of the CY 2013 final rule with comment
period.
Table 34--CY 2013 SGR Calculation
----------------------------------------------------------------------------------------------------------------
Estimate from CY 2013 final
Statutory factors rule Current estimate
----------------------------------------------------------------------------------------------------------------
Fees................................. 0.3 percent (1.003).......... 0.4 Percent (1.004).
Enrollment........................... 3.6 percent (1.036).......... 1.0 Percent (1.01).
Real per Capita GDP.................. 0.7 percent (1.007).......... 0.9 Percent (1.009).
Law and Regulation................... -23.3 percent (0.767)........ -0.5 Percent (0.995).
--------------------------------------------------------------------------
Total............................ -19.7 percent (0.803)........ 1.8 Percent (1.018).
----------------------------------------------------------------------------------------------------------------
Note: Consistent with section 1848(f)(2) of the Act, the statutory factors are multiplied, not added, to produce
the total (that is, 1.004 x 1.01 x 1.009 x 0.995 = 1.018). A more detailed explanation of each figure is
provided in section II.G.1.e. of this final rule with comment period.
d. Final Sustainable Growth Rate for CY 2012
The SGR for CY 2012 is 5.1 percent. Table 35 shows our preliminary
estimate of the CY 2012 SGR from the CY 2012 PFS final rule with
comment period, our revised estimate from the CY 2013 PFS final rule
with comment period, and the final figures determined using the best
available data as of September 1, 2013.
Table 35--CY 2012 SGR Calculation
----------------------------------------------------------------------------------------------------------------
Estimate from CY Estimate from CY
Statutory factors 2012 final rule 2013 final rule Final
----------------------------------------------------------------------------------------------------------------
Fees............................ 0.6 percent (1.006) 0.6 percent (1.006) 0.6 Percent (1.006).
Enrollment...................... 3.5 percent (1.035) 1.6 percent (1.016) 0.9 Percent (1.009).
Real per Capita GDP............. 0.6 percent (1.006) 0.7 percent (1.007) 0.9 Percent (1.009).
Law and Regulation.............. -20.7 percent 0.0 percent (1.000) 2.6 Percent (1.026).
(0.793).
-------------------------------------------------------------------------------
Total....................... -16.9 percent 2.3 percent (1.023) 5.1 Percent (1.051).
(0.831).
----------------------------------------------------------------------------------------------------------------
Note: Consistent with section 1848(f)(2) of the Act, the statutory factors are multiplied, not added, to produce
the total (that is, 1.006 x 1.009 x 1.009 x 1.026 = 1.051). A more detailed explanation of each figure is
provided in section II.G.1.e. of this final rule with comment period.
e. Calculation of CYs 2014, 2013, and 2012 SGRs
(1) Detail on the CY 2014 SGR
All of the figures used to determine the CY 2014 SGR are estimates
that will be revised based on subsequent data. Any differences between
these estimates and the actual measurement of these figures will be
included in future revisions of the SGR and allowed expenditures and
incorporated into subsequent PFS updates.
[[Page 74393]]
(a) Factor 1- Changes in Fees for Physicians' Services (Before Applying
Legislative Adjustments) for CY 2014
This factor is calculated as a weighted average of the CY 2014
changes in fees for the different types of services included in the
definition of physicians' services for the SGR. Medical and other
health services paid using the PFS are estimated to account for
approximately 87.7 percent of total allowed charges included in the SGR
in CY 2014 and are updated using the percent change in the MEI. As
discussed in section A of this final rule with comment period, the
percent change in the MEI for CY 2014 is 0.8 percent. Diagnostic
laboratory tests are estimated to represent approximately 12.3 percent
of Medicare allowed charges included in the SGR for CY 2014. Medicare
payments for these tests are updated by the Consumer Price Index for
Urban Areas (CPI-U), which is 1.8 percent for CY 2014. Section
1833(h)(2)(A)(iv) of the Act requires that the CPI-U update applied to
clinical laboratory tests be reduced by a multi-factor productivity
adjustment (MFP adjustment) and, for each of years 2011 through 2015,
by 1.75 percentage points (percentage adjustment). The MFP adjustment
will not apply in a year where the CPI-U is zero or a percentage
decrease for a year. Further, the application of the MFP adjustment
shall not result in an adjustment to the fee schedule of less than zero
for a year. However, the application of the percentage adjustment may
result in an adjustment to the fee schedule being less than zero for a
year and may result in payment rates for a year being less than such
payment rates for the preceding year. The applicable productivity
adjustment for CY 2014 is -0.8 percent. Adjusting the CPI-U update by
the productivity adjustment results in a 1.0 percent (1.8 percent (CPI-
U) minus 0.8 percent (MFP adjustment)) update for CY 2014.
Additionally, the percentage reduction of 1.75 percent is applied for
CYs 2011 through 2015, as discussed previously. Therefore, for CY 2014,
diagnostic laboratory tests will receive an update of -0.8 percent
(rounded). Table 36 shows the weighted average of the MEI and
laboratory price changes for CY 2014.
Table 36--Weighted-Average of the MEI and Laboratory Price Changes for
CY 2014
------------------------------------------------------------------------
Update
Weight (%)
------------------------------------------------------------------------
Physician......................................... 0.877 0.8
Laboratory........................................ 0.123 -0.8
Weighted-average.................................. 1.000 0.6
------------------------------------------------------------------------
We estimate that the weighted average increase in fees for
physicians' services in CY 2014 under the SGR (before applying any
legislative adjustments) will be 0.6 percent.
(b) Factor 2--Percentage Change in the Average Number of Part B
Enrollees From CY 2013 to CY 2014
This factor is our estimate of the percent change in the average
number of fee-for-service enrollees from CY 2013 to CY 2014. Services
provided to Medicare Advantage (MA) plan enrollees are outside the
scope of the SGR and are excluded from this estimate. We estimate that
the average number of Medicare Part B fee-for-service enrollees will
increase by 2.2 percent from CY 2013 to CY 2014. Table 37 illustrates
how this figure was determined.
Table 37--Average Number of Medicare Part B Fee-for-Service Enrollees
From CY 2013 to CY 2014
[Excluding beneficiaries enrolled in MA plans]
------------------------------------------------------------------------
CY 2013 CY 2014
------------------------------------------------------------------------
Overall..................... 47.982 million...... 49.459 million.
Medicare Advantage (MA)..... 14.837 million...... 15.569 million.
Net......................... 33.144 million...... 33.890 million.
Percent Increase............ 1 percent........... 2.2 percent.
------------------------------------------------------------------------
An important factor affecting fee-for-service enrollment is
beneficiary enrollment in MA plans. Because it is difficult to estimate
the size of the MA enrollee population before the start of a CY, at
this time we do not know how actual enrollment in MA plans will compare
to current estimates. For this reason, the estimate may change
substantially as actual Medicare fee-for-service enrollment for CY 2014
becomes known.
(c) Factor 3--Estimated Real Gross Domestic Product per Capita Growth
in CY 2014
We estimate that the growth in real GDP per capita from CY 2013 to
CY 2014 will be 0.8 percent (based on the annual growth in the 10 year
moving average of real GDP per capita 2005 through 2014). Our past
experience indicates that there have also been changes in estimates of
real GDP per capita growth made before the year begins and the actual
change in real GDP per capita growth computed after the year is
complete. Thus, it is possible that this figure will change as actual
information on economic performance becomes available to us in CY 2014.
(d) Factor 4--Percentage Change in Expenditures for Physicians'
Services Resulting From Changes in Statute or Regulations in CY 2014
Compared With CY 2013
The statutory and regulatory provisions that will affect
expenditures in CY 2014 relative to CY 2013 are estimated to have an
impact on expenditures of -19.6 percent. The impact is primarily due to
the expiration of the physician fee schedule update specified in
statute for CY 2013 only.
(2) Detail on the CY 2013 SGR
A more detailed discussion of our revised estimates of the four
elements of the CY 2013 SGR follows.
(a) Factor 1--Changes in Fees for Physicians' Services (Before Applying
Legislative Adjustments) for CY 2013
This factor was calculated as a weighted-average of the CY 2013
changes in fees that apply for the different types of services included
in the definition of physicians' services for the SGR in CY 2013.
We estimate that services paid using the PFS account for
approximately 90.1 percent of total allowed charges included in the SGR
in CY 2013. These services were updated using the CY 2013 percent
change in the MEI of 0.8 percent. We estimate that diagnostic
laboratory tests represent approximately 9.9 percent of total allowed
charges
[[Page 74394]]
included in the SGR in CY 2013. For CY 2013, diagnostic laboratory
tests received an update of -3.0 percent.
Table 38 shows the weighted-average of the MEI and laboratory price
changes for CY 2013.
Table 38--Weighted-Average of the MEI, and Laboratory Price Changes for
CY 2013
------------------------------------------------------------------------
Weight Update
------------------------------------------------------------------------
Physician......................................... 0.901 0.8
Laboratory........................................ 0.099 -3.0
Weighted-average.................................. 1.000 0.4
------------------------------------------------------------------------
After considering the elements described in Table 38, we estimate
that the weighted-average increase in fees for physicians' services in
CY 2013 under the SGR was 0.4 percent. Our estimate of this factor in
the CY 2013 PFS final rule with comment period was 0.3 percent (77 FR
69133).
(b) Factor 2--Percentage Change in the Average Number of Part B
Enrollees From CY 2012 to CY 2013
We estimate that the average number of Medicare Part B fee-for-
service enrollees (excluding beneficiaries enrolled in Medicare
Advantage plans) increased by 1.0 percent in CY 2013. Table 39
illustrates how we determined this figure.
Table 39--Average Number of Medicare Part B Fee-for-Service Enrollees
From CY 2012 to CY 2013
[Excluding beneficiaries enrolled in MA plans]
------------------------------------------------------------------------
CY 2012 CY 2013
------------------------------------------------------------------------
Overall..................... 46.405 million...... 47.982 million.
Medicare Advantage (MA)..... 13.586 million...... 14.837 million.
Net......................... 32.818 million...... 33.144 million.
Percent Increase............ 0.9 percent......... 1.0 percent.
------------------------------------------------------------------------
Our estimate of the 1.0 percent change in the number of fee-for-
service enrollees, net of Medicare Advantage enrollment for CY 2013
compared to CY 2012, is different than our original estimate of an
increase of 3.6 percent in the CY 2013 PFS final rule with comment
period (77 FR 69133). While our current projection based on data from 8
months of CY 2013 differs from our original estimate of 0.4 percent
when we had no actual data, it is still possible that our final
estimate of this figure will be different once we have complete
information on CY 2013 fee-for-service enrollment.
(c) Factor 3--Estimated Real GDP per Capita Growth in CY 2013
We estimate that the growth in real GDP per capita will be 0.9
percent for CY 2013 (based on the annual growth in the 10-year moving
average of real GDP per capita (2004 through 2013)). Our past
experience indicates that there have also been differences between our
estimates of real per capita GDP growth made prior to the year's end
and the actual change in this factor. Thus, it is possible that this
figure will change further as complete actual information on CY 2013
economic performance becomes available to us in CY 2014.
(d) Factor 4--Percentage Change in Expenditures for Physicians'
Services Resulting From Changes in Statute or Regulations in CY 2013
Compared With CY 2012
The statutory and regulatory provisions that affected expenditures
in CY 2013 relative to CY 2012 are estimated to have an impact on
expenditures of -0.5 percent. This impact is primarily due to the
expiration of the PFS update specified in statute for CY 2013 only.
(3) Detail on the CY 2012 SGR
A more detailed discussion of our final revised estimates of the
four elements of the CY 2012 SGR follows.
(a) Factor 1--Changes in Fees for Physicians' Services for CY 2012
This factor was calculated as a weighted average of the CY 2012
changes in fees that apply for the different types of services included
in the definition of physicians' services for the SGR in CY 2012.
We estimate that services paid under the PFS account for
approximately 90 percent of total allowed charges included in the SGR
in CY 2012. These services were updated using the CY 2012 percent
change in the MEI of 0.6 percent. We estimate that diagnostic
laboratory tests represent approximately 10 percent of total allowed
charges included in the SGR in CY 2012. For CY 2012, diagnostic
laboratory tests received an update of 0.7 percent.
Table 40 shows the weighted-average of the MEI and laboratory price
changes for CY 2012.
Table 40--Weighted-Average of the MEI, Laboratory, and Drug Price
Changes for 2012
------------------------------------------------------------------------
Weight Update
------------------------------------------------------------------------
Physician........................................ 0.900 0.6
Laboratory....................................... 0.100 0.7
Weighted-average................................. 1.00 0.6
------------------------------------------------------------------------
After considering the elements described in Table 40, we estimate
that the weighted-average increase in fees for physicians' services in
CY 2012 under the SGR (before applying any legislative adjustments) was
0.6 percent. This figure is a final one based on complete data for CY
2012.
(b) Factor 2--Percentage Change in the Average Number of Part B
Enrollees From CY 2011 to CY 2012
We estimate the change in the number of fee-for-service enrollees
(excluding beneficiaries enrolled in MA plans) from CY 2011 to CY 2012
was 0.9 percent. Our calculation of this factor is based on complete
data from CY 2012. Table 41 illustrates the calculation of this factor.
Table 41--Average Number of Medicare Part B Fee-for-Service Enrollees
From CY 2011 to CY 2012
[Excluding beneficiaries enrolled in MA Plans]
------------------------------------------------------------------------
CY 2011 CY 2012
------------------------------------------------------------------------
Overall........................................... 44.906 46.405
Medicare Advantage (MA)........................... 12.382 13.586
Net............................................... 32.524 32.818
[[Page 74395]]
Percent Change.................................... ......... 0.9%
------------------------------------------------------------------------
(c) Factor 3--Estimated Real GDP per Capita Growth in CY 2012
We estimate that the growth in real per capita GDP was 0.9 percent
in CY 2012 (based on the annual growth in the 10-year moving average of
real GDP per capita (2003 through 2012)). This figure is a final one
based on complete data for CY 2012.
(d) Factor 4--Percentage Change in Expenditures for Physicians'
Services Resulting From Changes in Statute or Regulations in CY 2012
Compared With CY 2011
Our final estimate for the net impact on expenditures from the
statutory and regulatory provisions that affect expenditures in CY 2012
relative to CY 2011 is 2.6 percent. This is primarily an effect of the
statutory requirements surrounding the temporary physician fee schedule
update in CY 2012.
2. The Update Adjustment Factor (UAF)
Section 1848(d) of the Act provides that the PFS update is equal to
the product of the MEI and the UAF. The UAF is applied to make actual
and target expenditures (referred to in the statute as ``allowed
expenditures'') equal. As discussed previously, allowed expenditures
are equal to actual expenditures in a base period updated each year by
the SGR. The SGR sets the annual rate of growth in allowed expenditures
and is determined by a formula specified in section 1848(f) of the Act.
The calculation of the UAF is not affected by sequestration.
Pursuant to 2 U.S.C. 906(d)(6), ``The Secretary of Health and Human
Services shall not take into account any reductions in payment amounts
which have been or may be effected under [sequestration], for purposes
of computing any adjustments to payment rates under such title XVIII''.
Therefore, allowed charges, which are unaffected by sequestration, were
used to calculate physician expenditures in lieu of Medicare payments
plus beneficiary cost-sharing. As a result, neither actual expenditures
or allowed expenditures were adjusted to reflect the impact of
sequestration.
a. Calculation Under Current Law
Under section 1848(d)(4)(B) of the Act, the UAF for a year
beginning with CY 2001 is equal to the sum of the following--
Prior Year Adjustment Component. An amount determined by--
++ Computing the difference (which may be positive or negative)
between the amount of the allowed expenditures for physicians' services
for the prior year (the year prior to the year for which the update is
being determined) and the amount of the actual expenditures for those
services for that year;
++ Dividing that difference by the amount of the actual
expenditures for those services for that year; and
++ Multiplying that quotient by 0.75.
Cumulative Adjustment Component. An amount determined by--
++ Computing the difference (which may be positive or negative)
between the amount of the allowed expenditures for physicians' services
from April 1, 1996, through the end of the prior year and the amount of
the actual expenditures for those services during that period;
++ Dividing that difference by actual expenditures for those
services for the prior year as increased by the SGR for the year for
which the UAF is to be determined; and
++ Multiplying that quotient by 0.33.
Section 1848(d)(4)(E) of the Act requires the Secretary to
recalculate allowed expenditures consistent with section 1848(f)(3) of
the Act. As discussed previously, section 1848(f)(3) specifies that the
SGR (and, in turn, allowed expenditures) for the upcoming CY (CY 2014
in this case), the current CY (that is, CY 2013) and the preceding CY
(that is, CY 2012) are to be determined on the basis of the best data
available as of September 1 of the current year. Allowed expenditures
for a year generally are estimated initially and subsequently revised
twice. The second revision occurs after the CY has ended (that is, we
are making the second revision to CY 2012 allowed expenditures in this
final rule with comment).
Table 42 shows the historical SGRs corresponding to each period
through CY 2014.
Table 42--Annual and Cumulative Allowed and Actual Expenditures for Physicians' Services From April 1, 1996 Through the End of the Upcoming Calendar
Year
--------------------------------------------------------------------------------------------------------------------------------------------------------
Cumulative
Annual allowed Annual actual allowed Cumulative actual
Period expenditures ($ expenditures ($ expenditures ($ expenditures ($ FY/CY SGR
in billions) in billions) in billions) in billions)
--------------------------------------------------------------------------------------------------------------------------------------------------------
4/1/96-3/31/97........................................... 47.0 47.0 47.0 47.0 .................
4/1/97-3/31/98........................................... 48.5 47.2 95.6 94.3 3.2
4/1/98-3/31/99........................................... 50.6 48.1 146.2 142.4 4.2
1/1/99-3/31/99........................................... 12.7 12.5 146.2 142.4 .................
4/1/99-12/31/99.......................................... 40.5 37.2 186.7 179.6 6.9
1/1/99-12/31/99.......................................... 53.2 49.7 186.7 179.6 .................
1/1/00-12/31/00.......................................... 57.1 54.4 243.7 234.0 7.3
1/1/01-12/31/01.......................................... 59.7 61.5 303.4 295.5 4.5
1/1/02-12/31/02.......................................... 64.6 64.8 368.0 360.3 8.3
1/1/03-12/31/03.......................................... 69.3 70.4 437.3 430.7 7.3
1/1/04-12/31/04.......................................... 73.9 78.5 511.2 509.1 6.6
1/1/05-12/31/05.......................................... 77.0 83.8 588.2 593.0 4.2
1/1/06-12/31/06.......................................... 78.2 85.1 666.4 678.1 1.5
1/1/07-12/31/07.......................................... 80.9 85.1 747.2 763.1 3.5
1/1/08-12/31/08.......................................... 84.5 87.3 831.8 850.4 4.5
1/1/09-12/31/09.......................................... 89.9 91.1 921.7 941.5 6.4
1/1/10-12/31/10.......................................... 97.9 96 1,019.60 1,037.40 8.9
1/1/11-12/31/11.......................................... 102.5 99.6 1,122.20 1,137.10 4.7
1/1/12-12/31/12.......................................... 107.8 99.5 1,230.00 1,236.60 5.1
[[Page 74396]]
1/1/13-12/31/13.......................................... 109.7 102.2 1,339.70 1,338.80 1.8
1/1/14-12/31/14.......................................... 91.4 N/A 1,431.10 N/A -16.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Allowed expenditures in the first year (April 1, 1996-March 31, 1997) are equal to actual expenditures. All subsequent figures are equal to
quarterly allowed expenditure figures increased by the applicable SGR. Cumulative allowed expenditures are equal to the sum of annual allowed
expenditures. We provide more detailed quarterly allowed and actual expenditure data on our Web site at the following address: http://www.cms.hhs.gov/SustainableGRatesConFact/ SustainableGRatesConFact/. We expect to update the Web site with the most current information later this month.
\2\ Allowed expenditures for the first quarter of 1999 are based on the FY 1999 SGR.
\3\ Allowed expenditures for the last three quarters of 1999 are based on the FY 2000 SGR.
Consistent with section 1848(d)(4)(E) of the Act, Table 42 includes
our second revision of allowed expenditures for CY 2012, a
recalculation of allowed expenditures for CY 2013, and our initial
estimate of allowed expenditures for CY 2014. To determine the UAF for
CY 2014, the statute requires that we use allowed and actual
expenditures from April 1, 1996 through December 31, 2013 and the CY
2014 SGR. Consistent with section 1848(d)(4)(E) of the Act, we will be
making revisions to the CY 2013 and CY 2014 SGRs and CY 2013 and CY
2014 allowed expenditures. Because we have incomplete actual
expenditure data for CY 2013, we are using an estimate for this period.
Any difference between current estimates and final figures will be
taken into account in determining the UAF for future years.
We are using figures from Table 42 in the following statutory
formula:
[GRAPHIC] [TIFF OMITTED] TR10DE13.000
UAF14 = Update Adjustment Factor for CY 2014 = 3.0
percent
Target13 = Allowed Expenditures for CY 2013 = $109.7
billion
Actual13 = Estimated Actual Expenditures for CY 2013 =
$102.2 billion
Target4/96-12/13 = Allowed Expenditures from 4/1/1996-12/
31/2013 = $1,339.70 billion
Actual4/96-12/13 = Estimated Actual Expenditures from 4/
1/1996-12/31/2013 = $1,338.80 billion
SGR14 = -16.7 percent (0.833)
[GRAPHIC] [TIFF OMITTED] TR10DE13.001
Section 1848(d)(4)(D) of the Act indicates that the UAF determined
under section 1848(d)(4)(B) of the Act for a year may not be less than
-0.07 or greater than 0.03. Since 0.059 (5.9 percent) is greater than
0.03, the UAF for CY 2014 will be 3 percent.
Section 1848(d)(4)(A)(ii) of the Act indicates that 1.0 should be
added to the UAF determined under section 1848(d)(4)(B) of the Act.
Thus, adding 1.0 to 0.03 makes the UAF equal to 1.03.
3. Percentage Change in the MEI for CY 2014
MEI is required by section 1842(b)(3) of the Act, which states that
prevailing charge levels beginning after June 30, 1973 may not exceed
the level from the previous year except to the extent that the
Secretary finds, on the basis of appropriate economic index data, that
the higher level is justified by year-to-year economic changes. The
current form of the MEI was detailed in the CY 2010 PFS final rule (75
FR 73262), which updated the cost structure of the index from a base
year of 2000 to 2006. Additional updates to the MEI are discussed in
section II.D of this final rule with comment period.
The MEI measures the weighted-average annual price change for
various inputs needed to produce physicians' services. The MEI is a
fixed-weight input price index, with an adjustment for the change in
economy-wide multifactor productivity. This index, which has CY 2006
base year weights, is comprised of two broad categories: (1)
Physician's own time; and (2) physician's practice expense (PE).
The physician's compensation (own time) component represents the
net income portion of business receipts and primarily reflects the
input of the physician's own time into the production of physicians'
services in physicians' offices. This category consists of two
subcomponents: (1) Wages and salaries; and (2) fringe benefits.
The physician's practice expense (PE) category represents
nonphysician inputs used in the production of services in physicians'
offices. This category consists of wages and salaries and fringe
benefits for nonphysician staff (who cannot bill independently) and
other nonlabor inputs. The physician's PE component also includes the
following categories of nonlabor inputs: Office expenses; medical
materials and supplies; professional liability insurance; medical
equipment; medical materials and supplies; and other professional
expenses.
Table 43 lists the MEI cost categories with associated weights and
percent changes for price proxies for the CY 2014 update. The CY 2014
final MEI update is 0.8 percent and reflects a 1.9 percent increase in
physician's own time and a 1.4 percent increase in physician's PE.
Within the physician's PE, the largest increase occurred in postage,
which increased 4.9 percent.
For CY 2014, the increase in the MEI is 0.8 percent, which reflects
an increase in the non-productivity adjusted MEI of 1.7 percent and a
productivity adjustment of 0.9 percent (which is based on the 10-year
moving average of economy-wide private nonfarm business
[[Page 74397]]
multifactor productivity). The BLS is the agency that publishes the
official measure of private non-farm business MFP. Please see http://www.bls.gov/mfp, which is the link to the BLS historical published data
on the measure of MFP.
Table 43--Increase in the Medicare Economic Index Update for CY 2014 \1\
------------------------------------------------------------------------
2006 revised
Revised cost category cost weight CY14 Update
\2\ (percent) (percent)
------------------------------------------------------------------------
MEI Total, productivity adjusted........ 100.000 0.8
Productivity: 10[dash]year moving \5\ N/A 0.9
average of MFP \1\.....................
MEI Total, without productivity 100.000 1.7
adjustment.............................
Physician Compensation \3\.............. 50.866 1.9
Wages and Salaries.................. 43.641 1.9
Benefits............................ 7.225 2.2
Practice Expense........................ 49.134 1.4
Non-physician compensation.......... 16.553 1.7
Non-physician wages................. 11.885 1.7
Non-health, non-physician wages. 7.249 1.8
Professional & Related...... 0.800 1.9
Management.................. 1.529 1.8
Clerical.................... 4.720 1.8
Services.................... 0.200 1.5
Health related, non-physician 4.636 1.4
wages..........................
Non-physician benefits.............. 4.668 1.9
Other Practice Expense.............. 32.581 1.2
Utilities....................... 1.266 0.7
Miscellaneous Office Expenses... 2.478 0.3
Chemicals................... 0.723 -1.2
Paper....................... 0.656 1.1
Rubber & Plastics........... 0.598 0.5
All other products.......... 0.500 1.9
Telephone....................... 1.501 0.0
Postage......................... 0.898 4.9
All Other Professional Services. 8.095 1.8
Professional, Scientific, 2.592 1.7
and Tech. Services.........
Administrative and support & 3.052 1.9
waste......................
All Other Services.......... 2.451 1.6
Capital......................... 10.310 0.7
Fixed....................... 8.957 0.7
Moveable.................... 1.353 0.7
Professional Liability Insurance 4.295 1.5
\4\............................
Medical Equipment............... 1.978 1.2
Medical supplies................ 1.760 1.0
------------------------------------------------------------------------
\1\ The forecasts are based upon the latest available Bureau of Labor
Statistics data on the 10-year average of BLS private nonfarm business
multifactor productivity published on June 28, 2013. (http://www.bls.gov/news.release/prod3.nr0.htm.)
\2\ The weights shown for the MEI components are the 2006 base-year
weights, which may not sum to subtotals or totals because of rounding.
The MEI is a fixed-weight, Laspeyres-type input price index whose
category weights indicate the distribution of expenditures among the
inputs to physicians' services for CY 2006. To determine the MEI level
for a given year, the price proxy level for each component is
multiplied by its 2006 weight. The sum of these products (weights
multiplied by the price index levels) overall cost categories yields
the composite MEI level for a given year. The annual percent change in
the MEI levels is an estimate of price change over time for a fixed
market basket of inputs to physicians' services.
\3\ The measures of productivity, average hourly earnings, Employment
Cost Indexes, as well as the various Producer and Consumer Price
Indexes can be found on the Bureau of Labor Statistics Web site at
http://stats.bls.gov.
\4\ Derived from a CMS survey of several major commercial insurers.
\5\ Productivity is factored into the MEI categories as an adjustment;
therefore, no explicit weight exists for productivity in the MEI.
4. Physician and Anesthesia Fee Schedule Conversion Factors for CY 2014
The CY 2014 PFS CF is $27.2006. The CY 2014 national average
anesthesia CF is $17.2283.
a. Physician Fee Schedule Update and Conversion Factor
(1) CY 2014 PFS Update
The formula for calculating the PFS update is set forth in section
1848(d)(4)(A) of the Act. In general, the PFS update is determined by
multiplying the CF for the previous year by the percentage increase in
the MEI less productivity times the UAF, which is calculated as
specified under section 1848(d)(4)(B) of the Act.
(2) CY 2014 PFS Conversion Factor
Generally, the PFS CF for a year is calculated in accordance with
section 1848(d)(1)(A) of the Act by multiplying the previous year's CF
by the PFS update.
We note section 101 of the Medicare Improvements and Extension Act,
Division B of the Tax Relief and Health Care Act of 2006 (MIEA-TRHCA)
provided a 1-year increase in the CY 2007 CF and specified that the CF
for CY 2008 must be computed as if the 1-year increase had never
applied.
Section 101 of the Medicare, Medicaid, and SCHIP Extension Act of
2007 (MMSEA) provided a 6-month increase in the CY 2008 CF, from
January 1, 2008, through June 30, 2008, and specified that the CF for
the remaining portion of CY 2008 and the CFs for CY 2009 and subsequent
years must be computed as if the 6-month increase had never applied.
[[Page 74398]]
Section 131 of the MIPPA extended the increase in the CY 2008 CF
that applied during the first half of the year to the entire year,
provided for a 1.1 percent increase to the CY 2009 CF, and specified
that the CFs for CY 2010 and subsequent years must be computed as if
the increases for CYs 2007, 2008, and 2009 had never applied.
Section 1011(a) of the DODAA and section 5 of the TEA specified a
zero percent update for CY 2010, effective January 1, 2010 through
March 31, 2010.
Section 4 of the Continuing Extension Act of 2010 (CEA) extended
the zero percent update for CY 2010 through May 31, 2010.
Subsequently, section 101(a)(2) of the PACMBPRA provided for a 2.2
percent update to the CF, effective from June 1, 2010 to November 30,
2010.
Section 2 of the Physician Payment and Therapy Relief Act of 2010
(Pub. L. No. 111-286) extended the 2.2 percent through the end of CY
2010.
Section 101 of the MMEA provided a zero percent update for CY 2011,
effective January 1, 2011 through December 31, 2011, and specified that
the CFs for CY 2012 and subsequent years must be computed as if the
increases in previous years had never applied.
Section 301 of the Temporary Payroll Tax Cut Continuation Act of
2011 (TPTCCA) provided a zero percent update effective January 1, 2012
through February 29, 2012, and specified that the CFs for subsequent
time periods must be computed as if the increases in previous years had
never applied.
Section 3003 of the Middle Class Tax Relief and Job Creation Act of
2012 (Job Creation Act) provided a zero percent update effective March
1, 2012 through December 31, 2012, and specified that the CFs for
subsequent time periods must be computed as if the increases in
previous years had never applied.
Section 601 of the American Taxpayer Relief Act (ATRA) of 2012
(Pub. L. 112-240) provided a zero percent update for CY 2013, effective
January 1, 2013 through December 31, 2013, and specified that the CFs
for subsequent time periods must be computed as if the increases in
previous years had not been applied.
Therefore, under current law, the CF that would be in effect in CY
2013 had the prior increases specified above not applied is $25.0070.
In addition, when calculating the PFS CF for a year, section
1848(c)(2)(B)(ii)(II) of the Act requires that increases or decreases
in RVUs may not cause the amount of expenditures for the year to differ
more than $20 million from what it would have been in the absence of
these changes. If this threshold is exceeded, we must make adjustments
to preserve budget neutrality. We estimate that CY 2014 RVU changes
would result in a decrease in Medicare physician expenditures of more
than $20 million. Accordingly, we are increasing the CF by 0.046
percent to offset this estimated decrease in Medicare physician
expenditures due to the CY 2014 RVU changes. Furthermore, as discussed
in section A of this final rule with comment period, we are increasing
the CF by 4.72 percent in order to offset the decrease in Medicare
physician payments due to the CY 2014 rescaling of the RVUs so that the
proportions of total payments for the work, PE, and malpractice RVUs
match the proportions in the final revised MEI for CY 2014.
Accordingly, we calculate the CY 2014 PFS CF to be $27.2006. This final
rule with comment period announces a reduction to payment rates for
physicians' services in CY 2014 under the SGR formula. These payment
rates are currently scheduled to be reduced under the SGR system on
January 1, 2014. The total reduction in the MPFS conversion factor
between CY 2013 and CY 2014 under the SGR system will be 20.1 percent.
By law, we are required to make these reductions in accordance with
section 1848(d) and (f) of the Act, and these reductions can only be
averted by an Act of Congress. While Congress has provided temporary
relief from these reductions every year since 2003, a long-term
solution is critical. We will continue to work with Congress to fix
this untenable situation so doctors and beneficiaries no longer have to
worry about the stability and adequacy of payments from Medicare under
the Physician Fee Schedule.
We illustrate the calculation of the CY 2014 PFS CF in Table 44.
Table 44--Calculation of the CY 2014 PFS CF
------------------------------------------------------------------------
------------------------------------------------------------------------
Conversion Factor in effect in CY ...................... $34.0230
2013.
CY 2013 Conversion Factor had ...................... $25.0070
statutory increases not applied.
CY 2014 Medicare Economic Index.... 0.8 percent (1.008)... ...........
CY 2014 Update Adjustment Factor... 3.0 percent (1.03).... ...........
CY 2014 RVU Budget Neutrality 0.046 percent ...........
Adjustment. (1.00046).
CY 2014 Rescaling to Match MEI 4.718 percent ...........
Weights Budget Neutrality (1.04718).
Adjustment.
CY 2014 Conversion Factor.......... ...................... $27.2006
Percent Change from Conversion ...................... -20.1%
Factor in effect in CY 2013 to CY
2014 Conversion Factor.
------------------------------------------------------------------------
We note payment for services under the PFS will be calculated as
follows:
Payment = [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(Malpractice RVU x Malpractice GPCI)] x CF.
b. Anesthesia Conversion Factor
We calculate the anesthesia CF as indicated in Table 45. Anesthesia
services do not have RVUs like other PFS services. Therefore, we
account for any necessary RVU adjustments through an adjustment to the
anesthesia CF to simulate changes to RVUs. More specifically, if there
is an adjustment to the work, PE, or malpractice RVUs, these
adjustments are applied to the respective shares of the anesthesia CF
as these shares are proxies for the work, PE, and malpractice RVUs for
anesthesia services. Information regarding the anesthesia work, PE, and
malpractice shares can be found at the following: https://www.cms.gov/center/anesth.asp.
The anesthesia CF in effect in CY 2013 is $ 21.9243. As explained
previously, in order to calculate the CY 2014 PFS CF, the statute
requires us to calculate the CFs for all previous years as if the
various legislative changes to the CFs for those years had not
occurred. Accordingly, under current law, the anesthesia CF in effect
in CY 2013 had statutory increases not applied is $16.1236. The percent
change from the anesthesia CF in effect in CY 2013 to the CF for CY
2014 is -21.4 percent. We illustrate the calculation of the CY 2014
anesthesia CF in Table 45.
[[Page 74399]]
Table 45--Calculation of the CY 2014 Anesthesia CF
------------------------------------------------------------------------
------------------------------------------------------------------------
2013 National Average Anesthesia ...................... $21.9243
Conversion Factor in effect in CY
2013.
2013 National Anesthesia Conversion ...................... $16.1236
Factor had Statutory Increases Not
Applied.
CY 2014 Medicare Economic Index.... 0.8 (1.008)........... ...........
CY 2014 Update Adjustment Factor... 3.0 (1.003)........... ...........
CY 2014 Budget Neutrality Work and 0.046 (1.00046)....... ...........
Malpractice Adjustment.
CY 2014 Rescaling to Match MEI 4.718 percent (1.4718) ...........
Weights Budget Neutrality
Adjustment.
CY 2014 Anesthesia Fee Schedule .9823 (.9823)......... ...........
Practice Expense Adjustment.
CY 2014 Anesthesia Conversion ...................... $17.2283
Factor.
Percent Change from 2013 to 2014... ...................... -21.4%
------------------------------------------------------------------------
H. Medicare Telehealth Services for the Physician Fee Schedule
1. Billing and Payment for Telehealth Services
a. History
Prior to January 1, 1999, Medicare coverage for services delivered
via a telecommunications system was limited to services that did not
require a face-to-face encounter under the traditional model of medical
care. Examples of these services included interpretation of an x-ray,
electroencephalogram tracing, and cardiac pacemaker analysis.
Section 4206 of the BBA provided for coverage of, and payment for,
consultation services delivered via a telecommunications system to
Medicare beneficiaries residing in rural health professional shortage
areas (HPSAs) as defined by the Public Health Service Act.
Additionally, the BBA required that a Medicare practitioner
(telepresenter) be with the patient at the time of a teleconsultation.
Further, the BBA specified that payment for a teleconsultation had to
be shared between the consulting practitioner and the referring
practitioner and could not exceed the fee schedule payment that would
have been made to the consultant for the service furnished. The BBA
prohibited payment for any telephone line charges or facility fees
associated with the teleconsultation. We implemented this provision in
the CY 1999 PFS final rule with comment period (63 FR 58814).
Effective October 1, 2001, section 223 of the Medicare, Medicaid
and SCHIP Benefits Improvement Protection Act of 2000 (BIPA) (Pub. L.
106-554) added section 1834(m) to the Act, which significantly expanded
Medicare telehealth services. Section 1834(m)(4)(F)(i) of the Act
defines Medicare telehealth services to include consultations, office
visits, office psychiatry services, and any additional service
specified by the Secretary, when delivered via a telecommunications
system. We first implemented this provision in the CY 2002 PFS final
rule with comment period (66 FR 55246). Section 1834(m)(4)(F)(ii) of
the Act required the Secretary to establish a process that provides for
annual updates to the list of Medicare telehealth services. We
established this process in the CY 2003 PFS final rule with comment
period (67 FR 79988).
As specified in regulations at Sec. 410.78(b), we generally
require that a telehealth service be furnished via an interactive
telecommunications system. Under Sec. 410.78(a)(3), an interactive
telecommunications system is defined as, ``multimedia communications
equipment that includes, at a minimum, audio and video equipment
permitting two-way, real-time interactive communication between the
patient and distant site physician or practitioner. Telephones,
facsimile machines, and electronic mail systems do not meet the
definition of an interactive telecommunications system.'' An
interactive telecommunications system is generally required as a
condition of payment; however, section 1834(m)(1) of the Act allows the
use of asynchronous ``store-and-forward'' technology when the
originating site is a federal telemedicine demonstration program in
Alaska or Hawaii. As specified in regulations at Sec. 410.78(a)(1),
store-and-forward means the asynchronous transmission of medical
information from an originating site to be reviewed at a later time by
the practitioner at the distant site.
Medicare telehealth services may be furnished to an eligible
telehealth individual notwithstanding the fact that the practitioner
furnishing the telehealth service is not at the same location as the
beneficiary. An eligible telehealth individual means an individual
enrolled under Part B who receives a telehealth service furnished at an
originating site. Under the BIPA, originating sites were limited under
section 1834(m)(3)(C) of the Act to specified medical facilities
located in specific geographic areas. The initial list of telehealth
originating sites included the office of a practitioner, CAH, a rural
health clinic (RHC), a federally qualified health center (FQHC) and a
hospital (as defined in section 1861(e) of the Act). More recently,
section 149 of the Medicare Improvements for Patients and Providers Act
of 2008 (Pub. L. 110-275) (MIPPA) expanded the list of telehealth
originating sites to include a hospital-based renal dialysis center, a
skilled nursing facility (SNF), and a community mental health center
(CMHC). To serve as a telehealth originating site, the Act requires
that a site must also be located in an area designated as a rural HPSA,
in a county that is not in a MSA, or must be an entity that
participates in a federal telemedicine demonstration project that has
been approved by (or receives funding from) the Secretary as of
December 31, 2000. Finally, section 1834(m) of the Act does not require
the eligible telehealth individual to be with a telepresenter at the
originating site.
b. Current Telehealth Billing and Payment Policies
As noted previously, Medicare telehealth services can only be
furnished to an eligible telehealth beneficiary in a qualifying
originating site. An originating site is defined as one of the
specified sites where an eligible telehealth individual is located at
the time the service is being furnished via a telecommunications
system. The originating sites authorized by the statute are as follows:
Offices of a physician or practitioner;
Hospitals;
CAHs;
RHCs;
FQHCs;
Hospital-Based or Critical Access Hospital-Based Renal
Dialysis Centers (including Satellites);
SNFs;
CMHCs.
Currently approved Medicare telehealth services include the
following:
Initial inpatient consultations;
Follow-up inpatient consultations;
Office or other outpatient visits;
Individual psychotherapy;
Pharmacologic management;
Psychiatric diagnostic interview examination;
End-stage renal disease (ESRD) related services;
[[Page 74400]]
Individual and group medical nutrition therapy (MNT);
Neurobehavioral status exam;
Individual and group health and behavior assessment and
intervention (HBAI);
Subsequent hospital care;
Subsequent nursing facility care;
Individual and group kidney disease education (KDE);
Individual and group diabetes self-management training
(DSMT);
Smoking cessation services;
Alcohol and/or substance abuse and brief intervention
services;
Screening and behavioral counseling interventions in
primary care to reduce alcohol misuse;
Screening for depression in adults;
Screening for sexually transmitted infections (STIs) and
high intensity behavioral counseling (HIBC) to prevent STIs;
Intensive behavioral therapy for cardiovascular disease;
and
Behavioral counseling for obesity.
In general, the practitioner at the distant site may be any of the
following, provided that the practitioner is licensed under state law
to furnish the service via a telecommunications system:
Physician;
Physician assistant (PA);
Nurse practitioner (NP);
Clinical nurse specialist (CNS);
Nurse-midwife;
Clinical psychologist;
Clinical social worker;
Registered dietitian or nutrition professional.
Practitioners furnishing Medicare telehealth services submit claims
for telehealth services to the Medicare contractors that process claims
for the service area where their distant site is located. Section
1834(m)(2)(A) of the Act requires that a practitioner who furnishes a
telehealth service to an eligible telehealth individual be paid an
amount equal to the amount that the practitioner would have been paid
if the service had been furnished without the use of a
telecommunications system. Distant site practitioners must submit the
appropriate HCPCS procedure code for a covered professional telehealth
service, appended with the -GT (via interactive audio and video
telecommunications system) or -GQ (via asynchronous telecommunications
system) modifier. By reporting the -GT or -GQ modifier with a covered
telehealth procedure code, the distant site practitioner certifies that
the beneficiary was present at a telehealth originating site when the
telehealth service was furnished. The usual Medicare deductible and
coinsurance policies apply to the telehealth services reported by
distant site practitioners.
Section 1834(m)(2)(B) of the Act provides for payment of a facility
fee to the originating site. To be paid the originating site facility
fee, the provider or supplier where the eligible telehealth individual
is located must submit a claim with HCPCS code Q3014 (telehealth
originating site facility fee), and the provider or supplier is paid
according to the applicable payment methodology for that facility or
location. The usual Medicare deductible and coinsurance policies apply
to HCPCS code Q3014. By submitting HCPCS code Q3014, the originating
site certifies that it is located in either a rural HPSA or non-MSA
county or is an entity that participates in a federal telemedicine
demonstration project that has been approved by (or receives funding
from) the Secretary as of December 31, 2000 as specified in section
1834(m)(4)(C)(i)(III) of the Act.
As previously described, certain professional services that are
commonly furnished remotely using telecommunications technology, but
that do not require the patient to be present in-person with the
practitioner when they are furnished, are covered and paid in the same
way as services delivered without the use of telecommunications
technology when the practitioner is in-person at the medical facility
furnishing care to the patient. Such services typically involve
circumstances where a practitioner is able to visualize some aspect of
the patient's condition without the patient being present and without
the interposition of a third person's judgment. Visualization by the
practitioner can be possible by means of x-rays, electrocardiogram or
electroencephalogram tracings, tissue samples, etc. For example, the
interpretation by a physician of an actual electrocardiogram or
electroencephalogram tracing that has been transmitted via telephone
(that is, electronically, rather than by means of a verbal description)
is a covered physician's service. These remote services are not
Medicare telehealth services as defined under section 1834(m) of the
Act. Rather, these remote services that utilize telecommunications
technology are considered physicians' services in the same way as
services that are furnished in-person without the use of
telecommunications technology; they are paid under the same conditions
as in-person physicians' services (with no requirements regarding
permissible originating sites), and should be reported in the same way
(that is, without the -GT or -GQ modifier appended).
c. Geographic Criteria for Originating Site Eligibility
Section 1834(m)(4)(C)(i)(I)-(III) of the Act specifies three
criteria for the location of eligible telehealth originating sites. One
of these is for entities participating in federal telemedicine
demonstration projects as of December 31, 2000, and the other two are
geographic. One of the geographic criteria is that the site is located
in a county that is not in an MSA and the other is that the site is
located in an area that is designated as a rural HPSA under section
332(a)(1)(A) of the Public Health Service Act (PHSA) (42 U.S.C.
254e(a)(1)(A)). Section 332(a)(1)(A) of the PHSA provides for the
designation of various types of HPSAs, but does not provide for
``rural'' HPSAs. In the absence of guidance in the PHSA, CMS has in the
past interpreted the term ``rural'' under section 1834(m)(4)(C)(i)(I)
to mean an area that is not located in an MSA. As such, the current
geographic criteria for telehealth originating sites limits eligible
sites to those that are not in an MSA.
To determine rural designations with more precision for other
purposes, HHS and CMS have sometimes used methods that do not rely
solely on MSA designations. For example, the Office of Rural Health
Policy (ORHP) uses the Rural Urban Commuting Areas (RUCAs) to determine
rural areas within MSAs. RUCAs are a census tract-based classification
scheme that utilizes the standard Bureau of Census Urbanized Area and
Urban Cluster definitions in combination with work commuting
information to characterize all of the nation's census tracts regarding
their rural and urban status and relationships. They were developed
under a collaborative project between ORHP, the U.S. Department of
Agriculture's Economic Research Service (ERS), and the WWAMI Rural
Health Research Center (RHRC). A more comprehensive description is
available at the USDA ERS Web site at: www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/documentation.aspx#.UcsKfZwzZKE. The
RUCA classification scheme contains 10 primary and 30 secondary codes.
The primary code numbers (1 through 10) refer to the primary, or single
largest, commuting share. Census tracts with RUCA codes of 4 through 10
refer to areas with a primary commuting share outside of a metropolitan
area. In addition to counties that are not in an MSA, ORHP considers
some census tracts in MSA counties to be rural.
[[Page 74401]]
Specifically, census tracts with RUCA codes 4 through 10 are considered
to be rural, as well as census tracts with RUCA codes 2 and 3 that are
also at least 400 square miles and have a population density of less
than 35 people per square mile.
We proposed to modify our regulations regarding originating sites
to define rural HPSAs as those located in rural census tracts as
determined by ORHP stating that by defining ``rural'' to include
geographic areas located in rural census tracts within MSAs we would
allow for the appropriate inclusion of additional HPSAs as areas for
telehealth originating sites. We also noted that by adopting the more
precise definition of ``rural'' for this purpose we would expand access
to health care services for Medicare beneficiaries located in rural
areas.
We also proposed to change our policy so that geographic
eligibility for an originating site would be established and maintained
on an annual basis, consistent with other telehealth payment policies.
Absent this proposed change, the status of a geographic area's
eligibility for telehealth originating site payment is effective at the
same time as the effective date for changes in designations that are
made outside of CMS. This proposed change would reduce the likelihood
that mid-year changes to geographic designations would result in sudden
disruptions to beneficiaries' access to services, unexpected changes in
eligibility for established telehealth originating sites, and avoid the
operational difficulties associated with administering mid-year
Medicare telehealth payment changes. We proposed to establish
geographic eligibility for Medicare telehealth originating sites for
each calendar year based upon the status of the area as of December
31st of the prior calendar year.
Accordingly, we proposed to revise our regulations at Sec.
410.78(b)(4) to conform with both of these proposed policies.
The following is a summary of the comments we received regarding
our proposed changes regarding geographic eligibility for serving as a
Medicare telehealth originating site.
Comment: Commenters supported our proposal to modify the geographic
criteria for originating site eligibility to define rural HPSAs as
those located in rural census tracts, as determined by ORHP. In
addition, commenters supported our proposal to establish and maintain
geographic eligibility on an annual basis. Commenters noted that these
modifications will:
Expand access to health care services for Medicare
beneficiaries by allowing some rural areas within MSAs to be eligible
for Medicare telehealth services.
Provide greater clarity and consistency for those involved
in telehealth.
Allow for better continuity of care in rural areas by
avoiding sudden disruptions to beneficiaries' access to telehealth
services.
Restore eligibility for some counties that were affected
by the updated MSAs based on the 2010 census.
Response: We appreciate the broad support for revising the
geographic criteria for originating site eligibility and for
establishing and maintaining geographic eligibility for an originating
site on an annual basis. We are finalizing our CY 2014 proposals (1) to
define rural HPSAs as those located in rural census tracts as
determined by ORHP, and (2) to establish and maintain geographic
eligibility for an originating site on an annual basis. Consistent with
these proposals, we are also revising our regulations at Sec.
410.78(b)(4) to conform to these policies.
Comment: Commenters expressed concern that our proposed definition
of a rural HPSA does not conform to the definition of a rural HPSA used
for rural health clinic qualification, that is, a federally designated
shortage area or a non-urbanized area, as defined by the U.S. Census
Bureau. As a result, existing RHCs may be excluded from providing
telehealth services to Medicare beneficiaries. To avoid this
discrepancy, the commenters requested further expansion of the
geographic criteria for originating site eligibility to include both
non-urbanized areas, as defined by the U.S. Census Bureau, and those
rural HPSAs located in rural census tracts, as determined by ORHP. A
commenter also recommended that CMS work with the Health Resources and
Services Administration (HRSA) to update all data with 2010 census
information.
Other commenters recommended expansion of the geographic criteria
for originating site to urban and suburban areas. A commenter
recommended including sites that are located in (1) areas other than
rural HPSAs and (2) counties that are included in MSAs. The commenter
noted that beneficiaries in both urban and rural areas face significant
barriers in accessing care, including access to certain specialists,
such as gerontologists, and access to transportation.
A commenter noted that urban and suburban areas do not have
appropriate access to acute stroke care, noting that 77 percent of U.S.
counties did not have a hospital with neurological services. As a
result of these and other barriers, only a small fraction of patients
receive the treatment recommended by the latest scientific guidelines
for acute stroke. The commenter concluded that our policy of limiting
payment for telehealth services to those originating in rural areas has
hampered the development of sufficient stroke consultation coverage and
recommend eliminating the rural originating site requirement. Another
commenter made similar points concerning cancer patients living in
small urban areas without access to complex subspecialty care. A
commenter proposed using RUCAs to determine eligible originating sites,
to ensure greater access to telemedicine services.
Response: Telehealth originating sites are defined in section
1834(m)(4)(C) of the Act. Only a site that meets one of these
requirements can qualify as an originating site:
(1) Located in an area that is designated as a rural health
professional shortage area under section 332(a)(1)(A) of the Public
Health Service Act (42 U.S.C. 254e(a)(1)(A));
(2) Located in a county that is not included in a Metropolitan
Statistical Area; or
(3) From an entity that participates in a Federal telemedicine
demonstration project that has been approved by (or receives funding
from) the Secretary of Health and Human Services as of December 31,
2000.
Although RHCs are among the types of locations that are statutorily
authorized to serve as originating sites for telehealth services, they
also must meet the geographic requirements specified in the statute in
order to serve as a telehealth originating site. While most RHCs would
meet at least one of the geographic requirements to serve as a
telehealth originating site, the separate statutory provisions that
establish geographic requirements for telehealth originating sites and
for RHCs are sufficiently different that they do not necessarily
overlap. We do not have the authority to waive the geographic
telehealth requirements for those RHCs that do not meet any of the
requirements to serve as an originating site.
Accordingly, we are not modifying our proposal to expand the scope
of telehealth originating sites to include all RHCs, and we are
finalizing our proposed regulation without change. We agree with the
commenter that the data that are used to determine which areas are
rural should be updated to reflect the 2010 census information.
Comment: Several commenters expressed that the complexity involved
[[Page 74402]]
in determining geographic eligibility to serve as an originating site
to provide telehealth services may deter providers from offering
telehealth services. Commenters indicated that due to recent changes in
the 2010 census there have been numerous changes in all rural
designations. Commenters noted that RUCAs are a census tract-based
classification scheme and there is no single source to determine one's
census tract. Commenters recommended that CMS provide an online tool to
allow beneficiaries and providers to determine what specific geographic
areas are eligible as telehealth originating sites. One commenter
suggested simplifying the process in future years by considering using
postal ZIP codes or ZIP+4.
Response: We share the commenters' concern that expanding the
geographic definition of ``rural'' to include more telehealth
originating sites has increased the complexity in determining the
eligibility of a particular location to serve as an originating site.
We are working with HRSA to develop a Web site tool to provide
assistance to potential originating sites to determine their
eligibility. As it becomes available, we will post further information
about this on the CMS Web site at www.cms.gov/teleheath/.
Comment: A commenter expressed concern about the annual changes in
coverage within census tracts that may occur under the proposal. The
commenter recommended that CMS use its authority under the statute to
avoid annual on/off/on/off coverage to reduce constant fluctuations in
coverage of telehealth services. The commenter concluded that once
covered for telehealth services, a beneficiary should not lose coverage
because of accidental circumstances of geographic location and
administrative designation.
Response: This regulation addresses which providers can qualify to
be an originating site to furnish telehealth services. Beneficiaries do
not have to meet specialized criteria for telehealth services.
Beneficiaries who are covered under Medicare Part B can receive
services on the list of Medicare telehealth services from providers
that meet the criteria to serve as an originating site (and other
criteria to furnish telehealth services). We recognize that
beneficiaries may experience disruptions in service or challenges in
accessing services when a provider that has been an originating site is
not eligible in a future year. As discussed above, we believe our
proposed policy mitigates the disruptions caused by mid-year changes in
geographic status and expands the scope of providers eligible to serve
as telehealth originating sites. However, as noted above, we believe it
is necessary to use updated information regarding whether a site meets
the statutory criteria for originating site eligibility. We do not
believe we have authority to continue treating a site as a telehealth
originating site if it ceases to meet the statutory criteria. Thus, we
are finalizing the regulations regarding originating sites, as proposed
to define rural HPSAs as those located in rural census tracts as
determined by ORHP and to establish and maintain geographic eligibility
for an originating site on an annual basis.
2. Adding Services to the List of Medicare Telehealth Services
As noted previously, in the December 31, 2002 Federal Register (67
FR 79988), we established a process for adding services to or deleting
services from the list of Medicare telehealth services. This process
provides the public with an ongoing opportunity to submit requests for
adding services. We assign any request to make additions to the list of
telehealth services to one of two categories. In the November 28, 2011
Federal Register (76 FR 73102), we finalized revisions to criteria that
we use to review requests in the second category. The two categories
are:
Category 1: Services that are similar to professional
consultations, office visits, and office psychiatry services that are
currently on the list of telehealth services. In reviewing these
requests, we look for similarities between the requested and existing
telehealth services for the roles of, and interactions among, the
beneficiary, the physician (or other practitioner) at the distant site
and, if necessary, the telepresenter. We also look for similarities in
the telecommunications system used to deliver the proposed service; for
example, the use of interactive audio and video equipment.
Category 2: Services that are not similar to the current
list of telehealth services. Our review of these requests includes an
assessment of whether the service is accurately described by the
corresponding code when delivered via telehealth and whether the use of
a telecommunications system to deliver the service produces
demonstrated clinical benefit to the patient. In reviewing these
requests, we look for evidence indicating that the use of a
telecommunications system in delivering the candidate telehealth
service produces clinical benefit to the patient. Submitted evidence
should include both a description of relevant clinical studies that
demonstrate the service furnished by telehealth to a Medicare
beneficiary improves the diagnosis or treatment of an illness or injury
or improves the functioning of a malformed body part, including dates
and findings, and a list and copies of published peer reviewed articles
relevant to the service when furnished via telehealth. Our evidentiary
standard of clinical benefit does not include minor or incidental
benefits.
Some examples of clinical benefit include the following:
Ability to diagnose a medical condition in a patient
population without access to clinically appropriate in-person
diagnostic services.
Treatment option for a patient population without access
to clinically appropriate in-person treatment options.
Reduced rate of complications.
Decreased rate of subsequent diagnostic or therapeutic
interventions (for example, due to reduced rate of recurrence of the
disease process).
Decreased number of future hospitalizations or physician
visits.
More rapid beneficial resolution of the disease process
treatment.
Decreased pain, bleeding, or other quantifiable symptom.
Reduced recovery time.
Since establishing the process to add or remove services from the
list of approved telehealth services, we have added the following to
the list of Medicare telehealth services: individual and group HBAI
services; psychiatric diagnostic interview examination; ESRD services
with 2 to 3 visits per month and 4 or more visits per month (although
we require at least 1 visit a month to be furnished in-person by a
physician, CNS, NP, or PA to examine the vascular access site);
individual and group MNT; neurobehavioral status exam; initial and
follow-up inpatient telehealth consultations for beneficiaries in
hospitals and SNFs; subsequent hospital care (with the limitation of
one telehealth visit every 3 days); subsequent nursing facility care
(with the limitation of one telehealth visit every 30 days); individual
and group KDE; and individual and group DSMT (with a minimum of 1 hour
of in-person instruction to ensure effective injection training),
smoking cessation services; alcohol and/or substance abuse and brief
intervention services; screening and behavioral counseling
interventions in primary care to reduce alcohol misuse; screening for
depression in adults; screening for sexually transmitted infections
(STIs) and high intensity behavioral counseling (HIBC) to prevent STIs;
intensive behavioral therapy for cardiovascular disease; and behavioral
counseling for obesity.
[[Page 74403]]
Requests to add services to the list of Medicare telehealth
services must be submitted and received no later than December 31 of
each calendar year to be considered for the next rulemaking cycle. For
example, requests submitted before the end of CY 2013 will be
considered for the CY 2015 proposed rule. Each request for adding a
service to the list of Medicare telehealth services must include any
supporting documentation the requester wishes us to consider as we
review the request. Because we use the annual PFS rulemaking process as
a vehicle for making changes to the list of Medicare telehealth
services, requestors should be advised that any information submitted
is subject to public disclosure for this purpose. For more information
on submitting a request for an addition to the list of Medicare
telehealth services, including where to mail these requests, we refer
readers to the CMS Web site at www.cms.gov/telehealth/.
3. Submitted Requests and Other Additions to the List of Telehealth
Services for CY 2014
We received a request in CY 2012 to add online assessment and E/M
services as Medicare telehealth services effective for CY 2014. The
following presents a discussion of this request, and our proposals for
additions to the CY 2014 telehealth list.
a. Submitted Requests
The American Telemedicine Association (ATA) submitted a request to
add CPT codes 98969 (Online assessment and management service provided
by a qualified nonphysician health care professional to an established
patient, guardian, or health care provider not originating from a
related assessment and management service provided within the previous
7 days, using the Internet or similar electronic communications
network) and 99444 (Online evaluation and management service provided
by a physician to an established patient, guardian, or health care
provider not originating from a related E/M service provided within the
previous 7 days, using the Internet or similar electronic
communications network) to the list of Medicare telehealth services.
As we explained in the CY 2008 PFS final rule with comment period
(72 FR 66371), we assigned a status indicator of ``N'' (Non-covered
service) to these services because: (1) these services are non-face-to-
face; and (2) the code descriptor includes language that recognizes the
provision of services to parties other than the beneficiary and for
whom Medicare does not provide coverage (for example, a guardian).
Under section 1834(m)(2)(A) of the Act, Medicare pays the physician or
practitioner furnishing a telehealth service an amount equal to the
amount that would have been paid if the service was furnished without
the use of a telecommunications system. Because CPT codes 98969 and
99444 are currently noncovered, there would be no Medicare payment if
these services were furnished without the use of a telecommunications
system. Since these codes are noncovered services for which no payment
may be made under Medicare, we did not propose to add online evaluation
and management services to the list of Medicare Telehealth Services for
CY 2014.
b. Other Additions
Under our existing policy, we add services to the telehealth list
on a category 1 basis when we determine that they are similar to
services on the existing telehealth list with respect to the roles of,
and interactions among, the beneficiary, physician (or other
practitioner) at the distant site and, if necessary, the telepresenter.
As we stated in the CY 2012 proposed rule (76 FR 42826), we believe
that the category 1 criteria not only streamline our review process for
publically requested services that fall into this category, the
criteria also expedite our ability to identify codes for the telehealth
list that resemble those services already on this list.
For CY 2013, CMS finalized a payment policy for new CPT code 99495
(Transitional care management services with the following required
elements: Communication (direct contact, telephone, electronic) with
the patient and/or caregiver within 2 business days of discharge
medical decision making of at least moderate complexity during the
service period face-to-face visit, within 14 calendar days of
discharge) and CPT code 99496 (Transitional care management services
with the following required elements: Communication (direct contact,
telephone, electronic) with the patient and/or caregiver within 2
business days of discharge medical decision making of high complexity
during the service period face-to-face visit, within 7 calendar days of
discharge). These services are for a patient whose medical and/or
psychosocial problems require moderate or high complexity medical
decision making during transitions in care from an inpatient hospital
setting (including acute hospital, rehabilitation hospital, long-term
acute care hospital), partial hospitalization, observation status in a
hospital, or skilled nursing facility/nursing facility, to the
patient's community setting (home, domiciliary, rest home, or assisted
living). Transitional care management is comprised of one face-to-face
visit within the specified time frames following a discharge, in
combination with non-face-to-face services that may be performed by the
physician or other qualified health care professional and/or licensed
clinical staff under his or her direction.
We believe that the interactions between the furnishing
practitioner and the beneficiary described by the required face-to-face
visit component of the transitional care management (TCM) services are
sufficiently similar to services currently on the list of Medicare
telehealth services for these services to be added under category 1.
Specifically, we believe that the required face-to-face visit component
of TCM services is similar to the office/outpatient evaluation and
management visits described by CPT codes 99201-99205 and 99211-99215.
We note that like certain other non-face-to-face PFS services, the
other components of the TCM service are commonly furnished remotely
using telecommunications technology, and do not require the patient to
be present in-person with the practitioner when they are furnished. As
such, we do not need to consider whether the non-face-to-face aspects
of the TCM service are similar to other telehealth services. Were these
components of the TCM services separately billable, they would not need
to be on the telehealth list to be covered and paid in the same way as
services delivered without the use of telecommunications technology.
Therefore, we proposed to add CPT codes 99495 and 99496 to the list of
telehealth services for CY 2014 on a category 1 basis. Consistent with
this proposal, we revised our regulations at Sec. 410.78(b) and Sec.
414.65(a)(1) to include TCM services as Medicare telehealth services.
4. Telehealth Frequency Limitations
The ATA asked that we remove the telehealth frequency limitation
for subsequent nursing facility services reported by CPT codes 99307
through 99310. Subsequent nursing facility services were added to the
list of Medicare telehealth services in the CY 2011 PFS final rule (75
FR 73317 through 73318), with a limitation of one telehealth subsequent
nursing facility care service every 30 days. In the CY 2011 PFS final
rule (75 FR 73615) we noted that, as specified in our regulation at
Sec. 410.78(e)(2), the federally mandated periodic SNF visits required
under
[[Page 74404]]
Sec. 483.40(c) could not be furnished through telehealth.
The ATA requested that the frequency limitation be removed due to
``recent federal telecommunications policy changes'' and newly
available information from recent studies. Specifically, the ATA
pointed to the Federal Communications Commission (FCC) pilot funding of
a program to facilitate the creation of a nationwide broadband network
dedicated to health care, connecting public and private non-profit
health care providers in rural and urban locations, and a series of
studies that demonstrated the value to patients of telehealth
technology.
In considering this request, we began with the analysis contained
in the CY 2011 proposed rule (75 FR 73318), when we proposed to add SNF
subsequent care, to the list of Medicare telehealth services. We
discussed our complementary commitments to ensuring that SNF residents,
given their potential clinical acuity, continue to receive in-person
visits as appropriate to manage their complex care and to make sure
that Medicare pays only for medically reasonable and necessary care. To
meet these commitments, we believed it was appropriate to limit the
provision of subsequent nursing facility care services furnished
through telehealth to once every 30 days.
We then reviewed the publicly available information regarding both
the FCC pilot program and the ATA-referenced studies in light of the
previously stated commitments to assess whether these developments
warrant a change in 30-day frequency limitation policy. Based on our
review of the FCC demonstration project and the studies referenced in
the request, we found no information regarding the relative clinical
benefits of SNF subsequent care when furnished via telehealth more
frequently than once every 30 days. We did note that the FCC
information reflected an aim to improve access to medical specialists
in urban areas for rural health care providers, and that medical
specialists in urban areas can continue to use the inpatient telehealth
consultation HCPCS G-codes (specifically G0406, G0407, G0408, G0425,
G0426, or G0427) when reporting medically reasonable and necessary
consultations furnished to SNF residents via telehealth without any
frequency limitation.
We also reviewed the studies referenced by the ATA to assess
whether they provided evidence that more frequent telehealth visits
would appropriately serve this particular population given the
potential medical acuity and complexity of patient needs. We did not
find any such evidence in the studies. Three of the studies identified
by the ATA were not directly relevant to SNF subsequent care services.
One of these focused on using telehealth technology to treat patients
with pressure ulcers after spinal cord injuries. The second focused on
the usefulness of telehealth technology for patients receiving home
health care services. A third study addressed the use of interactive
communication technology to facilitate the coordination of care between
hospital and SNF personnel on the day of hospital discharge. The ATA
also mentioned a peer-reviewed presentation delivered at its annual
meeting related to SNF patient care, suggesting that the presentation
demonstrated that telehealth visits are better for SNF patients than
in-person visits to emergency departments or, in some cases, visits to
physician offices. Although we did not have access to the full
presentation it does not appear to address subsequent nursing facility
services, so we do not believe this is directly relevant to the
clinical benefit of SNF subsequent care furnished via telehealth. More
importantly, none of these studies addresses the concerns we have
expressed about the possibility that nursing facility subsequent care
visits furnished too frequently through telehealth rather than in-
person could compromise care for this potentially acute and complex
patient population.
We remain committed to ensuring that SNF inpatients receive
appropriate in-person visits and that Medicare pays only for medically
reasonable and necessary care. We are not persuaded by the information
submitted by the ATA that it would be beneficial or advisable to remove
the frequency limitation we established for SNF subsequent care when
furnished via telehealth. Because we want to ensure that nursing
facility patients with complex medical conditions have appropriately
frequent, medically reasonable and necessary encounters with their
admitting practitioner, we continue to believe that it is appropriate
for some subsequent nursing facility care services to be furnished
through telehealth. At the same time, because of the potential acuity
and complexity of SNF inpatients, we remain committed to ensuring that
these patients continue to receive in-person, hands-on visits as
appropriate to manage their care. Therefore, we did not propose any
changes to the limitations regarding SNF subsequent care services
furnished via telehealth for CY 2014.
The following is summary of the comments we received regarding
adding services to the list of Medicare telehealth services.
Comment: All commenters expressed support for our proposals to add
transitional care management (CPT codes 99495 and 99496) to the list of
Medicare telehealth services for CY 2014. A commenter suggested that
CMS allow the required E/M visit component of the two CPT codes to be
delivered via telehealth.
Response: We appreciate the support for the proposed additions to
the list of Medicare telehealth services. In response to the commenter
asking that the required E/M visit component be allowed to be furnished
via telehealth, adding TCM CPT codes 99495 and 99496 to the list of
Medicare telehealth services allows the E/M portion of these services
to be furnished via telehealth. After consideration of the public
comments received, we are finalizing our CY 2014 proposal to add TCM
CPT codes 99495 and 99496 to the list of telehealth services for CY
2014 on a category 1 basis.
Comment: Another commenter recommended that the originating site be
required to conduct a physical examination of a patient's mental and
physical condition following a care transaction, and transmit the
results to the consulting physician before or during the telehealth
session, as a condition for coverage of transitional care management
services provided via telehealth.
Response: Concerning the conduct of a physical examination, nothing
would preclude such an in person, face-to-face examination from
occurring at the originating site; and the TCM codes describe
communication between practitioners, when appropriate. We are not
adopting this recommendation as we do not believe there is a reason to
treat these new additions to the list of telehealth services
differently than services already on the list.
Comment: A commenter asked whether providing transitional care
management via telehealth applies to services furnished in private
homes and assisted living facilities.
Response: No, in furnishing TCM services as telehealth services,
all other conditions for telehealth services still apply. In addition
to geographic criteria, the statutory criteria for eligible originating
sites include only certain types of locations specified in section
1834(m)(4)(C)(ii) of the Act, and those do not include private homes
and assisted living facilities.
Comment: A commenter supported our decision not to remove the
telehealth frequency limitation for subsequent nursing facility
services
[[Page 74405]]
reported by CPT codes 99307 through 99310. The commenter noted that
telehealth occupational therapy services are just beginning to be
provided and evaluated, and indicated that it is important to ensure
that care for the acute and complex patients found in SNFs is not
compromised, regardless of the mode used to provide services.
Another commenter disagreed with our determination that there is no
relative clinical benefit from allowing SNF services to be provided via
telehealth more than once every 30 days. The commenter indicated that
CMS recently issued Survey and Certification Memo 13-35-NH, which put
additional emphasis on the survey process for managing behavioral or
psychological symptoms of dementia and limiting the use of
antipsychotic medications in SNFs. The commenter concluded that having
this medical/behavioral evaluation performed by the primary care
provider or a psychiatrist using telehealth could help reduce the need
to transfer the patient to the emergency department, which could
possibly exacerbate dementia symptoms.
A commenter stated that the frequency limitation can result in
additional unnecessary transports for office or emergency department
visits, additional opportunities for patient injury, and significant
transportation costs especially for the immobile and disabled patient.
In light of the evolving mobile health technologies, robotics, and
miniaturization of telecommunications tools and medical devices, as
well as the increasing complexity and co-morbidities of SNF patients,
the commenter recommended setting the limit at one visit per 10 days.
A commenter suggested that subsequent nursing facility care
services furnished through telehealth should not be limited to one
service every 30 days, as long as the federally mandated SNF visits are
conducted on an in-person basis.
Response: We appreciate the comment in support of maintaining the
30-day limit. Commenters opposed to the 30-day limit offered no
clinically persuasive evidence to support their positions. Survey and
Certification Memo 13-35-NH addresses dementia care in nursing homes
and unnecessary drug use. The memo does not address telehealth
services, and does not represent clinical evidence supporting removal
of the telehealth frequency limitation for subsequent nursing facility
services. Therefore, we are maintaining the 30-day frequency limitation
for subsequent nursing facility services due to the absence of evidence
regarding the relative clinical benefits of SNF subsequent care when
furnished via telehealth more frequently than once every 30 days, and
to ensure that SNF patients continue to receive in-person, hands-on
visits as appropriate to manage their care.
Comment: A commenter urged CMS to reconsider its decision to not
include CPT codes 98969 (Online assessment and management service
provided by a qualified nonphysician health care professional to an
established patient, guardian, or health care provider not originating
from a related assessment and management service provided within the
previous 7 days, using the Internet or similar electronic
communications network) and 99444 (Online evaluation and management
service provided by a physician to an established patient, guardian, or
health care provider not originating from a related E/M service
provided within the previous 7 days, using the Internet or similar
electronic communications network) on the list of Medicare telehealth
services. The commenter noted that such services can serve as a
valuable preventive benefit in the treatment and care of Medicare
beneficiaries; that such services are often are unavailable to
beneficiaries who reside in very rural areas; and that telehealth
services should be expanded in view of the increasing number of
beneficiaries and the projected physician shortage.
Response: As noted previously, we did not propose to add the
subject codes to the list of telehealth services because they are
noncovered services for which no payment may be made under Medicare.
Accordingly we are finalizing our proposal.
In summary, after consideration of the comments we received we are
finalizing the changes to our regulation at Sec. 410.78 to add
``transitional care management'' to the list of services in paragraph
(b) as proposed.
We remind all interested stakeholders that we are currently
soliciting public requests to add services to the list of Medicare
telehealth services. To be considered during PFS rulemaking for CY
2015, these requests must be submitted and received by December 31,
2013, or the close of the comment period for this final rule with
comment period. Each request to add a service to the list of Medicare
telehealth services must include any supporting documentation the
requester wishes us to consider as we review the request. For more
information on submitting a request for an addition to the list of
Medicare telehealth services, including where to mail these requests,
we refer readers to the CMS Web site at www.cms.gov/telehealth/.
5. Telehealth Originating Site Facility Fee Payment Amount Update
Section 1834(m)(2)(B) of the Act establishes the payment amount for
the Medicare telehealth originating site facility fee for telehealth
services provided from October 1, 2001, through December 31 2002, at
$20.00. For telehealth services provided on or after January 1 of each
subsequent calendar year, the telehealth originating site facility fee
is increased by the percentage increase in the MEI as defined in
section 1842(i)(3) of the Act. The MEI increase for 2014 is 0.8
percent. Therefore, for CY 2014, the payment amount for HCPCS code
Q3014 (Telehealth originating site facility fee) is 80 percent of the
lesser of the actual charge or $24.63. The Medicare telehealth
originating site facility fee and MEI increase by the applicable time
period is shown in Table 46.
Table 46--The Medicare Telehealth Originating Site Facility Fee and MEI
Increase by the Applicable Time Period
------------------------------------------------------------------------
MEI
Facility fee increase Period
(%)
------------------------------------------------------------------------
$20.00............................... N/A 10/01/2001-12/31/2002
$20.60............................... 3.0 01/01/2003-12/31/2003
$21.20............................... 2.9 01/01/2004-12/31/2004
$21.86............................... 3.1 01/01/2005-12/31/2005
$22.47............................... 2.8 01/01/2006-12/31/2006
$22.94............................... 2.1 01/01/2007-12/31/2007
$23.35............................... 1.8 01/01/2008-12/31/2008
$23.72............................... 1.6 01/01/2009-12/31/2009
$24.00............................... 1.2 01/01/2010-12/31/2010
$24.10............................... 0.4 01/01/2011-12/31/2011
$24.24............................... 0.6 01/01/2012-12/31/2012
$24.43............................... 0.8 01/01/2013-12/31/2013
$24.63............................... 0.8 01/01/2014-12/31/2014
------------------------------------------------------------------------
I. Therapy Caps
1. Outpatient Therapy Caps for CY 2014
Section 1833(g) of the Act applies annual, per beneficiary,
limitations on expenses that can be considered as incurred expenses for
outpatient therapy services under Medicare Part B, commonly referred to
as ``therapy caps.''
[[Page 74406]]
There is one therapy cap for outpatient occupational therapy (OT)
services and another separate therapy cap for physical therapy (PT) and
speech-language pathology (SLP) services combined.
Until October 1, 2012, the therapy caps applied to all outpatient
therapy services except those under section 1833(a)(8)(B) of the Act,
which describes services furnished by a hospital or another entity
under an arrangement with a hospital. For convenience, we will refer to
the exemption from the caps for services described under section
1833(a)(8)(B) of the Act as the ``outpatient hospital services
exemption.'' Section 3005(b) of the MCTRJCA added section 1833(g)(6) of
the Act to temporarily suspend the outpatient hospital services
exemption, thereby requiring that the therapy caps apply to services
described under section 1833(a)(8)(B) of the Act from October 1, 2012
to December 31, 2012 for services furnished beginning January 1, 2012.
This broadened application of the therapy caps was extended through
December 31, 2013, by section 603(a) of the ATRA. In addition, section
603(b) of the ATRA amended section 1833(g)(6) of the Act to specify
that during CY 2013, for outpatient therapy services paid under section
1834(g) of the Act (those furnished by a CAH), we must count towards
the therapy caps the amount that would be payable for the services
under Medicare Part B if the services were paid as outpatient therapy
services under section 1834(k)(1)(B) of the Act, which describes
payment for outpatient therapy services furnished by hospitals and
certain other entities, instead of as CAH outpatient therapy services
under section 1834(g) of the Act. Payment for outpatient therapy
services under section 1834(k)(1)(B) of the Act is made at 80 percent
of the lesser of the actual charge for the services or the applicable
fee schedule amount as defined in section 1834(k)(3) of the Act.
Section 1834(k)(3) of the Act defines applicable fee schedule to mean
the payment amount determined under a fee schedule established under
section 1848 of the Act, which refers to the PFS, or an amount under a
fee schedule for comparable services as the Secretary specifies. The
PFS is the applicable fee schedule to be used as the payment basis
under section 1834(k)(3) of the Act. Section 603(b) of the ATRA
specified that nothing in the amendments to section 1833(g)(6) of the
Act ``shall be construed as changing the method of payment for
outpatient therapy services under 1834(g) of the Act.''
Since CY 2011, a therapy multiple procedure payment reduction
(MPPR) policy has applied to the second and subsequent ``always
therapy'' services billed on the same date of service for one patient
by the same practitioner or facility under the same NPI. Prior to April
1, 2013, the therapy MPPR reduced the practice expense portion of
office-based services by 20 percent and reduced the practice expense
portion of institutional-based services by 25 percent. As of April 1,
2013, section 633(a) of the ATRA amended sections 1848(b)(7) and
1834(k) of the Act to increase the therapy MPPR to 50 percent for all
outpatient therapy services furnished in office-based and institutional
settings. (For more information on the MPPR and its history, see
section II.C.4 of this final rule with comment period.)
Section 1833(g) of the Act applies the therapy caps to incurred
expenses for outpatient therapy services on a calendar year basis, and
section 603(b) of the ATRA requires that we accrue toward the therapy
caps a proxy value for a beneficiary's incurred expenses for outpatient
therapy services furnished by a CAH during CY 2013. Since payment for
outpatient therapy services under section 1834(k)(1)(B) of the Act is
made at the PFS rate and includes any applicable therapy MPPR, the
proxy amounts accrued toward the caps for therapy services furnished by
a CAH also reflect any applicable therapy MPPR.
We believe that this is consistent with the statutory amendments
made by the ATRA. Including the therapy MPPR in calculating incurred
expenses for therapy services furnished by CAHs treats CAH services
consistently with services furnished in other applicable settings.
Therefore, therapy services furnished by CAHs during CY 2013 count
towards the therapy caps using the amount that would be payable under
section 1834(k)(1)(B) of the Act, which includes an applicable MPPR.
For a list of the ``always therapy'' codes subject to the therapy MPPR
policy, see Addendum H of this final rule with comment period.
The therapy cap amounts under section 1833(g) of the Act are
updated each year based on the MEI. Specifically, the annual caps are
calculated by updating the previous year's cap by the MEI for the
upcoming calendar year and rounding to the nearest $10 as specified in
section 1833(g)(2)(B) of the Act. Increasing the CY 2013 therapy cap of
$1,900 by the CY 2014 MEI of 0.8 percent, results in a therapy cap
amount for CY 2014 of $1,920.
An exceptions process for the therapy caps has been in effect since
January 1, 2006. Originally required by section 5107 of the Deficit
Reduction Act of 2005 (DRA), which amended section 1833(g)(5) of the
Act, the exceptions process for the therapy caps has been continuously
extended several times through subsequent legislation (MIEA-TRHCA,
MMSEA, MIPPA, the Affordable Care Act, MMEA, TPTCCA, and MCTRJCA). Last
amended by section 603(a) of the ATRA, the Agency's current authority
to provide an exceptions process for therapy caps expires on December
31, 2013. After expenses incurred for the beneficiary's services for
the year have exceeded the therapy caps, therapy suppliers and
providers use the KX modifier on claims for services to request an
exception to the therapy caps. By use of the KX modifier, the therapist
is attesting that the services above the therapy caps are reasonable
and necessary and that there is documentation of medical necessity for
the services in the beneficiary's medical record.
Under section 1833(g)(5)(C) of the Act, which was added by the
MCTRJCA and extended through 2013 by the ATRA, we are required to apply
a manual medical review process to therapy claims when a beneficiary's
incurred expenses exceed a threshold amount of $3,700. There are two
separate thresholds of $3,700, just as there are two therapy caps, and
incurred expenses are counted towards the thresholds in the same manner
as the caps. Under the statute, the required application of the manual
medical review process expires December 31, 2013. For information on
the manual medical review process, go to www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/TherapyCap.html.
2. Application of Therapy Caps to Services Furnished by CAHs
Section 4541 of the BBA amended section 1833(g) of the Act to
create the therapy caps discussed above. This BBA provision applied the
therapy caps to outpatient therapy services described at section
1861(p) of the Act except for the outpatient therapy services described
in section 1833(a)(8)(B) of the Act. Section 1833(a)(8)(B) of the Act
refers to therapy services furnished by a hospital to an outpatient; to
services furnished to a hospital inpatient who has exhausted, or is not
entitled to, benefits under Part A; and to these same services when
furnished by an entity under arrangements with a hospital. Payment for
the services described under section
[[Page 74407]]
1833(a)(8)(B) of the Act is made under section 1834(k)(1)(B) of the
Act.
Section 4201 of the BBA amended section 1820 of the Act to require
a process for establishment of CAHs. Payment for CAH outpatient
services is described under section 1834(g) of the Act.
When we proposed language to implement the BBA provision
establishing therapy caps in the CY 1999 PFS proposed rule, we
indicated in the preamble that the therapy caps do not apply to therapy
services furnished directly or under arrangements by a hospital or CAH
to an outpatient or to an inpatient who is not in a covered Part A stay
(63 FR 30818, 30858). We included a similar statement in the preamble
to the final rule; however, we did not include the same reference to
CAHs in that sentence in the CY 1999 PFS final rule with comment period
(63 FR 58814, 58865). In the CY 1999 PFS final rule with comment
period, we also stated generally that the therapy caps apply only to
items and services furnished by nonhospital providers and therapists
(63 FR 58865). In the CY 1999 proposed rule, we proposed to include
provisions at Sec. 410.59(e)(3) and Sec. 410.60(e)(3) to describe,
respectively, the outpatient therapy services that are exempt from the
statutory therapy caps for outpatient OT services, and for outpatient
PT and SLP services combined. Specifically, in the CY 1999 PFS proposed
rule, we proposed to add the following regulatory language for OT and
for PT at Sec. 410.59(e)(3) and Sec. 410.60(e)(3): ``For purposes of
applying the limitation, outpatient [occupational therapy/physical
therapy] excludes services furnished by a hospital or CAH directly or
under arrangements'' (63 FR 30880). However, in the CY 1999 PFS final
rule with comment period, the phrase ``or CAH'' was omitted from the
final regulation text for OT in Sec. 410.59(e)(3), but was included in
the final regulation text for PT in Sec. 410.60(e)(3). We note that
for purposes of the therapy cap, outpatient PT services under our
regulation at Sec. 410.60 include outpatient SLP services described
under Sec. 410.62. As such, SLP services are included in the
references to PT under Sec. 410.60. Although the rulemaking history
and regulations appear inconclusive as to whether outpatient therapy
services furnished by CAHs were intended to be subject to the therapy
caps between January 1, 1999 and October 1, 2012, we believe that we
inadvertently omitted the phrase ``or CAH'' in the CY 1999 final
regulation for the occupational therapy cap. Moreover, we have
consistently excluded all outpatient therapy services furnished by CAHs
from the therapy caps over this time frame, whether the services were
PT, SLP, or OT.
Accordingly, from the outset of the therapy caps under section
1833(g) of the Act, therapy services furnished by CAHs have not been
subject to the therapy caps. Thus, CAHs have not been required to use
the exceptions process (including the KX modifier and other
requirements) when furnishing medically necessary therapy services
above the therapy caps; and therapy services furnished by CAHs above
the threshold amounts have not been subject to the manual medical
review process. Similarly, until section 603(b) of the ATRA amended the
statute to specify the amount that must be counted towards the therapy
caps and thresholds for outpatient therapy services furnished by CAHs
in CY 2013, we did not apply towards the therapy caps or thresholds any
amounts for therapy services furnished by CAHs. Therefore, we have
consistently interpreted the statutory exclusion for outpatient therapy
services furnished by hospital outpatient departments also to apply to
CAHs and implemented the therapy caps accordingly.
As noted above, section 3005(b) of the MCTRJCA temporarily
suspended the outpatient hospital services exemption from October 1,
2012 through December 31, 2012 (which has subsequently been extended
through December 31, 2013 by the ATRA). As a result, from October 1,
2012 to the present, CAH services have been treated differently than
services furnished in other outpatient hospital settings. In
implementing this change required by the MCTRJCA, we had reason to
assess whether, as a result of the amendment, the therapy caps should
be applied to outpatient therapy services furnished by CAHs. We
concluded that the MCTRJCA amendment did not make the therapy caps
applicable to services furnished by CAHs for which payment is made
under section 1834(g) of the Act because it affected only the
outpatient hospital services described under section 1833(a)(8)(B) of
the Act for which payment is made under section 1834(k)(1)(B) of the
Act. With the enactment in section 603(b) of the ATRA of specific
language requiring us to count amounts towards the therapy caps and
thresholds for services furnished by CAHs, we again had reason to
assess whether the therapy caps apply to services furnished by CAHs. We
concluded that the ATRA amendment did not explicitly make the therapy
caps applicable to services furnished by CAHs, but directed us to count
CAH services towards the caps. However, after reflecting on the
language of section 1833(g) of the Act, we have concluded based upon
the language of the Act that the therapy caps should be applied to
outpatient therapy services furnished by CAHs.
To explain further, under section 1833(g)(1) and (3) of the Act,
the therapy caps are made applicable to all services described under
section 1861(p) of the Act except those described under the outpatient
hospital services exemption. Section 1861(p) of the Act establishes the
benefit category for outpatient PT, SLP and OT services, (expressly for
PT services and, through section 1861(ll)(2) of the Act, for outpatient
SLP services and, through section 1861(g) of the Act, for outpatient OT
services). Section 1861(p) of the Act defines outpatient therapy
services in the three disciplines as those furnished by a provider of
services, a clinic, rehabilitation agency, or a public health agency,
or by others under an arrangement with, and under the supervision of,
such provider, clinic, rehabilitation agency, or public health agency
to an individual as an outpatient; and those furnished by a therapist
not under arrangements with a provider of services, clinic,
rehabilitation agency, or a public health agency. As such, section
1861(p) of the Act defines outpatient therapy services very broadly to
include those furnished by providers and other institutional settings,
as well as those furnished in office settings. Under section 1861(u) of
the Act, a CAH is a ``provider of services.'' As such, unless the
outpatient therapy services furnished by a CAH fit within the
outpatient hospital services exemption under section 1833(a)(8)(B) of
the Act, the therapy caps would be applicable to PT, SLP, OT services
furnished by a CAH. As noted above, section 1833(a)(8)(B) of the Act
describes only outpatient therapy services for which payment is made
under section 1834(k) of the Act. Payment for CAH services is made
under section 1834(g) of the Act. Thus, the outpatient hospital
services exemption to the therapy caps under section 1833(a)(8)(B) of
the Act does not apply, and the therapy caps are applicable, to
outpatient therapy services furnished by a CAH.
However, we recognize that our current regulation specifically
excludes PT and SLP services furnished by CAHs from the therapy caps,
and our consistent practice since 1999 has been to exclude PT, SLP and
OT services furnished by CAHs from the therapy caps. As such, in order
to apply the therapy caps and related policies to services furnished by
CAHs for CY 2014
[[Page 74408]]
and subsequent years, we believe we would need to revise our
regulations.
We proposed to apply the therapy cap limitations and related
policies to outpatient therapy services furnished by a CAH beginning on
January 1, 2014. In the proposed rule, we noted that not only do we
believe this is the proper statutory interpretation, but we also
believe it is the appropriate policy. Under the existing regulations,
with the suspension of the outpatient hospital services exemption
through 2013, the therapy caps apply to outpatient therapy services
paid under Medicare Part B and furnished in all applicable settings
except CAHs. We believe that outpatient therapy services furnished by a
CAH should be treated consistently with outpatient therapy services
furnished in all other settings. Therefore, we proposed to revise the
therapy cap regulation at Sec. 410.60(e)(3) to remove the exemption
for services furnished by a CAH and make conforming amendments.
CAH outpatient therapy services are distinct from other outpatient
therapy services in that outpatient therapy services furnished in
office-based or other institutional settings are paid at the rates
contained in the PFS, whereas CAHs are paid for outpatient therapy
services under the methodology described under section 1834(g) of the
Act. Because the CAH reasonable cost-based payment amounts are
reconciled at cost reporting year-end, and are different from the fee
schedule-based payments for other outpatient therapy services, it might
have been difficult to identify the amounts that we should have accrued
towards the therapy caps for services furnished by CAHs. Therefore,
prior to 2013, not only did CMS not apply any caps to services provided
by a CAH, but also did not count CAH services towards the caps.
However, the ATRA amended the statute to require for outpatient therapy
services furnished by CAHs during 2013 that we count towards the caps
and the manual medical review thresholds the amount that would be
payable for the services under Medicare Part B as if the services were
paid as outpatient therapy services under section 1834(k)(1)(B) of the
Act instead of as CAH services under section 1834(g) of the Act. We
proposed to continue this methodology of counting the amount payable
under section 1834(k)(1)(B) of the Act towards the therapy cap and
threshold for services furnished by CAHs in CY 2014 and subsequent
years.
We recognize that the outpatient hospital services exemption is
suspended under current law only through December 31, 2013. If this
provision is not extended, with our proposal to apply the therapy caps
to services furnished by CAHs, effective January 1, 2014, therapy
services furnished by CAHs would be treated differently than services
furnished in other outpatient hospital settings. We recognize that the
exceptions and manual medical review processes expire on December 31,
2013, and we would apply those polices to therapy services furnished by
a CAH only if they are extended by statute. The exceptions process
described above, including use of the KX modifier to attest to the
medical necessity of therapy services above the caps and other
requirements, if extended by legislation, would apply for services
furnished by a CAH in the same way that it applies to outpatient
therapy services furnished by other facilities (except for any that are
expressly exempted). Similarly, the manual medical review process for
claims that exceed the $3,700 thresholds, if extended by legislation,
would apply to therapy services furnished by a CAH in the same way that
they apply for outpatient therapy services furnished by certain other
facilities.
We proposed to amend the regulations establishing the conditions
for PT, OT, and SLP services by removing the exemption of CAH services
from the therapy caps and specifying that the therapy caps apply to
such services. Specifically, we proposed to amend the regulations,
which pertain to the OT therapy cap and the combined PT and SLP therapy
cap, respectively, by including paragraph (e)(1)(iv) under Sec. 410.59
and (e)(1)(iv) under Sec. 410.60 to specify that (occupational/
physical) therapy services furnished by a CAH directly or under
arrangements shall be counted towards the annual limitation on incurred
expenses as if such services were paid under section 1834(k)(1)(B) of
the Act. We also proposed to add new paragraph (e)(2)(v) to Sec.
410.59 and (e)(2)(vi) to Sec. 410.60. These new paragraphs would
expressly include outpatient (occupational/physical) therapy services
furnished by a CAH directly or under arrangements under the description
of services to which the annual limitation applies. Further, we
proposed to amend the regulation at Sec. 410.60(e)(3), which currently
excludes services furnished by a CAH from the therapy cap for PT and
SLP services, to remove the phrase ``or CAH.''
The following is a summary of the comments we received regarding
the proposal to apply the therapy cap limitations and related policies
to outpatient therapy services furnished by a CAH beginning on January
1, 2014. We received many comments from professional therapy
associations, hospital associations, health systems, nonprofit health
care organizations, and specialty provider groups regarding our
proposal, all of which opposed the application of the therapy caps to
CAH services. A summary of the reasons stated for opposition follow.
Comment: Most of the comments we received argued that due to the
critical role that CAHs play in furnishing healthcare services in
underserved or rural areas, imposing the financial and administrative
burden of the therapy caps on CAHs would result in Medicare
beneficiaries having fewer, if any, options for accessing needed
therapy services in CAH service areas. A few commenters noted that
Congress established the CAH designation in order to make health care
services accessible to Medicare beneficiaries in rural areas who would
otherwise be unable to access hospital services and argued that our
proposed policy would be contrary to Congress's goal. Commenters noted
that those most affected by this policy are beneficiaries living in
rural areas who are on average older, sicker, poorer, and more
geographically isolated compared to individuals in urban areas.
Commenters pointed out that in rural or underserved areas therapy
services enable beneficiaries to recover and reconstruct their lives
after experiencing medical emergencies such as a stroke. Commenters
also noted that if a therapy cap exceptions process is not in place,
our proposed policy would result in Medicare beneficiaries either being
financially liable for additional services or foregoing medically
necessary services. Several commenters stated that this proposal would
place an unnecessary burden on CAHs since it was unlikely that applying
the therapy caps to CAHs would result in significant cost savings or
reduce unnecessary care; and some even said that our proposed policy
would actually increase costs for the Medicare program.
Response: After reassessing our interpretation of section 1833(g)
of the Act under our proposed policy, we continue to conclude that the
proper statutory interpretation would be to apply the therapy caps and
related provisions to outpatient therapy services furnished by CAHs. We
agree with commenters that CAHs provide important access to medically
necessary therapy services for Medicare beneficiaries; however, we do
not believe that application of the therapy caps and related policies
to services furnished by CAHs will lead to significant new impediments
for
[[Page 74409]]
Medicare beneficiaries. Under our proposed policy, CAHs would be
subject to the therapy caps, as well as any potential extension of the
therapy caps exceptions and manual medical review processes, in the
same manner as other providers of therapy services except for those
that are specifically exempted by statute from application of the caps
and related provisions. As such, the therapy caps and related
provisions would affect therapy services furnished by a CAH and other
providers of such services in a comparable degree. We also do not
believe that applying the therapy caps to services furnished by CAHs
would negatively affect the ability of CAHs to furnish therapy services
to Medicare beneficiaries. We believe that any increase in the
administrative burden presented by the therapy caps and, if extended by
legislation, the exceptions and manual medical review processes, will
be only minor. As we explained in the proposed rule and noted above, we
believe the proper interpretation of the statute requires us to apply
the therapy caps to services furnished by CAHs.
Comment: We received a few comments stating that the drawbacks of
the therapy caps would be exacerbated by applying this policy to
additional provider settings. Most of these commenters argued that the
therapy cap has been problematic since its inception. One commenter
suggested that, instead of applying the therapy caps to CAHs, we should
develop an alternative policy to replace the cap.
Response: The therapy caps are mandated by statute and we do not
have authority to repeal the caps. As such, we will continue to apply
the statutorily mandated therapy caps as specified under the statute
which, as we have discussed above, includes applying the therapy caps
policy to CAHs.
Comment: We received several comments stating that our current
policies, in addition to our proposed regulations, overly control the
utilization of therapy services. Most of these commenters noted that
under Sec. 409.17 of the regulations, therapy services are required to
be ordered by a physician prior to a qualified professional initiating
a plan of care, and these commenters argued that the requirement for an
order can control utilization of therapy services in CAHs. One
commenter noted that the direct supervision policy expressed in the CY
2014 OPPS proposed rule coupled with our proposal would cause services
in CAHs to be overregulated.
Response: We disagree with commenters that CAHs are overregulated
with respect to outpatient therapy services. We do not believe our
proposed policy overregulates CAH services as compared to other
providers of therapy services. We also do not believe that Sec. 409.17
requires an order for outpatient therapy services in a CAH as suggested
by the commenters. This regulation requires that a qualified
professional pursuant to a plan of care furnish PT, OT, or SLP
services, which is not the same as an order. Section 409.17 does not
provide for any utilization control or limits on the quantity of
outpatient therapy services furnished by CAHs, but rather assures that
therapy is furnished under a plan of care by a qualified professional.
Further, as explained above, we believe that proper interpretation of
the statute requires us to apply the therapy caps and related
provisions to therapy services furnished by CAHs. As such, the therapy
caps and related provisions would have a comparable effect on therapy
services furnished by a CAH and those furnished by other therapy
services providers (unless they are exempted by statute from the
application of the caps).
Comment: We received numerous comments stating that our proposal
resulted from a misinterpretation of the ATRA, and that it is
preferable policy to treat CAHs and hospitals similarly for the purpose
of the therapy caps. Several commenters believed that we have
misinterpreted the language of the ATRA to conclude that the therapy
caps should be applied to services furnished by CAHs. Commenters noted
that the ATRA specifies a proxy value to accrue therapy services
furnished by CAHs toward the caps, but does not indicate that we should
count this value beyond December 31, 2013, or that we should generally
subject services furnished by CAHs to the therapy caps. Most of these
commenters argued that if Congress had intended to apply the therapy
cap to CAHs, it would have explicitly indicated in the ATRA that CAHs
should be subject to the therapy caps. One commenter raised concern
that ``the proposed change is unlawful'' since the ATRA neither
requires, nor allows the Secretary to revise the federal regulations to
permanently subject to the caps outpatient therapy services furnished
by CAHs.
Most commenters said that we should treat CAHs and outpatient
hospital departments similarly with regard to the therapy caps by
continuing to exclude services furnished by CAHs (presumably to the
extent such exclusion is required by statute). Commenters argued that a
CAH is intended to be ``provider of services'' by furnishing inpatient
and outpatient hospital services in areas where care is severely
limited and thereby acts as a ``hospital'' in the areas that it serves.
One commenter believed that our interpretation of the exemption from
the therapy caps of outpatient therapy services described under section
1833(a)(8)(B) of the Act and paid under section 1834(k)(1)(B) of the
Act is misguided since the exemption only describes the provider type
rather than the provider type and payment methodology for those
services. As evidence for this reasoning, the commenter noted that
skilled nursing facilities (SNFs), comprehensive outpatient
rehabilitation facilities (CORFs), rehabilitation agencies, and home
health agencies, described under section 1833(a)(8)(A) of the Act and
paid under section 1834(k)(1)(B) of the Act, are not exempt from the
therapy caps. The commenter suggested that we make a determination
that, based on the statutory definition in section 1861(e) of the Act,
a CAH is a hospital in the context of applying the therapy caps, and
interpret the hospital services exemption from the therapy caps to
include CAHs.
Response: We agree with commenters that the ATRA does not direct or
require us to apply the therapy caps to services furnished by CAHs. As
noted above, we agree that the ATRA only directed us to count therapy
services furnished by CAHs towards the caps. However, the ATRA is not
the basis of the proposed change to our regulations. Rather, we based
our proposed change on our reassessment of language of section 1833(g)
of the Act as added by the BBA.
After considering the comments concerning our interpretation of
section 1833(g) of the Act, we again reassessed the statute and
reviewed the rationale for our proposal. We continue to conclude that
our proposal to revise our regulations to apply the therapy caps to
services furnished by CAHs reflects the proper interpretation of
section 1833(g) of the statute. We continue to believe that therapy
services furnished by a CAH and paid under section 1834(g) of the Act
are not described under section 1833(a)(8)(B) of the Act and thus do
not meet the requirements of the outpatient hospital exemption. Rather,
as we explained in the proposed rule, the outpatient hospital services
exemption relates to the specific services described under section
1833(a)(8)(B) of the Act, which delineates both the entities that
furnish the services and the manner in which those services are paid.
We acknowledge the commenter's recognition that therapy services
furnished by rehabilitation agencies, CORFs, SNFs, and home health
agencies
[[Page 74410]]
(some of which are also considered ``providers of services'' along with
CAHs under section 1861(u) of the statute) are subject to the therapy
caps even though they are paid under 1834(k)(1)(B) of the Act, as are
hospitals. However, the providers mentioned by the commenters are
described under section 1833(a)(8)(A) of the Act rather than section
1833(a)(8)(B) of the Act. The outpatient hospital services exemption
only applies to services described under section 1833(a)(8)(B) of the
Act. We believe that the statute explicitly exempts only services
described under section 1833(a)(8)(B) of the Act, which does not
include any services for which payment is not made under section
1834(k)(1)(B) of the Act. We continue to believe that neither services
furnished by CAHs, nor those furnished by SNFs, CORFs, rehabilitation
agencies, and home health agencies, fall under that exemption.
Regardless of whether we consider a CAH as a ``hospital'' for purposes
of the therapy caps, therapy services furnished by CAHs are not
described under section 1833(a)(8)(B) of the Act and, as such, do not
fall within the scope of the outpatient hospital services exemption
from the therapy caps. Therefore, we continue to believe that the
outpatient hospital services exemption to the therapy caps under
section 1833(g)(1) and (3) of the Act does not apply to outpatient
therapy services furnished by a CAH.
Comment: Commenters expressed concern that therapy services
furnished by CAHs after January 1, 2014 would be treated differently
than therapy services furnished by outpatient hospital departments
although both entities are subject to the same regulations regarding
outpatient therapy services.
Response: Although we believe it would be preferable policy to
treat all outpatient therapy services furnished in all settings
consistently, we continue to believe the proper interpretation of the
statute requires application of the therapy caps and related policies
to services furnished by CAHs. As a result, if the outpatient hospital
services exemption is no longer suspended by legislation, there may be
differences in the application of the statutory therapy caps and
related provisions between outpatient hospitals and CAHs.
After consideration of all comments, we are finalizing our
proposal. As proposed, we are including paragraph (e)(1)(iv) under both
Sec. 410.59 and Sec. 410.60 to specify that outpatient occupational
therapy, physical therapy and speech-language pathology services
furnished by a CAH directly or under arrangements shall be counted
towards the annual limitation on incurred expenses as if such services
were paid under section 1834(k)(1)(B) of the Act. In order to improve
clarity that PT and SLP services are combined for the purposes of
applying the cap, but not to change the substance of the current
regulations or the proposed changes to the regulations, we are making a
modification to the proposal. Specifically, we are adding the phrase
``and speech-language pathology'' to the text in Sec.
410.60(e)(1)(iv). Also as proposed, we are adding new paragraph
(e)(2)(v) to Sec. 410.59 and (e)(2)(vi) to Sec. 410.60. These new
paragraphs will expressly include outpatient occupational therapy,
physical therapy and speech-language pathology services furnished by a
CAH directly or under arrangements in the description of services to
which the annual limitation applies. Lastly, as proposed, we are
amending the regulation at Sec. 410.60(e)(3), which currently excludes
services furnished by a CAH from the therapy cap for PT and SLP
services, to remove the phrase ``or CAH.''
We received a number of comments that were not related to our
proposal to amend our regulations to specify that the therapy caps and
related provisions are applicable to therapy services furnished by a
CAH. These comments pertained to repeal of the therapy caps, the
therapy caps exceptions process, the manual medical review process, the
therapy MPPR, and Functional Reporting. Because we made no proposals
regarding these subjects, these comments are outside of the scope of
the proposed rule and, therefore, are not addressed in this final rule
with comment period.
J. Requirements for Billing ``Incident To'' Services
1. Background
Section 1861(s)(2)(A) of the Act establishes the benefit category
for services and supplies furnished as incident to the professional
services of a physician. The statute specifies that ``incident to''
services and supplies are ``of kinds which are commonly furnished in
physicians' offices and are commonly either rendered without charge or
included in physicians' bills.''
In addition to the requirements of the statute, our regulation at
Sec. 410.26 sets forth specific requirements that must be met in order
for physicians and other practitioners to bill Medicare for incident to
physicians' services. Section 410.26(a)(7) limits ``incident to''
services to those included under section 1861(s)(2)(A) of the Act and
that are not covered under another benefit category. Section 410.26(b)
specifies (in part) that in order for services and supplies to be paid
as ``incident to'' services under Medicare Part B, the services or
supplies must be:
Furnished in a noninstitutional setting to
noninstitutional patients.
An integral, though incidental, part of the service of a
physician (or other practitioner) in the course of diagnosis or
treatment of an injury or illness.
Furnished under direct supervision (as specified under
Sec. 410.26(a)(2)) of a physician or other practitioner eligible to
bill and directly receive Medicare payment.
Furnished by a physician, a practitioner with an
``incident to'' benefit, or auxiliary personnel.
In addition to Sec. 410.26, there are regulations specific to each
type of practitioner who is allowed to bill for ``incident to''
services. These are found at Sec. 410.71(a)(2) (clinical psychologist
services), Sec. 410.74(b) (physician assistants' services), Sec.
410.75(d) (nurse practitioners' services), Sec. 410.76(d) (clinical
nurse specialists' services), and Sec. 410.77(c) (certified nurse-
midwives' services). When referring to practitioners who can bill for
services furnished incident to their professional services, we are
referring to physicians and these practitioners.
``Incident to'' services are treated as if they were furnished by
the billing practitioner for purposes of Medicare billing and payment.
Consistent with this terminology, in this discussion when referring to
the practitioner furnishing the service, we are referring to the
practitioner who is billing for the ``incident to'' service. When we
refer to the ``auxiliary personnel'' or the person who ``provides'' the
service, we are referring to an individual who is personally performing
the service or some aspect of it as distinguished from the practitioner
who bills for the ``incident to'' service.
Since we treat ``incident to'' services as services furnished by
the billing practitioner for purposes of Medicare billing and payment,
payment is made to the billing practitioner under the PFS, and all
relevant Medicare rules apply including, but not limited to,
requirements regarding medical necessity, documentation, and billing.
Those practitioners who can bill Medicare for ``incident to'' services
are paid at their applicable Medicare payment rate as if they furnished
the service. For example, when ``incident to'' services are billed by a
physician, they are paid at 100 percent of the fee schedule amount, and
when the services are billed by a nurse practitioner or clinical nurse
specialist, they are paid at
[[Page 74411]]
85 percent of the fee schedule amount. Payments are subject to the
usual deductible and coinsurance amounts.
As the services commonly furnished in physicians' offices and other
nonfacility settings have expanded to include more complicated
services, the types of services that can be furnished ``incident to''
physicians' services have also expanded. States have increasingly
adopted standards regarding the delivery of health care services in all
settings, including physicians' offices, in order to protect the health
and safety of their citizens. These state standards often include
qualifications for the individuals who are permitted to furnish
specific services or requirements about the circumstances under which
services may actually be furnished. For example, since 2009, New York
has required that offices in which surgery is furnished must be
accredited by a state-approved accredited agency or organization.
Similarly, Florida requires certain standards be met when surgery is
furnished in offices, including that the surgeon must ``examine the
patient immediately before the surgery to evaluate the risk of
anesthesia and of the surgical procedure to be performed'' and
``qualified anesthesia personnel shall be present in the room
throughout the conduct of all general anesthetics, regional anesthetics
and monitored anesthesia care.''
Over the past years, several situations have come to our attention
where Medicare was billed for ``incident to'' services that were
provided by auxiliary personnel who did not meet the state standards
for those services in the state in which the services were furnished.
The physician or practitioner billing for the services would have been
permitted under state law to personally furnish the services, but the
services were provided by auxiliary personnel who were not in
compliance with state law in providing the particular service (or
aspect of the service).
Practitioners authorized to bill Medicare for services that they
furnish to Medicare beneficiaries are required to comply with state law
when furnishing services for which Medicare will be billed. For
example, section 1861(r) of the Act specifies that an individual can be
considered a physician in the performance of any function or action
only when legally authorized to practice in the particular field by the
state in which he performs such function or action. Section 410.20(b)
of our regulations provides that payment is made for services only if
furnished by a doctor who is ``. . . legally authorized to practice by
the State in which he or she performs the functions or actions, and who
is acting within the scope of his or her license.'' Similar statutory
and regulatory requirements exist for nonphysician practitioners. For
example, section 1861(s)(2)(K)(i) of the Act, which provides a benefit
category for services of a physician assistant (PA), includes only
services that the PA is ``. . . legally authorized to perform by the
State in which the services are performed . . .'', and Sec.
410.74(a)(2)(ii) of our regulations provides that the services of a PA
are covered only if the PA is ``. . . legally authorized to perform the
services in the State in which they are performed. . .'' There are
similar statutory and regulatory provisions for nurse practitioner
services (1861(s)(2)(K)(ii), Sec. 410.75(b)), certified nurse
specialist services (1861(s)(2)(K)(ii), Sec. 410.76(b)), qualified
psychologist services (1861(s)(2)(M), Sec. 410.71(a)), and certified
nurse-midwife services (1861(s)(2)(L), Sec. 410.77(a)(1)).
However, the Medicare requirements for services and supplies
incident to a physician's professional services (Sec. 410.26 discussed
above), do not specifically make compliance with state law a condition
of payment for services (or aspects of services) and supplies furnished
and billed as ``incident to'' services. Nor do any of the regulations
regarding services furnished incident to the services of other
practitioners contain this requirement. Thus, Medicare has had limited
recourse when services furnished incident to a physician's or
practitioner's services are not furnished in compliance with state law.
In 2009, the Office of Inspector General issued a report entitled
``Prevalence and Qualifications of Nonphysicians Who Performed Medicare
Physician Services'' (OEI-09-06-00430) that considered in part the
qualifications of auxiliary personnel who provided incident to
physician services. This report found that services being billed to
Medicare were provided by auxiliary personnel. After finding that
services were being provided by auxiliary personnel ``. . . who did not
possess the required licenses or certifications according to State
laws, regulations, and/or Medicare rule'' and billed to Medicare the
OIG recommended that we revise the ``incident to'' rules to, among
other things, ``. . . require that physicians who do not personally
perform the services they bill to Medicare ensure that no persons
except . . . nonphysicians who have the necessary training,
certification, and/or licensure, pursuant to State laws, State
regulations, and Medicare regulations personally perform the services
under the direct supervision of a licensed physician.''
2. Compliance With State Law
To ensure that auxiliary personnel providing services to Medicare
beneficiaries incident to the services of other practitioners do so in
accordance with the requirements of the state in which the services are
furnished and to ensure that Medicare payments can be denied or
recovered when such services are not furnished in compliance with the
state law, we proposed to add a requirement to the ``incident to''
regulations at Sec. 410.26, Services and supplies incident to a
physician's professional services: Conditions. Specifically, we
proposed to amend Sec. 410.26(b) by redesignating paragraphs (b)(7)
and (b)(8) as paragraphs (b)(8) and (b)(9), respectively, and by adding
a new paragraph (b)(7) to state that ``Services and supplies must be
furnished in accordance with applicable State law.'' We also proposed
to amend the definition of auxiliary personnel at Sec. 410.26(a)(1) to
require that the individual providing ``incident to'' services ``meets
any applicable requirements to provide the services, including
licensure, imposed by the State in which the services are being
furnished.''
3. Elimination of Redundant Language
In addition, we proposed to eliminate redundant and potentially
incongruent regulatory language by replacing the specific ``incident
to'' requirements currently contained in the regulations relating to
each of the various types of practitioners with a reference to the
requirements of Sec. 410.26. Specifically, we proposed to:
Revise Sec. 410.71(a)(2) regarding clinical
psychologists' services to read ``Medicare Part B covers services and
supplies incident to the services of a clinical psychologist if the
requirements of Sec. 410.26 are met.''
Revise Sec. 410.74(b) regarding physician assistants'
services to read ``Medicare Part B covers services and supplies
incident to the services of a physician assistant if the requirements
of Sec. 410.26 are met.''
Revise Sec. 410.75(d) regarding nurse practitioners'
services to read ``Medicare Part B covers services and supplies
incident to the services of a nurse practitioner if the requirements of
Sec. 410.26 are met.''
Revise Sec. 410.76(d) regarding certified nurse
specialists' services to read ``Medicare Part B covers services and
supplies incident to the services of a clinical nurse specialist if the
requirements of Sec. 410.26 are met.''
[[Page 74412]]
Revise the language in Sec. 410.77(c) regarding certified
nurse-midwives' services to read ``Medicare Part B covers services and
supplies incident to the services of a certified nurse-midwife if the
requirements of Sec. 410.26 are met.''
We noted in the proposed rule that these practitioners are, and
would continue to be under this proposal, required to comply with the
regulation at Sec. 410.26 for services furnished incident to their
professional services. We believe it is redundant and potentially
confusing to have separate regulations that generally restate the
requirements for ``incident to'' services of Sec. 410.26 using
slightly different terminology. We stated that our goal in proposing
the revisions to refer to Sec. 410.26 in the regulation for each
practitioner's ``incident to'' services was to reduce the regulatory
burden and make it less difficult for practitioners to determine what
is required. Reconciling these regulatory requirements for physicians
and all other practitioners who have the authority to bill Medicare for
``incident to'' services is also consistent with our general policy to
treat nonphysician practitioners similarly to physicians unless there
is a compelling reason for disparate treatment. We noted that we
believed that this proposal made the requirements clearer for
practitioners furnishing ``incident to'' services without eliminating
existing regulatory requirements or imposing new ones and welcomed
comments on any requirements that we may have inadvertently overlooked
in our proposed revisions, or any benefit that accrues from continuing
to carry these separate regulatory requirements.
4. Rural Health Clinics and Federal Qualified Health Centers
The regulations applicable to Rural Health Clinics (RHCs) and
Federally Qualified Health Centers (FQHCs) have similar ``incident to''
rules, and we proposed to make conforming changes to these regulations.
Specifically, we proposed to revise Sec. 405.2413(a), which addresses
services and supplies incident to physicians' services for RHCs and
FQHCs, by redesignating paragraphs (a)(4) and (a)(5) as paragraphs
(a)(5) and (a)(6), respectively and by adding a new paragraph (a)(4)
that states services and supplies must be furnished in accordance with
applicable state law. Additionally, we proposed to amend Sec.
405.2415(a), which addresses services incident to nurse practitioner
and physician assistant services by redesignating paragraphs (a)(4) and
(a)(5) as paragraphs (a)(5) and (a)(6), respectively and by adding a
new paragraph (a)(4), which specifies services and supplies must be
furnished in accordance with applicable state law. We proposed to amend
Sec. 405.2452(a), which addresses services and supplies incident to
clinical psychologist and clinical social worker services by
redesignating paragraphs (a)(4) and (a)(5) as paragraphs (a)(5) and
(a)(6), respectively and by adding a new paragraph (a)(4), which states
services and supplies must be furnished in accordance applicable state
law. Finally, we also proposed the removal of the word ``personal'' in
Sec. 405.2413, Sec. 405.2415, and Sec. 405.2452 to be consistent
with the ``incident to'' provisions in Sec. 410.26.
The following is a summary of the comments we received regarding
the proposal to amend our regulations to include the requirement that
``incident to'' services must be furnished in accordance with
applicable state law.
Comment: The vast majority of commenters supported requiring
compliance with applicable state law as a condition of payment for
``incident to'' services. Many of these commenters noted that adoption
of this regulation would increase quality of care and safety for
Medicare beneficiaries and ensure that funds dedicated to services and
supplies are appropriately utilized. We received only two comments
opposing the adoption of a condition of payment requiring compliance
with state laws. One of these stated that since at least 1997, Medicare
has had a ``demonstration project'' that has tested the effects of
lifting state scope of practice restrictions, and that with this
proposed regulation we are abruptly ending this demonstration without
an assessment of the effects of such action. The other stated that this
regulation was unnecessary because section 1156 of the Act requires
health care practitioners to ensure that ``. . . the services it
furnishes are of a quality that meets professional standards of care. .
. .'' Some who supported the concept of our proposal suggested that the
condition of payment only require compliance with state laws relating
to training, certification, and/or licensure. In support of this
suggestion, a commenter noted that the broader requirement of
compliance with any applicable state laws would allow CMS to deny
Medicare payment for technical violations of state laws that are not
targeted at patient health or safety, even when care was appropriately
delivered and the quality of care not affected. One commenter pointed
out that our regulations if revised as proposed would put providers at
risk of having to defend False Claims Act actions brought on the theory
that the provider improperly billed for services based on a minor
defect with the physician or other practitioner's license or
certification; and, in turn that this minor defect is unrelated to the
quality of care furnished and outside the scope of practice and should
therefore not result in the risk of possible False Claims Act
allegations.
Response: After consideration of the comments, we are finalizing
our proposal to adopt a new condition of payment imposing a requirement
to comply with state laws for services furnished incident to a
physician's or other practitioner's professional services. We believe
this requirement will protect the health and safety of Medicare
beneficiaries and enhance our ability to recover federal dollars when
care is not delivered in accordance with state laws. In response to
concerns that the proposal should be limited to state laws relating to
who could perform the services, such as scope of practice or licensure
laws, we believe that there are many and varied state laws that would
protect the safety and health of Medicare beneficiaries. As such, we do
not believe it would be prudent to limit the applicability as
suggested. In response to the commenter's concern regarding technical
and unintended violations of state laws, it is important that CMS only
pays for services furnished in accordance with state law. In an effort
to ensure that services are furnished in accordance with state law, it
is expected that practitioners are cognizant of the qualifications of
any individuals who provide services incident to the physician (or
other practitioner). With regard to the comment stating that this
regulation is unnecessary based on section 1156 of the Act, we note
that compliance with section 1156 is a condition of eligibility and not
an explicit basis for CMS to deny or recover payments for services
furnished incident to services of a physician (or other practitioner)
where services are not furnished in accordance with state law. After
reviewing the comments we conclude that it is beneficial to make
explicit as a condition of payment for ``incident to'' services the
requirement to comply with state law. The fact that another provision
of the law might also be relevant to the situation does not mean that
both are not appropriate or beneficial to the program. With regard to
the comment that we are ending a demonstration project that has existed
since at least 1997 without an assessment, we disagree. We are unaware
of any such demonstration
[[Page 74413]]
project either currently underway, or undertaken in the past. Moreover,
as we noted in the proposed rule, practitioners furnishing services to
Medicare beneficiaries are not exempt from complying with state law.
Comment: Several commenters, including some who supported our
proposal, expressed concern about enforcement and expanding the
administrative burden on Medicare practitioners. Suggestions were made
that we be transparent in implementing the provision and provide ample
education on the policy and how it will be enforced. One commenter
asked that we ``. . . take into account the already significant
administrative burden that physicians face under Medicare, and avoid
adding to that burden.'' Another commenter urged us to work with
medical societies, particularly those representing practitioners in
rural communities, to ensure the policy is well understood and does not
impede beneficiary access to care. It was further suggested that we
should know who is actually providing services or at least when
services are provided ``incident to'' the billing professional's
services, and that we consider implementing the OIG's recommendation to
require the use of modifiers on the claim when reporting ``incident
to'' services.
Response: We do not believe that this condition of payment would
increase the administrative burden on practitioners as practitioners
are already expected to comply with state law. As we have discussed
above, we believe that this provision enhances our ability to deny or
recover payments when the condition is not met. With regard to the
suggestion that we impose a requirement for practitioners to bill
``incident to'' services using a modifier, we do not believe that a
modifier requirement would assist in implementing or enforcing this
condition of payment. Since a modifier requirement would not assist us
in implementing this provision, we are not adopting one at this time.
We would also note that there are impediments to imposing a modifier
requirement at this time, including that a modifier and required
definitions for use of a modifier do not exist. With regard to
informing those affected by this change in regulations, we will use our
usual methods to alert stakeholders of this new condition of payment
and feel confident that the information will be efficiently and
effectively disseminated to those who need it.
Comment: One commenter pointed out that states can and do punish
individuals for furnishing services inappropriately, and that CMS
should therefore leave it to the states to determine whether or when
services are provided by an unlicensed professional.
Response: We agree with this commenter that it is primarily the
responsibility of states to develop and enforce compliance with
licensure laws for health care professionals, and note that nothing in
this proposal would impede the states' ability to do so. Nor would
anything in this proposal duplicate the states' activities in this
arena. Rather, this proposal would reinforce the states' laws by
providing explicit authority to limit Medicare payment for ``incident
to'' services to those furnished in accordance with state laws. As
noted above, in the absence of our proposed regulation, situations
could arise where Medicare would otherwise make payment for services
not furnished in accordance with state law. Such situations are not
consistent with our recognition of states as principle regulators of
health care practices for the protection and benefit of their citizens.
The adoption of compliance with state law as a condition of Medicare
payment allows us to deny, or if already paid, recover payment when
services are not furnished in compliance with state law and thus
supports state activities.
Comment: A commenter suggested that we eliminate the new proposed
Sec. 410.26(b)(7), which requires that ``incident to'' services be
provided in compliance with applicable state law, because it was
redundant with Sec. 410.26(a)(1).
Response: Section 410.26(a)(1) defines ``Auxiliary personnel''
whereas Sec. 410.26(b)(7) provides the conditions that must be met for
Medicare Part B to pay for services and supplies. It is therefore not
redundant, but instead necessary, to both define auxiliary personnel
and to include the specific requirements that must be met.
In addition to the comments discussed above, we received several
comments regarding the ``incident to'' benefit that were not within the
scope of our proposal. Specifically, we received requests to expand the
types of practitioners who are allowed to bill Medicare for ``incident
to'' services and to limit auxiliary personnel under our ``incident
to'' regulations to those who cannot bill Medicare directly for their
services. Not only are these comments outside the scope of this
regulation, but in most respects they are addressed by the Medicare
statute and outside our discretion to change.
After consideration of public comments regarding our proposed rule,
we are finalizing the changes to our regulations as proposed. The
specific regulatory changes being made are described below.
Specifically, we are amending Sec. 410.26(a)(7), which defines
``auxiliary personnel'' to add ``and meets any applicable requirements
to provide the services, including licensure, imposed by the State in
which the services are being furnished.'' In Sec. 410.26(b) we are
redesignating paragraphs (b)(7) and (b)(8) as paragraphs (b)(8) and
(b)(9), respectively, and adding a new paragraph (b)(7) to state that
``Services and supplies must be furnished in accordance with applicable
State laws;''.
In addition, we are finalizing our proposal to eliminate redundant
and potentially incongruent regulatory language by replacing the
specific ``incident to'' requirements currently contained in the
regulations relating to each of the various types of practitioners with
a reference to the requirements of Sec. 410.26. Specifically, we are:
Revising Sec. 410.71(a)(2) regarding clinical
psychologist services to read ``Medicare Part B covers services and
supplies incident to the services of a clinical psychologist if the
requirements of Sec. 410.26 are met.''
Revising Sec. 410.74(b) regarding physician assistants'
services to read ``Medicare Part B covers services and supplies
incident to the services of a physician assistant if the requirements
of Sec. 410.26 are met.''
Revising Sec. 410.75(d) regarding nurse practitioners'
services to read ``Medicare Part B covers services and supplies
incident to the services of a nurse practitioner if the requirements of
Sec. 410.26 are met.''
Revising Sec. 410.76(d) regarding clinical nurse
specialists' services to read ``Medicare Part B covers services and
supplies incident to the services of a clinical nurse specialist if the
requirements of Sec. 410.26 are met.''
Revising the language in Sec. 410.77(c) regarding
certified nurse-midwives' services to read ``Medicare Part B covers
services and supplies incident to the services of a certified nurse-
midwife if the requirements of Sec. 410.26 are met.''
We are also revising the regulations applicable to RHCs and FQHCs
to make similar changes. Specifically, we are revising Sec.
405.2413(a), which addresses services and supplies incident to
physicians' services for RHCs and FQHCs, by redesignating paragraphs
(a)(4) and (a)(5) as paragraphs (a)(5) and (a)(6), respectively and by
adding a new paragraph (a)(4) that states ``Services and supplies must
be furnished in accordance with applicable State laws;''. Additionally,
we are amending Sec. 405.2415(a), which addresses services incident to
nurse practitioner and
[[Page 74414]]
physician assistant services by redesignating paragraphs (a)(4) and
(a)(5) as paragraphs (a)(5) and (a)(6), respectively and by adding a
new paragraph (a)(4) that ``Services and supplies must be furnished in
accordance with applicable State laws;''. We are amending Sec.
405.2452(a), which addresses services and supplies incident to clinical
psychologist and clinical social worker services by redesignating
paragraphs (a)(4) and (a)(5) as paragraphs (a)(5) and (a)(6),
respectively and by adding a new paragraph (a)(4) that states
``Services and supplies must be furnished in accordance with applicable
State laws.''
Finally, we are removing the word ``personal'' in Sec. 405.2413,
Sec. 405.2415, and Sec. 405.2452 to be consistent with the ``incident
to'' provisions in Sec. 410.26 Services and supplies incident to a
physician's professional services: Conditions.
The changes being adopted in this final rule with comment period
are consistent with the traditional approach of relying primarily on
the states to regulate the health and safety of their residents in the
delivery of health care services. Throughout the Medicare program, and
as evidenced by several examples above, the qualifications required for
the delivery of health care services are generally determined with
reference to state law. As discussed above, our current regulations
governing practitioners billing Medicare for services personally
furnished include a basic requirement to comply with state law when
furnishing Medicare covered services. However, the Medicare regulations
for ``incident to'' services and supplies did not specifically make
compliance with state law a condition of payment for services and
supplies furnished and billed as incident to a practitioner's services.
In addition to health and safety benefits that we believe will accrue
to Medicare beneficiaries, these changes will help to assure that
federal dollars are not expended for services that do not meet the
standards of the states in which they are being furnished while
providing the ability for the federal government to recover funds paid
where services and supplies are not furnished in accordance with these
requirements.
K. Chronic Care Management (CCM) Services
As we discussed in the CY 2013 PFS final rule with comment period,
we are committed to supporting primary care and we have increasingly
recognized care management as one of the critical components of primary
care that contributes to better health for individuals and reduced
expenditure growth (77 FR 68978). Accordingly, we have prioritized the
development and implementation of a series of initiatives designed to
improve payment for, and encourage long-term investment in, care
management services. These initiatives include the following programs
and demonstrations:
The Medicare Shared Savings Program (described in
``Medicare Program; Medicare Shared Savings Program: Accountable Care
Organizations; Final Rule'' which appeared in the November 2, 2011
Federal Register (76 FR 67802)).
The testing of the Pioneer ACO model, designed for
experienced health care organizations (described on the Center for
Medicare and Medicaid Innovation's (Innovation Center's) Web site at
innovations.cms.gov/initiatives/ACO/Pioneer/index.html).
The testing of the Advance Payment ACO model, designed to
support organizations participating in the Medicare Shared Savings
Program (described on the Innovation Center's Web site at
innovations.cms.gov/initiatives/ACO/Advance-Payment/index.html).
The Primary Care Incentive Payment (PCIP) Program
(described on the CMS Web site at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/PCIP-2011-Payments.pdf).
The patient-centered medical home model in the Multi-payer
Advanced Primary Care Practice (MAPCP) Demonstration designed to test
whether the quality and coordination of health care services are
improved by making advanced primary care practices more broadly
available (described on the CMS Web site at www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf).
The Federally Qualified Health Center (FQHC) Advanced
Primary Care Practice demonstration (described on the CMS Web site at
www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf and the Innovation Center's Web site
at innovations.cms.gov/initiatives/FQHCs/index.html).
The Comprehensive Primary Care (CPC) initiative (described
on the Innovation Center's Web site at innovations.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/index.html). The CPC initiative
is a multi-payer initiative fostering collaboration between public and
private health care payers to strengthen primary care in certain
markets across the country.
In addition, HHS leads a broad initiative focused on optimizing
health and quality of life for individuals with multiple chronic
conditions. HHS' Strategic Framework on Multiple Chronic Conditions
outlines specific objectives and strategies for HHS and private sector
partners centered on strengthening the health care and public health
systems; empowering the individual to use self-care management;
equipping care providers with tools, information, and other
interventions; and supporting targeted research about individuals with
multiple chronic conditions and effective interventions. Further
information on this initiative can be found on the HHS Web site at
http://www.hhs.gov/ash/initiatives/mcc/index.html.
In coordination with all of these initiatives, we also have
continued to explore potential refinements to the PFS that would
appropriately value care management within Medicare's statutory
structure for fee-for-service physician payment and quality reporting.
For example, in the CY 2013 PFS final rule with comment period, we
adopted a policy to pay separately for care management involving the
transition of a beneficiary from care furnished by a treating physician
during a hospital stay to care furnished by the beneficiary's primary
physician in the community (77 FR 68978 through 68993). We view
potential refinements to the PFS such as these as part of a broader
strategy that relies on input and information gathered from the
initiatives described above, research and demonstrations from other
public and private stakeholders, the work of all parties involved in
the potentially misvalued code initiative, and from the public at
large.
1. Patient Eligibility for Separately Payable Non-Face-to-Face Chronic
Care Management Services
Under current PFS policy, the payment for non-face-to-face care
management services is bundled into the payment for face-to-face E/M
visits because care management is a component of those E/M services.
The pre- and post-encounter non-face-to-face care management work is
included in calculating the total work for the typical E/M services,
and the total work for the typical service is used to develop RVUs for
the E/M services. In the CY 2012 PFS proposed rule, we highlighted some
of the E/M services that include substantial care management work.
Specifically, we noted that the vignettes that describe a typical
service for mid-
[[Page 74415]]
level office/outpatient services (CPT codes 99203 and 99213) include
furnishing care management, communication, and other necessary care
management related to the office visit in the post-service work (76 FR
42917).
However, the physician community continues to tell us that the care
management included in many of the E/M services, such as office visits,
does not adequately describe the typical non-face-to-face care
management work involved for certain categories of beneficiaries. In
addition, there has been substantial growth in medical practices that
are organized as medical homes and devote significant resources to care
management as one of the keys to improve the quality and coordination
of health care services. Practitioners in these medical homes have also
indicated that the care management included in many of the E/M services
does not adequately describe the typical non-face-to-face care
management work that they furnish to patients.
Because the current E/M office/outpatient visit CPT codes were
designed to support all office visits and reflect an overall
orientation toward episodic treatment, we agree that these E/M codes
may not reflect all the services and resources required to furnish
comprehensive, coordinated care management for certain categories of
beneficiaries. For example, we currently pay physicians separately for
the non face-to-face care plan oversight services furnished to
beneficiaries under the care of home health agencies or hospices and we
currently pay separately for care management services furnished to
beneficiaries transitioning from care furnished by a treating physician
during a hospital stay to care furnished by the beneficiary's primary
physician in the community.
Similar to these situations, we believe that the resources required
to furnish chronic care management services to beneficiaries with
multiple (that is, two or more) chronic conditions are not adequately
reflected in the existing E/M codes. Therefore, for CY 2015, we
proposed to establish a separate payment under the PFS for chronic care
management services furnished to patients with multiple chronic
conditions that are expected to last at least 12 months or until the
death of the patient, and that place the patient at significant risk of
death, acute exacerbation/decompensation, or functional decline.
We also stated our intent to develop standards for furnishing
chronic care management services to ensure that the physicians and
practitioners who bill for these services have the capability to
provide them.
Comment: The vast majority of commenters overwhelmingly supported
the broad policy of paying separately for non-face-to-face chronic care
management services, but submitted comments on many specific aspects of
our proposal.
Response: We appreciate the widespread support expressed by
commenters for our proposed policy. We address the more specific
comments below in this section.
Comment: Some commenters supported our proposed patient eligibility
for chronic care management services, at least for the initial
implementation of separate payment for the services. Typical of these
comments was this statement by one commenter:
``CMS should initially offer these services to patients with
multiple chronic conditions that are expected to last at least 12
months or until the death of the patient, and that place the patient
at significant risk of death, acute exacerbation/decompensation, or
functional decline.''
We also received comments indicating that the patient eligibility
should be broadened, for example, to allow eligibility for patients
with one condition or for all patients in a practice that meets the
practice standards we establish.
On the other hand, some commenters believed that the eligible
patient population should be narrowed. Many of these commenters
indicated that the benefits of chronic care management are likely to
increase with thethe patient's acuity and risk. Many commenters
indicated that the criteria described in the prefatory language for the
complex chronic care coordination CPT codes 99487-99489 describes a
narrower and more appropriate patient population. The CPT criteria for
CY 2014 currently state:
``Patients who require complex chronic care coordination
services may be identified by practice-specific or other published
algorithms that recognize multiple illnesses, multiple medication
use, inability to perform activities of daily living, requirement
for a caregiver, and/or repeat admissions or emergency department
visits. Typical adult patients take or receive three or more
prescription medications and may also be receiving other types of
therapeutic interventions (eg, physical therapy, occupational
therapy) and have two or more chronic continuous or episodic health
conditions expected to last at least 12 months, or until the death
of the patient, that place the patient at significant risk of death,
acute exacerbation/decompensation, or functional decline. Typical
pediatric patients receive three or more therapeutic interventions
(eg, medications, nutritional support, respiratory therapy) and have
two or more chronic continuous or episodic health conditions
expected to last at least 12 months, or until the death of the
patient, that place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline. Because of the
complex nature of their diseases and morbidities, these patients
commonly require the coordination of a number of specialties and
services. In some cases, due to inability to perform IADL/ADL and/or
cognitive impairment the patient is unable to adhere to the
treatment plan without substantial assistance from a caregiver. For
example, patients may have medical and psychiatric behavioral co-
morbidities (eg, dementia and chronic obstructive pulmonary disease
or substance abuse and diabetes) that complicate their care. Social
support requirements or access to care difficulties may cause a need
for these services. Medical, functional, and/or psychosocial
problems that require medical decision making of moderate or high
complexity and extensive clinical staff support are required.''
MedPAC and other some commenters did not recommend specific
alternative patient eligibility criteria, but stated that CMS should
develop such criteria to better target the beneficiaries requiring
significant management. One commenter recommended that the eligible
patient population be narrowed to patients with four or more chronic
conditions.
Response: As we stated in the proposed rule, we believe that the
resources required tofurnish chronic care management services to
beneficiaries with two or more chronic conditions are not adequately
reflected in the existing E/M codes. Furnishing care management to
beneficiaries with multiple chronic conditions requires
multidisciplinary care modalities that involve: regular physician
development and/or revision of care plans; subsequent reports of
patient status; review of laboratory and other studies; communication
with other health professionals not employed in the same practice who
are involved in the patient's care; integration of new information into
the care plan; and/or adjustment of medical therapy. Our proposal was
also supported by an analysis of Medicare claims for patients with
selected multiple chronic conditions (see http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf). This analysis indicated that
patients with these selected multiple chronic conditions are at
increased risk for hospitalizations, use of post-acute care services,
and emergency department visits. We continue to believe these findings
would hold in general for patients with
[[Page 74416]]
multiple chronic conditions that are expected to last at least 12
months or until the death of the patient, and that place the patient at
significant risk of death, acute exacerbation/decompensation, or
functional decline. (We note that we did not propose to limit the
eligible chronic conditions to those contained in our Medicare data
analysis.) We continue to believe that successful efforts to improve
chronic care management for these patients could improve the quality of
care while simultaneously decreasing costs (for example, through
reductions in hospitalizations, use of post-acute care services, and
emergency department visits.) Therefore, we agree with the commenters
who supported our proposed patient eligibility criteria.
While we also agree with the commenters who stated that the
benefits from chronic care management are likely to increase the
greater the acuity and risk to the patient, we disagree that the
benefits and higher resource requirements for furnishing the service
are limited to those even higher risk patients within the population of
patients with two or more chronic conditions. Therefore, we disagree
that the eligible patient population should be narrowed.
We also disagree with commenters who indicated that we should
immediately expand the eligible patient population, for example, to
include some patients with a single chronic condition or all the
patients in a practice that meets future standards. It is not clear at
this time that the resources required to provide typical chronic care
management to these patients are not reflected adequately in the
existing E/M codes. However, as we indicated in the proposed rule, we
have over time recognized certain categories of beneficiaries for whom
we allow separate payment for care management. We have not indicated
that we have exhaustively identified all such categories of
beneficiaries. We will continue to carefully consider whether there are
categories of patients for whom the resources required to provide
chronic care management services are not adequately reflected in the
existing E/M codes. We may consider changes to the patient eligibility
in future rulemaking.
In summary, we are finalizing without modification our proposed
patient eligibility for chronic care management services to be patients
with multiple chronic conditions that are expected to last at least 12
months or until the death of the patient, and that place the patient at
significant risk of death, acute exacerbation/decompensation, or
functional decline.
We note that although we are finalizing our proposed eligibility
criteria, since we agree with commenters that the benefits from chronic
care management are likely to increase with the greater the acuity and
risk to the patient, we expect that physicians and other practitioners
will particularly focus on higher acuity and higher risk patients (for
example, patients with four or more chronic conditions as suggested by
one commenter) when furnishing chronic care management services to
eligible patients.
Comment: Many commenters found our use of the term ``complex'' to
describe these services to be confusing in light of the number of
Medicare beneficiaries within a practice potentially meeting our
proposed eligibility criteria, and suggested that the word could be
interpreted to significantly narrow the appropriate patient population
eligible for chronic care management services.
Response: We regret any confusion generated by our proposed use of
the term ``complex'' to describe the chronic care management services
that are not adequately reflected in the existing E/M codes. Although
the provision of these services is complex relative to the care
management reflected in the existing E/M codes, we understand the
confusion on the part of commenters regarding the number of patients
within a practice that are potentially eligible for the service versus
those that would be considered ``complex.'' Therefore, to reduce
potential confusion, we will revise the code description for these
services to describe ``chronic care management'' services rather than
complex chronic care management services. We note that we have revised
references throughout this preamble to remove the word ``complex'' from
the description of these services.
2. Scope of Chronic Care Management Services
We proposed that the scope of chronic care management services
includes:
The provision of 24-hour- a-day, 7-day- a-week access to
address a patient's acute chronic care needs. To accomplish these
tasks, we would expect that the patient would be provided with a means
to make timely contact with health care providers in the practice to
address urgent chronic care needs regardless of the time of day or day
of the week. Members of the chronic care team who are involved in the
after-hours care of a patient must have access to the patient's full
electronic medical record even when the office is closed so they can
continue to participate in care decisions with the patient.
Continuity of care with a designated practitioner or
member of the care team with whom the patient is able to get successive
routine appointments.
Care management for chronic conditions including
systematic assessment of patient's medical, functional, and
psychosocial needs; system-based approaches to ensure timely receipt of
all recommended preventive care services; medication reconciliation
with review of adherence and potential interactions; and oversight of
patient self-management of medications. In consultation with the
patient and other key practitioners treating the patient, the
practitioner furnishing chronic care management services should create
a patient-centered plan of care document to assure that care is
provided in a way that is congruent with patient choices and values. A
plan of care is based on a physical, mental, cognitive, psychosocial,
functional and environmental (re)assessment and an inventory of
resources and supports. It is a comprehensive plan of care for all
health issues. It typically includes, but is not limited to, the
following elements: problem list, expected outcome and prognosis,
measurable treatment goals, symptom management, planned interventions,
medication management, community/social services ordered, how the
services of agencies and specialists unconnected to the practice will
be directed/coordinated, identify the individuals responsible for each
intervention, requirements for periodic review and, when applicable,
revision, of the care plan. The provider should seek to reflect a full
list of problems, medications and medication allergies in the
electronic health record to inform the care plan, care coordination and
ongoing clinical care.
Management of care transitions within health care
including referrals to other clinicians, visits following a patient
visit to an emergency department, and visits following discharges from
hospitals and skilled nursing facilities. The practice must be able to
facilitate communication of relevant patient information through
electronic exchange of a summary care record with other health care
providers regarding these transitions. The practice must also have
qualified personnel who are available to deliver transitional care
services to a patient in a timely way so as to reduce the need for
repeat visits to emergency departments and re-admissions to hospitals
and skilled nursing facilities.
[[Page 74417]]
Coordination with home and community based clinical
service providers required to support a patient's psychosocial needs
and functional deficits. Communication to and from home and community
based providers regarding these clinical patient needs must be
documented in practice's medical record system.
Enhanced opportunities for a patient to communicate with
the provider regarding their care through not only the telephone but
also through the use of secure messaging, internet or other
asynchronous non face-to-face consultation methods.
Comment: Some commenters supported our proposed scope of services,
indicating that the requirements are consistent with what is expected
in a primary care medical home. Other commenters, while generally
supportive of the proposed scope of services, provided comments on
specific aspects of the proposed scope.
Response: We agree with the commenters who supported our proposed
scope of services and agree that the requirements are consistent with
what is expected in a primary care medical home. We summarize and
respond to comments on specific aspects of the proposed scope below.
Comment: Some commenters indicated that while they agreed with the
goal of having members of the chronic care team who are involved in the
after-hours care of a patient having access to the patient's full EHR,
that this was not currently possible for too many physicians who would
otherwise be able to provide this service. Some commenters indicated
that many practices will be using EHR systems that qualify for
Meaningful Use Stage 2, but that do not support 24/7 remote access.
Some commenters suggested that the 24/7 EHR access requirement be
changed to require that members of the chronic care team have access to
timely EHR information (that is, through the EHR or other formats.)
Response: Given that the comments on our proposed policy to require
24/7 access to the EHR were generally part of broader comments on the
role of EHRs in the standards that must be met in order to furnish
chronic care management services, we intend to address this issue in
future rulemaking to establish the standards. Summaries of these
broader comments can be found below in the standards section.
Comment: Some commenters stated that it was not feasible in many
practices for a patient's personal practitioner or another clinical
team member to be available on a 24/7 basis for every patient. Other
commenters recommended gradually phasing in this requirement over time.
Response: The evolving medical literature on chronic care
management and patient centered medical homes emphasizes the central
importance of members of the care team being available 24/7 to address
a patient's acute chronic care needs. Moreover, we believe the 24/7
availability of the care team is an important factor contributing to
higher resource costs for these services that are not currently
reflected in E/M services. Therefore, we disagree with commenters who
requested that we relax or phase in the 24/7 requirement.
Comment: Some commenters requested that we clarify the scope of
services with respect to caregivers for patients with chronic care
needs. Some of these commenters recommended that we require providers
to address the needs of caregivers, especially caregivers who are
Medicare beneficiaries, since caregivers are at elevated risk of health
issues from emotional and physical stresses.
Response: As with transitional care management (77 FR 68989),
communication that is within the scope of services for chronic care
management includes communication with the patient and caregiver. We
also agree with commenters that caregivers who are Medicare
beneficiaries, as with any Medicare beneficiary, should be provided
with needed high quality, efficient care congruent with the patient's
choices and values. We note, however, that we do not have the statutory
authority to extend Medicare benefits to individuals who are not
eligible for those benefits.
Comment: While the majority of commenters expressed support for our
proposal to require a patient-centered plan of care, some commenters
believed that this requirement was not necessary in all cases. These
commenters suggested that the requirement be changed to require a plan
of care document as needed.
Response: We disagree with these comments. As we indicated in the
propose rule, we believe that patients with multiple chronic conditions
are at increased risk for hospitalizations, use of post-acute care
services, and emergency department visits. Given this increased risk,
we believe that a patient-centered plan of care document is a critical
tool to help ensure appropriate care management for these patients. In
the absence of such of document, we believe there would be
significantly greater potential for gaps in care coordination. In
addition, we received many comments supporting active involvement of
the patient and caregiver in chronic care management. We believe our
requirement that a written or electronic copy of the patient-centered
plan of care document be provided to the patient facilitates this
involvement.
Comment: Some commenters expressed concern regarding our proposal
to include enhanced opportunities for a patient to communicate with the
provider regarding their care through not only the telephone but also
through the use of secure messaging, internet or other asynchronous non
face-to-face consultation methods. They indicated that many patients
and/or caregivers may not be capable of using this type of
communication, even if the practice is equipped to provide it.
Response: We disagree with these comments. Recognizing the growing
use of, and patient and caregiver interest in, asynchronous
communication through secure email, text and other modalities to
support access to health care, we believe that it is reasonable for
beneficiaries and their caregivers who would receive non-face-to-face
chronic care management services to be able to communicate with the
practice not only by telephone but through asynchronous communication
modalities. We note that although the expectation is for the practice
to provide these communication options, there is no requirement that
the practice ensure that every patient and caregiver makes use of these
options.
Comment: Some commenters requested that we explicitly require the
chronic care management practitioner to consider various specific
services or disease specific services when furnishing the scope of
chronic care management services.
Response: In our proposed scope of services, we stated that, ``A
plan of care is based on a physical, mental, cognitive, psychosocial,
functional and environmental (re)assessment and an inventory of
resources and supports. It is a comprehensive plan of care for all
health issues (emphasis added).'' Since the plan of care, as we
described it, is to be comprehensive, we do not believe it is necessary
for the scope of services to exhaustively list specific possible
services that the chronic care management practitioner should consider
when furnishing the scope of chronic care management services.
In summary, we are finalizing the following as the scope of chronic
care management services.
The provision of 24-hour- a-day, 7-day- a-week access to
address a patient's acute chronic care needs. To accomplish these
tasks, we would expect that the
[[Page 74418]]
patient and caregiver would be provided with a means to make timely
contact with health care providers in the practice to address the
patient's urgent chronic care needs regardless of the time of day or
day of the week.
Continuity of care with a designated practitioner or
member of the care team with whom the patient is able to get successive
routine appointments.
Care management for chronic conditions including
systematic assessment of patient's medical, functional, and
psychosocial needs; system-based approaches to ensure timely receipt of
all recommended preventive care services; medication reconciliation
with review of adherence and potential interactions; and oversight of
patient self-management of medications. In consultation with the
patient, caregiver, and other key practitioners treating the patient,
the practitioner furnishing chronic care management services should
create a patient-centered plan of care document to assure that care is
provided in a way that is congruent with patient choices and values. A
plan of care is based on a physical, mental, cognitive, psychosocial,
functional and environmental (re)assessment and an inventory of
resources and supports. It is a comprehensive plan of care for all
health issues. It typically includes, but is not limited to, the
following elements: problem list, expected outcome and prognosis,
measurable treatment goals, symptom management, planned interventions,
medication management, community/social services ordered, how the
services of agencies and specialists unconnected to the practice will
be directed/coordinated, identify the individuals responsible for each
intervention, requirements for periodic review and, when applicable,
revision, of the care plan. The provider should seek to reflect a full
list of problems, medications and medication allergies in the
electronic health record to inform the care plan, care coordination and
ongoing clinical care.
Management of care transitions within health care
including referrals to other clinicians, visits following a patient
visit to an emergency department, and visits following discharges from
hospitals and skilled nursing facilities. The practice must be able to
facilitate communication of relevant patient information through
electronic exchange of a summary care record with other health care
providers regarding these transitions. The practice must also have
qualified personnel who are available to deliver transitional care
services to a patient in a timely way so as to reduce the need for
repeat visits to emergency departments and re-admissions to hospitals
and skilled nursing facilities.
Coordination with home and community based clinical
service providers required to support a patient's psychosocial needs
and functional deficits. Communication to and from home and community
based providers regarding these clinical patient needs must be
documented in practice's medical record system.
Enhanced opportunities for a patient and caregiver to
communicate with the provider regarding the patient's care through not
only the telephone but also through the use of secure messaging,
internet or other asynchronous non face-to-face consultation methods.
We also note that we continue to assess the potential impact of the
scope of our chronic care management policy on our current programs and
demonstrations designed to improve payment for, and encourage long-term
investment in, care management services. Likewise, to assure that there
are not duplicate payments for delivery of care management services, we
continue to consider whether such payments are appropriate for
providers participating in other programs and demonstrations.
3. Standards for Furnishing Chronic Care Management Services
Not all physicians and nonphysician practitioners who wish to
furnish chronic care management services currently have the capability
to fully furnish the scope of these services without making additional
investments in technology, staff training, and the development and
maintenance of systems and processes to furnish the services. We stated
in the proposed rule that we intended to establish standards that would
be necessary to furnish high quality, comprehensive and safe chronic
care management services. We also stated that one of the primary
reasons for our 2015 implementation date was to provide sufficient time
to develop and obtain public input on the standards. Since we continue
to believe that practice standards are one of the most critical
components of our chronic care management policy. We are developing the
standards in 2014 and will implement them in 2015. They will be
established through notice and comment rulemaking for CY 2015 PFS.
In the proposed rule (78 FR 43338-43339), we solicited public
comments for suggestions regarding standards for furnishing chronic
care management. Although we solicited comments, we did not propose to
adopt any specific standards and are, therefore, not finalizing a
policy relating to this issue in this final rule with comment period.
Below are our responses to public comments received. As stated
above, the public comments received for these potential standards for
chronic care management are beyond the scope of the proposed rule, and
therefore, the adoption of any such standards would be addressed
through separate notice-and-comment rulemaking.
Comment: Some commenters were in favor of establishing standards
for furnishing chronic care management services, generally supporting
CMS's acknowledgement of the critical importance of managing care for
these Medicare beneficiaries with chronic conditions. Commenters also
believe that care coordination is an integral part of improving patient
care.
Many commenters expressed concerns and did not support establishing
standards for furnishing chronic care management services as we
discussed in the proposed rule (78 FR 43338-43339). Some commenters
stated the standards we suggested were too aggressive, needed
clarification and/or refinement, and were overly burdensome citing that
adoption should be delayed, perhaps for years or indefinitely.
Commenters suggested that practice capabilities as outlined could
exclude many physicians from furnishing these services, despite the
physicians being specially trained in chronic care management and
having demonstrated the ability to furnish significant quality of care.
Many commenters suggested that CMS partner (through an advisory group,
workgroups, etc.) with interested stakeholders, obtain public input,
and work with the CMS Innovation Center to continue developing and
refining more reasonable potential future standards for furnishing
chronic care management in order to ensure that the physicians who bill
for these services have the capabilities to furnish them. Some
commenters suggested integration of chronic care management standards
with the State laws governing the practice of medicine. Commenters also
urged CMS not to impose requirements that would preclude specialists
from furnishing these critical services.
Response: We appreciate commenters' suggestions and will consider
these comments for any future rulemaking on this topic.
As discussed in the proposed rule, potential standards (78 FR
43338-43339) could include the following:
The practice must be using a certified Electronic Health
Record (EHR) for beneficiary care that meets the most
[[Page 74419]]
recent HHS regulatory standard for meaningful use. The EHR must be
integrated into the practice to support access to care, care
coordination, care management, and communication.
Comment: Commenters generally supported the value of EHRs in regard
to the capabilities to enhance the quality of care for chronic care
management. Commenters requested that CMS clarify the following issues
if CMS were to move forward with meaningful use as a standard for
chronic care management: how a provider new to Medicare or new to a
practice would be treated, and how a provider would be treated who
formerly met meaningful use but failed to do so in a subsequent year
(specifically, whether the practice would be required to repay the
chronic care management payment, and whether the practice would have to
stop providing these services to beneficiaries in the future). Other
commenters noted that while EHRs may facilitate documentation, they are
being replaced by ``cloud-based'' data repositories for beneficiary
medical records and social media is being used for communication
solutions.
Many commenters did not support requiring the practice to use a
certified EHR, some questioning whether an EHR is really essential to
providing these services. These commenters discouraged CMS from
including meaningful use as a standard for chronic care management,
noting that it is premature to link these services to meaningful use,
and that requiring meaningful use as a standard should be delayed until
the meaningful use policy has been stabilized and more practices have
achieved it. Commenters generally expressed concern regarding linking
the provision of chronic care management to meaningful use as practices
would have to delay furnishing care management for a full year until
they have met meaningful use, denying their patients the benefit of
those services. Commenters urged CMS not to require a specific stage of
meaningful use certification. Commenters urged elimination of this
requirement noting it interfered with the physician's prerogatives and
practice; and suggesting that it has nothing to do with how effectively
a physician manages patients with chronic conditions. Some commenters
suggested that the notion that there should be immediate online access
to every patient's complete EHR is unrealistic for many practices (that
is, internet access issues, 24/7 availability of the full EHR, on-call
health professional being from a different practice and not having
access, etc.), particularly those who would most benefit from the
potential chronic care management reimbursement. Commenters also noted
EHR interoperability is not yet attainable by the vast majority of
physicians across the country. Many commenters suggested CMS consider
flexibility (that is, a phased-in approach) in requiring EHRs to avoid
excluding otherwise qualified practices in areas of need. Some
commenters noted that phasing in EHR requirements would aid those
smaller practices, or rural areas, that do not currently utilize EHRs
and thus would not be able to be reimbursed for furnishing
beneficiaries with chronic care management services. Other commenters
expressed concern that this requirement could pose a problem for small
practices (that is, economically depressed, medically underserved,
etc.) for which the expense of obtaining and implementing EHR systems
could be prohibitive despite the fact they could meet the remainder of
the requirements for chronic care management. Commenters raised
concerns that language in the preamble suggests that all practitioners
participating in the care of a beneficiary receiving chronic care
management services would need to be able to share information related
to the care plan electronically, and that it would be very difficult to
meet this requirement as not all practices have access to electronic
means of communication.
Response: We appreciate commenters' suggestions and will consider
these comments for any future rulemaking on this topic.
The practice must employ one or more advanced practice
registered nurses or physicians assistants whose written job
descriptions indicate that their job roles include and are
appropriately scaled to meet the needs for beneficiaries receiving
services in the practice who require chronic care management services
furnished by the practice.
Comment: Some commenters supported the requirement to employ non-
physician professionals, and encouraged CMS to expand this list to
include registered nurses, pharmacists (particularly hematology/
oncology clinical specialist pharmacists), social workers, Emergency
Department physicians, ``caregivers'' (that is, those that help with
Alzheimer's disease and dementia patients), ``direct-care worker,'' and
other specialists such as hematologists, cardiologists, and
nephrologists. Some commenters sought clarification regarding whether
advanced practice nurse practitioners and physician assistants would
have to be available 24/7, and what type of chronic care management
services they must furnish.
Many commenters, however, were not in support of the requirement
that advanced practice nurses or physician assistants must be employed
by the medical practice. Commenters urged elimination of this
requirement noting that it interfered with the physician's
prerogatives; indicating that this staffing requirement would have
little, if anything, to do with how effectively a physician manages
patients with chronic conditions, and suggesting that it could be
considered cost prohibitive. Some commenters urged CMS to relax this
requirement and recognize that these services could be effectively
performed by appropriately trained, licensed, and, when applicable,
credentialed clinical staff. Commenters recommended that CMS not
prescribe the hiring decisions for practices to be eligible to furnish
chronic care management services. Commenters suggested that the agency
instead should provide greater flexibility for practices to demonstrate
that they have the structural capabilities, personnel, and systems to
coordinate care effectively, through their own engagement with
patients, as well as by having other qualified health care
professionals available, either within the practice itself or through
external arrangements to furnish chronic care management services.
Some commenters suggested that, under certain circumstances
independently contracted (but not necessarily employed) personnel could
participate in furnishing these services under the general supervision
of a physician or non-physician practitioner, and sought clarification
on whether ``employ'' could include ``contract'' personnel. Other
commenters requested that the standards recognize that nurses can
perform this work under the direction and supervision of physicians,
especially since many practices employ registered nurses who are well
qualified to provide care coordination. Some commenters believed that
this requirement was particularly ill-advised and inappropriate, and
strongly disagreed that employment of this level of staff should be a
consideration in furnishing these services. Other commenters noted that
this requirement would deter small and rural practices from offering
chronic care management services. Commenters supported care teams/team-
based care, but indicated that a practice should have the discretion to
hire and develop those care teams, and not be required specifically to
hire advanced practice nurse practitioners or physician
[[Page 74420]]
assistants. Some commenters suggested that a ``care manager'' concept
could be used, which could be a registered nurse, social worker,
advanced practice nurse or physician assistant who has received
training to perform the service. Commenters also suggested that CMS
revise the requirement regarding who must employ the care manager to
also allow the practice, or physician organization on the practice's
behalf, to be the employer.
Response: We appreciate commenters' suggestions and will consider
these comments for any future rulemaking on this topic.
The practice must be able to demonstrate the use of
written protocols by staff participating in the furnishing of services
that describe: (1) The methods and expected ``norms'' for furnishing
each component of chronic care management services furnished by the
practice; (2) the strategies for systematically furnishing health risk
assessments to identify all beneficiaries eligible and who may be
willing to participate in the chronic care management services; (3) the
procedures for informing eligible beneficiaries about chronic care
management services and obtaining their consent; (4) the steps for
monitoring the medical, functional and social needs of all
beneficiaries receiving chronic care management services; (5) system
based approaches to ensure timely furnishing of all recommended
preventive care services to beneficiaries; (6) guidelines for
communicating common and anticipated clinical and non-clinical issues
to beneficiaries; (7) care plans for beneficiaries post-discharge from
an emergency department or other institutional health care setting, to
assist beneficiaries with follow up visits with clinical and other
suppliers or providers, and in managing any changes in their
medications; (8) a systematic approach to communicate and
electronically exchange clinical information with and coordinate care
among all service providers involved in the ongoing care of a
beneficiary receiving chronic care management services; (9) a
systematic approach for linking the practice and a beneficiary
receiving chronic care management services with long-term services and
supports including home and community-based services; (10) a systematic
approach to the care management of vulnerable beneficiary populations
such as racial and ethnic minorities and people with disabilities; and
(11) patient education to assist the beneficiary to self-manage a
chronic condition that is considered at least one of his/her chronic
conditions. These protocols must be reviewed and updated as is
appropriate based on the best available clinical information at least
annually.
Comment: Some commenters expressed support for the outlined written
protocols. A few commenters suggested that CMS develop educational
materials to be made available to patients so they better understand
these services. Commenters suggested the 11th written protocol be
revised (to be more interactive) to read ``provide written protocols
that describe collaborative problem solving/decision making that
supports the patient in self-managing their chronic health
conditions.'' Other commenters believe that physicians and other
providers who care for chronically ill patients can be better supported
with evidence-based guidelines, specialty expertise, and information
systems; such as, providers encouraging patients (through partnerships
with community organizations, etc.) to participate in medical systems
like peer support groups, exercise programs, nurse educators, or
dieticians.
Commenters urged CMS to revise this requirement to provide more
flexibility for practices to demonstrate they have their own protocols
to ensure that patients with chronic diseases have timely access to
physicians and other team members within a realistic timeframe (that
is, practices could be required to demonstrate that their patients have
access the same or next day by phone, email, telemedicine, or in
person). Other commenters suggested CMS give more consideration to
therapy services, medication management, discharge planning, care
coordination, and caregiver education. Commenters also asked CMS to
clarify that the practice reporting these chronic care management
services does not have to perform all care management itself, and that
other practices or healthcare professionals can perform some services
in coordination with the reporting practice. Commenters conveyed
individuals with Alzheimer's and dementias may not be able to
participate in the development of a care plan in the same capacity as
individuals who are not cognitively impaired. Some commenters requested
CMS go a step further in noting the importance of coordination with
direct-care workers and family caregivers, and requiring that this
communication be documented as well.
Response: We appreciate commenters' suggestions and will consider
these comments for any future rulemaking on this topic.
All practitioners, including advanced practice registered
nurses or physicians assistants, involved in the furnishing of chronic
care management services must have access at the time of service to the
beneficiary's EHR that includes all of the elements necessary to meet
the most recent HHS regulatory standard for meaningful use. This
includes any and all clinical staff furnishing after hours care to
ensure that the chronic care management services are available with
this level of EHR support in the practice or remotely through a Virtual
Private Network (VPN), a secure Web site, or a health information
exchange (HIE) 24 hours per day and 7 days a week.
Comment: Commenters were generally in support of the concept that
24/7 access to the beneficiary's EHR would be a tremendous enhancement
to furnishing chronic care management. Some commenters noted that many
physicians practice in more than one setting, which can make it more
challenging for them to furnish all beneficiaries with 24/7 EHR support
to providers and care staff. Commenters noted that many of their
members do not have the resources to evaluate patients 24/7; therefore,
commenters urged CMS to clarify the 24/7 support can be furnished by
members of the chronic care team by phone, or allow more flexibility in
this requirement until the agency can assess the impact it may have on
beneficiary access to chronic care management services. Some commenters
noted that many physicians can access their own organization's EHR both
in and outside typical business hours, but do not currently have
``real-time'' access to all of the EHR data for beneficiaries under
their care, especially if they are moving provider settings.
Response: We appreciate commenters' suggestions and will consider
these suggestions for any future rulemaking.
Some have suggested that, to furnish these services, practices
could be recognized as a medical home by one of the national
organizations (including the National Committee for Quality Assurance
(NCQA), the Accreditation Association for Ambulatory Health Care, The
Joint Commission, URAC, etc.), which are formally recognizing primary
care practices as a patient-centered medical home. We understand there
are differences among the approaches taken by national organizations
that formally recognize medical homes and therefore, we solicited
comment on these and other potential care coordination standards, and
the potential for CMS recognizing a formal patient-centered medical
home designation as one means
[[Page 74421]]
for a practice to demonstrate it has met any final care coordination
standards for furnishing chronic care management services.
Comment: Some commenters supported recognizing a patient centered
medical home model to meet the care coordination standards. Commenters
recommended that CMS allow for multiple pathways for accreditation
recognition, and/or certification of patient centered medical homes and
patient centered medical home neighborhood practices, noting other
entities offer these programs, such as URAC and The Joint Commission.
Some commenters supported the specialty practice recognition program,
under NCQA, to be included to enable specialists to be able to
participate. Commenters also suggested that CMS include other
approaches to recognize medical homes as developed by private health
plans and within CMS via its Innovation Center Comprehensive Primary
Care Initiative, some of which may not have been formally certified by
an accreditation entity. Commenters noted medical homes would be good
candidates to provide chronic care management, but Patient Centered
Medical Homes represent a relatively small percentage of medical groups
across the country.
Other commenters noted they do not support a requirement that
physician practices be certified as a primary care medical home to
receive payment for chronic care management. Other commenters urged
elimination of this requirement, noting it is too burdensome and would
disqualify many practices furnishing these care coordination services.
Commenters believe that in general, medical societies have been
reluctant to accept proposals that would require medical homes or
patient-centered practices to obtain accreditation/recognition by
external entities; and therefore, urged CMS to work with the medical
community to develop an alternative to accreditation as a path for
furnishing chronic care management services. Other commenters noted
this approach ignores the fact that many patients--especially the
poor--do not have a primary care provider and by default, may receive
substantial services from the Emergency Department, especially when
other sources of primary care are unavailable or inaccessible. Some
commenters conveyed that many standards for accreditation as a patient
centered medical home do not consider the needs of those with dementia;
adding, accreditation bodies should include quality measures on
dementia care as a standard for accreditation. Some commenters
encouraged CMS to consider using QIOs to help determine if a provider
is meeting the requirements for chronic care management, instead of
relying on a formal recognition program.
Some commenters noted that, instead of requiring any particular
certification or designation, any physician practice should be able to
qualify for payment of chronic care management services as long as the
individual practice meets the practice requirements established to
report these individual codes. Other commenters recommended that CMS
instead require practices to have certain capabilities (that is, 24/7
access to care, 24/7 access to the individual's medical record, those
involved with the care of a patient are identified and accessible, the
health risk assessment data be addressed in the care of the patient,
etc.); moreover, commenters suggested that CMS should clearly
articulate that the ultimate goal is for primary care practices to
achieve patient-centered medical home certification by a certain date
(for instance 2019) as this would satisfy the agency's intention
without being overly restrictive. Commenters also recommended that if
CMS decides to recognize certified medical homes--through accreditation
organizations or otherwise--the certification standards should fully
reflect the Joint Principles for the Patient-Centered Medical Home
(