[Federal Register Volume 78, Number 237 (Tuesday, December 10, 2013)]
[Rules and Regulations]
[Pages 74229-74823]
From the Federal Register Online via the Government Printing 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

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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

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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).