[Federal Register Volume 80, Number 135 (Wednesday, July 15, 2015)]
[Proposed Rules]
[Pages 41685-41966]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-16875]



[[Page 41685]]

Vol. 80

Wednesday,

No. 135

July 15, 2015

Part III





Department of Health and Human Services





-----------------------------------------------------------------------





Centers for Medicare & Medicaid Services





-----------------------------------------------------------------------





42 CFR Parts 405, 410, 411, 414, et al.





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

Federal Register / Vol. 80 , No. 135 / Wednesday, July 15, 2015 / 
Proposed Rules

[[Page 41686]]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 405, 410, 411, 414, 425, 495

[CMS-1631-P]
RIN 0938-AS40


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

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

ACTION: Proposed rule.

-----------------------------------------------------------------------

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

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

ADDRESSES: In commenting, please refer to file code CMS-1631-P. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to www.regulations.gov. Follow the instructions for 
``submitting a comment.''
    2. By regular mail. You may mail written comments to the following 
address ONLY: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-1631-P, P.O. Box 8013, 
Baltimore, MD 21244-8013.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address ONLY: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-1631-P, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments before the close of the comment period 
to either of the following addresses:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
please call telephone number (410) 786-7195 in advance to schedule your 
arrival with one of our staff members.
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.

FOR FURTHER INFORMATION CONTACT: 
    Donta Henson, (410) 786-1947 for any physician payment issues not 
identified below.
    Gail Addis, (410) 786-4522, for issues related to the refinement 
panel.
    Chava Sheffield, (410) 786-2298, for issues related to practice 
expense methodology, impacts, conversion factors, target, and phase-in 
provisions.
    Jessica Bruton, (410) 786-5991, for issues related to potentially 
misvalued code lists.
    Geri Mondowney, (410) 786-4584, for issues related to geographic 
practice cost indices and malpractice RVUs.
    Ken Marsalek, (410) 786-4502, for issues related to telehealth 
services.
    Ann Marshall, (410) 786-3059, for issues related to advance care 
planning, and for primary care and care management services.
    Michael Soracoe, (410) 786-6312, for issues related to the 
valuation and coding of the global surgical packages.
    Roberta Epps, (410) 786-4503, for issues related to PAMA section 
218(a) policy.
    Regina Walker-Wren, (410) 786-9160, for issues related to the 
``incident to'' proposals.
    Lindsey Baldwin, (410) 786-1694, for issues related to valuation of 
moderate sedation and colonoscopy services and portable x-ray 
transportation fees.
    Emily Yoder, (410) 786-1804, for issues related to valuation of 
radiation treatment services.
    Amy Gruber, (410) 786-1542, for issues related to ambulance payment 
policy.
    Corinne Axelrod, (410) 786-5620, for issues related to rural health 
clinics or federally qualified health centers and payment to 
grandfathered tribal FQHCs.
    Simone Dennis, (410) 786-8409, for issues related to rural health 
clinics HCPCS reporting.
    Edmund Kasaitis (410) 786-0477, for issues related to Part B drugs, 
biologicals, and biosimilars.
    Alesia Hovatter, (410) 786-6861, for issues related to Physician 
Compare.
    Christine Estella, (410) 786-0485, for issues related to the 
physician quality reporting system and the merit-based incentive 
payment system.
    Alexandra Mugge (410) 786-4457, for issues related to EHR Incentive 
Program.
    Sarah Arceo, (410) 786-2356) or Patrice Holtz, (410-786-5663) for 
issues related to EHR Incentive Program-CPC initiative and meaningful 
use aligned reporting.
    Christiane LaBonte, (410) 786-7237, for issues related to 
comprehensive primary care initiative.
    Rabia Khan, (410) 786-9328 or Terri Postma, (410) 786-4169, for 
issues related to Medicare Shared Savings Program.
    Kimberly Spalding Bush, (410) 786-3232, or Sabrina Ahmed (410) 786-
7499, for issues related to value-based Payment Modifier and Physician 
Feedback Program.
    Frederick Grabau, (410) 786-0206, for issues related to changes to 
opt-out regulations.
    Lisa Ohrin Wilson (410) 786-8852, for issues related to physician 
self-referral updates.

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

[[Page 41687]]

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 Proposed Rule for PFS
    A. Determination of Practice Expense (PE) Relative Value Units 
(RVUs)
    B. Determination of Malpractice Relative Value Units (RVUs)
    C. Potentially Misvalued Services Under the Physician Fee 
Schedule
    D. Refinement Panel
    E. Improving Payment Accuracy for Primary Care and Care 
Management Services
    F. Target for Relative Value Adjustments for Misvalued Services
    G. Phase-In of Significant RVU Reductions
    H. Changes for Computed Tomography (CT) Under the Protecting 
Access to Medicare Act of 2014 (PAMA)
    I. Valuation of Specific Codes
    J. Medicare Telehealth Services
    K. Incident to Proposals: Billing Physician as the Supervising 
Physician and Ancillary Personnel Requirements
    L. Portable X-Ray: Billing of the Transportation Fee
    M. Technical Correction: Waiver of Deductible for Anesthesia 
Services Furnished on the Same Date as a Planned Screening 
Colorectal Cancer Test
III. Other Provisions of the Proposed Regulations
    A. Proposed Provisions Associated With the Ambulance Fee 
Schedule
    B. Chronic Care Management (CCM) Services for Rural Health 
Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
    C. Healthcare Common Procedure Coding System (HCPCS) Coding for 
Rural Health Clinics (RHCs)
    D. Payment to Grandfathered Tribal FQHCs That Were Provider-
Based Clinics on or Before April 7, 2000
    E. Part B Drugs--Biosimilars
    F. Productivity Adjustment for the Ambulance, Clinical 
Laboratory, and DMEPOS Fee Schedules
    G. Appropriate Use Criteria for Advanced Diagnostic Imaging 
Services
    H. Physician Compare Web site
    I. Physician Payment, Efficiency, and Quality Improvements--
Physician Quality Reporting System
    J. Electronic Clinical Quality Measures (eCQM) and Certification 
Criteria and Electronic Health Record (EHR) Incentive Program--
Comprehensive Primary Care (CPC) Initiative and Medicare Meaningful 
Use Aligned Reporting
    K. Potential Expansion of the Comprehensive Primary Care (CPC) 
Initiative
    L. Medicare Shared Savings Program
    M. Value-Based Payment Modifier and Physician Feedback Program
    N. Physician Self-Referral Updates
    O. Private Contracting/Opt-Out
IV. Collection of Information Requirements
V. Response to Comments
VI. Regulatory Impact Analysis
    Regulations Text

Acronyms

    In addition, because of the many organizations and terms to which 
we refer by acronym in this proposed rule, we are listing these 
acronyms and their corresponding terms in alphabetical order below:
AAA Abdominal aortic aneurysms
ACO Accountable care organization
AMA American Medical Association
ASC Ambulatory surgical center
ATA American Telehealth Association
ATRA American Taxpayer Relief Act (Pub. L. 112-240)
BBA Balanced Budget Act of 1997 (Pub. L. 105-33)
BBRA [Medicare, Medicaid and State Child Health Insurance Program] 
Balanced Budget Refinement Act of 1999 (Pub. L. 106-113)
CAD Coronary artery disease
CAH Critical access hospital
CBSA Core-Based Statistical Area
CCM Chronic care management
CEHRT Certified EHR technology
CF Conversion factor
CG-CAHPS Clinician and Group Consumer Assessment of Healthcare 
Providers and Systems
CLFS Clinical Laboratory Fee Schedule
CNM Certified nurse-midwife
CP Clinical psychologist
CPC Comprehensive Primary Care
CPEP Clinical Practice Expert Panel
CPT [Physicians] Current Procedural Terminology (CPT codes, 
descriptions and other data only are copyright 2014 American Medical 
Association. All rights reserved.)
CQM Clinical quality measure
CSW Clinical social worker
CT Computed tomography
CY Calendar year
DFAR Defense Federal Acquisition Regulations
DHS Designated health services
DM Diabetes mellitus
DSMT Diabetes self-management training
eCQM Electronic clinical quality measures
EHR Electronic health record
E/M Evaluation and management
EP Eligible professional
eRx Electronic prescribing
ESRD End-stage renal disease
FAR Federal Acquisition Regulations
FFS Fee-for-service
FQHC Federally qualified health center
FR Federal Register
GAF Geographic adjustment factor
GAO Government Accountability Office
GPCI Geographic practice cost index
GPO Group purchasing organization
GPRO Group practice reporting option
GTR Genetic Testing Registry
HCPCS Healthcare Common Procedure Coding System
HHS [Department of] Health and Human Services
HOPD Hospital outpatient department
HPSA Health professional shortage area
IDTF Independent diagnostic testing facility
IPPS Inpatient Prospective Payment System
IQR Inpatient Quality Reporting
ISO Insurance service office
IWPUT Intensity of work per unit of time
LCD Local coverage determination
MA Medicare Advantage
MAC Medicare Administrative Contractor
MAP Measure Applications Partnership
MAPCP Multi-payer Advanced Primary Care Practice
MAV Measure application validity [process]
MCP Monthly capitation payment
MedPAC Medicare Payment Advisory Commission
MEI Medicare Economic Index
MFP Multi-Factor Productivity
MIPPA Medicare Improvements for Patients and Providers Act (Pub. L. 
110-275)
MMA Medicare Prescription Drug, Improvement and Modernization Act of 
2003 (Pub. L. 108-173, enacted on December 8, 2003)
MP Malpractice
MPPR Multiple procedure payment reduction
MRA Magnetic resonance angiography
MRI Magnetic resonance imaging
MSA Metropolitan Statistical Areas
MSPB Medicare Spending per Beneficiary
MSSP Medicare Shared Savings Program
MU Meaningful use
NCD National coverage determination
NCQDIS National Coalition of Quality Diagnostic Imaging Services
NP Nurse practitioner
NPI National Provider Identifier
NPP Nonphysician practitioner
NQS National Quality Strategy
OACT CMS's Office of the Actuary
OBRA '89 Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239)
OBRA '90 Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508)
OES Occupational Employment Statistics
OMB Office of Management and Budget
OPPS Outpatient prospective payment system
OT Occupational therapy
PA Physician assistant
PAMA Protecting Access to Medicare Act of 2014 (Pub. L. 113-93)
PC Professional component
PCIP Primary Care Incentive Payment
PE Practice expense
PE/HR Practice expense per hour
PEAC Practice Expense Advisory Committee
PECOS Provider Enrollment, Chain, and Ownership System
PFS Physician Fee Schedule
PLI Professional Liability Insurance
PMA Premarket approval
PQRS Physician Quality Reporting System
PPIS Physician Practice Expense Information Survey
PT Physical therapy
PY Performance year
QCDR Qualified clinical data registry
QRUR Quality and Resources Use Report
RBRVS Resource-based relative value scale

[[Page 41688]]

RFA Regulatory Flexibility Act
RHC Rural health clinic
RIA Regulatory impact analysis
RUC American Medical Association/Specialty Society Relative (Value) 
Update Committee
RUCA Rural Urban Commuting Area
RVU Relative value unit
SBA Small Business Administration
SGR Sustainable growth rate
SIM State Innovation Model
SLP Speech-language pathology
SMS Socioeconomic Monitoring System
SNF Skilled nursing facility
TAP Technical Advisory Panel
TC Technical component
TIN Tax identification number
UAF Update adjustment factor
UPIN Unique Physician Identification Number
USPSTF United States Preventive Services Task Force
VBP Value-based purchasing
VM Value-Based Payment Modifier

Addenda Available Only Through the Internet on the CMS Web Site

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

CPT (Current Procedural Terminology) Copyright Notice

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

I. Executive Summary and Background

A. Executive Summary

1. Purpose
    This major proposed rule proposes to revise payment polices under 
the Medicare Physician Fee Schedule (PFS) and make other policy changes 
related to Medicare Part B payment. These proposed changes would be 
applicable to services furnished in CY 2016.
2. Summary of the Major Provisions
    The Social Security Act (the Act) requires us to establish payments 
under the PFS based on national uniform relative value units (RVUs) 
that account for the relative resources used in furnishing a service. 
The Act requires that RVUs be established for three categories of 
resources: Work, practice expense (PE); and malpractice (MP) expense; 
and, that we establish by regulation each year's payment amounts for 
all physicians' services paid under the PFS, incorporating geographic 
adjustments to reflect the variations in the costs of furnishing 
services in different geographic areas. In this major proposed rule, we 
establish RVUs for CY 2016 for the PFS, and other Medicare Part B 
payment policies, to ensure that our payment systems are updated to 
reflect changes in medical practice and the relative value of services, 
as well as changes in the statute. In addition, this proposed rule 
includes discussions and proposals regarding:
     Potentially Misvalued PFS Codes.
     Telehealth Services.
     Advance Care Planning Services.
     Establishing Values for New, Revised, and Misvalued Codes.
     Target for Relative Value Adjustments for Misvalued 
Services.
     Phase-in of Significant RVU Reductions.
     ``Incident to'' policy.
     Portable X-Ray Transportation Fee.
     Updating the Ambulance Fee Schedule regulations.
     Changes in Geographic Area Delineations for Ambulance 
Payment.
     Chronic Care Management Services for RHCs and FQHCs.
     HCPCS Coding for RHCs.
     Payment to Grandfathered Tribal FQHCs that were Provider-
Based Clinics on or before April 7, 2000.
     Payment for Biosimilars under Medicare Part B.
     Physician Compare Web site.
     Physician Quality Reporting System.
     Medicare Shared Savings Program.
     Electronic Health Record (EHR) Incentive Program.
     Value-Based Payment Modifier and the Physician Feedback 
Program.
3. Summary of Costs and Benefits
    The Act requires that annual adjustments to PFS RVUs may not cause 
annual estimated expenditures to differ by more than $20 million from 
what they would have been had the adjustments not been made. If 
adjustments to RVUs would cause expenditures to change by more than $20 
million, we must make adjustments to preserve budget neutrality. These 
adjustments can affect the distribution of Medicare expenditures across 
specialties. In addition, several proposed changes would affect the 
specialty distribution of Medicare expenditures. When considering the 
combined impact of work, PE, and MP RVU changes, the projected payment 
impacts are small for most specialties; however, the impact would be 
larger for a few specialties.
    We have determined that this major proposed rule is economically 
significant. For a detailed discussion of the economic impacts, see 
section VII. of this proposed rule.

B. Background

    Since January 1, 1992, Medicare has paid for physicians' services 
under section 1848 of the Act, ``Payment for Physicians' Services.'' 
The system relies on national relative values that are established for 
work, PE, and MP, which are adjusted for geographic cost variations. 
These values are multiplied by a conversion factor (CF) to convert the 
RVUs into payment rates. The concepts and methodology underlying the 
PFS were enacted as part of the Omnibus Budget Reconciliation Act of 
1989 (Pub. L. 101-239, enacted on December 19, 1989) (OBRA '89), and 
the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508, enacted 
on November 5, 1990) (OBRA '90). The final rule published on November 
25, 1991 (56 FR 59502) set forth the first fee schedule used for 
payment for physicians' services.
    We note that throughout this major proposed rule, unless otherwise 
noted, the term ``practitioner'' is used to describe both physicians 
and nonphysician practitioners (NPPs) who are permitted to bill 
Medicare under the PFS for services furnished to Medicare 
beneficiaries.
1. Development of the Relative Values
a. Work RVUs
    The work RVUs established for the initial fee schedule, which was 
implemented on January 1, 1992, were developed with extensive input 
from the physician community. A research team at the Harvard School of 
Public Health developed the original work RVUs for most codes under a 
cooperative agreement with the Department of Health and Human Services 
(HHS). In constructing the code-specific vignettes used in determining 
the original physician work

[[Page 41689]]

RVUs, Harvard worked with panels of experts, both inside and outside 
the federal government, and obtained input from numerous physician 
specialty groups.
    As specified in section 1848(c)(1)(A) of the Act, the work 
component of physicians' services means the portion of the resources 
used in furnishing the service that reflects physician time and 
intensity. We establish work RVUs for new, revised and potentially 
misvalued codes based on our review of information that generally 
includes, but is not limited to, recommendations received from the 
American Medical Association/Specialty Society Relative Value Update 
Committee (RUC), the Health Care Professionals Advisory Committee 
(HCPAC), the Medicare Payment Advisory Commission (MedPAC), and other 
public commenters; medical literature and comparative databases; as 
well as a comparison of the work for other codes within the Medicare 
PFS, and consultation with other physicians and health care 
professionals within CMS and the federal government. We also assess the 
methodology and data used to develop the recommendations submitted to 
us by the RUC and other public commenters, and the rationale for their 
recommendations.
b. Practice Expense RVUs
    Initially, only the work RVUs were resource-based, and the PE and 
MP RVUs were based on average allowable charges. Section 121 of the 
Social Security Act Amendments of 1994 (Pub. L. 103-432, enacted on 
October 31, 1994), amended section 1848(c)(2)(C)(ii) of the Act and 
required us to develop resource-based PE RVUs for each physicians' 
service beginning in 1998. We were required to consider general 
categories of expenses (such as office rent and wages of personnel, but 
excluding malpractice expenses) comprising PEs. The PE RVUs continue to 
represent the portion of these resources involved in furnishing PFS 
services.
    Originally, the resource-based method was to be used beginning in 
1998, but section 4505(a) of the Balanced Budget Act of 1997 (Pub. L. 
105-33, enacted on August 5, 1997) (BBA) delayed implementation of the 
resource-based PE RVU system until January 1, 1999. In addition, 
section 4505(b) of the BBA provided for a 4-year transition period from 
the charge-based PE RVUs to the resource-based PE RVUs.
    We established the resource-based PE RVUs for each physicians' 
service in a final rule, published on November 2, 1998 (63 FR 58814), 
effective for services furnished in CY 1999. Based on the requirement 
to transition to a resource-based system for PE over a 4-year period, 
payment rates were not fully based upon resource-based PE RVUs until CY 
2002. This resource-based system was based on two significant sources 
of actual PE data: the Clinical Practice Expert Panel (CPEP) data and 
the AMA's Socioeconomic Monitoring System (SMS) data. (These data 
sources are described in greater detail in the CY 2012 final rule with 
comment period (76 FR 73033).)
    Separate PE RVUs are established for services furnished in facility 
settings, such as a hospital outpatient department (HOPD) or an 
ambulatory surgical center (ASC), and in nonfacility settings, such as 
a physician's office. The nonfacility RVUs reflect all of the direct 
and indirect PEs involved in furnishing a service described by a 
particular HCPCS code. The difference, if any, in these PE RVUs 
generally results in a higher payment in the nonfacility setting 
because in the facility settings some costs are borne by the facility. 
Medicare's payment to the facility (such as the outpatient prospective 
payment system (OPPS) payment to the HOPD) would reflect costs 
typically incurred by the facility. Thus, payment associated with those 
facility resources is not made under the PFS.
    Section 212 of the Balanced Budget Refinement Act of 1999 (Pub. L. 
106-113, enacted on November 29, 1999) (BBRA) directed the Secretary of 
Health and Human Services (the Secretary) to establish a process under 
which we accept and use, to the maximum extent practicable and 
consistent with sound data practices, data collected or developed by 
entities and organizations to supplement the data we normally collect 
in determining the PE component. On May 3, 2000, we published the 
interim final rule (65 FR 25664) that set forth the criteria for the 
submission of these supplemental PE survey data. The criteria were 
modified in response to comments received, and published in the Federal 
Register (65 FR 65376) as part of a November 1, 2000 final rule. The 
PFS final rules published in 2001 and 2003, respectively, (66 FR 55246 
and 68 FR 63196) extended the period during which we would accept these 
supplemental data through March 1, 2005.
    In the CY 2007 PFS final rule with comment period (71 FR 69624), we 
revised the methodology for calculating direct PE RVUs from the top-
down to the bottom-up methodology beginning in CY 2007. We adopted a 4-
year transition to the new PE RVUs. This transition was completed for 
CY 2010. In the CY 2010 PFS final rule with comment period, we updated 
the practice expense per hour (PE/HR) data that are used in the 
calculation of PE RVUs for most specialties (74 FR 61749). In CY 2010, 
we began a 4-year transition to the new PE RVUs using the updated PE/HR 
data, which was completed for CY 2013.
c. Malpractice RVUs
    Section 4505(f) of the BBA amended section 1848(c) of the Act to 
require that we implement resource-based MP RVUs for services furnished 
on or after CY 2000. The resource-based MP RVUs were implemented in the 
PFS final rule with comment period published November 2, 1999 (64 FR 
59380). The MP RVUs are based on commercial and physician-owned 
insurers' malpractice insurance premium data from all the states, the 
District of Columbia, and Puerto Rico. For more information on MP RVUs, 
see section II.C. of this proposed rule.
d. Refinements to the RVUs
    Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no 
less often than every 5 years. Prior to CY 2013, we conducted periodic 
reviews of work RVUs and PE RVUs independently. We completed five-year 
reviews of work RVUs that were effective for calendar years 1997, 2002, 
2007, and 2012.
    Although refinements to the direct PE inputs initially relied 
heavily on input from the RUC Practice Expense Advisory Committee 
(PEAC), the shifts to the bottom-up PE methodology in CY 2007 and to 
the use of the updated PE/HR data in CY 2010 have resulted in 
significant refinements to the PE RVUs in recent years.
    In the CY 2012 PFS final rule with comment period (76 FR 73057), we 
finalized a proposal to consolidate reviews of work and PE RVUs under 
section 1848(c)(2)(B) of the Act and reviews of potentially misvalued 
codes under section 1848(c)(2)(K) of the Act into one annual process.
    In addition to the five-year reviews, beginning for CY 2009, CMS, 
and the RUC have identified and reviewed a number of potentially 
misvalued codes on an annual basis based on various identification 
screens. This annual review of work and PE RVUs for potentially 
misvalued codes was supplemented by the amendments to section 1848 of 
the Act, as enacted by section 3134 of the Affordable Care Act, which 
requires the agency to periodically identify, review and adjust values 
for potentially misvalued codes.

[[Page 41690]]

e. Application of Budget Neutrality to Adjustments of RVUs
    As described in section VI.C. of this proposed rule, in accordance 
with section 1848(c)(2)(B)(ii)(II) of the Act, if revisions to the RVUs 
caused expenditures for the year to change by more than $20 million, we 
make adjustments to ensure that expenditures did not increase or 
decrease by more than $20 million.
2. Calculation of Payments Based on RVUs
    To calculate the payment for each service, the components of the 
fee schedule (work, PE, and MP RVUs) are adjusted by geographic 
practice cost indices (GPCIs) to reflect the variations in the costs of 
furnishing the services. The GPCIs reflect the relative costs of work, 
PE, and MP in an area compared to the national average costs for each 
component. (See section II.D. of this proposed rule for more 
information about GPCIs.)
    RVUs are converted to dollar amounts through the application of a 
CF, which is calculated based on a statutory formula by CMS's Office of 
the Actuary (OACT). The formula for calculating the Medicare fee 
schedule payment amount for a given service and fee schedule area can 
be expressed as:

Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI 
MP)] x CF.
3. Separate Fee Schedule Methodology for Anesthesia Services
    Section 1848(b)(2)(B) of the Act specifies that the fee schedule 
amounts for anesthesia services are to be based on a uniform relative 
value guide, with appropriate adjustment of an anesthesia conversion 
factor, in a manner to assure that fee schedule amounts for anesthesia 
services are consistent with those for other services of comparable 
value. Therefore, there is a separate fee schedule methodology for 
anesthesia services. Specifically, we establish a separate conversion 
factor for anesthesia services and we utilize the uniform relative 
value guide, or base units, as well as time units, to calculate the fee 
schedule amounts for anesthesia services. Since anesthesia services are 
not valued using RVUs, a separate methodology for locality adjustments 
is also necessary. This involves an adjustment to the national 
anesthesia CF for each payment locality.
4. Most Recent Changes to the Fee Schedule
    Section 220(d) of the Protecting Access to Medicare Act of 2014 
(PAMA) (Pub. L. 113-93, enacted on April 1, 2014) added a new 
subparagraph (O) to section 1848(c)(2) of the Act to establish an 
annual target for reductions in PFS expenditures resulting from 
adjustments to relative values of misvalued codes. If the estimated net 
reduction in expenditures for a year is equal to or greater than the 
target for that year, the provision specifies that reduced expenditures 
attributable to such adjustments shall be redistributed in a budget-
neutral manner within the PFS. The provision also specifies that the 
amount by which such reduced expenditures exceed the target for a given 
year shall be treated as a reduction in expenditures for the subsequent 
year for purposes of determining whether the target for the subsequent 
year has been met. The provision also specifies that an amount equal to 
the difference between the target and the estimated net reduction, 
called the target recapture amount shall not be taken into account when 
applying the budget neutrality requirements specified in section 
1848(c)(2)(B)(ii)(II) of the Act. The PAMA originally applied the 
target to CYs 2017 through 2020 and set the target amount to 0.5 
percent of the estimated amount of expenditures under the PFS for each 
of those 4 years.
    More recently, section 202 of the Achieving a Better Life 
Experience Act of 2014 (ABLE) (Division B of Pub. L. 113-295, enacted 
December 19, 2014) accelerated the application of the target, amending 
section 1848(c)(2)(O) of the Act to specify that targets would apply 
for CYs 2016, 2017, and 2018 and set a 1 percent target for CY 2016 and 
0.5 percent for CYs 2017 and 2018. The implementation of the target 
legislation is discussed in section II.F. of this proposed rule.
    Section 1848(c)(7) of the Act, as added by section 220(e) of the 
PAMA, specifies that for services that are not new or revised codes, if 
the total RVUs for a service for a year would otherwise be decreased by 
an estimated 20 percent or more as compared to the total RVUs for the 
previous year, the applicable adjustments in work, PE, and MP RVUs 
shall be phased-in over a 2-year period. Although section 220(e) of the 
PAMA required the phase-in of RVU reductions of 20 percent or more to 
begin for 2017, section 202 of the ABLE Act now requires the phase-in 
to begin in CY 2016. The implementation of the phase-in legislation is 
discussed in section II.G. of this proposed rule.
    Section 218(a) of the PAMA adds a new section 1834(p) to the 
statute. Section 1834(p) requires reductions in payment for the 
technical component (TC) (and the TC of the global fee) of the PFS 
service and in the hospital OPPS payment (5 percent in 2016, and 15 
percent in 2017 and subsequent years) for computed tomography (CT) 
services (identified as of January 1, 2014 by HCPCS codes 70450-70498, 
71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-
74178, 74261-74263, and 75571-75574, and succeeding codes) furnished 
using equipment that does not meet each of the attributes of the 
National Electrical Manufacturers Association (NEMA) Standard XR-29-
2013, entitled ``Standard Attributes on CT Equipment Related to Dose 
Optimization and Management.'' The implementation of section 218(a) of 
the PAMA is discussed in section II.H. of this proposed rule.
    The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) 
(Pub. L. 114-10, enacted on April 16, 2015) makes several changes to 
the statute, including but not limited to:
    (1) Repealing the sustainable growth rate (SGR) update methodology 
for physicians' services.
    (2) Revising the PFS update for 2015 and subsequent years.
    (3) Establishing a Merit-based Incentive Payment System (MIPS) 
under which eligible professionals (initially including physicians, 
physician assistants, nurse practitioners, clinical nurse specialists, 
and certified registered nurse anesthetists) receive annual payment 
increases or decreases based on their performance in a prior period. 
These and other MACRA provisions are discussions in various sections of 
this proposed rule. Please refer to the table of contents for the 
location of the various MACRA provision discussions.

II. Provisions of the Proposed Rule for PFS

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

1. Overview
    Practice expense (PE) is the portion of the resources used in 
furnishing a service that reflects the general categories of physician 
and practitioner expenses, such as office rent and personnel wages, but 
excluding malpractice expenses, as specified in section 1848(c)(1)(B) 
of the Act. As required by section 1848(c)(2)(C)(ii) of the Act, we use 
a resource-based system for determining PE RVUs for each physicians' 
service. We develop PE RVUs by considering the direct and indirect 
practice resources involved in furnishing each service. Direct expense 
categories include clinical labor, medical supplies, and medical

[[Page 41691]]

equipment. Indirect expenses include administrative labor, office 
expense, and all other expenses. The sections that follow provide more 
detailed information about the methodology for translating the 
resources involved in furnishing each service into service-specific PE 
RVUs. We refer readers to the CY 2010 PFS final rule with comment 
period (74 FR 61743 through 61748) for a more detailed explanation of 
the PE methodology.
2. Practice Expense Methodology
a. Direct Practice Expense
    We determine the direct PE for a specific service by adding the 
costs of the direct resources (that is, the clinical staff, medical 
supplies, and medical equipment) typically involved with furnishing 
that service. The costs of the resources are calculated using the 
refined direct PE inputs assigned to each CPT code in our PE database, 
which are generally based on our review of recommendations received 
from the RUC and those provided in response to public comment periods. 
For a detailed explanation of the direct PE methodology, including 
examples, we refer readers to the Five-Year Review of Work Relative 
Value Units under the PFS and Proposed Changes to the Practice Expense 
Methodology proposed notice (71 FR 37242) and the CY 2007 PFS final 
rule with comment period (71 FR 69629).
b. Indirect Practice Expense per Hour Data
    We use survey data on indirect PEs incurred per hour worked in 
developing the indirect portion of the PE RVUs. Prior to CY 2010, we 
primarily used the practice expense per hour (PE/HR) by specialty that 
was obtained from the AMA's Socioeconomic Monitoring Surveys (SMS). The 
AMA administered a new survey in CY 2007 and CY 2008, the Physician 
Practice Expense Information Survey (PPIS). The PPIS is a 
multispecialty, nationally representative, PE survey of both physicians 
and nonphysician practitioners (NPPs) paid under the PFS using a survey 
instrument and methods highly consistent with those used for the SMS 
and the supplemental surveys. The PPIS gathered information from 3,656 
respondents across 51 physician specialty and health care professional 
groups. We believe the PPIS is the most comprehensive source of PE 
survey information available. We used the PPIS data to update the PE/HR 
data for the CY 2010 PFS for almost all of the Medicare-recognized 
specialties that participated in the survey.
    When we began using the PPIS data in CY 2010, we did not change the 
PE RVU methodology itself or the manner in which the PE/HR data are 
used in that methodology. We only updated the PE/HR data based on the 
new survey. Furthermore, as we explained in the CY 2010 PFS final rule 
with comment period (74 FR 61751), because of the magnitude of payment 
reductions for some specialties resulting from the use of the PPIS 
data, we transitioned its use over a 4-year period from the previous PE 
RVUs to the PE RVUs developed using the new PPIS data. As provided in 
the CY 2010 PFS final rule with comment period (74 FR 61751), the 
transition to the PPIS data was complete for CY 2013. Therefore, PE 
RVUs from CY 2013 forward are developed based entirely on the PPIS 
data, except as noted in this section.
    Section 1848(c)(2)(H)(i) of the Act requires us to use the medical 
oncology supplemental survey data submitted in 2003 for oncology drug 
administration services. Therefore, the PE/HR for medical oncology, 
hematology, and hematology/oncology reflects the continued use of these 
supplemental survey data.
    Supplemental survey data on independent labs from the College of 
American Pathologists were implemented for payments beginning in CY 
2005. Supplemental survey data from the National Coalition of Quality 
Diagnostic Imaging Services (NCQDIS), representing independent 
diagnostic testing facilities (IDTFs), were blended with supplementary 
survey data from the American College of Radiology (ACR) and 
implemented for payments beginning in CY 2007. Neither IDTFs, nor 
independent labs, participated in the PPIS. Therefore, we continue to 
use the PE/HR that was developed from their supplemental survey data.
    Consistent with our past practice, the previous indirect PE/HR 
values from the supplemental surveys for these specialties were updated 
to CY 2006 using the MEI to put them on a comparable basis with the 
PPIS data.
    We also do not use the PPIS data for reproductive endocrinology and 
spine surgery since these specialties currently are not separately 
recognized by Medicare, nor do we have a method to blend the PPIS data 
with Medicare-recognized specialty data.
    Previously, we established PE/HR values for various specialties 
without SMS or supplemental survey data by crosswalking them to other 
similar specialties to estimate a proxy PE/HR. For specialties that 
were part of the PPIS for which we previously used a crosswalked PE/HR, 
we instead used the PPIS-based PE/HR. We continue previous crosswalks 
for specialties that did not participate in the PPIS. However, 
beginning in CY 2010 we changed the PE/HR crosswalk for portable x-ray 
suppliers from radiology to IDTF, a more appropriate crosswalk because 
these specialties are more similar to each other for work time.
    For registered dietician services, the resource-based PE RVUs have 
been calculated in accordance with the final policy that crosswalks the 
specialty to the ``All Physicians'' PE/HR data, as adopted in the CY 
2010 PFS final rule with comment period (74 FR 61752) and discussed in 
more detail in the CY 2011 PFS final rule with comment period (75 FR 
73183).
    For CY 2016, we have incorporated the available utilization data 
for interventional cardiology, which became a recognized Medicare 
specialty during 2014. We are proposing to use a proxy PE/HR value for 
interventional cardiology, as there are no PPIS data for this 
specialty, by crosswalking the PE/HR for from Cardiology, since the 
specialties furnish similar services in the Medicare claims data. The 
proposed change is reflected in the ``PE/HR'' file available on the CMS 
Web site under the supporting data files for the CY 2016 PFS proposed 
rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
c. Allocation of PE to Services
    To establish PE RVUs for specific services, it is necessary to 
establish the direct and indirect PE associated with each service.
(1) Direct Costs
    The relative relationship between the direct cost portions of the 
PE RVUs for any two services is determined by the relative relationship 
between the sum of the direct cost resources (that is, the clinical 
staff, medical supplies, and medical equipment) typically involved with 
furnishing each of the services. The costs of these resources are 
calculated from the refined direct PE inputs in our PE database. For 
example, if one service has a direct cost sum of $400 from our PE 
database and another service has a direct cost sum of $200, the direct 
portion of the PE RVUs of the first service would be twice as much as 
the direct portion of the PE RVUs for the second service.
(2) Indirect Costs
    Section II.A.2.b. of this proposed rule describes the current data 
sources for specialty-specific indirect costs used in our PE 
calculations. We allocated the

[[Page 41692]]

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 work RVUs. We also incorporated the survey 
data described earlier in the PE/HR discussion. The general approach to 
developing the indirect portion of the PE RVUs is as follows:
     For a given service, we use the direct portion of the PE 
RVUs calculated as previously described and the average percentage that 
direct costs represent of total costs (based on survey data) across the 
specialties that furnish the service to determine an initial indirect 
allocator. In other words, the initial indirect allocator is calculated 
so that the direct costs equal the average percentage of direct costs 
of those specialties furnishing the service. For example, if the direct 
portion of the PE RVUs for a given service is 2.00 and direct costs, on 
average, represented 25 percent of total costs for the specialties that 
furnished the service, the initial indirect allocator would be 
calculated so that it equals 75 percent of the total PE RVUs. Thus, in 
this example, the initial indirect allocator would equal 6.00, 
resulting in a total PE RVUs of 8.00 (2.00 is 25 percent of 8.00 and 
6.00 is 75 percent of 8.00).
     Next, we add the greater of the work RVUs or clinical 
labor portion of the direct portion of the PE RVUs to this initial 
indirect allocator. In our example, if this service had work RVUs of 
4.00 and the clinical labor portion of the direct PE RVUs was 1.50, we 
would add 4.00 (since the 4.00 work RVUs are greater than the 1.50 
clinical labor portion) to the initial indirect allocator of 6.00 to 
get an indirect allocator of 10.00. In the absence of any further use 
of the survey data, the relative relationship between the indirect cost 
portions of the PE RVUs for any two services would be determined by the 
relative relationship between these indirect cost allocators. For 
example, if one service had an indirect cost allocator of 10.00 and 
another service had an indirect cost allocator of 5.00, the indirect 
portion of the PE RVUs of the first service would be twice as great as 
the indirect portion of the PE RVUs for the second service.
     Next, we incorporate the specialty-specific indirect PE/HR 
data into the calculation. In our example, if, based on the survey 
data, the average indirect cost of the specialties furnishing the first 
service with an allocator of 10.00 was half of the average indirect 
cost of the specialties furnishing the second service with an indirect 
allocator of 5.00, the indirect portion of the PE RVUs of the first 
service would be equal to that of the second service.
(4) Facility and Nonfacility Costs
    For procedures that can be furnished in a physician's office, as 
well as in a hospital or other facility setting, we establish two PE 
RVUs: facility and nonfacility. The methodology for calculating PE RVUs 
is the same for both the facility and nonfacility RVUs, but is applied 
independently to yield two separate PE RVUs. Because in calculating the 
PE RVUs for services furnished in a facility, we do not include 
resources that would generally not be provided by physicians when 
furnishing the service in a facility, the facility PE RVUs are 
generally lower than the nonfacility PE RVUs. Medicare makes a separate 
payment to the facility for its costs of furnishing a service.
(5) Services With Technical Components (TCs) and Professional 
Components (PCs)
    Diagnostic services are generally comprised of two components: A 
professional component (PC); and a technical component (TC). The PC and 
TC may be furnished independently or by different providers, or they 
may be furnished together as a ``global'' service. When services have 
separately billable PC and TC components, the payment for the global 
service equals the sum of the payment for the TC and PC. To achieve 
this we use a weighted average of the ratio of indirect to direct costs 
across all the specialties that furnish the global service, TCs, and 
PCs; that is, we apply the same weighted average indirect percentage 
factor to allocate indirect expenses to the global service, PCs, and 
TCs for a service. (The direct PE RVUs for the TC and PC sum to the 
global.)
(6) PE RVU Methodology
    For a more detailed description of the PE RVU methodology, we refer 
readers to the CY 2010 PFS final rule with comment period (74 FR 61745 
through 61746).
(a) Setup File
    First, we create a setup file for the PE methodology. The setup 
file contains the direct cost inputs, the utilization for each 
procedure code at the specialty and facility/nonfacility place of 
service level, and the specialty-specific PE/HR data calculated from 
the surveys.
(b) Calculate the Direct Cost PE RVUs
    Sum the costs of each direct input.
    Step 1: Sum the direct costs of the inputs for each service. Apply 
a scaling adjustment to the direct inputs.
    Step 2: Calculate the aggregate pool of direct PE costs for the 
current year. Under our current methodology, we first multiply the 
current year's conversion factor by the product of the current year's 
PE RVUs and utilization for each service to arrive at the aggregate 
pool of total PE costs (Step 2a). We then calculate the average direct 
percentage of the current pool of PE RVUs (using a weighted average of 
the survey data for the specialties that furnish each service (Step 
2b).) We then multiply the result of 2a by the result of 2b to arrive 
at the aggregate pool of direct PE costs for the current year. For CY 
2016, we are proposing a technical improvement to step 2a of this 
calculation. In place of the step 2a calculation described above, we 
propose to set the aggregate pool of PE costs equal to the product of 
the ratio of the current aggregate PE RVUs to current aggregate work 
RVUs and the proposed aggregate work RVUs. Historically, in allowing 
the current PE RVUs to determine the size of the base PE pool in the PE 
methodology, we have assumed that the relationship of PE RVUs to work 
RVUs is constant from year to year. Since this is not ordinarily the 
case, by not considering the proposed aggregate work RVUs in 
determining the size of the base PE pool, we have introduced some minor 
instability from year to year in the relative shares of work, PE, and 
MP RVUs. While this proposed modification would result in greater 
stability in the relationship among the work and PE RVU components in 
the aggregate, we do not anticipate it will affect the distribution of 
PE RVUs across specialties. The PE RVUs in addendum B of this proposed 
rule with comment period reflect this proposed refinement to the PE 
methodology.
    Step 3: Calculate the aggregate pool of direct PE costs for use in 
ratesetting. This is the product of the aggregate direct costs for all 
services from Step 1 and the utilization data for that service.
    Step 4: Using the results of Step 2 and Step 3, calculate a direct 
PE scaling adjustment to ensure that the aggregate pool of direct PE 
costs calculated in Step 3 does not vary from the aggregate pool of 
direct PE costs for the current year. Apply the scaling factor to the 
direct costs for each service (as calculated in Step 1).
    Step 5: Convert the results of Step 4 to an RVU scale for each 
service. To do this, divide the results of Step 4 by the CF. Note that 
the actual value of the CF used in this calculation does not influence 
the final direct cost PE RVUs, as long as the same CF is used in Step 2 
and Step 5. Different CFs will result in different direct PE scaling 
factors, but

[[Page 41693]]

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.
(c) Create the Indirect Cost PE RVUs
    Create indirect allocators.
    Step 6: Based on the survey data, calculate direct and indirect PE 
percentages for each physician specialty.
    Step 7: Calculate direct and indirect PE percentages at the service 
level by taking a weighted average of the results of Step 6 for the 
specialties that furnish the service. Note that for services with TCs 
and PCs, the direct and indirect percentages for a given service do not 
vary by the PC, TC, and global service.
    Historically, we have used the specialties that furnish the service 
in the most recent full year of Medicare claims data (crosswalked to 
the current year set of codes) to determine which specialties furnish 
individual procedures. For example, for CY 2015 ratesetting, we used 
the mix of specialties that furnished the services in the CY 2013 
claims data to determine the specialty mix assigned to each code. While 
we believe that there are clear advantages to using the most recent 
available data in making these determinations, we have also found that 
using a single year of data contributes to greater year-to-year 
instability in PE RVUs for individual codes and often creates extreme, 
annual fluctuations for low-volume services, as well as delayed 
fluctuations for some services described by new codes once claims data 
for those codes becomes available.
    We believe that using an average of the three most recent years of 
available data may increase stability of PE RVUs and mitigate code-
level fluctuations for both the full range of PFS codes, and for new 
and low-volume codes in particular. Therefore, we are proposing to 
refine this step of the PE methodology to use an average of the 3 most 
recent years of available Medicare claims data to determine the 
specialty mix assigned to each code. The PE RVUs in Addendum B of the 
CMS Web site reflect this proposed refinement to the PE methodology.
    Step 8: Calculate the service level allocators for the indirect PEs 
based on the percentages calculated in Step 7. The indirect PEs are 
allocated based on the three components: The direct PE RVUs; the 
clinical PE RVUs; and the work RVUs. For most services the indirect 
allocator is: Indirect PE percentage * (direct PE RVUs/direct 
percentage) + work RVUs.
    There are two situations where this formula is modified:
     If the service is a global service (that is, a service 
with global, professional, and technical components), then the indirect 
PE allocator is: Indirect percentage (direct PE RVUs/direct percentage) 
+ clinical labor PE RVUs + work RVUs.
     If the clinical labor PE RVUs exceed the work RVUs (and 
the service is not a global service), then the indirect allocator is: 
Indirect PE percentage (direct PE RVUs/direct percentage) + clinical 
labor PE RVUs.
    (Note: For global services, the indirect PE allocator is based on 
both the work RVUs and the clinical labor PE RVUs. We do this to 
recognize that, for the PC service, indirect PEs will be allocated 
using the work RVUs, and for the TC service, indirect PEs will be 
allocated using the direct PE RVUs and the clinical labor PE RVUs. This 
also allows the global component RVUs to equal the sum of the PC and TC 
RVUs.)
    For presentation purposes in the examples in Table 1, the formulas 
were divided into two parts for each service.
     The first part does not vary by service and is the 
indirect percentage (direct PE RVUs/direct percentage).
     The second part is either the work RVU, clinical labor PE 
RVU, or both depending on whether the service is a global service and 
whether the clinical PE RVUs exceed the work RVUs (as described earlier 
in this step).
    Apply a scaling adjustment to the indirect allocators.
    Step 9: Calculate the current aggregate pool of indirect PE RVUs by 
multiplying the result of step 2a (as calculated with the proposed 
change) by the average indirect PE percentage from the survey data.
    Step 10: Calculate an aggregate pool of indirect PE RVUs for all 
PFS services by adding the product of the indirect PE allocators for a 
service from Step 8 and the utilization data for that service.
    Step 11: Using the results of Step 9 and Step 10, calculate an 
indirect PE adjustment so that the aggregate indirect allocation does 
not exceed the available aggregate indirect PE RVUs and apply it to 
indirect allocators calculated in Step 8.
    Calculate the indirect practice cost index.
    Step 12: Using the results of Step 11, calculate aggregate pools of 
specialty-specific adjusted indirect PE allocators for all PFS services 
for a specialty by adding the product of the adjusted indirect PE 
allocator for each service and the utilization data for that service.
    Step 13: Using the specialty-specific indirect PE/HR data, 
calculate specialty-specific aggregate pools of indirect PE for all PFS 
services for that specialty by adding the product of the indirect PE/HR 
for the specialty, the work time for the service, and the specialty's 
utilization for the service across all services furnished by the 
specialty.
    Step 14: Using the results of Step 12 and Step 13, calculate the 
specialty-specific indirect PE scaling factors.
    Step 15: Using the results of Step 14, calculate an indirect 
practice cost index at the specialty level by dividing each specialty-
specific indirect scaling factor by the average indirect scaling factor 
for the entire PFS.
    Step 16: Calculate the indirect practice cost index at the service 
level to ensure the capture of all indirect costs. Calculate a weighted 
average of the practice cost index values for the specialties that 
furnish the service. (Note: For services with TCs and PCs, we calculate 
the indirect practice cost index across the global service, PCs, and 
TCs. Under this method, the indirect practice cost index for a given 
service (for example, echocardiogram) does not vary by the PC, TC, and 
global service.)
    Step 17: Apply the service level indirect practice cost index 
calculated in Step 16 to the service level adjusted indirect allocators 
calculated in Step 11 to get the indirect PE RVUs.
(d) Calculate the Final PE RVUs
    Step 18: Add the direct PE RVUs from Step 6 to the indirect PE RVUs 
from Step 17 and apply the final PE budget neutrality (BN) adjustment. 
The final PE BN adjustment is calculated by comparing the results of 
Step 18 to the proposed aggregate work RVUs scaled by the ratio of 
current aggregate PE and work RVUs, consistent with the proposed 
changes in Steps 2 and 9. This final BN adjustment is required to 
redistribute RVUs from step 18 to all PE RVUs in the PFS, and because 
certain specialties are excluded from the PE RVU calculation for 
ratesetting purposes, but we note that all specialties are included for 
purposes of calculating the final BN adjustment. (See ``Specialties 
excluded from ratesetting calculation'' later in this section.)
    (e) Setup File Information
     Specialties excluded from ratesetting calculation: For the 
purposes of calculating the PE RVUs, we exclude certain specialties, 
such as certain nonphysician practitioners paid at a percentage of the 
PFS and low-volume specialties, from the calculation. These specialties 
are included for the purposes of calculating the BN adjustment. They 
are displayed in Table 1.

[[Page 41694]]



       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 prosthetist.
57.....................  Individual certified
                          prosthetist[dash]orthotist.
58.....................  Medical supply company with registered
                          pharmacist.
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.
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.
B2.....................  Pedorthic personnel.
B3.....................  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 TC and 26 modifiers: Flag the services that 
are PC and TC services but do not use TC and 26 modifiers (for example, 
electrocardiograms). This flag associates the PC and TC with the 
associated global code for use in creating the indirect PE RVUs. For 
example, the professional service, CPT code 93010 (Electrocardiogram, 
routine ECG with at least 12 leads; interpretation and report only), is 
associated with the global service, CPT code 93000 (Electrocardiogram, 
routine ECG with at least 12 leads; with interpretation and report).
     Payment modifiers: Payment modifiers are accounted for in 
the creation of the file consistent with current payment policy as 
implemented in claims processing. For example, services billed with the 
assistant at surgery modifier are paid 16 percent of the PFS amount for 
that service; therefore, the utilization file is modified to only 
account for 16 percent of any service that contains the assistant at 
surgery modifier. Similarly, for those services to which volume 
adjustments are made to account for the payment modifiers, time 
adjustments are applied as well. For time adjustments to surgical 
services, the intraoperative portion in the work time file is used; 
where it is not present, the intraoperative percentage from the payment 
files used by contractors to process Medicare claims is used instead. 
Where neither is available, we use the payment adjustment ratio to 
adjust the time accordingly. Table 2 details the manner in which the 
modifiers are applied.

                         Table 2--Application of Payment Modifiers to Utilization Files
----------------------------------------------------------------------------------------------------------------
               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 LT and RT......................  Bilateral Surgery......  150%...................  150% of work time.
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%.

[[Page 41695]]

 
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 (MPPRs). We note that 
section 1848(c)(2)(B)(v) of the Act exempts certain reduced payments 
for multiple imaging procedures and multiple therapy services from the 
BN calculation under section 1848(c)(2)(B)(ii)(II) of the Act. These 
MPPRs are not included in the development of the RVUs.
    For anesthesia services, we do not apply adjustments to volume 
since we use the average allowed charge when simulating RVUs; 
therefore, the RVUs as calculated already reflect the payments as 
adjusted by modifiers, and no volume adjustments are necessary. 
However, a time adjustment of 33 percent is made only for medical 
direction of two to four cases since that is the only situation where a 
single practitioner is involved with multiple beneficiaries 
concurrently, so that counting each service without regard to the 
overlap with other services would overstate the amount of time spent by 
the practitioner furnishing these services.
     Work RVUs: The setup file contains the work RVUs from this 
proposed rule with comment period.
(7) Equipment Cost Per Minute
    The equipment cost per minute is calculated as:

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

Where:

minutes per year = maximum minutes per year if usage were continuous 
(that is, usage = 1); generally 150,000 minutes.
usage = variable, see discussion below.
price = price of the particular piece of equipment.
life of equipment = useful life of the particular piece of 
equipment.
maintenance = factor for maintenance; 0.05.
interest rate = variable, see discussion below.

    Usage: We currently use an equipment utilization rate assumption of 
50 percent for most equipment, with the exception of expensive 
diagnostic imaging equipment, for which we use a 90 percent assumption 
as required by section 1848(b)(4)(C) of the Act. We also direct the 
reader to section II.5.b of this proposed rule for a discussion of our 
proposed change in the utilization rate assumption for the linear 
accelerator used in furnishing radiation treatment services.
    Maintenance: This factor for maintenance was proposed and finalized 
during rulemaking for CY 1998 PFS (62 FR 33164). Several stakeholders 
have suggested that this maintenance factor assumption should be 
variable, similar to other assumptions in the equipment cost per minute 
calculation. In CY 2015 rulemaking, we solicited comments regarding the 
availability of reliable data on maintenance costs that vary for 
particular equipment items. We received several comments about variable 
maintenance costs, and in reviewing the information offered in those 
comments, it is clear that the relationship between maintenance costs 
and the price of equipment is not necessarily uniform across equipment. 
However, based on our review of comments, we have been unable to 
identify a systematic way of varying the maintenance cost assumption 
relative to the price or useful life of equipment. Therefore, in order 
to accommodate a variable, as opposed to a standard, maintenance rate 
within the equipment cost per minute calculation, we believe we would 
have to gather and maintain valid data on the maintenance costs for 
each equipment item in the direct PE input database, much like we do 
for price and useful life.
    Given our longstanding difficulties in acquiring accurate pricing 
information for equipment items, we are seeking comment on whether 
adding another item-specific financial variable for equipment costs 
will be likely to increase the accuracy of PE RVUs across the PFS. We 
note that most of the information for maintenance costs we have 
received is for capital equipment, and for the most part, this 
information has been limited to single invoices. Like the invoices for 
the equipment items themselves, we do not believe that very small 
numbers of voluntarily submitted invoices are likely to reflect typical 
costs for all of the same reasons we have discussed in previous 
rulemaking. We note that some commenters submitted high-level summary 
data from informal surveys but we currently have no means to validate 
that data. Therefore, we continue to seek a source of publicly 
available data on actual maintenance costs for medical equipment to 
improve the accuracy of the equipment costs used in developing PE RVUs.
    Interest Rate: In the CY 2013 final rule with comment period (77 FR 
68902), we updated the interest rates used in developing an equipment 
cost per minute calculation. The interest rate was based on the Small 
Business Administration (SBA) maximum interest rates for different 
categories of loan size (equipment cost) and maturity (useful life). 
The interest rates are listed in Table 3. (See 77 FR 68902 for a 
thorough discussion of this issue.)

                   Table 3--SBA Maximum Interest Rates
------------------------------------------------------------------------
                                                                Interest
                Price                        Useful life        rate (%)
------------------------------------------------------------------------
<$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
------------------------------------------------------------------------


[[Page 41696]]


                                                                                  Table 4--Calculation of PE RVUS Under Methodology for Selected Codes
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                            33533 CABG,
                                                                                                           99213 Office      arterial,    71020 chest x-  71020-TC chest  71020-26 chest    93000 ECG,      93005 ECG,      93010 ECG,
                                              Step                  Source                Formula           visit, est        single            ray           x-ray,          x-ray,         complete,        tracing         report
                                                                                                            nonfacility      facility       nonfacility     nonfacility     nonfacility     nonfacility     nonfacility     nonfacility
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(1) Labor cost (Lab)...............  Step 1...............  AMA..................  .....................           13.32           77.52            5.74            5.74               0             5.1             5.1               0
(2) Supply cost (Sup)..............  Step 1...............  AMA..................  .....................            2.98            7.34            0.53            0.53               0            1.19            1.19               0
(3) Equipment cost (Eqp)...........  Step 1...............  AMA..................  .....................            0.17            0.58            7.08            7.08               0            0.09            0.09               0
(4) Direct cost (Dir)..............  Step 1...............  .....................  =(1)+(2)+(3).........           16.48           85.45           13.36           13.36               0            6.38            6.38               0
(5) Direct adjustment (Dir. Adj.)..  Steps 2-4............  See footnote*........  .....................          0.6003          0.6003          0.6003          0.6003          0.6003          0.6003          0.6003          0.6003
(6) Adjusted Labor.................  Steps 2-4............  =Labor * Dir Adj.....  =(1)*(5).............               8           46.53            3.45            3.45               0            3.06            3.06               0
(7) Adjusted Supplies..............  Steps 2-4............  =Eqp * Dir Adj.......  =(2)*(5).............            1.79            4.41            0.32            0.32               0            0.72            0.72               0
(8) Adjusted Equipment.............  Steps 2-4............  =Sup * Dir Adj.......  =(3)*(5).............            0.10            0.35            4.25            4.25               0            0.05            0.05               0
(9) Adjusted Direct................  Steps 2-4............  .....................  =(6)+(7)+(8).........            9.89           51.29            8.02            8.02               0            3.83            3.83               0
(10) Conversion Factor (CF)........  Step 5...............  PFS..................  .....................         35.9335         35.9335         35.9335         35.9335         35.9335         35.9335         35.9335         35.9335
(11) Adj. labor cost converted.....  Step 5...............  =(Lab * Dir Adj)/CF..  =(6)/(10)............            0.22             1.3             0.1             0.1               0            0.09            0.09               0
(12) Adj. supply cost converted....  Step 5...............  =(Sup * Dir Adj)/CF..  =(7)/(10)............            0.05            0.12            0.01            0.01               0            0.02            0.02               0
(13) Adj. equipment cost converted.  Step 5...............  =(Eqp * Dir Adj)/CF..  =(8)/(10)............               0            0.01            0.12            0.12               0               0               0               0
(14) Adj. direct cost converted....  Step 5...............  .....................  =(11)+(12)+(13)......            0.28            1.43            0.22            0.22               0            0.11            0.11               0
(15) Work RVU......................  Setup File...........  PFS..................  .....................            0.97           33.75            0.22               0            0.22            0.17               0            0.17
(16) Dir_pct.......................  Steps 6,7............  Surveys..............  .....................            0.25            0.17            0.29            0.29            0.29            0.29            0.29            0.29
(17) Ind_pct.......................  Steps 6,7............  Surveys..............  .....................            0.75            0.83            0.71            0.71            0.71            0.71            0.71            0.71
(18) Ind. Alloc. Formula (1st part)  Step 8...............  See Step 8...........  .....................           (14)/           (14)/           (14)/           (14)/           (14)/           (14)/           (14)/           (14)/
                                                                                                               (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...............            0.83            6.75            0.54            0.54               0            0.26            0.26               0
(20) Ind. Alloc. Formula (2nd part)  Step 8...............  See Step 8...........  .....................            (15)            (15)         (15+11)            (11)            (15)         (15+11)            (11)            (15)
(21) Ind. Alloc.(2nd part).........  Step 8...............  .....................  See 20...............            0.97           33.75            0.32             0.1            0.22            0.26            0.09            0.17
(22) Indirect Allocator (1st + 2nd)  Step 8...............  .....................  =(19)+(21)...........             1.8           40.50            0.86            0.64            0.22            0.52            0.35            0.17
(23) Indirect Adjustment (Ind.       Steps 9-11...........  See Footnote**.......  .....................          0.3811          0.3811          0.3811          0.3811          0.3811          0.3811          0.3811          0.3811
 Adj.).
(24) Adjusted Indirect Allocator...  Steps 9-11...........  =Ind Alloc * Ind Adj.  .....................            0.69           15.43            0.33            0.24            0.08             0.2            0.13            0.06
(25) Ind. Practice Cost Index        Steps 12-16..........  .....................  .....................            1.07            0.76            0.98            0.98            0.98             0.9             0.9             0.9
 (IPCI).
(26) Adjusted Indirect.............  Step 17..............  = Adj.Ind Alloc * PCI  =(24)*(25)...........            0.73           11.68            0.32            0.24            0.08            0.18            0.12            0.06
(27) Final PE RVU..................  Step 18..............  =(Adj Dir + Adj Ind)   =((14)+(26)) * Other             1.01           13.15            0.54            0.46            0.08            0.28            0.23            0.06
                                                             * Other Adj.           Adj).
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CPT codes and descriptions are copyright 2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.
Notes: PE RVUs above (row 27), may not match Addendum B due to rounding.
The use of any particular conversion factor (CF) in the table to illustrate the PE Calculation has no effect on the resulting RVUs.
*The direct adj = [current pe rvus * CF * avg dir pct]/[sum direct inputs] = [step2]/[step3]; **The indirect adj =[current pe rvus * avg ind pct]/[sum of ind allocators]=[step9]/[step10]


[[Page 41697]]

c. Changes to Direct PE Inputs for Specific Services
    In this section, we discuss other CY 2016 proposals related to 
particular PE inputs. The proposed direct PE inputs are included in the 
proposed CY 2016 direct PE input database, which is available on the 
CMS Web site under downloads for the CY 2016 PFS proposed rule with 
comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
(1) PE Inputs for Digital Imaging Services
    Prior to CY 2015 rulemaking, the RUC provided a recommendation 
regarding the PE inputs for digital imaging services. Specifically, the 
RUC recommended that we remove supply and equipment items associated 
with film technology from a list of codes since these items are no 
longer typical resource inputs. The RUC also recommended that the 
Picture Archiving and Communication System (PACS) equipment be included 
for these imaging services since these items are now typically used in 
furnishing imaging services. However, since we did not receive any 
invoices for the PACS system, we were unable to determine the 
appropriate pricing to use for the inputs. For CY 2015, we proposed, 
and finalized our proposal, to remove the film supply and equipment 
items, and to create a new equipment item as a proxy for the PACS 
workstation as a direct expense. We used the current price associated 
with ED021 (computer, desktop, w-monitor) to price the new item, ED050 
(PACS Workstation Proxy), pending receipt of invoices to facilitate 
pricing specific to the PACS workstation.
    Subsequent to establishing payment rates for CY 2015, we received 
information from several stakeholders regarding pricing for items 
related to the digital acquisition and storage of images. Some of these 
stakeholders submitted information that included prices for items 
clearly categorized as indirect costs within the established PE 
methodology and equivalent to the storage mechanisms for film. 
Additionally, some of the invoices we received included other products 
(like training and maintenance costs) in addition to the equipment 
items, and there was no distinction on these invoices between the 
prices for the equipment items themselves and the related services. 
However, we did receive invoices from one stakeholder that facilitated 
a proposed price update for the PACS workstation. Therefore, we are 
proposing to update the price for the PACS workstation to $5,557 from 
the current price of $2,501 since the latter price was based on the 
proxy item and the former based on submitted invoices. The PE RVUs in 
Addendum B on the CMS Web site reflect the updated price.
    In addition to the workstation used by the clinical staff acquiring 
the images and furnishing the technical component of the services, a 
stakeholder also submitted more detailed information regarding a 
workstation used by the practitioner interpreting the image in 
furnishing the professional component of many of these services. As we 
stated in the CY 2015 final rule with comment period (79 FR 67563), we 
generally believe that workstations used by these practitioners are 
more accurately considered indirect costs associated with the 
professional component of the service. However, we understand that the 
professional workstations for interpretation of digital images are 
similar in principle to some of the previous film inputs incorporated 
into the global and technical components of the codes. Given that many 
of these services are reported globally in the nonfacility setting, we 
believe it may be appropriate to include these costs as direct inputs 
for the associated HCPCS codes. Based on our established methodology, 
these costs would be incorporated into the PE RVUs of the global and 
technical component of the HCPCS code. We are seeking comment on 
whether including the professional workstation as a direct PE input for 
these codes would be appropriate, given that the resulting PE RVUs 
would be assigned to the global and technical components of the codes.
    Another stakeholder expressed concern about the changes in direct 
PE inputs for CPT code 76377, (3D radiographic procedure with 
computerized image post-processing), that were proposed and finalized 
in CY 2015 rulemaking as part of the film to digital change. Based on a 
recommendation from the RUC, we removed the input called ``computer 
workstation, 3D reconstruction CT-MR'' from the direct PE input 
database and assigned the associated minutes to the proxy for the PACS 
workstation. We are seeking comment from stakeholders, including the 
RUC, about whether or not the PACS workstation used in in imaging codes 
is the same workstation that is used in the postprocessing described by 
CPT code 76377, or if more specific workstation should be incorporated 
in the direct PE input database . . .
(2) Standardization of Clinical Labor Tasks
    As we noted in PFS rulemaking for CY 2015, we continue to work on 
revisions to the direct PE input database to provide the number of 
clinical labor minutes assigned for each task for every code in the 
database instead of only including the number of clinical labor minutes 
for the pre-service, service, and post-service periods for each code. 
In addition to increasing the transparency of the information used to 
set PE RVUs, this improvement would allow us to compare clinical labor 
times for activities associated with services across the PFS, which we 
believe is important to maintaining the relativity of the direct PE 
inputs. This information will facilitate the identification of the 
usual numbers of minutes for clinical labor tasks and the 
identification of exceptions to the usual values. It will also allow 
for greater transparency and consistency in the assignment of equipment 
minutes based on clinical labor times. Finally, we believe that the 
information can be useful in maintaining standard times for particular 
clinical labor tasks that can be applied consistently to many codes as 
they are valued over several years, similar in principle to the use of 
physician pre-service time packages. We believe such standards will 
provide greater consistency among codes that share the same clinical 
labor tasks and could improve relativity of values among codes. For 
example, as medical practice and technologies change over time, changes 
in the standards could be updated at once for all codes with the 
applicable clinical labor tasks, instead of waiting for individual 
codes to be reviewed.
    While this work is not yet complete, we anticipate completing it in 
the near future. In the following paragraphs, we address a series of 
issues related to clinical labor tasks, particularly relevant to 
services currently being reviewed under the misvalued code initiative
(a) Clinical Labor Tasks Associated With Digital Imaging
    In PFS rulemaking for CY 2015, we noted that the RUC recommendation 
regarding inputs for digital imaging services indicated that, as each 
code is reviewed under the misvalued code initiative, the clinical 
labor tasks associated with digital technology (instead of film) would 
need to be addressed. When we reviewed that recommendation, we did not 
have the capability of assigning standard clinical labor times for the 
hundreds of individual codes since the direct PE

[[Page 41698]]

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

    Table 5--Clinical Labor Tasks Associated With Digital Technology
------------------------------------------------------------------------
                 Clinical labor task                    Typical minutes
------------------------------------------------------------------------
Availability of prior images confirmed...............                  2
Patient clinical information and questionnaire                         2
 reviewed by technologist, order from physician
 confirmed and exam protocoled by radiologist........
Technologist QC's * images in PACS, checking for all                   2
 images, reformats, and dose page....................
Review examination with interpreting MD..............                  2
Exam documents scanned into PACS. Exam completed in                    1
 RIS system to generate billing process and to
 populate images into Radiologist work queue.........
------------------------------------------------------------------------
* This clinical labor task is listed as it appears on the ``PE
  worksheets.'' QC refers to quality control, which we understand to
  mean the verification of the image using the PACS workstation.

(b) Pathology Clinical Labor Tasks
    As with the clinical labor tasks associated with digital imaging, 
many of the specialized clinical labor tasks associated with pathology 
services do not have consistent times across those codes. In reviewing 
the recommendations for pathology services, we have not identified 
information that suggests that the inconsistencies reflect the judgment 
that the same tasks take significantly more or less time depending on 
the individual service for which they are performed, especially given 
the specificity with which they are described.
    We have therefore developed proposed standard times that we have 
used in proposing direct PE inputs. These times are based on our review 
and assessment of the current times included for these clinical labor 
tasks in the direct PE input database. We have listed these proposed 
standard times in Table 6. For services reviewed for CY 2016, in cases 
where the RUC-recommended times differed from these standards, we have 
refined the time for those tasks to align with the values in Table 6. 
We seek comment on whether these standard times accurately reflect the 
typical time it takes to perform these clinical labor tasks when 
furnishing pathology services.

    Table 6--Standard Times for Clinical Labor Tasks Associated With
                           Pathology Services
------------------------------------------------------------------------
                                                       Standard clinical
                 Clinical Labor Task                      labor time
------------------------------------------------------------------------
Accession specimen/prepare for examination..........                 4
Assemble and deliver slides with paperwork to                        0.5
 pathologists.......................................
Assemble other light microscopy slides, open nerve                   0.5
 biopsy slides, and clinical history, and present to
 pathologist to prepare clinical pathologic
 interpretation.....................................
Assist pathologist with gross specimen examination..                 3
Clean room/equipment following procedure (including                  1
 any equipment maintenance that must be done after
 the procedure).....................................
Dispose of remaining specimens, spent chemicals/                     1
 other consumables, and hazardous waste.............
Enter patient data, computational prep for antibody                  1
 testing, generate and apply bar codes to slides,
 and enter data for automated slide stainer.........
Instrument start-up, quality control functions,                     13
 calibration, centrifugation, maintaining specimen
 tracking, logs and labeling........................
Load specimen into flow cytometer, run specimen,                     7
 monitor data acquisition and data modeling, and
 unload flow cytometer..............................
Preparation: labeling of blocks and containers and                   0.5
 document location and processor used...............
Prepare automated stainer with solutions and load                    4
 microscopic slides.................................
Prepare specimen containers/preload fixative/label                   0.5
 containers/distribute requisition form(s) to
 physician..........................................
Prepare, pack and transport specimens and records                    1
 for in-house storage and external storage (where
 applicable)........................................
Print out histograms, assemble materials with                        2
 paperwork to pathologists. Review histograms and
 gating with pathologist............................
Receive phone call from referring laboratory/                        5
 facility with scheduled procedure to arrange
 special delivery of specimen procurement kit,
 including muscle biopsy clamp as needed. Review
 with sender instructions for preservation of
 specimen integrity and return arrangements. Contact
 courier and arrange delivery to referring
 laboratory/facility................................
Register the patient in the information system,                      4
 including all demographic and billing information..
Stain air dried slides with modified Wright stain.                   3
 Review slides for malignancy/high cellularity
 (cross contamination)..............................
------------------------------------------------------------------------


[[Page 41699]]

(c) Clinical Labor Task: ``Complete Botox Log''
    In the process of improving the level of detail in the direct PE 
input database by including the minutes assigned for each clinical 
labor task, we noticed that there are several codes with minutes 
assigned for the clinical labor task called ``complete botox log.'' We 
do not believe the completion of such a log is a direct resource cost 
of furnishing a medically reasonable and necessary physician's service 
for a Medicare beneficiary. Therefore, we are proposing to eliminate 
the minutes assigned for the task ``complete botox log'' from the 
direct PE input database. The PE RVUs displayed in Addendum B on the 
CMS Web site were calculated with the modified inputs displayed in the 
CY 2016 direct PE input database.
(3) Clinical Labor Input Inconsistencies
    Subsequent to the publication of the CY 2015 PFS final rule with 
comment period, stakeholders alerted us to several clerical 
inconsistencies in the clinical labor nonfacility intraservice time for 
several vertebroplasty codes with interim final values for CY 2015, 
based on our understanding of RUC recommended values. We are proposing 
to correct these inconsistencies in the CY 2016 proposed direct PE 
input database to reflect the RUC recommended values, without 
refinement, as stated in the CY 2015 PFS final rule with comment 
period. The CY 2015 interim final direct PE inputs for these codes are 
displayed on the CMS Web site under downloads for the CY 2015 PFS final 
rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. For CY 2016, we are proposing the following adjustments. 
For CPT codes 22510 (percutaneous vertebroplasty (bone biopsy included 
when performed), 1 vertebral body, unilateral or bilateral injection, 
inclusive of all imaging guidance; cervicothoracic) and 22511 
(percutaneous vertebroplasty (bone biopsy included when performed), 1 
vertebral body, unilateral or bilateral injection, inclusive of all 
imaging guidance; lumbosacral), a value of 45 minutes for labor code 
L041B (``Radiologic Technologist'') were are proposing to assign for 
the ``assist physician'' task and a value of 5 minutes for labor code 
L037D (``RN/LPN/MTA'') for the ``Check dressings & wound/home care 
instructions/coordinate office visits/prescriptions'' task. For CPT 
code 22514 (percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) 
using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; lumbar), 
we are proposing to adjust the nonfacility intraservice time to 50 
minutes for L041B, 50 minutes for L051A (``RN''), 38 minutes for a 
second L041B, and 12 minutes for L037D. The PE RVUs displayed in 
Addendum B on the CMS Web site were calculated with the inputs 
displayed in the CY 2016 direct PE input database.
(4) Freezer
    We identified several pathology codes for which equipment minutes 
are assigned to the item EP110 ``Freezer.'' Minutes are only allocated 
to particular equipment items when those items cannot be used in 
conjunction with furnishing services to another patient at the same 
time. We do not believe that minutes should be allocated to items such 
as freezers since the storage of any particular specimen or item in a 
freezer for any given period of time would be unlikely to make the 
freezer unavailable for storing other specimens or items. Instead, we 
propose to classify the freezer as an indirect cost because we believe 
that would be most consistent with the principles underlying the PE 
methodology since freezers can be used for many specimens at once. The 
PE RVUs displayed in Addendum B on the CMS Web site were calculated 
with the modified inputs displayed in the CY 2016 direct PE input 
database.
(5) Updates to Price for Existing Direct Inputs
    In the CY 2011 PFS final rule with comment period (75 FR 73205), we 
finalized a process to act on public requests to update equipment and 
supply price and equipment useful life inputs through annual rulemaking 
beginning with the CY 2012 PFS proposed rule. During 2014, we received 
a request to update the price of supply item ``antigen, mite'' (SH006) 
from $4.10 per test to $59. In reviewing the request, it is evident 
that the requested price update does not apply to the SH006 item but 
instead represents a different item than the one currently included as 
an input in CPT code 86490 (skin test, coccidioidomycosis). Therefore, 
rather than changing the price for SH006 that is included in several 
codes, we are proposing to create a new supply code for Spherusol, 
valued at $590 per 1 ml vial and $59 per test, and to include this new 
item as a supply for 86490 instead of the current input, SH006. We also 
received a request to update the price for EQ340 (Patient Worn 
Telemetry System) used only in CPT code 93229 (External mobile 
cardiovascular telemetry with electrocardiographic recording, 
concurrent computerized real time data analysis and greater than 24 
hours of accessible ECG data storage (retrievable with query) with ECG 
triggered and patient selected events transmitted to a remote attended 
surveillance center for up to 30 days; technical support for connection 
and patient instructions for use, attended surveillance, analysis and 
transmission of daily and emergent data reports as prescribed by a 
physician or other qualified health care.) The requestor noted that we 
had previously proposed and finalized a policy to remove wireless 
communication and delivery costs related to the equipment item that had 
previously been included in the direct PE input database as supply 
items. The requestor asked that we alter the price of the equipment 
from $21,575 to $23,537 to account for the equipment costs specific to 
the patient-worn telemetry system.
    We have considered this request in the context of the unique nature 
of this particular equipment item. This equipment item is unique in 
several ways, including that it is used continuously 24 hours per day 
and 7 days per week for an individual patient over several weeks. It is 
also unique in that the equipment is primarily used outside of a 
healthcare setting. Within our current methodology, we currently 
account for these unique properties by calculating the per minute costs 
with different assumptions than those used for most other equipment by 
increasing the number of hours the equipment is available for use. 
Therefore, we also believe it would be appropriate to incorporate other 
unique aspects of the operating costs of this item in our calculation 
of the equipment cost per minute. We believe the requestor's suggestion 
to do so by increasing the price of the equipment is practicable and 
appropriate. Therefore, we are proposing to change the price for EQ340 
(Patient Worn Telemetry System) to $23,537. The PE RVUs displayed in 
Addendum B on the CMS Web site were calculated with the modified inputs 
displayed in the CY 2016 direct PE input database.
    For CY 2015, we received a request to update the price for supply 
item ``kit, HER-2/neu DNA Probe'' (SL196) from $105 to $144.50. 
Accordingly, we proposed to update the price to $144.50. In the CY 2015 
final rule with comment period, we indicated that we obtained new 
information suggesting that further study of the price of this item was 
necessary before proceeding to update

[[Page 41700]]

the input price. We obtained pricing information readily available on 
the Internet that indicated a price of $94 for this item for a 
particular hospital. Subsequent to the CY 2015 final rule with comment 
period, stakeholders requested that we use the updated price of 
$144.50. One stakeholder suggested that the price of $94 likely 
reflected discounts for volume purchases not received by the typical 
laboratory. We are seeking comment on how to consider the higher-priced 
invoice, which is 53 percent higher than the price listed, relative to 
the price currently in the direct PE database. Specifically, we are 
seeking information on the price of the disposable supply in the 
typical case of the service furnished to a Medicare beneficiary, 
including, based on data, whether the typical Medicare case is 
furnished by an entity likely to receive a volume discount.
(6) Typical Supply and Equipment Inputs for Pathology Services
    In reviewing public comments in response to the CY 2015 PFS final 
rule with comment period, we re-examined issues around the typical 
number of pathology tests furnished at once. In the CY 2013 final rule 
with comment period (77 FR 69074), we noted that the number of blocks 
assumed for a particular code significantly impacts the assumed 
clinical labor, supplies, and equipment for that service. We indicated 
that we had concerns that the assumed number of blocks was inaccurate, 
and that we sought corroborating, independent evidence that the number 
of blocks assumed in the current direct PE input recommendations is 
typical. We note that, given the high volume of many pathology 
services, these assumptions have a significant impact on the PE RVUs 
for all other PFS services. We refer readers to section II.I.5.d where 
we detail our concerns about the lack of information regarding typical 
batch size and typical block size for many pathology services and 
solicit stakeholder input on approaches to obtaining accurate 
information that can facilitate our establishing payment rates that 
best reflect the relative resources involved in furnishing the typical 
service, for both pathology services in particular and more broadly for 
services across the PFS.
d. Developing Nonfacility Rates
    We note that not all PFS services are priced in the nonfacility 
setting, but as medical practice changes, we routinely develop 
nonfacility prices for particular services when they can be furnished 
outside of a facility setting. We note that the valuation of a service 
under the PFS in particular settings does not address whether those 
services are medically reasonable and necessary in the case of 
individual patients, including being furnished in a setting appropriate 
to the patient's medical needs and condition.
(1) Request for Information on Nonfacility Cataract Surgery
    Cataract surgery generally has been performed in an ambulatory 
surgery center (ASC) or a hospital outpatient department (HOPD). 
Therefore, CMS has not assigned nonfacility PE RVUs under the PFS for 
cataract surgery. According to Medicare claims data, there are a 
relatively small number of these services furnished in nonfacility 
settings. Except in unusual circumstances, anesthesia for cataract 
surgery is either local or topical/intracameral. Advancements in 
technology have significantly reduced operating time and improved both 
the safety of the procedure and patient outcomes. We believe that it is 
now possible for cataract surgery to be furnished in an in-office 
surgical suite, especially for routine cases. Cataract surgery patients 
require a sterile surgical suite with certain equipment and supplies 
that we believe could be a part of a nonfacility-based setting that is 
properly constructed and maintained for appropriate infection 
prevention and control.
    We believe that there are potential advantages for all parties to 
furnishing appropriate cataract surgery cases in the nonfacility 
setting. Cataract surgery has been for many years the highest volume 
surgical procedure performed on Medicare beneficiaries. For 
beneficiaries, cataract surgery in the office setting might provide the 
additional convenience of receiving the preoperative, operative, and 
post-operative care in one location. It might also reduce delays 
associated with registration, processing, and discharge protocols 
associated with some facilities. Similarly, it might provide surgeons 
with greater flexibility in scheduling patients at an appropriate site 
of service depending on the individual patient's needs. For example, 
routine cases in patients with no comorbidities could be performed in 
the nonfacility surgical suite, while more complicated cases (for 
example, pseudoexfoliation) could be scheduled in the ASC or HOPD. In 
addition, furnishing cataract surgery in the nonfacility setting could 
result in lower Medicare expenditures for cataract surgery if the 
nonfacility payment rate were lower than the sum of the PFS facility 
payment rate and the payment to either the ASC or HOPD.
    We are seeking comments from ophthalmologists and other 
stakeholders on office-based surgical suite cataract surgery. In 
addition, we are soliciting comments from the RUC and other 
stakeholders on the direct practice expense inputs involved in 
furnishing cataract surgery in the nonfacility setting in conjunction 
with our consideration of information regarding the possibility of 
developing nonfacility PE RVUs for cataract surgery. We understand that 
cataract surgery generally requires some standard equipment and 
supplies (for example; phacoemulsification machine, surgical pack, 
intraocular lenses (IOL), etc.) that would be incorporated as direct PE 
inputs in calculating nonfacility PE RVUs.
(2) Direct PE Inputs for Functional Endoscopic Sinus Surgery Services
    A stakeholder indicated that due to changes in technology and 
technique, several codes that describe endoscopic sinus surgeries can 
now be furnished in the nonfacility setting. According to Medicare 
claims data, there are a relatively small number of these services 
furnished in nonfacility settings. These CPT codes are 31254 (Nasal/
sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)), 
31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total 
(anterior and posterior)), 31256 (Nasal/sinus endoscopy, surgical, with 
maxillary antrostomy;), 31267 (Nasal/sinus endoscopy, surgical, with 
maxillary antrostomy; with removal of tissue from maxillary sinus), 
31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, 
with or without removal of tissue from frontal sinus), 31287 (Nasal/
sinus endoscopy, surgical, with sphenoidotomy;), and 31288 (Nasal/sinus 
endoscopy, surgical, with sphenoidotomy; with removal of tissue from 
the sphenoid sinus). We are seeking input from stakeholders, including 
the RUC, about the appropriate direct PE inputs for these services.

B. Determination of Malpractice Relative Value Units (RVUs)

1. Overview
    Section 1848(c) of the Act requires that each service paid under 
the PFS be comprised of three components: work, PE, and malpractice 
(MP) expense. As required by section 1848(c)(2)(C)(iii) of the Act, 
beginning in CY 2000, MP RVUs are resource based. Malpractice RVUs for 
new codes after 1991 were

[[Page 41701]]

extrapolated from similar existing codes or as a percentage of the 
corresponding work RVU. Section 1848(c)(2)(B)(i) of the Act also 
requires that we review, and if necessary adjust, RVUs no less often 
than every 5 years. In the CY 2015 PFS final rule with comment period, 
we implemented the third review and update of MP RVUs. For a discussion 
of the third review and update of MP RVUs see the CY 2015 proposed rule 
(79 FR 40349 through 40355) and final rule with comment period (79 FR 
67591 through 67596).
    As explained in the CY 2011 PFS final rule with comment period (75 
FR 73208), MP RVUs for new and revised codes effective before the next 
five-year review of MP RVUs (for example, effective CY 2016 through CY 
2019, assuming that the next review of MP RVUs occurs for CY 2020) are 
determined either by a direct crosswalk from a similar source code or 
by a modified crosswalk to account for differences in work RVUs between 
the new/revised code and the source code. For the modified crosswalk 
approach, we adjust (or ``scale'') the MP RVU for the new/revised code 
to reflect the difference in work RVU between the source code and the 
new/revised work value (or, if greater, the clinical labor portion of 
the fully implemented PE RVU) for the new code. For example, if the 
proposed work RVU for a revised code is 10 percent higher than the work 
RVU for its source code, the MP RVU for the revised code would be 
increased by 10 percent over the source code MP RVU. Under this 
approach the same risk factor is applied for the new/revised code and 
source code, but the work RVU for the new/revised code is used to 
adjust the MP RVUs for risk.
    For CY 2016, we propose to continue our current approach for 
determining MP RVUs for new/revised codes. For the new and revised 
codes for which we include proposed work values and PE inputs in the 
proposed rule, we will also publish the proposed MP crosswalks used to 
determine their MP RVUs in the proposed rule. The MP crosswalks for 
those new and revised codes will be subject to public comment and 
finalized in the CY 2016 PFS final rule. The MP crosswalks for new and 
revised codes with interim final values established in the CY 2016 
final rule will be implemented for CY 2016 and subject to public 
comment. They will then be finalized in the CY 2017 PFS final rule with 
comment period.
2. Proposed Annual Update of MP RVUs
    In the CY 2012 PFS final rule with comment period (76 FR 73057), we 
finalized a process to consolidate the five-year reviews of physician 
work and PE RVUs with our annual review of potentially misvalued codes. 
We discussed the exclusion of MP RVUs from this process at the time, 
and we stated that, since it is not feasible to obtain updated 
specialty level MP insurance premium data on an annual basis, we 
believe the comprehensive review of MP RVUs should continue to occur at 
5-year intervals. In the CY 2015 PFS proposed rule (79 FR 40349 through 
40355), we stated that there are two main aspects to the update of MP 
RVUs: (1) Recalculation of specialty risk factors based upon updated 
premium data; and (2) recalculation of service level RVUs based upon 
the mix of practitioners providing the service. In the CY 2015 PFS 
final rule with comment period (79 FR 67596), in response to several 
stakeholders' comments, we stated that we would address potential 
changes regarding the frequency of MP RVU updates in a future proposed 
rule. For CY 2016, we are proposing to begin conducting annual MP RVU 
updates to reflect changes in the mix of practitioners providing 
services, and to adjust MP RVUs for risk. Under this approach, the 
specialty-specific risk factors would continue to be updated every five 
years using updated premium data, but would remain unchanged between 
the 5-year reviews. However, in an effort to ensure that MP RVUs are as 
current as possible, our proposal would involve recalibrating all MP 
RVUs on an annual basis to reflect the specialty mix based on updated 
Medicare claims data. Since under this proposal, we would be 
recalculating the MP RVUs annually, we are also proposing to maintain 
the relative pool of MP RVUs from year to year; this will preserve the 
relative weight of MP RVUs to work and PE RVUs. We are proposing to 
calculate the current pool of MP RVUs by using a process parallel to 
the one we use in calculating the pool of PE RVUs. (We direct the 
reader to section II.2.b.(6) for detailed description of that process, 
including a proposed technical revision for 2016.) To determine the 
specialty mix assigned to each code, we are also proposing to use the 
same process used in the PE methodology, described in section 
II.2.b.(6) of this proposed rule. We note that for CY 2016, we are 
proposing to modify the specialty mix assignment methodology to use an 
average of the 3 most recent years of available data instead of a 
single year of data as is our current policy. We anticipate that this 
change will increase the stability of PE and MP RVUs and mitigate code-
level fluctuations for all services paid under the PFS, and for new and 
low-volume codes in particular. We are also proposing to no longer 
apply the dominant specialty for low volume services, because the 
primary rationale for the policy has been mitigated by this proposed 
change in methodology. However, we are not proposing to adjust the 
code-specific overrides established in prior rulemaking for codes where 
the claims data are inconsistent with a specialty that could be 
reasonably expected to furnish the service. We believe that these 
proposed changes will serve to balance the advantages of using annually 
updated information with the need for year-to-year stability in values. 
We seek comment on both aspects of the proposal: updating the specialty 
mix for MP RVUs annually (while continuing to update specialty-specific 
risk factors every 5 years using updated premium data); and using the 
same process to determine the specialty mix assigned to each code as is 
used in the PE methodology, including the proposed modification to use 
the most recent 3 years of claims data. We also seek comment on whether 
this approach will be helpful in addressing some of the concerns 
regarding the calculation of MP RVUs for services with low volume in 
the Medicare population, including the possibility of limiting our use 
of code-specific overrides of the claims data.
    We are also proposing an additional refinement in our process for 
assigning MP RVUs to individual codes. Historically, we have used a 
floor of 0.01 MP RVUs for all nationally-priced PFS codes. This means 
that even when the code-level calculation for the MP RVU falls below 
0.005, we have rounded to 0.01. In general, we believe this approach 
accounts for the minimum MP costs associated with each service 
furnished to a Medicare beneficiary. However, in examining the 
calculation of MP RVUs, we do not believe that this floor should apply 
to add-on codes. Since add-on codes must be reported with another code, 
there is already an MP floor of 0.01 that applies to the base code, and 
therefore, to each individual service. By applying the floor to add-on 
codes, the current methodology practically creates a 0.02 floor for any 
service reported with one add-on code, and 0.03 for those with 2 add-on 
codes, etc. Therefore, we are proposing to maintain the 0.01 MP RVU 
floor for all nationally-priced PFS services that are described by base 
codes, but not for add-on codes. We will continue to calculate, 
display, and make payments that include MP RVUs for

[[Page 41702]]

add-on codes that are calculated to 0.01 or greater, including those 
that round to 0.01. We are only proposing to allow the MP RVUs for add-
on codes to round to 0.00 where the calculated MP RVU is less than 
0.005.
    We will continue to study the appropriate frequency for collecting 
and updating premium data and will address any further proposed changes 
in future rulemaking.
3. MP RVU Update for Anesthesia Services
    In the CY 2015 PFS proposed rule (79 FR 40354 through 40355), we 
did not include an adjustment under the anesthesia fee schedule to 
reflect updated MP premium information, and stated that we intended to 
propose an anesthesia adjustment for MP in the CY 2016 PFS proposed 
rule. We also solicited comments regarding how to best reflect updated 
MP premium amounts under the anesthesiology fee schedule.
    As we previously explained, anesthesia services under the PFS are 
paid based upon a separate fee schedule, so routine updates must be 
calculated in a different way than those for services for which payment 
is calculated based upon work, PE, and MP RVUs. To apply budget 
neutrality and relativity updates to the anesthesiology fee schedule, 
we typically develop proxy RVUs for individual anesthesia services that 
are derived from the total portion of PFS payments made through the 
anesthesia fee schedule. We then update the proxy RVUs as we would the 
RVUs for other PFS services and adjust the anesthesia fee schedule 
conversion factor based on the differences between the original proxy 
RVUs and those adjusted for relativity and budget neutrality.
    We believe that taking the same approach to update the anesthesia 
fee schedule based on new MP premium data is appropriate. However, 
because work RVUs are integral to the MP RVU methodology and anesthesia 
services do not have work RVUs, we decided to seek potential 
alternatives prior to implementing our approach in conjunction with the 
proposed CY 2015 MP RVUs based on updated premium data. One commenter 
supported the delay in proposing to update the MP for anesthesia at the 
same time as updating the rest of the PFS, and another commenter 
suggested using mean anesthesia MP premiums per provider over a 4 or 5 
year period prorated by Medicare utilization to yield the MP expense 
for anesthesia services; no commenters offered alternatives to 
calculating updated MP for anesthesia services. The latter suggestion 
might apply more broadly to the MP methodology for the PFS and does not 
address the methodology as much as the data source.
    We continue to believe that payment rates for anesthesia should 
reflect MP resource costs relative to the rest of the PFS, including 
updates to reflect changes over time. Therefore, for CY 2016, in order 
to appropriately update the MP resource costs for anesthesia, we are 
proposing to make adjustments to the anesthesia conversion factor to 
reflect the updated premium information collected for the five year 
review. To determine the appropriate adjustment, we calculated imputed 
work RVUs and MP RVUs for the anesthesiology fee schedule services 
using the work, PE, and MP shares of the anesthesia fee schedule. 
Again, this is consistent with our longstanding approach to making 
annual adjustments to the PE and work RVU portions of the 
anesthesiology fee schedule. To reflect differences in the complexity 
and risk among the anesthesia fee schedule services, we multiplied the 
service-specific risk factor for each anesthesia fee schedule service 
by the CY 2016 imputed proxy work RVUs and used the product as the 
updated raw proxy MP RVUs for each anesthesia service for CY 2016. We 
then applied the same scaling adjustments to these raw proxy MP RVUs 
that we apply to the remainder of the PFS MP RVUs. Finally, we 
calculated the aggregate difference between the 2015 proxy MP RVUs and 
the proxy MP RVUs calculated for CY 2016. We then adjusted the portion 
of the anesthesia conversion factor attributable to MP proportionately; 
we refer the reader to section VI.C. of this proposed rule for the 
Anesthesia Fee Schedule Conversion Factors for CY 2016. We are inviting 
public comments regarding this proposal.
4. MP RVU Methodology Refinements
    In the CY 2015 PFS final rule with comment period (79 FR 67591 
through 67596), we finalized updated MP RVUs that were calculated based 
on updated MP premium data obtained from state insurance rate filings. 
The methodology used in calculating the finalized CY 2015 review and 
update of resource-based MP RVUs largely paralleled the process used in 
the CY 2010 update. We posted our contractor's report, ``Final Report 
on the CY 2015 Update of Malpractice RVUs'' on the CMS Web site. It is 
also located under the supporting documents section of the CY 2015 PFS 
final rule with comment period located at http://www.cms.gov/PhysicianFeeSched/. A more detailed explanation of the 2015 MP RVU 
update can be found in the CY 2015 PFS proposed rule (79 FR 40349 
through 40355).
    In the CY 2015 PFS proposed rule, we outlined the steps for 
calculating MP RVUs. In the process of calculating MP RVUs for purposes 
of this proposed rule, we have identified a necessary refinement to way 
we have calculated Step 1, which involves computing a preliminary 
national average premium for each specialty, to align the calculations 
within the methodology to the calculations described within the 
aforementioned contractor's report. Specifically, in the calculation of 
the national premium for each specialty (refer to equations 2.3, 2.4, 
2.5 in the aforementioned contractor's report), we calculate a weighted 
sum of premiums across areas and divide it by a weighted sum of MP 
GPCIs across areas. The calculation currently takes the ratio of sums, 
rather than the weighted average of the local premiums to the MP GPCI 
in that area. Instead, we are proposing to update the calculation to 
use a price-adjusted premium (that is, the premium divided by the GPCI) 
in each area, and then taking a weighted average of those adjusted 
premiums. The CY 2016 PFS proposed rule MP RVUs were calculated in this 
manner.
    Additionally, in the calculation of the national average premium 
for each specialty as discussed above, our current methodology used the 
total RVUs in each area as the weight in the numerator (that is, for 
premiums), and total MP RVUs as the weights in the denominator (that 
is, for the MP GPCIs). After further consideration, we believe that the 
use of these RVU weights is problematic. Use of weights that are 
central to the process at hand presents potential circularity since 
both weights incorporate MP RVUs as part of the computation to 
calculate MP RVUs. The use of different weights for the numerator and 
denominator introduces potential inconsistency. Instead, we believe 
that it would be better to use a different measure that is independent 
of MP RVUs and better represents the reason for weighting. 
Specifically, we are proposing to use area population as a share of 
total U.S. population as the weight. The premium data are for all MP 
premium costs, not just those associated with Medicare patients, so we 
believe that the distribution of the population does a better job of 
capturing the role of each area's premium in the ``national'' premium 
for each specialty than our previous Medicare-specific measure. Use of 
population weights also avoids the potential problems of circularity 
and inconsistency.

[[Page 41703]]

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

C. Potentially Misvalued Services Under the Physician Fee Schedule

1. Background
    Section 1848(c)(2)(B) of the Act directs the Secretary to conduct a 
periodic review, not less often than every 5 years, of the RVUs 
established under the PFS. Section 1848(c)(2)(K) of the Act requires 
the Secretary to periodically identify potentially misvalued services 
using certain criteria and to review and make appropriate adjustments 
to the relative values for those services. Section 1848(c)(2)(L) to the 
Act also requires the Secretary to develop a process to validate the 
RVUs of certain potentially misvalued codes under the PFS, using the 
same criteria used to identify potentially misvalued codes, and to make 
appropriate adjustments.
    As discussed in section I.B. of this proposed rule, each year we 
develop appropriate adjustments to the RVUs taking into account 
recommendations provided by the American Medical Association/Specialty 
Society Relative Value Scale Update Committee (RUC), the Medicare 
Payment Advisory Commission (MedPAC), and others. For many years, the 
RUC has provided us with recommendations on the appropriate relative 
values for new, revised, and potentially misvalued PFS services. We 
review these recommendations on a code-by-code basis and consider these 
recommendations in conjunction with analyses of other data, such as 
claims data, to inform the decision-making process to establish 
relative values for these codes. We may also consider analyses of work 
time, work RVUs, or direct practice expense (PE) inputs using other 
data sources, such as Department of Veteran Affairs (VA), National 
Surgical Quality Improvement Program (NSQIP), the Society for Thoracic 
Surgeons (STS), and the Physician Quality Reporting System (PQRS) 
databases. In addition to considering the most recently available data, 
we also assess the results of physician surveys and specialty 
recommendations submitted to us by the RUC. We also consider 
information provided by other stakeholders. We conduct a review to 
assess the appropriate RVUs in the context of contemporary medical 
practice. We note that section 1848(c)(2)(A)(ii) of the Act authorizes 
the use of extrapolation and other techniques to determine the RVUs for 
physicians' services for which specific data are not available, in 
addition to requiring us to take into account the results of 
consultations with organizations representing physicians who furnish 
the services. In accordance with section 1848(c) of the Act, we 
determine and make appropriate adjustments to the RVUs. We discuss 
these methodologies as applied to particular codes in section I.B. of 
this proposed rule.
    Section 1848(c)(2)(K)(ii) of the Act augments our efforts by 
directing the Secretary to specifically examine, as determined 
appropriate, potentially misvalued services in the following 
categories:
     Codes that have experienced the fastest growth.
     Codes that have experienced substantial changes in 
practice expenses.
     Codes that describe new technologies or services within an 
appropriate time period (such as 3 years) after the relative values are 
initially established for such codes.
     Codes which are multiple codes that are frequently billed 
in conjunction with furnishing a single service.
     Codes with low relative values, particularly those that 
are often billed multiple times for a single treatment.
     Codes that have not been subject to review since 
implementation of the fee schedule.
     Codes that account for the majority of spending under the 
PFS.
     Codes for services that have experienced a substantial 
change in the hospital length of stay or procedure time.
     Codes for which there may be a change in the typical site 
of service since the code was last valued.
     Codes for which there is a significant difference in 
payment for the same service between different sites of service.
     Codes for which there may be anomalies in relative values 
within a family of codes.
     Codes for services where there may be efficiencies when a 
service is furnished at the same time as other services.
     Codes with high intra-service work per unit of time.
     Codes with high practice expense relative value units.
     Codes with high cost supplies.
     Codes as determined appropriate by the Secretary.
    Section 1848(c)(2)(K)(iii) of the Act also specifies that the 
Secretary may use existing processes to receive recommendations on the 
review and appropriate adjustment of potentially misvalued services. In 
addition, the Secretary may conduct surveys, other data collection 
activities, studies, or other analyses, as the Secretary determines to 
be appropriate, to facilitate the review and appropriate adjustment of 
potentially misvalued services. This section also authorizes the use of 
analytic contractors to identify and analyze potentially misvalued 
codes, conduct surveys or collect data, and make recommendations on the 
review and appropriate adjustment of potentially misvalued services. 
Additionally, this section provides that the Secretary may coordinate 
the review and adjustment of any RVU with the periodic review described 
in section 1848(c)(2)(B) of the Act. Section 1848(c)(2)(K)(iii)(V) of 
the Act specifies that the Secretary may make appropriate coding 
revisions (including using existing processes for consideration of 
coding changes) that may include consolidation of individual services 
into bundled codes for payment under the PFS.
2. Progress in Identifying and Reviewing Potentially Misvalued Codes
    To fulfill our statutory mandate, we have identified and reviewed 
numerous potentially misvalued codes as specified in section 
1848(c)(2)(K)(ii) of the Act, and we plan to continue our work 
examining potentially misvalued codes in these areas over the upcoming 
years. As part of our current process, we identify potentially 
misvalued codes for review, and request recommendations from the RUC 
and other public commenters on revised work RVUs and direct PE inputs 
for those codes. The RUC, through its own processes, also identifies 
potentially misvalued codes for review. Through our public nomination 
process for potentially misvalued codes established in the CY 2012 PFS 
final rule with comment period, other individuals and stakeholder 
groups submit nominations for review of potentially misvalued codes as 
well.
    Since CY 2009, as a part of the annual potentially misvalued code 
review and Five-Year Review process, we have reviewed over 1,560 
potentially misvalued codes to refine work RVUs and direct PE inputs. 
We have assigned appropriate work RVUs and direct PE inputs for these 
services as a result of these reviews. A more detailed discussion of 
the extensive prior reviews of potentially misvalued codes is included 
in the CY 2012 PFS final rule with comment period (76 FR 73052

[[Page 41704]]

through 73055). In the CY 2012 final rule with comment period, we 
finalized our policy to consolidate the review of physician work and PE 
at the same time (76 FR 73055 through 73958), and established a process 
for the annual public nomination of potentially misvalued services.
    In the CY 2013 final rule with comment period, we built upon the 
work we began in CY 2009 to review potentially misvalued codes that 
have not been reviewed since the implementation of the PFS (so-called 
``Harvard-valued codes''). In CY 2009, we requested recommendations 
from the RUC to aid in our review of Harvard-valued codes that had not 
yet been reviewed, focusing first on high-volume, low intensity codes 
(73 FR 38589). In the Fourth Five-Year Review, we requested 
recommendations from the RUC to aid in our review of Harvard-valued 
codes with annual utilization of greater than 30,000 (76 FR 32410). In 
the CY 2013 final rule with comment period, we identified as 
potentially misvalued Harvard-valued services with annual allowed 
charges that total at least $10,000,000. In addition to the Harvard-
valued codes, in the CY 2013 final rule with comment period we 
finalized for review a list of potentially misvalued codes that have 
stand-alone PE (codes with physician work and no listed work time, and 
codes with no physician work and listed work time).
    In the CY 2014 final rule with comment period, we finalized for 
review a list of potentially misvalued services. We included on the 
list for review ultrasound guidance codes that had longer procedure 
times than the typical procedure with which the code is billed to 
Medicare. We also finalized our proposal to replace missing post-
operative hospital E/M visit information and work time for 
approximately 100 global surgery codes. In CY 2014, we also considered 
a proposal to limit Medicare PFS payments for services furnished in a 
non-facility setting when the PFS payment would exceed the combined 
Medicare payment made to the practitioner under the PFS and facility 
payment made to either the ASC or hospital outpatient. Based upon 
extensive public comment we did not finalize this proposal.
    In the CY 2015 final rule with comment period, we finalized a list 
of potentially misvalued services. The potentially misvalued codes list 
included the publicly nominated CPT code 41530; two neurostimulator 
implantation codes, CPT 64553 and 64555; four epidural injection codes, 
CPT 62310, 62311, 62318 and 62319; three breast mammography codes, CPT 
77055, 77056 and 77057; an abdominal aortic aneurysm ultrasound 
screening code, HCPCS G0389; a prostate biopsy code, G0416; and an 
obesity behavioral group counseling code, HCPCS G0473. We also 
finalized our ``high expenditure services across specialty'' screen as 
a tool to identify potentially misvalued codes though we did not 
finalize the particular list of codes identified in that rule as 
potentially misvalued. In CY 2015, we also considered and finalized a 
proposal addressing the valuation and coding of global surgical 
packages, which would revalue and transition 10 and 90-day global codes 
to 0-day codes. We also sought comment on approaches to revalue 
services that included moderate sedation as an inherent part of 
furnishing the procedure.
3. Validating RVUs of Potentially Misvalued Codes
    Section 1848(c)(2)(L) of the Act requires the Secretary to 
establish a formal process to validate RVUs under the PFS. The Act 
specifies that the validation process may include validation of work 
elements (such as time, mental effort and professional judgment, 
technical skill and physical effort, and stress due to risk) involved 
with furnishing a service and may include validation of the pre-, post-
, and intra-service components of work. The Secretary is directed, as 
part of the validation, to validate a sampling of the work RVUs of 
codes identified through any of the 16 categories of potentially 
misvalued codes specified in section 1848(c)(2)(K)(ii) of the Act. 
Furthermore, the Secretary may conduct the validation using methods 
similar to those used to review potentially misvalued codes, including 
conducting surveys, other data collection activities, studies, or other 
analyses as the Secretary determines to be appropriate to facilitate 
the validation of RVUs of services.
    In the CY 2011 PFS proposed rule (75 FR 40068) and CY 2012 PFS 
proposed rule (76 FR 42790), we solicited public comments on possible 
approaches, methodologies, and data sources that we should consider for 
a validation process. A summary of the comments along with our 
responses is included in the CY 2011 PFS final rule with comment period 
(75 FR 73217) and the CY 2012 PFS final rule with comment period (73054 
through 73055).
    We contracted with two outside entities to develop validation 
models for RVUs. Given the central role of time in establishing work 
RVUs and the concerns that have been raised about the current time 
values used in rate setting, we contracted with the Urban Institute to 
collect time data from several practices for services selected by the 
contractor in consultation with CMS. Urban Institute has used a variety 
of approaches to develop objective time estimates, depending on the 
type of service. Objective time estimates will be compared to the 
current time values used in the fee schedule. The project team will 
then convene groups of physicians from a range of specialties to review 
the new time data and the potential implications for work and the ratio 
of work to time. Urban Institute has prepared an interim report, 
``Development of a Model for the Valuation of Work Relative Value 
Units,'' which discusses the challenges encountered in collecting 
objective time data and offers some thoughts on how these can be 
overcome. This interim report is posted on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/RVUs-Validation-UrbanInterimReport.pdf. A 
final report will be available once the project is complete.
    The second contract is with the RAND Corporation, which is using 
available data to build a validation model to predict work RVUs and the 
individual components of work RVUs, time and intensity. The model 
design was informed by the statistical methodologies and approach used 
to develop the initial work RVUs and to identify potentially misvalued 
procedures under current CMS and RUC processes. RAND consulted with a 
technical expert panel on model design issues and the test results. The 
RAND report is available on the CMS Web site under downloads for the CY 
2015 PFS Final Rule with Comment Period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html.
4. CY 2016 Identification of Potentially Misvalued Services for Review
a. Public Nomination of Potentially Misvalued Codes
    In the CY 2012 PFS final rule with comment period, we finalized a 
process for the public to nominate potentially misvalued codes (76 FR 
73058). The public and stakeholders may nominate potentially misvalued 
codes for review by submitting the code with supporting documentation 
during the 60-day public comment period following the release of the 
annual PFS final rule with comment period. Supporting documentation for 
codes nominated for the annual review of potentially misvalued codes 
may

[[Page 41705]]

include, but are not limited to, the following:
     Documentation in the peer reviewed medical literature or 
other reliable data that there have been changes in physician work due 
to one or more of the following: technique; knowledge and technology; 
patient population; site-of-service; length of hospital stay; and work 
time.
     An anomalous relationship between the code being proposed 
for review and other codes.
     Evidence that technology has changed physician work, that 
is, diffusion of technology.
     Analysis of other data on time and effort measures, such 
as operating room logs or national and other representative databases.
     Evidence that incorrect assumptions were made in the 
previous valuation of the service, such as a misleading vignette, 
survey, or flawed crosswalk assumptions in a previous evaluation.
     Prices for certain high cost supplies or other direct PE 
inputs that are used to determine PE RVUs are inaccurate and do not 
reflect current information.
     Analyses of work time, work RVU, or direct PE inputs using 
other data sources (for example, Department of Veteran Affairs (VA) 
National Surgical Quality Improvement Program (NSQIP), the Society for 
Thoracic Surgeons (STS) National Database, and the Physician Quality 
Reporting System (PQRS) databases).
     National surveys of work time and intensity from 
professional and management societies and organizations, such as 
hospital associations.
    After we receive the nominated codes during the 60-day comment 
period following the release of the annual PFS final rule with comment 
period, we evaluate the supporting documentation and assess whether the 
nominated codes appear to be potentially misvalued codes appropriate 
for review under the annual process. In the following year's PFS 
proposed rule, we publish the list of nominated codes and indicate 
whether we are proposing each nominated code as a potentially misvalued 
code.
    During the comment period on the CY 2015 proposed rule and final 
rule with comment period, we received nominations and supporting 
documentation for three codes to be considered as potentially misvalued 
codes. We evaluated the supporting documentation for each nominated 
code to ascertain whether the submitted information demonstrated that 
the code should be proposed as potentially misvalued.
    CPT Code 36516 (Therapeutic apheresis; with extracorporeal 
selective adsorption or selective filtration and plasma reinfusion) was 
nominated for review as potentially misvalued. The nominator stated 
that CPT code 36516 is misvalued because of incorrect direct and 
indirect PE inputs and an incorrect work RVU. Specifically, the 
nominator stated that the direct supply costs failed to include an $18 
disposable bag and the $37 cost for biohazard waste disposal of the 
post-treatment bag, and the labor costs associated with nursing being 
inaccurate. The nominator also stated that the overhead expenses 
associated with this service were unrealistic and that the current work 
RVU undervalues a physician's time and expertise. We are proposing this 
code as a potentially misvalued code. We note that we established a 
policy in CY 2011 to consider biohazard bags as an indirect expense, 
and not as a direct PE input (75 FR 73192).
    CPT Codes 52441 (Cystourethroscopy with insertion of permanent 
adjustable transprostatic implant; single implant) and 52442 
(Cystourethroscopy with insertion of permanent adjustable 
transprostatic implant; each additional permanent adjustable 
transprostatic implant) were nominated for review as potentially 
misvalued. The nominator stated that the costs of the direct practice 
expense inputs were inaccurate, including the cost of the implant. We 
are proposing these codes as potentially misvalued codes.
b. Electronic Analysis of Implanted Neurostimulator (CPT Codes 95970-
95982)
    All of the inputs for CPT codes 95971 (Electronic analysis of 
implanted neurostimulator pulse generator system (eg, rate, pulse 
amplitude, pulse duration, configuration of wave form, battery status, 
electrode selectability, output modulation, cycling, impedance and 
patient compliance measurements); simple spinal cord, or peripheral 
(ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator 
pulse generator/transmitter, with intraoperative or subsequent 
programming), 95972 (Electronic analysis of implanted neurostimulator 
pulse generator system (eg, rate, pulse amplitude, pulse duration, 
configuration of wave form, battery status, electrode selectability, 
output modulation, cycling, impedance and patient compliance 
measurements); complex spinal cord, or peripheral (ie, peripheral 
nerve, sacral nerve, neuromuscular) (except cranial nerve) 
neurostimulator pulse generator/transmitter, with intraoperative or 
subsequent programming, up to one hour) and 95973 (Electronic analysis 
of implanted neurostimulator pulse generator system (eg, rate, pulse 
amplitude, pulse duration, configuration of wave form, battery status, 
electrode selectability, output modulation, cycling, impedance and 
patient compliance measurements); complex spinal cord, or peripheral 
(ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial 
nerve) neurostimulator pulse generator/transmitter, with intraoperative 
or subsequent programming, each additional 30 minutes after first hour 
(List separately in addition to code for primary procedure)) were 
reviewed and valued in the CY 2015 final rule with comment period (79 
FR 67670). Due to significant time changes in the base codes, we 
believe the entire family detailed in Table 7 should be considered as 
potentially misvalued and reviewed in a manner consistent with our 
review of CPT codes 95971, 95972 and 95973.

     Table 7--Proposed Potentially Misvalued Codes Identified in the
         Electronic Analysis of Implanted Neurostimulator Family
------------------------------------------------------------------------
             HCPCS                          Short descriptor
------------------------------------------------------------------------
95970.........................  Analyze neurostim no prog.
95974.........................  Cranial neurostim complex.
95975.........................  Cranial neurostim complex.
95978.........................  Analyze neurostim brain/1h.
95979.........................  Analyz neurostim brain addon.
95980.........................  Io anal gast n-stim init.
95981.........................  Io anal gast n-stim subsq.
95982.........................  Io ga n-stim subsq w/reprog.
------------------------------------------------------------------------

c. Review of High Expenditure Services across Specialties with Medicare 
Allowed Charges of $10,000,000 or More
    In the CY 2015 PFS rule, we proposed and finalized the high 
expenditure screen as a tool to identify potentially misvalued codes in 
the statutory category of ``codes that account for the majority of 
spending under the PFS.'' We also identified codes through this screen 
and proposed them as potentially misvalued in the CY 2015 PFS proposed 
rule (79 FR 40337-40338). However, given the resources required for the 
revaluation of codes with 10- and 90-day global periods, we did not 
finalize those codes as potentially misvalued codes in the CY 2015 PFS 
final rule with comment period. We stated that we would re-run the high 
expenditure screen at a future date, and subsequently propose the 
specific set of

[[Page 41706]]

codes that meet the high expenditure criteria as potentially misvalued 
codes (79 FR 67578).
    We believe that our current resources will not necessitate further 
delay in proceeding with the high expenditure screen for CY 2016. We 
have re-run the screen with the same criteria finalized in last year's 
rule. However, in developing this year's proposed list, we excluded all 
codes with 10- and 90-day global periods since we believe these codes 
should be reviewed as part of the global surgery revaluation. We are 
proposing the 118 codes listed in Table 8 as potentially misvalued 
codes, identified using the high expenditure screen under the statutory 
category, ``codes that account for the majority of spending under the 
PFS.''
    To develop this list, we followed the same approach taken last year 
except we excluded 10 and 90- day global periods. Specifically, we 
identified the top 20 codes by specialty (using the specialties used in 
Table 45) in terms of allowed charges. As we did last year, we excluded 
codes that we have reviewed since CY 2010, those with fewer than $10 
million in allowed charges, and those that describe anesthesia or E/M 
services. We excluded E/M services from the list of proposed 
potentially misvalued codes for the same reasons that we excluded them 
in a similar review in CY 2012. These reasons were explained in the CY 
2012 final rule with comment period (76 FR 73062 through 73065).

  Table 8--Proposed Potentially Misvalued Codes Identified Through High
                     Expenditure by Specialty Screen
------------------------------------------------------------------------
             HCPCS                          Short descriptor
------------------------------------------------------------------------
10022.........................  Fna w/image
11100.........................  Biopsy skin lesion
11101.........................  Biopsy skin add-on
11730.........................  Removal of nail plate
20550.........................  Inj tendon sheath/ligament
20552.........................  Inj trigger point 1/2 muscl
20553.........................  Inject trigger points 3/>
22614.........................  Spine fusion extra segment
22840.........................  Insert spine fixation device
22842.........................  Insert spine fixation device
22845.........................  Insert spine fixation device
27370.........................  Injection for knee x-ray
29580.........................  Application of paste boot
31500.........................  Insert emergency airway
31575.........................  Diagnostic laryngoscopy
31579.........................  Diagnostic laryngoscopy
31600.........................  Incision of windpipe
33518.........................  Cabg artery-vein two
36215.........................  Place catheter in artery
36556.........................  Insert non-tunnel cv cath
36569.........................  Insert picc cath
36620.........................  Insertion catheter artery
38221.........................  Bone marrow biopsy
51700.........................  Irrigation of bladder
51702.........................  Insert temp bladder cath
51720.........................  Treatment of bladder lesion
51728.........................  Cystometrogram w/vp
51729.........................  Cystometrogram w/vp&up
51784.........................  Anal/urinary muscle study
51797.........................  Intraabdominal pressure test
51798.........................  Us urine capacity measure
52000.........................  Cystoscopy
55700.........................  Biopsy of prostate
58558.........................  Hysteroscopy biopsy
67820.........................  Revise eyelashes
70491.........................  Ct soft tissue neck w/dye
70543.........................  Mri orbt/fac/nck w/o &w/dye
70544.........................  Mr angiography head w/o dye
70549.........................  Mr angiograph neck w/o&w/dye
71010.........................  Chest x-ray 1 view frontal
71020.........................  Chest x-ray 2vw frontal&latl
71260.........................  Ct thorax w/dye
71270.........................  Ct thorax w/o & w/dye
72195.........................  Mri pelvis w/o dye
72197.........................  Mri pelvis w/o & w/dye
73110.........................  X-ray exam of wrist
73130.........................  X-ray exam of hand
73718.........................  Mri lower extremity w/o dye
73720.........................  Mri lwr extremity w/o&w/dye
74000.........................  X-ray exam of abdomen
74022.........................  X-ray exam series abdomen
74181.........................  Mri abdomen w/o dye
74183.........................  Mri abdomen w/o & w/dye
75635.........................  Ct angio abdominal arteries
75710.........................  Artery x-rays arm/leg
75978.........................  Repair venous blockage
76512.........................  Ophth us b w/non-quant a
76519.........................  Echo exam of eye
76536.........................  Us exam of head and neck
77059.........................  Mri both breasts
77263.........................  Radiation therapy planning
77334.........................  Radiation treatment aid(s)
77470.........................  Special radiation treatment
78306.........................  Bone imaging whole body
78452.........................  Ht muscle image spect mult
88185.........................  Flowcytometry/tc add-on
88189.........................  Flowcytometry/read 16 & >
88321.........................  Microslide consultation
88360.........................  Tumor immunohistochem/manual
88361.........................  Tumor immunohistochem/comput
91110.........................  Gi tract capsule endoscopy
92002.........................  Eye exam new patient
92136.........................  Ophthalmic biometry
92240.........................  Icg angiography
92250.........................  Eye exam with photos
92275.........................  Electroretinography
92557.........................  Comprehensive hearing test
92567.........................  Tympanometry
93280.........................  Pm device progr eval dual
93288.........................  Pm device eval in person
93293.........................  Pm phone r-strip device eval
93294.........................  Pm device interrogate remote
93295.........................  Dev interrog remote 1/2/mlt
93296.........................  Pm/icd remote tech serv
93306.........................  Tte w/doppler complete
93350.........................  Stress tte only
93351.........................  Stress tte complete
93503.........................  Insert/place heart catheter
93613.........................  Electrophys map 3d add-on
93965.........................  Extremity study
94010.........................  Breathing capacity test
94620.........................  Pulmonary stress test/simple
95004.........................  Percut allergy skin tests
95165.........................  Antigen therapy services
95957.........................  Eeg digital analysis
96101.........................  Psycho testing by psych/phys
96116.........................  Neurobehavioral status exam
96118.........................  Neuropsych tst by psych/phys
96360.........................  Hydration iv infusion init
96372.........................  Ther/proph/diag inj sc/im
96374.........................  Ther/proph/diag inj iv push
96375.........................  Tx/pro/dx inj new drug addon
96401.........................  Chemo anti-neopl sq/im
96402.........................  Chemo hormon antineopl sq/im
96409.........................  Chemo iv push sngl drug
96411.........................  Chemo iv push addl drug
96567.........................  Photodynamic tx skin
96910.........................  Photochemotherapy with uv-b
97032.........................  Electrical stimulation
97035.........................  Ultrasound therapy
97110.........................  Therapeutic exercises
97112.........................  Neuromuscular reeducation
97113.........................  Aquatic therapy/exercises
97116.........................  Gait training therapy
97140.........................  Manual therapy 1/regions
97530.........................  Therapeutic activities
97535.........................  Self care mngment training
G0283.........................  Elec stim other than wound
------------------------------------------------------------------------

5. Valuing Services That Include Moderate Sedation as an Inherent Part 
of Furnishing the Procedure
    The CPT manual includes more than 400 diagnostic and therapeutic 
procedures, listed in Appendix G, for which CPT has determined that 
moderate sedation is an inherent part of furnishing the procedure. 
Therefore, only the procedure code is reported when furnishing the 
service, and in developing RVUs for these services, we include the 
resource costs associated with moderate sedation in the valuation of 
these diagnostic and therapeutic procedures. To the extent that 
moderate sedation is inherent in the diagnostic or therapeutic service, 
we believe that the inclusion of moderate sedation in the valuation of 
the procedure is accurate. In the CY 2015 PFS proposed rule (79 FR 
40349), we noted that it appeared that practice patterns for endoscopic 
procedures were changing, with anesthesia increasingly being separately 
reported for these procedures. Due to the changing nature of medical 
practice, we noted that we were considering establishing a uniform 
approach to valuation for all Appendix G services. We continue to seek 
an approach that is based on using the best available objective 
information about the provision of moderate sedation broadly, rather 
than merely addressing this issue on a code-by-code basis using RUC 
survey data when individual procedures

[[Page 41707]]

are revalued. We sought public comment on approaches to address the 
appropriate valuation of these services given that moderate sedation is 
no longer inherent for many of these services. To the extent that 
Appendix G procedure values are adjusted to no longer include moderate 
sedation, we requested suggestions as to how moderate sedation should 
be reported and valued, and how to remove from existing valuations the 
RVUs and inputs related to moderate sedation.
    To establish an approach to valuation for all Appendix G services 
based on the best data about the provision of moderate sedation, we 
need to determine the extent of the misvaluation for each code. We know 
that there are standard packages for the direct PE inputs associated 
with moderate sedation, and we began to develop approaches to estimate 
how much of the work is attributable to moderate sedation. However, we 
believe that we should seek input from the medical community prior to 
proposing changes in values for these services, given the different 
methodologies used to develop work RVUs for the hundreds of services in 
Appendix G. Therefore, we are seeking recommendations from the RUC and 
other interested stakeholders for appropriate valuation of the work 
associated with moderate sedation before formally proposing an approach 
that allows Medicare to adjust payments based on the resource costs 
associated with the moderate sedation or anesthesia services that are 
being furnished.
    The anesthesia procedure codes 00740 (Anesthesia for procedure on 
gastrointestinal tract using an endoscope) and 00810 (Anesthesia for 
procedure on lower intestine using an endoscope) are used for 
anesthesia furnished in conjunction with lower GI procedures. In 
reviewing Medicare claims data, we noted that a separate anesthesia 
service is now reported more than 50 percent of the time that several 
types of colonoscopy procedures are reported. Given the significant 
change in the relative frequency with which anesthesia codes are 
reported with colonoscopy services, we believe the relative values of 
the anesthesia services should be re-examined. Therefore, we are 
proposing to identify CPT codes 00740 and 00810 as potentially 
misvalued. We welcome comments on both of these issues.
6. Improving the Valuation and Coding of the Global Package
a. Proposed Transition of 10-Day and 90-Day Global Packages Into 0-Day 
Global Packages
    In the CY 2015 PFS final rule (79 FR 67582 through 67591) we 
finalized a policy to transition all 10-day and 90-day global codes to 
0-day global codes to improve the accuracy of valuation and payment for 
the various components of global surgical packages, including pre- and 
post-operative visits and performance of the surgical procedure. 
Although we have marginally addressed some of the concerns noted with 
global packages in previous rulemaking, we believe there is still an 
unmet need to address some of the fundamental issues with the 10- and 
90-day post-operative global packages. We believe it is critical that 
the RVUs used to develop PFS payment rates reflect the most accurate 
resource costs associated with PFS services. We believe that valuing 
global codes that package services together without objective, 
auditable data on the resource costs associated with the components of 
the services contained in the packages may significantly skew 
relativity and create unwarranted payment disparities within PFS fee-
for-service payment. We also believe that the resource based valuation 
of individual physicians' services will continue to serve as a critical 
foundation for Medicare payment to physicians. Therefore, we believe it 
is critical that the RVUs under the PFS be based as closely and 
accurately as possible on the actual resources involved in furnishing 
the typical occurrence of specific services.
    We stated our belief that transforming all 10- and 90-day global 
codes to 0-day global codes would:
     Increase the accuracy of PFS payment by setting payment 
rates for individual services based more closely upon the typical 
resources used in furnishing the procedures;
     Avoid potentially duplicative or unwarranted payments when 
a beneficiary receives post-operative care from a different 
practitioner during the global period;
     Eliminate disparities between the payment for E/M services 
in global periods and those furnished individually;
     Maintain the same-day packaging of pre- and post-operative 
physicians' services in the 0-day global; and
     Facilitate availability of more accurate data for new 
payment models and quality research.
b. Impact of the Medicare Access and CHIP Reauthorization Act of 2015
    The Medicare Access and CHIP Reauthorization Act (MACRA) was 
enacted into law on April 16, 2015. Section 523 of the MACRA addresses 
payment for global surgical packages. Section 523(a) adds a new 
paragraph at section 1848(c)(8) of the Act. Section 1848(c)(8)(A)(i) of 
the Act prohibits the Secretary from implementing the policy 
established in the CY 2015 PFS final rule with comment period that 
would have transitioned all 10-day and 90-day global surgery packages 
to 0-day global periods. Section 1848(c)(8)(A)(ii) of the Act provides 
that nothing in the previous clause shall be construed to prevent the 
Secretary from revaluing misvalued codes for specific surgical services 
or assigning values to new or revised codes for surgical services.
    Section 1848(c)(8)(B)(i) of the Act requires CMS to develop through 
rulemaking a process to gather information needed to value surgical 
services from a representative sample of physicians, and requires that 
the data collection shall begin no later than January 1, 2017. The 
collected information must include the number and level of medical 
visits furnished during the global period and other items and services 
related to the surgery, as appropriate. This information must be 
reported on claims at the end of the global period or in another manner 
specified by the Secretary. Section 1848(c)(8)(B)(ii) of the Act 
requires that, every 4 years, we must reassess the value of this 
collected information, and allows us to discontinue the collection if 
the Secretary determines that we have adequate information from other 
sources in order to accurately value global surgical services. Section 
1848(c)(8)(B)(iii) of the Act specifies that the Inspector General will 
audit a sample of the collected information to verify its accuracy. 
Section 1848(c)(8)(C) of the Act requires that, beginning in CY 2019, 
we must use the information collected as appropriate, along with other 
available data, to improve the accuracy of valuation of surgical 
services under the PFS. Section 523(b) of the MACRA adds a new 
paragraph at section 1848(c)(9) of the Act which authorizes the 
Secretary, through rulemaking, to delay up to 5 percent of the PFS 
payment for services for which a physician is required to report 
information under section 1848(c)(8)(B)(i) of the Act until the 
required information is reported.
    Since section 1848(c)(8)(B)(i) of the Act, as added by section 
523(a) of the MACRA, requires us to use rulemaking

[[Page 41708]]

to develop and implement the process to gather information needed to 
value surgical services no later than January 1, 2017, we are seeking 
input from stakeholders on various aspects of this task. We are 
soliciting comments from the public regarding the kinds of auditable, 
objective data (including the number and type of visits and other 
services furnished by the practitioner reporting the procedure code 
during the current post-operative periods) needed to increase the 
accuracy of the values for surgical services. We are also seeking 
comment on the most efficient means of acquiring these data as 
accurately and efficiently as possible. For example, we seek 
information on the extent to which individual practitioners or 
practices may currently maintain their own data on services, including 
those furnished during the post-operative period, and how we might 
collect and objectively evaluate those data for use in increasing the 
accuracy of the values beginning in CY 2019. We will use the 
information from the public comments to help develop a proposed 
approach for the collection of this information in future rulemaking.
    Section 1848(c)(8)(C) of the Act mandates that we use the collected 
data to improve the accuracy of valuation of surgery services beginning 
in 2019. We described in previous rulemaking (79 FR 67582 through 
67591) the limitations and difficulties involved in the appropriate 
valuation of the global packages, especially when the values of the 
component services are not clear. We are seeking public comment on 
potential methods of valuing the individual components of the global 
surgical package, including the procedure itself, and the pre- and 
post-operative care, including the follow-up care during post-operative 
days. We are particularly interested in stakeholder input regarding the 
overall accuracy of the values and descriptions of the component 
services within the global packages. For example, we seek information 
from stakeholders on whether (both qualitatively and quantitatively) 
postoperative visits differ from other E/M services. We are also 
interested in stakeholder input on what other items and services 
related to the surgery, aside from postoperative visits, are furnished 
to beneficiaries during post-operative care. We believe that 
stakeholder input regarding these questions will help determine what 
data should be collected, as well as how to improve the accuracy of the 
valuations. We welcome the full range of public feedback from 
stakeholders to assist us in this process.
    We intend to provide further opportunities for public feedback 
prior to developing a proposal for CY 2017 to collect this required 
data. We also seek comments regarding stakeholder interest in the 
potential for an open door forum, town hall meetings with the public, 
or other avenues for direct communication regarding implementation of 
these provisions of the Act.

D. Refinement Panel

1. Background
    As discussed in the CY 1993 PFS final rule with comment period (57 
FR 55938), we adopted a refinement panel process to assist us in 
reviewing the public comments on CPT codes with interim final work RVUs 
for a year and in developing final work values for the subsequent year. 
We decided the panel would be composed of a multispecialty group of 
physicians who would review and discuss the work involved in each 
procedure under review, and then each panel member would individually 
rate the work of the procedure. We believed establishing the panel with 
a multispecialty group would balance the interests of the specialty 
societies who commented on the work RVUs with the budgetary and 
redistributive effects that could occur if we accepted extensive 
increases in work RVUs across a broad range of services.
    Following enactment of section 1848(c)(2)(K) of the Act, which 
required the Secretary periodically to identify and review potentially 
misvalued codes and make appropriate adjustments to the RVUs, we 
reassessed the refinement panel process. As detailed in the CY 2011 PFS 
final rule with comment period (75 FR 73306), we continued using the 
established refinement panel process with some modifications.
    For CY 2015, in light of the changes we made to the process for 
valuing new, revised and potentially misvalued codes (79 FR 67606), we 
reassessed the role that the refinement panel process plays in the code 
valuation process. We noted that the current refinement panel process 
is tied to the review of interim final values. It provides an 
opportunity for stakeholders to provide new clinical information that 
was not available at the time of the RUC valuation that might affect 
work RVU values that are adopted in the interim final value process. 
For CY 2015 interim final rates, we stated in the CY 2015 PFS final 
rule with comment period that we will use the refinement panel process 
as usual for these codes (79 FR 67609).
2. CY 2016 Refinement Panel Proposal
    Beginning in CY 2016, we are proposing to permanently eliminate the 
refinement panel and instead publish the proposed rates for all interim 
final codes in the PFS proposed rule for the subsequent year. For 
example, we will publish the proposed rates for all CY 2016 interim 
final codes in the CY 2017 PFS proposed rule. With the change in the 
process for valuing codes adopted in the CY 2015 final rule with 
comment period (79 FR 67606), proposed values for most codes that are 
being valued for CY 2016 will be published in the CY 2016 PFS proposed 
rule. As explained in the CY 2015 final rule with comment period, only 
a small number of codes being valued for CY 2016 will be published as 
interim final in the 2016 PFS final rule with comment period and be 
subject to comment. We will evaluate the comments we receive on these 
code values, and both respond to these comments and propose values for 
these codes for CY 2017 in the CY 2017 PFS proposed rule. Therefore, 
stakeholders will have two opportunities to comment and to provide any 
new clinical information that was not available at the time of the RUC 
valuation that might affect work RVU values that are adopted on an 
interim final basis. We believe that this proposed process, which 
includes two opportunities for public notice and comment, offers 
stakeholders a better mechanism and ample opportunity for providing any 
additional data for our consideration, and discussing any concerns with 
our interim final values, than the current refinement process. It also 
provides greater transparency because comments on our rules are made 
available to the public at www.regulations.gov. We welcome comments on 
this proposed change to eliminate the use of refinement panels in our 
process for establishing final values for interim final codes.

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

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

[[Page 41709]]

    In addition to the Medicare Shared Savings Program, various 
demonstration initiatives including the Pioneer Accountable Care 
Organization (ACO), the patient-centered medical home model in the 
Multi-payer Advanced Primary Care Practice (MAPCP), the Federally 
Qualified Health Center (FQHC) Advanced Primary Care Practice 
demonstration, the Comprehensive Primary Care (CPC) initiative, among 
others (see the CY 2015 PFS final rule (79 FR 67715) for a discussion 
of these), we also have continued to explore potential refinements to 
the PFS that would appropriately value care management within 
Medicare's statutory structure for fee-for-service physician payment 
and quality reporting. The payment for some non-face-to-face care 
management services is bundled into the payment for face-to-face 
evaluation and management (E/M) visits. However, because the current E/
M office/outpatient visit CPT codes were designed with an overall 
orientation toward episodic treatment, we have recognized that these E/
M codes may not reflect all the services and resources involved with 
furnishing certain kinds of care, particularly comprehensive, 
coordinated care management for certain categories of beneficiaries.
    Over several years, we have developed proposals and sought 
stakeholder input regarding potential PFS refinements to improve the 
accuracy of payment for care management services. For example, in the 
CY 2013 PFS final rule with comment period, we adopted a policy to pay 
separately for transitional care management (TCM) involving the 
transition of a beneficiary from care furnished by a treating physician 
during an inpatient stay to care furnished by the beneficiary's primary 
physician in the community (77 FR 68978 through 68993). In the CY 2014 
PFS final rule with comment period, we finalized a policy, beginning in 
CY 2015 (78 FR 74414), to pay separately for chronic care management 
(CCM) services furnished to Medicare beneficiaries with two or more 
chronic conditions. We believe that these new separately billable codes 
more accurately describe, recognize, and make payment for non-face-to-
face care management services furnished by practitioners and clinical 
staff to particular patient populations.
    We view ongoing refinements to payment for care management services 
as part of a broader strategy to incorporate input and information 
gathered from research, initiatives, and demonstrations conducted by 
CMS and other public and private stakeholders, the work of all parties 
involved in the potentially misvalued code initiative, and, more 
generally, from the public at large. Based on input and information 
gathered from these sources, we are considering several potential 
refinements that would continue our efforts to improve the accuracy of 
PFS payments. In this section, we discuss these potential refinements.
1. Improved Payment for the Professional Work of Care Management 
Services
    Although both the TCM and CCM services describe certain aspects of 
professional work, some stakeholders have suggested that neither of 
these new sets of codes nor the inputs used in their valuations 
explicitly account for all of the services and resources associated 
with the more extensive cognitive work that primary care physicians and 
other practitioners perform in planning and thinking critically about 
the individual chronic care needs of particular subsets of Medicare 
beneficiaries. Stakeholders assert that the time and intensity of the 
cognitive efforts are in addition to the work typically required to 
supervise and manage the clinical staff associated with the current TCM 
and CCM codes. Similarly, we continue to receive requests from a few 
stakeholders for CMS to lead efforts to revise the current CPT E/M 
codes or construct a new set of E/M codes. The goal of such efforts 
would be to better describe and value the physician work (time and 
intensity) specific to primary care and other cognitive specialties in 
the context of complex care of patients relative to the time and 
intensity of the procedure-oriented care physicians and practitioners, 
who use the same codes to report E/M services. Some of these 
stakeholders have suggested that in current medical practice, many 
physicians, in addition to the time spent treating acute illnesses, 
spend substantial time working toward optimal outcomes for patients 
with chronic conditions and patients they treat episodically, which can 
involve additional work not reflected in the codes that describe E/M 
services since that work is not typical across the wide range of 
practitioners that report the same codes. According to these groups, 
this work involves medication reconciliation, the assessment and 
integration of numerous data points, effective coordination of care 
among multiple other clinicians, collaboration with team members, 
continuous development and modification of care plans, patient or 
caregiver education, and the communication of test results.
    We agree with stakeholders that it is important for Medicare to use 
codes that accurately describe the services furnished to Medicare 
beneficiaries and to accurately reflect the relative resources involved 
with furnishing those services. Therefore, we are interested in 
receiving public comments on ways to recognize the different resources 
(particularly in cognitive work) involved in delivering broad-based, 
ongoing treatment, beyond those resources already incorporated in the 
codes that describe the broader range of E/M services. The resource 
costs of this work may include the time and intensity related to the 
management of both long-term and, in some cases, episodic conditions. 
In order to appropriately recognize the different resource costs for 
this additional cognitive work within the structure of PFS resource-
based payments, we are particularly interested in codes that could be 
used in addition to, not instead of, the current E/M codes.
    In principle, these codes could be similar to the hundreds of 
existing add-on codes that describe additional resource costs, such as 
additional blocks or slides in pathology services, additional units of 
repair in dermatologic procedures, or additional complexity in 
psychotherapy services. For example, these codes might allow for the 
reporting of the additional time and intensity of the cognitive work 
often undertaken by primary care and other cognitive specialties in 
conjunction with an evaluation and management service, much like add-on 
codes for certain procedures or diagnostic test describe the additional 
resources sometimes involved in furnishing those services. Similar to 
the CCM code, the codes might describe the increased resources used 
over a longer period of time than during one patient visit. For 
example, the add-on codes could describe the professional time in 
excess of 30 minutes and/or a certain set of furnished services, per 
one calendar month for a single patient to coordinate care, provide 
patient or caregiver education, reconcile and manage medications, 
assess and integrate data, or develop and modify care plans. Such 
activity may be particularly relevant for the care of patients with 
multiple or complicated chronic or acute conditions and should 
contribute to optimal patient outcomes, including more coordinated, 
safer care.
    Like CCM, we would require that the patient have an established 
relationship with the billing professional; and additionally, the use 
of an add-on code would require the extended professional resources to 
be reported with another

[[Page 41710]]

separately payable service. However, in contrast to the CCM code, the 
new codes might be reported based on the resources involved in 
professional work, instead of the resource costs in terms of clinical 
staff time. The codes might also apply broadly to patients in a number 
of different circumstances, and would not necessarily make reporting 
the code(s) contingent on particular business models or technologies 
for medical practices. We are interested in stakeholder comments on the 
kinds of services that involve the type of cognitive work described 
above and whether or not the creation of particular codes might improve 
the accuracy of the relative values used for such services on the PFS. 
Finally, we are interested in receiving information from stakeholders 
on the overlap between the kinds of cognitive resource costs discussed 
above and those already accounted for through the currently payable 
codes that describe CCM and other care management services.
    We strongly encourage stakeholders to comment on this topic in 
order to assist us in developing potential proposals to address these 
issues through rulemaking in CY 2016 for implementation in CY 2017. We 
anticipate using this approach, which would parallel our multi-year 
approach for implementing CCM and TCM services, in order to facilitate 
broader input from stakeholders regarding details of implementing such 
codes, including their structure and description, valuation, and any 
requirements for reporting.
2. Establishing Separate Payment for Collaborative Care
    We believe that the care and management for Medicare beneficiaries 
with multiple chronic conditions, a particularly complicated disease or 
acute condition, or common behavioral health conditions often requires 
extensive discussion, information-sharing and planning between a 
primary care physician and a specialist (for example, with a 
neurologist for a patient with Alzheimer's disease plus other chronic 
diseases). We note that for CY 2014, CPT created four codes that 
describe interprofessional telephone/internet consultative services 
(CPT codes 99446-99449). Because Medicare pays for telephone 
consultations with or about a beneficiary as a part of other services 
furnished to the beneficiary, we currently do not make separate payment 
for these services. We note that such interprofessional consultative 
services are distinct from the face-to-face visits previously reported 
to Medicare using the consultation codes, and we refer the reader to 
the CY 2010 PFS final rule for information regarding Medicare payment 
policies for those services (74 FR 61767).
    However, in considering how to improve the accuracy of our payments 
for care coordination particularly for patients requiring more 
extensive care, we are seeking comment on how Medicare might accurately 
account for the resource costs of a more robust interprofessional 
consultation within the current structure of PFS payment. For example, 
we would be interested in stakeholders' perspectives regarding whether 
there are conditions under which it might be appropriate to make 
separate payment for services like those described by these CPT codes. 
We are interested in stakeholder input regarding the parameters of, and 
resources involved in these collaborations between a specialist and 
primary care practitioner, especially in the context of the structure 
and valuation of current E/M services. In particular, we are interested 
in comments about how these collaborations could be distinguished from 
the kind of services included in other E/M services, how these services 
could be described if stakeholders believe the current CPT codes are 
not adequate, and how these services should be valued on the PFS. We 
are also interested in comments on whether we should tie those 
interprofessional consultations to a beneficiary encounter and on 
developing appropriate beneficiary protections to ensure that 
beneficiaries are fully aware of the involvement of the specialist in 
the beneficiary's care and the associated benefits of the collaboration 
between the primary care physician and the specialist physician prior 
to being billed for such services.
    Additionally, we are seeking comment on whether this kind of care 
might benefit from inclusion in a CMMI model that would allow Medicare 
to test its effectiveness with a waiver of beneficiary financial 
liability and/or variation of payment amounts for the consulting and 
the primary care practitioners. Without such protections, beneficiaries 
could be responsible for coinsurance for services of physicians whose 
role in the beneficiary's care is not necessarily understood by the 
beneficiary. Finally, we also are seeking comment on key technology 
supports needed to support collaboration between specialist and primary 
care practitioners in support of high quality care management services, 
on whether we should consider including technology requirements as part 
of any proposed services, and on how such requirements could be 
implemented in a way that minimizes burden on providers. We strongly 
encourage stakeholders to comment on this topic in order to assist us 
in developing potential proposals to address these issues through 
rulemaking in CY 2016 for implementation in CY 2017. We anticipate 
using this approach, which would parallel our multi-year approach for 
implementing CCM and TCM services, in order to facilitate broader input 
from stakeholders regarding details of implementing such codes, 
including their structure and description, valuation, and any 
requirements for reporting.
a. Collaborative Care Models for Beneficiaries With Common Behavioral 
Health Conditions
    In recent years, many randomized controlled trials have established 
an evidence base for an approach to caring for patients with common 
behavioral health conditions called ``Collaborative Care.'' 
Collaborative care typically is provided by a primary care team, 
consisting of a primary care provider and a care manager, who works in 
collaboration with a psychiatric consultant, such as a psychiatrist. 
Care is directed by the primary care team and includes structured care 
management with regular assessments of clinical status using validated 
tools and modification of treatment as appropriate. The psychiatric 
consultant provides regular consultations to the primary care team to 
review the clinical status and care of patients and to make 
recommendations. Several resources have been published that describe 
collaborative care models in greater detail and assess their impact, 
including pieces from the University of Washington (http://aims.uw.edu/
), the Institute for Clinical and Economic Review (http://ctaf.org/reports/integration-behavioral-health-primary-care), and the Cochrane 
Collaboration (http://www.cochrane.org/CD006525/DEPRESSN_collaborative-care-for-people-with-depression-and-anxiety).
    Because this particular kind of collaborative care model has been 
tested and documented in medical literature, we are particularly 
interested in seeking comment on how coding under the PFS might 
facilitate appropriate valuation of the services furnished under such a 
collaborative care model. As these kinds of collaborative models of 
care become more prevalent, we will evaluate potential refinements to 
the PFS to account for the provision of services through such a model. 
We are seeking information to assist us in considering refinements to 
coding and payment to

[[Page 41711]]

address this model in particular. We also would assess application of 
the collaborative care model for other diagnoses and treatment 
modalities. For example, we seek comments on how a code similar to the 
CCM code applicable to multiple diagnoses and treatment plans could be 
used to describe collaborative care services, as well as other 
interprofessional services and could be appropriately valued and 
reported within the resource-based relative value PFS system, and how 
the resources involved in furnishing such services could be 
incorporated into the current set of PFS codes without overlap. We also 
request input on whether requirements similar to those used for CCM 
services should apply to a new collaborative care code, and whether 
such a code could be reported in conjunction with CCM or other E/M 
services. For example, we might consider whether the code should 
describe a minimum amount of time spent by the psychiatric consultant 
for a particular patient per one calendar month and be complemented by 
either the CCM or other care management code to support the care 
management and primary care elements of the collaborative care model. 
As with our discussion on interprofessional consultation in this 
section of the proposed rule, because the patient may not have direct 
contact with the psychiatric consultant, we seek comment on whether 
and, if so, how written consent for the non-face-to-face services 
should be required prior to practitioners reporting any new 
interprofessional consultation code or the care management code.
    We are also seeking comment on appropriate care delivery 
requirements for billing, the appropriateness of CCM technology 
requirements or other technology requirements for these services, 
necessary qualifications for psychiatric consultants, and whether or 
not there are particular conditions for which payment would be more 
appropriate than others; as well as how these services may interact 
with quality reporting, the resource inputs we might use to value the 
services under the PFS (specifically, work RVUs, time, and direct PE 
inputs), and whether or not separate codes should be developed for the 
psychiatric consultant and the care management components of the 
service.
    We are also seeking comment on whether this kind of care model 
should be implemented through a CMMI demonstration that would allow 
Medicare to test its effectiveness with a waiver of beneficiary 
financial liability and/or variation of payment methodology and amounts 
for the psychiatric consultant and the primary care physician. Again, 
we strongly encourage stakeholders to comment on this topic in order to 
assist us in developing potential proposals to address these issues 
through rulemaking in CY 2016 for implementation in CY 2017.
3. CCM and TCM Services
a. Reducing Administrative Burden for CCM and TCM Services
    In CY 2013, we implemented separate payment for TCM services, and 
in CY 2015, we implemented separate payment for CCM services. Both have 
many service elements and billing requirements that the physician or 
nonphysician practitioner must satisfy in order to fully furnish these 
services and to report these codes (77 FR 68989, 79 FR 67728). These 
elements and requirements are relatively extensive and generally exceed 
those for other E/M and similar services. Since the implementation of 
these services, some practitioners have stated that the service 
elements and billing requirements are too burdensome, and suggested 
that they interfere with their ability to provide these care management 
services to their patients who could benefit from them. In light of 
this feedback from the physician and practitioner community, we are 
soliciting comments on steps that we could take to further improve 
beneficiary access to TCM and CCM services. Our aims in implementing 
separate payment for these services are that Medicare practitioners are 
paid appropriately for the services they furnish, and that 
beneficiaries receive comprehensive care management that benefits their 
long term health outcomes. However, we understand that excessive 
requirements on practitioners could possibly undermine the overall 
goals of the payment policies. We are interested in stakeholder input 
in how we can best balance access to these services and practitioner 
burdens such that Medicare beneficiaries may obtain the full benefit of 
these services.
b. Payment for CPT Codes Related to CCM Services
    As we stated in the CY 2015 PFS final rule (79 FR 67719), we 
believe that Medicare beneficiaries with two or more chronic conditions 
as defined under the CCM code can benefit from the care management 
services described by that code, and we want to make this service 
available to all such beneficiaries. As with most services paid under 
the PFS, we recognize that furnishing CCM services to some 
beneficiaries will require more resources and some less; but we value 
and make payment based upon the typical service. Because CY 2015 is the 
first year for which we are making separate payment for CCM services, 
we are seeking information regarding the circumstances under which this 
service is furnished. This information includes the clinical status of 
the beneficiaries receiving the service and the resources involved in 
furnishing the service, such as the number of documented non-face-to-
face minutes furnished by clinical staff in the months the code is 
reported. We would be interested in examining such information in order 
to identify the range of minutes furnished over those months as well as 
the distribution of the number of minutes within the total volume of 
services. We are also seeking objective data regarding the resource 
costs associated with furnishing the services described by this code. 
As we review that information, in addition to our own claims data, we 
will consider any changes in payment and coding that may be warranted 
in the coming years, including the possibility of establishing separate 
payment amounts and making Medicare payment for the related CPT codes, 
such as the complex care coordination codes, CPT codes 99487 and 99489.

F. Target for Relative Value Adjustments for Misvalued Services

    Section 220(d) of the Protecting Access to Medicare Act of 2014 
(PAMA) (Pub. L. 113-93, enacted on April 1, 2014) added a new 
subparagraph at section 1848(c)(2) of the Act to establish an annual 
target for reductions in PFS expenditures resulting from adjustments to 
relative values of misvalued codes. Under section 1848(c)(2)(O)(ii) of 
the Act, if the estimated net reduction in expenditures for a year is 
equal to or greater than the target for the year, reduced expenditures 
attributable to such adjustments shall be redistributed in a budget-
neutral manner within the PFS in accordance with the existing budget 
neutrality requirement under section 1848(c)(2)(B)(ii)(II) of the Act. 
The provision also specifies that the amount by which such reduced 
expenditures exceeds the target for a given year shall be treated as a 
net reduction in expenditures for the succeeding year, for purposes of 
determining whether the target has been met for that subsequent year. 
Section 1848(c)(2)(O)(iv) of the Act defines a target recapture amount 
as the amount by which the target for the year exceeds the estimated 
net reduction in expenditures under the PFS resulting from adjustments 
to RVUs for misvalued codes. Section 1848(c)(2)(O)(iii) of the

[[Page 41712]]

Act specifies that, if the estimated net reduction in PFS expenditures 
for the year is less than the target for the year, an amount equal to 
the target recapture amount shall not be taken into account when 
applying the budget neutrality requirements specified in section 
1848(c)(2)(B)(ii)(II) of the Act. Section 220(d) of the PAMA applied to 
calendar years (CYs) 2017 through 2020 and set the target under section 
1848(c)(2)(O)(v) of the Act at 0.5 percent of the estimated amount of 
expenditures under the PFS for each of those 4 years.
    Section 202 of the Achieving a Better Life Experience Act of 2014 
(ABLE) (Division B of Pub. L. 113-295, enacted December 19, 2014)) 
amended section 1848(c)(2)(O) of the Act to accelerate the application 
of the PFS expenditure reduction target to CYs 2016, 2017, and 2018, 
and to set a 1 percent target for CY 2016 and 0.5 percent for CYs 2017 
and 2018. As a result of these provisions, if the estimated net 
reduction for a given year is less than the target for that year, 
payments under the fee schedule will be reduced.
    In this section, we are proposing a methodology to implement this 
statutory provision in a manner consistent with the broader statutory 
construct of the PFS. In developing this proposed methodology, we have 
identified several aspects of our approach for which we are 
specifically seeking comment. We have organized this discussion by 
identifying and explaining these aspects in particular but we are 
seeking comment on all aspects of our proposal.
1. Distinguishing ``Misvalued Code'' Adjustments From Other RVU 
Adjustments
    The potentially misvalued code initiative has resulted in changes 
in PFS payments in several ways. First, potentially misvalued codes 
have been identified, reviewed, and revalued through notice and comment 
rulemaking. However, in many cases, the identification of particular 
codes as potentially misvalued has led to the review and revaluation of 
related codes, and frequently, to revisions to the underlying coding 
for large sets of related services. Similarly, the review of individual 
codes has initiated reviews and proposals to make broader adjustments 
to values for codes across the PFS, such as when the review of a series 
of imaging codes prompted a RUC recommendation and CMS proposal to 
update the direct PE inputs for imaging services to assume digital 
instead of film costs. This change, originating through the misvalued 
code initiative, resulted in a significant reduction in RVUs for a 
large set of PFS services, even though the majority of affected codes 
were not initially identified through potentially misvalued code 
screens. Finally, due to both the relativity inherent in the PFS 
ratesetting process and the budget neutrality requirements specified in 
section 1848(c)(2)(B)(ii)(II) of the Act, adjustments to the RVUs for 
individual services necessarily result in the shifting of RVUs to broad 
sets of other services across the PFS.
    To implement the PFS expenditure reduction target provisions under 
section 1848(c)(2)(O) of the Act, we must identify a subset of the 
adjustments in RVUs for a year to reflect an estimated ``net 
reduction'' in expenditures. Therefore, we dismissed the possibility of 
including all changes in RVUs for a year in calculating the estimated 
net reduction in PFS expenditures, even though we believe that the 
redistributions in RVUs to other services are an important aspect of 
the potentially misvalued code initiative. Conversely, we similarly 
considered the possibility of limiting the calculation of the estimated 
net reduction in expenditures to reflect RVU adjustments made to the 
codes formally identified as ``potentially misvalued.'' We do not 
believe that calculation would reflect the significant changes in 
payments that have directly resulted from the review and revaluation of 
misvalued codes under section 1848(c)(2) of the Act. We further 
considered whether to include only those codes that underwent a 
comprehensive review (work and PE). As we previously have stated (76 FR 
73057), we believe that a comprehensive review of the work and PE for 
each code leads to the more accurate assignment of RVUs and appropriate 
payments under the PFS than do fragmentary adjustments for only one 
component. However, if we calculated the net reduction in expenditures 
using revisions to RVUs only from comprehensive reviews, the 
calculation would not include changes in PE RVUs that result from 
proposals like the film-to-digital change for imaging services, which 
not only originated from the review of potentially misvalued codes, but 
substantially improved the accuracy of PFS payments faster and more 
efficiently than could have been done through the multiple-year process 
required to complete a comprehensive review of all imaging codes.
    After considering these options, we believe that the best approach 
is to define the reduction in expenditures as a result of adjustments 
to RVUs for misvalued codes to include the estimated pool of all 
services with revised input values. This would limit the pool of RVU 
adjustments used to calculate the net reduction in expenditures to 
those for the services for which individual, comprehensive review or 
broader proposed adjustments have resulted in changes to service-level 
inputs of work RVUs, direct PE inputs, or MP RVUs, as well as services 
directly affected by changes to coding for related services. For 
example, coding changes in certain codes can sometimes necessitate 
revaluations for related codes that have not been reviewed as misvalued 
codes, because the coding changes have also affected the scope of the 
related services. This definition would incorporate all reduced 
expenditures from revaluations for services that are deliberately 
addressed as potentially misvalued codes, as well as those for services 
with broad-based adjustments like film-to-digital and services that are 
redefined through coding changes as a result of the review of misvalued 
codes.
    Because the annual target is calculated by measuring changes from 
one year to the next, we also considered how to account for changes in 
values that are best measured over 3 years, instead of 2 years. Under 
our current process, the overall change in valuation for many misvalued 
codes is measured across values for 3 years: The original value in the 
first year, the interim final value in the second year, and the 
finalized value in the third year. As we describe in section II.I.2. of 
this proposed rule, our misvalued code process has been to establish 
interim final RVUs for the potentially misvalued, new, and revised 
codes in the final rule with comment period for a year. Then, during 
the 60-day period following the publication of the final rule with 
comment period, we accept public comment about those valuations. For 
the final rule with comment period for the subsequent year, we consider 
and respond to public comments received on the interim final values, 
and make any appropriate adjustments to values based on those comments. 
However, the straightforward calculation of the target would only 
compare changes between 2 years and not among 3 years, so the 
contribution of a particular change towards the target for any single 
year would be measured against only the preceding year without regard 
to the overall change that takes place over 3 years.
    For recent years, interim final values for misvalued codes (year 2) 
have generally reflected reductions relative to original values (year 
1), and for most codes, the interim final values (year 2) are 
maintained and finalized (year 3). However, when values for particular

[[Page 41713]]

codes have changed between the interim final (year 2) and final values 
(year 3) based on public comment, the general tendency has been that 
codes increase in the final value (year 3) relative to the interim 
final value (year 2), even in cases where the final value (year 3) 
represents a decrease from the original value (year 1). Therefore, for 
these codes, the year 2 changes compared to year 1 would risk over-
representing the overall reduction, while the year 3 to year 2 changes 
would represent an increase in value. If there were similar targets in 
every PFS year, and a similar number of misvalued code changes made on 
an interim final basis, the incongruence in measuring what is really a 
3-year change in 2-year increments might not be particularly 
problematic since each year's calculation would presumably include a 
similar number of codes measured between years 1 and 2 and years 2 and 
3.
    However, including changes that take place over 3 years is 
particularly problematic for calculating the target for CY 2016 for two 
reasons. First, CY 2015 was the final full year of establishing interim 
final values for all new, revised, and potentially misvalued codes. 
Starting with this proposed rule, we are proposing and finalizing 
values for a significant portion of misvalued codes during one calendar 
year. Therefore, CY 2015 will include a disproportionate number of 
services that would be measured between years 2 and 3 relative to the 
services measured between 1 and 2 years. Second, because there was no 
target for CY 2015, any reductions that occurred on an interim final 
basis for CY 2015 were not counted toward achievement of a target. If 
we were to include any upward adjustments made to these codes based on 
public comment as ``misvalued code'' changes for CY 2016, we would 
effectively be counting the service-level increases for 2016 (year 3) 
relative to 2015 (year 2) against achievement of the target without any 
consideration to the service-level changes relative to 2014 (year 1), 
even in cases where the overall change in valuation was negative.
    Therefore, we are proposing to exclude code-level input changes for 
CY 2015 interim final values from the calculation of the CY 2016 
misvalued code target since the misvalued change occurred over multiple 
years, including years not applicable to the misvalued code target 
provision.
    We note that the impact of interim final values in the calculation 
of targets for future years will be diminished as we transition to 
proposing values for almost all new, revised, and potentially misvalued 
codes in the proposed rule. We anticipate a smaller number of interim 
final values for CY 2016 relative to CY 2015. For calculation of the CY 
2018 target, we anticipate almost no impact based on misvalued code 
adjustments that occur over multiple years.
    The list of codes with proposed changes for CY 2016 included under 
this proposed definition of ``adjustments to RVUs for misvalued codes'' 
is available on the CMS Web site under downloads for the CY 2016 PFS 
proposed rule with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
2. Calculating ``Net Reduction''
    Once the RVU changes attributable to misvalued codes are 
identified, estimated net reductions would be calculated summing the 
decreases and offsetting any applicable increases in valuation within 
the changes defined as misvalued, as described above. Because the 
provision only explicitly addresses reductions, and we recognize many 
stakeholders will want to maximize the overall magnitude of the 
measured reductions in order to prevent an overall reduction to the PFS 
conversion factor, we considered the possibility of ignoring the 
applicable increases in valuation in the calculation of net reduction. 
However, we believe that the requirement to calculate ``net'' 
reductions implies that we are to take into consideration both 
decreases and increases. Additionally, we believe this approach may be 
the only practical one due to the presence of new and deleted codes on 
an annual basis.
    For example, a service that is described by a single code in a 
given year, like intensity-modulated radiation therapy (IMRT) treatment 
delivery, could be addressed as a misvalued service in a subsequent 
year through a coding revision that splits the service into two codes, 
``simple'' and ``complex.'' If we counted only the reductions in RVUs, 
we would count only the change in value between the single code and the 
new code that describes the ``simple'' treatment delivery code. In this 
scenario, the change in value from the single code to the new 
``complex'' treatment delivery code would be ignored, so that even if 
there were an increase in the payment for IMRT treatment delivery 
service(s) overall, the mere change in coding would contribute 
inappropriately to a ``net reduction in expenditures.'' Therefore, we 
are proposing to net the increases and decreases in values for 
services, including those for which there are coding revisions, in 
calculating the estimated net reduction in expenditures as a result of 
adjustments to RVUs for misvalued codes.
3. Measuring the Adjustments
    The most straightforward method to estimating the net reduction in 
expenditures due to adjustments to RVUs for misvalued codes is to 
compare the total RVUs of the relevant set of codes (by volume) in the 
current year to the update year, and divide that by the total RVUs for 
all codes (by volume) for the current year. This approach is intuitive 
and relatively easy to replicate.
    However, this method is imprecise for several reasons. First, and 
most significantly, the code-level PE RVUs in the update year include 
either increases due to the redistribution of RVUs from other services 
or reductions due to increases in PE for other services. Second, 
because relativity for work RVUs is maintained through annual 
adjustments to the CF, the precise value of a work RVU in any given 
year is adjusted based on the total number of work RVUs in that year. 
Finally, relativity for the MP RVUs is maintained by both 
redistribution of MP RVUs and adjustments to the CF, when necessary 
(under our proposed methodology this is true annually; based on our 
established methodology the redistribution of the MP RVUs only takes 
place once every 5 years and the CF is adjusted otherwise). Therefore, 
to make a more precise assessment of the net reduction in expenditures 
that are the result of adjustments to the RVUs for misvalued codes, we 
would need to compare, for the included codes, the update year's total 
work RVUs (by volume), direct PE RVUs (by volume), indirect PE RVUs (by 
volume), and MP RVUs (by volume) to the same RVUs in the current year, 
prior to the application of any scaling factors or adjustments. This 
would make for a direct comparison between years.
    However, this approach would mean that the calculation of the net 
reduction in expenditures would occur within various steps of the PFS 
ratesetting methodology. While we believe that this approach would be 
transparent and external stakeholders could replicate this method, it 
may be difficult and time-consuming for stakeholders to do so. We also 
noted that when we modeled the interaction of the phase-in legislation 
and the calculation of the target using this approach during the 
development of this proposal, there were methodological challenges in 
making these calculations. When we simulated the two approaches using

[[Page 41714]]

information from prior PFS years, we found that both approaches 
generally resulted in similar estimated net reductions. After 
considering these options, we are proposing to use the approach of 
comparing the total RVUs (by volume) for the relevant set of codes in 
the current year to the update year, and divide that result by the 
total RVUs (by volume) for the current year. We seek comment on whether 
comparing the update year's work RVUs, direct PE RVUs, indirect PE 
RVUs, and MP RVUs for the relevant set of codes (by volume) prior to 
the application of any scaling factors or adjustments to those of the 
current year would be a preferable methodology for determining the 
estimated net reduction.
4. Estimating the Target for CY 2016
    CY 2016 represents a transition year in our new process of 
proposing values for new, revised and misvalued codes in the proposed 
rule, rather than establishing them as interim final in the final rule 
with comment period. For CY 2016, we will propose values for which we 
had the RUC's recommendations by our deadline of February 10th, and 
will establish interim final values for any codes received after the 
February 10th deadline but in time for us to value for the final rule. 
For CY 2016, there will still be a significant number of codes valued 
not in the proposed rule but in the final rule with comment period. In 
future years (with the exception of entirely new services), all codes, 
even those for which we do not receive RUC recommendations in time for 
the proposed rule, will be in the proposed rule for the subsequent year 
and not in the final rule with comment period. Therefore, for CY 2016, 
unlike for the targets for CY 2017 and CY 2018, because we will not be 
able to calculate a realistic estimate of the target amount at the time 
the proposed rule is published, we will not incorporate the impact of 
the target into the calculation of the proposed PFS payment rates. 
However, because we would apply any required budget neutrality 
adjustment related to this provision to the conversion factor, the 
proposed RVUs for individual services in this proposed rule would be 
the same, regardless of the estimate of the target. We also refer 
readers to the regulatory impact analysis section of this proposed rule 
for an interim estimate of the estimated net reduction in expenditures 
relative to the 1 percent target for CY 2016, based solely on the 
proposed changes in this rule.

G. Phase-in of Significant RVU Reductions

    Section 1848(c)(7) of the Act, as added by section 220(e) of the 
PAMA, also specifies that for services that are not new or revised 
codes, if the total RVUs for a service for a year would otherwise be 
decreased by an estimated 20 percent or more as compared to the total 
RVUs for the previous year, the applicable adjustments in work, PE, and 
MP RVUs shall be phased-in over a 2-year period. Although section 
220(e) of the PAMA required the phase-in to begin for 2017, section 202 
of the ABLE Act amended section 1848(c)(7) of the Act to require that 
the phase-in begin for CY 2016.
    In this section, we are proposing a methodology to implement this 
statutory provision. In developing this proposed methodology, we have 
identified several aspects of our approach for which we are 
specifically seeking comment, given the challenges inherent in 
implementing this provision in a manner consistent with the broader 
statutory construct of the PFS. We have organized this discussion by 
identifying and explaining these aspects in particular but we are 
seeking comment on all aspects of our proposal.
1. Identifying Services that are Not New or Revised Codes
    As described in this proposed rule, the statute specifies that 
services described by new or revised codes are not subject to the 
phase-in of RVUs. We believe this exclusion recognizes the reality that 
there is no practical way to phase-in over 2 years changes to RVUs that 
occur as a result of a coding change for a particular service because 
there is no relevant reference code or value on which to base the 
transition. To determine which services are described by new or revised 
codes for purposes of the phase-in provision, we are proposing to apply 
the phase-in to all services that are described by the same, unrevised 
code in both the current and update year, and to exclude codes that 
describe different services in the current and update year. This 
approach would exclude services described by new codes or existing 
codes for which the descriptors were altered substantially for the 
update year to change the services that are reported using the code. We 
would also exclude as new and revised codes those codes that describe a 
different set of services in the update year when compared to the 
current year by virtue of changes in other, related codes, or codes 
that are part of a family with significant coding revisions. For 
example, significant coding revisions within a family of codes can 
change the relationships among codes to the extent that it changes the 
way that all services in the group are reported, even if some 
individual codes retain the same number or, in some cases, the same 
descriptor. Excluding codes from the phase-in when there are 
significant revisions to the code family would also help to maintain 
the appropriate rank order among codes in the family, avoiding years 
for which RVU changes for some codes in a family are in transition 
while others were fully implemented. This proposed application of the 
phase-in would also be consistent with previous RVU transitions, 
especially for PE RVUs, for which we only applied transition values to 
those codes that described the same service in both the current and the 
update years. We would also exclude from the phase-in as new and 
revised codes those codes with changes to the global period, since the 
code in the current year would not describe the same units of service 
as the code in the update year.
2. Estimating the 20 Percent Threshold
    Because the phase-in of RVUs falls within the budget neutrality 
requirements specified in section 1848(c)(2)(B)(ii)(II) of the Act, we 
are proposing to estimate total RVUs for a service prior to the budget-
neutrality redistributions that result from implementing phase-in 
values. We recognize that the result of this approach could mean that 
some codes may not qualify for the phase-in despite a reduction in RVUs 
that is ultimately slightly greater than 20 percent due to budget 
neutrality adjustments that are made after identifying the codes that 
meet the threshold in order to reflect the phase-in values for other 
codes. We believe the only alternative to this approach is not 
practicable, since it would be circular, resulting in cyclical 
iteration.
3. RVUs in the First Year of the Phase-In
    Section 1848(c)(7) of the Act states that the applicable 
adjustments in work, PE, and MP RVUs shall be phased-in over a 2-year 
period when the RVU reduction for a code is estimated to be equal to or 
greater than 20 percent. We believe that there are two reasonable ways 
to determine the portion of the reduction to be phase-in for the first 
year. Most recent RVU transitions have distributed the values evenly 
across several years. For example, for a 2-year transition we would 
estimate the fully implemented value and set a rate

[[Page 41715]]

approximately 50 percent between the value for the current year and the 
value for the update year. We believe that this is the most intuitive 
approach to the phase-in and is likely the expectation for many 
stakeholders. However, we believe that the 50 percent phase-in in the 
first year has a significant drawback. For instance, since the statute 
establishes a 20 percent threshold as the trigger for phasing in the 
change in RVUs, under the 50 percent phase-in approach, a service that 
is estimated to be reduced by a total of 19 percent for an update year 
would be reduced by a full 19 percent in that update year, while a 
service that is estimated to be reduced by 20 percent in an update year 
would only be reduced 10 percent in that update year.
    The logical alternative approach is to consider a 19 percent 
reduction as the maximum 1-year reduction for any service not described 
by a new or revised code. This approach would be to reduce the service 
by the maximum allowed amount (that is, 19 percent) in the first year, 
and then phase in the remainder of the reduction in the second year. 
Under this approach, the code that is reduced by 19 percent in a year 
and the code that would otherwise have been reduced by 20 percent would 
both be reduced by 19 percent in the first year, and the latter code 
would see an additional 1 percent reduction in the second year of the 
phase-in. For most services, this would likely mean that the majority 
of the reduction would take place in the first year of the phase-in. 
However, for services with the most drastic reductions (greater than 40 
percent), the majority of the reduction would take place in the second 
year of the phase-in.
    After considering both of these options, we are proposing to 
consider the 19 percent reduction as the maximum 1-year reduction and 
to phase-in any remaining reduction greater than 19 percent in the 
second year of the phase-in. We believe that this approach is more 
equitable for codes with significant reductions but that are less than 
20 percent. We are seeking comment on this proposal.
4. Applicable Adjustments to RVUs
    The phase-in provision instructs that the applicable adjustments in 
work, PE, and MP RVUs be phased-in over 2 years for any service that 
would otherwise be decreased by an estimated amount equal to or greater 
than 20 percent as compared to the total RVUs for the previous year. 
However, for several thousand services, we develop separate RVUs for 
facility and nonfacility sites of service. For nearly one thousand 
other services, we develop separate RVUs for the professional and 
technical components of the service and sum those RVUs to allow for 
global billing. Therefore, for individual practitioners furnishing 
particular services to Medicare beneficiaries, the relevant changes in 
RVUs for a particular code are based on the total RVUs for a code for a 
particular setting (facility/nonfacility) or for a particular component 
(professional/technical). We believe the most straightforward and fair 
approach to addressing both the site of service differential and the 
codes with professional and technical components is to consider the 
RVUs for the different sites of service and components independently 
for purposes of identifying when and how the phase-in applies. We are 
proposing, therefore, to estimate whether a particular code meets the 
20 percent threshold for change in total RVUs by taking into account 
the total RVUs that apply to a particular setting or to a particular 
component. This would mean that if the change in total facility RVUs 
for a code met the threshold, then that change would be phased-in over 
2 years, even if the change for the total nonfacility RVUs for the same 
code would not be phased-in over 2 years. Similarly, if the change in 
the total RVUs for the technical component of a service meets the 20 
percent threshold, then that change would be phased-in over 2 years, 
even if the change for the professional component did not meet the 
threshold. (Because the global is the sum of the professional and 
technical components, the portion of the global attributable to the 
technical component would then be phased-in, while the portion 
attributable to the professional component would not be.)
    However, we note that we create the site of service differential 
exclusively by developing independent PE RVUs for each service in the 
nonfacility and facility settings. That is, for these codes, we use the 
same work RVUs and MP RVUs in both settings and vary only the PE RVUs 
to implement the difference in resources depending on the setting. 
Similarly, we use the work RVUs assigned to the professional component 
codes as the work RVUs for the service when billed globally. Like the 
codes with the site of service differential, the PE RVUs for each 
component are developed independently. The resulting PE RVUs are then 
summed for use as the PE RVUs for the code, billed globally. Since 
variation of PE RVUs is the only constant across all individual codes, 
codes with site of service differentials, and codes with professional 
and technical components, we are proposing to apply all adjustments for 
the phase-in to the PE RVUs.
    We considered alternatives to this approach. For example, for codes 
with a site of service differential, we considered applying a phase-in 
for codes in both settings (and all components) whenever the total RVUs 
in either setting reached the 20 percent threshold. However, there are 
cases where the total RVUs for a code in one setting (or one component) 
may reach the 20 percent reduction threshold, while the total RVUs for 
the other setting (or other component) are increasing. In those cases, 
applying phase-in values for work or MP RVUs would mean applying an 
additional increase in total RVUs for particular services. We also 
considered basing the phase-in of the RVUs for the component codes 
billed globally and for the codes with site of service differentials 
developing an overall, blended set of overall PE RVUs using a weighted 
average of site of service volume in the Medicare claims data. We would 
then compare the global or blended value in the prior year versus the 
global or blended value in the current year and apply the phase-in to 
the value for the current year before re-allocating the new value to 
the respective RVUs in each setting. We did not pursue this approach 
for several reasons. First, the resulting phase-in amounts would not 
relate logically to the values paid to any individual practitioner, 
except those who bill the PC/TC codes globally. Second, the approach 
would be so administratively complicated that it would likely be 
difficult to replicate or predict.
    Therefore, we have concluded that applying the adjustments to the 
PE RVUs for individual codes in order to effect the appropriate phase-
in amount is the most straightforward and fair approach to mitigate the 
impact of significant reductions of total RVUs for services furnished 
by individual practitioners. The list of codes subject to the phase-in, 
and the RVUs that result from this proposed methodology, is available 
on the CMS Web site under downloads for the CY 2016 PFS proposed rule 
with comment period at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.

[[Page 41716]]

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

1. Section 218(a) of the Protecting Access to Medicare Act of 2014 
(PAMA)
    Section 218(a) of PAMA is entitled ``Quality Incentives To Promote 
Patient Safety and Public Health in Computed Tomography Diagnostic 
Imaging.'' It amends the statute by reducing payment for the technical 
component (TC) (and the TC of the global fee) of the PFS service and 
the hospital outpatient prospective payment system (OPPS) payment (5 
percent in 2016 and 15 percent in 2017 and subsequent years) for 
computed tomography (CT) services identified by CPT codes 70450-70498, 
71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-
74178, 74261-74263, and 75571-75574 furnished using equipment that does 
not meet each of the attributes of the National Electrical 
Manufacturers Association (NEMA) Standard XR-29-2013, entitled 
``Standard Attributes on CT Equipment Related to Dose Optimization and 
Management.''
    The statutory provision requires that information be provided and 
attested to by a supplier and a hospital outpatient department that 
indicates whether an applicable CT service was furnished that was not 
consistent with the NEMA CT equipment standard, and that such 
information may be included on a claim and may be a modifier. The 
statutory provision also provides that such information shall be 
verified, as appropriate, as part of the periodic accreditation of 
suppliers under section 1834(e) of the Act and hospitals under section 
1865(a) of the Act. Any reduced expenditures resulting from this 
provision are not budget neutral. To implement this provision, we will 
create modifier ``CT'' (Computed tomography services furnished using 
equipment that does not meet each of the attributes of the National 
Electrical Manufacturers Association (NEMA) XR-29-2013 standard). 
Beginning in 2016, claims for CT scans described by above-listed CPT 
codes (and any successor codes) that are furnished on non-NEMA Standard 
XR-29-2013-compliant CT scans must include modifier ``CT'' and that 
modifier will result in the applicable payment reduction for the 
service.

I. Valuation of Specific Codes

1. Background
    Establishing valuations for newly created and revised CPT codes is 
a routine part of maintaining the PFS. Since inception of the PFS, it 
has also been a priority to revalue services regularly to assure that 
the payment rates reflect the changing trends in the practice of 
medicine and current prices for inputs used in the PE calculations. 
Initially, this was accomplished primarily through the five-year review 
process, which resulted in revised work RVUs for CY 1997, CY 2002, CY 
2007, and CY 2012, and revised PE RVUs in CY 2001, CY 2006, and CY 
2011. Under the five-year review process, revisions in RVUs were 
proposed in a proposed rule and finalized in a final rule. In addition 
to the five-year reviews, in each year beginning with CY 2009, CMS and 
the RUC have identified a number of potentially misvalued codes using 
various identification screens, as discussed in section II.C. of this 
proposed rule. Each year, when we received RUC recommendations, our 
process has been to establish interim final RVUs for the potentially 
misvalued codes, new codes, and any other codes for which there were 
coding changes in the final rule with comment period for a year. Then, 
during the 60-day period following the publication of the final rule 
with comment period, we accept public comment about those valuations. 
For services furnished during the calendar year following the 
publication of interim final rates, we pay for services based upon the 
interim final values established in the final rule with comment period. 
In the final rule with comment period for the subsequent year, we 
consider and respond to public comments received on the interim final 
values, and make any appropriate adjustments to values based on those 
comments. We then typically finalize the values for the codes.
2. Process for Valuing New, Revised, and Potentially Misvalued Codes
    In the CY 2015 PFS final rule with comment period, we finalized a 
new process for establishing values for new, revised and potentially 
misvalued codes. Under the new process, we include proposed values for 
these services in the proposed rule, rather than establishing them as 
interim final in the final rule with comment period. CY 2016 represents 
a transition year for this new process. For CY 2016, we are proposing 
new values in the proposed rule for the codes for which we received 
complete RUC recommendations by February 10, 2015. For recommendations 
regarding any new or revised codes received after the February 10, 2015 
deadline, including updated recommendations for codes included in this 
proposed rule, we will establish interim final values in the final rule 
with comment period, consistent with previous practice. We note that we 
will consider all comments received in response to proposed values for 
codes in this rule, including alternative recommendations to those used 
in developing the proposed rule. In other words, if the RUC or other 
interested stakeholders submit public comments that include new 
recommendations for codes for which we propose values as part of this 
proposed rule, we would consider those recommendations in developing 
final values for the codes in the CY 2016 PFS final rule with comment.
    Beginning with valuations for CY 2017, the new process will be 
applicable to all codes. That is, beginning with rulemaking for CY 
2017, we will propose values for the vast majority of new, revised, and 
potentially misvalued codes and consider public comments before 
establishing final values for the codes; use G-codes as necessary to 
facilitate continued payment for certain services for which we do not 
receive recommendations in time to propose values; and adopt interim 
final values in the case of wholly new services for which there are no 
predecessor codes or values and for which we do not receive 
recommendations in time to propose values.
    For CY 2016, we received RUC recommendations prior to February 10, 
2015 for many new, revised and potentially misvalued codes and have 
included proposed values for these codes in this proposed rule. 
However, the RUC recommendations included CPT tracking codes instead of 
the actual 2016 CPT codes that will first be made available to the 
public subsequent to the publication of this proposed rule. Because CPT 
procedure codes are 5 alpha-numeric characters but CPT tracking codes 
typically have 6 or 7 alpha-numeric characters and CMS systems only 
utilize 5-character HCPCS codes, we have developed and used alternative 
5-character placeholder codes for this proposed rule. For the 
convenience of stakeholders and commenters with access to the CPT 
tracking codes, we have displayed a crosswalk from the 5-character 
placeholder codes to the CPT tracking codes on our Web site under 
downloads for the CY 2016 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/downloads/. The final CPT codes will be included in 
the CY 2016 final rule with comment period.
3. Methodology for Establishing Work RVUs
    We conducted a review of each code identified in this section and 
reviewed the current work RVU (if any), RUC-

[[Page 41717]]

recommended work RVUs, intensity, time to furnish the preservice, 
intraservice, and postservice activities, as well as other components 
of the service that contribute to the value. Our review of recommended 
work RVUs and time generally includes, but is not limited to, a review 
of information provided by the RUC, HCPAC, and other public commenters, 
medical literature, and comparative databases, as well as a comparison 
with other codes within the Medicare PFS, consultation with other 
physicians and health care professionals within CMS and the federal 
government, as well as Medicare claims data. We also assessed the 
methodology and data used to develop the recommendations submitted to 
us by the RUC and other public commenters and the rationale for the 
recommendations. In the CY 2011 PFS final rule with comment period (75 
FR 73328 through 73329), we discussed a variety of methodologies and 
approaches used to develop work RVUs, including survey data, building 
blocks, crosswalk to key reference or similar codes, and magnitude 
estimation. More information on these issues is available in that rule. 
When referring to a survey, unless otherwise noted, we mean the surveys 
conducted by specialty societies as part of the formal RUC process. The 
building block methodology is used to construct, or deconstruct, the 
work RVU for a CPT code based on component pieces of the code. 
Components used in the building block approach may include preservice, 
intraservice, or postservice time and post-procedure visits. When 
referring to a bundled CPT code, the building block components could be 
the CPT codes that make up the bundled code and the inputs associated 
with those codes. Magnitude estimation refers to a methodology for 
valuing physician work that determines the appropriate work RVU for a 
service by gauging the total amount of physician work for that service 
relative to the physician work for similar service across the PFS 
without explicitly valuing the components of that work.
    The PFS incorporates cross-specialty and cross-organ system 
relativity. Valuing services requires an assessment of relative value 
and takes into account the clinical intensity and time required to 
furnish a service. In selecting which methodological approach will best 
determine the appropriate value for a service, we consider the current 
and recommended work and time values, as well as the intensity of the 
service, all relative to other services.
    Several years ago, to aid in the development of preservice time 
recommendations for new and revised CPT codes, the RUC created 
standardized preservice time packages. The packages include preservice 
evaluation time, preservice positioning time, and preservice scrub, 
dress and wait time. Currently there are six preservice time packages 
for services typically furnished in the facility setting, reflecting 
the different combinations of straightforward or difficult procedure, 
straightforward or difficult patient, and without or with sedation/
anesthesia. Currently, there are three preservice time packages for 
services typically furnished in the nonfacility setting, reflecting 
procedures without and with sedation/anesthesia care.
    We have developed several standard building block methodologies to 
value services appropriately when they have common billing patterns. In 
cases where a service is typically furnished to a beneficiary on the 
same day as an evaluation and management (E/M) service, we believe that 
there is overlap between the two services in some of the activities 
furnished during the preservice evaluation and postservice time. We 
believe that at least one-third of the work time in both the preservice 
evaluation and postservice period is duplicative of work furnished 
during the E/M visit. Accordingly, in cases where we believe that the 
RUC has not adequately accounted for the overlapping activities in the 
recommended work RVU and/or times, we adjust the work RVU and/or times 
to account for the overlap. The work RVU for a service is the product 
of the time involved in furnishing the service times the intensity of 
the work. Preservice evaluation time and postservice time both have a 
long-established intensity of work per unit of time (IWPUT) of 0.0224, 
which means that 1 minute of preservice evaluation or postservice time 
equates to 0.0224 of a work RVU. Therefore, in many cases when we 
remove 2 minutes of preservice time and 2 minutes of postservice time 
from a procedure to account for the overlap with the same day E/M 
service, we also remove a work RVU of 0.09 (4 minutes x 0.0224 IWPUT) 
if we do not believe the overlap in time has already been accounted for 
in the work RVU. The RUC has recognized this valuation policy and, in 
many cases, addresses the overlap in time and work when a service is 
typically provided on the same day as an E/M service.
    Table 11 contains a list of proposed work RVUs for all codes with 
RUC recommendations received by February 10, 2015. Proposed work RVUs 
that vary from those recommended by the RUC or for which we do not have 
RUC recommendations are addressed in the portions of this section that 
are dedicated to particular codes.
    The work RVUs and other payment information for all CY 2016 payable 
codes are available in Addendum B, including codes for which we have 
proposed changes in this proposed rule subject to public comment. 
Addendum B is available on the CMS Web site under downloads for the CY 
2016 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/downloads/. The proposed time values for all CY 2016 codes are listed 
in a file called ``CY 2016 PFS Work Time,'' available on the CMS Web 
site under downloads for the CY 2016 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/downloads/.
4. Methodology for Establishing the Direct PE Inputs Used to Develop PE 
RVUs
a. Background
    On an annual basis, the RUC provides CMS with recommendations 
regarding PE inputs for new, revised, and potentially misvalued codes. 
We review the RUC-recommended direct PE inputs on a code-by-code basis. 
Like our review of recommended work RVUs, our review of recommended 
direct PE inputs generally includes, but is not limited to, a review of 
information provided by the RUC, HCPAC, and other public commenters, 
medical literature, and comparative databases, as well as a comparison 
with other codes within the Medicare PFS, consultation with other 
physicians and health care professionals within CMS and the federal 
government, as well as Medicare claims data. We also assess the 
methodology and data used to develop the recommendations submitted to 
us by the RUC and other public commenters and the rationale for the 
recommendations. When we determine that the RUC recommendations 
appropriately estimate the direct PE inputs (clinical labor, disposable 
supplies, and medical equipment) required for the typical service, 
consistent with the principles of relativity, and reflect our payment 
policies, we use those direct PE inputs to value a service. If not, we 
refine the recommended PE inputs to better reflect our estimate of the 
PE resources required for the service. We also confirm whether CPT 
codes should have facility and/or nonfacility direct PE inputs and 
refine the inputs accordingly.
    Our review and refinement of RUC-recommended direct PE input 
includes many refinements that are common

[[Page 41718]]

across codes as well as refinements that are specific to particular 
services. Table 13 details our refinements of the RUC's direct PE 
recommendations at the code-specific level. In this proposed rule, we 
address several refinements that are common across codes, and 
refinements to particular codes are addressed in the portions of this 
section that are dedicated to particular codes. We note that for each 
refinement, we indicate the impact on direct costs for that service. We 
point out that, on average, in any case where the impact on the direct 
cost for a particular refinement is $0.32 or less, the refinement has 
no impact on the final PE RVUs. This calculation considers both the 
impact on the direct portion of the PE RVU as well as the impact on the 
indirect allocator for the average service. We also note that nearly 
half of the refinements listed in Table 13 result in changes under the 
$0.32 threshold and are unlikely to result in a change to the final 
RVUs.
    We also note that the proposed direct PE inputs for CY 2016 are 
displayed in the proposed CY 2016 direct PE input database, available 
on the CMS Web site under the downloads for the CY 2016 proposed rule 
at www.cms.gov/PhysicianFeeSched/. The inputs displayed there have also 
been used in developing the CY 2016 PE RVUs as displayed in Addendum B 
of this proposed rule.
b. Common Refinements
(1) Changes in Work Time
    Some direct PE inputs are directly affected by revisions in work 
time. Specifically, changes in the intraservice portions of the work 
time and changes in the number or level of postoperative visits 
associated with the global periods result in corresponding changes to 
direct PE inputs. Although the direct PE input recommendations 
generally correspond to the work time values associated with services, 
we believe that in some cases inadvertent discrepancies between work 
time values and direct PE inputs should be refined in the establishment 
of proposed direct PE inputs. In other cases, CMS refinement of 
recommended proposed work times prompts necessary adjustments in the 
direct PE inputs.
(2) Equipment Time
    Prior to CY 2010, the RUC did not generally provide CMS with 
recommendations regarding equipment time inputs. In CY 2010, in the 
interest of ensuring the greatest possible degree of accuracy in 
allocating equipment minutes, we requested that the RUC provide 
equipment times along with the other direct PE recommendations, and we 
provided the RUC with general guidelines regarding appropriate 
equipment time inputs. We continue to appreciate the RUC's willingness 
to provide us with these additional inputs as part of its PE 
recommendations.
    In general, the equipment time inputs correspond to the service 
period portion of the clinical labor times. We have clarified this 
principle, indicating that we consider equipment time as the time 
within the intraservice period when a clinician is using the piece of 
equipment plus any additional time that the piece of equipment is not 
available for use for another patient due to its use during the 
designated procedure. For those services for which we allocate cleaning 
time to portable equipment items, because the portable equipment does 
not need to be cleaned in the room where the service is furnished, we 
do not include that cleaning time for the remaining equipment items as 
those items and the room are both available for use for other patients 
during that time. In addition, when a piece of equipment is typically 
used during follow-up post-operative visits included in the global 
period for a service, the equipment time would also reflect that use.
    We believe that certain highly technical pieces of equipment and 
equipment rooms are less likely to be used during all of the pre-
service or post-service tasks performed by clinical labor staff on the 
day of the procedure (the clinical labor service period) and are 
typically available for other patients even when one member of clinical 
staff may be occupied with a pre-service or post-service task related 
to the procedure. We also note that we believe these same assumptions 
would apply to inexpensive equipment items that are used in conjunction 
with and located in a room with non-portable highly technical equipment 
items. Some stakeholders have objected to this rationale for our 
refinement of equipment minutes on this basis. We refer readers to our 
extensive discussion in response to those objections in the CY 2012 PFS 
final rule with comment period (76 FR 73182) and the CY 2015 PFS final 
rule with comment period (79 FR 67639).
(3) Standard Tasks and Minutes for Clinical Labor Tasks
    In general, the preservice, intraservice period, and postservice 
clinical labor minutes associated with clinical labor inputs in the 
direct PE input database reflect the sum of particular tasks described 
in the information that accompanies the RUC-recommended direct PE 
inputs, commonly called the ``PE worksheets.'' For most of these 
described tasks, there are a standardized number of minutes, depending 
on the type of procedure, its typical setting, its global period, and 
the other procedures with which it is typically reported. The RUC 
sometimes recommends a number of minutes either greater than or less 
than the time typically allotted for certain tasks. In those cases, CMS 
staff reviews the deviations from the standards and any rationale 
provided for the deviations. When we do not accept the RUC-recommended 
exceptions, we refine the proposed direct PE inputs to match the 
standard times for those tasks. In addition, in cases when a service is 
typically billed with an E/M service, we remove the pre-service 
clinical labor tasks to avoid duplicative inputs and to reflect the 
resource costs of furnishing the typical service.
    In general, clinical labor tasks fall into one of the categories on 
the PE worksheets. In cases where tasks cannot be attributed to an 
existing category, the tasks are labeled ``other clinical activity.'' 
We believe that continual addition of new and distinct clinical labor 
tasks each time a code is reviewed under the misvalued code initiative 
is likely to degrade relativity between newly reviewed services and 
those with already existing inputs. To mitigate the potential negative 
impact of these additions, our staff reviews these tasks to determine 
whether they are fully distinct from existing clinical labor tasks, 
typically included for other clinically similar services under the PFS, 
and thoroughly explained in the recommendation. For those tasks that do 
not meet these criteria, we do not accept these newly recommended 
clinical labor tasks; two examples of such tasks encountered during our 
review of the recommendations include ``Enter data into laboratory 
information system, multiparameter analyses and field data entry, 
complete quality assurance documentation'' and ``Consult with 
pathologist regarding representation needed, block selection and 
appropriate technique.''
    In conducting our review of the RUC recommendations for CY 2016, we 
noted that several of the recommended times for clinical labor tasks 
associated with pathology services differed across codes, both within 
the CY 2016 recommendations and in comparison to codes currently in the 
direct PE database. We refer readers to Table 6 in section II.A.3. of 
this proposed rule where we outline our proposed standard times for 
clinical labor tasks associated with pathology services.

[[Page 41719]]

(4) Recommended Items That Are Not Direct PE Inputs
    In some cases, the PE worksheets included with the RUC 
recommendations include items that are not clinical labor, disposable 
supplies, or medical equipment that cannot be allocated to individual 
services or patients. Two examples of such items are ``emergency 
service container/safety kit'' and ``service contract.'' We have 
addressed these kinds of recommendations in previous rulemaking (78 FR 
74242), and we do not use these recommended items as direct PE inputs 
in the calculation of PE RVUs.
(5) Moderate Sedation Inputs
    In the CY 2012 PFS final rule (76 FR 73043 through 73049), we 
finalized a standard package of direct PE inputs for services where 
moderate sedation is considered inherent in the procedure. In the CY 
2015 final rule with comment period, we finalized a refinement to the 
standard package to include a stretcher for the same length of time as 
the other equipment items in the standard package. We are proposing to 
refine the RUC's direct PE recommendations to conform to these 
policies. This includes the removal of a power table where it was 
included during the intraservice period, as the stretcher takes the 
place of the table. These refinements are reflected in the final CY 
2016 PFS direct PE input database and detailed in Table 13.
(6) New Supply and Equipment Items
    The RUC generally recommends the use of supply and equipment items 
that already exist in the direct PE input database for new, revised, 
and potentially misvalued codes. Some recommendations include supply or 
equipment items that are not currently in the direct PE input database. 
In these cases, the RUC has historically recommended a new item be 
created and has facilitated our pricing of that item by working with 
the specialty societies to provide copies of sales invoices to us. We 
received invoices for several new supply and equipment items for CY 
2016. We have accepted the majority of these items and added them to 
the direct PE input database. Tables 9 and 10 detail the invoices 
received for new and existing items in the direct PE database. As 
discussed in section II.A. of this proposed rule, we encourage 
stakeholders to review the prices associated with these new and 
existing items to determine whether these prices appear to be accurate. 
Where prices appear inaccurate, we encourage stakeholders to provide 
invoices or other information to improve the accuracy of pricing for 
these items in the direct PE database. We remind stakeholders that due 
to the relativity inherent in the development of RVUs, reductions in 
existing prices for any items in the direct PE database increase the 
pool of direct PE RVUs available to all other PFS services. Tables 9 
and 10 also include the number of invoices received as well as the 
number of nonfacility allowed services for procedures that use these 
equipment items. We provide the nonfacility allowed services so that 
stakeholders will note the impact the particular price might have on PE 
relativity, as well as to identify items that are used frequently, 
since we believe that stakeholders are more likely to have better 
pricing information for items used more frequently. We are concerned 
that a single invoice may not be reflective of typical costs and 
encourage stakeholders to provide additional invoices so that we might 
identify and use accurate prices in the development of PE RVUs.
    In some cases, we do not accept the price listed on the invoice 
that accompanies the recommendation because we identify publicly 
available alternative prices or information that suggests a different 
price is more accurate. In these cases, we include this in the 
discussion of these codes. In other cases, we cannot adequately price a 
newly recommended item due to inadequate information. Sometimes, no 
supporting information regarding the price of the item has been 
included in the recommendation. In other cases, the supporting 
information does not demonstrate that the item has been purchased at 
the listed price (for example, vendor price quotes instead of paid 
invoices). In cases where the information provided on the item allows 
us to identify clinically appropriate proxy items, we might use 
existing items as proxies for the newly recommended items. In other 
cases, we have included the item in the direct PE input database 
without any associated price. Although including the item without an 
associated price means that the item does not contribute to the 
calculation of the proposed PE RVU for particular services, it 
facilitates our ability to incorporate a price once we obtain 
information and are able to do so.
(7) Service Period Clinical Labor Time in the Facility Setting
    Several of the PE worksheets included in the RUC recommendations 
contained clinical labor minutes assigned to the service period in the 
facility setting. Our proposed inputs do not include these minutes 
because the cost of clinical labor during the service period for a 
procedure in the facility setting is not considered a resource cost to 
the practitioner since Medicare makes separate payment to the facility 
for these costs.
(8) Duplicative Inputs
    Several of the PE worksheets included in the RUC recommendations 
contained time for the equipment item ``xenon light source'' (EQ167). 
Because there appear to be two special light sources already present 
(the fiberoptic headlight and the endoscope itself) in the services for 
which this equipment item was recommended, we are not proposing to 
include the time for this equipment item from these services, and are 
seeking comment on whether there is a rationale for including this 
additional light source as a direct PE input for these procedures.
5. Methodology for Establishing Malpractice RVUs
    As discussed in section II.B. of this proposed rule, our 
malpractice methodology uses a crosswalk to establish risk factors for 
new services until utilization data becomes available. Table 15 lists 
the CY 2016 HCPCS codes and their respective source codes used to set 
the proposed CY 2016 MP RVUs. The MP RVUs for these services are 
reflected in Addendum B on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.

                                                   Table 9--Invoices Received for New Direct PE Inputs
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                  Estimated non-facility
                                                                                                                     Number of     allowed services for
             CPT/HCPCS Codes                       Item name            CMS Code            Average price             invoices   HCPCS codes using  this
                                                                                                                                           item
--------------------------------------------------------------------------------------------------------------------------------------------------------
31626...................................  Gold Fiducial Marker.......       SB053  135............................            1                        6

[[Page 41720]]

 
3160A, 3160B, 3160C.....................  endoscope, ultrasound             ES045  0..............................            0                      212
                                           radial probe.
3725A...................................  IVUS catheter..............       SD304  1025...........................            3                      795
3725A...................................  IVUS Catheter Sterile Cover       SD305  120............................            3                      795
3725A, 3725B............................  IVUS system................       ES047  134,025........................            3                    2,948
44385, 44386, 45330, 45331, 45332,        Video Sigmoidoscope........       ES043  215,00.........................            1                   18,058
 45333, 45334, 45335, 45338, 45340,
 45346.
44401, 45346, 45388.....................  catheter, RF ablation,            SC103  1,780..........................            1                    3,543
                                           endoscopic.
44401, 45346............................  radiofrequency generator,         EQ369  108,291.67.....................            1                      174
                                           endoscopy.
45350, 45398............................  hemorrhoidal banding system       SA115  223.50.........................            4                        3
5039D, 5039M............................  Nephroureteral Catheter....       SD306  117.90.........................            1                       70
657XG...................................  suture, nylon, 10-0........       SC104  12.17..........................            2
657XG...................................  intrastromal corneal ring..       SA120  1,145..........................            7
657XG...................................  patient/laser interface           SD307  172.50.........................            1
                                           (single--use, disposable).
657XG...................................  femtosecond laser..........       ES048  293,000........................            2
657XG...................................  incision programming              ES049  10,012.50......................            1
                                           software.
692XX...................................  earwash bottle disposable         SD308  1.72...........................            1
                                           tips.
77385, 77386, 77402, 77407, 77412.......  Power Conditioner..........       ER102  26,400.........................            2                2,198,441
7778A, 7778B, 7778C, 7778D, 7778E.......  brachytherapy treatment           ES052  175,000........................            1                   24,936
                                           vault.
88104, 88106, 88108.....................  fixative spray for cytospin       SL503  1.53...........................            1                   62,552
88108...................................  Shannon cyto funnel,              SD298  2.27...........................            1                   48,740
                                           cytospin.
88108...................................  slide, microscope coated          SL504  0.39...........................            1                   48,740
                                           cytospin (single circle).
88182...................................  Protease...................       SL506  0.43...........................            1                      568
88346, 8835X............................  Immunofluorescent mounting        SD309  3.50...........................            1                  114,211
                                           media.
88346, 8835X............................  Zeus medium................       SL518  0.85...........................            2                  114,211
88346, 8835X............................  Hydrophobic PAP Pen........       SK120  1.76...........................            1                  114,211
                                                                                   (100 uses).....................
88360, 88361............................  Antibody Estrogen Receptor        SL493  13.89..........................            3                  116,718
                                           monoclonal.
--------------------------------------------------------------------------------------------------------------------------------------------------------


                                                Table 10--Invoices Received for Existing Direct PE Inputs
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                  Estimated non-facility
                                                                                     Current    Updated    Percent    Number of    allowed services for
             CPT/HCPCS Codes                         Item name           CMS  Code    price      price      change    invoices   HCPCS codes using  this
                                                                                                                                           item
--------------------------------------------------------------------------------------------------------------------------------------------------------
31300, 31320, 31360, 31365, 31367, 31368,  endosheath..................      SD070       9.50      17.25         82           1                   65,318
 31370, 31375, 31380, 31382, 31390,
 31395, 31628, 31632, 31750, 31755,
 31800, 41120, 41130, 41135, 41140,
 41145, 41150, 41153, 41155, 41500,
 41510, 41512, 41530, 42120, 42842,
 42844, 42845, 42870, 42890, 42892,
 42894, 42950, 42953, 42955, 43215,
 43247, 58555, 58558, 58562, 58563,
 60605, 92511, 92612.
41530, 43228, 43229, 43270, 64633, 64634,  radiofrequency generator          EQ214     32,900     10,000        -70           1                  265,270
 64635, 64636.                              (NEURO).
88341, 88342, 88343, 88344, 88360, 88361.  Benchmark ULTRA automated         EP112    134,000    150,000         12           1                3,279,993
                                            slide preparation system.
8835X....................................  antibody IgA FITC...........      SL012      71.40      41.18        -42           1                   93,520
95018....................................  benzylpenicilloyl polylysine      SH103      72.45      83.00         15           1                   60,683
                                            (eg, PrePen) 0.25ml uou.

[[Page 41721]]

 
95923....................................  kit, electrode,                   SA014      11.99       4.01        -67           3                   96,189
                                            iontophoresis.
--------------------------------------------------------------------------------------------------------------------------------------------------------

6. CY 2016 Valuation of Specific Codes

              Table 11--CY 2016 Proposed Work RVUs for New, Revised and Potentially Misvalued Codes
----------------------------------------------------------------------------------------------------------------
                                                                                                    CMS time
     HCPCS             Descriptor           Current work RVU     RUC work RVU    CMS work RVU      refinement
----------------------------------------------------------------------------------------------------------------
11750.........  Removal of nail.........  2.5.................            1.99            1.58  No.
20240.........  Biopsy of bone, open      3.28................            3.73            2.61  No.
                 procedure.
27280.........  Arthrodesis, open,        14.64...............           20              20     No.
                 sacroiliac joint
                 including obtaining
                 bone graft.
3160A.........  Bronchoscopy, rigid or    NEW.................            5               4.71  No.
                 flexible, including
                 fluoroscopic guidance,
                 when performed; with
                 endobronchial
                 ultrasound (EBUS)
                 guided transtracheal
                 and/or transbronchial
                 sampling (eg,
                 aspiration[s]/
                 biopsy[ies]), one or
                 two mediastinal and/or
                 hilar lymph node stat.
3160B.........  Bronchoscopy, rigid or    NEW.................            5.5             5.21  No.
                 flexible, including
                 fluoroscopic guidance,
                 when performed; with
                 endobronchial
                 ultrasound (EBUS)
                 guided transtracheal
                 and/or transbronchial
                 sampling (eg,
                 aspiration[s]/
                 biopsy[ies]), 3 or more
                 mediastinal and/or
                 hilar lymph node stati.
3160C.........  Bronchoscopy, rigid or    NEW.................            1.7             1.4   No.
                 flexible, including
                 fluoroscopic guidance,
                 when performed; with
                 transendoscopic
                 endobronchial
                 ultrasound (EBUS)
                 during bronchoscopic
                 diagnostic or
                 therapeutic
                 intervention(s) for
                 peripheral lesion(s)
                 (List separately in
                 addition to.
31622.........  Diagnostic examination    2.78................            2.78            2.78  No.
                 of lung airways using
                 an endoscope.
31625.........  Biopsy of lung airways    3.36................            3.36            3.36  No.
                 using an endoscope.
31626.........  Insertion of radiation    4.16................            4.16            4.16  No.
                 therapy markers into
                 lung airways using an
                 endoscope.
31628.........  Biopsy of one lobe of     3.8.................            3.8             3.8   No.
                 lung using an endoscope.
31629.........  Needle biopsy of          4.09................            4               4     No.
                 windpipe cartilage,
                 airway, and/or lung
                 using an endoscope.
31632.........  Biopsy of lung using an   1.03................            1.03            1.03  No.
                 endoscope.
31633.........  Needle biopsy of lung     1.32................            1.32            1.32  No.
                 using an endoscope.
3347A.........  Transcatheter pulmonary   NEW.................           25              25     No.
                 valve implantation,
                 percutaneous approach,
                 including pre-stenting
                 of the valve delivery
                 site, when performed.
37215.........  Transcatheter placement   19.68...............           18              18     No.
                 of intravascular
                 stent(s), cervical
                 carotid artery,
                 percutaneous; with
                 distal embolic
                 protection.
3725A.........  Intravascular ultrasound  NEW.................            1.8             1.8   No.
                 (noncoronary vessel)
                 during diagnostic
                 evaluation and/or
                 therapeutic
                 intervention, including
                 radiological
                 supervision and
                 interpretation; initial
                 non-coronary vessel
                 (List separately in
                 addition to code for
                 primary procedure).
3725B.........  Intravascular ultrasound  NEW.................            1.44            1.44  No.
                 (noncoronary vessel)
                 during diagnostic
                 evaluation and/or
                 therapeutic
                 intervention, including
                 radiological
                 supervision and
                 interpretation; each
                 additional noncoronary
                 vessel (List separately
                 in addition to code for
                 primary procedure.
38570.........  Removal of abdominal      9.34................            9.34            8.49  No.
                 cavity lymph nodes
                 using an endoscope.
38571.........  Removal of total lymph    14.76...............           12              12     No.
                 nodes of both sides of
                 pelvis using an
                 endoscope.
38572.........  Removal of total lymph    16.94...............           15.6            15.6   No.
                 nodes of both sides of
                 pelvis and abdominal
                 lymph node biopsy using
                 an endoscope.
3940A.........  Mediastinoscopy;          NEW.................            5.44            5.44  No.
                 includes biopsy(ies) of
                 mediastinal mass (eg,
                 lymphoma), when
                 performed.
3940B.........  Mediastinoscopy; with     NEW.................            7.5             7.25  No.
                 lymph node biopsy(ies)
                 (eg, lung cancer
                 staging).
43775.........  Stomach reduction         C...................           21.4            20.38  No.
                 procedure with partial
                 removal of stomach
                 using an endoscope.
44380.........  Ileoscopy, through        1.05................            0.97            0.9   No.
                 stoma; diagnostic,
                 including collection of
                 specimen(s) by brushing
                 or washing, when
                 performed.
44381.........  Ileoscopy, through        N/A.................            1.48            1.48  Yes
                 stoma; with
                 transendoscopic balloon
                 dilation.
44382.........  Ileoscopy, through        1.27................            1.27            1.2   No.
                 stoma; with biopsy,
                 single or multiple.
44384.........  Ileoscopy, through        N/A.................            3.11            2.88  No.
                 stoma; with placement
                 of endoscopic stent
                 (includes pre- and post-
                 dilation and guide wire
                 passage, when
                 performed).

[[Page 41722]]

 
44385.........  Endoscopic evaluation of  1.82................            1.3             1.23  No.
                 small intestinal pouch
                 (eg, Kock pouch, ileal
                 reservoir [S or J]);
                 diagnostic, including
                 collection of
                 specimen(s) by brushing
                 or washing, when
                 performed.
44386.........  Endoscopic evaluation of  2.12................            1.6             1.53  No.
                 small intestinal pouch
                 (eg, Kock pouch, ileal
                 reservoir [S or J]);
                 with biopsy, single or
                 multiple.
44388.........  Colonoscopy through       2.82................            2.82            2.75  No.
                 stoma; diagnostic,
                 including collection of
                 specimen(s) by brushing
                 or washing, when
                 performed (separate
                 procedure).
44389.........  Colonoscopy through       3.13................            3.12            3.05  No.
                 stoma; with biopsy,
                 single or multiple.
44390.........  Colonoscopy through       3.82................            3.82            3.77  No.
                 stoma; with removal of
                 foreign body.
44391.........  Colonoscopy through       4.31................            4.22            4.22  No.
                 stoma; with control of
                 bleeding, any method.
44392.........  Colonoscopy through       3.81................            3.63            3.63  No.
                 stoma; with removal of
                 tumor(s), polyp(s), or
                 other lesion(s) by hot
                 biopsy forceps or
                 bipolar cautery.
44394.........  Colonoscopy through       4.42................            4.13            4.13  No.
                 stoma; with removal of
                 tumor(s), polyp(s), or
                 other lesion(s) by
                 snare technique.
44401.........  Colonoscopy through       N/A.................            4.44            4.44  No.
                 stoma; with ablation of
                 tumor(s), polyp(s), or
                 other lesion (includes
                 pre-and post-dilation
                 and guide wire passage,
                 when performed).
44402.........  Colonoscopy through       N/A.................            4.96            4.73  No.
                 stoma; with endoscopic
                 stent placement
                 (including pre- and
                 post-dilation and
                 guidewire passage, when
                 performed).
44403.........  Colonoscopy through       N/A.................            5.81            5.53  No.
                 stoma; with endoscopic
                 mucosal resection.
44404.........  Colonoscopy through       N/A.................            3.13            3.05  No.
                 stoma; with directed
                 submucosal
                 injection(s), any
                 substance.
44405.........  Colonoscopy through       N/A.................            3.33            3.33  No.
                 stoma; with
                 transendoscopic balloon
                 dilation.
44406.........  Colonoscopy through       N/A.................            4.41            4.13  No.
                 stoma; with endoscopic
                 ultrasound examination,
                 limited to the sigmoid,
                 descending, transverse,
                 or ascending colon and
                 cecum and adjacent
                 structures.
44407.........  Colonoscopy through       N/A.................            5.06            5.06  No.
                 stoma; with
                 transendoscopic
                 ultrasound guided
                 intramural or
                 transmural fine needle
                 aspiration/biopsy(s),
                 includes endoscopic
                 ultrasound examination
                 limited to the sigmoid,
                 descending, transverse,
                 or ascending colon and
                 cecum and adjace.
44408.........  Colonoscopy through       N/A.................            4.24            4.24  No.
                 stoma; with
                 decompression (for
                 pathologic distention)
                 (eg, volvulus,
                 megacolon), including
                 placement of
                 decompression tube,
                 when performed.
45330.........  Sigmoidoscopy, flexible;  0.96................            0.84            0.77  No.
                 diagnostic, including
                 collection of
                 specimen(s) by brushing
                 or washing when
                 performed.
45331.........  Sigmoidoscopy, flexible;  1.15................            1.14            1.07  No.
                 with biopsy, single or
                 multiple.
45332.........  Sigmoidoscopy, flexible;  1.79................            1.85            1.79  No.
                 with removal of foreign
                 body.
45333.........  Sigmoidoscopy, flexible;  1.79................            1.65            1.65  No.
                 with removal of
                 tumor(s), polyp(s), or
                 other lesion(s) by hot
                 biopsy forceps.
45334.........  Sigmoidoscopy, flexible;  2.73................            2.1             2.1   No.
                 with control of
                 bleeding, any method.
45335.........  Sigmoidoscopy, flexible;  1.46................            1.15            1.07  No.
                 with directed
                 submucosal
                 injection(s), any
                 substance.
45337.........  Sigmoidoscopy, flexible;  2.36................            2.2             2.2   No.
                 with decompression (for
                 pathologic distention)
                 (eg, volvulus,
                 megacolon), including
                 placement of
                 decompression tube,
                 when performed.
45338.........  Sigmoidoscopy, flexible;  2.34................            2.15            2.15  No.
                 with removal of
                 tumor(s), polyp(s), or
                 other lesion(s) by
                 snare technique.
45340.........  Sigmoidoscopy, flexible;  1.89................            1.35            1.35  No.
                 with transendoscopic
                 balloon dilation.
45341.........  Sigmoidoscopy, flexible;  2.6.................            2.43            2.15  No.
                 with endoscopic
                 ultrasound examination.
45342.........  Sigmoidoscopy, flexible;  4.05................            3.08            3.08  No.
                 with transendoscopic
                 ultrasound guided
                 intramural or
                 transmural fine needle
                 aspiration/biopsy(s).
45346.........  Sigmoidoscopy, flexible;  N/A.................            2.97            2.84  No.
                 with ablation of
                 tumor(s), polyp(s), or
                 other lesion(s)
                 (includes pre- and post-
                 dilation and guide wire
                 passage, when
                 performed).
45347.........  Sigmoidoscopy, flexible;  N/A.................            2.98            2.75  No.
                 with placement of
                 endoscopic stent
                 (includes pre- and post-
                 dilation and guide wire
                 passage, when
                 performed).
45349.........  Sigmoidoscopy, flexible;  N/A.................            3.83            3.55  No.
                 with endoscopic mucosal
                 resection.
45350.........  Sigmoidoscopy,            N/A.................            1.78            1.78  No.
                 flexible;with banding
                 (eg, hemorrhoids).
45378.........  Colonoscopy, flexible;    3.69................            3.36            3.29  No.
                 diagnostic, including
                 collection of
                 specimen(s) by brushing
                 or washing, when
                 performed, (separate
                 procedure).
45379.........  Colonoscopy, flexible;    4.68................            4.37            4.31  No.
                 with removal of foreign
                 body.
45380.........  Colonoscopy, flexible,    4.43................            3.66            3.59  No.
                 proximal to splenic
                 flexure; with biopsy,
                 single or multiple.
45381.........  Colonoscopy, flexible;    4.19................            3.67            3.59  No.
                 with directed
                 submucosal
                 injection(s), any
                 substance.
45382.........  Colonoscopy, flexible;    5.68................            4.76            4.76  No.
                 with control of
                 bleeding, any method.

[[Page 41723]]

 
45384.........  Colonoscopy, flexible;    4.69................            4.17            4.17  No.
                 with removal of
                 tumor(s), polyp(s), or
                 other lesion(s) by hot
                 biopsy forceps or
                 bipolar cautery.
45385.........  Colonoscopy, flexible;    5.3.................            4.67            4.67  No.
                 with removal of
                 tumor(s), polyp(s), or
                 other lesion(s) by
                 snare technique.
45386.........  Colonoscopy, flexible;    4.57................            3.87            3.87  No.
                 with transendoscopic
                 balloon dilation.
45388.........  Colonoscopy, flexible;    N/A.................            4.98            4.98  No.
                 with ablation of
                 tumor(s), polyp(s), or
                 other lesion(s)
                 (includes pre- and post-
                 dilation and guide wire
                 passage, when
                 performed).
45389.........  Colonoscopy, flexible;    N/A.................            5.5             5.27  No.
                 with endoscopic stent
                 placement (includes pre-
                  and post-dilation and
                 guide wire passage,
                 when performed).
45390.........  Colonoscopy, flexible;    N/A.................            6.35            6.07  No.
                 with endoscopic mucosal
                 resection.
45391.........  Colonoscopy, flexible;    5.09................            4.95            4.67  No.
                 with endoscopic
                 ultrasound examination
                 limited to the rectum,
                 sigmoid, descending,
                 transverse, or
                 ascending colon and
                 cecum, and adjacent
                 structures.
45392.........  Colonoscopy, flexible;    6.54................            5.6             5.6   No.
                 with transendoscopic
                 ultrasound guided
                 intramural or
                 transmural fine needle
                 aspiration/biopsy(s),
                 includes endoscopic
                 ultrasound examination
                 limited to the rectum,
                 sigmoid, descending,
                 transverse, or
                 ascending colon and
                 cecum, and a.
45393.........  Colonoscopy, flexible;    N/A.................            4.78            4.78  No.
                 with decompression (for
                 pathologic distention)
                 (eg, volvulus,
                 megacolon), including
                 placement of
                 decompression tube,
                 when performed.
45398.........  Colonoscopy, flexible;    N/A.................            4.3             4.3   No.
                 with banding, (eg,
                 hemorrhoids).
46500.........  Injection of hemorrhoids  1.69................            1.69            1.42  No.
46601.........  Anoscopy; diagnostic,     N/A.................            1.6             1.6   No.
                 with high-resolution
                 magnification.
46607.........  Anoscopy; with high-      N/A.................            2.2             2.2   No.
                 resolution
                 magnification (hra),
                 with biopsy, single or
                 multiple.
47135.........  Transplantation of donor  83.64...............           91.78           90     No.
                 liver to anatomic
                 position.
50390.........  Aspiration and/or         1.96................            1.96            1.96  No.
                 injection kidney cyst,
                 accessed through the
                 skin.
5039A.........  Injection procedure for   NEW.................            3.15            3.15  No.
                 antegrade nephrostogram
                 and/or ureterogram,
                 complete diagnostic
                 procedure including
                 imaging guidance (eg,
                 ultrasound and
                 fluoroscopy) and all
                 associated radiological
                 supervision and
                 interpretation; new
                 access.
5039B.........  Injection procedure for   NEW.................            1.42            1.1   No.
                 antegrade nephrostogram
                 and/or ureterogram,
                 complete diagnostic
                 procedure including
                 imaging guidance (eg,
                 ultrasound and
                 fluoroscopy) and all
                 associated radiological
                 supervision and
                 interpretation;
                 existing access.
5039C.........  Placement of nephrostomy  NEW.................            4.7             4.25  No.
                 catheter, percutaneous,
                 including diagnostic
                 nephrostogram and/or
                 ureterogram when
                 performed, imaging
                 guidance (eg,
                 ultrasound and/or
                 fluoroscopy) and all
                 associated radiological
                 supervision and
                 interpretation.
5039D.........  Placement of              NEW.................            5.75            5.3   No.
                 nephroureteral
                 catheter, percutaneous,
                 including diagnostic
                 nephrostogram and/or
                 ureterogram when
                 performed, imaging
                 guidance (eg,
                 ultrasound and/or
                 fluoroscopy) and all
                 associated radiological
                 supervision and
                 interpretation, new
                 access.
5039E.........  Exchange nephrostomy      NEW.................            2               1.82  No.
                 catheter, percutaneous,
                 including diagnostic
                 nephrostogram and/or
                 ureterogram when
                 performed, imaging
                 guidance (eg,
                 ultrasound and/or
                 fluoroscopy) and all
                 associated radiological
                 supervision and
                 interpretation.
5039M.........  Convert nephrostomy       NEW.................            4.2             4     No.
                 catheter to
                 nephroureteral
                 catheter, percutaneous,
                 including diagnostic
                 nephrostogram and/or
                 ureterogram when
                 performed, imaging
                 guidance (eg,
                 ultrasound and/or
                 fluoroscopy) and all
                 associated radiological
                 supervision and
                 interpretation.
5069G.........  Placement of ureteral     NEW.................            4.6             4.21  No.
                 stent, percutaneous,
                 including diagnostic
                 nephrostogram and/or
                 ureterogram when
                 performed, imaging
                 guidance (eg,
                 ultrasound and/or
                 fluoroscopy) and all
                 associated radiological
                 supervision and
                 interpretation; pre-
                 existing nephrostomy.
5069H.........  Placement of ureteral     NEW.................            6               5.5   No.
                 stent, percutaneous,
                 including diagnostic
                 nephrostogram and/or
                 ureterogram when
                 performed, imaging
                 guidance (eg,
                 ultrasound and/or
                 fluoroscopy) and all
                 associated radiological
                 supervision and
                 interpretation; new
                 access, without
                 separate.
5069I.........  Placement of ureteral     NEW.................            7.55            7.05  No.
                 stent, percutaneous,
                 including diagnostic
                 nephrostogram and/or
                 ureterogram when
                 performed, imaging
                 guidance (eg,
                 ultrasound and/or
                 fluoroscopy) and all
                 associated radiological
                 supervision and
                 interpretation; new
                 access, with separate.
5443A.........  Repair of traumatic       NEW.................           11.5            11.5   No.
                 corporeal tear(s).
5443B.........  Replantation, penis,      NEW.................           24.5            22.1   No.
                 complete amputation
                 including urethral
                 repair.

[[Page 41724]]

 
63045.........  Laminectomy, facetectomy  17.95...............           17.95           17.95  No.
                 and foraminotomy;
                 cervical.
63046.........  Laminectomy, facetectomy  17.25...............           17.25           17.25  No.
                 and foraminotomy;
                 thoracic.
657XG.........  Implantation of           NEW.................            5.93            5.39  No.
                 intrastromal corneal
                 ring segments.
68801.........  Dilation of tear-         1...................            1               0.82  No.
                 drainage opening.
68810.........  Insertion of probe into   2.15................            1.54            1.54  No.
                 the tear duct.
68811.........  Insertion of probe into   2.45................            2.03            1.74  No.
                 the tear duct under
                 anesthesia.
68815.........  Probing of nasal-tear     3.3.................            3               2.7   No.
                 duct with insertion of
                 tube or stent.
68816.........  Probing of nasal-tear     3.06................            2.35            2.1   No.
                 duct with balloon
                 catheter dilation.
71100.........  Radiologic examination,   0.22................            0.22            0.22  No.
                 ribs, unilateral; 2
                 views.
72070.........  Radiologic examination,   0.22................            0.22            0.22  No.
                 spine; thoracic, 2
                 views.
7208A.........  Entire spine x ray, one   NEW.................            0.3             0.26  No.
                 view.
7208B.........  Entire spine x-ray; 2 or  NEW.................            0.35            0.31  No.
                 3 views.
7208C.........  Entire spine x-ray; 4 or  NEW.................            0.39            0.35  No.
                 5 views.
7208D.........  Entire spine x-ray; min   NEW.................            0.45            0.41  No.
                 6 views.
73060.........  Radiologic examination;   0.17................            0.16            0.16  No.
                 humerus, minimum of 2
                 views.
73560.........  Radiologic examination,   0.17................            0.16            0.16  No.
                 knee; 1 or 2 views.
73562.........  Radiologic examination,   0.18................            0.18            0.18  No.
                 knee; 3 views.
73564.........  Radiologic examination,   0.22................            0.22            0.22  No.
                 knee; complete, 4 or
                 more views.
73565.........  Radiologic examination,   0.17................            0.16            0.16  No.
                 knee; both knees,
                 standing,
                 anteroposterior.
73590.........  Radiologic examination;   0.17................            0.16            0.16  No.
                 tibia and fibula, 2
                 views.
73600.........  Radiologic examination,   0.16................            0.16            0.16  No.
                 ankle; 2 views.
76999.........  Ultrasound procedure....  C...................            C               C     N/A
77387.........  Guidance for              N/A.................            0.58            0.58  No.
                 localization of target
                 volume for delivery of
                 radiation treatment
                 delivery, includes
                 intrafraction tracking
                 when performed.
7778B.........  Remote afterloading high  NEW.................            1.4             1.4   No.
                 dose rate radionuclide
                 skin surface
                 brachytherapy, includes
                 basic dosimetry, when
                 performed; lesion
                 diameter over 2.0 cm
                 and 2 or more channels,
                 or multiple lesions.
7778C.........  Remote afterloading high  NEW.................            1.95            1.95  No.
                 dose rate radionuclide
                 interstitial or
                 intracavitary
                 brachytherapy, includes
                 basic dosimetry, when
                 performed; 1 channel.
7778D.........  Remote afterloading high  NEW.................            3.8             3.8   No.
                 dose rate radionuclide
                 interstitial or
                 intracavitary
                 brachytherapy, includes
                 basic dosimetry, when
                 performed; 2-12
                 channels.
7778E.........  Remote afterloading high  NEW.................            5.4             5.4   No.
                 dose rate radionuclide
                 interstitial or
                 intracavitary
                 brachytherapy, includes
                 basic dosimetry, when
                 performed; over 12
                 channels.
88346.........  Antibody evaluation.....  0.86................            0.74            0.56  No.
8835X.........  Immunofluorescence, per   NEW.................            0.7             0.53  No.
                 specimen; each
                 additional single
                 antibody stain
                 procedure (List
                 separately in addition
                 to code for primary
                 procedure).
88367.........  Morphometric analysis,    0.73................            0.86            0.73  No.
                 in situ hybridization
                 (quantitative or semi-
                 quantitative), using
                 computer-assisted
                 technology, per
                 specimen: initial
                 single probe stain
                 procedure.
88368.........  Morphometric analysis,    0.88................            0.88            0.88  No.
                 in situ hybridization
                 (quantitative or semi-
                 quantitative) manual,
                 per specimen; initial
                 single probe stain
                 procedure.
91299.........  Procedure for             C...................            C               C     N/A
                 gastrointestinal
                 diagnosis.
9254A.........  Caloric vestibular test   NEW.................            0.8             0.6   No.
                 with recording,
                 bilateral; bithermal
                 (ie, one warm and one
                 cool irrigation in each
                 ear for a total of four
                 irrigations).
9254B.........  Caloric vestibular test   NEW.................            0.55            0.3   No.
                 with recording,
                 bilateral; monothermal
                 (ie, one irrigation in
                 each ear for a total of
                 two irrigations).
99174.........  Instrument-based ocular   N...................            0               N     No.
                 screening (eg,
                 photoscreening,
                 automated-refraction),
                 bilateral.
9917X.........  Instrument-based ocular   NEW.................            0               N     No.
                 screening (eg,
                 photoscreening,
                 automated-refraction),
                 bilateral; with on-site
                 analysis.
G0104.........  Colorectal cancer         0.96................            0.84            0.77  No.
                 screening; flexible
                 sigmoidoscopy.
G0105.........  Colorectal cancer         3.36................            3.36            3.29  No.
                 screening; colonoscopy
                 on individual at high
                 risk.
G0121.........  Colorectal cancer         3.36................            3.36            3.29  No.
                 screening; colonoscopy
                 on individual not
                 meeting criteria for
                 high risk.
----------------------------------------------------------------------------------------------------------------


[[Page 41725]]


  Table 12--CY 2016 Proposed Codes With Direct PE Input Recommendations
                       Accepted Without Refinement
------------------------------------------------------------------------
              HCPCS                             Descriptor
------------------------------------------------------------------------
20245...........................  Bone biopsy excisional.
20697...........................  Comp ext fixate strut change.
27280...........................  Fusion of sacroiliac joint.
3160A...........................  Bronch ebus 141 gmt. 141 ng 1/2 node.
3160B...........................  Bronch ebus 141 gmt. 141 ng 3/> node.
3160C...........................  Bronch ebus ivntj perph les.
31622...........................  Dx bronchoscope/wash.
31625...........................  Bronchoscopy w/biopsy(s).
31626...........................  Bronchoscopy w/markers.
31628...........................  Bronchoscopy/lung bx each.
31629...........................  Bronchoscopy/needle bx each.
31632...........................  Bronchoscopy/lung bx addl.
31633...........................  Bronchoscopy/needle bx addl.
3347A...........................  Implant tcat pulm vlv perq.
37215...........................  Transcath stent cca w/eps.
3725A...........................  Intrvasc us noncoronary 1st.
3725B...........................  Intrvasc us noncoronary addl.
38570...........................  Laparoscopy lymph node biop.
38571...........................  Laparoscopy lymphadenectomy.
3940A...........................  Mediastinoscpy w/medstnl bx.
3940B...........................  Mediastinoscpy w/lmph nod bx.
44384...........................  Small bowel endoscopy.
44402...........................  Colonoscopy w/stent plcmt.
44403...........................  Colonoscopy w/resection.
44406...........................  Colonoscopy w/ultrasound.
44407...........................  Colonoscopy w/ndl aspir/bx.
44408...........................  Colonoscopy w/decompression.
45337...........................  Sigmoidoscopy & decompress.
45341...........................  Sigmoidoscopy w/ultrasound.
45342...........................  Sigmoidoscopy w/us guide bx.
45347...........................  Sigmoidoscopy w/plcmt stent.
45349...........................  Sigmoidoscopy w/resection.
45389...........................  Colonoscopy w/stent plcmt.
45390...........................  Colonoscopy w/resection.
45391...........................  Colonoscopy w/endoscope us.
45392...........................  Colonoscopy w/endoscopic fnb.
45393...........................  Colonoscopy w/decompression.
47135...........................  Transplantation of liver.
5443B...........................  Replantation of penis.
63045...........................  Remove spine lamina 1 crvl.
63046...........................  Remove spine lamina 1 thrc.
68811...........................  Probe nasolacrimal duct.
68815...........................  Probe nasolacrimal duct.
692XX...........................  Remove impacted ear wax uni.
76948...........................  Echo guide ova aspiration.
7778A...........................  Hdr rdncl skn surf brachytx.
7778B...........................  Hdr rdncl skn surf brachytx.
7778C...........................  Hdr rdncl ntrstl/icav brchtx.
7778D...........................  Hdr rdncl ntrstl/icav brchtx.
7778E...........................  Hdr rdncl ntrstl/icav brchtx.
88346...........................  Immunofluorescent study.
8835X...........................  Immunofluor antb addl stain.
9254A...........................  Caloric vstblr test w/rec.
9254B...........................  Caloric vstblr test w/rec.
9935A...........................  Prolong clincl staff svc.
9935B...........................  Prolong clincl staff svc add.
------------------------------------------------------------------------


                             Table 13--CY 2016 Proposed Codes With Direct PE Input Recommendations Accepted With Refinements
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                  RUC
                                                                           Labor activity    recommendation      CMS                             Direct
 HCPCS code      HCPCS code      Input code      Input code       NF/F         (where          or current     refinement         Comment          costs
                 description                    description                 applicable)      value  (min or    (min or                           change
                                                                                                  qty)           qty)                              ($)
--------------------------------------------------------------------------------------------------------------------------------------------------------
10021......  Fna w/o image.....  EF015.....  mayo stand.......  NF       .................               24           28  Refined equipment     ........
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF023.....  table, exam......  NF       .................               29           28  Refined equipment     ........
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  NF       Greet patient,                   1            0  Typically billed        (0.37)
                                                                          provide gowning,                                 with an E/M or
                                                                          ensure                                           other evaluation
                                                                          appropriate                                      service.
                                                                          medical records
                                                                          are available.
11750......  Removal of nail     EF015.....  mayo stand.......  NF       .................               27           45  Refined equipment         0.02
              bed.                                                                                                         time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF031.....  table, power.....  NF       .................               54           62  Refined equipment         0.13
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               34           45  Refined equipment         0.03
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ168.....  light, exam......  NF       .................               54           62  Refined equipment         0.03
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  NF       Provide pre-                     0            2  Refined time to           0.74
                                                                          service                                          standard time for
                                                                          education/obtain                                 this clinical labor
                                                                          consent.                                         task.
                                 SG067.....  penrose drain      NF       .................                1            0  Removed supply not      (0.50)
                                              (0.25in x 4in).                                                              typically used in
                                                                                                                           this service.
11760......  Repair of nail bed  EF014.....  light, surgical..  NF       .................               45           43  Refined equipment       (0.02)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF015.....  mayo stand.......  NF       .................               45           43  Refined equipment     ........
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.

[[Page 41726]]

 
                                 EF031.....  table, power.....  NF       .................               72           70  Refined equipment       (0.03)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               52           47  Refined equipment       (0.01)
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ168.....  light, exam......  NF       .................               72           70  Refined equipment       (0.01)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Complete pre-                    5            0  Emergency procedure,    (1.85)
                                                                          service                                          input would not
                                                                          diagnostic &                                     typically be used.
                                                                          referral forms.
                                 L037D.....  RN/LPN/MTA.......  NF       Coordinate pre-                  3            0  Emergency procedure,    (1.11)
                                                                          surgery services.                                input would not
                                                                                                                           typically be used.
                                 L037D.....  RN/LPN/MTA.......  NF       Provide pre-                     5            0  Duplication with        (1.85)
                                                                          service                                          other clinical
                                                                          education/obtain                                 labor task.
                                                                          consent.
12005......  Rpr s/n/a/gen/      EF023.....  table, exam......  NF       .................               40           44  Refined equipment         0.01
              trk12.6-20.0cm.                                                                                              time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ110.....  electrocautery-    NF       .................               40           44  Refined equipment         0.01
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ168.....  light, exam......  NF       .................               40           44  Refined equipment         0.02
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Check dressings &                7            3  Refined time to         (1.48)
                                                                          wound/home care                                  standard time for
                                                                          instructions/                                    this clinical labor
                                                                          coordinate                                       task.
                                                                          office visits/
                                                                          prescriptions.
12006......  Rpr s/n/a/gen/      EF031.....  table, power.....  NF       .................               45           49  Refined equipment         0.07
              trk20.1-30.0cm.                                                                                              time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ110.....  electrocautery-    NF       .................               45           49  Refined equipment         0.01
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ168.....  light, exam......  NF       .................               45           49  Refined equipment         0.02
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Check dressings &                7            3  Refined time to         (1.48)
                                                                          wound/home care                                  standard time for
                                                                          instructions/                                    this clinical labor
                                                                          coordinate                                       task.
                                                                          office visits/
                                                                          prescriptions.
12007......  Rpr s/n/ax/gen/     EF031.....  table, power.....  NF       .................               50           54  Refined equipment         0.07
              trnk >30.0 cm.                                                                                               time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.

[[Page 41727]]

 
                                 EQ110.....  electrocautery-    NF       .................               50           54  Refined equipment         0.01
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ168.....  light, exam......  NF       .................               50           54  Refined equipment         0.02
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Check dressings &                7            3  Refined time to         (1.48)
                                                                          wound/home care                                  standard time for
                                                                          instructions/                                    this clinical labor
                                                                          coordinate                                       task.
                                                                          office visits/
                                                                          prescriptions.
12013......  Rpr f/e/e/n/l/m     EF031.....  table, power.....  NF       .................               27           33  Refined equipment         0.10
              2.6-5.0 cm.                                                                                                  time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ110.....  electrocautery-    NF       .................               27           33  Refined equipment         0.02
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ168.....  light, exam......  NF       .................               27           33  Refined equipment         0.03
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Check dressings &                5            3  Refined time to         (0.74)
                                                                          wound/home care                                  standard time for
                                                                          instructions/                                    this clinical labor
                                                                          coordinate                                       task.
                                                                          office visits/
                                                                          prescriptions.
12014......  Rpr f/e/e/n/l/m     EF031.....  table, power.....  NF       .................               32           38  Refined equipment         0.10
              5.1-7.5 cm.                                                                                                  time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ110.....  electrocautery-    NF       .................               32           38  Refined equipment         0.02
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ168.....  light, exam......  NF       .................               32           38  Refined equipment         0.03
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Check dressings &                5            3  Refined time to         (0.74)
                                                                          wound/home care                                  standard time for
                                                                          instructions/                                    this clinical labor
                                                                          coordinate                                       task.
                                                                          office visits/
                                                                          prescriptions.
12015......  Rpr f/e/e/n/l/m     EF031.....  table, power.....  NF       .................               37           43  Refined equipment         0.10
              7.6-12.5 cm.                                                                                                 time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ110.....  electrocautery-    NF       .................               37           43  Refined equipment         0.02
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ168.....  light, exam......  NF       .................               37           43  Refined equipment         0.03
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.

[[Page 41728]]

 
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Check dressings &                5            3  Refined time to         (0.74)
                                                                          wound/home care                                  standard time for
                                                                          instructions/                                    this clinical labor
                                                                          coordinate                                       task.
                                                                          office visits/
                                                                          prescriptions.
12016......  Rpr fe/e/en/l/m     EF031.....  table, power.....  NF       .................               42           48  Refined equipment         0.10
              12.6-20.0 cm.                                                                                                time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ110.....  electrocautery-    NF       .................               42           48  Refined equipment         0.02
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ168.....  light, exam......  NF       .................               42           48  Refined equipment         0.03
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Check dressings &                5            3  Refined time to         (0.74)
                                                                          wound/home care                                  standard time for
                                                                          instructions/                                    this clinical labor
                                                                          coordinate                                       task.
                                                                          office visits/
                                                                          prescriptions.
12041......  Intmd rpr n-hf/     ED004.....  camera, digital    F        .................                0           27  Input added to            0.10
              genit 2.5cm/<.                  (6 mexapixel).                                                               maintain
                                                                                                                           consistency with
                                                                                                                           all other codes
                                                                                                                           within family.
                                 ED004.....  camera, digital    NF       .................               60           27  Refined equipment       (0.12)
                                              (6 mexapixel).                                                               time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 EF014.....  light, surgical..  NF       .................               33           42  Refined equipment         0.09
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF015.....  mayo stand.......  NF       .................               33           42  Refined equipment         0.01
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF023.....  table, exam......  NF       .................               60           27  Refined equipment       (0.10)
                                                                                                                           time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 EF031.....  table, power.....  NF       .................               33           42  Refined equipment         0.15
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ110.....  electrocautery-    NF       .................               33           42  Refined equipment         0.02
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................                0           46  Equipment item            0.11
                                              basic ($500-                                                                 replaces another
                                              $1,499).                                                                     item (EQ138); see
                                                                                                                           preamble.
                                 EQ138.....  instrument pack,   NF       .................               40            0  Equipment item          (0.28)
                                              medium ($1,500                                                               replaced by another
                                              and up).                                                                     item (EQ137); see
                                                                                                                           preamble.
                                 EQ168.....  light, exam......  NF       .................               60           27  Refined equipment       (0.14)
                                                                                                                           time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  F        Provide pre-                     2            0  Intraservice direct     (0.74)
                                                                          service                                          PE inputs are not
                                                                          education/obtain                                 included in the
                                                                          consent.                                         facility setting;
                                                                                                                           See preamble text.

[[Page 41729]]

 
                                 L037D.....  RN/LPN/MTA.......  NF       Complete pre-                    5            0  Emergency procedure,    (1.85)
                                                                          service                                          input would not
                                                                          diagnostic &                                     typically be used.
                                                                          referral forms.
                                 L037D.....  RN/LPN/MTA.......  NF       Coordinate pre-                  3            0  Emergency procedure,    (1.11)
                                                                          surgery services.                                input would not
                                                                                                                           typically be used.
                                 L037D.....  RN/LPN/MTA.......  NF       Follow-up phone                  3            0  Emergency procedure,    (1.11)
                                                                          calls and                                        input would not
                                                                          prescriptions.                                   typically be used.
12054......  Intmd rpr face/mm   ED004.....  camera, digital    NF       .................               90           27  Refined equipment       (0.24)
              7.6-12.5cm.                     (6 mexapixel).                                                               time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 EF014.....  light, surgical..  NF       .................               63           71  Refined equipment         0.08
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF015.....  mayo stand.......  NF       .................               63           71  Refined equipment         0.01
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF023.....  table, exam......  NF       .................               90           27  Refined equipment       (0.19)
                                                                                                                           time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 EF031.....  table, power.....  NF       .................               63           71  Refined equipment         0.13
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ110.....  electrocautery-    NF       .................               63           71  Refined equipment         0.02
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ138.....  instrument pack,   NF       .................               75           80  Refined equipment         0.03
                                              medium ($1,500                                                               time to conform to
                                              and up).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ168.....  light, exam......  NF       .................               90           27  Refined equipment       (0.27)
                                                                                                                           time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  F        Provide pre-                     2            0  Intraservice direct     (0.74)
                                                                          service                                          PE inputs are not
                                                                          education/obtain                                 included in the
                                                                          consent.                                         facility setting;
                                                                                                                           See preamble text.
                                 L037D.....  RN/LPN/MTA.......  NF       Complete pre-                    5            0  Emergency procedure,    (1.85)
                                                                          service                                          input would not
                                                                          diagnostic &                                     typically be used.
                                                                          referral forms.
                                 L037D.....  RN/LPN/MTA.......  NF       Coordinate pre-                  3            0  Emergency procedure,    (1.11)
                                                                          surgery services.                                input would not
                                                                                                                           typically be used.
                                 L037D.....  RN/LPN/MTA.......  NF       Follow-up phone                  3            0  Emergency procedure,    (1.11)
                                                                          calls and                                        input would not
                                                                          prescriptions.                                   typically be used.
12055......  Intmd rpr face/mm   ED004.....  camera, digital    NF       .................              136           63  Refined equipment       (0.27)
              12.6-20 cm.                     (6 mexapixel).                                                               time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 EF014.....  light, surgical..  NF       .................               73           81  Refined equipment         0.08
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF015.....  mayo stand.......  NF       .................               73           81  Refined equipment         0.01
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF023.....  table, exam......  NF       .................              136           63  Refined equipment       (0.22)
                                                                                                                           time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 EF031.....  table, power.....  NF       .................               73           81  Refined equipment         0.13
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.

[[Page 41730]]

 
                                 EQ110.....  electrocautery-    NF       .................               73           81  Refined equipment         0.02
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ138.....  instrument pack,   NF       .................               85           90  Refined equipment         0.03
                                              medium ($1,500                                                               time to conform to
                                              and up).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ168.....  light, exam......  NF       .................              136           63  Refined equipment       (0.32)
                                                                                                                           time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 L037D.....  RN/LPN/MTA.......  F        Provide pre-                     2            0  Intraservice direct     (0.74)
                                                                          service                                          PE inputs are not
                                                                          education/obtain                                 included in the
                                                                          consent.                                         facility setting;
                                                                                                                           See preamble text.
                                 L037D.....  RN/LPN/MTA.......  NF       Complete pre-                    5            0  Emergency procedure,    (1.85)
                                                                          service                                          input would not
                                                                          diagnostic &                                     typically be used.
                                                                          referral forms.
                                 L037D.....  RN/LPN/MTA.......  NF       Coordinate pre-                  3            0  Emergency procedure,    (1.11)
                                                                          surgery services.                                input would not
                                                                                                                           typically be used.
                                 L037D.....  RN/LPN/MTA.......  NF       Follow-up phone                  3            0  Emergency procedure,    (1.11)
                                                                          calls and                                        input would not
                                                                          prescriptions.                                   typically be used.
                                 SA054.....  pack, post-op      F        .................                2            1  No rationale was        (4.91)
                                              incision care                                                                provided for
                                              (suture).                                                                    quantity change
                                                                                                                           relative to current
                                                                                                                           value; maintaining
                                                                                                                           current value.
12057......  Intmd rpr face/mm   ED004.....  camera, digital    NF       .................              166           63  Refined equipment       (0.39)
              >30.0 cm.                       (6 mexapixel).                                                               time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 EF014.....  light, surgical..  NF       .................              103          111  Refined equipment         0.08
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF015.....  mayo stand.......  NF       .................              103          111  Refined equipment         0.01
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF023.....  table, exam......  NF       .................              166           63  Refined equipment       (0.31)
                                                                                                                           time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 EF031.....  table, power.....  NF       .................              103          111  Refined equipment         0.13
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ110.....  electrocautery-    NF       .................              103          111  Refined equipment         0.02
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ138.....  instrument pack,   NF       .................              115          120  Refined equipment         0.03
                                              medium ($1,500                                                               time to conform to
                                              and up).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ168.....  light, exam......  NF       .................              166           63  Refined equipment       (0.45)
                                                                                                                           time to conform to
                                                                                                                           office visit
                                                                                                                           duration.
                                 L037D.....  RN/LPN/MTA.......  F        Provide pre-                     2            0  Intraservice direct     (0.74)
                                                                          service                                          PE inputs are not
                                                                          education/obtain                                 included in the
                                                                          consent.                                         facility setting;
                                                                                                                           See preamble text.
                                 L037D.....  RN/LPN/MTA.......  NF       Complete pre-                    5            0  Emergency procedure,    (1.85)
                                                                          service                                          input would not
                                                                          diagnostic &                                     typically be used.
                                                                          referral forms.
                                 L037D.....  RN/LPN/MTA.......  NF       Coordinate pre-                  3            0  Emergency procedure,    (1.11)
                                                                          surgery services.                                input would not
                                                                                                                           typically be used.
                                 L037D.....  RN/LPN/MTA.......  NF       Follow-up phone                  3            0  Emergency procedure,    (1.11)
                                                                          calls and                                        input would not
                                                                          prescriptions.                                   typically be used.
                                 SA054.....  pack, post-op      F        .................                2            1  No rationale was        (4.91)
                                              incision care                                                                provided for
                                              (suture).                                                                    quantity change
                                                                                                                           relative to current
                                                                                                                           value; maintaining
                                                                                                                           current value.

[[Page 41731]]

 
                                 SA054.....  pack, post-op      NF       .................                2            1  No rationale was        (4.91)
                                              incision care                                                                provided for
                                              (suture).                                                                    quantity change
                                                                                                                           relative to current
                                                                                                                           value; maintaining
                                                                                                                           current value.
20240......  Bone biopsy         L037D.....  RN/LPN/MTA.......  F        Dischrg gmt. same                6            0  Aligned clinical        (2.22)
              excisional.                                                 day (0.5 x                                       labor discharge day
                                                                          99238) (enter 6                                  management time
                                                                          min).                                            with the work time
                                                                                                                           discharge day code.
30300......  Remove nasal        EF008.....  chair with         NF       .................               59           67  Refined equipment         0.09
              foreign body.                   headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF015.....  mayo stand.......  NF       .................               22           40  Refined equipment         0.02
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               29           47  Refined equipment         0.04
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ167.....  light source,      F        .................               27            0  Redundant when used     (0.72)
                                              xenon.                                                                       together with
                                                                                                                           EQ170; see preamble.
                                 EQ167.....  light source,      NF       .................               59            0  Redundant when used     (1.57)
                                              xenon.                                                                       together with
                                                                                                                           EQ170; see preamble.
                                 EQ170.....  light, fiberoptic  NF       .................               59           67  Refined equipment         0.06
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ234.....  suction and        NF       .................               59           67  Refined equipment         0.07
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 ES013.....  endoscope, rigid,  NF       .................               71           74  Refined equipment         0.02
                                              sinoscopy.                                                                   time to conform to
                                                                                                                           established
                                                                                                                           policies for scopes.
                                 ES031.....  video system,      NF       .................               59           67  Refined equipment         1.03
                                              endoscopy                                                                    time to conform to
                                              (processor,                                                                  established
                                              digital capture,                                                             policies for non-
                                              monitor,                                                                     highly technical
                                              printer, cart).                                                              equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Discharge day                    6            0  Aligned clinical        (2.22)
                                                                          management.                                      labor discharge day
                                                                                                                           management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 SA041.....  pack, basic        NF       .................                1            0  Supply item replaced   (11.67)
                                              injection.                                                                   by another item
                                                                                                                           (component parts);
                                                                                                                           see preamble.
                                 SB001.....  cap, surgical....  NF       .................                0            1  Supply item replaces      0.21
                                                                                                                           another item
                                                                                                                           (SA041); see
                                                                                                                           preamble.
                                 SB012.....  drape, sterile,    NF       .................                0            1  Supply item replaces      1.69
                                              for Mayo stand.                                                              another item
                                                                                                                           (SA041); see
                                                                                                                           preamble.
                                 SB024.....  gloves, sterile..  NF       .................                0            2  Supply item replaces      1.68
                                                                                                                           another item
                                                                                                                           (SA041); see
                                                                                                                           preamble.
                                 SB027.....  gown, staff,       NF       .................                0            2  Supply item replaces      2.37
                                              impervious.                                                                  another item
                                                                                                                           (SA041); see
                                                                                                                           preamble.
                                 SB033.....  mask, surgical...  NF       .................                0            1  Supply item replaces      0.20
                                                                                                                           another item
                                                                                                                           (SA041); see
                                                                                                                           preamble.
                                 SB044.....  underpad 2ft x     NF       .................                0            1  Supply item replaces      0.23
                                              3ft (Chux).                                                                  another item
                                                                                                                           (SA041); see
                                                                                                                           preamble.
                                 SG009.....  applicator,        NF       .................                0            3  Supply item replaces      0.42
                                              sponge-tipped.                                                               another item
                                                                                                                           (SA041); see
                                                                                                                           preamble.
                                 SG055.....  gauze, sterile     NF       .................                0            2  Supply item replaces      0.32
                                              4in x 4in.                                                                   another item
                                                                                                                           (SA041); see
                                                                                                                           preamble.
                                 SM010.....  cleaning brush,    F        .................                2            1  Refined supply          (4.99)
                                              endoscope.                                                                   quantity to what is
                                                                                                                           typical for the
                                                                                                                           procedure.

[[Page 41732]]

 
                                 SM010.....  cleaning brush,    NF       .................                4            2  Refined supply          (9.98)
                                              endoscope.                                                                   quantity to what is
                                                                                                                           typical for the
                                                                                                                           procedure.
30903......  Control of          EF008.....  chair with         NF       .................               54          110  Refined equipment         0.60
              nosebleed.                      headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 EQ110.....  electrocautery-    NF       .................               54           50  Refined equipment       (0.01)
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               61           54  Refined equipment       (0.02)
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ170.....  light, fiberoptic  NF       .................               54           50  Refined equipment       (0.03)
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ234.....  suction and        NF       .................               54          110  Refined equipment         0.52
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 L037D.....  RN/LPN/MTA.......  F        Dischrg gmt. same                6            0  Aligned clinical        (2.22)
                                                                          day (0.5 x                                       labor discharge day
                                                                          99238) (enter 6                                  management time
                                                                          min).                                            with the work time
                                                                                                                           discharge day code.
30905......  Control of          EF008.....  chair with         NF       .................               72          128  Refined equipment         0.60
              nosebleed.                      headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 EQ110.....  electrocautery-    NF       .................               72           68  Refined equipment       (0.01)
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               79           72  Refined equipment       (0.02)
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ170.....  light, fiberoptic  NF       .................               72           68  Refined equipment       (0.03)
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ234.....  suction and        NF       .................               72          128  Refined equipment         0.52
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 L037D.....  RN/LPN/MTA.......  F        Dischrg gmt. same                6            0  Aligned clinical        (2.22)
                                                                          day (0.5 x                                       labor discharge day
                                                                          99238) (enter 6                                  management time
                                                                          min).                                            with the work time
                                                                                                                           discharge day code.
30906......  Repeat control of   EF008.....  chair with         NF       .................               84          140  Refined equipment         0.60
              nosebleed.                      headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 EQ110.....  electrocautery-    NF       .................               84           80  Refined equipment       (0.01)
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               91           84  Refined equipment       (0.02)
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ170.....  light, fiberoptic  NF       .................               84           80  Refined equipment       (0.03)
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ234.....  suction and        NF       .................               84          140  Refined equipment         0.52
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
31295......  Sinus endo w/       EF008.....  chair with         NF       .................               50          103  Refined equipment         0.57
              balloon dil.                    headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.

[[Page 41733]]

 
                                 EF015.....  mayo stand.......  NF       .................               32           43  Refined equipment         0.01
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               42           47  Refined equipment         0.01
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ167.....  light source,      NF       .................               50            0  Redundant when used     (1.33)
                                              xenon.                                                                       together with
                                                                                                                           EQ170; see preamble.
                                 EQ170.....  light, fiberoptic  NF       .................               50           43  Refined equipment       (0.06)
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ234.....  suction and        NF       .................               50          103  Refined equipment         0.49
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 ES013.....  endoscope, rigid,  NF       .................               44           47  Refined equipment         0.02
                                              sinoscopy.                                                                   time to conform to
                                                                                                                           established
                                                                                                                           policies for scopes.
                                 ES031.....  video system,      NF       .................               50           43  Refined equipment       (0.90)
                                              endoscopy                                                                    time to conform to
                                              (processor,                                                                  established
                                              digital capture,                                                             policies for non-
                                              monitor,                                                                     highly technical
                                              printer, cart).                                                              equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Dischrg gmt. same                6            0  Aligned clinical        (2.22)
                                                                          day (0.5 x                                       labor discharge day
                                                                          99238) (enter 6                                  management time
                                                                          min).                                            with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Complete pre-                    5            0  See preamble text...    (1.85)
                                                                          service
                                                                          diagnostic &
                                                                          referral forms.
                                 L037D.....  RN/LPN/MTA.......  NF       Provide pre-                     7            3  Refined time to         (1.48)
                                                                          service                                          standard time for
                                                                          education/obtain                                 this clinical labor
                                                                          consent.                                         task.
                                 L037D.....  RN/LPN/MTA.......  NF       Sedate/Apply                     5            2  Refined time to         (1.11)
                                                                          anesthesia.                                      standard time for
                                                                                                                           this clinical labor
                                                                                                                           task.
                                 SJ037.....  oxymetazoline      NF       .................                3            1  Refined supply          (3.66)
                                              nasal spray                                                                  quantity to what is
                                              (Afrin) (15ml                                                                typical for the
                                              uou).                                                                        procedure.
31296......  Sinus endo w/       EF008.....  chair with         NF       .................               60          113  Refined equipment         0.57
              balloon dil.                    headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 EF015.....  mayo stand.......  NF       .................               60           53  Refined equipment       (0.01)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               52           57  Refined equipment         0.01
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ167.....  light source,      NF       .................               60            0  Redundant when used     (1.60)
                                              xenon.                                                                       together with
                                                                                                                           EQ170; see preamble.
                                 EQ170.....  light, fiberoptic  NF       .................               60           53  Refined equipment       (0.06)
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ234.....  suction and        NF       .................               60          113  Refined equipment         0.49
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 ES013.....  endoscope, rigid,  NF       .................               54           57  Refined equipment         0.02
                                              sinoscopy.                                                                   time to conform to
                                                                                                                           established
                                                                                                                           policies for scopes.
                                 ES031.....  video system,      NF       .................               60           53  Refined equipment       (0.90)
                                              endoscopy                                                                    time to conform to
                                              (processor,                                                                  established
                                              digital capture,                                                             policies for non-
                                              monitor,                                                                     highly technical
                                              printer, cart).                                                              equipment.

[[Page 41734]]

 
                                 L037D.....  RN/LPN/MTA.......  F        Dischrg gmt. same                6            0  Aligned clinical        (2.22)
                                                                          day (0.5 x                                       labor discharge day
                                                                          99238) (enter 6                                  management time
                                                                          min).                                            with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Complete pre-                    5            0  See preamble text...    (1.85)
                                                                          service
                                                                          diagnostic &
                                                                          referral forms.
                                 L037D.....  RN/LPN/MTA.......  NF       Provide pre-                     7            3  Refined time to         (1.48)
                                                                          service                                          standard time for
                                                                          education/obtain                                 this clinical labor
                                                                          consent.                                         task.
                                 L037D.....  RN/LPN/MTA.......  NF       Sedate/Apply                     5            2  Refined time to         (1.11)
                                                                          anesthesia.                                      standard time for
                                                                                                                           this clinical labor
                                                                                                                           task.
                                 SJ037.....  oxymetazoline      NF       .................                3            1  Refined supply          (3.66)
                                              nasal spray                                                                  quantity to what is
                                              (Afrin) (15ml                                                                typical for the
                                              uou).                                                                        procedure.
31297......  Sinus endo w/       EF008.....  chair with         NF       .................               58          111  Refined equipment         0.57
              balloon dil.                    headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 EF015.....  mayo stand.......  NF       .................               40           51  Refined equipment         0.01
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               47           55  Refined equipment         0.02
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ167.....  light source,      NF       .................               58            0  Redundant when used     (1.55)
                                              xenon.                                                                       together with
                                                                                                                           EQ170; see preamble.
                                 EQ170.....  light, fiberoptic  NF       .................               58           51  Refined equipment       (0.06)
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ234.....  suction and        NF       .................               58          111  Refined equipment         0.49
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 ES013.....  endoscope, rigid,  NF       .................               52           55  Refined equipment         0.02
                                              sinoscopy.                                                                   time to conform to
                                                                                                                           established
                                                                                                                           policies for scopes.
                                 ES031.....  video system,      NF       .................               58           51  Refined equipment       (0.90)
                                              endoscopy                                                                    time to conform to
                                              (processor,                                                                  established
                                              digital capture,                                                             policies for non-
                                              monitor,                                                                     highly technical
                                              printer, cart).                                                              equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Dischrg gmt. same                6            0  Aligned clinical        (2.22)
                                                                          day (0.5 x                                       labor discharge day
                                                                          99238) (enter 6                                  management time
                                                                          min).                                            with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Complete pre-                    5            0  See preamble text...    (1.85)
                                                                          service
                                                                          diagnostic &
                                                                          referral forms.
                                 L037D.....  RN/LPN/MTA.......  NF       Provide pre-                     7            3  Refined time to         (1.48)
                                                                          service                                          standard time for
                                                                          education/obtain                                 this clinical labor
                                                                          consent.                                         task.
                                 L037D.....  RN/LPN/MTA.......  NF       Sedate/Apply                     5            2  Refined time to         (1.11)
                                                                          anesthesia.                                      standard time for
                                                                                                                           this clinical labor
                                                                                                                           task.
                                 SJ037.....  oxymetazoline      NF       .................                3            1  Refined supply          (3.66)
                                              nasal spray                                                                  quantity to what is
                                              (Afrin) (15ml                                                                typical for the
                                              uou).                                                                        procedure.
38572......  Laparoscopy         SA051.....  pack, pelvic exam  F        .................                1            0  Removed supply not      (1.17)
              lymphadenectomy.                                                                                             typically used in
                                                                                                                           this service.
40804......  Removal foreign     EF008.....  chair with         NF       .................               74           82  Refined equipment         0.09
              body mouth.                     headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ110.....  electrocautery-    NF       .................               29           39  Refined equipment         0.03
                                              hyfrecator, up                                                               time to conform to
                                              to 45 watts.                                                                 established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.

[[Page 41735]]

 
                                 EQ137.....  instrument pack,   NF       .................               36           38  Refined equipment           --
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ170.....  light, fiberoptic  NF       .................               74           82  Refined equipment         0.06
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ234.....  suction and        F        .................               27            0  Equipment usage not     (0.25)
                                              pressure                                                                     typical for a
                                              cabinet, ENT                                                                 follow-up office
                                              (SMR).                                                                       visit.
                                 EQ234.....  suction and        NF       .................               61           39  Refined equipment       (0.20)
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Dischrg gmt. same                6            0  Aligned clinical        (2.22)
                                                                          day (0.5 x                                       labor discharge day
                                                                          99238) (enter 6                                  management time
                                                                          min).                                            with the work time
                                                                                                                           discharge day code.
                                 SD009.....  canister, suction  NF       .................                2            1  Refined supply          (3.91)
                                                                                                                           quantity to what is
                                                                                                                           typical for the
                                                                                                                           procedure.
42809......  Remove pharynx      EF008.....  chair with         NF       .................               58           74  Refined equipment         0.17
              foreign body.                   headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF015.....  mayo stand.......  NF       .................               26           47  Refined equipment         0.02
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               60           51  Refined equipment       (0.02)
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ170.....  light, fiberoptic  NF       .................               58           74  Refined equipment         0.13
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ234.....  suction and        F        .................               27            0  Equipment usage not     (0.25)
                                              pressure                                                                     typical for a
                                              cabinet, ENT                                                                 follow-up office
                                              (SMR).                                                                       visit.
                                 EQ234.....  suction and        NF       .................               58           47  Refined equipment       (0.10)
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 ES020.....  fiberscope,        NF       .................              115          128  Refined equipment         0.47
                                              flexible,                                                                    time to conform to
                                              rhinolaryngoscop                                                             established
                                              y.                                                                           policies for scopes.
                                 L037D.....  RN/LPN/MTA.......  F        Dischrg gmt. same                6            0  Aligned clinical        (2.22)
                                                                          day (0.5 x                                       labor discharge day
                                                                          99238) (enter 6                                  management time
                                                                          min).                                            with the work time
                                                                                                                           discharge day code.
                                 SA048.....  pack, minimum      F        .................                2            1  Refined supply          (1.14)
                                              multi-specialty                                                              quantity to what is
                                              visit.                                                                       typical for the
                                                                                                                           procedure.
44380......  Small bowel         EF018.....  stretcher........  NF       .................               73           77  Standard time for         0.02
              endoscopy br/wa.                                                                                             moderate sedation
                                                                                                                           equipment.
                                 EF027.....  table,             NF       .................               29           77  Standard time for         0.07
                                              instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               29            0  Equipment removed       (0.47)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               52           77  Standard time for         0.35
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               52           77  Standard time for         0.16
                                                                                                                           moderate sedation
                                                                                                                           equipment.
44381......  Small bowel         EF018.....  stretcher........  NF       .................               83           87  Standard equipment        0.02
              endoscopy br/wa.                                                                                             and time for
                                                                                                                           moderate sedation.
                                 EF027.....  table,             NF       .................               39           87  Standard equipment        0.07
                                              instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EQ011.....  ECG, 3-channel     NF       .................               62           87  Standard equipment        0.35
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).

[[Page 41736]]

 
                                 EQ032.....  IV infusion pump.  NF       .................               62           87  Standard equipment        0.16
                                                                                                                           and time for
                                                                                                                           moderate sedation.
44382......  Small bowel         EF018.....  stretcher........  NF       .................               78           82  Standard time for         0.02
              endoscopy.                                                                                                   moderate sedation
                                                                                                                           equipment.
                                 EF027.....  table,             NF       .................               34           82  Standard time for         0.07
                                              instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               34            0  Equipment removed       (0.56)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               57           82  Standard time for         0.35
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               57           82  Standard time for         0.16
                                                                                                                           moderate sedation
                                                                                                                           equipment.
44385......  Endoscopy of bowel  EF027.....  table,             NF       .................               29           77  Standard time for         0.07
              pouch.                          instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               29            0  Equipment removed       (0.47)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               52           77  Refined equipment         0.35
                                              (with SpO2,                                                                  time to conform to
                                              NIBP, temp,                                                                  established
                                              resp).                                                                       policies for
                                                                                                                           equipment with 4x
                                                                                                                           monitoring time.
                                 EQ032.....  IV infusion pump.  NF       .................               52           77  Standard time for         0.16
                                                                                                                           moderate sedation
                                                                                                                           equipment.
44386......  Endoscopy bowel     EF027.....  table,             NF       .................               31           79  Standard time for         0.07
              pouch/biop.                     instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               31            0  Equipment removed       (0.51)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               54           79  Standard time for         0.35
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               54           79  Standard time for         0.16
                                                                                                                           moderate sedation
                                                                                                                           equipment.
44388......  Colonoscopy thru    EF027.....  table,             NF       .................               57           87  Standard time for         0.04
              stoma spx.                      instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               39            0  Equipment removed       (0.64)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               57           87  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               57           87  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
44389......  Colonoscopy with    EF027.....  table,             NF       .................               62           92  Standard time for         0.04
              biopsy.                         instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               44            0  Equipment removed       (0.72)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               62           92  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               62           92  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
44390......  Colonoscopy for     EF027.....  table,             NF       .................               67           97  Standard time for         0.04
              foreign body.                   instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               49            0  Equipment removed       (0.80)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.

[[Page 41737]]

 
                                 EQ011.....  ECG, 3-channel     NF       .................               67           97  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               67           97  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
44391......  Colonoscopy for     EF027.....  table,             NF       .................               72          102  Standard time for         0.04
              bleeding.                       instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               54            0  Equipment removed       (0.88)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               72          102  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               72          102  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
44392......  Colonoscopy &       EF027.....  table,             NF       .................               62           92  Standard time for         0.04
              polypectomy.                    instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               44            0  Equipment removed       (0.72)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               62           92  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               62           92  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
44394......  Colonoscopy w/      EF027.....  table,             NF       .................               62           92  Standard time for         0.04
              snare.                          instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               44            0  Equipment removed       (0.72)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               62           92  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               62           92  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
44401......  Colonoscopy with    EF027.....  table,             NF       .................               62           92  Standard equipment        0.04
              ablation.                       instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EF031.....  table, power.....  NF       .................               44            0  Refined equipment       (0.72)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ011.....  ECG, 3-channel     NF       .................               62           92  Standard equipment        0.42
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               62           92  Standard equipment        0.19
                                                                                                                           and time for
                                                                                                                           moderate sedation.
44404......  Colonoscopy w/      EF027.....  table,             NF       .................               62           92  Standard equipment        0.04
              injection.                      instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EQ011.....  ECG, 3-channel     NF       .................               62           92  Standard equipment        0.42
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               62           92  Standard equipment        0.19
                                                                                                                           and time for
                                                                                                                           moderate sedation.
44405......  Colonoscopy w/      EF027.....  table,             NF       .................               40          100  Standard equipment        0.08
              dilation.                       instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EQ011.....  ECG, 3-channel     NF       .................               50          100  Standard equipment        0.70
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               50          100  Standard equipment        0.32
                                                                                                                           and time for
                                                                                                                           moderate sedation.
45330......  Diagnostic          EF027.....  table,             NF       .................               12            0  No moderate sedation    (0.02)
              sigmoidoscopy.                  instrument,
                                              mobile.

[[Page 41738]]

 
                                 EQ011.....  ECG, 3-channel     NF       .................               18            0  No moderate sedation    (0.25)
                                              (with SpO2,
                                              NIBP, temp,
                                              resp).
                                 EQ235.....  suction machine    NF       .................               12           22  Increased to reflect      0.02
                                              (Gomco).                                                                     Intra-Service
                                                                                                                           clinical labor
                                                                                                                           tasks.
                                 ES031.....  video system,      NF       .................               12           22  Increased to reflect      1.29
                                              endoscopy                                                                    Intra-Service
                                              (processor,                                                                  clinical labor
                                              digital capture,                                                             tasks.
                                              monitor,
                                              printer, cart).
                                 ES043.....  Video Sigmoid-     NF       .................               42           49  Refined equipment         0.49
                                              oscope.                                                                      time to conform to
                                                                                                                           established
                                                                                                                           policies for scopes.
45331......  Sigmoidoscopy and   EF027.....  table,             NF       .................               12            0  No moderate sedation    (0.02)
              biopsy.                         instrument,
                                              mobile.
                                 EQ011.....  ECG, 3-channel     NF       .................               33            0  No moderate sedation    (0.46)
                                              (with SpO2,
                                              NIBP, temp,
                                              resp).
                                 EQ235.....  suction machine    NF       .................               12           27  Matches time spent        0.03
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
                                 ES031.....  video system,      NF       .................               12           27  Increased to reflect      1.93
                                              endoscopy                                                                    Intra-Service
                                              (processor,                                                                  clinical labor
                                              digital capture,                                                             tasks.
                                              monitor,
                                              printer, cart).
                                 ES043.....  Video Sigmoid-     NF       .................               42           54  Refined equipment         0.83
                                              oscope.                                                                      time to conform to
                                                                                                                           established
                                                                                                                           policies for scopes.
45332......  Sigmoidoscopy w/fb  EF027.....  table,             NF       .................               34           82  Standard time for         0.07
              removal.                        instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               34            0  Equipment removed       (0.56)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               57           82  Standard time for         0.35
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               57           82  Standard time for         0.16
                                                                                                                           moderate sedation
                                                                                                                           equipment.
45333......  Sigmoidoscopy &     EF027.....  table,             NF       .................               29           77  Standard time for         0.07
              polypectomy.                    instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               29            0  Equipment removed       (0.47)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               52           77  Standard time for         0.35
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               52           77  Standard time for         0.16
                                                                                                                           moderate sedation
                                                                                                                           equipment.
45334......  Sigmoidoscopy for   EF027.....  table,             NF       .................               34           82  Standard time for         0.07
              bleeding.                       instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               34            0  Equipment removed       (0.56)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               57           82  Standard time for         0.35
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               57           82  Standard time for         0.16
                                                                                                                           moderate sedation
                                                                                                                           equipment.
45335......  Sigmoidoscopy w/    EF027.....  table,             NF       .................               29           77  Standard time for         0.07
              submuc inj.                     instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               29            0  Equipment removed       (0.47)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.

[[Page 41739]]

 
                                 EQ011.....  ECG, 3-channel     NF       .................               52           77  Standard time for         0.35
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               52           77  Standard time for         0.16
                                                                                                                           moderate sedation
                                                                                                                           equipment.
45338......  Sigmoidoscopy w/    EF027.....  table,             NF       .................               29           77  Standard time for         0.07
              tumr remove.                    instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EQ011.....  ECG, 3-channel     NF       .................               52           77  Standard time for         0.35
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               52           77  Standard time for         0.16
                                                                                                                           moderate sedation
                                                                                                                           equipment.
45340......  Sig w/tndsc         EF027.....  table,             NF       .................               34           82  Standard time for         0.07
              balloon dilation.               instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EQ011.....  ECG, 3-channel     NF       .................               57           82  Standard time for         0.35
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               57           82  Standard time for         0.16
                                                                                                                           moderate sedation
                                                                                                                           equipment.
45346......  Sigmoidoscopy w/    EF027.....  table,             NF       .................               34           82  Standard equipment        0.07
              ablation.                       instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EQ011.....  ECG, 3-channel     NF       .................               57           82  Standard equipment        0.35
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               57           82  Standard equipment        0.16
                                                                                                                           and time for
                                                                                                                           moderate sedation.
45350......  Sgmdsc w/band       EF027.....  table,             NF       .................               94           82  Standard equipment      (0.02)
              ligation.                       instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EQ011.....  ECG, 3-channel     NF       .................               94           82  Standard equipment      (0.17)
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               94           82  Standard equipment      (0.08)
                                                                                                                           and time for
                                                                                                                           moderate sedation.
                                 SH074.....  water, sterile     NF       .................                1            0  This input is not       (2.09)
                                              for irrigation                                                               contained within
                                              (250-1000ml uou).                                                            any other code in
                                                                                                                           this family;
                                                                                                                           maintaining
                                                                                                                           consistency with
                                                                                                                           all other codes
                                                                                                                           within family.
                                 SK087.....  water, distilled.  NF       .................                0            5  This input is not         0.07
                                                                                                                           contained within
                                                                                                                           any other code in
                                                                                                                           this family;
                                                                                                                           maintaining
                                                                                                                           consistency with
                                                                                                                           all other codes
                                                                                                                           within family.
45378......  Diagnostic          EF027.....  table,             NF       .................               57           87  Standard time for         0.04
              colonoscopy.                    instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               39            0  Equipment removed       (0.64)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               57           87  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               57           87  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
                                 EQ235.....  suction machine    NF       .................               72           39  Matches time spent      (0.07)
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
45379......  Colonoscopy w/fb    EF027.....  table,             NF       .................               67           97  Standard time for         0.04
              removal.                        instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               49            0  Equipment removed       (0.80)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               67           97  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               67           97  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.

[[Page 41740]]

 
                                 EQ235.....  suction machine    NF       .................               92           49  Matches time spent      (0.08)
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
45380......  Colonoscopy and     EF027.....  table,             NF       .................               60           90  Standard time for         0.04
              biopsy.                         instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               42            0  Equipment removed       (0.69)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               60           90  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               60           90  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
                                 EQ235.....  suction machine    NF       .................               78           42  Matches time spent      (0.07)
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
45381......  Colonoscopy         EF027.....  table,             NF       .................               60           90  Standard time for         0.04
              submucous njx.                  instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               42            0  Equipment removed       (0.69)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               60           90  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               60           90  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
                                 EQ235.....  suction machine    NF       .................               78           42  Matches time spent      (0.07)
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
45382......  Colonoscopy w/      EF027.....  table,             NF       .................               72          102  Standard time for         0.04
              control bleed.                  instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               54            0  Equipment removed       (0.88)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               72          102  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               72          102  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
                                 EQ235.....  suction machine    NF       .................              102           54  Matches time spent      (0.09)
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
45384......  Colonoscopy w/      EF027.....  table,             NF       .................               60           90  Standard time for         0.04
              lesion removal.                 instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               42            0  Equipment removed       (0.69)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               60           90  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               60           90  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
                                 EQ235.....  suction machine    NF       .................               78           42  Matches time spent      (0.07)
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
45385......  Colonoscopy w/      EF027.....  table,             NF       .................               62           92  Standard time for         0.04
              lesion removal.                 instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.
                                 EF031.....  table, power.....  NF       .................               44            0  Equipment removed       (0.72)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               62           92  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               62           92  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
                                 EQ235.....  suction machine    NF       .................               82           44  Matches time spent      (0.07)
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
45386......  Colonoscopy w/      EF027.....  table,             NF       .................               67           97  Standard time for         0.04
              balloon dilat.                  instrument,                                                                  moderate sedation
                                              mobile.                                                                      equipment.

[[Page 41741]]

 
                                 EF031.....  table, power.....  NF       .................               49            0  Equipment removed       (0.80)
                                                                                                                           due to redundancy
                                                                                                                           when used together
                                                                                                                           with equipment item
                                                                                                                           EF018, stretcher.
                                 EQ011.....  ECG, 3-channel     NF       .................               67           97  Standard time for         0.42
                                              (with SpO2,                                                                  moderate sedation
                                              NIBP, temp,                                                                  equipment.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               67           97  Standard time for         0.19
                                                                                                                           moderate sedation
                                                                                                                           equipment.
                                 EQ235.....  suction machine    NF       .................               92           49  Matches time spent      (0.08)
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
45388......  Colonoscopy w/      EF027.....  table,             NF       .................               67           97  Standard equipment        0.04
              ablation.                       instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EF031.....  table, power.....  NF       .................               49            0  Refined equipment       (0.80)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ011.....  ECG, 3-channel     NF       .................               67           97  Standard equipment        0.42
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               67           97  Standard equipment        0.19
                                                                                                                           and time for
                                                                                                                           moderate sedation.
                                 EQ235.....  suction machine    NF       .................               92           49  Matches time spent      (0.08)
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
45398......  Colonoscopy w/band  EF027.....  table,             NF       .................               52           82  Standard equipment        0.04
              ligation.                       instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EF031.....  table, power.....  NF       .................               34            0  Refined equipment       (0.56)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ011.....  ECG, 3-channel     NF       .................               52           82  Standard equipment        0.42
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................               52           82  Standard equipment        0.19
                                                                                                                           and time for
                                                                                                                           moderate sedation.
                                 EQ235.....  suction machine    NF       .................               62           34  Matches time spent      (0.06)
                                              (Gomco).                                                                     using endoscope
                                                                                                                           system.
46500......  Injection into      EF014.....  light, surgical..  NF       .................               73           60  Refined equipment       (0.13)
              hemorrhoid(s).                                                                                               time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF031.....  table, power.....  NF       .................               73           60  Refined equipment       (0.21)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ235.....  suction machine    NF       .................               73           60  Refined equipment       (0.03)
                                              (Gomco).                                                                     time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 ES002.....  anoscope with      NF       .................               78           60  Refined equipment       (0.07)
                                              light source.                                                                time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Cleaning scope at                5            0  Included in clinical    (1.85)
                                                                          POV.                                             labor task ``Clean
                                                                                                                           room, equipment,
                                                                                                                           and supplies''
                                                                                                                           included in post-
                                                                                                                           operative visit.
                                 L037D.....  RN/LPN/MTA.......  F        Complete pre-                    3            0  Standard 0 day          (1.11)
                                                                          service                                          global pre-service
                                                                          diagnostic and                                   times; exception
                                                                          referral forms.                                  not accepted as
                                                                                                                           service is rarely
                                                                                                                           furnished in the
                                                                                                                           facility.
                                 L037D.....  RN/LPN/MTA.......  F        Coordinate pre-                  3            0  Standard 0 day          (1.11)
                                                                          surgery services.                                global pre-service
                                                                                                                           times; exception
                                                                                                                           not accepted as
                                                                                                                           service is rarely
                                                                                                                           furnished in the
                                                                                                                           facility.
                                 L037D.....  RN/LPN/MTA.......  F        Follow-up phone                  3            0  Standard 0 day          (1.11)
                                                                          calls and                                        global pre-service
                                                                          prescriptions.                                   times; exception
                                                                                                                           not accepted as
                                                                                                                           service is rarely
                                                                                                                           furnished in the
                                                                                                                           facility.

[[Page 41742]]

 
                                 L037D.....  RN/LPN/MTA.......  F        Schedule space                   3            0  Standard 0 day          (1.11)
                                                                          and equipment in                                 global pre-service
                                                                          facility.                                        times; exception
                                                                                                                           not accepted as
                                                                                                                           service is rarely
                                                                                                                           furnished in the
                                                                                                                           facility.
                                 L037D.....  RN/LPN/MTA.......  F        Setup scope at                   5            0  Included in clinical    (1.85)
                                                                          POV.                                             labor task
                                                                                                                           ``Prepare room,
                                                                                                                           equipment,
                                                                                                                           supplies'' included
                                                                                                                           in post-operative
                                                                                                                           visit.
                                 L037D.....  RN/LPN/MTA.......  NF       Clean scope......                5            0  Included in clinical    (1.85)
                                                                                                                           labor task ``Clean
                                                                                                                           room, equipment,
                                                                                                                           and supplies''.
                                 L037D.....  RN/LPN/MTA.......  NF       Cleaning scope at                5            0  Included in clinical    (1.85)
                                                                          POV.                                             labor task ``Clean
                                                                                                                           room, equipment,
                                                                                                                           and supplies''
                                                                                                                           included in post-
                                                                                                                           operative visit.
                                 L037D.....  RN/LPN/MTA.......  NF       Follow-up phone                  3            0  Typically billed        (1.11)
                                                                          calls and                                        with an E/M or
                                                                          prescriptions.                                   other evaluation
                                                                                                                           service.
                                 L037D.....  RN/LPN/MTA.......  NF       Setup scope (non                 5            0  Included in clinical    (1.85)
                                                                          facility setting                                 labor task
                                                                          only).                                           ``Prepare room,
                                                                                                                           equipment,
                                                                                                                           supplies''.
                                 L037D.....  RN/LPN/MTA.......  NF       Setup scope at                   5            0  Included in clinical    (1.85)
                                                                          POV.                                             labor task ``Clean
                                                                                                                           room, equipment,
                                                                                                                           and supplies''
                                                                                                                           included in post-
                                                                                                                           operative visit.
                                 SA042.....  pack, cleaning     NF       .................                2            0  Removed supply         (34.12)
                                              and                                                                          associated with
                                              disinfecting,                                                                equipment item not
                                              endoscope.                                                                   typically used in
                                                                                                                           this service.
46601......  Diagnostic          EF031.....  table, power.....  NF       .................               41           33  Refined equipment       (0.13)
              anoscopy.                                                                                                    time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
46607......  Diagnostic          EF031.....  table, power.....  NF       .................               49           38  Refined equipment       (0.18)
              anoscopy & biopsy.                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
5039A......  Njx px nfrosgrm &/  ED050.....  PACS Workstation   NF       .................               58           67  Refined equipment         0.20
              urtrgrm.                        Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time.
                                 EF027.....  table,             NF       .................              284          277  Standard equipment      (0.01)
                                              instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EL011.....  room, angiography  NF       .................               44            0  Equipment item        (231.21)
                                                                                                                           replaced by another
                                                                                                                           item; see preamble.
                                 EL014.....  room,              NF       .................                0           44  Equipment item           61.30
                                              radiographic-                                                                replaces another
                                              fluoroscopic.                                                                item; see preamble.
                                 EQ011.....  ECG, 3-channel     NF       .................              284          277  Standard equipment      (0.10)
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................              284          277  Standard equipment      (0.04)
                                                                                                                           and time for
                                                                                                                           moderate sedation.
                                 EQ168.....  light, exam......  NF       .................               44           62  Refined equipment         0.08
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  NF       Monitor pt                       0           45  Clinical labor type      16.65
                                                                          following                                        replaces another
                                                                          service/check                                    clinical labor
                                                                          tubes, monitors,                                 type; see preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 L051A.....  RN...............  NF       Monitor pt                      45            0  Clinical labor type    (22.95)
                                                                          following                                        replaced by another
                                                                          service/check                                    labor type; see
                                                                          tubes, monitors,                                 preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 SA019.....  kit, iv starter..  NF       .................                1            0  Duplicative; a          (1.60)
                                                                                                                           similar item is
                                                                                                                           already included in
                                                                                                                           this service.

[[Page 41743]]

 
                                 SA042.....  pack, cleaning     NF       .................                1            0  Removed supply         (17.06)
                                              and                                                                          associated with
                                              disinfecting,                                                                equipment item not
                                              endoscope.                                                                   typically used in
                                                                                                                           this service.
                                 SB022.....  gloves, non-       NF       .................                2            0  Duplicative; items      (0.17)
                                              sterile.                                                                     included in pack,
                                                                                                                           minimum multi-
                                                                                                                           specialty visit
                                                                                                                           (SA048).
                                 SB024.....  gloves, sterile..  NF       .................                2            1  Duplicative; items      (0.84)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SB028.....  gown, surgical,    NF       .................                2            1  Duplicative; items      (4.67)
                                              sterile.                                                                     included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SC049.....  stop cock, 3-way.  NF       .................                1            0  Duplicative; items      (1.18)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
5039B......  Njx px nfrosgrm &/  ED050.....  PACS Workstation   NF       .................               21           45  Refined equipment         0.53
              urtrgrm.                        Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time
                                                                                                                           (Full intraservice
                                                                                                                           period minus
                                                                                                                           monitoring time).
                                 EF027.....  table,             NF       .................               22           40  Refined equipment         0.03
                                              instrument,                                                                  time to conform to
                                              mobile.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EL011.....  room, angiography  NF       .................               22            0  Equipment item        (115.60)
                                                                                                                           replaced by another
                                                                                                                           item; see preamble.
                                 EL014.....  room,              NF       .................                0           22  Equipment item           30.65
                                              radiographic-                                                                replaces another
                                              fluoroscopic.                                                                item; see preamble.
                                 EQ168.....  light, exam......  NF       .................               22           40  Refined equipment         0.08
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  NF       Assist physician                15            0  Removed clinical        (5.55)
                                                                          in performing                                    labor associated
                                                                          procedure.                                       with moderate
                                                                                                                           sedation; moderate
                                                                                                                           sedation not
                                                                                                                           typical for this
                                                                                                                           procedure.
                                 SA042.....  pack, cleaning     NF       .................                1            0  Removed supply         (17.06)
                                              and                                                                          associated with
                                              disinfecting,                                                                equipment item not
                                              endoscope.                                                                   typically used in
                                                                                                                           this service.
                                 SB001.....  cap, surgical....  NF       .................                4            3  Aligned supply          (0.21)
                                                                                                                           quantities with
                                                                                                                           changes to number
                                                                                                                           of clinical labor
                                                                                                                           staff.
                                 SB022.....  gloves, non-       NF       .................                2            0  Duplicative; items      (0.17)
                                              sterile.                                                                     included in pack,
                                                                                                                           minimum multi-
                                                                                                                           specialty visit
                                                                                                                           (SA048).
                                 SB033.....  mask, surgical...  NF       .................                2            1  Aligned supply          (0.20)
                                                                                                                           quantities with
                                                                                                                           changes to number
                                                                                                                           of clinical labor
                                                                                                                           staff.
                                 SB039.....  shoe covers,       NF       .................                4            3  Aligned supply          (0.34)
                                              surgical.                                                                    quantities with
                                                                                                                           changes to number
                                                                                                                           of clinical labor
                                                                                                                           staff.
5039C......  Plmt nephrostomy    ED050.....  PACS Workstation   NF       .................               71           80  Refined equipment         0.20
              catheter.                       Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time.
                                 EF027.....  table,             NF       .................              300          290  Standard equipment      (0.01)
                                              instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EL011.....  room, angiography  NF       .................               60            0  Equipment item        (315.28)
                                                                                                                           replaced by another
                                                                                                                           item; see preamble.
                                 EL014.....  room,              NF       .................                0           60  Equipment item           83.59
                                              radiographic-                                                                replaces another
                                              fluoroscopic.                                                                item; see preamble.
                                 EQ011.....  ECG, 3-channel     NF       .................              300          290  Standard equipment      (0.14)
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................              300          290  Standard equipment      (0.06)
                                                                                                                           and time for
                                                                                                                           moderate sedation.
                                 EQ168.....  light, exam......  NF       .................               60           75  Refined equipment         0.06
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.

[[Page 41744]]

 
                                 L037D.....  RN/LPN/MTA.......  NF       Monitor pt                       0           45  Clinical labor type      16.65
                                                                          following                                        replaces another
                                                                          service/check                                    clinical labor
                                                                          tubes, monitors,                                 type; see preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 L041B.....  Radiologic         NF       Clean room/                      6            3  Refined time to         (1.23)
                                              Technologist.               equipment by                                     standard time for
                                                                          physician staff.                                 this clinical labor
                                                                                                                           task.
                                 L051A.....  RN...............  NF       Monitor pt.                     45            0  Clinical labor type    (22.95)
                                                                          following                                        replaced by another
                                                                          service/check                                    labor type; see
                                                                          tubes, monitors,                                 preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 SA019.....  kit, iv starter..  NF       .................                1            0  Duplicative; items      (1.60)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SA042.....  pack, cleaning     NF       .................                1            0  Removed supply         (17.06)
                                              and                                                                          associated with
                                              disinfecting,                                                                equipment item not
                                              endoscope.                                                                   typically used in
                                                                                                                           this service.
                                 SB022.....  gloves, non-       NF       .................                2            0  Duplicative; items      (0.17)
                                              sterile.                                                                     included in pack,
                                                                                                                           minimum multi-
                                                                                                                           specialty visit
                                                                                                                           (SA048).
                                 SB024.....  gloves, sterile..  NF       .................                2            1  Duplicative; items      (0.84)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SB028.....  gown, surgical,    NF       .................                2            1  Duplicative; items      (4.67)
                                              sterile.                                                                     included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SC049.....  stop cock, 3-way.  NF       .................                1            0  Duplicative; items      (1.18)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
5039D......  Plmt                ED050.....  PACS Workstation   NF       .................               83           92  Refined equipment         0.20
              nephroureteral                  Proxy.                                                                       time to conform to
              catheter.                                                                                                    clinical labor time.
                                 EF027.....  table,             NF       .................              312          302  Standard equipment      (0.01)
                                              instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EL011.....  room, angiography  NF       .................               72            0  Equipment item        (378.34)
                                                                                                                           replaced by another
                                                                                                                           item; see preamble.
                                 EL014.....  room,              NF       .................                0           72  Equipment item          100.30
                                              radiographic-                                                                replaces another
                                              fluoroscopic.                                                                item; see preamble.
                                 EQ011.....  ECG, 3-channel     NF       .................              312          302  Standard equipment      (0.14)
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................              312          302  Standard equipment      (0.06)
                                                                                                                           and time for
                                                                                                                           moderate sedation.
                                 EQ168.....  light, exam......  NF       .................               72           87  Refined equipment         0.06
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  NF       Monitor pt.                      0           45  Clinical labor type      16.65
                                                                          following                                        replaces another
                                                                          service/check                                    clinical labor
                                                                          tubes, monitors,                                 type; see preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 L041B.....  Radiologic         NF       Clean room/                      6            3  Refined time to         (1.23)
                                              Technologist.               equipment by                                     standard time for
                                                                          physician staff.                                 this clinical labor
                                                                                                                           task.
                                 L051A.....  RN...............  NF       Monitor pt.                     45            0  Clinical labor type    (22.95)
                                                                          following                                        replaced by another
                                                                          service/check                                    labor type; see
                                                                          tubes, monitors,                                 preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 SA019.....  kit, iv starter..  NF       .................                1            0  Duplicative; a          (1.60)
                                                                                                                           similar item is
                                                                                                                           already included in
                                                                                                                           this service.

[[Page 41745]]

 
                                 SA042.....  pack, cleaning     NF       .................                1            0  Removed supply         (17.06)
                                              and                                                                          associated with
                                              disinfecting,                                                                equipment item not
                                              endoscope.                                                                   typically used in
                                                                                                                           this service.
                                 SB022.....  gloves, non-       NF       .................                2            0  Duplicative; items      (0.17)
                                              sterile.                                                                     included in pack,
                                                                                                                           minimum multi-
                                                                                                                           specialty visit
                                                                                                                           (SA048).
                                 SB024.....  gloves, sterile..  NF       .................                2            1  Duplicative; items      (0.84)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SB028.....  gown, surgical,    NF       .................                2            1  Duplicative; items      (4.67)
                                              sterile.                                                                     included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SC049.....  stop cock, 3-way.  NF       .................                1            0  Duplicative; items      (1.18)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SD306.....  Nephroureteral     NF       .................                1            0  Supply not mentioned  (117.90)
                                              Catheter.                                                                    in SOR work
                                                                                                                           description.
5039E......  Exchange            ED050.....  PACS Workstation   NF       .................               21           50  Refined equipment         0.64
              nephrostomy cath.               Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time.
                                 EF027.....  table,             NF       .................               90           45  Refined equipment       (0.06)
                                              instrument,                                                                  time to conform to
                                              mobile.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EL011.....  room, angiography  NF       .................               30            0  Equipment item        (157.64)
                                                                                                                           replaced by another
                                                                                                                           item; see preamble.
                                 EL014.....  room,              NF       .................                0           30  Equipment item           41.79
                                              radiographic-                                                                replaces another
                                              fluoroscopic.                                                                item; see preamble.
                                 EQ168.....  light, exam......  NF       .................               30           45  Refined equipment         0.06
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  NF       Assist physician                20            0  Clinical labor type     (7.40)
                                                                          in performing                                    replaced by another
                                                                          procedure.                                       labor type; see
                                                                                                                           preamble.
                                 L041B.....  Radiologic         NF       Clean room/                      6            3  Refined time to         (1.23)
                                              Technologist.               equipment by                                     standard time for
                                                                          physician staff.                                 this clinical labor
                                                                                                                           task.
                                 SA031.....  kit, suture        NF       .................                1            0  Redundant when used     (1.05)
                                              removal.                                                                     together with
                                                                                                                           supply catheter
                                                                                                                           percutaneous
                                                                                                                           fastener (Percu--
                                                                                                                           Stay) (SD146).
                                 SA042.....  pack, cleaning     NF       .................                1            0  Removed supply         (17.06)
                                              and                                                                          associated with
                                              disinfecting,                                                                equipment item not
                                              endoscope.                                                                   typically used in
                                                                                                                           this service.
                                 SB001.....  cap, surgical....  NF       .................                4            3  Aligned supply          (0.21)
                                                                                                                           quantities with
                                                                                                                           changes to number
                                                                                                                           of clinical labor
                                                                                                                           staff.
                                 SB022.....  gloves, non-       NF       .................                2            0  Duplicative; items      (0.17)
                                              sterile.                                                                     included in pack,
                                                                                                                           minimum multi-
                                                                                                                           specialty visit
                                                                                                                           (SA048).
                                 SB033.....  mask, surgical...  NF       .................                2            1  Aligned supply          (0.20)
                                                                                                                           quantities with
                                                                                                                           changes to number
                                                                                                                           of clinical labor
                                                                                                                           staff.
                                 SB039.....  shoe covers,       NF       .................                4            3  Aligned supply          (0.34)
                                              surgical.                                                                    quantities with
                                                                                                                           changes to number
                                                                                                                           of clinical labor
                                                                                                                           staff.
5039M......  Convert             ED050.....  PACS Workstation   NF       .................               68           77  Refined equipment         0.20
              nephrostomy                     Proxy.                                                                       time to conform to
              catheter.                                                                                                    clinical labor time.
                                 EF027.....  table,             NF       .................              297          287  Standard equipment      (0.01)
                                              instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EL011.....  room, angiography  NF       .................               57            0  Equipment item        (299.52)
                                                                                                                           replaced by another
                                                                                                                           item; see preamble.
                                 EL014.....  room,              NF       .................                0           57  Equipment item           79.41
                                              radiographic-                                                                replaces another
                                              fluoroscopic.                                                                item; see preamble.
                                 EQ011.....  ECG, 3-channel     NF       .................              297          287  Standard equipment      (0.14)
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................              297          287  Standard equipment      (0.06)
                                                                                                                           and time for
                                                                                                                           moderate sedation.

[[Page 41746]]

 
                                 EQ168.....  light, exam......  NF       .................               57           72  Refined equipment         0.06
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  NF       Monitor pt                       0           45  Clinical labor type      16.65
                                                                          following                                        replaces another
                                                                          service/check                                    clinical labor
                                                                          tubes, monitors,                                 type; see preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 L041B.....  Radiologic         NF       Clean room/                      6            3  Refined time to         (1.23)
                                              Technologist.               equipment by                                     standard time for
                                                                          physician staff.                                 this clinical labor
                                                                                                                           task.
                                 L051A.....  RN...............  NF       Monitor pt                      45            0  Clinical labor type    (22.95)
                                                                          following                                        replaced by another
                                                                          service/check                                    labor type; see
                                                                          tubes, monitors,                                 preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 SA019.....  kit, iv starter..  NF       .................                1            0  Duplicative; items      (1.60)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SA031.....  kit, suture        NF       .................                1            0  Redundant when used     (1.05)
                                              removal.                                                                     together with
                                                                                                                           supply catheter
                                                                                                                           percutaneous
                                                                                                                           fastener (Percu--
                                                                                                                           Stay) (SD146).
                                 SA042.....  pack, cleaning     NF       .................                1            0  Removed supply         (17.06)
                                              and                                                                          associated with
                                              disinfecting,                                                                equipment item not
                                              endoscope.                                                                   typically used in
                                                                                                                           this service.
                                 SB022.....  gloves, non-       NF       .................                2            0  Duplicative; items      (0.17)
                                              sterile.                                                                     included in pack,
                                                                                                                           minimum multi-
                                                                                                                           specialty visit
                                                                                                                           (SA048).
                                 SB024.....  gloves, sterile..  NF       .................                2            1  Duplicative; items      (0.84)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SB028.....  gown, surgical,    NF       .................                2            1  Duplicative; items      (4.67)
                                              sterile.                                                                     included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SC049.....  stop cock, 3-way.  NF       .................                1            0  Duplicative; items      (1.18)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
5069G......  Plmt ureteral       ED050.....  PACS Workstation   NF       .................               68           77  Refined equipment         0.20
              stent prq.                      Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time.
                                 EF027.....  table,             NF       .................              297          287  Standard equipment      (0.01)
                                              instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EL011.....  room, angiography  NF       .................               57            0  Equipment item        (299.52)
                                                                                                                           replaced by another
                                                                                                                           item; see preamble.
                                 EL014.....  room,              NF       .................                0           57  Equipment item           79.41
                                              radiographic-                                                                replaces another
                                              fluoroscopic.                                                                item; see preamble.
                                 EQ011.....  ECG, 3-channel     NF       .................              297          287  Standard equipment      (0.14)
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................              297          287  Standard equipment      (0.06)
                                                                                                                           and time for
                                                                                                                           moderate sedation.
                                 EQ168.....  light, exam......  NF       .................               57           72  Refined equipment         0.06
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  NF       Monitor pt.                      0           45  Clinical labor type      16.65
                                                                          following                                        replaces another
                                                                          service/check                                    clinical labor
                                                                          tubes, monitors,                                 type; see preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 L041B.....  Radiologic         NF       Clean room/                      6            3  Refined time to         (1.23)
                                              Technologist.               equipment by                                     standard time for
                                                                          physician staff.                                 this clinical labor
                                                                                                                           task.

[[Page 41747]]

 
                                 L051A.....  RN...............  NF       Monitor pt.                     45            0  Clinical labor type    (22.95)
                                                                          following                                        replaced by another
                                                                          service/check                                    labor type; see
                                                                          tubes, monitors,                                 preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 SA019.....  kit, iv starter..  NF       .................                1            0  Duplicative; items      (1.60)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SA031.....  kit, suture        NF       .................                1            0  Redundant when used     (1.05)
                                              removal.                                                                     together with
                                                                                                                           supply catheter
                                                                                                                           percutaneous
                                                                                                                           fastener (Percu--
                                                                                                                           Stay) (SD146).
                                 SA042.....  pack, cleaning     NF       .................                1            0  Removed supply         (17.06)
                                              and                                                                          associated with
                                              disinfecting,                                                                equipment item not
                                              endoscope.                                                                   typically used in
                                                                                                                           this service.
                                 SB022.....  gloves, non-       NF       .................                2            0  Duplicative; items      (0.17)
                                              sterile.                                                                     included in pack,
                                                                                                                           minimum multi-
                                                                                                                           specialty visit
                                                                                                                           (SA048).
                                 SB024.....  gloves, sterile..  NF       .................                2            1  Duplicative; items      (0.84)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SB028.....  gown, surgical,    NF       .................                2            1  Duplicative; items      (4.67)
                                              sterile.                                                                     included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SC049.....  stop cock, 3-way.  NF       .................                1            0  Duplicative; items      (1.18)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
5069H......  Plmt ureteral       ED050.....  PACS Workstation   NF       .................               85           94  Refined equipment         0.20
              stent prq.                      Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time.
                                 EF027.....  table,             NF       .................              314          304  Standard equipment      (0.01)
                                              instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EL011.....  room, angiography  NF       .................               74            0  Equipment item        (388.85)
                                                                                                                           replaced by another
                                                                                                                           item; see preamble.
                                 EL014.....  room,              NF       .................                0           74  Equipment item          103.09
                                              radiographic-                                                                replaces another
                                              fluoroscopic.                                                                item; see preamble.
                                 EQ011.....  ECG, 3-channel     NF       .................              314          304  Standard equipment      (0.14)
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................              314          304  Standard equipment      (0.06)
                                                                                                                           and time for
                                                                                                                           moderate sedation.
                                 EQ168.....  light, exam......  NF       .................               74           89  Refined equipment         0.06
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  NF       Monitor pt.                      0           45  Clinical labor type      16.65
                                                                          following                                        replaces another
                                                                          service/check                                    clinical labor
                                                                          tubes, monitors,                                 type; see preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 L041B.....  Radiologic         NF       Acquire images                  47           46  Rounding error in CL    (0.41)
                                              Technologist.               (75%).                                           time calculation.
                                 L041B.....  Radiologic         NF       Clean room/                      6            3  Refined time to         (1.23)
                                              Technologist.               equipment by                                     standard time for
                                                                          physician staff.                                 this clinical labor
                                                                                                                           task.
                                 L051A.....  RN...............  NF       Monitor pt.                     45            0  Clinical labor type    (22.95)
                                                                          following                                        replaced by another
                                                                          service/check                                    labor type; see
                                                                          tubes, monitors,                                 preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 SA019.....  kit, iv starter..  NF       .................                1            0  Duplicative; items      (1.60)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SA042.....  pack, cleaning     NF       .................                1            0  Removed supply         (17.06)
                                              and                                                                          associated with
                                              disinfecting,                                                                equipment item not
                                              endoscope.                                                                   typically used in
                                                                                                                           this service.

[[Page 41748]]

 
                                 SB022.....  gloves, non-       NF       .................                2            0  Duplicative; items      (0.17)
                                              sterile.                                                                     included in pack,
                                                                                                                           minimum multi-
                                                                                                                           specialty visit
                                                                                                                           (SA048).
                                 SB024.....  gloves, sterile..  NF       .................                2            1  Duplicative; items      (0.84)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SB028.....  gown, surgical,    NF       .................                2            1  Duplicative; a          (4.67)
                                              sterile.                                                                     similar item is
                                                                                                                           already included in
                                                                                                                           this service.
                                 SC049.....  stop cock, 3-way.  NF       .................                1            0  Duplicative; items      (1.18)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
5069I......  Plmt ureteral       ED050.....  PACS Workstation   NF       .................               98          107  Refined equipment         0.20
              stent prq.                      Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time.
                                 EF027.....  table,             NF       .................              327          317  Standard equipment      (0.01)
                                              instrument,                                                                  and time for
                                              mobile.                                                                      moderate sedation.
                                 EL011.....  room, angiography  NF       .................               87            0  Equipment item        (457.16)
                                                                                                                           replaced by another
                                                                                                                           item; see preamble.
                                 EL014.....  room,              NF       .................                0           87  Equipment item          121.20
                                              radiographic-                                                                replaces another
                                              fluoroscopic.                                                                item; see preamble.
                                 EQ011.....  ECG, 3-channel     NF       .................              327          317  Standard equipment      (0.14)
                                              (with SpO2,                                                                  and time for
                                              NIBP, temp,                                                                  moderate sedation.
                                              resp).
                                 EQ032.....  IV infusion pump.  NF       .................              327          317  Standard equipment      (0.06)
                                                                                                                           and time for
                                                                                                                           moderate sedation.
                                 EQ168.....  light, exam......  NF       .................               87          102  Refined equipment         0.06
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  NF       Monitor pt.                      0           45  Clinical labor type      16.65
                                                                          following                                        replaces another
                                                                          service/check                                    clinical labor
                                                                          tubes, monitors,                                 type; see preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 L041B.....  Radiologic         NF       Clean room/                      6            3  Refined time to         (1.23)
                                              Technologist.               equipment by                                     standard time for
                                                                          physician staff.                                 this clinical labor
                                                                                                                           task.
                                 L051A.....  RN...............  NF       Monitor pt.                     45            0  Clinical labor type    (22.95)
                                                                          following                                        replaced by another
                                                                          service/check                                    labor type; see
                                                                          tubes, monitors,                                 preamble.
                                                                          drains (not
                                                                          related to
                                                                          moderate
                                                                          sedation).
                                 SA019.....  kit, iv starter..  NF       .................                1            0  Duplicative; items      (1.60)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SA042.....  pack, cleaning     NF       .................                1            0  Removed supply         (17.06)
                                              and                                                                          associated with
                                              disinfecting,                                                                equipment item not
                                              endoscope.                                                                   typically used in
                                                                                                                           this service.
                                 SB022.....  gloves, non-       NF       .................                2            0  Duplicative; items      (0.17)
                                              sterile.                                                                     included in pack,
                                                                                                                           minimum multi-
                                                                                                                           specialty visit
                                                                                                                           (SA048).
                                 SB024.....  gloves, sterile..  NF       .................                2            1  Duplicative; items      (0.84)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SB028.....  gown, surgical,    NF       .................                2            1  Duplicative; items      (4.67)
                                              sterile.                                                                     included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
                                 SC049.....  stop cock, 3-way.  NF       .................                1            0  Duplicative; items      (1.18)
                                                                                                                           included in pack,
                                                                                                                           moderate sedation
                                                                                                                           (SA044).
5443A......  Repair corporeal    EF031.....  table, power.....  F        .................              144          135  Refined equipment       (0.15)
              tear.                                                                                                        time to conform to
                                                                                                                           clinical labor time.
                                 EF031.....  table, power.....  NF       .................              144          135  Refined equipment       (0.15)
                                                                                                                           time to conform to
                                                                                                                           clinical labor time.

[[Page 41749]]

 
                                 EQ168.....  light, exam......  F        .................              144          135  Refined equipment       (0.04)
                                                                                                                           time to conform to
                                                                                                                           clinical labor time.
                                 EQ168.....  light, exam......  NF       .................              144          135  Refined equipment       (0.04)
                                                                                                                           time to conform to
                                                                                                                           clinical labor time.
657XG......  Impltj ntrstrml     L038A.....  COMT/COT/RN/CST..  F        Discharge day                    6            0  Aligned clinical        (2.28)
              crnl rng seg.                                               management same                                  labor discharge day
                                                                          day 99238 -6                                     management time
                                                                          minutes.                                         with the work time
                                                                                                                           discharge day code.
68801......  Dilate tear duct    L038A.....  COMT/COT/RN/CST..  F        Discharge day                    6            0  Aligned clinical        (2.28)
              opening.                                                    management same                                  labor discharge day
                                                                          day 99238 -6                                     management time
                                                                          minutes.                                         with the work time
                                                                                                                           discharge day code.
68810......  Probe nasolacrimal  L038A.....  COMT/COT/RN/CST..  F        Discharge day                    6            0  Aligned clinical        (2.28)
              duct.                                                       management same                                  labor discharge day
                                                                          day 99238 -6                                     management time
                                                                          minutes.                                         with the work time
                                                                                                                           discharge day code.
68816......  Probe nl duct w/    EL006.....  lane, screening    NF       .................               16           47  Refined equipment         2.77
              balloon.                        (oph).                                                                       time to conform to
                                                                                                                           clinical labor time.
69200......  Clear outer ear     EF008.....  chair with         NF       .................               22           27  Refined equipment         0.05
              canal.                          headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF015.....  mayo stand.......  NF       .................               19           27  Refined equipment         0.01
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................               26           31  Refined equipment         0.01
                                              basic ($500-                                                                 time to conform to
                                              $1,499).                                                                     established
                                                                                                                           policies for
                                                                                                                           instrument packs.
                                 EQ170.....  light, fiberoptic  NF       .................               22           27  Refined equipment         0.04
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ183.....  microscope,        NF       .................               22           27  Refined equipment         0.14
                                              operating.                                                                   time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ234.....  suction and        NF       .................               22           27  Refined equipment         0.05
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Dischrg gmt. same                6            0  Aligned clinical        (2.22)
                                                                          day (0.5 x                                       labor discharge day
                                                                          99238) (enter 6                                  management time
                                                                          min).                                            with the work time
                                                                                                                           discharge day code.
                                 SH047.....  lidocaine 1%-2%    NF       .................                5            0  Supply item replaced    (0.18)
                                              inj (Xylocaine).                                                             by another item
                                                                                                                           (SH050); see
                                                                                                                           preamble.
                                 SH050.....  lidocaine 4%       NF       .................                0            3  Supply item replaces      0.46
                                              soln, topical                                                                another item
                                              (Xylocaine).                                                                 (SH047); see
                                                                                                                           preamble.
69220......  Clean out mastoid   EF008.....  chair with         NF       .................               20           25  Refined equipment         0.05
              cavity.                         headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EF015.....  mayo stand.......  NF       .................               17           25  Refined equipment         0.01
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ137.....  instrument pack,   NF       .................                0           29  Equipment item            0.07
                                              basic ($500-                                                                 replaces another
                                              $1,499).                                                                     item (EQ138); see
                                                                                                                           preamble.
                                 EQ138.....  instrument pack,   NF       .................               29            0  Equipment item          (0.20)
                                              medium ($1,500                                                               replaced by another
                                              and up).                                                                     item (EQ137); see
                                                                                                                           preamble.
                                 EQ183.....  microscope,        NF       .................               20           25  Refined equipment         0.14
                                              operating.                                                                   time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.

[[Page 41750]]

 
                                 EQ234.....  suction and        NF       .................               20           25  Refined equipment         0.05
                                              pressure                                                                     time to conform to
                                              cabinet, ENT                                                                 established
                                              (SMR).                                                                       policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Dischrg day gmt.                 6            0  Aligned clinical        (2.22)
                                                                          (0.5 x 99238)                                    labor discharge day
                                                                          (enter 6 min).                                   management time
                                                                                                                           with the work time
                                                                                                                           discharge day code.
                                 L037D.....  RN/LPN/MTA.......  NF       Clean surgical                  15           10  Refined time to         (1.85)
                                                                          instrument                                       standard time for
                                                                          package.                                         this clinical labor
                                                                                                                           task.
                                 L037D.....  RN/LPN/MTA.......  NF       Provide pre-                     0            2  Refined time to           0.74
                                                                          service                                          standard time for
                                                                          education/obtain                                 this clinical labor
                                                                          consent.                                         task.
7208A......  X-ray exam entire   ED050.....  PACS Workstation   NF       .................               21           25  Refined equipment         0.09
              spi 1 vw.                       Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time.
7208B......  X-ray exam entire   ED050.....  PACS Workstation   NF       .................               36           40  Refined equipment         0.09
              spi 2/3 vw.                     Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time.
7208C......  X-ray exam entire   ED050.....  PACS Workstation   NF       .................               44           48  Refined equipment         0.09
              spi 4/5 vw.                     Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time.
7208D......  X-ray exam entire   ED050.....  PACS Workstation   NF       .................               53           57  Refined equipment         0.09
              spi 6/ vw.                      Proxy.                                                                       time to conform to
                                                                                                                           clinical labor time.
73565......  X-ray exam of       L041B.....  Radiologic         NF       Greet patient and                0            3  Input added to            1.23
              knees.                          Technologist.               provide gowning.                                 maintain
                                                                                                                           consistency with
                                                                                                                           all other codes
                                                                                                                           within family.
77385......  Ntsty modul rad tx  EQ139.....  intercom (incl.    NF       .................               27            0  Indirect Practice       (0.10)
              dlvr smpl.                      master, pt                                                                   Expense; not
                                              substation,                                                                  individually
                                              power, wiring).                                                              allocable to a
                                                                                                                           particular patient
                                                                                                                           for a particular
                                                                                                                           service.
                                 ER040.....  laser, diode, for  NF       .................               29           27  Refined equipment       (0.12)
                                              patient                                                                      time to conform to
                                              positioning                                                                  established
                                              (Probe).                                                                     policies for highly
                                                                                                                           technical equipment.
                                 ER056.....  radiation          NF       .................               29           27  Refined equipment       (3.15)
                                              treatment vault.                                                             time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER065.....  water chiller      NF       .................               29           27  Refined equipment       (0.13)
                                              (radiation                                                                   time to conform to
                                              treatment).                                                                  established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER089.....  IMRT accelerator.  NF       .................               29           27  Refined equipment      (16.14)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER102.....  Power conditioner  NF       .................               29           27  Refined equipment       (0.17)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
77386......  Ntsty modul rad tx  EQ139.....  intercom (incl.    NF       .................               42            0  Indirect Practice       (0.15)
              dlvr cplx.                      master, pt                                                                   Expense; not
                                              substation,                                                                  individually
                                              power, wiring).                                                              allocable to a
                                                                                                                           particular patient
                                                                                                                           for a particular
                                                                                                                           service.
                                 ER040.....  laser, diode, for  NF       .................               44           42  Refined equipment       (0.12)
                                              patient                                                                      time to conform to
                                              positioning                                                                  established
                                              (Probe).                                                                     policies for highly
                                                                                                                           technical equipment.
                                 ER056.....  radiation          NF       .................               44           42  Refined equipment       (3.15)
                                              treatment vault.                                                             time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER065.....  water chiller      NF       .................               44           42  Refined equipment       (0.13)
                                              (radiation                                                                   time to conform to
                                              treatment).                                                                  established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER089.....  IMRT accelerator.  NF       .................               44           42  Refined equipment      (16.14)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.

[[Page 41751]]

 
                                 ER102.....  Power conditioner  NF       .................               44           42  Refined equipment       (0.17)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 L050C.....  Radiation          NF       Check dressings &                2            1  Refined to conform      (0.50)
                                              Therapist.                  wound/home care                                  with identical
                                                                          instructions/                                    labor activity in
                                                                          coordinate                                       other codes in the
                                                                          office visits/                                   family.
                                                                          prescriptions.
77402......  Radiation           EQ139.....  intercom (incl.    NF       .................               12            0  Indirect Practice       (0.04)
              treatment                       master, pt                                                                   Expense; not
              delivery.                       substation,                                                                  individually
                                              power, wiring).                                                              allocable to a
                                                                                                                           particular patient
                                                                                                                           for a particular
                                                                                                                           service.
                                 ER040.....  laser, diode, for  NF       .................               14           12  Refined equipment       (0.12)
                                              patient                                                                      time to conform to
                                              positioning                                                                  established
                                              (Probe).                                                                     policies for highly
                                                                                                                           technical equipment.
                                 ER056.....  radiation          NF       .................               14           12  Refined equipment       (3.15)
                                              treatment vault.                                                             time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER065.....  water chiller      NF       .................               14           12  Refined equipment       (0.13)
                                              (radiation                                                                   time to conform to
                                              treatment).                                                                  established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER089.....  IMRT accelerator.  NF       .................               14           12  Refined equipment      (16.14)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER102.....  Power conditioner  NF       .................               14           12  Refined equipment       (0.17)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
77407......  Radiation           EQ139.....  intercom (incl.    NF       .................               17            0  Indirect Practice       (0.06)
              treatment                       master, pt                                                                   Expense; not
              delivery.                       substation,                                                                  individually
                                              power, wiring).                                                              allocable to a
                                                                                                                           particular patient
                                                                                                                           for a particular
                                                                                                                           service.
                                 ER040.....  laser, diode, for  NF       .................               19           17  Refined equipment       (0.12)
                                              patient                                                                      time to conform to
                                              positioning                                                                  established
                                              (Probe).                                                                     policies for highly
                                                                                                                           technical equipment.
                                 ER056.....  radiation          NF       .................               19           17  Refined equipment       (3.15)
                                              treatment vault.                                                             time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER065.....  water chiller      NF       .................               19           17  Refined equipment       (0.13)
                                              (radiation                                                                   time to conform to
                                              treatment).                                                                  established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER089.....  IMRT accelerator.  NF       .................               19           17  Refined equipment      (16.14)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER102.....  Power conditioner  NF       .................               19           17  Refined equipment       (0.17)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
77412......  Radiation           EQ139.....  intercom (incl.    NF       .................               21            0  Indirect Practice       (0.08)
              treatment                       master, pt                                                                   Expense; not
              delivery.                       substation,                                                                  individually
                                              power, wiring).                                                              allocable to a
                                                                                                                           particular patient
                                                                                                                           for a particular
                                                                                                                           service.
                                 ER040.....  laser, diode, for  NF       .................               23           21  Refined equipment       (0.12)
                                              patient                                                                      time to conform to
                                              positioning                                                                  established
                                              (Probe).                                                                     policies for highly
                                                                                                                           technical equipment.
                                 ER056.....  radiation          NF       .................               23           21  Refined equipment       (3.15)
                                              treatment vault.                                                             time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER065.....  water chiller      NF       .................               23           21  Refined equipment       (0.13)
                                              (radiation                                                                   time to conform to
                                              treatment).                                                                  established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.

[[Page 41752]]

 
                                 ER089.....  IMRT accelerator.  NF       .................               23           21  Refined equipment      (16.14)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
                                 ER102.....  Power conditioner  NF       .................               23           21  Refined equipment       (0.17)
                                                                                                                           time to conform to
                                                                                                                           established
                                                                                                                           policies for highly
                                                                                                                           technical equipment.
88104......  Cytopath fl nongyn  EP024.....  microscope,        NF       .................               60           56  Refined to conform      (0.15)
              smears.                         compound.                                                                    with identical
                                                                                                                           labor activity in
                                                                                                                           other codes in the
                                                                                                                           family.
                                 L033A.....  Lab Technician...  NF       Order, restock,                0.5            0  Indirect Practice       (0.17)
                                                                          and distribute                                   Expense; not
                                                                          specimen                                         individually
                                                                          containers with                                  allocable to a
                                                                          requisition                                      particular patient
                                                                          forms..                                          for a particular
                                                                                                                           service.
88106......  Cytopath fl nongyn  L033A.....  Lab Technician...  NF       Order, restock,                0.5            0  Indirect Practice       (0.17)
              filter.                                                     and distribute                                   Expense; not
                                                                          specimen                                         individually
                                                                          containers with                                  allocable to a
                                                                          requisition                                      particular patient
                                                                          forms..                                          for a particular
                                                                                                                           service.
88108......  Cytopath            L033A.....  Lab Technician...  NF       Order, restock,                0.5            0  Indirect Practice       (0.17)
              concentrate tech.                                           and distribute                                   Expense; not
                                                                          specimen                                         individually
                                                                          containers with                                  allocable to a
                                                                          requisition                                      particular patient
                                                                          forms..                                          for a particular
                                                                                                                           service.
88160......  Cytopath smear      EP038.....  solvent recycling  NF       .................                1            0  Refined equipment       (0.05)
              other source.                   system.                                                                      time to conform to
                                                                                                                           clinical labor time.
                                 L035A.....  Lab Tech/          NF       Prepare automated                6            4  Refined time to         (0.70)
                                              Histotechnologis            stainer with                                     standard time for
                                              t.                          solutions and                                    this clinical labor
                                                                          load microscopic                                 task.
                                                                          slides. Set and
                                                                          confirm stainer
                                                                          program. Set and
                                                                          confirm stainer
                                                                          program.
                                 L035A.....  Lab Tech/          NF       Stain air dried                  5            0  See preamble text...    (1.75)
                                              Histotechnologis            slides with
                                              t.                          modified Wright
                                                                          stain. Review
                                                                          slides for
                                                                          malignancy/high
                                                                          cellularity
                                                                          (cross
                                                                          contamination).
88161......  Cytopath smear      EP038.....  solvent recycling  NF       .................                1            0  Refined equipment       (0.05)
              other source.                   system.                                                                      time to conform to
                                                                                                                           clinical labor time.
             Cytopath smear      L035A.....  Lab Tech/          NF       Prepare automated                6            4  Refined time to         (0.70)
              other source.                   Histotechnologis            stainer with                                     standard time for
                                              t.                          solutions and                                    this clinical labor
                                                                          load microscopic                                 task.
                                                                          slides. Set and
                                                                          confirm stainer
                                                                          program. Set and
                                                                          confirm stainer
                                                                          program.
             Cytopath smear      L035A.....  Lab Tech/          NF       Stain air dried                  5            3  Refined time to         (0.70)
              other source.                   Histotechnologis            slides with                                      standard time for
                                              t.                          modified Wright                                  this clinical labor
                                                                          stain. Review                                    task.
                                                                          slides for
                                                                          malignancy/high
                                                                          cellularity
                                                                          (cross
                                                                          contamination).
88162......  Cytopath smear      EP038.....  solvent recycling  NF       .................                1            0  Refined equipment       (0.05)
              other source.                   system.                                                                      time to conform to
                                                                                                                           clinical labor time.

[[Page 41753]]

 
             Cytopath smear      L035A.....  Lab Tech/          NF       Other Clinical                   6            4  Refined time to         (0.70)
              other source.                   Histotechnologis            Activity (please                                 standard time for
                                              t.                          specify):                                        this clinical labor
                                                                          Prepare                                          task.
                                                                          automated
                                                                          stainer with
                                                                          solutions and
                                                                          load microscopic
                                                                          slides.
88182......  Cell marker study.  L033A.....  Lab Technician...  NF       Accession                        6            4  Refined time to         (0.66)
                                                                          specimen/prepare                                 standard time for
                                                                          for examination.                                 this clinical labor
                                                                                                                           task.
             Cell marker study.  L033A.....  Lab Technician...  NF       Clean room/                      2            1  Refined time to         (0.33)
                                                                          equipment                                        standard time for
                                                                          following                                        this clinical labor
                                                                          procedure                                        task.
                                                                          (including any
                                                                          equipment
                                                                          maintenance that
                                                                          must be done
                                                                          after the
                                                                          procedure).
                                 L033A.....  Lab Technician...  NF       Dispose of                       2            1  Refined time to         (0.33)
                                                                          remaining                                        standard time for
                                                                          specimens, spent                                 this clinical labor
                                                                          chemicals/other                                  task.
                                                                          consumables, and
                                                                          hazardous waste.
                                 L033A.....  Lab Technician...  NF       Prepare, pack and                2            1  Refined time to         (0.33)
                                                                          transport                                        standard time for
                                                                          specimens and                                    this clinical labor
                                                                          records for in-                                  task.
                                                                          house storage
                                                                          and external
                                                                          storage (where
                                                                          applicable).
                                 L045A.....  Cytotechnologist.  NF       Clean room/                      2            1  Refined time to         (0.45)
                                                                          equipment                                        standard time for
                                                                          following                                        this clinical labor
                                                                          procedure                                        task.
                                                                          (including any
                                                                          equipment
                                                                          maintenance that
                                                                          must be done
                                                                          after the
                                                                          procedure).
                                 L045A.....  Cytotechnologist.  NF       Enter data into                  2            0  Refined time to         (0.90)
                                                                          laboratory                                       standard time for
                                                                          information                                      this clinical labor
                                                                          system,                                          task.
                                                                          multiparameter
                                                                          analyses and
                                                                          field data en.
                                 L045A.....  Cytotechnologist.  NF       Print out                        5            2  Refined time to         (1.35)
                                                                          histograms,                                      standard time for
                                                                          assemble                                         this clinical labor
                                                                          materials with                                   task.
                                                                          paperwork to
                                                                          pathologists
                                                                          Review
                                                                          histograms and
                                                                          gating with
                                                                          pathologist.
88184......  Flowcytometry/tc 1  ED031.....  printer, dye       NF       .................                5            1  Refined equipment       (0.04)
              marker.                         sublimation                                                                  time to conform to
                                              (photo, color).                                                              clinical labor time.
                                 L033A.....  Lab Technician...  NF       Clean room/                      2            1  Refined time to         (0.33)
                                                                          equipment                                        standard time for
                                                                          following                                        this clinical labor
                                                                          procedure                                        task.
                                                                          (including any
                                                                          equipment
                                                                          maintenance that
                                                                          must be done
                                                                          after the
                                                                          procedure).

[[Page 41754]]

 
                                 L033A.....  Lab Technician...  NF       Enter data into                  4            0  Refined time to         (1.32)
                                                                          laboratory                                       standard time for
                                                                          information                                      this clinical labor
                                                                          system,                                          task.
                                                                          multiparameter
                                                                          analyses and
                                                                          field data en.
                                 L045A.....  Cytotechnologist.  NF       Instrument start-               15           13  Refined to conform      (0.90)
                                                                          up, quality                                      with identical
                                                                          control                                          labor activity in
                                                                          functions,                                       other codes in the
                                                                          calibration,                                     family.
                                                                          centrifugation,
                                                                          maintaining
                                                                          specimen
                                                                          tracking, logs
                                                                          and labeling.
                                 L045A.....  Cytotechnologist.  NF       Other Clinical                  10            7  Refined to conform      (1.35)
                                                                          Activity (please                                 with identical
                                                                          specify) Load                                    labor activity in
                                                                          specimen into                                    other codes in the
                                                                          flow cytometer,                                  family.
                                                                          run specimen,
                                                                          monitor data
                                                                          acquisition, and.
                                 L045A.....  Cytotechnologist.  NF       Print out                        5            2  Refined time to         (1.35)
                                                                          histograms,                                      standard time for
                                                                          assemble                                         this clinical labor
                                                                          materials with                                   task.
                                                                          paperwork to
                                                                          pathologists
                                                                          Review
                                                                          histograms and
                                                                          gating with
                                                                          pathologist.
88185......  Flowcytometry/tc    ED031.....  printer, dye       NF       .................                2            1  Refined equipment       (0.01)
              add-on.                         sublimation                                                                  time to conform to
                                              (photo, color).                                                              clinical labor time.
                                 L033A.....  Lab Technician...  NF       Enter data into                  1            0  Refined time to         (0.33)
                                                                          laboratory                                       standard time for
                                                                          information                                      this clinical labor
                                                                          system,                                          task.
                                                                          multiparameter
                                                                          analyses and
                                                                          field data en.
88321......  Microslide          L033A.....  Lab Technician...  NF       Accession                        4            0  Duplication with        (1.32)
              consultation.                                               specimen/prepare                                 other clinical
                                                                          for examination.                                 labor task.
                                 L033A.....  Lab Technician...  NF       Register the                    13            5  See preamble text...    (2.64)
                                                                          patient in the
                                                                          information
                                                                          system,
                                                                          including all
                                                                          demographic and
                                                                          billing
                                                                          information. In
                                                                          addition to
                                                                          stand.
                                 L037B.....  Histotechnologist  NF       Phone calls for                  0            3  Input added to            1.11
                                                                          clarifications                                   maintain
                                                                          and/or                                           consistency with
                                                                          additional                                       all other codes
                                                                          materials.                                       within family.
88323......  Microslide          L033A.....  Lab Technician...  NF       Register the                    13            5  Non-standard            (2.64)
              consultation.                                               patient in the                                   refinement, see
                                                                          information                                      preamble text.
                                                                          system,
                                                                          including all
                                                                          demographic and
                                                                          billing
                                                                          information. In
                                                                          addition to
                                                                          stand.
                                 L037B.....  Histotechnologist  NF       Assemble and                     1            0  Duplication with        (0.37)
                                                                          deliver slides                                   other clinical
                                                                          with paperwork                                   labor task.
                                                                          to pathologists.
                                 L037B.....  Histotechnologist  NF       Clean equipment                  1            0  Duplication with        (0.37)
                                                                          while performing                                 other clinical
                                                                          service.                                         labor task.
                                 SL063.....  eosin y..........  NF       .................                8            0  Redundant when used     (6.41)
                                                                                                                           together with SL135.

[[Page 41755]]

 
                                 SL135.....  stain,             NF       .................               32            8  Refined supply          (1.06)
                                              hematoxylin.                                                                 quantity to what is
                                                                                                                           typical for the
                                                                                                                           procedure.
88325......  ..................  EP019.....  hood, ventilator   NF       .................                1            0  See preamble text...        --
                                              with blower.
                                 EP033.....  slide              NF       .................                6            0  See preamble text...    (0.57)
                                              coverslipper,
                                              robotic.
                                 EP034.....  slide dryer......  NF       .................                1            0  See preamble text...        --
                                 EP035.....  slide etcher-      NF       .................                1            0  See preamble text...    (0.05)
                                              labeler.
                                 EP036.....  slide stainer,     NF       .................               12            0  See preamble text...    (0.55)
                                              automated, high-
                                              volume
                                              throughput.
                                 EP038.....  solvent recycling  NF       .................                4            0  See preamble text...    (0.18)
                                              system.
                                 EP043.....  water bath,        NF       .................                6            0  See preamble text...    (0.01)
                                              general purpose
                                              (lab).
                                 ER041.....  microtome........  NF       .................                6            0  See preamble text...    (0.26)
                                 L033A.....  Lab Technician...  NF       Prepare room.                   10            0  Indirect Practice       (3.30)
                                                                          Filter and                                       Expense; not
                                                                          replenish stains                                 individually
                                                                          and supplies.                                    allocable to a
                                                                          (including OCT                                   particular patient
                                                                          blocks, set up                                   for a particular
                                                                          grossing station                                 service.
                                                                          with colored
                                                                          stain.
                                 L033A.....  Lab Technician...  NF       Accession                        4            0  Duplication with        (1.32)
                                                                          specimen/prepare                                 other clinical
                                                                          for examination.                                 labor task.
                                 L033A.....  Lab Technician...  NF       Dispose of                       1            0  See preamble text...    (0.33)
                                                                          remaining
                                                                          specimens, spent
                                                                          chemicals/other
                                                                          consumables, and
                                                                          hazardous waste.
                                 L033A.....  Lab Technician...  NF       Register the                    13            5  See preamble text...    (2.64)
                                                                          patient in the
                                                                          information
                                                                          system,
                                                                          including all
                                                                          demographic and
                                                                          billing
                                                                          information. In
                                                                          addition to
                                                                          stand.
                                 L033A.....  Lab Technician...  NF       prepare, pack and                2            0  See preamble text...    (0.66)
                                                                          transport
                                                                          specimens and
                                                                          records for in-
                                                                          house storage
                                                                          and external
                                                                          storage.
                                 L037B.....  Histotechnologist  NF       Clean equipment                  1            0  Duplication with        (0.37)
                                                                          while performing                                 other clinical
                                                                          service.                                         labor task.
                                 L037B.....  Histotechnologist  NF       Complete workload                1            0  See preamble text...    (0.37)
                                                                          recording logs.
                                                                          Collate slides
                                                                          and paperwork.
                                                                          Deliver to
                                                                          pathologist.
                                 L037B.....  Histotechnologist  NF       Prepare automated                1            0  See preamble text...    (0.37)
                                                                          coverslipper,
                                                                          remove slides
                                                                          from stainer and
                                                                          place on
                                                                          coverslipper.

[[Page 41756]]

 
                                 L037B.....  Histotechnologist  NF       Prepare automated                1            0  See preamble text...    (0.37)
                                                                          stainer with
                                                                          solutions and
                                                                          load microscopic
                                                                          slides. Set and
                                                                          confirm stainer
                                                                          program. Set and
                                                                          confirm stainer
                                                                          program.
                                 L037B.....  Histotechnologist  NF       Slide preparation                4            0  See preamble text...    (1.48)
                                                                          sectioning and
                                                                          recuts, quality
                                                                          control
                                                                          function,
                                                                          maintaining
                                                                          specimen
                                                                          tracking, logs
                                                                          and labeling.
                                 SB023.....  gloves, non-       NF       .................                2            0  See preamble text...    (0.38)
                                              sterile, nitrile.
                                 SB027.....  gown, staff,       NF       .................              0.1            0  See preamble text...    (0.12)
                                              impervious.
                                 SF004.....  blade, microtome.  NF       .................              0.2            0  See preamble text...    (0.34)
                                 SL020.....  bleach...........  NF       .................               10            0  See preamble text...    (0.01)
                                 SL030.....  cover slip, glass  NF       .................                2            0  See preamble text...    (0.16)
                                 SL063.....  eosin y..........  NF       .................                8            0  See preamble text...    (6.41)
                                 SL078.....  histology          NF       .................              0.2            0  See preamble text...    (0.29)
                                              freezing spray
                                              (Freeze-It).
                                 SL085.....  label for          NF       .................               20           10  See preamble text...    (0.26)
                                              microscope
                                              slides.
                                 SL095.....  mounting media     NF       .................                2            0  See preamble text...    (0.07)
                                              (Histomount).
                                 SL122.....  slide, microscope  NF       .................                2            0  See preamble text...    (0.11)
                                 SL135.....  stain,             NF       .................               32            0  See preamble text...    (1.41)
                                              hematoxylin.
                                 SL151.....  xylenes solvent..  NF       .................               60            0  See preamble text...    (0.72)
                                 SL189.....  ethanol, 100%....  NF       .................               60            0  See preamble text...    (0.20)
                                 SL190.....  ethanol, 70%.....  NF       .................                8            0  See preamble text...    (0.03)
                                 SL248.....  ethanol, 95%.....  NF       .................               36            0  See preamble text...    (0.12)
                                 SM027.....  wipes, lens        NF       .................                2            0  See preamble text...    (0.03)
                                              cleaning (per
                                              wipe) (Kimwipe).
88329......  Path consult        L037B.....  Histotechnologist  NF       Assist                          10            3  Refined time to         (2.59)
              introp.                                                     pathologist with                                 standard time for
                                                                          gross specimen                                   this clinical labor
                                                                          examination.                                     task.
                                 L037B.....  Histotechnologist  NF       Clean room/                      5            1  Refined time to         (1.48)
                                                                          equipment                                        standard time for
                                                                          following                                        this clinical labor
                                                                          procedure                                        task.
                                                                          (including any
                                                                          equipment
                                                                          maintenance that
                                                                          must be done
                                                                          after the
                                                                          procedure).
88331......  Path consult        L033A.....  Lab Technician...  NF       Prepare room.                   10            0  Indirect Practice         1.48
              intraop 1 bloc.                                             Filter and                                       Expense; not
                                                                          replenish stains                                 individually
                                                                          and supplies.                                    allocable to a
                                                                          (including OCT                                   particular patient
                                                                          blocks, set up                                   for a particular
                                                                          grossing station                                 service.
                                                                          with colored
                                                                          stai.
                                 L037B.....  Histotechnologist  NF       Accession                        0            4  Input added to            1.48
                                                                          specimen/prepare                                 maintain
                                                                          for examination.                                 consistency with
                                                                                                                           all other codes
                                                                                                                           within family.
                                 L037B.....  Histotechnologist  NF       Assemble and                     2          0.5  Refined time to         (0.56)
                                                                          deliver slides                                   standard time for
                                                                          with paperwork                                   this clinical labor
                                                                          to pathologists.                                 task.
                                 L037B.....  Histotechnologist  NF       Assist                          10            3  Refined time to         (2.59)
                                                                          pathologist with                                 standard time for
                                                                          gross specimen                                   this clinical labor
                                                                          examination.                                     task.

[[Page 41757]]

 
                                 L037B.....  Histotechnologist  NF       Clean room/                     10            1  Refined time to         (3.33)
                                                                          equipment                                        standard time for
                                                                          following                                        this clinical labor
                                                                          procedure                                        task.
                                                                          (including any
                                                                          equipment
                                                                          maintenance that
                                                                          must be done
                                                                          after the
                                                                          procedure).
                                 SL134.....  stain, frozen      NF       .................                0            1  Supply item replaces      0.57
                                              section, H&E                                                                 another item
                                              (1ml per slide).                                                             (SL231); see
                                                                                                                           preamble.
                                 SL231.....  kit, stain, H&E..  NF       .................              0.1            0  Supply item replaced    (9.80)
                                                                                                                           by another item
                                                                                                                           (SL134); see
                                                                                                                           preamble.
88332......  Path consult        L037B.....  Histotechnologist  NF       Assemble and                     2          0.5  Refined time to         (0.56)
              intraop addl.                                               deliver slides                                   standard time for
                                                                          with paperwork                                   this clinical labor
                                                                          to pathologists.                                 task.
                                 L037B.....  Histotechnologist  NF       Assist                           2            3  Refined time to           0.37
                                                                          pathologist with                                 standard time for
                                                                          gross specimen                                   this clinical labor
                                                                          examination.                                     task.
                                 L037B.....  Histotechnologist  NF       Clean room/                      0            1  Input added to            0.37
                                                                          equipment                                        maintain
                                                                          following                                        consistency with
                                                                          procedure                                        all other codes
                                                                          (including any                                   within family.
                                                                          equipment
                                                                          maintenance that
                                                                          must be done
                                                                          after the
                                                                          procedure).
                                 SF047.....  scalpel, safety,   NF       .................                0            1  Input added to            2.14
                                              surgical, with                                                               maintain
                                              blade (#10-20).                                                              consistency with
                                                                                                                           all other codes
                                                                                                                           within family.
                                 SL134.....  stain, frozen      NF       .................                0            1  Supply item replaces      0.57
                                              section, H&E                                                                 another item
                                              (1ml per slide).                                                             (SL231); see
                                                                                                                           preamble.
                                 SL231.....  kit, stain, H&E..  NF       .................              0.1            0  Supply item replaced    (9.80)
                                                                                                                           by another item
                                                                                                                           (SL134); see
                                                                                                                           preamble.
88333......  Intraop cyto path   L033A.....  Lab Technician...  NF       Prepare room.                   10            0  Indirect Practice       (3.30)
              consult 1.                                                  Filter and                                       Expense; not
                                                                          replenish stains                                 individually
                                                                          and supplies.                                    allocable to a
                                                                          (including OCT                                   particular patient
                                                                          blocks, set up                                   for a particular
                                                                          grossing station                                 service.
                                                                          with colored
                                                                          stai.
                                 L037B.....  Histotechnologist  NF       Accession                        0            4  Input added to            1.48
                                                                          specimen/prepare                                 maintain
                                                                          for examination.                                 consistency with
                                                                                                                           all other codes
                                                                                                                           within family.
                                 L037B.....  Histotechnologist  NF       Assemble and                     2          0.5  Refined time to         (1.48)
                                                                          deliver slides                                   standard time for
                                                                          with paperwork                                   this clinical labor
                                                                          to pathologists.                                 task.
                                 L037B.....  Histotechnologist  NF       Assist                           7            3  Refined time to         (1.48)
                                                                          pathologist with                                 standard time for
                                                                          gross specimen                                   this clinical labor
                                                                          examination                                      task.
                                                                          (including
                                                                          performance of
                                                                          intraoperative
                                                                          frozen sections).
                                 L037B.....  Histotechnologist  NF       Clean room/                      5            1  Refined time to         (1.48)
                                                                          equipment                                        standard time for
                                                                          following                                        this clinical labor
                                                                          procedure                                        task.
                                                                          (including any
                                                                          equipment
                                                                          maintenance that
                                                                          must be done
                                                                          after the
                                                                          procedure).

[[Page 41758]]

 
                                 SL122.....  slide, microscope  NF       .................               10            4  Refined supply          (0.33)
                                                                                                                           quantity to what is
                                                                                                                           typical for the
                                                                                                                           procedure.
                                 SL231.....  kit, stain, H&E..  NF       .................              0.1            0  Removed supply not      (9.80)
                                                                                                                           typically used in
                                                                                                                           this service.
88334......  Intraop cyto path   L037B.....  Histotechnologist  NF       Assemble and                     2          0.5  Refined time to         (0.56)
              consult 2.                                                  deliver slides                                   standard time for
                                                                          with paperwork                                   this clinical labor
                                                                          to pathologists.                                 task.
                                 L037B.....  Histotechnologist  NF       Assist                           5            3  Refined time to         (0.74)
                                                                          pathologist with                                 standard time for
                                                                          gross specimen                                   this clinical labor
                                                                          examination                                      task.
                                                                          (including
                                                                          performance of
                                                                          intraoperative
                                                                          frozen sections).
                                 L037B.....  Histotechnologist  NF       Clean room/                      0            1  Input added to            0.37
                                                                          equipment                                        maintain
                                                                          following                                        consistency with
                                                                          procedure                                        all other codes
                                                                          (including any                                   within family.
                                                                          equipment
                                                                          maintenance that
                                                                          must be done
                                                                          after the
                                                                          procedure).
                                 SL122.....  slide, microscope  NF       .................               10            4  Refined supply          (0.33)
                                                                                                                           quantity to what is
                                                                                                                           typical for the
                                                                                                                           procedure.
                                 SL231.....  kit, stain, H&E..  NF       .................              0.1            0  Removed supply not      (9.80)
                                                                                                                           typically used in
                                                                                                                           this service.
88355......  Analysis skeletal   EP046.....  freezer,           NF       .................               30            0  Indirect Practice       (1.32)
              muscle.                         ultradeep (-70                                                               Expense; not
                                              degrees).                                                                    individually
                                                                                                                           allocable to a
                                                                                                                           particular patient
                                                                                                                           for a particular
                                                                                                                           service.
                                 L033A.....  Lab Technician...  NF       Accession                        6            4  Refined time to         (0.66)
                                                                          specimen/prepare                                 standard time for
                                                                          for examination.                                 this clinical labor
                                                                                                                           task.
                                 L033A.....  Lab Technician...  NF       Assemble and                     2          0.5  Refined time to         (0.50)
                                                                          deliver slides                                   standard time for
                                                                          with paperwork                                   this clinical labor
                                                                          to pathologists.                                 task.
                                 L033A.....  Lab Technician...  NF       Clean room,                      2            1  Refined time to         (0.33)
                                                                          equipment                                        standard time for
                                                                          following                                        this clinical labor
                                                                          procedure                                        task.
                                                                          including any
                                                                          equipment
                                                                          maintenance that
                                                                          must be done
                                                                          after the
                                                                          procedure.
                                 L033A.....  Lab Technician...  NF       Dispose of                       2            1  Refined time to         (0.33)
                                                                          remaining                                        standard time for
                                                                          specimens, spent                                 this clinical labor
                                                                          chemicals/other                                  task.
                                                                          consumables, and
                                                                          hazardous waste.
                                 L033A.....  Lab Technician...  NF       Prepare specimen                 9          0.5  Refined time to         (2.81)
                                                                          containers/                                      standard time for
                                                                          preload fixative/                                this clinical labor
                                                                          label containers/                                task.
                                                                          distribute
                                                                          requisition
                                                                          form(s) to
                                                                          physician.
                                 L033A.....  Lab Technician...  NF       Prepare specimen                 5            0  Refined time to         (1.65)
                                                                          for -70 degree                                   standard time for
                                                                          storage, log                                     this clinical labor
                                                                          specimen and                                     task.
                                                                          place in freezer
                                                                          for retrieval
                                                                          and performance
                                                                          of quantitative.

[[Page 41759]]

 
                                 L033A.....  Lab Technician...  NF       Prepare, pack and                4            1  Refined time to         (0.99)
                                                                          transport                                        standard time for
                                                                          specimens and                                    this clinical labor
                                                                          records for                                      task.
                                                                          storage.
                                 L033A.....  Lab Technician...  NF       Receive phone                    7            5  See preamble text...    (0.66)
                                                                          call from
                                                                          referring
                                                                          laboratory/
                                                                          facility with
                                                                          scheduled
                                                                          procedure to
                                                                          arrange special
                                                                          delivery of
                                                                          specimen p.
                                 L037B.....  Histotechnologist  NF       Assist                           7            3  Refined time to         (1.48)
                                                                          pathologist with                                 standard time for
                                                                          gross                                            this clinical labor
                                                                          examination.                                     task.
88360......  Tumor               EP024.....  microscope,        NF       .................               36           25  See preamble text...    (0.41)
              immunohistochem/                compound.
              manual.
                                 L033A.....  Lab Technician...  NF       Recycle xylene                   1            0  Non-standard            (0.33)
                                                                          from tissue                                      clinical labor task.
                                                                          processor and
                                                                          stainer.
                                 L037B.....  Histotechnologist  NF       Enter patient                    5            1  Refined time to         (1.48)
                                                                          data,                                            standard time for
                                                                          computational                                    this clinical labor
                                                                          prep for                                         task.
                                                                          antibody
                                                                          testing,
                                                                          generate and
                                                                          apply bar codes
                                                                          to slides, and
                                                                          enter data for.
                                 L037B.....  Histotechnologist  NF       Verify results                   1            0  Refined time to         (0.37)
                                                                          and complete                                     standard time for
                                                                          work load                                        this clinical labor
                                                                          recording logs.                                  task.
88361......  Tumor               L033A.....  Lab Technician...  NF       Recycle xylene                   1            0  Non-standard            (0.33)
              immunohistochem/                                            from tissue                                      clinical labor task.
              comput.                                                     processor and
                                                                          stainer.
                                 L037B.....  Histotechnologist  NF       Enter patient                    5            1  Refined time to         (1.48)
                                                                          data,                                            standard time for
                                                                          computational                                    this clinical labor
                                                                          prep for                                         task.
                                                                          antibody
                                                                          testing,
                                                                          generate and
                                                                          apply bar codes
                                                                          to slides, and
                                                                          enter data for.
                                 L037B.....  Histotechnologist  NF       Verify results                   1            0  Refined time to         (0.37)
                                                                          and complete                                     standard time for
                                                                          work load                                        this clinical labor
                                                                          recording logs.                                  task.
88362......  Nerve teasing       L033A.....  Lab Technician...  NF       Assemble and                     2          0.5  Refined time to         (0.50)
              preparations.                                               deliver cedar                                    standard time for
                                                                          mounted slides                                   this clinical labor
                                                                          with paperwork                                   task.
                                                                          to pathologists.
                                 L033A.....  Lab Technician...  NF       Assemble other                   5          0.5  Refined time to         (1.49)
                                                                          light microscopy                                 standard time for
                                                                          slides, epon                                     this clinical labor
                                                                          nerve biopsy                                     task.
                                                                          slides, and
                                                                          clinical
                                                                          history, and
                                                                          present to
                                                                          pathologist to
                                                                          pr.

[[Page 41760]]

 
                                 L033A.....  Lab Technician...  NF       Clean room/                      7            1  Refined time to         (1.98)
                                                                          equipment                                        standard time for
                                                                          following                                        this clinical labor
                                                                          procedure                                        task.
                                                                          (including
                                                                          dissecting
                                                                          microscope and
                                                                          dissection work
                                                                          area. Cedar oil
                                                                          specific c.
                                 L033A.....  Electrodiagnostic  NF       Preparation:                     2          0.5  Refined time to         (0.50)
                                              Technologist.               labeling of                                      standard time for
                                                                          blocks and                                       this clinical labor
                                                                          containers and                                   task.
                                                                          document
                                                                          location and
                                                                          processor used.
                                 L037B.....  Histotechnologist  NF       Accession                       10            4  Refined time to         (2.22)
                                                                          specimen and                                     standard time for
                                                                          prepare for                                      this clinical labor
                                                                          examination.                                     task.
                                 L037B.....  Histotechnologist  NF       Assist                          10            5  Non-standard            (1.85)
                                                                          pathologist with                                 refinement, see
                                                                          gross specimen                                   preamble text.
                                                                          examination
                                                                          including the
                                                                          following; A ;
                                                                          Selection of
                                                                          fresh unfixed
                                                                          tissue samp.
                                 L037B.....  Histotechnologist  NF       Consult with                     7            0  Task would not be       (2.59)
                                                                          pathologist                                      required for the
                                                                          regarding                                        typical procedure.
                                                                          representation
                                                                          needed, block
                                                                          selection and
                                                                          appropriate
                                                                          technique.
                                 L037B.....  Histotechnologist  NF       Dispose of                       2            1  Refined time to         (0.37)
                                                                          remaining                                        standard time for
                                                                          specimens, spent                                 this clinical labor
                                                                          chemicals/other                                  task.
                                                                          consumables, and
                                                                          hazardous waste.
                                 L037B.....  Histotechnologist  NF       Manage any                       2            0  Refined time to         (0.74)
                                                                          relevant                                         standard time for
                                                                          utilization                                      this clinical labor
                                                                          review/quality                                   task.
                                                                          assurance
                                                                          activities and
                                                                          regulatory
                                                                          compliance
                                                                          documentation.
                                 L037B.....  Histotechnologist  NF       Prepare specimen                12          0.5  Refined time to         (4.26)
                                                                          containers                                       standard time for
                                                                          preload fixative                                 this clinical labor
                                                                          label containers                                 task.
                                                                          distribute
                                                                          requisition
                                                                          form(s) to
                                                                          physician.
                                 L037B.....  Histotechnologist  NF       Prepare, pack and               10            0  Refined time to         (3.70)
                                                                          transport cedar                                  standard time for
                                                                          oiled glass                                      this clinical labor
                                                                          slides and                                       task.
                                                                          records for in-
                                                                          house special
                                                                          storage (need to
                                                                          be stored flat).
                                 L037B.....  Histotechnologist  NF       Prepare, pack and                2            1  Refined time to         (0.37)
                                                                          transport                                        standard time for
                                                                          specimens and                                    this clinical labor
                                                                          records for in-                                  task.
                                                                          house storage
                                                                          and external
                                                                          storage (where
                                                                          applicable).

[[Page 41761]]

 
                                 L037B.....  Histotechnologist  NF       Storage remaining                5            0  Refined time to         (1.85)
                                                                          specimen.                                        standard time for
                                                                          (Osmicated nerve                                 this clinical labor
                                                                          strands,                                         task.
                                                                          potential for
                                                                          additional
                                                                          teased
                                                                          specimens).
92511......  Nasopharyngoscopy.  EF008.....  chair with         NF       .................               19           26  Refined equipment         0.08
                                              headrest, exam,                                                              time to conform to
                                              reclining.                                                                   established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ167.....  light source,      NF       .................               19            0  Redundant when used     (0.51)
                                              xenon.                                                                       together with
                                                                                                                           EQ170; see preamble.
                                 EQ170.....  light, fiberoptic  NF       .................               19           26  Refined equipment         0.06
                                              headlight w-                                                                 time to conform to
                                              source.                                                                      established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 ES020.....  fiberscope,        NF       .................               46           53  Refined equipment         0.26
                                              flexible,                                                                    time to conform to
                                              rhinolaryngoscop                                                             established
                                              y.                                                                           policies for scopes.
                                 ES031.....  video system,      NF       .................               19           26  Refined equipment         0.90
                                              endoscopy                                                                    time to conform to
                                              (processor,                                                                  established
                                              digital capture,                                                             policies for non-
                                              monitor,                                                                     highly technical
                                              printer, cart).                                                              equipment.
                                 L037D.....  RN/LPN/MTA.......  F        Dischrge Day                     6            0  Aligned clinical        (2.22)
                                                                          mgmt. (0.5 x                                     labor discharge day
                                                                          99238) (enter 6                                  management time
                                                                          min).                                            with the work time
                                                                                                                           discharge day code.
                                 SB006.....  drape, non-        NF       .................                1            0  Removed supply not      (0.22)
                                              sterile, sheet                                                               typically used in
                                              40in x 60in.                                                                 this service.
                                 SB027.....  gown, staff,       NF       .................                2            0  Removed supply not      (2.37)
                                              impervious.                                                                  typically used in
                                                                                                                           this service.
                                 SB033.....  mask, surgical...  NF       .................                2            0  Removed supply not      (0.39)
                                                                                                                           typically used in
                                                                                                                           this service.
                                 SD070.....  endosheath.......  NF       .................                1            0  Removed supply not     (17.25)
                                                                                                                           typically used in
                                                                                                                           this service.
95812......  Eeg 41-60 minutes.  EF003.....  bedroom furniture  NF       .................              124           99  Refined equipment       (0.15)
                                              (hospital bed,                                                               time to conform to
                                              table, reclining                                                             established
                                              chair).                                                                      policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ017.....  EEG, digital,      NF       .................              133           99  Refined equipment       (4.99)
                                              prolonged                                                                    time to conform to
                                              testing system                                                               established
                                              (computer w-                                                                 policies for non-
                                              remote camera).                                                              highly technical
                                                                                                                           equipment.
                                 L047B.....  REEGT............  NF       Assist physician                79           50  Refined clinical       (13.63)
                                                                          in performing                                    labor time to match
                                                                          procedure.                                       physician
                                                                                                                           intraservice time.
                                 L047B.....  REEGT............  NF       Enter patient                    2            0  Refined to conform      (0.94)
                                                                          information into                                 with identical
                                                                          laboratory log                                   labor activity in
                                                                          book.                                            other codes in the
                                                                                                                           family.
                                 L047B.....  REEGT............  NF       Provide pre-                     2            0  Duplication with        (0.94)
                                                                          service                                          other clinical
                                                                          education/obtain                                 labor task.
                                                                          consent.
                                 L047B.....  REEGT............  NF       Transfer data to                 4            2  Refined time to         (0.94)
                                                                          reading station                                  standard time for
                                                                          & archive data.                                  this clinical labor
                                                                                                                           task.
95813......  Eeg over 1 hour...  EF003.....  bedroom furniture  NF       .................              147          129  Refined equipment       (0.11)
                                              (hospital bed,                                                               time to conform to
                                              table, reclining                                                             established
                                              chair).                                                                      policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ017.....  EEG, digital,      NF       .................              156          129  Refined equipment       (3.96)
                                              prolonged                                                                    time to conform to
                                              testing system                                                               established
                                              (computer w-                                                                 policies for non-
                                              remote camera).                                                              highly technical
                                                                                                                           equipment.
                                 L047B.....  REEGT............  NF       Assist physician               102           80  Refined clinical       (10.34)
                                                                          in performing                                    labor time to match
                                                                          procedure.                                       physician
                                                                                                                           intraservice time.

[[Page 41762]]

 
                                 L047B.....  REEGT............  NF       Enter patient                    2            0  Refined to conform      (0.94)
                                                                          information into                                 with identical
                                                                          laboratory log                                   labor activity in
                                                                          book.                                            other codes in the
                                                                                                                           family.
                                 L047B.....  REEGT............  NF       Provide pre-                     2            0  Duplication with        (0.94)
                                                                          service                                          other clinical
                                                                          education/obtain                                 labor task.
                                                                          consent.
                                 L047B.....  REEGT............  NF       Transfer data to                 4            2  Refined time to         (0.94)
                                                                          reading station                                  standard time for
                                                                          & archive data.                                  this clinical labor
                                                                                                                           task.
95863......  Muscle test 3       EF023.....  table, exam......  NF       .................               52           55  Refined equipment         0.01
              limbs.                                                                                                       time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ024.....  EMG-NCV-EP         NF       .................               52           55  Refined equipment         0.44
                                              system, 8                                                                    time to conform to
                                              channel.                                                                     established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037A.....  Electrodiagnostic  NF       Clean room/                      0            3  Refined to conform        1.11
                                              Technologist.               equipment by                                     with identical
                                                                          physician staff.                                 labor activity in
                                                                                                                           other codes in the
                                                                                                                           family.
95864......  Muscle test 4       EF023.....  table, exam......  NF       .................               62           65  Refined equipment         0.01
              limbs.                                                                                                       time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ024.....  EMG-NCV-EP         NF       .................               62           65  Refined equipment         0.44
                                              system, 8                                                                    time to conform to
                                              channel.                                                                     established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037A.....  Electrodiagnostic  NF       Other Clinical                   6            0  Refined to conform      (2.22)
                                              Technologist.               Activity--specif                                 with identical
                                                                          y:Prepare                                        labor activity in
                                                                          technician                                       other codes in the
                                                                          report,                                          family.
                                                                          summarize
                                                                          clinical and
                                                                          electrodiagnosti
                                                                          c data, and
                                                                          interpre.
95869......  Muscle test thor    EF023.....  table, exam......  NF       .................               27           30  Refined equipment         0.01
              paraspinal.                                                                                                  time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ024.....  EMG-NCV-EP         NF       .................               27           30  Refined equipment         0.44
                                              system, 8                                                                    time to conform to
                                              channel.                                                                     established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037A.....  Electrodiagnostic  NF       Clean room/                      0            3  Refined to conform        1.11
                                              Technologist.               equipment by                                     with identical
                                                                          physician staff.                                 labor activity in
                                                                                                                           other codes in the
                                                                                                                           family.
95870......  Muscle test         EF023.....  table, exam......  NF       .................               27           30  Refined equipment         0.01
              nonparaspinal.                                                                                               time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ024.....  EMG-NCV-EP         NF       .................               27           30  Refined equipment         0.44
                                              system, 8                                                                    time to conform to
                                              channel.                                                                     established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037A.....  Electrodiagnostic  NF       Clean room/                      0            3  Refined to conform        1.11
                                              Technologist.               equipment by                                     with identical
                                                                          physician staff.                                 labor activity in
                                                                                                                           other codes in the
                                                                                                                           family.
                                 SD275.....  Disposable         NF       .................                6            1  Refined supply         (13.75)
                                              electrode pack.                                                              quantity to what is
                                                                                                                           typical for the
                                                                                                                           procedure.
95923......  Autonomic nrv syst  EF023.....  table, exam......  NF       .................               51           43  Refined equipment       (0.02)
              funj test.                                                                                                   time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ035.....  QSART acquisition  NF       .................               46           43  Refined equipment       (0.33)
                                              system (Q-Sweat).                                                            time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.

[[Page 41763]]

 
                                 EQ124.....  stimulator,        NF       .................               46           43  Refined equipment       (0.01)
                                              constant                                                                     time to conform to
                                              current, w-                                                                  established
                                              stimulating and                                                              policies for non-
                                              grounding                                                                    highly technical
                                              electrodes                                                                   equipment.
                                              (Grass
                                              Telefactor).
                                 EQ171.....  light, infra-red,  NF       .................               46           43  Refined equipment     ........
                                              ceiling mount.                                                               time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L037A.....  Electrodiagnostic  NF       Clean room/                      5            0  Typically billed        (1.85)
                                              Technologist.               equipment by                                     with an E/M or
                                                                          physician staff.                                 other evaluation
                                                                                                                           service.
                                 L037A.....  Electrodiagnostic  NF       Complete                         5            0  Typically billed        (1.85)
                                              Technologist.               diagnostic                                       with an E/M or
                                                                          forms, lab & X-                                  other evaluation
                                                                          ray requisitions.                                service.
                                 L037A.....  Electrodiagnostic  NF       Complete pre-                    5            2  Refined to conform      (1.11)
                                              Technologist.               service                                          with identical
                                                                          diagnostic &                                     labor activity in
                                                                          referral forms.                                  other codes in the
                                                                                                                           family.
                                 L037A.....  Electrodiagnostic  NF       Prepare room,                    0            2  Refined time to           0.74
                                              Technologist.               equipment,                                       standard time for
                                                                          supplies.                                        this clinical labor
                                                                                                                           task.
                                 SA014.....  kit, electrode,    NF       .................                4            3  See preamble text...    (4.01)
                                              iontophoresis.
                                 SA048.....  pack, minimum      NF       .................                1            0  Typically billed        (1.14)
                                              multi-specialty                                                              with an E/M or
                                              visit.                                                                       other evaluation
                                                                                                                           service.
95928......  C motor evoked      EF023.....  table, exam......  NF       .................               65           45  Refined equipment       (0.06)
              uppr limbs.                                                                                                  time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ024.....  EMG-NCV-EP         NF       .................               65           45  Refined equipment       (2.95)
                                              system, 8                                                                    time to conform to
                                              channel.                                                                     established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ178.....  magnetic           NF       .................               65           45  Refined equipment       (0.16)
                                              stimulator hand                                                              time to conform to
                                              coil (70-90mm).                                                              established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ180.....  magnetic           NF       .................               65           45  Refined equipment       (1.43)
                                              stimulator                                                                   time to conform to
                                              system (BiStim).                                                             established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L047B.....  REEGT............  NF       Assist physician                60           40  Refined clinical        (9.40)
                                                                          in performing                                    labor time to match
                                                                          procedure.                                       physician
                                                                                                                           intraservice time.
                                 L047B.....  REEGT............  NF       Other Clinical                   3            0  Duplication with        (1.41)
                                                                          Activity--specif                                 other clinical
                                                                          y: Review                                        labor task.
                                                                          requisition.
                                                                          Assess for
                                                                          special needs.
                                                                          Give patient
                                                                          instructions for
                                                                          test prepa.
                                 SA048.....  pack, minimum      NF       .................                1            0  Typically billed        (1.14)
                                              multi-specialty                                                              with an E/M or
                                              visit.                                                                       other evaluation
                                                                                                                           service.
95929......  C motor evoked lwr  EF023.....  table, exam......  NF       .................               65           45  Refined equipment       (0.06)
              limbs.                                                                                                       time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ024.....  EMG-NCV-EP         NF       .................               65           45  Refined equipment       (2.95)
                                              system, 8                                                                    time to conform to
                                              channel.                                                                     established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ179.....  magnetic           NF       .................               65           45  Refined equipment       (0.24)
                                              stimulator leg                                                               time to conform to
                                              coil (110mm).                                                                established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ180.....  magnetic           NF       .................               65           45  Refined equipment       (1.43)
                                              stimulator                                                                   time to conform to
                                              system (BiStim).                                                             established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.

[[Page 41764]]

 
                                 L047B.....  REEGT............  NF       Assist physician                60           40  Refined clinical        (9.40)
                                                                          in performing                                    labor time to match
                                                                          procedure.                                       physician
                                                                                                                           intraservice time.
                                 L047B.....  REEGT............  NF       Other Clinical                   3            0  Duplication with        (1.41)
                                                                          Activity--specif                                 other clinical
                                                                          y:Review                                         labor task.
                                                                          requisition.
                                                                          Assess for
                                                                          special needs.
                                                                          Give patient
                                                                          instructions for
                                                                          test prepa.
95933......  Blink reflex test.  L037A.....  Electrodiagnostic  NF       Clean room/                      5            3  Refined time to         (0.74)
                                              Technologist.               equipment by                                     standard time for
                                                                          physician staff.                                 this clinical labor
                                                                                                                           task.
                                 L037A.....  Electrodiagnostic  NF       Prepare room,                    0            2  Refined time to           0.74
                                              Technologist.               equipment,                                       standard time for
                                                                          supplies.                                        this clinical labor
                                                                                                                           task.
95956......  Eeg monitor         EF003.....  bedroom furniture  NF       .................              772          769  Refined equipment       (0.02)
              technol attended.               (hospital bed,                                                               time to conform to
                                              table, reclining                                                             established
                                              chair).                                                                      policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 EQ017.....  EEG, digital,      NF       .................              772          769  Refined equipment       (0.44)
                                              prolonged                                                                    time to conform to
                                              testing system                                                               established
                                              (computer w-                                                                 policies for non-
                                              remote camera).                                                              highly technical
                                                                                                                           equipment.
                                 EQ047.....  air compressor,    NF       .................               52           49  Refined equipment     ........
                                              safety.                                                                      time to conform to
                                                                                                                           established
                                                                                                                           policies for non-
                                                                                                                           highly technical
                                                                                                                           equipment.
                                 L047B.....  REEGT............  NF       Other Clinical                   3            0  Duplication with        (1.41)
                                                                          Activity--specif                                 other clinical
                                                                          y: Coordinate                                    labor task.
                                                                          pretesting
                                                                          services/review
                                                                          test/exam
                                                                          results.
                                 L047B.....  REEGT............  NF       Provide pre-                     2            0  Duplication with        (0.94)
                                                                          service                                          other clinical
                                                                          education/obtain                                 labor task.
                                                                          consent.
--------------------------------------------------------------------------------------------------------------------------------------------------------


   Table 14--Crosswalk for Establishing CY 2016 New, Revised, and Potentially Misvalued Codes Malpractice RVUs
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
   CY 2016 New, Revised or Potentially MMalpractice Risk Factor Crosswalk Code
----------------------------------------------------------------------------------------------------------------
11750........................  Removal of nail bed.....  11750........................  Removal of nail bed.
20240........................  Bone biopsy excisional..  20240........................  Bone biopsy excisional.
27280........................  Fusion of sacroiliac      27280........................  Fusion of sacroiliac
                                joint.                                                   joint.
31622........................  Dx bronchoscope/wash....  31622........................  Dx bronchoscope/wash.
3160A........................  Bronch ebus sampling 1/2  31620........................  Endobronchial us add-on.
                                node.
3160B........................  Bronch ebus samplng 3/>   31620........................  Endobronchial us add-on.
                                node.
31625........................  Bronchoscopy w/biopsy(s)  31625........................  Bronchoscopy w/
                                                                                         biopsy(s).
31626........................  Bronchoscopy w/markers..  31626........................  Bronchoscopy w/markers.
31628........................  Bronchoscopy/lung bx      31628........................  Bronchoscopy/lung bx
                                each.                                                    each.
31629........................  Bronchoscopy/needle bx    31629........................  Bronchoscopy/needle bx
                                each.                                                    each.
3160C........................  Bronch ebus ivntj perph   31620........................  Endobronchial us add-on.
                                les.
31632........................  Bronchoscopy/lung bx      31632........................  Bronchoscopy/lung bx
                                addl.                                                    addl.
31633........................  Bronchoscopy/needle bx    31633........................  Bronchoscopy/needle bx
                                addl.                                                    addl.
3347A........................  Implant tcat pulm vlv     93581........................  Transcath closure of
                                perq.                                                    vsd.
3725A........................  Intrvasc us noncoronary   37250........................  Iv us first vessel add-
                                1st.                                                     on.
3725B........................  Intrvasc us noncoronary   37251........................  Iv us each add vessel
                                addl.                                                    add-on.
38570........................  Laparoscopy lymph node    38570........................  Laparoscopy lymph node
                                biop.                                                    biop.
38571........................  Laparoscopy               38571........................  Laparoscopy
                                lymphadenectomy.                                         lymphadenectomy.
38572........................  Laparoscopy               38572........................  Laparoscopy
                                lymphadenectomy.                                         lymphadenectomy.
3940A........................  Mediastinoscpy w/medstnl  33924........................  Remove pulmonary shunt.
                                bx.
3940B........................  Mediastinoscpy w/lmph     32606........................  Thoracoscopy w/bx med
                                nod bx.                                                  space.
44380........................  Small bowel endoscopy br/ 44380........................  Small bowel endoscopy br/
                                wa.                                                      wa.
44381........................  Small bowel endoscopy br/ 45340........................  Sig w/tndsc balloon
                                wa.                                                      dilation.
44382........................  Small bowel endoscopy...  44382........................  Small bowel endoscopy.

[[Page 41765]]

 
44384........................  Small bowel endoscopy...  44383........................  Ileoscopy w/stent.
44385........................  Endoscopy of bowel pouch  44385........................  Endoscopy of bowel
                                                                                         pouch.
44386........................  Endoscopy bowel pouch/    44386........................  Endoscopy bowel pouch/
                                biop.                                                    biop.
44388........................  Colonoscopy thru stoma    44388........................  Colonoscopy thru stoma
                                spx.                                                     spx.
44389........................  Colonoscopy with biopsy.  44389........................  Colonoscopy with biopsy.
44390........................  Colonoscopy for foreign   44390........................  Colonoscopy for foreign
                                body.                                                    body.
44391........................  Colonoscopy for bleeding  44391........................  Colonoscopy for
                                                                                         bleeding.
44392........................  Colonoscopy &             44392........................  Colonoscopy &
                                polypectomy.                                             polypectomy.
44394........................  Colonoscopy w/snare.....  44394........................  Colonoscopy w/snare.
44401........................  Colonoscopy with          44393........................  Colonoscopy lesion
                                ablation.                                                removal.
44402........................  Colonoscopy w/stent       44397........................  Colonoscopy w/stent.
                                plcmt.
44403........................  Colonoscopy w/resection.  44392........................  Colonoscopy &
                                                                                         polypectomy.
44404........................  Colonoscopy w/injection.  44389........................  Colonoscopy with biopsy.
44405........................  Colonoscopy w/dilation..  44390........................  Colonoscopy for foreign
                                                                                         body.
44406........................  Colonoscopy w/ultrasound  44394........................  Colonoscopy w/snare.
45330........................  Diagnostic sigmoidoscopy  45330........................  Diagnostic
                                                                                         sigmoidoscopy.
45331........................  Sigmoidoscopy and biopsy  45331........................  Sigmoidoscopy and
                                                                                         biopsy.
45332........................  Sigmoidoscopy w/fb        45332........................  Sigmoidoscopy w/fb
                                removal.                                                 removal.
45333........................  Sigmoidoscopy &           45333........................  Sigmoidoscopy &
                                polypectomy.                                             polypectomy.
45334........................  Sigmoidoscopy for         45334........................  Sigmoidoscopy for
                                bleeding.                                                bleeding.
45335........................  Sigmoidoscopy w/submuc    45335........................  Sigmoidoscopy w/submuc
                                inj.                                                     inj.
45337........................  Sigmoidoscopy &           45337........................  Sigmoidoscopy &
                                decompress.                                              decompress.
45338........................  Sigmoidoscopy w/tumr      45338........................  Sigmoidoscopy w/tumr
                                remove.                                                  remove.
45340........................  Sig w/tndsc balloon       45340........................  Sig w/tndsc balloon
                                dilation.                                                dilation.
45341........................  Sigmoidoscopy w/          45341........................  Sigmoidoscopy w/
                                ultrasound.                                              ultrasound.
45342........................  Sigmoidoscopy w/us guide  45342........................  Sigmoidoscopy w/us guide
                                bx.                                                      bx.
45346........................  Sigmoidoscopy w/ablation  45339........................  Sigmoidoscopy w/ablate
                                                                                         tumr.
45347........................  Sigmoidoscopy w/plcmt     45345........................  Sigmoidoscopy w/stent.
                                stent.
45349........................  Sigmoidoscopy w/          45338........................  Sigmoidoscopy w/tumr
                                resection.                                               remove.
45350........................  Sgmdsc w/band ligation..  45334........................  Sigmoidoscopy for
                                                                                         bleeding.
45378........................  Diagnostic colonoscopy..  45378........................  Diagnostic colonoscopy.
45379........................  Colonoscopy w/fb removal  45379........................  Colonoscopy w/fb
                                                                                         removal.
45380........................  Colonoscopy and biopsy..  45380........................  Colonoscopy and biopsy.
45381........................  Colonoscopy submucous     45381........................  Colonoscopy submucous
                                njx.                                                     njx.
45382........................  Colonoscopy w/control     45382........................  Colonoscopy w/control
                                bleed.                                                   bleed.
45384........................  Colonoscopy w/lesion      45384........................  Colonoscopy w/lesion
                                removal.                                                 removal.
45385........................  Colonoscopy w/lesion      45385........................  Colonoscopy w/lesion
                                removal.                                                 removal.
45386........................  Colonoscopy w/balloon     45386........................  Colonoscopy w/balloon
                                dilat.                                                   dilat.
45388........................  Colonoscopy w/ablation..  45383........................  Lesion removal
                                                                                         colonoscopy.
45389........................  Colonoscopy w/stent       45387........................  Colonoscopy w/stent.
                                plcmt.
45390........................  Colonoscopy w/resection.  45385........................  Colonoscopy w/lesion
                                                                                         removal.
45391........................  Colonoscopy w/endoscope   45391........................  Colonoscopy w/endoscope
                                us.                                                      us.
45392........................  Colonoscopy w/endoscopic  45392........................  Colonoscopy w/endoscopic
                                fnb.                                                     fnb.
45393........................  Colonoscopy w/            45382........................  Colonoscopy w/control
                                decompression.                                           bleed.
45398........................  Colonoscopy w/band        45382........................  Colonoscopy w/control
                                ligation.                                                bleed.
46500........................  Injection into            46500........................  Injection into
                                hemorrhoid(s).                                           hemorrhoid(s).
47135........................  Transplantation of liver  47135........................  Transplantation of
                                                                                         liver.
5039A........................  Njx px nfrosgrm &/        50390........................  Drainage of kidney
                                urtrgrm.                                                 lesion.
5039B........................  Njx px nfrosgrm &/        50394........................  Injection for kidney x-
                                urtrgrm.                                                 ray.
5039C........................  Plmt nephrostomy          50392........................  Insert kidney drain.
                                catheter.
5039D........................  Plmt nephroureteral       50393........................  Insert ureteral tube.
                                catheter.
5039M........................  Convert nephrostomy       50393........................  Insert ureteral tube.
                                catheter.
5039E........................  Exchange nephrostomy      50398........................  Change kidney tube.
                                cath.
5069G........................  Plmt ureteral stent prq.  50398........................  Change kidney tube.
5069H........................  Plmt ureteral stent prq.  50393........................  Insert ureteral tube.
5069I........................  Plmt ureteral stent prq.  50393........................  Insert ureteral tube.
5443A........................  Repair corporeal tear...  54406........................  Remove muti-comp penis
                                                                                         pros.
5443B........................  Replantation of penis...  53448........................  Remov/replc ur sphinctr
                                                                                         comp.
657XG........................  Impltj ntrstrml crnl rng  65426........................  Removal of eye lesion.
                                seg.
7208A........................  X-ray exam entire spi 1   72050........................  X-ray exam neck spine 4/
                                vw.                                                      5vws.
7208B........................  X-ray exam entire spi 2/  72052........................  X-ray exam neck spine 6/
                                3 vw.                                                    >vws.
7208C........................  X-ray exam entire spi 4/  72052........................  X-ray exam neck spine 6/
                                5 vw.                                                    > vws.
7208D........................  X-ray exam entire spi 6/  72052........................  X-ray exam neck spine 6/
                                > vw.                                                    > vws.
73560........................  X-ray exam of knee 1 or   73560........................  X-ray exam of knee 1 or
                                2.                                                       2.
73562........................  X-ray exam of knee 3....  73562........................  X-ray exam of knee 3.
73564........................  X-ray exam knee 4 or      73564........................  X-ray exam knee 4 or
                                more.                                                    more.
73565........................  X-ray exam of knees.....  73565........................  X-ray exam of knees.
73590........................  X-ray exam of lower leg.  73590........................  X-ray exam of lower leg.
73600........................  X-ray exam of ankle.....  73600........................  X-ray exam of ankle.
77402........................  Radiation treatment       G6003........................  Radiation treatment
                                delivery.                                                delivery.
77407........................  Radiation treatment       G6007........................  Radiation treatment
                                delivery.                                                delivery.
77412........................  Radiation treatment       G6011........................  Radiation treatment
                                delivery.                                                delivery.
77385........................  Ntsty modul rad tx dlvr   G6015........................  Radiation tx delivery
                                smpl.                                                    imrt.

[[Page 41766]]

 
77386........................  Ntsty modul rad tx dlvr   G6015........................  Radiation treatment
                                cplx.                                                    delivery.
77387........................  Guidance for radiaj tx    77014........................  Ct scan for therapy
                                dlvr.                                                    guide.
76948........................  Echo guide ova            76948........................  Echo guide ova
                                aspiration.                                              aspiration.
7778A........................  Hdr rdncl skn surf        77785........................  Hdr brachytx 1 channel.
                                brachytx.
7778B........................  Hdr rdncl skn surf        77786........................  Hdr brachytx 2-12
                                brachytx.                                                channel.
7778C........................  Hdr rdncl ntrstl/icav     77785........................  Hdr brachytx 1 channel.
                                brchtx.
7778D........................  Hdr rdncl ntrstl/icav     77786........................  Hdr brachytx 2-12
                                brchtx.                                                  channel.
7778E........................  Hdr rdncl ntrstl/icav     77787........................  Hdr brachytx over 12
                                brchtx.                                                  chan.
88346........................  Immunofluorescent study.  88346........................  Immunofluorescent study.
8835X........................  Immunofluor antb addl     88346........................  Immunofluorescent study.
                                stain.
88367........................  Insitu hybridization      88367........................  Insitu hybridization
                                auto.                                                    auto.
88368........................  Insitu hybridization      88368........................  Insitu hybridization
                                manual.                                                  manual.
91200........................  Liver elastography......  91200........................  Liver elastography.
9254A........................  Caloric vestibular test   92540........................  Basic vestibular
                                with recording.                                          evaluation.
9254B........................  Caloric vestibular test   92540........................  Basic vestibular
                                with recording.                                          evaluation.
99497........................  Advncd care plan 30 min.  99214........................  Office/outpatient visit
                                                                                         est.
99498........................  Advncd care plan addl 30  99214........................  Office/outpatient visit
                                min.                                                     est.
----------------------------------------------------------------------------------------------------------------
Note: For any codes not included in Table 14, we are proposing to use the utilization crosswalk, when a
  crosswalk exists, in order to calculate the malpractice risk factor for these services, as discussed in the
  preamble text.

a. Lower GI Endoscopy Services
    CPT revised the lower gastrointestinal endoscopy code set for CY 
2015 following identification of some of the codes as potentially 
misvalued and the affected specialty society's contention that this 
code set did not allow for accurate reporting of services based upon 
current medical practice. The RUC subsequently provided recommendations 
to us for valuing these services. In the CY 2015 PFS final rule with 
comment period, we delayed valuing the lower GI codes and indicated 
that we would propose values for these codes in the CY 2016 proposed 
rule, citing the new process for including proposed values for new, 
revised and potentially misvalued codes in the proposed rule as one of 
the reasons for the delay.
(1) Gastrointestinal (GI) Endoscopy (CPT Codes 43775, 44380-46607 and 
HCPCS Codes G0104, G0105, and G0121)
    In the CY 2014 PFS final rule with comment period, we indicated 
that we used what we called an ``incremental difference methodology'' 
in valuing the upper GI codes for that year. We explained that the RUC 
made extensive use of a methodology that uses the incremental 
difference in codes to determine values for many of these services. 
This 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 sets of similar 
codes. As with the esophagoscopy subfamily, many of the procedures 
described within the colonoscopy subfamily have identical counterparts 
in the esophagogastroduodenoscopy (EGD) subfamily. For instance, the 
base colonoscopy CPT code 45378 is described as ``Colonoscopy, 
flexible; diagnostic, including collection of specimen(s) by brushing 
or washing when performed, (separate procedure).'' 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 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 colonoscopy versus 
utilizing EGD. For example, the EGD CPT code 43239 includes a biopsy in 
addition to the base diagnostic EGD CPT code 43235. The RUC valued this 
by adding the incremental difference in the base colonoscopy code over 
the base EGD CPT code to the value it recommended for the esophagoscopy 
biopsy, CPT code 43202. With some variations, the RUC used this 
incremental difference methodology extensively in valuing subfamilies 
of codes. We have made use of similar methodologies in establishing 
work RVUs for codes in this family.
    We agreed with several of the RUC recommendations for codes in this 
family. Where we did not agree, we consistently applied the incremental 
difference methodology. Table I7 reflects how we applied this 
methodology and the values we are proposing. To calculate the base RVU 
for the colonoscopy subfamily, we looked at the current intraservice 
time for CPT code 45378, which is 30 minutes, and the current work RVU, 
which is 3.69. The RUC recommended an intraservice time of 25 minutes 
and 3.36 RVUs. We then compared that service to the base EGD CPT code 
43235 for which the RUC recommended a work RVU of 2.26, giving an 
increment between EGD and colonoscopy of 1.10 RVUs. We added that 
increment to our proposed work RVU for CPT 43235 of 2.19 to arrive at 
our proposed work RVU for the base colonoscopy CPT code 45378 of 3.29. 
We use this value as the base code in the incremental methodology for 
establishing the work value for the other base codes in the colonoscopy 
subfamilies which were then used to value the other codes in that 
subfamily.

                                             Table 15--Application of the Incremental Difference Methodology
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                            Current                                                                              Increment    Calculated
      HCPCS             Descriptor            WRVU      RUC  WRVU       Base procedure       Base  RVU         Increment           value         WRVU
--------------------------------------------------------------------------------------------------------------------------------------------------------
44380...........  Ileoscopy, through             1.05         0.97  Colonoscopy...........         3.29  Colonoscopy to               -2.39          0.9
                   stoma; diagnostic,                                                                     Ileoscopy.
                   including collection
                   of specimen(s) by
                   brushing or washing,
                   when performed.

[[Page 41767]]

 
44382...........  Ileoscopy, through             1.27         1.27  Ileoscopy.............          0.9  Biopsy...............          0.3          1.2
                   stoma; with biopsy,
                   single or multiple.
44384...........  Ileoscopy, through               NA         3.11  Ileoscopy.............          0.9  Stent................         1.98         2.88
                   stoma; with placement
                   of endoscopic stent
                   (includes pre- and
                   post-dilation and
                   guide wire passage,
                   when performed).
44385...........  Endoscopic evaluation          1.82          1.3  Colonoscopy...........         3.29  Colonoscopy to endo.         -2.06         1.23
                   of small intestinal                                                                    eval.
                   pouch (eg, Kock
                   pouch, ileal
                   reservoir [S or J]);
                   diagnostic, including
                   collection of
                   specimen(s) by
                   brushing or washing,
                   when performed.
44386...........  Endoscopic evaluation          2.12          1.6  Endo. Eval............         1.23  Biopsy...............          0.3         1.53
                   of small intestinal
                   pouch (eg, Kock
                   pouch, ileal
                   reservoir [S or J]);
                   with biopsy, single
                   or multiple.
44388...........  Colonoscopy through            2.82         2.82  Colonoscopy...........         3.29  Colonoscopy to               -0.54         2.75
                   stoma; diagnostic,                                                                     Colonoscopy through
                   including collection                                                                   stoma.
                   of specimen(s) by
                   brushing or washing,
                   when performed
                   (separate procedure).
44389...........  Colonoscopy through            3.13         3.12  Colonoscopy through            2.75  Biopsy...............          0.3         3.05
                   stoma; with biopsy,                               stoma.
                   single or multiple.
44390...........  Colonoscopy through            3.82         3.82  Colonoscopy through            2.75  Foreign body.........         1.02         3.77
                   stoma; with removal                               stoma.
                   of foreign body.
44402...........  Colonoscopy through             4.7         4.96  Colonoscopy through            2.75  Stent................         1.98         4.73
                   stoma; with                                       stoma.
                   endoscopic stent
                   placement (including
                   pre- and post-
                   dilation and
                   guidewire passage,
                   when performed).
44403...........  Colonoscopy through              NA         5.81  Colonoscopy through            2.75  Endoscopic mucosal            2.78         5.53
                   stoma; with                                       stoma.                               resection.
                   endoscopic mucosal
                   resection.
44404...........  Colonoscopy through              NA         3.13  Colonoscopy through            2.75  Submucosal injection.          0.3         3.05
                   stoma; with directed                              stoma.
                   submucosal
                   injection(s), any
                   substance.
45330...........  Sigmoidoscopy,                 0.96         0.84  Colonoscopy...........         3.29  Colonoscopy to               -2.52         0.77
                   flexible; diagnostic,                                                                  Sigmoidoscopy.
                   including collection
                   of specimen(s) by
                   brushing or washing
                   when performed.
45331...........  Sigmoidoscopy,                 1.15         1.14  Sigmoidoscopy.........         0.77  Biopsy...............          0.3         1.07
                   flexible; with
                   biopsy, single or
                   multiple.
45332...........  Sigmoidoscopy,                 1.79         1.85  Sigmoidoscopy.........         0.77  Foreign body.........         1.02         1.79
                   flexible; with
                   removal of foreign
                   body.
45335...........  Sigmoidoscopy,                 1.46         1.15  Sigmoidoscopy.........         0.77  Submucosal injection.          0.3         1.07
                   flexible; with
                   directed submucosal
                   injection(s), any
                   substance.
45341...........  Sigmoidoscopy,                  2.6         2.43  Sigmoidoscopy.........         0.77  Endoscopic ultrasound         1.38         2.15
                   flexible; with
                   endoscopic ultrasound
                   examination.

[[Page 41768]]

 
45346...........  Sigmoidoscopy,                   NA         2.97  Sigmoidoscopy.........         0.77  Ablation.............         2.07         2.84
                   flexible; with
                   ablation of tumor(s),
                   polyp(s), or other
                   lesion(s) (includes
                   pre- and post-
                   dilation and guide
                   wire passage, when
                   performed).
45347...........  Sigmoidoscopy,                   NA         2.98  Sigmoidoscopy.........         0.77  Stent................         1.98         2.75
                   flexible; with
                   placement of
                   endoscopic stent
                   (includes pre- and
                   post-dilation and
                   guide wire passage,
                   when performed).
45349...........  Sigmoidoscopy,                   NA         3.83  Sigmoidoscopy.........         0.77  Endoscopic mucosal            2.78         3.55
                   flexible; with                                                                         resection.
                   endoscopic mucosal
                   resection.
45378...........  Colonoscopy, flexible;         3.69         3.36  Colonoscopy...........         3.29
                   diagnostic, including
                   collection of
                   specimen(s) by
                   brushing or washing,
                   when performed,
                   (separate procedure).
45379...........  Colonoscopy, flexible;         4.68         4.37  Colonoscopy...........         3.29  Foreign body.........         1.02         4.31
                   with removal of
                   foreign body.
45380...........  Colonoscopy, flexible,         4.43         3.66  Colonoscopy...........         3.29  Biopsy...............          0.3         3.59
                   proximal to splenic
                   flexure; with biopsy,
                   single or multiple.
45381...........  Colonoscopy, flexible;         4.19         3.67  Colonoscopy...........         3.29  Submucosal injection.          0.3         3.59
                   with directed
                   submucosal
                   injection(s), any
                   substance.
45389...........  Colonoscopy, flexible;           NA          5.5  Colonoscopy...........         3.29  Stent................         1.98         5.27
                   with endoscopic stent
                   placement (includes
                   pre- and post-
                   dilation and guide
                   wire passage, when
                   performed).
45390...........  Colonoscopy, flexible;           NA         6.35  Colonoscopy...........         3.29  Endoscopic mucosal            2.78         6.07
                   with endoscopic                                                                        resection.
                   mucosal resection.
45391...........  Colonoscopy, flexible;         5.09         4.95  Colonoscopy...........         3.29  Endoscopic ultrasound         1.38         4.67
                   with endoscopic
                   ultrasound
                   examination limited
                   to the rectum,
                   sigmoid, descending,
                   transverse, or
                   ascending colon and
                   cecum, and adjacent
                   structures.
--------------------------------------------------------------------------------------------------------------------------------------------------------

(2) Laparoscopic Sleeve Gastrectomy (CPT Code 43775)
    Prior to CY 2013, CPT code 43775 described a non-covered service. 
For CY 2013, this service was covered as part of the bariatric surgery 
National Coverage Determination (NCD) and has been contractor-priced 
since 2013. We are now proposing to establish national pricing for CPT 
code 43775. To establish a work RVU, we are crosswalking this code to 
CPT code 37217 (Transcatheter 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), due to their identical intraservice times, similar 
total times, and similar levels of intensity. Therefore, we are 
proposing a work RVU of 20.38 for CPT code 43775.
(3) Incomplete Colonoscopy (CPT codes 44388, 45378, G0105, and G0121)
    Prior to CY 2015, according to CPT instruction, an incomplete 
colonoscopy was defined as a colonoscopy that did not evaluate the 
colon past the splenic flexure (the distal third of the colon). In 
accordance with that definition, the Medicare Claims Processing Manual 
(pub. 100-04, chapter 12, section 30.1.B., available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items) states that physicians should report an incomplete 
colonoscopy with 45378 and append modifier -53, which is paid at the 
same rate as a sigmoidoscopy.
    In CY 2015, the CPT instruction changed the definition of an 
incomplete colonoscopy to a colonoscopy that does not evaluate the 
entire colon. The 2015 CPT Manual states, ``When performing a 
diagnostic or screening endoscopic procedure on a patient who is 
scheduled and prepared for a total colonoscopy, if the physician is 
unable to advance the colonoscope to the

[[Page 41769]]

cecum or colon-small intestine anastomosis due to unforeseen 
circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through 
stoma) with modifier -53 and provide appropriate documentation.''
    Given that the new definition of an incomplete colonoscopy also 
includes colonoscopies where the colonoscope is advanced past the 
splenic flexure but not to the cecum, we are proposing to establish new 
values for the incomplete colonoscopies, reported with the -53 
modifier. At present, we crosswalk the RVUs for the incomplete 
colonoscopies from the values of the corresponding sigmoidoscopy. Given 
that the new CPT instructions will reduce the number of reported 
complete colonoscopies and increase the number of colonoscopies that 
proceeded further toward completion reported with the -53 modifier, we 
believe CPT code 45378 reported with the -53 modifier will now describe 
a more resource-intensive group of services than were previously 
reported. Therefore, we are proposing to develop RVUs for these codes 
reported with the -53 modifier by using one-half the value of the 
inputs for the corresponding codes reported without the -53 modifier.
    In addition to this proposed change in input values, we are also 
seeking comment on how to address the disparity of resource costs among 
the broader range of services now described by the colonoscopy codes 
billed with the -53 modifier. We believe that it may be appropriate for 
practitioners to report the sigmoidoscopy CPT code 45330 under 
circumstances when a beneficiary is scheduled and prepared for a total 
colonoscopy (diagnostic colonoscopy, screening colonoscopy or 
colonoscopy through stoma), but the practitioner is unable to advance 
the colonoscope beyond the splenic flexure. We are seeking comment and 
recommendations on that possibility, as well as more generally, the 
typical resource costs of these incomplete colonoscopy services under 
CPT's new definition. Finally, we are seeking information regarding the 
number of colonoscopies that will be considered incomplete under CPT's 
new definition relative to the old definition, as well as the number of 
incomplete colonoscopies where the practitioner is unable to advance 
the colonoscope beyond the splenicflexure. This information will help 
us determine whether or not differential payment is required, and if it 
is, how to make the appropriate utilization assumptions within our 
ratesetting process.
(4) Malpractice (MP) Crosswalk
    We examined the RUC's recommended MP crosswalk for this family of 
codes. The MP crosswalks are used to identify the presumed mix of 
specialties that furnish particular services until there is Medicare 
claims data for the new codes. We direct the reader to section II.B.1. 
of this proposed rule for further explanation regarding these 
crosswalks. In reviewing the recommended MP crosswalks for CPT codes 
43775, 44407, 44408, 46601, and 46607, we noted that the RUC-
recommended MP crosswalk codes are inconsistent with our analysis of 
the specialties likely to furnish the service based on the description 
of the services and our review of the RUC-recommended utilization 
crosswalk. The inconsistency between the RUC's recommended MP and 
utilization crosswalks is not altogether unusual. However when there 
are discrepancies between the MP and utilization crosswalk 
recommendations, they generally reflect the RUC's expectation that due 
to changes in coding, there will be a different mix of specialties 
reporting a new code than might be reflected in the claims data for the 
code previously used to report that service. This often occurs when the 
new coding structure for a particular family of services is either more 
or less specific than the old set of codes. In most of these cases, we 
could identify a rationale for why the RUC's recommended MP crosswalks 
for these codes were likely to be more accurate than the RUC's 
recommended utilization crosswalk. But in the case of these codes, the 
reason for the discrepancies were neither apparent nor explained as 
part of the recommendation. Since the specialty mix in the claims data 
is used to determine the specialty mix for each HCPCS code for the 
purposes of calculating MP RVUs, and that data will be used to set the 
MP RVUs once it is available, we believe using a specialty mix derived 
from the claims data of the predecessor codes is more likely to be 
accurate than the RUC-recommended MP crosswalk as well as more likely 
to result in stable MP RVUs for these services over several years. 
Therefore, until claims data under the new set of codes is available, 
we are proposing to use the specialty mix of the source code(s) in the 
RUC-recommended utilization crosswalk in order to calculate the 
malpractice risk factor for these services instead of the RUC-
recommended MP crosswalk. Once claims data are available, those data 
will be incorporated into the calculation of MP RVUs for these services 
under the MP RVU methodology.
b. Radiation Treatment and Related Image Guidance Services
    For CY 2015, the CPT Editorial Panel revised the set of codes that 
describe radiation treatment delivery services based in part on the CMS 
identification of these services as potentially misvalued in CY 2012. 
We identified these codes as potentially misvalued under a screen 
called ``Services with Stand-Alone PE Procedure Time.'' We proposed 
this screen following our discovery of significant discrepancies 
between the RUC-recommended 60 minute procedure time assumptions for 
intensity modulated radiation therapy (IMRT) and information available 
to the public suggesting that the procedure typically took between 5 
and 30 minutes per treatment.
    The CPT Editorial Panel's revisions included the addition and 
deletion of several codes and the development of new guidelines and 
coding instructions. Four treatment delivery codes (77402, 77403, 
77404, and 77406) were condensed into 77402 (Radiation Treatment 
Delivery, Simple), three treatment delivery codes (77407, 77408, 77409) 
were condensed into 77407 (Radiation treatment delivery, intermediate), 
and four treatment codes (77412, 77413, 77414, 77416) were condensed 
into 77412 (Radiation treatment delivery, complex). Intensity Modulated 
Radiation Therapy (IMRT) treatment delivery, previously reported under 
a single code, was split into two codes, 77385 (IMRT treatment 
delivery, simple) and 77386 (IMRT treatment delivery, complex). The CPT 
Editorial Panel also created a new image guidance code, 77387 (Guidance 
for localization of target volume for delivery of treatment, includes 
intrafraction tracking when performed) to replace 77014 (computed 
tomography guidance for placement of radiation therapy fields), 77421 
(stereoscopic X-ray guidance for localization of target volume for the 
delivery of radiation therapy,) and 76950 (ultrasonic guidance for 
placement of radiation therapy fields) when any of these services were 
furnished in conjunction with radiation treatment delivery.
    In response to stakeholder concerns regarding the magnitude of the 
coding changes and in light of the process changes we adopted for 
valuing new and revised codes, we did not implement interim final 
values for the new codes and delayed implementing the new code set 
until 2016. To address the valuation of the new code set through 
proposed rulemaking, and

[[Page 41770]]

continue making payment based the previous valuations even though CPT 
deleted the prior radiation treatment delivery codes for CY 2015, we 
created G-codes that mimic the predecessor CPT codes (79 FR 67667).
    We propose to establish values for the new codes based on RUC 
recommendations, subject to standard CMS refinements that appear in 
Table 15 in section II.B.4. of this proposed rule. We also note that 
because the invoices used to price the capital equipment included ``on-
board imaging,'' the cost of that equipment is already reflected in the 
price per minute associated with the capital equipment. Therefore, we 
have not included it as a separate item in the proposed direct PE 
inputs for these codes, even though it appeared as a separate item on 
the PE worksheet included with the RUC recommendations for these codes. 
The direct PE inputs for these codes are reflected in the proposed 
direct PE input database available on the CMS Web site under the 
supporting data files for the CY 2016 PFS proposed rule with comment 
period at http://www.cms.gov/PhysicianFeeSched/. The RVUs that result 
from the use of these proposed direct PE inputs (and work RVUs and work 
time, as applicable) are displayed in Addendum B on the CMS Web site.
    In addition to the refinements addressed above, there are three 
additional issues for which we are seeking comment and/or making 
specific proposals related to these services: image guidance, equipment 
utilization rate assumptions for linear accelerators, and superficial 
radiation treatment services.
(1) Image Guidance Services
    Under the previous CPT coding structure, image guidance was 
separately billable when furnished in conjunction with the radiation 
treatment delivery services. The image guidance was reported using 
different CPT codes, depending on which image guidance modality was 
used. These codes were split into professional and/or technical 
components that allowed practitioners to report a single component or 
the global service. The professional component of each of these codes 
included the work of the physician furnishing the image guidance. CPT 
code 77014, used to report CT guidance, had a work RVU of 0.85; CPT 
code 77421, used to report stereotactic guidance, had a work RVU of 
0.39, and CPT code 76950, used to report ultrasonic guidance, had a 
work RVU of 0.58. The technical component of these codes incorporated 
the resource costs of the image guidance capital equipment (such as CT, 
ultrasound, or stereotactic) and the clinical staff involved in 
furnishing the image guidance associated with the radiation treatment. 
When billed globally, the RVUs reflected the sum of the professional 
and technical components. In the revised coding structure, one new 
image guidance code is to be reported regardless of the modality used, 
and in developing its recommended values, the RUC assumed that CT 
guidance would be typical.
    However, the 2013 Medicare claims data for separately reported 
image guidance indicates that stereotactic guidance for radiation 
treatment services was furnished more frequently than CT guidance. The 
RUC has recommended a work RVU of 0.58 and associated work times of 3 
pre-service minutes, 10 intraservice minutes, and 3 post-service 
minutes for image guidance CPT code 77387. We reviewed this 
recommendation considering the discrepancy between the modality the RUC 
assumed to be typical in the vignette and the modality typically 
reported in the Medicare claims data. Given that the recommended work 
RVU for the new single code is similar to the work RVUs of the 
predecessor codes, roughly prorated based on their distribution in 
Medicare claims data, we agree with the RUC-recommended work RVU for 
the service. However, the RUC also recommended an increase in overall 
work time associated with image guidance consistent with the survey 
data used to value the new services. If accurate, this increase in time 
and maintenance of total work would suggest a decrease in the overall 
intensity for image guidance relative to the current codes. Given this 
implication, we are seeking comment as to the appropriate work time 
associated with CPT code 77387.
    Although 77421 (stereotactic guidance) and 76950 (ultrasonic 
guidance) have been deleted, we note that CPT maintained CPT code 77014 
(Computed tomography guidance for placement of radiation therapy 
fields) and the RUC recommendation states that CPT did so based on 
concerns that without this option, some practitioners might have no 
valid CPT alternative than to use higher valued diagnostic CT codes 
when they used this CT guidance. The RUC recommendation also includes a 
statement that utilization of this code is expected to drop to 
negligible levels by 2015, assuming that practitioners would use the 
new codes that are not differentiated based on imaging modality. Once 
all the new codes are implemented for Medicare, we anticipate that CPT 
and/or the RUC will address the continued use of 77014 and, if it 
continues to be part of the code set, provide recommendations as to the 
appropriate values given changes in utilization.
    Regarding the reporting of the new image guidance codes, CPT 
guidance instructs that the technical portion of image guidance is now 
bundled into the IMRT and Stereotactic Radiation Treatment delivery 
codes, but it is not bundled into the simple, intermediate, and complex 
radiation treatment delivery codes. CPT guidance states that the 
technical component of the image guidance code can be reported with 
codes 77402, 77407, and 77412 (simple, intermediate, and complex 
radiation treatment) when furnished, which means that the technical 
component of the image guidance code should not be reported with the 
IMRT or Stereotactic Radiation Treatment delivery codes. The RUC 
recommendation, however, incorporates the same capital cost of image 
guidance equipment (a linear accelerator, or linac), for all these 
radiation treatment delivery codes, including the codes that describe 
IMRT and Stereotactic Radiation Treatment delivery services. The RUC 
explains that the recommendations were done this way because the older 
lower-dose external beam radiation machines are no longer manufactured 
and the image guidance technology is integrated into the single kind of 
linear accelerator used for all the radiation treatment services. In 
reviewing the new code structure and the RUC recommendations, we assume 
that the CPT editorial panel did not foresee that the RUC would 
recommend that we develop PE RVUs for all the radiation treatment 
delivery codes based on the assumption that the same capital equipment 
is typically used in furnishing the entire range of external beam 
radiation treatments. Because the RUC recommendations incorporate the 
more extensive capital equipment in the lower dose treatment codes as 
well, a portion of the resource costs of the technical portion of 
imaging guidance are already allocated into the PE RVUs for all of the 
treatment delivery codes, not just the IMRT and Stereotactic Radiation 
Treatment delivery codes as CPT guidance would suggest.
    In order to avoid incorporating the cost of this equipment into 
both the treatment delivery codes (77402, 77407, and 77412) and the 
technical component of the new imaging guidance code (77387-TC), we 
considered valuing 77387 as a professional service only and not 
creating the professional/technical component splits envisioned by CPT. 
In the context of the budget neutral PFS, incorporating a duplicative

[[Page 41771]]

direct input with a cost of more than six dollars per minute has 
significant impacts on the PE RVUs for all other services. However, we 
also noted that the RUC did not address this apparent contradiction in 
its recommendation and not all of the recommended direct PE inputs for 
the technical component of 77387 are capital equipment costs. 
Therefore, we are proposing to allow for professional and technical 
component billing for these services, as reflected in CPT guidance, and 
we are proposing to use the RUC recommended direct PE inputs for these 
services (refined as described in Table 15). However, we are also 
seeking comment on the apparent contradiction between technical 
component billing for image guidance in the context of the inclusion of 
a single linac with integrated imaging guidance technology being 
included for all external beam treatment codes.
(2) Equipment Utilization Rate for Linear Accelerators
    The cost of the capital equipment is the primary determining factor 
in the payment rates for these services. For each CPT code, the 
equipment costs are estimated based on multiplying the assumed number 
of minutes the equipment is used for that procedure by the per minute 
cost of the particular equipment item. Under our PE methodology, we 
currently use two default equipment usage assumptions in allocating 
capital equipment costs to calculate PE RVUs. The first is that each 
equipment item is only available to be used during what are assumed to 
be regular business hours for a physician's office: 10 hours per day, 5 
days per week (50 hours per week) and 50 weeks per year. The second 
assumption is that the equipment is in use only 50 percent of the time 
that it is available for use. The current default 50 percent 
utilization rate assumption translates into 25 hours per week out of a 
50-hour work week.
    We have previously addressed the accuracy of these default 
assumptions as they apply to particular equipment resources and 
particular services. In the CY 2008 PFS proposed rule (72 FR 38132) we 
discussed the 50 percent utilization assumption and acknowledged that 
the default 50 percent usage assumption is unlikely to capture the 
actual usage rates for all equipment. However, we stated that we did 
not believe that we had strong empirical evidence to justify any 
alternative approaches. We indicated that we would continue to monitor 
the appropriateness of the equipment utilization assumption, and 
evaluate whether changes should be proposed in light of the data 
available.
    Subsequently, a 2009 report on equipment utilization by MedPAC 
included studies that suggested a higher utilization rate for 
diagnostic imaging equipment costing more than $1 million. These 
studies cited by MedPAC suggested that for Magnetic Resonance Imaging 
equipment, a utilization rate of 92 percent on a 50-hour week would be 
most accurate. Similarly, another MedPAC cited study suggested that for 
Computed Tomography scanners, 45 hours was more accurate and that is 
equivalent to a 90 percent utilization rate on a 50-hour work week. For 
the CY 2010 PFS proposed rule, we proposed to increase the equipment 
usage rate to 90 percent for all services containing equipment that 
cost in excess of $1 million dollars. We stated that the studies cited 
by MedPAC suggested that physicians and suppliers would not typically 
make huge capital investments in equipment that would only be utilized 
50 percent of the time (74 FR 33532).
    In response to comments to that proposal, we finalized a 90 percent 
utilization rate assumption for MRI and CT to be transitioned over a 4-
year period. Regarding the utilization assumptions for other equipment 
priced over $1 million, we stated that we would continue to explore 
data sources regarding use of the most accurate utilization rates 
possible (74 FR 61755). Congress subsequently specified the utilization 
rate to be assumed for MRI and CT by successive amendments to Section 
1848(b)(4)(C) of the Act. Section 3135(a) of the Affordable Care Act 
(Pub. L. 111-148) set the assumed utilization rate for expensive 
diagnostic imaging equipment to 75 percent, effective for 2011 and 
subsequent years. Section 635 of the American Taxpayer Relief Act 
(ATRA) (Pub. L. 112-240) set the assumed equipment utilization rate to 
90%, effective for 2014 and subsequent years. Both of these changes 
were exempted from the budget neutrality requirements described in 
section 1848(c)(2)(B)(ii)(II) of the Act.
    We have also made other adjustments to the default assumptions 
regarding the number of hours for which the equipment is available to 
be used. For example, some equipment used in furnishing services to 
Medicare beneficiaries is available to be used on a 24-hour/day, 7 
days/per week basis. For these items, we develop the rate per minute by 
amortizing the cost over the extended period of time the equipment is 
in use.
    Based on the RUC recommendations for the new codes that describe 
radiation treatment services, we do not believe our default assumptions 
regarding equipment usage are accurate for the capital equipment used 
in radiation treatment services. As we noted above, the RUC 
recommendations assume that the same type of linear accelerator is now 
typically used to furnish all levels and types of external beam 
radiation treatment services because the machines previously used to 
furnish these services are no longer manufactured. In valuing the 
previous code set and making procedure time assumptions, different 
equipment items were assumed to be used to furnish the different levels 
and types of radiation treatment. With the current RUC-recommended 
inputs, we can then assume that the same equipment item is used to 
furnish more services. If we assume the RUC recommendation to include 
the same kind of capital equipment for all of these codes is accurate, 
we believe that it is illogical to continue to assume that the 
equipment is only used for 25 out of a possible 50 hours per week. In 
order to estimate the difference between the previous number of minutes 
the linear accelerator was assumed to be in use under the previous 
valuation and the number of minutes now being recommended, we applied 
the change in assumptions to the services reported in the most recent 
year of Medicare claims data. Under the assumptions reflected in the 
previous direct PE inputs, the kind of linear accelerator used for IMRT 
made up a total of 44.8 million out of 65 million minutes of external 
beam treatments furnished to Medicare beneficiaries. Under the new code 
set, however, a single kind of linear accelerator would be used for all 
of the 65 million minutes furnished to Medicare beneficiaries. This 
represents a 45 percent increase in the aggregate amount of time that 
this kind of linac is in use. Of course, the utilization rate that 
corresponds with that increase in minutes is not necessarily precise 
since the current utilization rate only reflects the default assumption 
and is not itself rooted in empirical data. Additionally, in some 
cases, individual practices that already use linear accelerators for 
IMRT may have replaced the now-obsolete capital equipment with new, 
additional linear accelerators instead of increasing the use of capital 
equipment already owned. However, we do not believe that the latter 
scenario is likely to be common in cases where the linear accelerators 
had previously been used only 25 hours per week.
    Therefore, we are proposing to adjust the equipment utilization 
rate

[[Page 41772]]

assumption for the linear accelerator to account for the significant 
increase in usage. Instead of applying our default 50 percent 
assumption, we are proposing to use a 70 percent assumption based on 
the recognition that the item is now being typically used in a 
significantly broader range of services, and that would increase its 
overall usage in comparison to the previous assumption. We note that we 
developed the 70 percent rate based on a rough reconciliation between 
the number of minutes the equipment is being used according to the new 
recommendations versus the current number of minutes based on an 
analysis of claims data. We continue to seek evidence to ensure that 
the usage assumptions, both the utilization rate and number of 
available hours, used to calculate equipment costs are as accurate as 
possible. We believe that comparing the changes in direct PE input 
recommendations and using the Medicare claims data indicates that the 
utilization assumption to 70 percent is more accurate than the default 
utilization assumption of 50 percent. However, we have reviewed other 
information that suggests this utilization rate may be higher than 70 
percent and that the number of available hours per week is greater than 
50.
    For example, as part of the 2014 RUC recommendations for the 
Radiation Treatment Delivery codes, the RUC submitted a 2011 staffing 
survey conducted by the American Society for Radiology Technicians 
(ASRT). Using the 2014 version of the same study, we noted that there 
are an average of 2.3 linacs per radiation treatment facility and 52.7 
patients per day treated per radiation treatment facility. These data 
suggest that an average of 22.9 patients is treated on each linac per 
day. Using an average of the RUC-recommended procedure times for CPT 
codes 77385, 77386, 77402, 77407, and 77412 weighted by the annual 
volume of procedures derived from Medicare claims data yielded a total 
of 670.39 minutes or 11.2 hours that a single linac is in use per day. 
This is in contrast to both the number of hours of use reflected in our 
default assumptions (5 of the 10 available business hours per day) and 
in our proposed revision to the equipment utilization rate assumption 
(7 hours out of 10 available business hours per day).
    For advanced diagnostic imaging services, we finalized a policy to 
change the equipment utilization assumption only by 10 percent per 
year, in response to suggestions from commenters. Because capital 
equipment costs are amortized over several years, we believe it is 
reasonable to transition changes to the default assumptions for 
particular items over several years. We note that the change from one 
kind of capital equipment to another is likely to occur over a number 
of years, roughly equivalent to the useful life of particular items as 
they become obsolete. In the case of most of these items, we have 
assumed a 7-year useful life, and therefore, we assume that the 
transition to use of the single kind of capital equipment would likely 
take place over 7 years as individual pieces of equipment age into 
obsolescence. However, in the case of this transition in capital 
equipment, we have reasons to believe that the transition to the new 
capital equipment has already occurred. First, we note that the 
specialty societies concluded that the single linear accelerator was 
typical for these services at the time that the current recommendations 
were developed in 2013. Therefore, we believe it is logical to assume 
that, at a minimum, the first several years of the transition to new 
capital equipment had already taken place by 2013. This would account 
for the linear accelerator being typically used at that time. This 
would not be surprising, given that prior to the 2013 review by the 
RUC, the codes describing the non-IMRT external beam radiation 
treatments had last been reviewed in 2002. Second, because we are 
proposing to use the 2013 recommendations for 2016 PFS payment rates, 
we believe it would be reasonable to assume that in the years between 
2013 and 2016, the majority of the rest of the obsolete machines would 
have been replaced with the single linear accelerator.
    Nonetheless, we recognize that there would be value in following 
precedent to transition changes in utilization assumptions over several 
years.
    Given the fact that it is likely that the transition to the linear 
accelerator began prior to the 2013 revaluation of the radiation 
treatment delivery codes by CPT and that the useful life of the newest 
generation of linear accelerator is 7 years, we believe a 2-year 
transition to the 70 percent utilization rate assumption would account 
for any remaining time to transition to the new equipment. Therefore, 
in developing PE RVUs for these services, we are proposing to use a 60 
percent utilization rate assumption for CY 2016 and a 70 percent 
utilization rate assumption for CY 2017. The PE RVUs displayed in 
addendum B on the CMS Web site were calculated using the proposed 60 
percent equipment utilization rate for the linac as displayed in the CY 
2016 direct PE input database.
    Additionally, we continue to seek empirical data on the capital 
equipment costs, including equipment utilization rates, for the linac 
and other capital-intensive machines, and seek comment on how to most 
accurately address issues surrounding those costs within the PE 
methodology.
(3) Superficial Radiation Treatment Delivery
    In the CY 2015 PFS final rule with comment period, we noted that 
changes to the CPT prefatory language modify the services that are 
appropriately billed with CPT code 77401 (radiation treatment delivery, 
superficial and/or ortho voltage, per day). The changes effectively 
meant that many other procedures supporting superficial radiation 
therapy were bundled with 77401. The RUC, however, did not review the 
inputs for superficial radiation therapy procedures, and therefore, did 
not assess whether changes in its valuation were appropriate in light 
of this bundling. Some stakeholders suggested that the change in the 
prefatory language precluded them from billing for codes that were 
previously frequently billed in addition to this code and expressed 
concern that as a result there would be significant reduction in their 
overall payments. In the CY 2015 PFS final rule with comment period, we 
requested information on whether the new radiation therapy code set 
combined with modifications in prefatory text allowed for appropriate 
reporting of the services associated with superficial radiation and 
whether the payment continued to reflect the relative resources 
required to furnish superficial radiation therapy services.
    In response to our request, we received a recommendation from a 
stakeholder to make adjustments to both the physician work and PE 
components for code 77401. The stakeholder suggested that since crucial 
aspects of the service, such as treatment planning and device design 
and construction, were not currently reflected in 77401, and 
practitioners were precluded from reporting these activities 
separately, that physician work should be included for CPT code 77401. 
Additionally, the stakeholders suggested that the current inputs used 
to value the code are not accurate because the inputs include zero 
physician work and minutes for a radiation therapist to provide the 
service directly to the patient. The stakeholders suggested, 
alternatively, that physicians, not radiation therapists, typically 
provide superficial radiation services directly. Therefore, we are 
seeking recommendations from other stakeholders, including the RUC, 
regarding whether or not it would be

[[Page 41773]]

appropriate to add physician work for this service and remove minutes 
for the radiation therapists, even though physician work is not 
included in other radiation treatment services.
    The stakeholder also suggested that we amend the direct PE inputs 
by including nurse time and updating the price of the capital equipment 
used in furnishing the service. We believe it would be most appropriate 
to address the clinical labor assigned to the code in the context of 
the information regarding the physician work that might be associated 
with the service. Therefore, we seek information on the possible 
inclusion of nurse time for this service as part of the comments and/or 
recommendations regarding physician work for the service. However, we 
reviewed the submitted invoices for the request to update the capital 
equipment for the service. We are proposing to update the equipment 
item ER045 ``orthovoltage radiotherapy system'' by renaming it ``SRT-
100 superficial radiation therapy system'' and updating the price from 
$140,000 to $216,000, on the basis of the submitted invoices. The PE 
RVUs displayed in Addendum B on the CMS Web site were calculated with 
this proposed modification that is displayed in the CY 2016 direct PE 
input database.
c. Advance Care Planning Services
    For CY 2015, the CPT Editorial Panel created two new codes 
describing advance care planning (ACP) services: CPT code 99497 
(Advance care planning including the explanation and discussion of 
advance directives such as standard forms (with completion of such 
forms, when performed), by the physician or other qualified health 
professional; first 30 minutes, face-to-face with the patient, family 
member(s) and/or surrogate); and an add-on CPT code 99498 (Advance care 
planning including the explanation and discussion of advance directives 
such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health professional; each 
additional 30 minutes (List separately in addition to code for primary 
procedure)). In the CY 2015 PFS final rule with comment period (79 FR 
67670-71), we assigned a PFS interim final status indicator of ``I'' 
(Not valid for Medicare purposes. Medicare uses another code for the 
reporting and payment of these services) to CPT codes 99497 and 99498 
for CY 2015. We said that we would consider whether to pay for CPT 
codes 99497 and 99498 after we had the opportunity to go through notice 
and comment rulemaking.
    We received many public comments to the final rule recommending 
that we recognize these two CPT codes and make separate payment for ACP 
services, in view of the time required to furnish the services and 
their importance for the quality of care and treatment of the patient. 
For CY 2016, we are proposing to assign CPT codes 99497 and 99498 PFS 
status indicator ``A,'' which is defined as: ``Active code. These codes 
are separately payable under the PFS. There will be RVUs for codes with 
this status.'' The presence of an ``A'' indicator does not mean that 
Medicare has made a national coverage determination regarding the 
service. Contractors remain responsible for local coverage decisions in 
the absence of a national Medicare policy. We are proposing to adopt 
the RUC-recommended values (work RVUs, time, and direct PE inputs) for 
CPT codes 99497 and 99498 beginning in CY 2016 and will consider all 
public comments that we receive on this proposal.
    Physicians' services are covered and paid by Medicare in accordance 
with section 1862(a)(1)(A) of the Act. Therefore, CPT code 99497 (and 
CPT code 99498 when applicable) should be reported when the described 
service is reasonable and necessary for the diagnosis or treatment of 
illness or injury. For example, this could occur in conjunction with 
the management or treatment of a patient's current condition, such as a 
68 year old male with heart failure and diabetes on multiple 
medications seen by his physician for the evaluation and management of 
these two diseases, including adjusting medications as appropriate. In 
addition to discussing the patient's short-term treatment options, the 
patient expresses interest in discussing long-term treatment options 
and planning, such as the possibility of a heart transplant if his 
congestive heart failure worsens and advance care planning including 
the patient's desire for care and treatment if he suffers a health 
event that adversely affects his decision-making capacity. In this case 
the physician would report a standard E/M code for the E/M service and 
one or both of the ACP codes depending upon the duration of the ACP 
service. However, the ACP service as described in this example would 
not necessarily have to occur on the same day as the E/M service.
    We seek comment on this proposal, including whether payment is 
needed and what type of incentives this proposal creates. In addition, 
we seek comment on whether payment for advance care planning is 
appropriate in other circumstances such as an optional element, at the 
beneficiary's discretion, of the annual wellness visit (AWV) under 
section 1861(hhh)(2)(G) of the Act.
d. Proposed Valuation of Other Codes for CY 2016
(1) Excision of Nail Bed (CPT Code 11750)
    The RUC's review of 10-day global services identified 18 services 
currently valued with greater than 1.5 office visits and 2012 Medicare 
utilization data over 1,000, including CPT code 11750. As a result, the 
RUC requested this service be surveyed for work and reviewed for CY 
2016.
    The RUC recommended a work RVU of 1.99 for CPT code 11750, despite 
a decrease in the associated post-operative visits. We believe the 
recommendation for this service overstates the work involved in 
performing this procedure specifically given the decrease in post-
operative visits. Due to similarity in service and time, we believe a 
direct crosswalk of the work RVUs for CPT code 10140 (Drainage of blood 
or fluid accumulation), which is also a 10 day global service with one 
post-operative visit, to CPT code 11750 more accurately reflects the 
time and intensity of furnishing the service. Therefore, for CY 2016 we 
are proposing a work RVU of 1.58 for CPT code 11750.
(2) Bone Biopsy Excisional (CPT Code 20240)
    In the same review of 10-day global services, the RUC identified 
CPT code 20240 as potentially misvalued. As a result, the RUC requested 
this service be surveyed and reviewed for CY 2016. Subsequent to this 
identification, the RUC also requested and we approved a global period 
change from a 10-day to a 0-day global period for this procedure. Based 
on the survey data, the RUC recommended a decrease in the intraservice 
time from 39 to 30 minutes, removal of two postoperative visits (one 
99238 and one 99212), and an increase in the work RVUs for CPT code 
20240 from 3.28 to 3.73. We do not believe this recommendation 
accurately reflects the work involved in this procedure, especially 
given the decrease in intraservice time and post-operative visits. 
Therefore, for CY 2016, we are proposing a work RVU of 2.61 for CPT 
code 20240 based on the reductions in time for the service.

[[Page 41774]]

(3) Endobronchial Ultrasound (CPT Codes 31622, 3160A, 3160B, 31625, 
31626, 31628, 31629, 3160C, 31632 and 31633)
    For CY 2016, the CPT Editorial Panel deleted one code, CPT 31620 
(Ultrasound of lung airways using an endoscope), and created three new 
codes, CPT 3160A-3160C, to describe bronchoscopic procedures that are 
inherently performed with endobronchial ultrasound (EBUS).
    In their review of the newly revised EBUS family, the RUC 
recommended a change in the work RVU for CPT code 31629 from 4.09 to 
4.00. The RUC also recommended maintaining the current work RVUs for 
CPT codes 31622, 31625, 31626, 31628, 31632 and 31633. We are proposing 
to use those values for CY 2016.
    For the newly created codes, the RUC recommended a work RVU of 5.00 
for CPT code 3160A, 5.50 for CPT code 3160B and 1.70 for CPT code 
3160C. We believe the recommended work RVUs for these services 
overstate the work involved in furnishing the procedures. In order to 
develop proposed work RVUs for CPT code 3160A, we compared the service 
described by the new code to deleted CPT codes 31620 and 31629, because 
this new code describes a service that combines services described by 
31620 and 31629. Specifically, we took the sum of the current work RVU 
of CPT code 31629 (WRVU=4.09) and the CY 2015 work RVU of CPT code 
31620 (WRVU=1.40) and multiplied it by the quotient of CPT code 3160A's 
RUC-recommended intraservice time (INTRA=60 min) and the sum of CPT 
codes 31620 and 31629's current and CY 2015 intraservice times 
(INTRA=70 min), respectively. This resulted in a work RVU of 4.71 and 
we are proposing that value. To value CPT code 3160B, we used the RUC-
recommended increment of 0.5 work RVU between this service and CPT code 
3160A to calculate for CPT code 3160B our proposed work RVUs of 5.21. 
Lastly, because the service described by new CPT code 3160C is very 
similar to deleted CPT code 31620, we believe a direct crosswalk of the 
previous values for 31620 accurately reflects the time and intensity of 
furnishing the service described by 3160C. Therefore, we are proposing 
a work RVUs of 1.40 for CPT code 3160C.
(4) Laparoscopic Lymphadenectomy (CPT Codes 38570, 38571 and 38572)
    The RUC identified three laparoscopic lymphadenectomy codes as 
potentially misvalued: CPT code 38570 (Laparoscopy, surgical; with 
retroperitoneal lymph node sampling (biopsy), single or multiple); CPT 
code 38571 (Laparoscopy, surgical; with retroperitoneal lymph node 
sampling (biopsy), single or multiple with bilateral total pelvic 
lymphadenectomy); and CPT code 38572 (Laparoscopy, surgical; with 
retroperitoneal lymph node sampling (biopsy), single or multiple with 
bilateral total pelvic lymphadenectomy and periaortic lymph node 
sampling (biopsy), single or multiple). Accordingly, the specialty 
society resurveyed these 10-day global codes, and the survey results 
indicated decreases in intraservice and total work times. After 
reviewing the survey responses, the RUC recommended that CMS maintain 
the current work RVU for CPT code 38570 of 9.34; reduce the work RVU 
for CPT code 38571 from 14.76 to 12.00; and reduce the work RVU for CPT 
code 38572 from 16.94 to 15.60. We propose to accept the RUC 
recommendations for CPT codes 38571 and 38572, as the RUC is 
recommending reductions in the work RVUs that correspond with marked 
decreases in intraservice time and decreases in total time. However, we 
do not agree with the RUC's recommendation to maintain the current work 
RVU for CPT code 38570 in spite of similar changes in intraservice and 
total times as were shown in the RUC recommendations for CPT codes 
38571 and 38572. Therefore, we propose to reduce the work RVU for CPT 
code 38570 to 8.49, which reflects the ratio of the reduction in total 
time for this code and would maintain rank order among the three codes.
(5) Mediastinoscopy With Biopsy (CPT Codes 3940A and 3940B)
    The RUC identified CPT code 39400 (Mediastinoscopy, including 
biopsy(ies) when performed) as a potentially misvalued code due to an 
unusually high preservice time and Medicare utilization over 10,000. In 
reviewing the code's history, it became apparent that the code has been 
used to report two distinct procedural variations although the code was 
valued using a vignette for only one of them. As a result, CPT code 
39400 is being deleted and replaced with CPT codes 3940A and 3940B to 
describe each of the two mediastinoscopy procedures.
    We are proposing to accept the RUC-recommended work RVU of 5.44 for 
code 3940A. We agree with the RUC that the crosswalk from CPT code 
52235 (Cystourethroscopy, with fulguration) appropriately estimates the 
overall work for CPT code 3940A. For CPT code 3940B, we disagree with 
the RUC recommended work RVU of 7.50. We believe that the work value 
for CPT code 3940A establishes an accurate baseline for this family of 
codes, so we are scaling the work RVU of CPT code 3940B in accordance 
with the change in the intraservice times between CPT codes 3940A and 
3940B. Applying this ratio in the intraservice time to the work value 
of CPT code 3940A yields a total work RVU of 7.25 for CPT code 3940B. 
We also note that the RUC recommendation for CPT code 3940A represents 
a decrease in value by 0.64 work RVUs, which is roughly proportionate 
to the reduction from a full hospital discharge visit (99238) to a half 
discharge visit assumed to be typical in the post-operative period. The 
RUC recommendation for CPT code 3940B had the same reduction in the 
post-operative work without a corresponding decrease in its recommended 
work RVU. In order to reflect the reduction in post-operative work and 
to maintain relativity between the two codes in the family, we are 
proposing 7.25 as the work RVU for CPT code 3940B.
(6) Hemorrhoid(s) Injection (CPT Code 46500)
    The RUC also identified CPT code 46500 (Injection of sclerosing 
solution, hemorrhoids) as potentially misvalued, and the specialty 
society resurveyed this 10-day global code. The survey showed a 
significant decrease in the reported intraservice and total work times. 
After reviewing the survey responses, the RUC recommended that CMS 
should maintain the current work RVU of 1.69 in spite of these drops in 
intraservice and total times. We propose to instead reduce the work RVU 
to 1.42, which reduces the work RVU by the same ratio as the reduction 
in total time.
    We are also proposing to refine the recommended PE inputs by 
removing the inputs associated with cleaning the scope. As recommended 
by the RUC, we are proposing to include a scope as a direct PE input 
that is disposable, and therefore, does not require cleaning.
(7) Liver Allotransplantation (CPT Code 47135)
    The RUC also identified CPT code 47135 (Liver allotransplantation; 
orthotopic, partial or whole, from cadaver or living donor, any age) as 
potentially misvalued, and the specialty society resurveyed this 90-day 
global code. The survey showed a significant decrease in reported 
intraservice work time, but a significant increase in total work time 
(the number of post-operative visits significantly declined while the 
level of visits increased). After reviewing the survey responses, the

[[Page 41775]]

RUC recommended an increase in the work RVU from 83.64 to 91.78, which 
is the median of the survey, as well as the exact value for CPT code 
33935 (Heart-lung transplant with recipient cardiectomy-pneumonectomy). 
However, we do not believe this crosswalk is the most accurate from 
among the group of transplant codes. CPT code 32854 (Lung transplant, 
double (bilateral sequential or en bloc); with cardiopulmonary bypass) 
has intraservice and total times that are closer to those the RUC 
recommended for CPT code 47135, and CPT code 32854 has a work RVU of 
90.00 which is the 25th percentile of the survey for CPT code 47135. 
Therefore, we propose to increase the work RVU of CPT code 47135 to 
90.00.
(8) Genitourinary Catheter Procedures (CPT Codes 5039A, 5039B, 5039C, 
5039D, 5039M, 5039E, 5069G, 5069H, 5069I)
    For CY 2016, the CPT Editorial Panel is deleting six codes (50392, 
50393, 50394, 50398, 74475, and 74480) that were commonly reported 
together, and are creating 12 new codes both to describe these 
genitourinary catheter procedures more accurately and to bundle 
inherent imaging services. Three of these codes (506XF, 507XK, and 
507XL) were referred back to CPT to be resurveyed as add-on codes. The 
other nine codes were reviewed at the January 2015 RUC meeting and 
assigned recommended work RVUs and direct PE inputs.
    We are proposing to use the RUC-recommended work RVU of 3.15 for 
CPT code 5039A. We agree that this is an appropriate value, and that 
the code should be used as a basis for establishing relativity with the 
rest of the family. As a result, we began by making comparisons between 
the service times of CPT code 5039A and the other codes in the family 
in order to determine the appropriate proposed work value of each 
procedure.
    For CPT code 5039B, we disagree with the RUC recommended work RVU 
of 1.42, and we are instead proposing a work RVU of 1.10, based on 
three separate data points. First, the RUC summary of recommendations 
stated that CPT code 5039B describes work previously described by a 
combination of CPT codes 50394 and 74425. These two codes have work 
RVUs of 0.76 and 0.36, respectively, which sum together to 1.12. 
Second, we noted that the work of CPT code 49460 (Mechanical removal of 
obstructive material from gastrostomy) is similar, with the same 
intraservice time of 15 minutes and same total time of 55 minutes but a 
work RVU of 0.96. Finally, we observed that the minimum survey result 
had a work RVU of 1.10, and we believe this value appropriately 
reflects the total work for the service. Accordingly, we are proposing 
1.10 as the work RVU for CPT code 5039B.
    We employed a similar methodology to develop a proposed work RVU of 
4.25 for CPT code 5039C. The three previously established codes are 
being combined in CPT code 5039C; these had respective work values of 
3.37 (CPT code 50392), 0.54 (CPT code 74475), and 0.36 (CPT code 
74425); together these sum to 4.27 work RVUs. We also looked at valuing 
CPT code 5039C based on relativity with other codes in the family. The 
ratio of the intraservice time of 35 minutes for CPT code 5039A and the 
intraservice time of 48 minutes for CPT code 5039C; applied to the work 
RVU of base code 5039A (3.15) results in a potential work RVU of 4.32. 
The total time compared to CPT code 5039A also went from 91 minutes to 
107 minutes and this ratio applied to the base work RVU results in a 
work RVU of 3.70. We utilized these data to inform our choice of an 
appropriate crosswalk. We believe CPT code 31660 (Bronchoscopy, rigid 
or flexible, including fluoroscopic guidance) is an appropriate 
reference crosswalk for CPT code 5039C. CPT code 31660 has an 
intraservice time of 50 minutes, total time of 105 minutes, and a work 
RVU of 4.25. Therefore, we propose to establish the work RVU for CPT 
code 5039C at the crosswalked value of 4.25 work RVUs.
    According to the RUC recommendations, CPT codes 5039C and 5039D are 
very similar procedures, with CPT code 5039D making use of a 
nephroureteral catheter instead of a nephrostomy catheter. The RUC 
valued the added difficulty of CPT code 5039D at 1.05 work RVUs 
compared to code CPT code 5039C. We are maintaining the relative 
difference in work between these two codes by proposing a value of 5.30 
for CPT code 5039D. (This is the work RVU of 4.25 for CPT code 5039C 
plus 1.05 RVUs.) Additionally, we are using CPT code 57155 (Insertion 
of uterine tandem and/or vaginal ovoids for clinical brachytherapy) as 
our reference crosswalk. CPT code 57155 has a work RVU of 5.40 and an 
identical intraservice time of 60 minutes, but it also has fourteen 
additional minutes of total time, 133 minutes compared to 119 minutes 
for CPT code 5039D, which supports the difference of 0.10 RVUs. For 
these reasons, we are proposing the value of CPT code 5039D at 5.30 
work RVUs.
    As with the other genitourinary codes, we developed the proposed 
work value of CPT code 5039M in order to preserve relativity within the 
family. CPT code 5039M has 15 fewer minutes of intraservice time 
compared to CPT code 5039D (45 minutes compared to 60 minutes). This is 
a ratio of 0.75, applied to the based work RVU of CPT code 5039D (5.30) 
resulted in a potential work RVU of 3.98. CPT code 5039C was another 
close match within the family, with 3 more minutes of intraservice time 
compared to 5039M, 48 minutes of intraservice time instead of 45 
minutes. This ratio (0.94) applied to the base work RVU of CPT code 
5039C (4.25) also resulted in a potential work RVU of 3.98. Based on 
this information, we identified CPT code 31634 (Bronchoscopy, rigid or 
flexible, with balloon occlusion) as an appropriate crosswalk, and 
propose a work RVU of 4.00 for CPT code 5039M. The two codes share an 
identical intraservice time of 45 minutes, though the latter possesses 
a lower total time of 90 minutes.
    For CPT code 5039E, we considered how the code and work RVU would 
fit within the family in comparison to our proposed values for CPT 
codes 5039A and 5039C. CPT code 5039A serves as the base code for this 
group; it has 35 minutes of intraservice time in comparison to 20 
minutes for CPT code 5039E. This intraservice time ratio of 0.57 
resulted in a potential work RVU of 1.80 for CPT code 5039E when 
applied to the work RVU of CPT code 5039A (3.15). Similarly, CPT code 
5039C is the most clinically similar procedure to CPT code 5039E. CPT 
code 5039C has 48 minutes of intraservice time compared to 20 minutes 
of intraservice time for CPT code 5039E. This ratio of 0.42 applied to 
the base work RVU of CPT code 5039C (4.25) results in a potential work 
RVU of 1.77. We also made use of two crosswalks to help determine a 
proposed value for CPT code 5039E. CPT code 64416 (Injection, 
anesthetic agent; brachial plexus) also includes 20 minutes of 
intraservice time and has a work RVU of 1.81. CPT code 36569 (Insertion 
of peripherally inserted central venous catheter) has the same 
intraservice and total time as CPT code 5039E, with a work RVU of 1.82. 
Accordingly, we are crosswalking the work RVU for CPT code 5039E to CPT 
code 36569 and proposing a work RVU of 1.82 for CY 2016.
    The remaining three codes all utilize ureteral stents and form 
their own small subfamily within the larger group of genitourinary 
catheter procedures. For CPT code 5069G, we are proposing a

[[Page 41776]]

work RVU of 4.21, which is the 25th percentile result from the survey 
information. We believe that the 25th percentile provides a more 
accurate value for CPT code 5069G based on the work involved in the 
procedure and within the context of other codes in the family. We are 
also referencing CPT code 31648 (Bronchoscopy, rigid or flexible, with 
removal of bronchial valve), which shares 45 minutes of intraservice 
time and has a work RVU of 4.20, as an appropriate crosswalk for CPT 
code 5069G.
    For CPT code 5069H, we compared its intraservice time to the code 
within the family that had the most similar duration, CPT code 5039D. 
This code has 60 minutes of intraservice time compared to 62 minutes 
for CPT code 5069H. This is a ratio of 1.03 applied to the base work 
RVU of CPT code 5039D (5.30) resulted in a potential work RVU of 5.48. 
We also looked to crosswalks with similar numbers, in particular CPT 
code 50382 (Removal and replacement of internally dwelling ureteral 
stent). This code has 60 minutes of intraservice time, 125 minutes of 
total time, and a work RVU of 5.50. For these reasons, we are 
crosswalking CPT code 5069H to CPT code 50382 and proposing a work RVU 
of 5.50.
    Finally, we developed the proposed value for CPT code 5069I using 
three related methods. CPT codes 5069H and 5069I describe very similar 
procedures, with 5069I adding the use of a nephrostomy tube. The RUC 
addressed the additional difficulty of this procedure by recommending 
1.55 more work RVUs for CPT code 5069I than for CPT code 5069H. Adding 
the 1.55 work RVUs to the proposed work RVU for CPT code 5069H (5.50) 
would produce a work RVU of 7.05 for CPT code 5069I. We also looked at 
the ratio of intraservice times for CPT code 5069I (75 minutes) and the 
base code in the subfamily, CPT code 5069G (45 minutes). The 
intraservice time ratio between these two codes is 1.67 when applied to 
the base work RVU of CPT code 5069G (4.21) resulted in a potential work 
RVU of 7.02. We also identified an appropriate crosswalk reference in 
CPT code 36481 (Percutaneous portal vein catheterization by any method) 
which shares the same intraservice time as CPT code 5069I and has a 
work RVU of 6.98. Accordingly, to maintain relativity among this 
subfamily of codes, we are proposing a work RVU of 7.05 for CPT code 
5069I based on an incremental increase of 1.55 RVUs from CPT code 
5069H.
    In reviewing the direct PE inputs for this family of codes, we 
refined a series of the RUC- recommended inputs in order to maintain 
relativity with current standards. All of the following refinements 
refer to the non-facility setting for this family of codes. Under the 
clinical labor inputs, we are proposing to remove the RN/LPN/MTA 
(L037D) (intraservice time for assisting physician in performing 
procedure) for CPT codes 5039B and 5039E. This amounts to 15 minutes 
for CPT code 5039B and 20 minutes for CPT code 5039E. Moderate sedation 
is not inherent in these procedures and, therefore, we do not believe 
that this clinical labor task would typically be completed in the 
course of this procedure. We are also reducing the RadTech (L041B) 
intraservice time for acquiring images from 47 minutes to 46 minutes 
for CPT code 5069H. This procedure contains 62 minutes of intraservice 
time, with clinical labor assigned for acquiring images (75 percent) 
and a circulator (25 percent). The exact time for these clinical labor 
tasks multiplies out to 46.5 minutes and 15.5 minutes, respectively. 
The RUC recommendation for CPT code 5069H rounded both of these values 
upwards, assigning 47 minutes for acquiring images and 16 minutes for 
the circulator, which together sum to 63 minutes. We are reducing the 
clinical labor time for acquiring images to 46 minutes to preserve the 
62 minutes of total intraservice time for CPT code 5069H.
    During the post-service portion of the clinical labor service 
period, we are proposing to change the labor type for the ``patient 
monitoring following service/check tubes, monitors, drains (not related 
to moderate sedation)'' input. There are 45 minutes of clinical labor 
time assigned under this category to CPT codes 5039A, 5039C, 5039D, 
5039M, 5069G, 5069H, and 5069I. Although we agree that the 45 minutes 
are appropriate for these procedures as part of moderate sedation, we 
are changing the clinical labor type from the recommended RN (L051A) to 
RN/LPN/MTA (L037D) to reflect the staff that will typically be doing 
the monitoring for these procedures. Even though the CPT Editorial 
Committee's description of post-service work for CPT code 5039E 
includes a recovery period for sedation, we recognize that according to 
the recommendation, CPT codes 5039B and 5039E do not use moderate 
sedation, so we did not propose to include moderate sedation inputs for 
these codes.
    The RUC recommendation for CPT code 5039D includes a nephroureteral 
catheter as a new supply input with an included invoice. However, in 
the RUC summary of recommendations for this code, there is no mention 
of a nephroureteral catheter in the intraservice work description. CPT 
code 5039D does mention the use of a nephroureteral stent in this 
description, but there is no request for a nephroureteral stent supply 
item on the PE worksheet for this code. We are therefore seeking 
clarification from stakeholders regarding the use of the nephroureteral 
catheter for CPT code 5039D. We have not proposed to add the 
nephroureteral catheter as a supply item for CPT code 5039D pending 
this information. We are also requesting a clarification to the 
intraservice work description in the summary of recommendations for 
this code to explain the use, if any, of the nephroureteral catheter in 
this procedure.
    The RUC recommended the inclusion of ``room, angiography'' (EL011) 
for this family of codes. We do not agree with the RUC that an 
angiography room would be used in the typical case for these 
procedures, as there are other rooms available which can provide 
fluoroscopic guidance. Most of the codes that make use of an 
angiography room are cardiovascular codes, and much of the equipment 
listed for this room would not be used for non-cardiovascular 
procedures. We are therefore proposing to replace equipment item 
``room, angiography'' (EL011) with equipment item ``room, radiographic-
fluoroscopic'' (EL014) for the same number of minutes. We are 
requesting public comment regarding the typical room type used to 
furnish the services described by these CPT codes, as well as the more 
general question of the typical room type used for GU and GI 
procedures. In the past, the RUC has developed broad recommendations 
regarding the typical uses of rooms for particular procedures, 
including the radiographic-fluoroscopy room. We believe that such a 
recommendation from the RUC concerning all of these codes could be 
useful in ensuring relativity across the PFS.
(9) Penile Trauma Repair (CPT Codes 5443A and 5443B)
    CPT created these two new codes because there are no existing codes 
to capture penile traumatic injury that includes penile fracture, also 
known as traumatic corporal tear, and complete penile amputation. CPT 
code 5443A will describe a repair of traumatic corporeal tear(s) while 
CPT code 5443B will describe a replantation, penis, complete 
amputation. For CPT code 5443B, we disagree with the RUC recommendation 
of a work RVU of 24.50. We believe that the 25th

[[Page 41777]]

percentile work RVU of 22.10 provides a more accurate value based on 
the work involved in the procedure and within the context of other 
codes in the same family, since CPT code 5443A was also valued using 
the 25th percentile. We find further support for this valuation through 
a crosswalk to CPT code 43334 (Repair, paraesophageal hiatal hernia via 
thoracotomy, except neonatal) which has an identical intraservice time 
and a work RVU of 22.12. Therefore we are proposing a work RVU of 22.10 
for CPT code 5443B.
    Because CPT codes 5443A and 5443B are typically performed on an 
emergency basis, we question the appropriateness of the standard 60 
minutes of preservice clinical labor in the facility setting, as the 
typical procedure would not make use of office-based clinical labor. 
For example, we do not believe that the typical case would require 8 
minutes to schedule space in the facility for an emergency procedure, 
or 20 minutes to obtain consent. We are seeking further public comment 
on this issue from the RUC and other stakeholders.
(10) Intrastromal Corneal Ring Implantation (CPT Code 657XG)
    CPT code 657XG is a new code describing insertion of prosthetic 
ring segments into the corneal stroma for treatment of keratoconus in 
patients whose disease has progressed to a degree that they no longer 
tolerate contact lens wear for visual rehabilitation.
    We disagree with the RUC recommendation of a work RVU of 5.93 for 
CPT code 657XG. Although we appreciated the extensive list of other 
codes the RUC provided as references, we are concerned that the 
recommended value for CPT code 657XG overestimates the work involved in 
furnishing this service relative to other PFS services. We did not find 
a single code with comparable intraservice and total time that had a 
higher work RVU. The recommended crosswalk, CPT code 67917 (Repair of 
ectropion; extensive), appears to have the highest work RVU of any 90-
day global surgery service in this range of work time values. It also 
has longer intraservice time and total time than the code in question, 
making a direct crosswalk inappropriate.
    As a result, we are proposing a new value for CPT code 657XG based 
on the intraservice time ratio in relation to the recommended 
crosswalk. We compared the 33 minutes of intraservice time in CPT code 
67917 to the 30 minutes of intraservice time in CPT code 657XG. The 
intraservice time ratio between these two codes is 0.91, and when 
multiplied by the work RVU of CPT code 67917 (5.93) resulted in a 
potential work RVU of 5.39. We also considered CPT code 58605 (Ligation 
or transection of fallopian tube(s)), which has the same intraservice 
time, seven additional minutes of total time, and a work RVU of 5.28. 
We believe that CPT 58605 is a closer fit for a direct crosswalk 
because it shares the same intraservice time of 30 minutes with CPT 
code 657XG. Accordingly, we are proposing a work RVU of 5.39 for CPT 
code 657XG.
    The RUC recommendation for CPT code 657XG includes a series of 
invoices for several new supplies and equipment items. One of these was 
the 10-0 nylon suture with two submitted invoice prices of $245.62 per 
box of 12, or $20.47 per suture, and another was priced at $350.62 per 
box of 12, or $29.22 per suture. Given the range of prices between 
these two invoices, we sought publicly available information and 
identified numerous sutures that appear to be consistent with those 
recommended by the specialty society, at lower prices, which we believe 
are more likely to be typical since we assume that the typical 
practitioner would seek the best price. One example is ``Surgical 
Suture, Black Monofilament, Nylon, Size: 10-0, 12''/30cm, Needle: DSL6, 
12/bx'' for $146. Therefore, we are proposing to establish a new supply 
code for ``suture, nylon 10-0'' and price that item at $12.17 each. We 
welcome comments from stakeholders regarding this supply item.
(11) Dilation and Probing of Lacrimal and Nasolacrimal Duct (CPT Codes 
66801, 68810, 68811, 68815 and 68816)
    The RUC's review of 10-day global services identified 18 services 
with greater than 1.5 office visits and 2012 Medicare utilization data 
over 1,000, including CPT codes 66801, 68810, 68811, 68815, and 68816. 
As a result, the RUC requested these services be surveyed reviewed for 
CY 2016.
    The RUC recommended a work RVU of 1.00 for CPT code 68801 and a 
work RVU of 1.54 for CPT code 68810. While we are proposing to use the 
RUC-recommended work RVU for CPT code 68810, we do not believe the 
recommendation for CPT code 68801 best reflects the work involved in 
the procedure because of a discrepancy between the post-operative work 
time and work RVU. Specifically, the RUC recommendation for the 
procedure included the removal of a 99211 visit, but the RUC-
recommended work RVU did not reflect any corresponding adjustment. As a 
result, we are proposing to accept the RUC's recommendation to remove 
the 99211 visit from the service but are proposing to further reduce 
the work RVU for CPT code 68801 by removing the RVUs associated with 
CPT code 99211. Therefore, for CY 2016, we are proposing a work RVUs of 
0.82 to CPT code 68801 and 1.54 to CPT code 68810.
    The RUC recommended a work RVU of 2.03, 3.00, and 2.35 for CPT 
codes 68811, 68815 and 68816, respectively. We do not believe the RUC 
recommendations for these services best reflect the work involved in 
performing these procedures. To value these services, we calculated a 
total time ratio by dividing the code's current total time by the RUC-
recommended total time, and then applying that ratio to the current 
work RVU. This produces our CY 2016 proposed work RVUs of 1.74, 2.70, 
and 2.10 for CPT codes 68811, 68815, and 68816, respectively.
(12) Spinal Instability (CPT Code 7208A, 7208B, 7208C, and 7208D)
    For CY 2015, the CPT Editorial Panel deleted codes 72010 
(radiologic examination, spine, entire, survey study, anteroposterior 
and lateral), 72069 (radiologic examination, spine, thorocolumbar, 
standing (scoliosis)), and 72090 (radiological examination, spine; 
scoliosis study, including supine and erect studies), revised one code, 
72080 (Radiologic examination, spine; thoracolumbar junction, minimum 
of 2 views) and created four new codes which cover radiologic 
examination of the entire thoracic and lumbar spine, including the 
skull, cervical and sacral spine if performed. The new codes were 
organized by number of views, ranging from one view in 7208A, two to 
three views in 7208B, four to five views in 7208C, and minimum of 6 
views in 7208D.
    We disagree with the RUC's work RVU recommendations for these four 
codes. For 7208A, we noted that the one minute increase in time 
resulted in a larger work RVU than would be expected when taking the 
ratio between time and RVU in the source code and comparing that to the 
time and work RVU ratio in the new code. Using the relationship between 
time and RVU from deleted code 72069, we are proposing a work RVU of 
0.26 for 7208A, which differs from the RUC-recommended value of 0.30. 
Using an incremental methodology based on the relationship between work 
and time in the first code we are proposing to adjust the RUC-
recommended work RVUs for CPT codes 7208B, 7208C and 7208D to, 
respectively, 0.31, 0.35, and 0.41.

[[Page 41778]]

(13) Echo Guidance for Ova Aspiration (CPT Code 76948)
    In the CY 2014 PFS final rule with comment period, we requested 
additional information to assist us in the valuation of ultrasound 
guidance codes. We nominated these codes as potentially misvalued based 
on the extent to which standalone ultrasound guidance codes were billed 
separately from services where ultrasound guidance was an integral part 
of the procedure. CPT code 76948 was among the codes considered 
potentially misvalued. CPT code 76948 was surveyed by the specialty 
societies and the RUC issued a recommendation for CY 2016. We have 
concerns about valuation this code, considering that it is a guidance 
code used only for a single procedure: 58970 (aspiration of ova), and 
we believe that these two codes are almost always billed concurrently. 
We believe codes 76948 and 58970 should be bundled to accurately 
reflect how the service is furnished.
    We are proposing to use work times based on refinements of the RUC-
recommended values by removing the 3 minutes of pre and post service 
time since these times are reflected in the 58970 procedure code. We 
are proposing work and time values for 76948 based on a crosswalk from 
76945 (Ultrasonic guidance for chorionic villus sampling, imaging 
supervision and interpretation) which has a physician work time of 30 
minutes and an RVU of 0.56. Therefore we are proposing to maintain 25 
minutes of intraservice time for 76948 and proposing a work RVU of 
0.56.
(14) Immunohistochemistry (CPT Codes 88341, 88342, and 88344)
    In establishing interim final direct PE inputs for CY 2015 for CPT 
codes 88341, 88342, and 88344, we replaced the RUC-recommended supply 
item ``UltraView Universal DAB Detection Kit'' (SL488) with ``Universal 
Detection Kit'' (SA117), since the RUC did not provide an explanation 
for the required use of a more expensive kit. We also adjusted the 
equipment time for equipment item ``microscope, compound'' (EP024). We 
re-examined these codes when valuing the immunofluorescence family of 
codes for CY 2016, and reviewed information received by commenters that 
explained the need for these supply items. Specifically, commenters 
explained that the universal detection kit that CMS included in place 
of the RUC-recommended kit was not typically used in these services as 
it was not clinically appropriate. We are proposing to include the RUC-
recommended supply item, SL488, for CPT codes 88341, 88342, and 88344, 
as well as the RUC-recommended equipment time for ``microscope, 
compound'' for CY 2016.
(15) Immunofluorescent Studies (CPT Codes 88346 and 8835X)
    For CY 2016, the CPT Editorial Panel deleted one code, CPT 88347 
(Antibody evaluation), created a new add-on service, CPT 8835X, and 
revised CPT code 88346 to describe immunofluorescent studies. The RUC 
recommended a work RVU of 0.74 for CPT code 88346 and 0.70 for CPT code 
8835X. While we are accepting the RUC recommendation for CPT code 
88346, we do not believe the recommendation for CPT code 8835X best 
reflects the work involved in the procedure due to our concerns with 
the relationship between the RUC-recommended intraservice times for the 
base code and the newly created add-on code. We examined intraservice 
time relationships between other base codes and add-on codes and found 
that two codes in the Intravascular ultrasound family, CPT 37250 
(Ultrasound evaluation of blood vessel during diagnosis or treatment) 
and 37251(Ultrasound evaluation of blood vessel during diagnosis or 
treatment), share a similar base code/add-on code intraservice time 
relationship, and are also diagnostic in nature, as are CPT codes 88346 
and 8835X. Due to these similarities, we believe it is appropriate to 
apply the relationship, which is a 24 percent difference, between CPT 
codes 37250 and 37251 in calculating work RVUs for CPT codes 88346 and 
8835X. Multiplying the RVU of CPT code 88346, 0.74, by 24 percent, and 
then subtracted the product from 0.74 results in a work RVU of 0.56 for 
CPT code 8835X. Therefore, for CY 2016, we are proposing a work RVU of 
0.74 for CPT code 88346 and 0.56 for CPT code 8835X.
(16) Morphometric Analysis (CPT Codes 88364, 88365, 88366, 88367, 
88373, 88374, 88377, 88368, and 88369)
    CPT codes 88367 and 88368 were reviewed and valued in the CY 2015 
PFS final rule with comment period (79 FR 67668 through 67669). Since 
then, the RUC has re-reviewed these services for CY 2016 due to the 
specialty society's initially low survey response rate. In our review 
of these codes, we noticed that the latest RUC recommendation is 
identical to the RUC recommendation provided for CY 2015 rulemaking. As 
a result, we do not believe there is any reason to modify our CY 2015 
work RVUs or work time for these procedures. Therefore, we are 
proposing to retain the CY 2015 work RVUs and work time for CPT codes 
88367 and 88368 for CY 2016.
    In establishing interim final direct PE inputs for CY 2015 for CPT 
codes 88364, 88365, 88366, 88367, 88373, 88374, 88377, 88368, and 
88369, we refined the RUC-recommended direct PE inputs as follows. We 
refined the units of several supply items, including ``ethanol, 100%'' 
(SL189), ``ethanol, 70%'' (SL190), ``ethanol, 85%'' (SL191), ``ethanol, 
95%'' (SL248), ``kit, FISH paraffin pretreatment'' (SL195), ``kit, HER-
2/neu DNA Probe'' (SL196), positive and negative control slides (SL112, 
SL118, SL119, SL184, SL185, SL508, SL509, SL510, SL511), ``(EBER) DNA 
Probe Cocktail'' (SL497),''Kappa probe cocktails'' (SL498) and ``Lambda 
probe cocktails'' (SL499), to maintain consistency within the codes in 
the family, and adjusted the quantities included in these codes to 
align with the code descriptors and better reflect the typical 
resources used in furnishing these services. We also adjusted the 
equipment time for equipment items ``water bath, FISH procedures 
(lab)'' (EP054), ``chamber, Hybridization'' (EP045), ``microscope, 
compound'' (EP024), ``instrument, microdissection (Veritas)'' (EP087), 
and ``ThermoBrite'' (EP088), to reflect the typical time the equipment 
is used, among other common refinements.
    We re-examined these codes when valuing the immunofluorescence 
family of codes for CY 2016, and reviewed information received from 
commenters that described the typical batch size for each of these 
services, thereby explaining the apparent inconsistencies and 
discrepancies in the quantity of units among the codes in the family. 
We are proposing to include the RUC-recommended quantities for each of 
these supply items for the CPT codes 88364, 88365, 88366, 88367, 88373, 
88374, 88377, 88368, and 88369 for CY 2016. With regard to the 
equipment items, we received information explaining that the 
recommended equipment times already accounted for the typical batch 
size, and thus, the recommended times were already reflective of the 
typical case. Therefore, we are proposing to adjust the equipment time 
for equipment items EP054, EP045, and EP087 to align with the RUC-
recommended times. We also received comments explaining the need for 
equipment item EP088. Based on that information, we are proposing to 
include this equipment item consistent with the RUC recommendations for 
CPT code 88366.
    We note that the information we received regarding the typical 
batch size

[[Page 41779]]

was critical in determining the appropriate direct PE inputs for these 
pathology services. We also note that we usually do not have 
information regarding the typical batch size or block size when we are 
reviewing the direct PE inputs for pathology services. The supply 
quantity and equipment minutes are often a direct function of the 
number of tests processed at once. Given the importance of the typical 
number of tests being processed by a laboratory in determining the 
direct PE inputs, which often include expensive supplies, we are very 
concerned that the direct PE inputs included in many pathology services 
may not reflect the typical resource costs involved in furnishing the 
typical service.
    In particular, we note that since laboratories of various sizes 
furnish pathology tests and that, depending on the test, a large 
laboratory may be at least as likely to have furnished a test to a 
Medicare beneficiary compared to a small laboratory, we believe that an 
equipment item included in a recommendation that is commercially 
available to a small laboratory may not be the same equipment item that 
is used in the typical case. If the majority of services billed under 
the PFS for a particular CPT code are furnished by laboratories that 
run many of these tests each day, then assumptions informed by 
commercially available products may significantly underestimate the 
typical number of tests processed together, and thus the assumptions 
underlying current valuations for per-test cost of supplies and 
equipment may be much higher than the typical resources used in 
furnishing the service. We invite stakeholders to provide us with 
information about the equipment and supply inputs used in the typical 
case for particular pathology services.
(17) Vestibular Caloric Irrigation (CPT Codes 9254A and 9254B)
    For CY 2016, the CPT Editorial Panel deleted CPT code 92543 
(Assessment and recording of balance system during irrigation of both 
ears) and created two new CPT codes, 9254A and 9254B, to report caloric 
vestibular testing for bithermal and monothermal testing procedures, 
respectively. The RUC recommended a work RVU of 0.80 for CPT code 9254A 
and a work RVU of 0.55 for CPT code 9254B. We believe the 
recommendations for these services overstate the work involved in 
performing these procedures. Due to similarity in service and time, we 
believe a direct crosswalk of CPT code 97606 (Negative pressure wound 
therapy, surface area greater than 50 square centimeters, per session) 
to CPT code 9254A is appropriate. To value CPT code 9254B, we divided 
the proposed work RVU for 9254A in half since the code descriptor for 
this procedure describes the service as having two irrigations as 
opposed to the four involved in 9254A. Therefore, for CY 2016, we are 
proposing a work RVUs of 0.60 to 9254A and 0.30 to 9254B.
(18) Instrument-Based Ocular Screening (CPT Codes 99174 and 9917X)
    For CY 2015, the CPT Editorial Panel created a new code, CPT code 
9917X, to describe instrument-based ocular screening with on-site 
analysis and also revised existing CPT code 99174, which describes 
instrument-based ocular screening with remote analysis and report. 
Currently, CPT code 99174 is assigned a status indicator of N (non-
covered service) which we believe should be maintained due to its 
nature as a screening service. After review of CPT code 9917X, we 
believe this service is also a screening service and should be assigned 
a status indicator of N (non-covered service). Therefore, for CY 2016, 
we are proposing to assign a PFS status indicator of N (non-covered 
service) for CPT codes 99174 and 9917X.
(19) Low-Dose Computer Tomography, Lung, Screening (GXXX1) and Lung 
Cancer Screening Counseling and Shared Decision Making Visit (GXXX2)
    We have issued national coverage determination (NCD) for the 
coverage of a lung cancer screening counseling and shared decision 
making visit and, for appropriate beneficiaries, annual screening with 
low dose computed tomography (LDCT) as an additional preventive 
benefit. The American College of Radiology (ACR) submitted 
recommendations for work and direct PE inputs. The ACR recommended that 
we crosswalk GXXX1 to 71250 (computed tomography, thorax; without 
contrast material) with additional physician work added to account for 
the added intensity of the service. After reviewing this 
recommendation, we believe that the physician work (time and intensity) 
is identical in both GXXX1 and 71250, and therefore, we are proposing a 
work RVU of 1.02 for GXXX1.
    We are proposing to value the lung cancer screening counseling and 
shared decision making visit (GXXX2) using a crosswalk from the work 
value for G0443 (Brief face-to-face counseling for alcohol misuse, 15 
minutes) which has a work RVU of 0.45. We added 2 minutes of pre-
service time, and 1 minute post-service time which we valued at 0.0224 
RVU per minute yielding a total of 0.062 additional RVUs which we then 
added to 0.45, bringing the total proposed work RVUs for GXXX2 to 0.52. 
The direct PE input recommendations from the ACR were refined according 
to CMS standard refinements and appear in the CY 2016 proposed direct 
PE input database.
7. Direct PE Input-Only Recommendations
    In CY 2014, 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. In developing the proposal, we 
sought a reliable means for Medicare to set upper payment limits for 
office-based procedures given our several longstanding concerns 
regarding the accuracy of certain aspects of the direct PE inputs, 
including both items and procedure time assumptions, and prices of 
individual supplies and equipment (78 FR 74248 through 74250). After 
considering the many comments we received regarding our proposal, the 
majority of which urged us to withdraw the proposal for a variety of 
reasons, we decided not to finalize the policy. However, we continue to 
believe that using practice expense data that are auditable, 
comprehensive, and regularly updated would contribute to the accuracy 
of practice expense calculations.
    Subsequent to our decision not to finalize the proposal, the RUC 
forwarded direct PE input recommendations for a subset of codes with 
nonfacility PE RVUs that would have been limited by the policy. Some of 
these codes also include work values, but the RUC recommendations did 
not address the accuracy of those values.
    We generally believe that combined reviews of work and PE for each 
code under the potentially misvalued codes initiative leads to more 
accurate and appropriate assignment of RVUs. We also believe, and have 
previously stated, that our standard process for evaluating potentially 
misvalued codes is unlikely to be the most effective means of 
addressing our concerns regarding the accuracy of some aspects of the 
direct PE inputs (79 FR 74248).
    However, we also believe it is important to use the most accurate 
and up-to-date information available to us when developing PFS RVUs for 
individual services. Therefore, we have reviewed the RUC-recommended 
direct PE inputs for these services and are proposing to use them, with 
the refinements addressed in this section. However, we are also 
identifying these

[[Page 41780]]

codes as potentially misvalued because their direct PE inputs were not 
reviewed alongside review of their work RVUs and time. We considered 
not addressing these recommendations until such time as comprehensive 
reviews could occur, but we recognized the public interest in using the 
updated recommendations regarding the PE inputs until such time as the 
work RVUs and time can be addressed. Therefore, we note that while we 
are proposing adjusted PE inputs for these services based on these 
recommendations, we would anticipate addressing any corresponding 
change to direct PE inputs once the work RVUs and time are addressed.
a. Repair of Nail Bed (CPT Code 11760)
    This recommendation includes 22 minutes of clinical labor time 
assigned for ``Assist physician in performing procedure.'' Because CPT 
code 11760 has 33 minutes of work intraservice time, we believe that 
this clinical labor input was intended to be calculated at 67 percent 
of work time. However, the equipment times are also calculated based on 
the 22 minutes of intraservice time. We are seeking comment on whether 
or not it would be appropriate to include the full 33 minutes of work 
intraservice time for the equipment.
b. Submucosal Ablation of the Tongue Base (CPT Code 41530)
    We did not review CPT code 41530 for direct PE inputs, because we 
noted that the RUC anticipates making recommendations regarding the 
work RVU and direct PE inputs for this service in the near future.
c. Cytopathology Fluids, Washings or Brushings (CPT Codes 88104, 88106, 
88108)
    We are proposing to update the Millipore filter supply (SL502) 
based on stakeholder submission of new information following the RUC's 
original recommendation. As requested, we are proposing to crosswalk 
the price of the Millipore filter to the cytology specimen filter 
(Transcyst) supply (SL041) and assign a value of $4.15. This change is 
reflected in the proposed direct PE input database.
d. Cytopathology Smears, Screening and Interpretation (CPT Codes 88160, 
88161, 88162)
    We are concerned that there is a lack of clarity and the 
possibility for confusion contained in the CPT descriptors of CPT codes 
88160 and 88161. The CPT descriptor for the first code refers to the 
``screening and interpretation'' of Cytopathology smears, while the 
descriptor for the second code refers to the ``preparation, screening 
and interpretation'' of Cytopathology smears. We believe that there is 
currently the potential for duplicative counting of direct PE inputs 
due to the overlapping nature of these two codes. We are concerned that 
the same procedure may be billed multiple times under both CPT code 
88160 and 88161. We believe that these codes are potentially misvalued, 
and we are seeking a full review of this family of codes for both work 
and PE, given the potential for overlap. We recognize that the ideal 
solution may involve revisions by the CPT Editorial Panel.
    With regard to the current direct PE input recommendations, we are 
proposing to remove the clinical labor minutes recommended for ``Stain 
air dried slides with modified Wright stain'' for CPT code 88160 since 
staining slides would not be a typical clinical labor task if there is 
no slide preparation taking place, as the descriptor for this code 
suggests.
    We are proposing to update the protease solution supply (SL506) 
based on stakeholder submission of new information following the RUC's 
original recommendation. As requested, we are proposing to change the 
name of the supply to ``Protease'', alter the unit of measurement from 
milliliters to milligrams, change the quantity assigned to CPT code 
88182 from 1 to 1.12, and update the price from $0.47 to $0.4267. These 
changes are reflected in the proposed direct PE input database.
    We are requesting additional information regarding the use of the 
desktop computer with monitor (ED021) for CPT code 88182. We have made 
no change to the current equipment time value pending the submission of 
additional information.
e. Flow Cytometry, Cytoplasmic Cell Surface (CPT Code 88184, 88185)
    We are requesting additional information regarding the specific use 
of the desktop computer with monitor (ED021) for CPT codes 88184 and 
88185 since the recommendation does not specify how it is used.
f. Consultation on Referred Slides and Materials (CPT Codes 88321, 
88323, 88325)
    We are proposing to remove the clinical labor time for ``Accession 
specimen/prepare for examination'' for CPT codes 88321 and 88325. These 
codes do not involve the preparation of slides, so this clinical labor 
task is duplicative with the labor carried out under ``Open shipping 
package, remove and sort slides based on outside number.'' We are 
proposing to maintain the recommended 4 minutes for this clinical labor 
task for CPT code 88323, since it does require slide preparation.
    We are proposing to refine the clinical labor time for ``Register 
the patient in the information system, including all demographic and 
billing information'' from 13 minutes to 5 minutes for all three codes. 
As indicated in Table 6, our proposed standard clinical labor time for 
entering patient data is 4 minutes for pathology codes, and we believe 
that the extra tasks involving label preparation described in this 
clinical labor task would typically require an additional 1 minute to 
complete. We also believe that the additional recommended time likely 
reflects administrative tasks that are appropriately accounted for in 
the indirect PE methodology.
    We are proposing to refine the clinical labor time from 7 minutes 
to 5 minutes for the new task ``Receive phone call from referring 
laboratory/facility with scheduled procedure to arrange special 
delivery of specimen procurement kit, including muscle biopsy clamp as 
needed. Review with sender instructions for preservation of specimen 
integrity and return arrangements. Contact courier and arrange delivery 
to referring laboratory/facility.'' Based on the description of this 
task, we believe that this task would typically take 5 minutes to be 
performed by the Lab Technician.
    We are proposing to remove the eosin solution supply (SL063) from 
CPT code 88323. We do not agree that this supply would be typically 
used in this procedure, and the eosin solution is redundant when used 
together with the hematoxylin stain supply (SL135). We are also 
refining the quantity of the hematoxylin stain from 32 to 8 for CPT 
code 88323, to be consistent with its use in other related Pathology 
codes.
    We are proposing to remove many of the inputs for clinical labor, 
supplies, and equipment for CPT code 88325. The descriptor for this 
code indicates that it does not involve slide preparation, and 
therefore we are proposing labor, supplies, and equipment inputs to 
match the inputs recommended for CPT code 88321, which also does not 
include the preparation of slides.
g. Morphometric Analysis, Tumor Immunohistochemistry (CPT Codes 88360, 
88361)
    We are proposing to update the pricing for the Benchmark ULTRA 
automated slide preparation system (EP112) and the E-Bar II Barcode 
Slide Label System (EP113). Based on stakeholder submission of 
information subsequent to the original RUC recommendation, we are 
reclassifying

[[Page 41781]]

these two pieces of equipment as a single item with a price of 
$150,000. CPT codes 88360 and 88361 have been valued using this new 
price. The equipment time values remain unchanged.
    The RUC recommendation for CPT codes 88360 and 88361 included an 
invoice for the Antibody Estrogen Receptor monoclonal supply (SL493). 
The submitted invoice has a price of $694.70 per box of 50, or $13.89 
per test. We sought publically available information regarding this 
supply and identified numerous monoclonal antibody estrogen receptors 
that appear to be consistent with those recommended by the specialty 
society, at publicly available lower prices, which we believe are more 
likely to be typical since we assume that the typical practitioner 
would seek the best price available to the public. One example is 
Estrogen Receptor Antibody (h-151) [DyLight 405], priced at 100 tests 
per box for $319. Therefore, we are proposing to establish a new supply 
code for ``Antibody Estrogen Receptor monoclonal'' and price that item 
at $3.19 each. We welcome comments from stakeholders regarding this 
supply item.
h. Nerve Teasing Preparations (CPT Code 88362)
    We are proposing to refine the recommended clinical labor time for 
``Assist pathologist with gross specimen examination including the 
following; Selection of fresh unfixed tissue sample; selection of 
tissue for formulant fixation for paraffin blocking and epon blocking. 
Reserve some specimen for additional analysis'' from 10 minutes to 5 
minutes. We note that the 5 minutes includes 3 minutes for assisting 
the pathologist with the gross specimen examination (as listed in Table 
6) and an additional 2 minutes for the additional tasks due to the work 
taking place on a fresh specimen.
i. Nasopharyngoscopy With Endoscope (CPT Code 92511)
    We are proposing to remove the endosheath (SD070) from this 
procedure, because we do not believe it would be typically used and it 
was not included in the recommendations for any of the other related 
codes in the same tab. If the endosheath were included as a supply with 
the presentation of additional clinical information, then we believe it 
would be appropriate to remove all of the clinical labor and equipment 
time currently assigned to cleaning the scope.
j. Needle Electromyography (CPT Codes 95863, 95864, 95869, 95870)
    We are proposing to reduce the quantity of the iontophoresis 
electrode kit (SA014) supply from 4 to 3. According to the description 
of this code, the procedure typically uses 2-4 electrodes, and 
therefore we believe that a supply quantity of 3 would better reflect 
the typical case. We are requesting further information regarding the 
typical number of electrodes used in this procedure; if the maximum of 
4 electrodes is in fact typical for the procedure, then we recommend 
that the code descriptor be referred to CPT for further clarification.

J. Medicare Telehealth Services

1. Billing and Payment for Telehealth Services
    Several conditions must be met for Medicare to make payments for 
telehealth services under the PFS. The service must be on the list of 
Medicare telehealth services and meet all of the following additional 
requirements:
     The service must be furnished via an interactive 
telecommunications system.
     The service must be furnished by a physician or authorized 
practitioner.
     The service must be furnished to an eligible telehealth 
individual.
     The individual receiving the service must be located in a 
telehealth originating site.
    When all of these conditions are met, Medicare pays a facility fee 
to the originating site and makes a separate payment to the distant 
site practitioner furnishing the service.
    Section 1834(m)(4)(F)(i) of the Act defines Medicare telehealth 
services to include consultations, office visits, office psychiatry 
services, and any additional service specified by the Secretary, when 
furnished via a telecommunications system. We first implemented this 
statutory provision, which was effective October 1, 2001, in the CY 
2002 PFS final rule with comment period (66 FR 55246). We established a 
process for annual updates to the list of Medicare telehealth services 
as required by section 1834(m)(4)(F)(ii) of the Act in the CY 2003 PFS 
final rule with comment period (67 FR 79988).
    As specified at Sec.  410.78(b), we generally require that a 
telehealth service be furnished via an interactive telecommunications 
system. Under Sec.  410.78(a)(3), an interactive telecommunications 
system is defined as multimedia communications equipment that includes, 
at a minimum, audio and video equipment permitting two-way, real-time 
interactive communication between the patient and distant site 
physician or practitioner.
    Telephones, facsimile machines, and stand-alone electronic mail 
systems that are not integrated into an electronic health record system 
do not meet the definition of an interactive telecommunications system. 
An interactive telecommunications system is generally required as a 
condition of payment; however, section 1834(m)(1) of the Act allows the 
use of asynchronous ``store-and-forward'' technology when the 
originating site is part of a federal telemedicine demonstration 
program in Alaska or Hawaii. As specified in Sec.  410.78(a)(1), 
asynchronous store-and-forward is the transmission of medical 
information from an originating site for review by the distant site 
physician or practitioner at a later time.
    Medicare telehealth services may be furnished to an eligible 
telehealth individual notwithstanding the fact that the practitioner 
furnishing the telehealth service is not at the same location as the 
beneficiary. An eligible telehealth individual is an individual 
enrolled under Part B who receives a telehealth service furnished at an 
originating site.
    Practitioners furnishing Medicare telehealth services are reminded 
that these services are subject to the same non-discrimination laws as 
other services, including the effective communication requirements for 
persons with disabilities of section 504 of the Rehabilitation Act and 
language access for persons with limited English proficiency, as 
required under Title VI of the Civil Rights Act of 1964. For more 
information, see http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication.
    Practitioners furnishing Medicare telehealth services submit claims 
for telehealth services to the Medicare Administrative Contractors that 
process claims for the service area where their distant site is 
located. Section 1834(m)(2)(A) of the Act requires that a practitioner 
who furnishes a telehealth service to an eligible telehealth individual 
be paid an amount equal to the amount that the practitioner would have 
been paid if the service had been furnished without the use of a 
telecommunications system.
    Originating sites, which can be one of several types of sites 
specified in the statute where an eligible telehealth individual is 
located at the time the service is being furnished via a 
telecommunications system, are paid a fee under the PFS a facility fee 
for each Medicare telehealth service. The statute

[[Page 41782]]

specifies both the types of entities that can serve as originating 
sites and the geographic qualifications for originating sites. With 
regard to geographic qualifications, Sec.  410.78(b)(4) limits 
originating sites to those located in rural health professional 
shortage areas (HPSAs) or in a county that is not included in a 
metropolitan statistical areas (MSAs).
    Historically, we have defined rural HPSAs to be those located 
outside of MSAs. Effective January 1, 2014, we modified the regulations 
regarding originating sites to define rural HPSAs as those located in 
rural census tracts as determined by the Office of Rural Health Policy 
(ORHP) of the Health Resources and Services Administration (HRSA) (78 
FR 74811). Defining ``rural'' to include geographic areas located in 
rural census tracts within MSAs allows for broader inclusion of sites 
within HPSAs as telehealth originating sites. Adopting the more precise 
definition of ``rural'' for this purpose expands access to health care 
services for Medicare beneficiaries located in rural areas. HRSA has 
developed a Web site tool to provide assistance to potential 
originating sites to determine their geographic status. To access this 
tool, see the CMS Web site at www.cms.gov/teleheath/.
    An entity participating in a federal telemedicine demonstration 
project that has been approved by, or received funding from, the 
Secretary as of December 31, 2000 is eligible to be an originating site 
regardless of its geographic location.
    Effective January 1, 2014, we also changed our policy so that 
geographic status for an originating site would be established and 
maintained on an annual basis, consistent with other telehealth payment 
policies (78 FR 74400). Geographic status for Medicare telehealth 
originating sites for each calendar year is now based upon the status 
of the area as of December 31 of the prior calendar year.
    For a detailed history of telehealth payment policy, see 78 FR 
74399.
2. Adding Services to the List of Medicare Telehealth Services
    As noted previously, in the December 31, 2002 Federal Register (67 
FR 79988), we established a process for adding services to or deleting 
services from the list of Medicare telehealth services. This process 
provides the public with an ongoing opportunity to submit requests for 
adding services. Under this process, we assign any qualifying request 
to make additions to the list of telehealth services to one of two 
categories. Revisions to criteria that we use to review requests in the 
second category were finalized in the November 28, 2011 Federal 
Register (76 FR 73102). The two categories are:
     Category 1: Services that are similar to professional 
consultations, office visits, and office psychiatry services that are 
currently on the list of telehealth services. In reviewing these 
requests, we look for similarities between the requested and existing 
telehealth services for the roles of, and interactions among, the 
beneficiary, the physician (or other practitioner) at the distant site 
and, if necessary, the telepresenter, a practitioner who is present 
with the beneficiary in the originating site. We also look for 
similarities in the telecommunications system used to deliver the 
proposed service; for example, the use of interactive audio and video 
equipment.
     Category 2: Services that are not similar to the current 
list of telehealth services. Our review of these requests includes an 
assessment of whether the service is accurately described by the 
corresponding code when furnished via telehealth and whether the use of 
a telecommunications system to deliver the service produces 
demonstrated clinical benefit to the patient. In reviewing these 
requests, we look for evidence indicating that the use of a 
telecommunications system in furnishing the candidate telehealth 
service produces clinical benefit to the patient. Submitted evidence 
should include both a description of relevant clinical studies that 
demonstrate the service furnished by telehealth to a Medicare 
beneficiary improves the diagnosis or treatment of an illness or injury 
or improves the functioning of a malformed body part, including dates 
and findings, and a list and copies of published peer reviewed articles 
relevant to the service when furnished via telehealth. Our evidentiary 
standard of clinical benefit does not include minor or incidental 
benefits.
    Some examples of clinical benefit include the following:
     Ability to diagnose a medical condition in a patient 
population without access to clinically appropriate in-person 
diagnostic services.
     Treatment option for a patient population without access 
to clinically appropriate in-person treatment options.
     Reduced rate of complications.
     Decreased rate of subsequent diagnostic or therapeutic 
interventions (for example, due to reduced rate of recurrence of the 
disease process).
     Decreased number of future hospitalizations or physician 
visits.
     More rapid beneficial resolution of the disease process 
treatment.
     Decreased pain, bleeding, or other quantifiable symptom.
     Reduced recovery time.
    For the list of covered telehealth services, see the CMS Web site 
at www.cms.gov/teleheath/. Requests to add services to the list of 
Medicare telehealth services must be submitted and received no later 
than December 31 of each calendar year to be considered for the next 
rulemaking cycle. For example, qualifying requests submitted before the 
end of CY 2015 will be considered for the CY 2017 proposed rule. Each 
request to add a service to the list of Medicare telehealth services 
must include any supporting documentation the requester wishes us to 
consider as we review the request. Because we use the annual PFS 
rulemaking process as a vehicle for making changes to the list of 
Medicare telehealth services, requestors should be advised that any 
information submitted is subject to public disclosure for this purpose. 
For more information on submitting a request for an addition to the 
list of Medicare telehealth services, including where to mail these 
requests, see the CMS Web site at www.cms.gov/telehealth/.
3. Submitted Requests to the List of Telehealth Services for CY 2016
    Under our existing policy, we add services to the telehealth list 
on a category 1 basis when we determine that they are similar to 
services on the existing telehealth list with respect to the roles of, 
and interactions among, the beneficiary, physician (or other 
practitioner) at the distant site and, if necessary, the telepresenter. 
As we stated in the CY 2012 final rule with comment period (76 FR 
73098), we believe that the category 1 criteria not only streamline our 
review process for publicly requested services that fall into this 
category, the criteria also expedite our ability to identify codes for 
the telehealth list that resemble those services already on this list.
a. Submitted Requests
    We received several requests in CY 2014 to add various services as 
Medicare telehealth services effective for CY 2016. The following 
presents a discussion of these requests, and our proposals for 
additions to the CY 2016 telehealth list. Of the requests received, we 
find that the following services are sufficiently similar to 
psychiatric diagnostic procedures or office/outpatient visits currently 
on the telehealth list to qualify on a category one basis. Therefore, 
we propose to add the following services to the telehealth list on a 
category 1 basis for CY 2016:

[[Page 41783]]

     CPT code 99356 (prolonged service in the inpatient or 
observation setting, requiring unit/floor time beyond the usual 
service; first hour (list separately in addition to code for inpatient 
evaluation and management service); and 99357 (prolonged service in the 
inpatient or observation setting, requiring unit/floor time beyond the 
usual service; each additional 30 minutes (list separately in addition 
to code for prolonged service).
    The prolonged service codes can only be billed in conjunction with 
hospital inpatient and skilled nursing facility evaluation & management 
(E/M) codes, and of these, only subsequent hospital and subsequent 
nursing facility visit codes are on list of Medicare telehealth 
services. Therefore, CPT codes 99356 and 99357 would only be reportable 
with codes for which limits of one subsequent hospital visit every 
three days via telehealth, and one subsequent nursing facility visit 
every thirty days, would continue to apply.
     CPT codes 90963 (end-stage renal disease (ESRD) related 
services for home dialysis per full month, for patients younger than 2 
years of age to include monitoring for the adequacy of nutrition, 
assessment of growth and development, and counseling of parents); 90964 
(end-stage renal disease (ESRD) related services for home dialysis per 
full month, for patients 2-11 years of age to include monitoring for 
the adequacy of nutrition, assessment of growth and development, and 
counseling of parents); 90965 (end-stage renal disease (ESRD) related 
services for home dialysis per full month, for patients 12-19 years of 
age to include monitoring for the adequacy of nutrition, assessment of 
growth and development, and counseling of parents); and 90966 (end-
stage renal disease (ESRD) related services for home dialysis per full 
month, for patients 20 years of age and older).
    Although these services are for home-based dialysis, and a 
patient's home is not an authorized originating site for telehealth, we 
recognize that many components of these services would be furnished 
from an authorized originating site and, therefore, can be furnished 
via telehealth.
    The required clinical examination of the catheter access site must 
be furnished face-to-face ``hands on'' (without the use of an 
interactive telecommunications system) by a physician, certified nurse 
specialist (CNS), nurse practitioner (NP), or physician's assistant 
(PA). An interactive telecommunications system may be used for 
providing additional visits required under the 2 to 3 visit Monthly 
Capitation Payment (MCP) code and the 4 or more visit MCP code. See the 
final rule for CY 2005 (69 FR 66276) for further information on 
furnishing ESRD services via telehealth.
    We also received requests to add services to the telehealth list 
that do not meet our criteria for Medicare telehealth services. We are 
not proposing to add the following procedures for the reasons noted:
     All evaluation and management services, telerehabilitation 
services, and palliative care, pain management and patient navigation 
services for cancer patients.
    None of these requests identified the specific codes that were 
being requested for addition as telehealth services, and two of the 
requests did not include evidence of any clinical benefit when the 
services are furnished via telehealth. Since we did not have 
information on the specific codes requested for addition or evidence of 
clinical benefit for these requests, we cannot evaluate whether the 
services are appropriate for addition to the Medicare telehealth 
services list.
     CPT codes 99291 (critical care, evaluation and management 
of the critically ill or critically injured patient; first 30-74 
minutes); and 99292 (critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 
minutes (list separately in addition to code for primary service).
    We previously considered and rejected adding these codes to the 
list of Medicare telehealth services in the CY 2009 PFS final rule (74 
FR 69744) on a category 1 basis because, due to the acuity of 
critically ill patients, we did not consider critical care services 
similar to any services on the current list of Medicare telehealth 
services. In that rule, we said that critical care services must be 
evaluated as category 2 services. Because we would consider critical 
care services under category 2, we needed to evaluate whether these are 
services for which telehealth can be an adequate substitute for a face-
to-face encounter. We had no evidence suggesting that the use of 
telehealth could be a reasonable surrogate for the face-to-face 
delivery of this type of care.
    The American Telemedicine Association (ATA) submitted a request, 
which cited several studies to support adding these services on a 
category 2 basis. To qualify under category 2, we would need evidence 
that the service produces a clinical benefit for the patient. However, 
in reviewing the information provided by the ATA and a study entitled, 
``Impact of an Intensive Care Unit Telemedicine Program on Patient 
Outcomes in an Integrated Health Care System,'' published July 2014, in 
``JAMA Internal Medicine,'' which found no evidence that the 
implementation of ICU TM significantly reduced mortality rates or 
hospital length of stay, we do not believe that the evidence 
demonstrates a clinical benefit to patients. Therefore, we are not 
proposing to add these services on a category 2 basis to the list of 
Medicare telehealth services for CY 2016.
     CPT code 99358 (prolonged evaluation and management 
service before and/or after direct patient care; first hour) and 99359 
(prolonged evaluation and management service before and/or after direct 
patient care; each additional 30 minutes (list separately in addition 
to code for prolonged service).
    As we indicated in the CY 2015 PFS final rule with comment period 
(79 FR 67600), these services are not separately payable by Medicare. 
It would be inappropriate to include a service as a telehealth service 
when Medicare does not otherwise make a separate payment for it. 
Therefore, we are not proposing to add these non-payable services to 
the list of Medicare telehealth services for CY 2016.
     CPT code 99444 (online evaluation and management service 
provided by a physician or other qualified health care professional who 
may report an evaluation and management services provided to an 
established patient or guardian, not originating from a related E/M 
service provided within the previous 7 days, using the internet or 
similar electronic communications network).
    As we indicated in the CY 2014 PFS final rule with comment period 
(78 FR 74403), we assigned a status indicator of ``N'' (Noncovered 
service) to this service because: (1) this service is non-face-to-face; 
and (2) the code descriptor includes language that recognizes the 
provision of services to parties other than the beneficiary and for 
whom Medicare does not provide coverage (for example, a guardian). 
Under section 1834(m)(2)(A) of the Act, Medicare pays the physician or 
practitioner furnishing a telehealth service an amount equal to the 
amount that would have been paid if the service was furnished without 
the use of a telecommunications system. Because CPT code 99444 is 
currently noncovered, there would be no Medicare payment if this 
service was furnished without the use of a telecommunications system. 
Since this service is noncovered under Medicare, we are not proposing 
to add it to the list of Medicare telehealth services for CY 2016.

[[Page 41784]]

     CPT code 99490 (chronic care management services, at least 
20 minutes of clinical staff time directed by a physician or other 
qualified health care professional, per calendar month, with the 
following required elements: multiple (two or more) chronic conditions 
expected to last at least 12 months, or until the death of the patient; 
chronic conditions place the patient at significant risk of death, 
acute exacerbation/decompensation, or functional decline; comprehensive 
care plan established, implemented, revised, or monitored).
    This service is one that can be furnished without the beneficiary's 
face-to-face presence, and using any number of non-face-to-face means 
of communication. Therefore, the service is not appropriate for 
consideration as a Medicare telehealth service. It is unnecessary to 
add this service to the list of Medicare telehealth services. 
Therefore, we are not proposing to add it to the list of Medicare 
telehealth services for CY 2016.
     CPT codes 99605 (medication therapy management service(s) 
provided by a pharmacist, individual, face-to-face with patient, with 
assessment and intervention if provided; initial 15 minutes, new 
patient); 99606 (medication therapy management service(s) provided by a 
pharmacist, individual, face-to-face with patient, with assessment and 
intervention if provided; initial 15 minutes, established patient); and 
99607 (medication therapy management service(s) provided by a 
pharmacist, individual, face-to-face with patient, with assessment and 
intervention if provided; each additional 15 minutes (list separately 
in addition to code for primary service).
    These codes are noncovered services for which no payment may be 
made under the PFS. Therefore, we are not proposing to add these 
services to the list of Medicare telehealth services for CY 2016.
    In summary, we are proposing to add the following codes to the list 
of Medicare telehealth services beginning in CY 2016 on a category 1 
basis: Prolonged service inpatient CPT codes 99356 and 99357 and ESRD-
related services 90933 through 90936. As indicated above, the prolonged 
service codes can only be billed in conjunction with subsequent 
hospital and subsequent nursing facility codes. Limits of one 
subsequent hospital visit every three days, and one subsequent nursing 
facility visit every thirty days, would continue to apply when the 
services are furnished as telehealth services. For the ESRD related 
services, the required clinical examination of the catheter access site 
must be furnished face-to-face ``hands on'' (without the use of an 
interactive telecommunications system) by a physician, certified nurse 
specialist (CNS), nurse practitioner (NP), or physician's assistant 
(PA).
    We remind all interested stakeholders that we are currently 
soliciting public requests to add services to the list of Medicare 
telehealth services. To be considered during PFS rulemaking for CY 
2017, these requests must be submitted and received by December 31, 
2015. Each request to add a service to the list of Medicare telehealth 
services must include any supporting documentation the requester wishes 
us to consider as we review the request. For more information on 
submitting a request for an addition to the list of Medicare telehealth 
services, including where to mail these requests, we refer readers to 
the CMS Web site at www.cms.gov/telehealth/.
4. Proposal To Amend Sec.  410.78 To Include Certified Registered Nurse 
Anesthetists as Practitioners for Telehealth Services
    Under section 1834(m)(1) of the Act, Medicare makes payment for 
telehealth services furnished by physicians and practitioners. Section 
1834(m)(4)(E) of the Act specifies that, for purposes of furnishing 
Medicare telehealth services, the term ``practitioner'' has the meaning 
given that term in section 1842(b)(18)(C), which includes a certified 
registered nurse anesthetist (CRNA) as defined in section 1861 (bb)(2).
    We initially omitted CRNAs from the list of distant site 
practitioners for telehealth services in the regulation because we did 
not believe these practitioners would furnish any of the service on the 
list of Medicare telehealth services. However, CRNAs in some states are 
licensed to furnish certain services on the telehealth list, including 
E/M services. Therefore, we propose to revise the regulation at Sec.  
410.78(b)(2) to include a CRNA, as described under Sec.  410.69, to the 
list of distant site practitioners who can furnish Medicare telehealth 
services.

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

1. Background
    Section 1861(s)(2)(A) of the Act establishes the benefit category 
for services and supplies furnished as ``incident to'' the professional 
services of a physician. The statute specifies that services and 
supplies furnished as an incident to a physician's professional service 
(hereinafter ``incident to services'') are ``of kinds which are 
commonly furnished in physicians' offices and are commonly either 
rendered without charge or included in physicians' bills.'' In addition 
to the requirements of the statute, Sec.  410.26 sets forth specific 
requirements that must be met for physicians and other practitioners to 
bill Medicare for incident to services. Section 410.26(a)(7) limits 
incident to services to those included under section 1861(s)(2)(A) of 
the Act and that are not covered under another benefit category. 
Section 410.26(b) specifies (in part) that in order for services and 
supplies to be paid as incident to services under Medicare Part B, the 
services or supplies must be:
     Furnished in a noninstitutional setting to 
noninstitutional patients.
     An integral, though incidental, part of the service of a 
physician (or other practitioner) in the course of diagnosis or 
treatment of an injury or illness.
     Furnished under direct supervision (as specified under 
Sec.  410.26(a)(2)) of a physician or other practitioner eligible to 
bill and directly receive Medicare payment.
     Furnished by a physician, a practitioner with an incident 
to benefit, or auxiliary personnel.
    In addition to Sec.  410.26, there are regulations specific to each 
type of practitioner who is allowed to bill for incident to services as 
specified in Sec.  410.71(a)(2) (clinical psychologist services), Sec.  
410.74(b) (physician assistants' services), Sec.  410.75(d) (nurse 
practitioners' services), Sec.  410.76(d) (clinical nurse specialists' 
services), and Sec.  410.77(c) (certified nurse-midwives' services). 
When referring to practitioners who can bill for services furnished 
incident to their professional services, we are referring to physicians 
and these practitioners.
    Incident to services are treated as if they were furnished by the 
billing physician or other practitioner for purposes of Medicare 
billing and payment. Consistent with this terminology, in this 
discussion when referring to the physician or other practitioner 
furnishing the service, we are referring to the physician or other 
practitioner who is billing for the incident to service. When we refer 
to the ``auxiliary personnel'' or the person who provides the service, 
we are referring to an individual who is personally performing the 
service or some aspect of it as distinguished from the physician or 
other practitioner who bills for the incident to service.
    Since we treat incident to services as services furnished by the 
billing physician or other practitioner for

[[Page 41785]]

purposes of Medicare billing and payment, payment is made to the 
billing physician or other practitioner under the PFS, and all relevant 
Medicare rules apply including, but not limited to, requirements 
regarding medical necessity, documentation, and billing. Those 
practitioners who can bill Medicare for incident to services are paid 
at their applicable Medicare payment rate as if they personally 
furnished the service. For example, when incident to services are 
billed by a physician, they are paid at 100 percent of the fee schedule 
amount, and when the services are billed by a nurse practitioner or 
clinical nurse specialist, they are paid at 85 percent of the fee 
schedule amount. Payments are subject to the usual deductible and 
coinsurance amounts.
    In the CY 2014 PFS final rule with comment period, we amended Sec.  
410.26 by adding a paragraph (b)(7) to require that, as a condition for 
Medicare Part B payment, all incident to services must be furnished in 
accordance with applicable state law. Additionally, we amended the 
definition of auxiliary personnel at Sec.  410.26(a)(1) to require that 
the individual who provides the incident to services must meet any 
applicable requirements to provide such services (including licensure) 
imposed by the state in which the services are furnished. These 
requirements for compliance with applicable state laws apply to any 
individual providing incident to services as a means to protect the 
health and safety of Medicare beneficiaries in the delivery of health 
care services, and to provide the Medicare program with additional 
recourse for denying or recovering Part B payment for incident to 
services that are not furnished in compliance with state law (78 FR 
74410). Revisions to Sec.  410.26(a)(1) and (b)(7) were intended to 
clarify the longstanding payment policy of paying only for services 
that are furnished in compliance with any applicable state or federal 
requirements. The amended regulations also provide the Medicare program 
with additional recourse for denying or recovering Part B payment for 
incident to services that are not furnished in compliance with 
applicable requirements.
2. Billing Physician as the Supervising Physician
    In addition to the CY 2014 revisions to the regulations for 
incident to services, we believe that additional requirements for 
incident to services should be explicitly and unambiguously stated in 
the regulations. As described in this proposed rule, incident to a 
physician's or other practitioner's professional services means that 
the services or supplies are furnished as an integral, although 
incidental, part of the physician's or other practitioner's personal 
professional services in the course of diagnosis or treatment of an 
injury or illness (Sec.  410.26(b)(2)). Incident to services require 
direct supervision of the auxiliary personnel providing the service by 
the physician or other practitioner (Sec.  410.26(b)(5)).
    We are proposing to revise the regulations specifying the 
requirements for which physicians or other practitioners can bill for 
incident to services. In the CY 2002 PFS final rule, in response to a 
comment seeking clarification regarding what physician billing number 
should be used on the claim form for an incident to service, at 66 FR 
55267, we stated that when a claim is submitted to Medicare under the 
billing number of a physician or other practitioner for an `incident 
to' service, the physician or other practitioner is stating that he or 
she performed the service or directly supervised the auxiliary 
personnel performing the service. Accordingly, the Medicare billing 
number of the ordering physician or other practitioner should not be 
used if that person did not directly supervise the auxiliary personnel.
    Section 410.26(b)(5) currently states that the physician (or other 
practitioner) supervising the auxiliary personnel need not be the same 
physician (or other practitioner) upon whose professional service the 
incident to service is based. To be certain that the incident to 
services furnished to a beneficiary are in fact an integral, although 
incidental, part of the physician's or other practitioner's personal 
professional service that is billed to Medicare, we believe that the 
physician or other practitioner who bills for the incident to service 
must also be the physician or other practitioner who directly 
supervises the service. It has been our position that billing 
practitioners should have a personal role in, and responsibility for, 
furnishing services for which they are billing and receiving payment as 
an incident to their own professional services. This is consistent with 
the requirements that all physicians and billing practitioners attest 
on each Medicare claim that he or she ``personally furnished'' the 
services for which he or she is billing. Without this requirement, 
there could be an insufficient nexus with the physician's or other 
practitioner's services being billed on a claim to Medicare as incident 
to services and the actual services being furnished to the Medicare 
beneficiary by the auxiliary personnel. Therefore, we are proposing to 
amend Sec.  410.26(b)(5) to state that the physician or other 
practitioner who bills for incident to services must also be the 
physician or other practitioner who directly supervises the auxiliary 
personnel who provide the incident to services. Also, to further 
clarify the meaning of the proposed amendment to this regulation, we 
are proposing to remove the last sentence from Sec.  410.26(b)(5) 
specifying that the physician (or other practitioner) supervising the 
auxiliary personnel need not be the same physician (or other 
practitioner) upon whose professional service the incident to service 
is based.
3. Auxiliary Personnel Who Have Been Excluded or Revoked From Medicare
    As a condition of Medicare payment, auxiliary personnel who, under 
the direct supervision of a physician or other practitioner, provide 
incident to services to Medicare beneficiaries must comply with all 
applicable Federal and State laws. This includes not having been 
excluded from Medicare, Medicaid and all other federally funded health 
care programs by the Office of Inspector General. We are proposing to 
amend the regulation to explicitly prohibit auxiliary personnel from 
providing incident to services who have either been excluded from 
Medicare, Medicaid and all other federally funded health care programs 
by the Office of Inspector General or who have had their enrollment 
revoked for any reason. These excluded or revoked individuals are 
already prohibited from providing services to Medicare beneficiaries, 
so this proposed revision is an additional safeguard to ensure that 
these excluded or revoked individuals are not providing incident to 
services and supplies under the direct supervision of a physician or 
other authorized supervising practitioner. These proposed revisions to 
the incident to regulations will provide the Medicare program with 
additional recourse for denying or recovering Part B payment for 
incident to services and supplies that are not furnished in compliance 
with our program requirements.
4. Compliance and Oversight
    We recognize that there are many ways in which compliance with 
these requirements could be consistently and fairly assured across the 
Medicare program. In considering implementation of these proposals, we 
wish to be mindful of the need to minimize or eliminate any 
practitioner administrative burden while at the same time ensuring that 
practitioners are not subjected to unnecessary audits or

[[Page 41786]]

placed at risk of inadvertent non-compliance. Therefore, while we 
believe that the initial responsibility of compliance rests with the 
practitioner, we invite comments through this proposed rule about 
possible approaches we could take to improve our ability ensure that 
incident to services are provided to beneficiaries by qualified 
individuals in a manner consistent with Medicare statute and 
regulations. We invite commenters to consider the options we will 
consider, such as creating new categories of enrollment, implementing a 
mechanism for registration short of full enrollment, requiring the use 
of claim elements such as modifiers to identify the types of 
individuals providing services, or relying on post-payment audits, 
investigations and recoupments by CMS contractors such as Recovery 
Auditors or Program Integrity Contractors. We will consider these 
comments in the course of implementing the proposals we finalize in 
rulemaking for CY 2016, and further, if we decide in the future that 
additional regulations or guidance will be necessary to monitor 
compliance with these or other requirements surrounding incident to 
services.

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

    Portable X-ray suppliers receive a transportation fee for 
transporting portable X-ray equipment to the location where portable X-
rays are taken. If more than one patient at the same location is X-
rayed, the portable X-ray transportation fee is allocated among the 
patients. We have received feedback that some portable x-ray suppliers 
have been operating under the assumption that the prorated 
transportation payment when more than one patient is receiving portable 
X-ray services at the same location refers to only a subset of 
patients. The Medicare Claims Processing Manual (Pub. 100-4, Chapter 
13, Section 90.3) currently states:

    Carriers shall allow only a single transportation payment for 
each trip the portable X-ray supplier makes to a particular 
location. When more than one Medicare patient is X-rayed at the same 
location, e.g., a nursing home, prorate the single fee schedule 
transportation payment among all patients receiving the services. 
For example, if two patients at the same location receive X-rays, 
make one-half of the transportation payment for each.

    In some jurisdictions, Medicare contractors have been allowing the 
portable X-ray transportation fee to be allocated only among Medicare 
Part B beneficiaries. In other jurisdictions, Medicare contractors have 
required the transportation fee to be allocated among all Medicare 
patients (Parts A and B). We believe it would be more appropriate to 
allocate the transportation fee among all patients who receive portable 
X-ray services in a single trip. Medicare should not pay for more than 
its share of the transportation costs for portable X-ray services.
    We are proposing to revise the Medicare Claims Processing Manual 
(Pub. 100-4, Chapter 13, Section 90.3) to remove the word ``Medicare'' 
before ``patient'' in section 90.3. We are also proposing to clarify 
that this subregulatory guidance means that, when more than one patient 
is X-rayed at the same location, the single transportation payment 
under the PFS is to be prorated among all patients (Medicare Parts A 
and B, and non-Medicare) receiving portable X-ray services during that 
trip, regardless of their insurance status.
    For example, for portable x-ray services furnished at a SNF, we 
believe that the transportation fee should be allocated among all 
patients receiving portable X-ray services at the same location in a 
single trip irrespective of whether the patient is in a Part A stay, a 
Part B patient, or not a Medicare beneficiary at all. If the patient is 
in a Part A SNF stay, payment for the allocated portion of the 
transportation fee (and the X-ray) would be the SNF's responsibility. 
For a privately insured patient, it would be the responsibility of that 
patient's insurer. For a Medicare Part B patient, payment would be made 
under Part B for the share of the transportation fee attributable to 
that patient. We welcome comments on this proposal to determine 
Medicare Part B's portion of the transportation payment by prorating 
the single fee among all patients.

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

    Section 1833(b)(1) of the Act waives the deductible for colorectal 
cancer screening tests regardless of the code that is billed for the 
establishment of a diagnosis as a result of the test, or the removal of 
tissue or other matter or other procedure that is furnished in 
connection with, as a result of, and in the same clinical encounter as 
the screening test. To implement this statutory provision, we amended 
our regulation at Sec.  410.160 to add to the list of services to which 
the deductible does not apply, beginning January 1, 2011, a surgical 
service furnished in connection with, as a result of, and in the same 
clinical encounter as a planned colorectal cancer screening test. A 
surgical service furnished in connection with, as a result of, and in 
the same clinical encounter as a colorectal cancer screening test means 
a surgical service furnished on the same date as a planned colorectal 
cancer screening test as described in Sec.  410.37.
    In the CY 2015 PFS final rule with comment period, we modified the 
regulatory definition of colorectal cancer screening test with regard 
to colonoscopies to include anesthesia services whether billed as part 
of the colonoscopy service or separately. (See Sec.  410.37(a)(1)(iii) 
of our regulations). In the preamble to the final rule, we stated that 
the statutory waiver of deductible would apply to anesthesia services 
furnished in conjunction with a colorectal cancer screening test even 
when a polyp or other tissue is removed during a colonoscopy (79 FR 
67731). We also indicated that practitioners should report anesthesia 
services with the PT modifier in such circumstances. The final policy 
was implemented for services furnished during CY 2015. While we 
modified the definition of colorectal cancer screening services in the 
regulation at Sec.  410.37(a)(1)(iii) to include anesthesia furnished 
with a screening colonoscopy, we did not make a conforming change to 
our regulations to expressly reflect the inapplicability of the 
deductible to those anesthesia services.
    To better reflect our policy in the regulations, we propose a 
technical correction to amend Sec.  410.160(b)(8) to expressly 
recognize anesthesia services. Specifically, we propose to amend Sec.  
410.160(b)(8) to add ``and beginning January 1, 2015, for an anesthesia 
service,'' following the first use of the phrase ``a surgical service'' 
and to add ``or anesthesia'' following the word ``surgical'' each time 
it is used in the second sentence of Sec.  410.160(b)(8). This 
amendment to our regulation will ensure that both surgical or 
anesthesia services furnished in connection with, as a result of, and 
in the same clinical encounter as a colorectal cancer screening test 
will be exempt from the deductible requirement when furnished on the 
same date as a planned colorectal cancer screening test as described in 
Sec.  410.37.

[[Page 41787]]

III. Other Provisions of the Proposed Regulations

A. Proposed Provisions associated with the Ambulance Fee Schedule

1. Overview of Ambulance Services
a. Ambulance Services
    Under the ambulance fee schedule, the Medicare program pays for 
ambulance transportation services for Medicare beneficiaries when other 
means of transportation are contraindicated by the beneficiary's 
medical condition and all other coverage requirements are met. 
Ambulance services are classified into different levels of ground 
(including water) and air ambulance services based on the medically 
necessary treatment provided during transport.
    These services include the following levels of service:

 For Ground--
++ Basic Life Support (BLS) (emergency and non-emergency)
++ Advanced Life Support, Level 1 (ALS1) (emergency and non-emergency)
++ Advanced Life Support, Level 2 (ALS2)
++ Paramedic ALS Intercept (PI)
++ Specialty Care Transport (SCT)
 For Air--
++ Fixed Wing Air Ambulance (FW)
++ Rotary Wing Air Ambulance (RW)
b. Statutory Coverage of Ambulance Services
    Under sections 1834(l) and 1861(s)(7) of the Act, Medicare Part B 
(Supplemental Medical Insurance) covers and pays for ambulance 
services, to the extent prescribed in regulations, when the use of 
other methods of transportation would be contraindicated by the 
beneficiary's medical condition.
    The House Ways and Means Committee and Senate Finance Committee 
Reports that accompanied the 1965 Social Security Amendments suggest 
that the Congress intended that--
     The ambulance benefit cover transportation services only 
if other means of transportation are contraindicated by the 
beneficiary's medical condition; and
     Only ambulance service to local facilities be covered 
unless necessary services are not available locally, in which case, 
transportation to the nearest facility furnishing those services is 
covered (H.R. Rep. No. 213, 89th Cong., 1st Sess. 37 and Rep. No. 404, 
89th Cong., 1st Sess. Pt 1, 43 (1965)).
    The reports indicate that transportation may also be provided from 
one hospital to another, to the beneficiary's home, or to an extended 
care facility.
c. Medicare Regulations for Ambulance Services
    Our regulations relating to ambulance services are set forth at 42 
CFR part 410, subpart B and 42 CFR part 414, subpart H. Section 
410.10(i) lists ambulance services as one of the covered medical and 
other health services under Medicare Part B. Therefore, ambulance 
services are subject to basic conditions and limitations set forth at 
Sec.  410.12 and to specific conditions and limitations included at 
Sec.  410.40 and Sec.  410.41. Part 414, subpart H, describes how 
payment is made for ambulance services covered by Medicare.
2. Ambulance Extender Provisions
a. Amendment to Section 1834(l)(13) of the Act
    Section 146(a) of the MIPPA amended section 1834(l)(13)(A) of the 
Act to specify that, effective for ground ambulance services furnished 
on or after July 1, 2008 and before January 1, 2010, the ambulance fee 
schedule amounts for ground ambulance services shall be increased as 
follows:
     For covered ground ambulance transports that originate in 
a rural area or in a rural census tract of a metropolitan statistical 
area, the fee schedule amounts shall be increased by 3 percent.
     For covered ground ambulance transports that do not 
originate in a rural area or in a rural census tract of a metropolitan 
statistical area, the fee schedule amounts shall be increased by 2 
percent.
    The payment add-ons under section 1834(l)(13)(A) of the Act have 
been extended several times. Most recently, section 203(a) of the 
Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10, 
enacted on April 16, 2015) amended section 1834(l)(13)(A) of the Act to 
extend the payment add-ons through December 31, 2017. Thus, these 
payment add-ons apply to covered ground ambulance transports furnished 
before January 1, 2018. We are proposing to revise Sec.  
414.610(c)(1)(ii) to conform the regulations to this statutory 
requirement. (For a discussion of past legislation extending section 
1834(l)(13) of the Act, please see the CY 2014 PFS final rule with 
comment period (78 FR 74438 through 74439)).
    This statutory requirement is self-implementing. A plain reading of 
the statute requires only a ministerial application of the mandated 
rate increase, and does not require any substantive exercise of 
discretion on the part of the Secretary.
b. Amendment to Section 1834(l)(12) of the Act
    Section 414(c) of the Medicare Prescription Drug, Improvement and 
Modernization Act of 2003 (Pub. L. 108-173, enacted on December 8, 
2003) (MMA) added section 1834(l)(12) to the Act, which specified that, 
in the case of ground ambulance services furnished on or after July 1, 
2004, and before January 1, 2010, for which transportation originates 
in a qualified rural area (as described in the statute), the Secretary 
shall provide for a percent increase in the base rate of the fee 
schedule for such transports. The statute requires this percent 
increase to be based on the Secretary's estimate of the average cost 
per trip for such services (not taking into account mileage) in the 
lowest quartile of all rural county populations as compared to the 
average cost per trip for such services (not taking into account 
mileage) in the highest quartile of rural county populations. Using the 
methodology specified in the July 1, 2004 interim final rule (69 FR 
40288), we determined that this percent increase was equal to 22.6 
percent. As required by the MMA, this payment increase was applied to 
ground ambulance transports that originated in a ``qualified rural 
area,'' that is, to transports that originated in a rural area included 
in those areas comprising the lowest 25th percentile of all rural 
populations arrayed by population density. For this purpose, rural 
areas included Goldsmith areas (a type of rural census tract). This 
rural bonus is sometimes referred to as the ``Super Rural Bonus'' and 
the qualified rural areas (also known as ``super rural'' areas) are 
identified during the claims adjudicative process via the use of a data 
field included in the CMS-supplied ZIP code file.
    The Super Rural Bonus under section 1834(l)(12) of the Act has been 
extended several times. Most recently, section 203(b) of the Medicare 
Access and CHIP Reauthorization Act of 2015 amended section 
1834(l)(12)(A) of the Act to extend this rural bonus through December 
31, 2017. Therefore, we are continuing to apply the 22.6 percent rural 
bonus described above (in the same manner as in previous years) to 
ground ambulance services with dates of service before January 1, 2018 
where transportation originates in a qualified rural area. Accordingly, 
we are proposing to revise Sec.  414.610(c)(5)(ii) to conform the 
regulations to this statutory requirement. (For a discussion of past 
legislation extending section 1834(l)(12) of the Act, please see the CY 
2014 PFS

[[Page 41788]]

final rule with comment period (78 FR 74439 through 74440)).
    This statutory provision is self-implementing. It requires an 
extension of this rural bonus (which was previously established by the 
Secretary) through December 31, 2017, and does not require any 
substantive exercise of discretion on the part of the Secretary.
3. Changes in Geographic Area Delineations for Ambulance Payment
a. Background
    In the CY 2015 PFS final rule with comment period (79 FR 67744 
through 67750) as amended by the correction issued December 31, 2014 
(79 FR 78716 through 78719), we adopted, beginning in CY 2015, the 
revised OMB delineations as set forth in OMB's February 28, 2013 
bulletin (No. 13-01) and the most recent modifications of the Rural-
Urban Commuting Area (RUCA) codes for purposes of payment under the 
ambulance fee schedule. With respect to the updated RUCA codes, we 
designated any census tracts falling at or above RUCA level 4.0 as 
rural areas. In addition, we stated that none of the super rural areas 
would lose their status upon implementation of the revised OMB 
delineations and updated RUCA codes. After publication of the CY 2015 
PFS final rule with comment period and the correction, we received 
feedback and comments from stakeholders expressing concerns about the 
implementation of the new geographic area delineations finalized in 
that rule (as corrected). In response to these concerns, we are 
clarifying our implementation of the revised OMB delineations and the 
updated RUCA codes in CY 2015, and reproposing the implementation of 
the revised OMB delineations and updated RUCA codes for CY 2016 and 
subsequent calendar years. We are requesting public comment on our 
proposals, as further discussed in section III A.3.b. of this proposed 
rule.
b. Provisions of the Proposed Rule
    Under section 1834(l)(2)(C) of the Act, the Secretary is required 
to consider appropriate regional and operational differences in 
establishing the ambulance fee schedule. Historically, the Medicare 
ambulance fee schedule has used the same geographic area designations 
as the acute care hospital inpatient prospective payment system (IPPS) 
and other Medicare payment systems to take into account appropriate 
regional (urban and rural) differences. This use of consistent 
geographic standards for Medicare payment purposes provides for 
consistency across the Medicare program.
    The geographic areas used under the ambulance fee schedule 
effective in CY 2007 were based on OMB standards published on December 
27, 2000 (65 FR 82228 through 82238), Census 2000 data, and Census 
Bureau population estimates for 2007 and 2008 (OMB Bulletin No. 10-02). 
For a discussion of OMB's delineation of Core-Based Statistical Areas 
(CBSAs) and our implementation of the CBSA definitions under the 
ambulance fee schedule, we refer readers to the preamble of the CY 2007 
Ambulance Fee Schedule proposed rule (71 FR 30358 through 30361) and 
the CY 2007 PFS final rule with comment period (71 FR 69712 through 
69716). On February 28, 2013, OMB issued OMB Bulletin No. 13-01, which 
established revised delineations for Metropolitan Statistical Areas 
(MSAs), Micropolitan Statistical Areas, and Combined Statistical Areas, 
and provided guidance on the use of the delineations of these 
statistical areas. A copy of this bulletin may be obtained at http://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b-13-01.pdf. 
According to OMB, this bulletin provides the delineations of all 
Metropolitan Statistical Areas, Metropolitan Divisions, Micropolitan 
Statistical Areas, Combined Statistical Areas, and New England City and 
Town Areas in the United States and Puerto Rico based on the standards 
published on June 28, 2010, in the Federal Register (75 FR 37246-37252) 
and Census Bureau data. OMB defines an MSA as a CBSA associated with at 
least one urbanized area that has a population of at least 50,000, and 
a Micropolitan Statistical Area (referred to in this discussion as a 
Micropolitan Area) as a CBSA associated with at least one urban cluster 
that has a population of at least 10,000 but less than 50,000 (75 FR 
37252). Counties that do not qualify for inclusion in a CBSA are deemed 
``Outside CBSAs.'' We note that, when referencing the new OMB 
geographic boundaries of statistical areas, we are using the term 
``delineations'' consistent with OMB's use of the term (75 FR 37249).
    Although the revisions OMB published on February 28, 2013 were not 
as sweeping as the changes made when we adopted the CBSA geographic 
designations for CY 2007, the February 28, 2013 OMB bulletin did 
contain a number of significant changes. For example, there are new 
CBSAs, urban counties that became rural, rural counties that became 
urban, and existing CBSAs that were split apart. As we stated in the CY 
2015 PFS final rule with comment period (79 FR 67745), we reviewed our 
findings and impacts relating to the new OMB delineations, and found no 
compelling reason to further delay implementation. We stated in the CY 
2015 final rule with comment period, and we continue to believe, that 
it is important for the ambulance fee schedule to use the latest labor 
market area delineations available as soon as reasonably possible to 
maintain a more accurate and up-to-date payment system that reflects 
the reality of population shifts.
    Additionally, in the FY 2015 IPPS final rule (79 FR 49952), we 
adopted OMB's revised delineations to identify urban areas and rural 
areas for purposes of the IPPS wage index. For the reasons discussed in 
this section above, we believe that it would be appropriate to adopt 
the same geographic area delineations for use under the ambulance fee 
schedule as are used under the IPPS and other Medicare payment systems. 
Thus, we are proposing to continue implementation of the new OMB 
delineations as described in the February 28, 2013 OMB Bulletin No. 13-
01 for CY 2016 and subsequent CYs to more accurately identify urban and 
rural areas for ambulance fee schedule payment purposes. We continue to 
believe that the updated OMB delineations more realistically reflect 
rural and urban populations, and that the use of such delineations 
under the ambulance fee schedule would result in more accurate payment. 
Under the ambulance fee schedule, consistent with our current 
definitions of urban and rural areas (Sec.  414.605), in CY 2016 and 
subsequent CYs, MSAs would continue to be recognized as urban areas, 
while Micropolitan and other areas outside MSAs, and rural census 
tracts within MSAs (as discussed below in this section), would continue 
to be recognized as rural areas. We invite public comments on this 
proposal.
    In addition to the OMB's statistical area delineations, the current 
geographic areas used in the ambulance fee schedule also are based on 
rural census tracts determined under the most recent version of the 
Goldsmith Modification. These rural census tracts within MSAs are 
considered rural areas under the ambulance fee schedule (see Sec.  
414.605). For certain rural add-on payments, section 1834(l) of the Act 
requires that we use the most recent version of the Goldsmith 
Modification to determine rural census tracts within MSAs. In the CY 
2007 PFS final rule with comment period (71 FR 69714 through 69716), we 
adopted the most recent (at that time) version of the

[[Page 41789]]

Goldsmith Modification, designated as RUCA codes. RUCA codes use 
urbanization, population density, and daily commuting data to 
categorize every census tract in the country. For a discussion about 
RUCA codes, we refer the reader to the CY 2007 PFS final rule with 
comment period (71 FR 69714 through 69716) and the CY 2015 PFS final 
rule with comment period (79 FR 67745 through 67746). As stated 
previously, on February 28, 2013, OMB issued OMB Bulletin No. 13-01, 
which established revised delineations for Metropolitan Statistical 
Areas, Micropolitan Statistical Areas, and Combined Statistical Areas, 
and provided guidance on the use of the delineations of these 
statistical areas. Several modifications of the RUCA codes were 
necessary to take into account updated commuting data and the revised 
OMB delineations. We refer readers to the U.S. Department of 
Agriculture's Economic Research Service Web site for a detailed listing 
of updated RUCA codes found at http://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx. The updated RUCA code 
definitions were introduced in late 2013 and are based on data from the 
2010 decennial census and the 2006-2010 American Community Survey. 
Information regarding the American Community Survey can be found at 
http://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx. We believe that the most recent RUCA codes provide more 
accurate and up-to-date information regarding the rurality of census 
tracts throughout the country. Accordingly, we are proposing to 
continue to use the most recent modifications of the RUCA codes for CY 
2016 and subsequent CYs, to recognize levels of rurality in census 
tracts located in every county across the nation, for purposes of 
payment under the ambulance fee schedule. If we continue to use the 
most recent RUCA codes, many counties that are designated as urban at 
the county level based on population would continue to have rural 
census tracts within them that would be recognized as rural areas 
through our use of RUCA codes.
    As we stated in the CY 2015 PFS final rule with comment period (79 
FR 67745), the 2010 Primary RUCA codes are as follows:
    (1) Metropolitan area core: primary flow with an urbanized area 
(UA).
    (2) Metropolitan area high commuting: primary flow 30 percent or 
more to a UA.
    (3) Metropolitan area low commuting: primary flow 10 to 30 percent 
to a UA.
    (4) Micropolitan area core: primary flow within an Urban Cluster of 
10,000 to 49,999 (large UC).
    (5) Micropolitan high commuting: primary flow 30 percent or more to 
a large UC.
    (6) Micropolitan low commuting: primary flow 10 to 30 percent to a 
large UC.
    (7) Small town core: primary flow within an Urban Cluster of 2,500 
to 9,999 (small UC).
    (8) Small town high commuting: primary flow 30 percent or more to a 
small UC.
    (9) Small town low commuting: primary flow 10 to 30 percent to a 
small UC.
    (10) Rural areas: primary flow to a tract outside a UA or UC.
    Based on this classification, and consistent with our current 
policy as set forth in the CY 2015 PFS final rule with comment period 
(79 FR 67745), we are proposing to continue to designate any census 
tracts falling at or above RUCA level 4.0 as rural areas for purposes 
of payment for ambulance services under the ambulance fee schedule. As 
discussed in the CY 2007 PFS final rule with comment period (71 FR 
69715) and the CY 2015 PFS final rule with comment period (79 FR 
67745), the Office of Rural Health Policy within the Health Resources 
and Services Administration (HRSA) determines eligibility for its rural 
grant programs through the use of the RUCA code methodology. Under this 
methodology, HRSA designates any census tract that falls in RUCA level 
4.0 or higher as a rural census tract. In addition to designating any 
census tracts falling at or above RUCA level 4.0 as rural areas, under 
the updated RUCA code definitions, HRSA has also designated as rural 
census tracts those census tracts with RUCA codes 2 or 3 that are at 
least 400 square miles in area with a population density of no more 
than 35 people. We refer readers to HRSA's Web site at ftp://ftp.hrsa.gov/ruralhealth/Eligibility2005.pdf for additional 
information. Consistent with the HRSA guidelines discussed above and 
the policy we adopted in the CY 2015 PFS final rule with comment period 
(79 FR 67750), we are proposing for CY 2016 and subsequent CYs, to 
designate as rural areas those census tracts that fall at or above RUCA 
level 4.0. We continue to believe that this HRSA guideline accurately 
identifies rural census tracts throughout the country, and thus would 
be appropriate to apply for ambulance fee schedule payment purposes.
    Also, consistent with the policy we finalized in the CY 2015 PFS 
final rule with comment period (79 FR 67749), we would not designate as 
rural areas those census tracts that fall in RUCA levels 2 or 3 that 
are at least 400 square miles in area with a population density of no 
more than 35 people. We have determined that it is not feasible to 
implement this guideline due to the complexities of identifying these 
areas at the ZIP code level. We do not have sufficient information 
available to identify the ZIP codes that fall in these specific census 
tracts. Also, payment under the ambulance fee schedule is based on the 
ZIP codes; therefore, if the ZIP code is predominantly metropolitan but 
has some rural census tracts, we do not split the ZIP code areas to 
distinguish further granularity to provide different payments within 
the same ZIP code. We believe that payment for all ambulance 
transportation services at the ZIP code level provides for a more 
consistent and administratively feasible payment system. For example, 
if we were to pay based on ZIP codes for some areas and counties or 
census tracts for other areas, there are circumstances where ZIP codes 
cross county or census tract borders and where counties or census 
tracts cross ZIP code borders. Such overlaps in geographic designations 
would complicate our ability to appropriately assign ambulance 
transportation services to geographic areas for payment under the 
ambulance fee schedule. Therefore, under the ambulance fee schedule, we 
would not designate as rural areas those census tracts that fall in 
RUCA levels 2 or 3 that are at least 400 square miles in area with a 
population density of no more than 35 people.
    We invite public comments on our proposals, as discussed in this 
proposed rule, to continue to use the updated RUCA codes under the 
ambulance fee schedule for CY 2016 and subsequent CYs.
    As we stated in the CY 2015 PFS proposed rule (79 FR 40374), the 
adoption of the most current OMB delineations and the updated RUCA 
codes would affect whether certain areas are recognized as rural or 
urban. The distinction between urban and rural is important for 
ambulance payment purposes because urban and rural transports are paid 
differently. The determination of whether a transport is urban or rural 
is based on the point of pick-up for the transport; thus, a transport 
is paid differently depending on whether the point of pick-up is in an 
urban or a rural area. During claims processing, a geographic 
designation of urban, rural, or super rural is assigned to each claim 
for an ambulance

[[Page 41790]]

transport based on the point of pick-up ZIP code that is indicated on 
the claim.
    The continued implementation of the revised OMB delineations and 
the updated RUCA codes would continue to affect whether or not 
transports would be eligible for rural adjustments under the ambulance 
fee schedule statute and regulations. For ground ambulance transports 
where the point of pick-up is in a rural area, the mileage rate is 
increased by 50 percent for each of the first 17 miles (Sec.  
414.610(c)(5)(i)). For air ambulance services where the point of pick-
up is in a rural area, the total payment (base rate and mileage rate) 
is increased by 50 percent (Sec.  414.610(c)(5)(i)).
    Section 1834(l)(12) of the Act (as amended most recently by section 
203(b) of the Medicare Access and CHIP Reauthorization Act of 2015) 
specifies that, for services furnished during the period July 1, 2004 
through December 31, 2017, the payment amount for the ground ambulance 
base rate is increased by a ``percent increase'' (Super Rural Bonus) 
where the ambulance transport originates in a ``qualified rural area,'' 
which is a rural area that we determine to be in the lowest 25th 
percentile of all rural populations arrayed by population density (also 
known as a ``super rural area''). We implement this Super Rural Bonus 
in Sec.  414.610(c)(5)(ii). As discussed in section III.A.2.b. of this 
proposed rule, we are proposing to revise Sec.  414.610(c)(5)(ii) to 
conform the regulations to this statutory requirement. As we stated in 
the CY 2015 PFS proposed rule (79 FR 40374) and final rule with comment 
period (79 FR 67746), adoption of the revised OMB delineations and the 
updated RUCA codes would have no negative impact on ambulance 
transports in super rural areas, as none of the current super rural 
areas would lose their status due to the revised OMB delineations and 
the updated RUCA codes. Furthermore, under section 1834(l)(13) of the 
Act (as amended most recently by section 203(a) of the Medicare Access 
and CHIP Reauthorization Act of 2015), for ground ambulance transports 
furnished through December 31, 2017, transports originating in rural 
areas are paid based on a rate (both base rate and mileage rate) that 
is 3 percent higher than otherwise is applicable. (See also Sec.  
414.610(c)(1)(ii)). As discussed in section III.A.2.a. of this proposed 
rule, we are proposing to revise Sec.  414.610(c)(1)(ii) to conform the 
regulations to this statutory requirement.
    Similar to our discussion in the CY 2015 PFS proposed rule (79 FR 
40374) and final rule with comment period (79 FR 67746), if we continue 
to use OMB's revised delineations and the updated RUCA codes for CY 
2016 and subsequent CYs, ambulance providers and suppliers that pick up 
Medicare beneficiaries in areas that would be Micropolitan or otherwise 
outside of MSAs based on OMB's revised delineations or in a rural 
census tract of an MSA based on the updated RUCA codes (but were within 
urban areas under the geographic delineations in effect in CY 2014) 
would continue to experience increases in payment for such transports 
(as compared to the CY 2014 geographic delineations) because they may 
be eligible for the rural adjustment factors discussed above in this 
section. In addition, those ambulance providers and suppliers that pick 
up Medicare beneficiaries in areas that would be urban based on OMB's 
revised delineations and the updated RUCA codes (but were previously in 
Micropolitan Areas or otherwise outside of MSAs, or in a rural census 
tract of an MSA under the geographic delineations in effect in CY 2014) 
would continue to experience decreases in payment for such transports 
(as compared to the CY 2014 geographic delineations) because they would 
no longer be eligible for the rural adjustment factors discussed above 
in this section.
    The continued use of the revised OMB delineations and the updated 
RUCA codes for CY 2016 and subsequent CYs would mean the continued 
recognition of urban and rural boundaries based on the population 
migration that occurred over a 10-year period, between 2000 and 2010. 
As discussed above in this section, we are proposing to continue to use 
the updated RUCA codes to identify rural census tracts within MSAs, 
such that any census tracts falling at or above RUCA level 4.0 would 
continue to be designated as rural areas. In order to determine which 
ZIP codes are included in each such rural census tract, we are 
proposing to continue to use the ZIP code approximation file developed 
by HRSA. This file includes the 2010 RUCA code designation for each ZIP 
code and can be found at http://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx. If ZIP codes are added over time to 
the USPS ZIP code file (and thus are not included in the 2010 ZIP code 
approximation file provided to us by HRSA) or if ZIP codes are revised 
over time, we would determine the appropriate urban/rural designation 
for such ZIP code based on any updates provided on the HRSA and OMB Web 
sites, located at http://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx and http://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b-13-01.pdf.
    Based on the April 2015 USPS ZIP code file that we are using in 
this proposed rule to assess the impacts of the revised geographic 
delineations, there are a total of 42,925 ZIP codes in the U.S. Table 
16 sets forth an analysis of the number of ZIP codes that changed 
urban/rural status in each U.S. state and territory after CY 2014 due 
to our implementation of the revised OMB delineations and the updated 
RUCA codes beginning in CY 2015, using the April 2015 USPS ZIP code 
file, the revised OMB delineations, and the updated RUCA codes 
(including the RUCA ZIP code approximation file discussed above). Based 
on this data, the geographic designations for approximately 95.22 
percent of ZIP codes are unchanged by OMB's revised delineations and 
the updated RUCA codes. Similar to the analysis set forth in the CY 
2015 PFS final rule with comment period, as corrected (79 FR 78716 
through 78719), as reflected in Table 16, more ZIP codes have changed 
from rural to urban (1,600 or 3.73 percent) than from urban to rural 
(451 or 1.05 percent). In general, it is expected that ambulance 
providers and suppliers in 451 ZIP codes within 42 states, may continue 
to experience payment increases under the revised OMB delineations and 
the updated RUCA codes, as these areas have been redesignated from 
urban to rural. The state of Ohio has the most ZIP codes that changed 
from urban to rural with a total of 54, or 3.63 percent. Ambulance 
providers and suppliers in 1,600 ZIP codes within 44 states and Puerto 
Rico may continue to experience payment decreases under the revised OMB 
delineations and the updated RUCA codes, as these areas have been 
redesignated from rural to urban. The state of West Virginia has the 
most ZIP codes that changed from rural to urban (149 or 15.92 percent). 
As discussed above, these findings are illustrated in Table 16.

[[Page 41791]]



                                 Table 16--ZIP Code Analysis Based on OMB's Revised Delineations and Updated RUCA Codes
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                           Percentage of
                                             Total ZIP       Total ZIP     Percentage of     Total ZIP     Percentage of     Total ZIP       total ZIP
            State/Territory *                  codes       codes changed     total ZIP     codes changed     total ZIP       codes not       codes not
                                                          rural to urban       codes      urban to rural       codes          changed         changed
--------------------------------------------------------------------------------------------------------------------------------------------------------
AK......................................             276               0            0.00               0            0.00             276          100.00
AL......................................             854              43            5.04               8            0.94             803           94.03
AR......................................             725              19            2.62               9            1.24             697           96.14
AS......................................               1               0            0.00               0            0.00               1          100.00
AZ......................................             569              21            3.69               7            1.23             541           95.08
CA......................................            2723              85            3.12              43            1.58            2595           95.30
CO......................................             677               4            0.59               9            1.33             664           98.08
CT......................................             445              37            8.31               0            0.00             408           91.69
DC......................................             303               0            0.00               0            0.00             303          100.00
DE......................................              99               6            6.06               0            0.00              93           93.94
EK......................................              63               0            0.00               0            0.00              63          100.00
EM......................................             857              35            4.08               4            0.47             818           95.45
FL......................................            1513              69            4.56               9            0.59            1435           94.84
FM......................................               4               0            0.00               0            0.00               4          100.00
GA......................................            1032              47            4.55               4            0.39             981           95.06
GU......................................              21               0            0.00               0            0.00              21          100.00
HI......................................             143               9            6.29               3            2.10             131           91.61
IA......................................            1080              20            1.85               3            0.28            1057           97.87
ID......................................             335               0            0.00               0            0.00             335          100.00
IL......................................            1629              68            4.17               7            0.43            1554           95.40
IN......................................            1000              33            3.30              20            2.00             947           94.70
KY......................................            1030              30            2.91               5            0.49             995           96.60
LA......................................             739              69            9.34               1            0.14             669           90.53
MA......................................             751               8            1.07               9            1.20             734           97.74
MD......................................             630              69           10.95               0            0.00             561           89.05
ME......................................             505               5            0.99              12            2.38             488           96.63
MH......................................               2               0            0.00               0            0.00               2          100.00
MI......................................            1185              22            1.86              21            1.77            1142           96.37
MN......................................            1043              31            2.97               7            0.67            1005           96.36
MP......................................               3               0            0.00               0            0.00               3          100.00
MS......................................             541              14            2.59               1            0.18             526           97.23
MT......................................             411               0            0.00               3            0.73             408           99.27
NC......................................            1102              87            7.89              10            0.91            1005           91.20
ND......................................             419               2            0.48               0            0.00             417           99.52
NE......................................             632               7            1.11               6            0.95             619           97.94
NH......................................             292               0            0.00               2            0.68             290           99.32
NJ......................................             748               1            0.13               2            0.27             745           99.60
NM......................................             438               4            0.91               2            0.46             432           98.63
NV......................................             257               1            0.39               2            0.78             254           98.83
NY......................................            2246              84            3.74              42            1.87            2120           94.39
OH......................................            1487              23            1.55              54            3.63            1410           94.82
OK......................................             791               5            0.63               7            0.88             779           98.48
OR......................................             496              26            5.24               9            1.81             461           92.94
PA......................................            2244             129            5.75              38            1.69            2077           92.56
PR......................................             177              21           11.86               0            0.00             156           88.14
PW......................................               2               0            0.00               0            0.00               2          100.00
RI......................................              91               2            2.20               1            1.10              88           96.70
SC......................................             544              47            8.64               2            0.37             495           90.99
SD......................................             418               0            0.00               1            0.24             417           99.76
TN......................................             814              52            6.39              12            1.47             750           92.14
TX......................................            2726              64            2.35              32            1.17            2630           96.48
UT......................................             360               2            0.56               0            0.00             358           99.44
VA......................................            1277              98            7.67              19            1.49            1160           90.84
VI......................................              16               0            0.00               0            0.00              16          100.00
VT......................................             309               3            0.97               0            0.00             306           99.03
WA......................................             744              17            2.28               6            0.81             721           96.91
WI......................................             919              19            2.07               5            0.54             895           97.39
WK......................................             711              11            1.55               7            0.98             693           97.47
WM......................................             342               2            0.58               3            0.88             337           98.54
WV......................................             936             149           15.92               3            0.32             784           83.76
WY......................................             198               0            0.00               1            0.51             197           99.49
                                         ---------------------------------------------------------------------------------------------------------------
    TOTALS..............................          42,925            1600            3.73             451            1.05          40,874           95.22
--------------------------------------------------------------------------------------------------------------------------------------------------------
* ZIP code analysis includes U.S. States and Territories (FM--Federated States of Micronesia, GU--Guam, MH--Marshall Islands, MP--Northern Mariana
  Islands, PW--Palau, AS--American Samoa; VI--Virgin Islands; PR--Puerto Rico). Missouri is divided into east and west regions due to work distribution
  of the Medicare Administrative Contractors (MACs): EM--East Missouri, WM--West Missouri. Johnson and Wyandotte counties in Kansas were changed as of
  January 2010 to East Kansas (EK) and the rest of the state is West Kansas (WK).


[[Page 41792]]

    For more detail on the impact of our proposals, in addition to 
Table 16, the following files are available through the Internet on the 
Ambulance Fee Schedule Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/index.html: ZIP 
Codes By State Changed From Urban To Rural: ZIP Codes By State Changed 
From Rural To Urban: List of ZIP Codes With RUCA Code Designations: and 
Complete List of ZIP Codes.
    As discussed in the CY 2015 PFS final rule with comment period (79 
FR 67750), we believe the most current OMB statistical area 
delineations, coupled with the updated RUCA codes, more accurately 
reflect the contemporary urban and rural nature of areas across the 
country, and thus we believe the use of the most current OMB 
delineations and RUCA codes under the ambulance fee schedule will 
enhance the accuracy of ambulance fee schedule payments. As we 
discussed in the CY 2015 PFS final rule with comment period (79 FR 
67750), we considered, as alternatives, whether it would be appropriate 
to delay the implementation of the revised OMB delineations and the 
updated RUCA codes, or to phase in the implementation of the new 
geographic delineations over a transition period for those ZIP codes 
losing rural status. We determined that it would not be appropriate to 
implement a delay or a transition period for the revised geographic 
delineations for the reasons set forth in the CY 2015 PFS final rule. 
Similarly, we considered whether a delay in implementation or a 
transition period would be appropriate for CY 2016 and subsequent CYs. 
We continue to believe that it is important to use the most current OMB 
delineations and RUCA codes available as soon as reasonably possible to 
maintain a more accurate and up-to-date payment system that reflects 
the reality of population shifts. Because we believe the revised OMB 
delineations and updated RUCA codes more accurately identify urban and 
rural areas and enhance the accuracy of the Medicare ambulance fee 
schedule, we do not believe a delay in implementation or a transition 
period would be appropriate for CY 2016 and subsequent CYs. Areas that 
have lost their rural status and become urban have become urban because 
of recent population shifts. We believe it is important to base payment 
on the most accurate and up-to-date geographic area delineations 
available. Furthermore, we believe a delay in implementation of the 
revised OMB delineations and the updated RUCA codes would be a 
disadvantage to the ambulance providers or suppliers experiencing 
payment increases based on these updated and more accurate OMB 
delineations and RUCA codes. Thus, we are not proposing a delay in 
implementation or a transition period for the revised OMB delineations 
and updated RUCA codes for CY 2016 and subsequent CYs.
    We invite public comments on our proposals to continue 
implementation of the revised OMB delineations as set forth in OMB's 
February 28, 2013 bulletin (No. 13-01) and the most recent 
modifications of the RUCA codes as discussed above for CY 2016 and 
subsequent CYs for purposes of payment under the ambulance fee 
schedule. In addition, we invite public comments on any alternative 
methods for implementing the revised OMB delineations and the updated 
RUCA codes.
4. Proposed Changes to the Ambulance Staffing Requirement
    Under section 1861(s)(7) of the Act, Medicare Part B covers 
ambulance services when the use of other methods of transportation is 
contraindicated by the individual's medical condition, but only to the 
extent provided in regulations. Section 410.41(b)(1) requires that a 
vehicle furnishing ambulance services at the Basic Life Support (BLS) 
level must be staffed by at least two people, one of whom must meet the 
following requirements: (1) be certified as an emergency medical 
technician by the state or local authority where the services are 
furnished, and (2) be legally authorized to operate all lifesaving and 
life-sustaining equipment on board the vehicle.
    Section 410.41(b)(2) states that, for vehicles furnishing ambulance 
services at the Advanced Life Support (ALS) level, ambulance providers 
and suppliers must meet the staffing requirements for vehicles 
furnishing services at the BLS level. In addition, one of the two staff 
members must be certified as a paramedic or an emergency medical 
technician, by the state or local authority where the services are 
being furnished, to perform one or more ALS services. These staffing 
requirements are further explained in the Medicare Benefit Policy 
Manual (Pub. No. 100-02), Chapter 10 (see sections 10.1.2 and 30.1.1)
    In its July 24, 2014 Management Implication Report, 13-0006, 
entitled ``Medicare Requirements for Ambulance Crew Certification,'' 
the Office of Inspector General (OIG) discussed its investigation of 
ambulance suppliers in a state that requires a higher level of training 
than Medicare requires for ambulance staff. In some instances, OIG 
found that second crew members: (1) possessed a lower level of training 
than required by state law, or (2) had purchased or falsified 
documentation to establish their credentials. The OIG expressed its 
concern that our current regulations and manual provisions do not set 
forth licensure or certification requirements for the second crew 
member. The OIG was informed by federal prosecutors that prosecuting 
individuals who had purchased or falsified documentation to establish 
their credentials would be difficult because Medicare had no 
requirements regarding the second ambulance staff member and the 
ambulance transports complied with the relevant Medicare regulations 
and manual provisions for ambulance staffing.
    The OIG recommended that Medicare revise its regulations and manual 
provisions related to ambulance staffing to parallel the standard used 
for vehicle requirements at Sec.  410.41(a), which requires that 
ambulances be equipped in ways that comply with state and local laws. 
Specifically, the OIG recommended that our regulation and manual 
provisions addressing ambulance vehicle staffing should indicate that, 
for Medicare to cover ambulance services furnished to a Medicare 
beneficiary, the ambulance crew must meet the requirements currently 
set forth in Sec.  410.41(b) or the state and local requirements, 
whichever are more stringent. Currently, Sec.  410.41(b) does not 
require that ambulance vehicle staff comply with all applicable state 
and local laws. We agree with OIG's concerns and believe that requiring 
ambulance staff to also comply with state and local requirements would 
enhance the quality and safety of ambulance services furnished to 
Medicare beneficiaries.
    Accordingly, we are proposing to revise Sec.  410.41(b) to require 
that all Medicare-covered ambulance transports must be staffed by at 
least two people who meet both the requirements of applicable state and 
local laws where the services are being furnished, and the current 
Medicare requirements under Sec.  410.41(b). We believe that this 
would, in effect, require both of the required ambulance vehicle staff 
to also satisfy any applicable state and local requirements that may be 
more stringent than those currently set forth at Sec.  410.41(b), 
consistent with OIG's recommendation. In addition, we are proposing to 
revise the definition of Basic Life Support (BLS) in Sec.  414.605 to 
include the proposed revised staffing requirements discussed above for

[[Page 41793]]

Sec.  410.41(b). These proposed revisions to Sec.  410.41(b) and Sec.  
414.605 would account for differences in individual state or local 
staffing and licensure requirements, better accommodating state or 
local laws enacted to ensure beneficiaries' health and safety. 
Likewise, these proposed revisions would strengthen the federal 
government's ability to prosecute violations associated with such 
requirements and recover inappropriately or fraudulently received funds 
from ambulance companies found to be operating in violation of state or 
local laws. Furthermore, as discussed above, we believe that these 
proposals would enhance the quality and safety of ambulance services 
provided to Medicare beneficiaries.
    In addition, we are proposing to revise Sec.  410.41(b) and the 
definition of Basic Life Support (BLS) in Sec.  414.605 to clarify 
that, for BLS vehicles, at least one of the staff members must be 
certified at a minimum as an emergency medical technician-basic (EMT-
Basic), which we believe would more clearly state our current policy. 
Currently, these regulations require that, for BLS vehicles, one staff 
member be certified as an EMT (Sec.  410.41(b)) or EMT-Basic (Sec.  
414.605). These proposed revisions to the regulations do not change our 
current policy, but clarify that one of the BLS vehicle staff members 
must be certified at the minimum level of EMT-Basic, but may also be 
certified at a higher level, for example, EMT-intermediate or EMT 
paramedic.
    Finally, we are proposing to revise the definition of Basic Life 
Support (BLS) in Sec.  414.605 to delete the last sentence, which sets 
forth examples of certain state law provisions. This sentence (``For 
example, only in some states is an EMT-Basic permitted to operate 
limited equipment on board the vehicle, assist more qualified personnel 
in performing assessments and interventions, and establish a peripheral 
intravenous (IV) line''), has been included in the definition of BLS 
since the ambulance fee schedule was finalized in 2002 (67 FR 9100, 
Feb. 27, 2002). Because state laws may change over the course of time, 
we are concerned that this sentence may not accurately reflect the 
status of the relevant state laws over time. Therefore, we are 
proposing to delete the last sentence of this definition. Furthermore, 
we do not believe that the examples set forth in this sentence are 
necessary to convey the definition of BLS for Medicare coverage and 
payment purposes.
    We invite public comments on our proposals to revise the ambulance 
vehicle staffing requirements in Sec.  410.41(b) and Sec.  414.605 as 
discussed above. If we finalize these proposals, we will revise our 
manual provisions addressing ambulance vehicle staffing as appropriate, 
consistent with our finalized policy.

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

1. Background
a. Primary Care and Care Coordination
    Over the last several years, we have been increasing our focus on 
primary care, and have explored ways in which care coordination can 
improve health outcomes and reduce expenditures.
    In the CY 2012 PFS proposed rule (76 FR 42793 through 42794, and 
42917 through 42920), and the CY 2012 PFS final rule (76 FR 73063 
through 73064), we discussed how primary care services have evolved to 
focus on preventing and managing chronic disease, and how refinements 
for payment for post-discharge care management services could improve 
care management for a beneficiary's transition from the hospital to the 
community setting. We acknowledged that the care coordination included 
in services such as office visits does not always describe adequately 
the non-face-to-face care management work involved in primary care and 
may not reflect all the services and resources required to furnish 
comprehensive, coordinated care management for certain categories of 
beneficiaries, such as those who are returning to a community setting 
following discharge from a hospital or skilled nursing facility (SNF) 
stay. We initiated a public discussion on primary care and care 
coordination services, and stated that we would consider payment 
enhancements in future rulemaking as part of a multiple year strategy 
exploring the best means to encourage primary care and care 
coordination services.
    In the CY 2013 PFS proposed rule (77 FR 44774 through 44775), we 
noted several initiatives and programs designed to improve payment for, 
and encourage long-term investment in, care management services. These 
include the Medicare Shared Savings Program; testing of the Pioneer 
Accountable Care Organization (ACO) and the Advance Payment ACO model; 
the Primary Care Incentive Payment (PCIP) Program; the patient-centered 
medical home model in the Multi-payer Advanced Primary Care Practice 
(MAPCP) Demonstration; the Federally Qualified Health Center (FQHC) 
Advanced Primary Care Practice demonstration; the Comprehensive Primary 
Care (CPC) initiative; and the HHS Strategic Framework on Multiple 
Chronic Conditions. We also noted that we were monitoring the progress 
of the AMA Chronic Care Coordination Workgroup in developing codes to 
describe care transition and care coordination activities, and proposed 
refinement of the PFS payment for post discharge care management 
services.
    In the CY 2013 PFS final rule (77 FR 68978 through 68994), we 
finalized policies for payment of Transitional Care Management (TCM) 
services, effective January 1, 2013. We adopted two CPT codes (99495 
and 99496) to report physician or qualifying nonphysician practitioner 
care management services for a patient following a discharge from an 
inpatient hospital or SNF, an outpatient hospital stay for observation 
or partial hospitalization services, or partial hospitalization in a 
community mental health center. As a condition for receiving TCM 
payment, a face-to-face visit was required.
    In the CY 2014 PFS proposed rule (78 FR 43337 through 43343), we 
proposed to establish separate payment under the PFS for chronic care 
management (CCM) services and proposed a scope of services and 
requirements for billing and supervision. In the CY 2014 PFS final rule 
(78 74414 through 74427), we finalized policies to establish separate 
payment under the PFS for CCM services furnished to patients with 
multiple chronic conditions that are expected to last at least 12 
months or until the death of the patient, and that place the patient at 
significant risk of death, acute exacerbation/decompensation, or 
functional decline. In the CY 2015 PFS final rule (79 FR 67715 through 
67730), additional billing requirements were finalized, including the 
requirement to furnish CCM services using a certified electronic health 
record or other electronic technology. Payment for CCM services was 
effective beginning on January 1, 2015, for physicians billing under 
the PFS.
b. RHC and FQHC Payment Methodologies
    A RHC or FQHC visit must be a face-to-face encounter between the 
patient and a RHC or FQHC practitioner (physician, nurse practitioner, 
physician assistant, certified nurse midwife, clinical psychologist, or 
clinical social worker, and under certain conditions, an RN or LPN 
furnishing care to a homebound RHC or FQHC patient) during which time 
one or more RHC or FQHC services are furnished. A TCM service can also 
be a RHC or FQHC visit. A Diabetes Self-Management Training

[[Page 41794]]

(DSMT) service or a Medical Nutrition Therapy (MNT) service furnished 
by a certified DSMT or MNT provider may also be a FQHC visit.
    RHCs are paid an all-inclusive rate (AIR) for medically-necessary 
medical and mental health services, and qualified preventive health 
services furnished on the same day (with some exceptions). In general, 
the A/B MAC calculates the AIR for each RHC by dividing total allowable 
costs by the total number of visits for all patients. Productivity, 
payment limits, and other factors are also considered in the 
calculation. Allowable costs must be reasonable and necessary and may 
include practitioner compensation, overhead, equipment, space, 
supplies, personnel, and other costs incident to the delivery of RHC 
services. The AIR is subject to a payment limit, except for those RHCs 
that have an exception to the payment limit. Services furnished 
incident to a RHC professional service are included in the per-visit 
payment and are not billed separately.
    FQHCs have also been paid under the AIR methodology; however, on 
October 1, 2014, FQHCs began to transition to a FQHC PPS system in 
which they are paid based on the lesser of a national encounter-based 
rate or their total adjusted charges. The FQHC PPS rate is adjusted for 
geographic differences in the cost of services by the FQHC geographic 
adjustment factor. It is also increased by 34 percent when a FQHC 
furnishes care to a patient that is new to the FQHC or to a beneficiary 
receiving an Initial Preventive Physical Examination (IPPE) or an 
Annual Wellness Visit (AWV). Both the AIR and FQHC PPS payment rates 
were designed to reflect all the services that a RHC or FQHC furnishes 
in a single day, regardless of the length or complexity of the visit or 
the number or type of practitioners seen.
c. Payment for CCM Services
    To address the concern that the non-face-to-face care management 
work involved in furnishing comprehensive, coordinated care management 
for certain categories of beneficiaries is not adequately paid for as 
part of an office visit, beginning on January 1, 2015, practitioners 
billing under the PFS are paid separately for CCM services under CPT 
code 99490 when CCM service requirements are met.
    RHCs and FQHCs cannot bill under the PFS for RHC or FQHC services 
and individual practitioners working at RHCs and FQHCs cannot bill 
under the PFS for RHC or FQHC services while working at the RHC or 
FQHC. While many RHCs and FQHCs coordinate services within their own 
facilities, and may sometimes help to coordinate services outside their 
facilities, the type of structured care management services that are 
now payable under the PFS for patients with multiple chronic 
conditions, particularly for those who are transitioning from a 
hospital or SNF back into their communities, are not included in the 
RHC or FQHC payment. This proposed rule proposes to provide an 
additional payment for the costs of CCM services that are not already 
captured in the RHC AIR or the FQHC PPS payment, beginning on January 
1, 2016. Services that are currently being furnished and paid under the 
RHC AIR or FQHC PPS payment methodology will not be affected by the 
ability of the RHC or FQHC to receive payment for additional services 
that are not included in the RHC AIR or FQHC PPS.
d. Solicitation of Comments on Payment for CCM Services in RHCs and 
FQHCs
    In the May 2, 2014 ``Medicare Program: Prospective Payment System 
for Federally Qualified Health Centers; Changes to Contracting Policies 
for Rural Health Clinics; and Changes to Clinical Laboratory 
Improvement Amendments of 1988 Enforcement Actions for Proficiency 
Testing Referral; Final Rule'' (79 FR 25447), we discussed ways to 
achieve the Affordable Care Act goal of furnishing integrated and 
coordinated services, and specifically noted the CCM services program 
beginning in 2015 for physicians billing under the PFS. We encouraged 
RHCs and FQHCs to review the CCM services information in the CY 2014 
PFS final rule with comment period and submit comments to us on how the 
CCM services payment could be adapted for RHCs and FQHCs to promote 
integrated and coordinated care in RHCs and FQHCs.
    All of the comments we received in response to this request were 
strongly supportive of payment to RHCs and FQHCs for CCM services. Some 
commenters were concerned that the requirements for electronic exchange 
of information and interoperability with other providers would be 
difficult for some entities, and that some patients do not have the 
resources to receive secure messages via the internet. One commenter 
suggested that the additional G-codes for CCM services should be 
sufficient to cover the associated costs of documenting care 
coordination in FQHCs, and another commenter suggested that we develop 
a risk-adjusted CCM services fee. We also received subsequent 
recommendations from the National Association of Rural Health Clinics 
on various payment options for CCM services in RHCs. These comments 
were very helpful in forming the basis for this proposal, and we thank 
the commenters for their comments.
2. Proposed Payment Methodology and Billing for CCM Services in RHCs 
and FQHCs
a. Proposed Payment Methodology and Billing Requirements
    The requirements we are proposing for RHCs and FQHCs to receive 
payment for CCM services are consistent with those finalized in the CY 
2015 PFS final rule with comment period for practitioners billing under 
the PFS and are summarized in Table 17. We propose to establish 
payment, beginning on January 1, 2016, for RHCs and FQHCs who furnish a 
minimum of 20 minutes of qualifying CCM services during a calendar 
month to patients with multiple (two or more) chronic conditions that 
are expected to last at least 12 months or until the death of the 
patient, and that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline. The CPT code 
descriptor sets forth the eligibility guidelines for CCM services and 
will serve as the basis for potential medical review. In accordance 
with both the CPT instructions and Medicare policy, only one 
practitioner can bill this code per month, and there are restrictions 
regarding the billing of other overlapping care management services 
during the same service period. The following section discusses these 
aspects of our proposal in more detail and additional information will 
be communicated in subregulatory guidance.
    We propose that a RHC or FQHC can bill for CCM services furnished 
by, or incident to, a RHC or FQHC physician, nurse practitioner, 
physician assistant, or certified nurse midwife for a RHC or FQHC 
patient once per month, and that only one CCM payment per beneficiary 
per month can be paid. If another practice furnishes CCM services to a 
beneficiary, the RHC or FQHC cannot bill for CCM services for the same 
beneficiary for the same service period. We also propose that TCM and 
any other program that provides additional payment for care management 
services (outside of the RHC AIR or FQHC PPS payment) cannot be billed 
during the same service period.
    For purposes of meeting the minimum 20-minute requirement, the RHC 
or FQHC could count the time of only one practitioner or auxiliary 
staff (for example, a nurse, medical assistant, or

[[Page 41795]]

other individual working under the supervision of a RHC or FQHC 
physician or other practitioner) at a time, and could not count 
overlapping intervals such as when two or more RHC or FQHC 
practitioners are meeting about the patient. Only conversations that 
fall under the scope of CCM services would be included towards the time 
requirement.
    We noted that for billing under the PFS, the care coordination 
included in services such as office visits do not always describe 
adequately the non-face-to-face care management work involved in 
primary care. We also noted that payment for office visits may not 
reflect all the services and resources required to furnish 
comprehensive, coordinated care management for certain categories of 
beneficiaries, such as those who are returning to a community setting 
following discharge from a hospital or SNF stay. In considering CCM 
payment for RHCs and FQHCs, we believe that the non-face-to-face time 
required to coordinate care is also not captured in the RHC AIR or the 
FQHC PPS payment, particularly for the rural and/or low-income 
populations served by RHCs and FQHCs. Allowing separate payment for CCM 
services in RHCs and FQHCs is intended to reflect the additional 
resources necessary for the unique services that are required in order 
to furnish CCM services that are not already captured in the RHC AIR or 
the FQHC PPS payment.
    We propose that payment for CCM services be based on the PFS 
national average non-facility payment rate when CPT code 99490 is 
billed alone or with other payable services on a RHC or FQHC claim. 
(For the first quarter of 2015, the national average payment rate is 
$42.91 per beneficiary per calendar month.) CCM payment to RHCs and 
FQHCs would be based on the PFS amount, but would be paid as part of 
the RHC and FQHC benefit, using the CPT code to identify that the 
requirements for payment are met and a separate payment should be made. 
We also propose to waive the RHC and FQHC face-to-face requirements 
when CCM services are furnished to a RHC or FQHC patient. Coinsurance 
would be applied as applicable to FQHC claims, and coinsurance and 
deductibles would apply as applicable to RHC claims. RHCs and FQHCs 
would continue to be required to meet the RHC and FQHC Conditions of 
Participation and any additional RHC or FQHC payment requirements. We 
intend to provide detailed billing instructions in subregulatory 
guidance following publication of a final rule.
b. Other Options Considered
    We considered adding CCM services as a RHC or FQHC covered stand-
alone service and removing the RHC/FQHC policy requiring a face-to-face 
visit requirement for this service. Under this option, payment for RHCs 
would be at the AIR, payment for FQHCs would be the lesser of total 
charges or the PPS rate, and if CCM services are furnished on the same 
day as another payable medical visit, only one visit would be paid. We 
are not proposing this payment option because it would result in a 
significant overpayment if no other services were furnished on the same 
day, and would result in no additional payment if furnished on the same 
day as another medical visit.
    We also considered allowing RHCs and FQHCs to carve out CCM 
services and bill them separately to the PFS. We are not proposing this 
payment option because CCM services are a RHC and FQHC service and only 
non-RHC/FQHC services can be billed through the PFS.
    We also considered developing a modifier that could be added to the 
claim for additional payment when CCM services are furnished. We are 
not proposing this option because it would require that payment for CCM 
services be made only when furnished along with a billable service that 
qualifies as an RHC or FQHC service.
    We also considered establishing payment for CCM costs on a 
reasonable cost basis though the cost report. We are not proposing this 
option because payment for CCM services through the cost report would 
complicate coinsurance and/or deductible accountability, whereas it is 
more administratively feasible to apply coinsurance and/or deductible 
on a RHC/FQHC claim, as applicable. For example, section 1833(a)(3) of 
the Act specifies that influenza and pneumococcal vaccines and their 
administration are exempt from payment at 80 percent of reasonable 
costs and payment to RHCs and FQHCs for such services is at 100 percent 
of reasonable cost. Since influenza and pneumococcal vaccines and their 
administration are not subject to copayment, it is administratively 
feasible to pay these services through the cost report.
3. Proposed Requirements for CCM Payment in RHCs and FQHCs
a. Proposed Beneficiary Eligibility for CCM Services
    Consistent with beneficiary eligibility requirements under the PFS, 
we propose that RHCs and FQHCs receive payment for furnishing CCM 
services to patients with multiple chronic conditions that are expected 
to survive at least 12 months or until the death of the patient, and 
that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline. RHCs and FQHCs are 
encouraged to focus on patients with high acuity and high risk when 
furnishing CCM services to eligible patients, including those who are 
returning to a community setting following discharge from a hospital or 
SNF.
b. Proposed Beneficiary Agreement Requirements
    Not all patients who are eligible for separately payable CCM 
services may necessarily want these services to be provided, and some 
patients who receive CCM services may wish to discontinue them. A 
beneficiary who declines to receive CCM services from the RHC or FQHC, 
or who accepts the services and then chooses to revoke his/her 
agreement, would continue to be able to receive care from the RHC or 
FQHC and receive any care management services that are currently being 
furnished under the RHC AIR or FQHC PPS payment system.
    Consistent with beneficiary notification and consent requirements 
under the PFS, we propose that the following requirements be met before 
the RHC or FQHC can furnish or bill for CCM services:
     The eligible beneficiary must be informed about the 
availability of CCM services from the RHC or FQHC and provide his or 
her written agreement to have the services provided, including the 
electronic communication of the patient's information with other 
treating providers as part of care coordination. This would include a 
discussion with the patient about what CCM services are, how they 
differ from any care management services the RHC or FQHC currently 
offers, how these services are accessed, how the patient's information 
will be shared among others, that a non RHC or FQHC cannot furnish or 
bill for CCM services during the same calendar month that the RHC or 
FQHC furnishes CCM services, the applicability of coinsurance even when 
CCM services are not delivered face-to-face in the RHC or FQHC, and 
that any care management services that are currently provided will 
continue even if the patient does not agree to have CCM services 
provided.
     The RHC or FQHC must document in the patient's medical 
record that all of the CCM services were explained and offered to the 
patient, and note the patient's decision to accept these services.

[[Page 41796]]

     At the time the agreement is obtained, the eligible 
beneficiary must be informed that the agreement for CCM services could 
be revoked by the beneficiary at any time either verbally or in 
writing, and the RHC or FQHC practitioner must explain the effect of a 
revocation of the agreement for CCM services. If the revocation occurs 
during a CCM 30-day period, the revocation would be effective at the 
end of that period. The eligible beneficiary must also be informed that 
the RHC or FQHC is able to be separately paid for these services during 
the 30-day period only if no other practitioner or eligible entity, 
including another RHC or FQHC that is not part of the RHC's or FQHC's 
organization, has already billed for this service. Since only one CCM 
payment can be paid per beneficiary per month, the RHC or FQHC would 
need to ask the patient if they are already receiving CCM services from 
another practitioner. Revocation by the beneficiary of the agreement 
must also be noted by recording the date of the revocation in the 
beneficiary's medical record and by providing the beneficiary with 
written confirmation that the RHC or FQHC would not be providing CCM 
services beyond the current 30-day period. A beneficiary who has 
revoked the agreement for CCM services from a RHC or FQHC may choose 
instead to receive these services from a different practitioner 
(including another RHC or FQHC), beginning at the conclusion of the 30-
day period.
     The RHC or FQHC must provide a written or electronic copy 
of the care plan to the beneficiary and record this in the 
beneficiary's electronic medical record.
c. Proposed Scope of CCM Services in RHCs and FQHCs
    We propose that all of the following scope of service requirements 
must be met to bill for CCM services:
     Initiation of CCM services during a comprehensive 
Evaluation/Management (E/M), AWV, or IPPE visit. The time spent 
furnishing these services would not be included in the 20 minute 
monthly minimum required for CCM billing.
     Continuity of care with a designated RHC or FQHC 
practitioner with whom the patient is able to get successive routine 
appointments.
     Care management for chronic conditions, including 
systematic assessment of a patient's medical, functional, and 
psychosocial needs; system-based approaches to ensure timely receipt of 
all recommended preventive care services; medication reconciliation 
with review of adherence and potential interactions; and oversight of 
patient self-management of medications.
     A patient-centered plan of care document created by the 
RHC or FQHC practitioner furnishing CCM services in consultation with 
the patient, caregiver, and other key practitioners treating the 
patient to assure that care is provided in a way that is congruent with 
patient choices and values. The plan would be a comprehensive plan of 
care for all health issues based on a physical, mental, cognitive, 
psychosocial, functional and environmental (re)assessment and an 
inventory of resources and supports. It would typically include, but 
not be limited to, the following elements: problem list, expected 
outcome and prognosis, measurable treatment goals, symptom management, 
planned interventions, medication management, community/social services 
ordered, how the services of agencies and specialists unconnected to 
the practice will be directed/coordinated, the individuals responsible 
for each intervention, requirements for periodic review and, when 
applicable, revision, of the care plan. A complete list of problems, 
medications, and medication allergies would be in the electronic health 
record to inform the care plan, care coordination, and ongoing clinical 
care.
     Creation of an electronic care plan that would be 
available 24 hours a day and 7 days a week to all practitioners within 
the RHC or FQHC who are furnishing CCM services whose time counts 
towards the time requirement for billing the CCM code, and to other 
practitioners and providers, as appropriate, who are furnishing care to 
the beneficiary, to address a patient's urgent chronic care needs. No 
specific electronic solution or format is required to meet this scope 
of service element. However, we encourage RHCs and FQHCs who wish to 
learn more about currently available electronic standards for care 
planning to refer to the proposed rulemaking for the 2015 Edition of 
Health Information Technology Certification Criteria, which includes a 
proposal to enable users of certified health IT to create and receive 
care plan information in accordance with the C-CDA Release 2.0 standard 
(80 FR 16842).
     Management of care transitions within health care 
including referrals to other clinicians, visits following a patient 
visit to an emergency department, and visits following discharges from 
hospitals and SNFs. The RHC or FQHC must be able to facilitate 
communication of relevant patient information through electronic 
exchange of a summary care record with other health care providers 
regarding these transitions. The RHC or FQHC must also have qualified 
personnel who are available to deliver transitional care services to a 
patient in a timely way to reduce the need for repeat visits to 
emergency departments and readmissions to hospitals and SNFs.
     Coordination with home and community based clinical 
service providers required to support a patient's psychosocial needs 
and functional deficits. Communication to and from home and community 
based providers regarding these clinical patient needs must be 
documented in the RHC's or FQHC's medical record system.
     Secure messaging, internet or other asynchronous non-face-
to-face consultation methods for a patient and caregiver to communicate 
with the provider regarding the patient's care in addition to the use 
of the telephone. We would note that the faxing of information would 
not meet this requirement. These methods would be required to be 
available, but would not be required to be used by every practitioner 
or for every patient receiving CCM services.
d. Proposed Electronic Health Records (EHR) Requirements
    We believe that the use of EHR technology that allows data sharing 
is necessary to assure that RHCs and FQHCs can effectively coordinate 
services with other practitioners for patients with multiple chronic 
conditions. Therefore, we propose the following requirements:
     Certified health IT must be used for the recording of 
demographic information, health-related problems, medications, and 
medication allergies; a clinical summary record; and other scope of 
service requirements that reference a health or medical record.
     RHCs and FQHCs must use technology certified to the 
edition(s) of certification criteria that is, at a minimum, acceptable 
for the EHR Incentive Programs as of December 31st of the year 
preceding each CCM payment year to meet the following core technology 
capabilities: structured recording of demographics, problems, 
medications, medication allergies, and the creation of a structured 
clinical summary. For example, technology used to furnish CCM services 
beginning on January 1, 2016, would be required to meet, at a minimum, 
the requirements included in the 2014 Edition certification criteria. 
For the purposes of the scope of services, we refer to technology 
meeting these requirements as ``CCM Certified Technology.''

[[Page 41797]]

     Applicable HIPAA standards would apply to electronic 
sharing of patient information.

 Table 17--Summary of Proposed CCM Scope of Service Elements and Billing
                              Requirements
------------------------------------------------------------------------
      CCM Scope of service/billing
              requirements                    Health IT requirements
------------------------------------------------------------------------
Initiation of CCM services at an AWV,    None.
 IPPE, or a comprehensive E/M visi.
Structured recording of demographics,    Structured recording of
 problems, medications, medication        demographics, problems,
 allergies, and the creation of a         medications, medication
 structured clinical summary record. A    allergies, and creation of
 full